The mid-level

Alternative workforce models continue to develop in dentistry

by Heidi Emmerling, RDH, PhD, and Ellen Standley, RDH, BS, MA

Mid-level provider. Alternative workforce models. Collaborative agreements. What does all this mean to the dental hygiene profession? From the community dental health coordinator proposed by the American Dental Association to the advanced dental hygiene practitioner proposed by the American Dental Hygienists' Association, there is an impact on the dental hygiene profession and opportunities for members of the dental team to provide consumers with increased access to care. These may specify additional educational requirements, specific practice settings, and varying levels of supervision.

Dental hygienists have a long history of supporting access to care. A progressive model that emerged in 1986 was independent dental hygiene practice in Colorado. According to Deborah Bailey Astroth and Gail Cross-Poline, the Colorado Dental Practice Law (DPL) "does not require any additional education in order to practice unsupervised or require a dental hygienist who is practicing independently to register as such with the regulatory board."

Being a proprietor and practicing without supervision were two key elements for this unprecedented independent practice. At the time, it was innovative and not without controversy. There were some legal challenges; however, 25 years later, independent practice is still going strong, delivering safe and effective care for Colorado's consumers.

Another milestone in the history of dental hygiene alternative workforce models is California's Registered Dental Hygienist in Alternative Practice (RDHAP). Like Colorado, the RDHAP may practice unsupervised and own their business.

However, there are more restrictions with this license. For example, the RDHAP must have documentation of a relationship with a dentist to whom they refer patients for needed follow-up. Every 18 to 24 months, the patient must have a referral from a dentist or physician that allows the RDHAP to continue to provide dental hygiene services.

To obtain this license, the RDHAP must complete the following requirements:

Be a California licensed RDH
Have a bachelor's degree or equivalent
Complete an additional 150 hours of an RDHAP educational program
Have a minimum of 2,000 hours of clinical experience within the last 36 months
Pass a law and ethics exam specific to the RDHAP duties and supervision level for the state of California.

This had been a successful model in California and has provided much needed care to populations at risk. These include clients in facilities and institutions, schools, homebound, and dental health shortage areas. At the deadline for this article, more than 300 RDHAP licenses have been awarded.

The Advanced Dental Hygiene Practitioner (ADHP) is a model created by the American Dental Hygienists' Association (ADHA) as a way to provide access to care for underserved populations via professional development. According to Cynthia Gadbury-Amyot and Colleen Brickle, it was in response to the U.S. Department of Health and Human Services' National Call to Action to Promote Oral Health that prompted ADHA to propose the model of the Advanced Dental Hygiene Practitioner (ADHP) in 2004 House of Delegates. This model was further developed with competencies and curriculum in 2008.

The ADHP is considered a mid-level oral health provider. According to ADHA's model, the ADHP would be a master's level program open to individuals currently licensed as dental hygienists who have a bachelor's degree. The proposed settings would be the community and public health, and perhaps private practice. Like the RDHAP, there would be a collaborative arrangement with good communication and referral networks. ADHPs would provide oral health education, a full range of dental hygiene preventive services, radiographs, and nonsurgical periodontal therapy. In addition to the preventive and periodontal scope, a restorative aspect includes simple restorations, pulp capping, and uncomplicated extractions. Furthermore, additional competencies are included for local anesthesia, nitrous oxide administration, and limited prescriptive authority.

The ADHP is not a state license but a model with a proposed set of competencies set forth by ADHA. This model can be used as a framework for individual states to pursue their own license categories and scope of practice through a legislative modality based on need and political climates.

Minnesota was the first state to adopt ADHA's model of this new mid-level oral health provider. It evolved into two pathways: the Advanced Dental Therapist (ADT) which follows the ADHP model, and the Dental Therapist (DT) which follows a model set forth by Minnesota dentists. The ADT graduates earn a master's degree (offered by Metropolitan State University) and requires that the students be dental hygienists who are licensed and actively practicing. The DT graduates earn either a bachelor's degree or a master's degree (offered by the University of Minnesota), and are not required to be licensed dental hygienists. While the DT will be able to administer nitrous oxide and local anesthesia, they may not perform scaling or extract teeth (which ADTs may do). Graduates of both programs are anticipated to enter the workforce this year.

However, one doesn't become an ADT without extensive postgraduate clinical hours. According to Colleen Brickle, Dean of Health Sciences at Normandale Community College in Bloomington, Minn., "After graduation in June [2011], they will be licensed as dental therapists. Once each graduate reaches 2,000 hours as a dental therapist under the indirect supervision of a dentist, he or she will take a certification exam given by the board of dentistry. Upon passing the examination, a dental therapist becomes certified as an advanced dental therapist."

This is obviously a program for dedicated professionals.

Brickle continues, "These seven students are courageous pioneers. The students entered the program not knowing if a law would be passed that would allow them to practice dental therapy. Yet, each had a desire to build on the competencies they have as licensed dental hygienists and expand their scope of practice to meet unmet oral health needs. This innovative program creates a dual license option as each graduate will be licensed as both a dental hygienist and a dental therapist. This dual licensure will greatly increase access to early interventions, quality preventive, restorative and primary oral health care, especially for the underserved."

The Alaskan Dental Health Aide Therapist (DHAT) began as a result of the many distant, rural underserved Alaska native communities and the collaboration of stakeholders to meet the needs of those underserved areas. The DHAT training is a 24-month program and graduates are certified by the Indian Health Service's Community Health Aide Program.

A key feature of this program is that the students are recruited from within the native Alaskan community with the purpose of returning to those communities to deliver care that is culturally competent and acceptable to the community. Although these non-dental hygienist providers may administer local anesthesia, provide nonsurgical periodontal therapy, and extract teeth, they may only practice in rural villages and their Community Health Aide Certificate is not a state license and does not transfer to other states.

According to ADHA's governmental affairs, other states are pursuing legislation to establish a mid-level oral health provider:

Washington State House Bill 1310 would create the practice of dental therapy in that state. Similar to the Minnesota dental therapist structure, the new law authorizes DTs to provide restorative services and ADTs to be licensed dental hygienists; ADTs would have completed additional dental therapy coursework and would provide both restorative and dental hygiene services. ADTs would practice with a collaborative agreement with a dentist, while DTs would practice under a form of general supervision as well as a collaborative agreement. DTs would need 400 hours and ADTs 250 hours of dentist-supervised dental therapy clinical experience.
Connecticut House Bill 5616 establishes an advanced dental hygiene practitioner in public health settings. A bill was submitted in 2010, which overwhelmingly passed the Human Services Committee. However, the legislative session closed before the bill could receive an up or down vote.
Oregon SB 227 is another dental therapy bill. Upon satisfactorily completing the education, passing an exam, and earning a certificate, dental hygienist therapists would be able to provide all dental hygiene services without supervision. With the authorization of a collaborating dentist, the therapist could also provide restorative services, place preformed crowns, perform pulpotomies on primary teeth, and nonsurgically extract primary and periodontally diseased permanent teeth.
According to ADHA, "Kansas HB 2280/SB 192 proposes a registered dental practitioner who would be a dental hygienist who completes an up-to-18-month education program and practices in a collaborative manner. The provider would be licensed to administer both dental hygiene and dental therapist services." At this point, Kansas is the only state where a dental hygiene-based dental therapist model has been proposed. The other states' models include avenues for non-dental hygienists. Some of the states have dual based models where both hygienists as well as entry level students can obtain the dental therapist education.
As we saw in Minnesota, hygienists are not the only members of the dental community looking into the concept of mid-level providers. The American Dental Association's answer and solution to addressing the access to care issue is the model of the Community Dental Health Coordinator. The time requirement is 18 months of training, no formal state licensure required, and the proposed settings would be in the community and public health. According to ADHA, there are several pilot sites including the University of Oklahoma and Temple University in Philadelphia. The CDHC would provide mostly palliative treatment with some scaling for Type I periodontal patients under either general or on-site supervision.

The main differences between the dental hygiene and the dental proposals are that the dental models require stricter supervision, less education, and do not require licensure as a dental hygienist.

The New Mexico dental therapists bill, HB 495, was not supported by the New Mexico Dental Hygienists' Association due to the limited educational requirement and the addition of prophylaxis to the dental therapists' duties. The two-year education did not provide an avenue for dental hygienists to transition into this modality. Although the bill did not come to a vote, it is likely to be reintroduced.
Vermont HB 398, another dental therapist bill (which is not supported by the state dental hygiene association) includes preventive and restorative services under the general supervision of a dentist. The proposed dental therapy program is two academic years with 100 hours of clinical practice. This bill provides an avenue for dental hygienists to become dental therapists with one year of dental therapy education.

This is an exciting time for dental hygiene as new workforce models emerge. As licensed dental hygienists increasingly face difficulty obtaining traditional employment in a private practice setting and as increasing numbers of clients face difficulty obtaining care in the traditional model of private practice dentistry, these new workforce models address the concerns of many. Although this appears to be a win-win, it behooves the dental hygiene community and consumers alike to keep a close watch on the variety of proposals set forth by the various stakeholders.

Heidi Emmerling, RDH, PhD, is interim director and professor of dental hygiene at Sacramento City College and a CODA site consultant. She is also owner of Writing Cures (www.writingcures.com), a writing and editing service, and co-author of Purple Guide: Paper Persona, a guide to preparing professional development and job search materials. Dr. Emmerling can be reached at [email protected].

Ellen Standley, RDH, BS, MA, is professor of dental hygiene at Sacramento City College and has taught in the department for over 30 years. She is a member of the California Dental Hygiene Educators Association and the American Academy of Dental Hygiene. Ms. Standley is president of the California Dental Hygienists' Association. She can be reached at [email protected].

References

ADHA. Spotlight. http://adha.org/spotlight/2011/03212011.htm. Accessed March 21, 2011.

ADHA. Fact Sheet. http://www.adha.org/downloads/ADHP_Fact_Sheet.pdf . Accessed March 21, 2011.

ADHA. Direct Access States. Stateline. http://www.adha.org/governmental_affairs/downloads/direct_access.pdf

http://www.adha.org/governmental_affairs/stateline.htm. Accesses March 12, 2011.

Astroth DB, Cross-Poline GN. (Jan 1998) Pilot study of six Colorado dental hygiene independent practices. Journal of Dental Hygiene.

Brickle C. Email communication. March 27, 2011.

Emmerling H. (Aug 2009) The ADHP initiative: A National Overview. RDH Magazine. 18+

Gadbury-Amyot C, Brickle C. (2010). Legislative Initiatives of the Developing Advanced Dental Hygiene Practitioner. JDH Volume 84 Issue 3 Summer 2010 110-113. From http://docserver.ingentaconnect.com/deliver/connect/adha/15530205/v84n3/s2.pdf?expires=1299981030&id=61691730&titleid=10950&accname=ADHA+Members&checksum=CBCBF248A5EFB219A84BC5D62796539C Accessed March 12, 2011.

Minnesota Statutes

Six Dental Hygienists You Want to Know. Dimensions. December 2010. 8 (12): 20. http://www.dimensionsofdentalhygiene.com/ddhright.aspx?id=10003 . Accessed March 15, 2011.

Workforce Model Terminology

Note: Much of this information has been adapted from ADHA's "Direct Access States" April 2010.

Advanced dental hygiene practitioner (ADHP): ADHA's model for a mid-level provider for services from dental hygiene care to simple restorations and extractions without the direct supervision of a dentist.
Affiliated practice agreement: The dental hygienist has an agreement with a consulting dentist and provides services according to protocols established in that agreement to patients enrolled in a federal, state, county, or local health program, or who have income below twice the poverty level. Arizona
Collaborative agreement/practice: The science of the prevention and treatment of oral disease through the provision of education, assessment, preventive, clinical, and other therapeutic services in a cooperative working relationship with a consulting dentist, but without general supervision; a formal written document that outlines the professional practice relationship between a licensed dental hygienist and a dentist. Alaska, Minnesota, New Mexico
Community dental health coordinator (CDHC). ADA's proposed model for a nonhygienist, mid-level provider who would not be able to perform dental hygiene services and would require dental supervision.
Direct access: The dental hygienist can initiate treatment based on her or his assessment of a patient's need without the specific authorization of a dentist, treat the patient without the presence of a dentist, and can maintain a provider-patient relationship. ADHA has identified 32 states as being direct access states
Extended access endorsement/agreement: Hygienists can provide services in hospitals, long-term care facilities, public health facilities, health or migrant clinics, or other board approved settings if the dentist affiliated with the setting authorizes services. Idaho
Extended care: Hygienist may practice without the prior authorization of a dentist if the hygienist has an agreement with sponsoring dentist who will monitor his or her practice. Examples of settings are schools, Head Start programs, state correctional institutions, local health departments, indigent care clinics, as well as in adult care homes, hospital long-term units, or at the home of homebound persons on medical assistance. The ECP I permit authorizes treatment of children in various limited access categories, while the EPT II permit is for seniors and persons with developmental disabilities. Special requirements are that hygienists must have 1,200 clinical hours or two years of teaching within last three years for ECP I; 1,800 hours or two years of teaching within last three years, plus a six hour course for ECP II. Hygienists must also carry liability insurance and must be paid by the dentist or facility. Hygienists can provide prophylaxis, fluoride treatments, dental hygiene instruction, assessment of the patient's need for further treatment by a dentist, and other services if delegated by the sponsoring dentist. Kansas
General supervision: A circumstance of treatment in which the dental professional must diagnose and authorize the work to be performed on the patient by the dental staff but is not required to be on the premises while the treatment is carried out. New York, Oklahoma, Rhode Island, South Carolina, Texas, Vermont
Independent practice: An independent practice dental hygienist may practice without supervision by a dentist to the extent permitted by statute and may be the proprietor of a place where independent practice dental hygiene is performed and may purchase, own or lease equipment necessary for the performance of independent practice dental hygiene. Maine
Limited access permit: A dental hygienist who renders services to patients who have limited access to regular dental hygiene services (homebound adults, students, Job Corps Women, Infants and Children Program enrollees, patients in hospitals, and so forth). Montana, Oregon
Mid-level provider: a clinical professional who provides patient care under the supervision of a dentist or physician. Medical models include nurse practitioners (NP), physician assistants (PA), and CRNAs. Mid-level providers can examine patients, diagnose them, and provide some treatments, all of which must be signed off by a supervising licensed dentist/physician. Mid-levels are referred to as such because they are somewhat "in between" physicians and nurses, technicians, and allied professionals in the level of health care they are licensed to administer. Mid-levels have a minimum of a bachelor's degree and most have also completed graduate or master's level education.
Oral health access supervision: Dental hygienists who possess an oral health access supervision permit may provide dental hygiene services through a written agreement with a dentist in public health settings including, and not limited to, health care facilities, state correctional institutions, residential facilities, schools, shelters for victims of domestic abuse or runaways, foster homes, nonprofit clinics, dispensaries, mobile dental clinic. Prior to providing services, a dental hygienist with an oral health access supervision permit must have a written agreement with a dentist who possesses an oral health supervision permit that states the dentist has evaluated the dental hygienist's skills and the dentist has reviewed and evaluated the patient's health history. The dentist need not be present or examine the patient before the dental hygienist may provide care. The collaborating dentist must perform a clinical evaluation of the patient before the dental hygienist may provide subsequent care. The evaluation may be done using electronic communication. Special requirements include two years and a minimum of 3,000 hours of clinical experience; a minimum of 24 continuing education credits during the two years prior to applying for the oral health access supervision permit, including a course on identification and prevention of potential medical emergencies; and completed an oral health access supervision permit class approved by the board. Services provided are prophylactic, preventive, and other procedures a dentist can delegate to a hygienist, except definitive root planing, definitive subgingival curettage, administration of local anesthesia, and other procedures specified in rules adopted by the board. Ohio
Public health dental hygienist: Under general supervision, the dental hygienist performs technical and consultative dental and health educational services as a part of a statewide preventive dental health program, performing related work as required. Connecticut, Iowa, Maine, Massachusetts, Michigan, Missouri, Montana, Nebraska, New Hampshire, Nevada, Pennsylvania, Washington, West Virginia, Wisconsin
Registered dental hygienist in alternative practice (RDHAP): RDHAPs may provide unsupervised services for homebound persons or at schools, residential facilities, institutions, and in dental health professional shortage areas. RDHAPs can offer a patient care for up to 18 months and provide additional care if the patient obtains a prescription from a dentist or physician. The special requirements are that the RDHAP must have a bachelor's degree (or equivalent), three years of clinical experience, completion of additional 150 clock hours in designated courses, and pass exam. RDHAP must provide board with documentation of an existing relationship with at least one dentist for referral, consultation, and emergency services. The services provided by RDHAPs are all services permitted under general supervision, including prophylaxis, root planing, pit and fissure sealants, charting, and examination of soft tissue. Direct Medicaid reimbursement is allowed. California
Remote supervision: A Virginia pilot project, hygienists may treat patients in the dental health professional shortage areas and refer patients without a dental provider to a dentist with the goal of establishing a dental home. Hygienists must enter into a remote supervision agreement with a licensed dentist and maintain regular, periodic communication (14 day intervals) with the licensed dentist (protocol must be submitted to the department of health). The special requirements are that hygienists must have two years of experience and must be employed by the Department of Health. Virginia
Unsupervised practice: There is no requirement that a dentist must authorize or supervise most dental hygiene services. Dental hygienists may also own a dental hygiene practice. The services provided include dental hygiene diagnosis, radiographs, remove deposits, curettage (without anesthesia), and apply topical anesthesia. Direct Medicaid reimbursement allowed. Colorado, Washington
Volunteer community health settings: A dental hygienist may provide the following services without the supervision of a dentist in volunteer community health settings: OHI, nutritional counseling, oral screening with subsequent dental referral, fluoride applications, and sealants. Kentucky
Workforce modeling: The process for identifying and addressing the gaps between the workforce and the human needs.