ABSTRACT
Introduction
Alternative models of healthcare delivery are becoming essential to close the current gaps in dental care.
Methods
These alternative care models also provide an opportunity to the dental team to work in non-traditional clinical settings and allow the approach to be designed around chronic disease management, enhanced patient engagement, and ease of access. One such model is the mobile dental clinic. Mobile clinics can be impactful in providing dental services and reaching communities that experience the most difficulty in accessing traditional dental clinics.
Results
Mobile service delivery can be achieved utilizing a mobile dental van or transporting dental equipment to a site and setting up a temporary dental office. They are slowly growing in popularity in urban, sub-urban and rural United States as it offers to address barriers and increase utilization of dental services. They allow for flexibility for the dental team and at the same time address social determinants of health, making it a promising dental service delivery model.
Practical Implications
This manuscript reviews the use of mobile dental units and its effectiveness as an adjunct to traditional brick and mortar dental clinics and its challenges and also describes implementation of a mobile dental clinic program by a Federally Qualified Health Center (FQHC) in the Bay Area, CA.
KEYWORDS:
- Access to care
- mobile dental units
- alternate pathways in dentistry
Introduction
Good oral health supports the overall health and well-being of individuals and their families, and the communities in which they attend school, work, and live. Lack of access to regular oral healthcare, including preventive care, results in an increased risk for dental disease, pain, and infectionCitation1. This lack of access leads to inequities that further complicate disparities in oral health status. This was highlighted in the first ever Surgeon general’s report of Oral Health published over two decades ago.Citation2 The report also suggested that the current infrastructure of dental care delivery in the United States is not sufficient to meet the needs of the people and the innovative models required should be aimed at primary prevention, early detection and intervention.Citation3 The report brought to the forefront the need to experiment and innovate in oral health service delivery. While the developments witnessed in the two decades to address unmet oral health have been uneven, it has also created opportunities to pilot and implement innovative strategies to expand access.
To address disparities in access to oral healthcare, the Institute of Medicine and the National Research Council recommend that the HRSA further expand the capacity of FQHCs to deliver essential oral health services.Citation4
While FQHCs are uniquely positioned to provide integrated, patient-centered care, they experience challenges related to the oral health literacy of patients and to the building of sufficient physical capacity to meet the high demand for oral healthcare services.Citation5,Citation6 Thus, there needs to be continued focus on eliminating barriers that prevent people from seeking care and solutions that seek to improve health outcomes, reduce costs and improve patient and provider satisfaction along with being equitable.Citation7
The United States (US) House of Representatives voted in favor of the Action for Dental Health Act of 2017.Citation8 This bill includes specific language on grant funding to support portable or mobile dental equipment which may lead to an expansion of opportunities to deliver and receive care through the use of portable dental equipment and mobile dental vans and increase access to preventive services and improve emergency room diversion programs to address barriers to access. The current legislation encourages innovative use of mobile dental units (MDUs) in other environments including the for-profit sector.Citation9 Aung et al.Citation10 reported that the mobile units serve as a platform to navigate the complex healthcare system and provide sustainable high-quality care.Citation10
Mobile clinics have been utilized in a variety of service delivery configurations and services can range from comprehensive primary care to discrete selected services. Mobile dental programs can be described in two broad categories. They are:
Mobile dental services delivered on a mobile van that is configured to serve as a self-contained dental clinic with dental chair(s), delivery units, x-ray equipment and dental sterilization. The mobile dental vans may travel to different locations to serve patients or be parked at a facility.
Mobile dental programs that transports portable dental equipment which is set up at a community site such as preschools, schools, community centers, nursing homes. Such programs may either use dedicated space or shared space at the center of care delivery and may move from location to location after care provision is complete. Portable dental equipment (dental chair, overhead light, dental unit, x-ray equipment, sensor, instruments and dental materials) once transported to the location is set up inside a room such as the gym, library or other available spaces within the facility. The set up either includes dental sterilization equipment or a plan to transport instruments for processing at the end of the day.
Most of the literature on mobile dental programs considers its use in preschools, schools and nursing home facilities.Citation1 In recent times, however, the mobile dental programs are no longer limited to be associated with a dental school, hospital nonprofit dental clinics or FQHCs serving the underserved. A popular for-profit model of mobile dental units delivering dental services at business corporate offices has been very popular in California and other states where mobile dental clinics provide dental services on office campuses, thereby increasing access to services and limiting the time off needed to receive care. In some instances, dentists renovating their offices may choose to work out of a mobile dental unit temporarily. The main idea of mobile dental clinics is to increase access by eliminating transportation barriers and getting the care close to the patients. This has other positive attributes such that the clinics enjoy a low “no-show” rate and increase utilization of services.
Dr Alfred Fones started the first school-based dental program in the US in 1914. This program was built on the principles of dental hygiene and was intended to be a model that could be replicated at schools across the country. The program utilized portable dental equipment to provide preventive and simple restorative procedures. Prevalence of dental caries in children with access to the mobile dental services at school was much lower than those in a control school.Citation11 Other mobile dental programs were created and implemented in schools over the years and proved to be a reliable way of delivering preventive services to children. There are an estimated 1500 mobile clinics providing five million visits nationwide per year. Mobile clinics improve access for vulnerable populations, bolster prevention and chronic disease management, and reduce costs.Citation12 https://www.mobilehealthmap.org/find-clinics/ provides a visual representation of the locations of mobile dental clinics across the United States.Citation13
Conceptual Model for Comprehensive Oral Healthcare Delivery
A conceptual model of an effective and equitable oral healthcare delivery has been proposed by National Network of Oral Health Access (NNOHA)Citation14 and is presented in .
Figure 1. Conceptual model of equitable oral healthcare delivery.
In an effort to reduce healthcare costs and improve patient outcomes, the emphasis in the recent years is shifting from the amount of care delivered to the people who actively seek out the care. Rather the emphasis is on how to reach those who bear the most burden of disease and are the least likely to seek routine preventive care. The conceptual model put forth by NNOHA represents all ways in which a patient may be connected to receive the care they need. This model takes in to account the patient’s needs and the dental workforce to make oral healthcare more accessible and equitable. The model presents a comprehensive care delivery model that is supportive of the patients’ needs and aims to address them through multiple different models such as medical dental integration, school-based health centers, tele-dentistry (both synchronous and asynchronous) and utilizing mobile dental units. These adjunct programs work hand in hand with the traditional dental clinics and support the patients to attain their full health potential by addressing barriers to seeking care. This is a comprehensive model that supports patient-centered care and is applicable to patients from all walks of life. This comprehensive delivery model opens options for dentists, dental hygienists, dental assistants and case managers (dental navigators) to assume different roles and work in non-traditional dental practice setups. The new models allow flexibility and creativity, offer providers to work with a diverse population and acquire unique perspectives while working to improve access to care.
Mobile dental programs have several unique characteristics and they are presented and discussed here.
Community Collaboration
A key component of a successful mobile dental program is community collaborations and partnerships. The collaborations help with needs assessment and designing care delivery in such a way that the services are well utilized. Potential collaborators include schools, Head Start programs, WIC programs, Homeless Shelters, nursing homes, jails, and Community Based Organizations that address the Social Determinants of Health. Community partnerships are key to a successful program as the CBOs are crucial in promoting the work. Community collaborations are also key in helping navigating enrollment and utilization of services. Successful implementation of mobile health services depends on full engagement with and buy-in from the community throughout the planning process, and ongoing partnerships must be formed and maintained in order to ensure continued communication and collaboration of MHCs with each neighborhood.Citation15
Clinic Design
While the mobile clinic designs may vary slightly, depending on the size of the mobile unit the clinics usually house two or three dental chairs and have an area for sterilization and storage. They also have on board dental imaging equipment, dental units and small dental equipment. Storage space is usually limited and forces the dental team to plan and carry what is needed to see the patients. Mobile dental van manufacturers’ have evolved over time to take into consideration ergonomics, patient privacy, staff safety and infection control in the design of the clinic.
Licensing and Safety Standards
The mobile clinics are required to follow all safety standards as a brick and mortar dental clinic and may have additional requirements through the state dental boards. The mobile dental units need to be registered and licensed with the State Dental Board and follow the health and safety code regulations. Regulations may vary from state to state and may change over time. Contact your state board to get the latest information. In California, the state dental board requires that the clinics/agencies operating MDUs have a written procedure for emergency follow-up care for patients treated on the MDU, availability of communication facilities on the MDU that enable providers to contact necessary parties in the event of a medical emergency, MDU holds necessary permits and is built to code, has a properly functioning access ramp or lift, sterilization system, access to portable water, readily accessible toilet facilities and covered waste bins.Citation16
Staffing
Staffing at minimum would consist of a dentist along with dental assistant and front office staff. In some instances, the mobile dental unit may also be staffed by a Registered Dental Hygienist in Alternate Practice. In some instances, the assistant manages both the front office and the back-office operations. An additional staff member is needed to drive the mobile van and assist with maintenance. The driver of the mobile van may have a special CA driver’s license depending on the size of the MDU.
Patient Flow and Operations
Good communication with partners is essential to get the message to the community of the clinic location and timings and it parallels networking in a private practice setting. The staff working on the mobile dental units need to be flexible to accommodate patients and communicate with patients using different communication strategies such as phone calls, texts, etc.
Flexible Work Schedules
The mobile dental units may allow flexibility in choosing the neighborhood they serve and how often the providers return to the same neighborhood. This allows the dental team to design their work hours to meet the needs of the patients and offers them flexibility as well.
Billing and Credentialing with Insurances
The mobile dental units have to be credentialed with dental payors including medicaid as a dental clinic entity to be able to accept dental insurances and bill insurances for reimbursem*nt. State medicaid programs contract with mobile dental programs much like a fixed dental site on the fee for service model in California. If the mobile dental programs are run by federally qualified health centers they can either be licensed as independent service locations or intermittent clinic locations.
Challenges
With several benefits and perks of a mobile dental clinic mentioned above, there are some challenges that are unique to the mobile dental van operations. These are:
Storage of the unit itself and equipment and supplies within the unit: The mobile dental units are large and require a safe location to be parked in when not in use. There is a possibility of damage to the dental equipment while driving the van if the equipment is not secured as recommended. Small equipment may move and damage the mobile van interiors and break if not secured appropriately. The dental materials may need to be removed when not in use from the dental van to prevent damage due to extreme temperatures.
Upkeep and maintenance of the unit: Repairs of the mobile van can be expensive and may take a long time and can put the unit out of commission thus limiting access to the services. Often run as nonprofit organizations, mobile clinics may not be able to secure a steady source of funding to afford the usual maintenance costs, which increase as the vehicles age.Citation15
Costs of operating a mobile dental unit could be greater than that of a fixed clinic location. This is due to additional costs of operating and insuring a large automobile along with maintenance costs for dental equipment.
Fragmentation of care and difficulty in following up with referrals Mobile healthcare units have also been attributed to provide fragmented care and continuity of care may be a challenge.Citation17
Finding a suitable location to safely park a mobile clinic for hours at a time can also be problematic, especially in urban areas and may require city permits.Citation15,Citation17
Ravenswood Mobile Dental Program
Ravenswood Family Health Network’s dental clinic provides comprehensive oral health services to children and adults irrespective of the patient’s ability to pay. This includes: preventative care, oral surgery, emergency services, and more. The organization’s mission is “To improve the health of the community by providing culturally sensitive, integrated primary and preventative health care to all, regardless of ability to pay or immigration status, and collaborating with community partners to address the social determinants of health”.Citation18 According to 2021 data reports, 90% of the patients are low income (below 200% of poverty), and 27% of their patients are not covered by insurance. Ravenswood cares for about 20,689 patients; with 7,576 of those patients being children and adolescents. Ravenswood Family Health Network serves the communities of Southern San Mateo county and Northern Santa Clara County through five fixed medical clinics. Three of the fixed sites located in Santa Clara County (Palo Alto, Mountain View and Sunnyvale) have medical services but do not offer dental services with no physical room for expansion to provide dental services. While the patients can access the services at the dental clinic in East Palo Alto, several patients cite transportation and distance as a barrier to seek affordable and reliable dental care. To address these barriers and increase accessibility of services to the patients served in Mountain View, Palo Alto and Sunnyvale sites the clinic created the mobile dental clinic. Independent of the mobile dental unit, Ravenswood provides preventive dental services in Head Start, Early Head Start and pre-schools in San Mateo County through the Virtual Dental Home model. Ravenswood employs both models of mobile dental care delivery referenced above in that we have a medical/dental mobile van that is configured to serve as a dental clinic and also has the Virtual Dental Home program that utilizes portable equipment that is transported from one location to another and is staffed by a dental hygienist in alternate practice and a patient navigator. In the following paragraphs the authors describe both mobile dental programs at Ravenswood.
Mobile Dental Unit
In 2021, local philanthropic organizations came together to help fund a mobile health expansion of dental services to the FQHC’s medical clinics where dental services were currently unavailable. The mobile van was built to be able to offer dental and medical services and is operated by a generator and has water tanks that store water for use in the sinks. The dental unit utilizes distilled water with water purification system in place. The mobile dental program is an extension of the fixed dental clinic and is registered as an intermittent clinic site for the FQHC. All patient visits are billed at the FQHC’s encounter rate if eligible (for medicaid patients) and uninsured patients pay for services on a sliding fee scale. The patients seen on the mobile dental program are established patients of the FQHC. The mobile dental van is staffed by the employees of the FQHC and consist of a part-time dentist, dental hygienist in alternate practice (RDH-AP) and dental assistant/support staff. The mobile dental van is equipped to perform general dental procedures such as preventive services, restorative dentistry, scaling and root planning, extractions and minor oral surgery, endodontics and fixed and removable prostheses.
The mobile program is unique in that it utilizes asynchronous tele-dentistry the patients are seen by the RDH-AP for preventive services: data collection with x-rays, photographs, prophylaxis, topical fluoride applications including SDF and varnish, sealants on primary and permanent teeth, interim therapeutic restorations; and scaling and root plannings. The dentist reviews the records and formulates a treatment plan and the patients are appointed with the dentist for definitive treatment on the mobile van providing restorative and surgical dental services one to two days a month as needed. In the event of a patient requiring immediate dental treatment they are referred to the dental clinic in East Palo Alto. Currently the mobile dental clinic is operational at one of our sites (Mountain View) one day a week and we plan to expand to the other two sites in Palo Alto and Sunnyvale in 2024. The slow expansion of the program is due to staff shortages and while we work diligently to recruit and train additional staff to work on the mobile van, the program in its current capacity has allowed for us to figure out our workflows and manage equipment and inventory of materials Number of patients seen on the mobile van ranges from 6 to 9 patients per day, the patient volume is determined by the services provided. There is a scope to increase the efficiency of the program if the DDS/RDH-AP: ratio can be increased from 1:1 to 1:2 in the future.
Patients seen on the mobile van are referred by the primary care physicians at the health center’s medical clinic and minor patients are accompanied by parents who provide informed consent for treatment. Dental assistants call the patient or the families informing treatment plans and assist with making follow-up appointments.
Mobile Dental Programs
Ravenswood received funding from San Mateo County First 5 in 2012 to partner with pre-schools that serve children from low-income families to increase access to preventive oral health services. Through this program our staff continues to provide preventive services and collect intraoral photos and x-rays. The dentist reviews records making treatment and follow-up recommendations based on risk assessments and clinical findings. The dental navigators help connect the families to the dental offices for restorative care. Since the program is offered at different schools, we utilize portable equipment that is moved from site to site and is set up either in dedicated space or shared spaces in the pre-schools and community sites. In 2022, the program served 700 children in over 1000 visits.
Conclusion
In the era of accountability, it is critical to recognize and address barriers that prevent patients from seeking care. Mobile dental programs attempt to address barriers of transportation and accessibility. Mobile programs are a viable way to provide dental services and dentists and allied dental professionals may find it satisfying working in mobile dental programs. Mobile dental programs are not just limited to providing care to the underserved. Successful models exist in the United States where mobile dental units are serving patients in the corporate office locations. While services on a mobile unit are not set up the same as in a dental practice, understanding the differences can help make programs effective and efficient. Utilization of all available ways that a patient can be evaluated by the dental team as suggested by the conceptual model put forth by NNOHA has helped advance access to dental services and increase treatment plan completions at Ravenswood. Mobile dental programs despite all their challenges are able to serve as dental homes for patients they serve if the program planning includes consistently returning to the area they serve and with patient education and direction on how to access services on days when the mobile units are not at the community location.
Disclosure Statement
No potential conflict of interest was reported by the authors.
