Hartford is the only Connecticut city with more than a dozen dental clinics right in schools. Guess what? Preventive care rates are far higher than in the rest of the state. That means fewer achy mouths to divert attention from the teacher, and probably fewer adults with costly oral health issues down the road. Beyond their obvious medical benefits, school-based dental clinics make sure students eligible for HUSKY medical insurance actually enroll. So as Connecticut policymakers grapple with how to open up quality health care to needy children, Hartford’s school-based dental clinics are a bright example of service delivery done right.Cavity patrol: Hygienist Jill Quast shows Ivan the damage.
Walk past the main office inside SAND Elementary School on Main Street, through the thick, heavy aroma of hot lunch cafeteria beef. Smells like sloppy joe day. A left at the auditorium, through a door, and visitors have suddenly departed the world of colorful classrooms into an antiseptic room with a dentist’s chair. In walks Ivan, a self-possessed ten year old with a mouth full of pearly whites. He’s got to wait for his cleaning until hygienist Jill Quast finishes with another child. “If you’re real good, you can sit in my slidy chair,” Quast tells him.“Yay!” Ivan answers. It isn’t more than five minutes, though, before Ivan is on his feet, drifting towards the door.“Get back here!” Quast cheerfully commands. Ivan flashes an ‘it was worth a try’ grin and sits back down. Business is good at the SAND dental clinic, with a steady stream of students/patients excused from class to come in for a cleaning. The clinic serviced 341 students at the school last year, or 3841 total procedures completed, according to statistics provided by Dianne Dimmock, Coordinator of Health Services for Hartford Public Schools. SAND is one of 14 elementary schools in Hartford with dental clinics (Hartford has a total of 27 elementary schools). Ten of the clinics are full, comprehensive operations. Started decades ago, it is by far the largest program of its kind in Connecticut and the only one that employs so many dentists and hygienists, so kids can get comprehensive treatment, not just preventive care. The program also operates a “Molar Express,” a mobile clinic that visits schools that don’t have an onsite facility.“We can really follow kids. They’re not just getting episodic care,” Dimmock said, describing how kids start in the clinics as early as kindergarten and then stay through the important elementary years. “I think it’s a system that makes sense, and it works. The fifth and sixth graders look beautiful. They’ve got beautiful teeth, just as nice as any kid in Simsbury.“According to Connecticut Voices for Children, a low income advocacy group, 70 percent of Hartford eight year olds enrolled in Medicaid receive preventive dental care. For all other Connecticut eight year olds in Medicaid, that number drops to under 50 percent. Overall, 47 percent of Hartford children on Medicaid receive preventive dental, compared to 40 percent in Bridgeport, 35 percent in New Haven, and 39 percent in all other towns, according to Connecticut Voices. How They Pay For ItEmployees at Hartford’s dental clinics all work directly for the city’s Board of Education, so the program’s $1.4 million annual cost is built into the school system’s budget.But that doesn’t mean the Board pays for it.When a new clinic is set up, independent foundations usually pay for capital costs like the chair and other equipment, Dimmock said. As for the operating expenses, that comes mostly from HUSKY, the state’s Medicaid program for low-income children.Every student in a school with a clinic gets screened, regardless their insurance status, Dimmock said. But the program has very little money to treat children who don’t qualify for Medicaid, like the undocumented, she said. And since the program must be self-supporting, front line providers are incentivized to make sure every kid who can participate in HUSKY, does participate in HUSKY.That means in addition to cleaning teeth, Quast chases down parents, calls them, helps them navigate complicated forms to keep the kids insured. “The dental staff is really, really motivated,” Dimmock said. “They know they have to make budget.“So business has to be good, said Dr. Kurt Myers, medical director for Hartford Public Schools, because the program can’t be financially viable unless the providers are productive and see a certain number of kids per day.He might rather be back in class.It takes ruthless fiscal discipline to survive. Replicating Hartford’s system from scratch in other cities would take real commitment, Dimmock acknowledges, due to low Medicaid reimbursement rates for providers. That’s why Hartford’s dental pros have to see so many children in order to be self-supporting. And even then, the system runs budget deficits.“Most school districts would look at this as a costly proposition,” Dimmock said. “We’ve done this a very long time. [When] we start a new school, it takes three years until we break even.”A Model for the State?Last fall, Speaker of the House James Amann (D-Milford) convened a working group to examine how to get more Connecticut children enrolled in HUSKY. At least 71,000 children are eligible, but aren’t signed up. One of Amann’s appointees, health policy guru Dr. K.J. Lee, suggested installing a pediatrician (or a physician’s assistant) in every school, so children can get signed up for HUSKY in the process of seeing a doctor (click here to read ctnewsjunkie.com’s interview with Dr. Lee). In Hartford, the school system does run some medical clinics in addition to the dental services, mostly for older children. Since the dental clinics work so well for younger kids, is that evidence Dr. Lee’s idea can work? Why not provide full fledged medical care in the schools?Not so fast, Dr. Myers said. Putting a young child’s primary physician in a school isn’t a good idea, he said, because unlike with dental care, medical emergencies often occur at odd times, when schools aren’t open. And parents must come to the doctor with their kids so they can digest the diagnoses, which is not as necessary with the dentist.“You cannot have a primary care center operating in a school that’s effective,” Myers said. “Parents don’t come in with the kids. The access [to children in school] is great, but parents aren’t there…You can’t provide care in the school system in isolation from the parent.“And while no statistics are available to compare Medicaid enrollment rates at schools with dental clinics versus those without them, Dimmock suggests a state pilot program attaching a social worker to the clinics. That person could target children for HUSKY enrollment and track down the parents, freeing hygienists like Quast to focus on what she knows best: teeth. Sometimes, the clinics’ impact can be miraculous. Dimmock told a story about a girl at M.D. Fox Elementary School who rarely lifted her head off the desk in class, never spoke or participated. When she came to the dental clinic, they discovered her mouth full of rot. “A soon as her teeth were fixed, bingo! She was like Chatty Cathy,” Dimmock recalls. “I could tell you these stories all day long.”