The Florida Department of Health in Broward County (DOH-Broward) is the official public health agency in Broward County and has been in operation since 1936. It is part of the integrated Florida Department of Health (DOH) and operates in cooperation with the Broward County Commission under Florida Statute 154. DOH-Broward's mission is to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts.” DOH-Broward is the lead agency providing core public health functions and essential services in the county as part of a complex public health system that includes hospitals, clinics, planning agencies, and community-based organizations. The website of DOH-Broward is broward.floridahealth.gov
In 2018, Broward County had 1.9 million residents, with 15.3% between the ages of 0-12 and 6.1% between ages 13-17. The median household income is $51,968 with an average of 2.7 people per household. Almost 20% of children under the age of 18 are living below 100% of the federal poverty level. More than 271,000 children attend the county's public schools, 194 of which are elementary, middle, or charter schools that have been classified as Title I and therefore have a student population of at least 50% who qualify for federal free or reduced lunch programs.
Dental care remains to be the largest unmet health need of children who reside in the United States. Tooth decay is the most common chronic childhood disease, occurring five times more often than asthma and twenty times more often than diabetes. However, it is almost entirely avoidable using preventive dental care. DOH-Broward's School-Based Sealant Program provides preventive dental services, including cleanings, fluoride varnish treatments, sealants, and oral health-nutritional education, in a school setting to approximately 32% of its target population of Pre-Kindergarten to 8th grade students who attend elementary and middle schools. The program provides for the dental needs of many underserved families who would not have access to dental care for their children.
During the days' schools were in session from March 2016 through October 2018, DOH-Broward's School-Based Sealant program has provided dental services to more than 60,000 distinct children throughout Broward County. Over 185,000 teeth have been sealed to protect the teeth from decay and its effects. The processes and goals were updated after program evaluation of data which has contributed to increased availability during the school calendar to provide preventive dental services to a larger proportion of Broward County students that otherwise would not have access dental care.
Support staff perform tasks not directly related to direct dental care, which has allowed for an increase of each hygienist's daily production from an initial 13 students seen per day in the 2015-2016 school year to 19 per day in the 2018-2019 school year. Prior to the hygienists arrival at a school, screener staff have reviewed parental consent forms for complete medical histories, parental signatures and have organized the completed forms by class roster so the hygienists can quickly and easily locate participating students. Any needed supplies are delivered and portable dental equipment is set up by support staff in an available classroom in advance of the hygienists' arrival, allowing them to promptly begin seeing students with minimal downtime. Autoclaves are utilized in each school for on-site sterilization of instruments. These practices minimize interruptions in seeing students for dental care.
DOH-Broward supports the oral health objectives of Healthy People 2020. These include reducing the proportion of children who have tooth decay and increasing the rate of children who have received dental sealants. To increase the effect of this innovative program to the community, each hygienist has a productivity goal of providing dental services to 19 children per school day. This target has allowed an increase from previous school years in the number of children seen throughout the year. During the 2017-2018 school year, 33,472 children received preventive dental services. From the end of August 2018 through October 2018, 16,039 children have received dental services by the program's hygienists. The program's target for the 2018-2019 school year is to provide dental services to 60,000 of Broward County's children and teens.
Tooth decay is the most common chronic childhood disease and is almost entirely preventable, yet dental care continues to be the largest unmet health need of children in the United States. This condition is especially prevalent in low-income families who may not have access to regular dental care. In 2013, almost 50% of the children who were enrolled in a Medicaid plan did not receive any dental care. DOH-Broward, with the support of Florida's State Surgeon General, endorses the implementation and expansion of school-based dental sealant programs to provide preventive dental services to youth in local communities.
Broward County is a densely-populated area with more than 271,000 children and teenagers attending the 6th largest public school system in the nation, and a school-based sealant program is a highly-effective approach to improving dental access to such many children in the community. Demographics vary throughout Broward County's 1323 square miles and the operation of each individual school reflects the specific needs of its community's students and their families. Regardless of location and demographics, a common issue among school administrators, faculty, and parents, was the lack of knowledge regarding the importance of dental care and how tooth decay can affect numerous aspects of a child's life. Children can easily avoid difficulties with eating, speaking, sleeping, socializing, self-esteem, and learning through the prevention of dental pain and infection. Children who are experiencing pain, infection, and other dental-related emergencies miss school days three times more often than those without tooth decay. This event results in lower educational outcomes throughout childhood, and the effects continue into adulthood. In doing so, the program is contributing to the oral health objectives of Healthy People 2020, which include reducing the proportion of children who have tooth decay and increasing the rate of children who have received dental sealants.
School-based dental sealant programs are slowly becoming more widespread as states expand efforts to meet the oral health objectives of Healthy People 2020, which include reducing the proportion of children who have tooth decay and increasing the rate of children who have received dental sealants. By taking the steps to increase access to dental care for children for Broward County public school families, DOH-Broward is supporting not only the Healthy People 2020 objectives but also the state of Florida's goal of being the healthiest state in the nation.
In 2003, the Association of State and Territorial Dental Directors published a Best Practice Approach Report that reviewed the scientific evidence that school-based sealant programs are successful in improving dental health outcomes. This report presented specific examples of practices in state programs. These programs provide sealants and other preventive dental services to children and teens, many of whom are unlikely to receive them outside of a school setting. School-based sealant programs are particularly significant for impacting the lives of children from low-income families who are less likely to access private dental care. These programs commonly target schools that enroll a large percentage of children eligible for federal free or reduced-cost lunch programs, which are classified as Title I by the Department of Education. Based on the positive response from parents and school staff, DOH-Broward's School-Based Sealant program has expanded from visiting a select 59 Title I elementary schools in the 2015-2016 school year to visiting 256 elementary and middle schools, including charter schools and regardless of Title I status, in the 2018-2019 school year. Doing so provides every student in the Broward County Public School system an equal opportunity to receive preventive dental services.
The program's target population is the 187,756 students who attend Pre-Kindergarten through 8th grade at public and charter elementary and middle schools throughout the county. Of the 256 elementary, middle, and charter schools in the county, 194 schools, or approximately 76%, are classified as Title I. The classification of Title I indicates that the school population consists of 50% or more children who qualify for free or reduced-fee lunch, and likewise many of the children who participate in the program belong to families that have difficulties affording dental care.
Through October 2018, a total of 60,638 distinct children have received preventive dental services during school hours since the inception of DOH-Broward's School-Based Sealant Program in March 2016. This amounted to approximately 32% of the student population. All children who participate in DOH-Broward's School-Based Sealant program receive information on the agency's pediatric dental clinics which offers a free/lost cost dental home to ensure continued dental care. In the 2017-2018 school year, approximately 14,000 of the children seen through the School-Based Sealant program did not have a dental home and their parents or legal guardians were contacted by DOH-Broward's Call Center to offer an appointment for their child at a DOH-Broward dental clinic.
A hygiene workforce model is utilized for the DOH-Broward School-Based Sealant program. Registered dental hygienists receive extensive training around preventive dental treatments, including the placement of dental sealants. Using a hygienist model for a school-based dental sealant program allows a licensed health care professional to deliver valuable services to underserved members of the community while also being cost-efficient. The DOH-Broward Dental Director, who is a dentist, oversees the program through general supervision and is then able to provide restorative treatment in the DOH-Broward pediatric dental clinic while multiple hygienists are providing preventative services in the schools, allowing a larger population to be served in a condensed period. Utilizing the hygienist model increases the overall number of children treated, which reduces the occurrences of dental caries as well as the detrimental effects that may accompany it, such as loss of tooth structure, emergency room visits, child absenteeism from school, missed learning opportunities, parents missing work, and expensive dental bills. Additionally, hygienists have a background in communicating in terminology that is easily understandable by children and can make the School-Based Sealant program a positive experience for many students who have not previously received dental care to promote lifelong beneficial oral hygiene and nutritional habits.
Each member of the program's staff underwent a recruitment process that included technical and behavioral event interviewing, and the roles of the staff are modeled around the needs of both the students and the program. By employing 20 licensed dental hygienists as the program's dental practitioners, it is achievable to visit each of Broward County's 256 elementary and middle schools, both public and charter, over the course of one school year. These dental professionals provide children with preventive dental services that include sealants, fluoride treatments, cleanings, assessments, and education to children who would otherwise not receive any dental care.
At the inception of the program, the movement and setup of equipment between schools, was completed by the dental hygienists. Additionally, staff needed to return to DOH-Broward's main campus to sterilize instruments, drop off medical records to the data entry clerks, and collect supplies daily which decreased productivity. These necessary steps consumed a significant amount of time, which is already extremely limited due to the school hours and days in session. The number of children seen each day averaged to 12.02 in September 2016 and 12.92 in October 2016, which did not allow for the possibility of increasing the number of children to receive dental services in a school setting. As school calendars are limited, the time for the hygienists to focus on providing dental services, as opposed to paperwork and equipment setup, has been maximized by adding support staff to the program.
Through a process of continuous improvement and to ensure downtime is minimized, prior to the 2017-2018 school year, the program invested in additional sets of portal dental equipment that are rotated through the schools and are set up in advance of the hygienists' arrival, allowing them to begin seeing students promptly after arriving to their assigned school. Drivers were hired for this task as well as to deliver supplies and securely transfer medical records between the hygienists and the data entry clerks. Autoclaves were purchased to create a convenient portable sterilization area near the dental equipment, allowing the hygienists to remain in their assigned school throughout the day as opposed to traveling offsite each afternoon. Additionally, clerical staff assist in both preparing paperwork for the hygienists as well as entering it into electronic records. Prior to the hygienists arrival at a school, screeners have reviewed consent forms for complete medical histories and parental signatures, and have organized them by class roster so the hygienists can quickly and easily locate the participating students. After services are provided, dental records are entered into DOH-Broward's electronic health management system by data entry clerks. Together, these aspects provide ample time for such a large population to be seen each school year.
In the 2017-2018 school year, the productivty rate increased to 15.13 in September 2017 and 15.30 in October 2017, with a total average of 210 students per day. After streamlining the new processes, each hygienist has could achieve a highly productive schedule of an average of at least 19 students in a classroom setting throughout the available school hours, with an average of 19.7 students seen per day in September 2018 and 19.2 students per day in October 2018. Through October 2018, more than 16,000 students have been seen in just 42 school days, which amounted to an average of 380 students per day and added up to approximately 48% of the total number of students seen throughout the entirety of the previous school year. This daily production statistic is an 81% increase from the previous school year. The program's processes and the needs of the students are continuously evaluated to increase participation of the target population in future school years.
DOH-Broward and the Broward County School Board have a scope of work in place that allows all students who are enrolled in public elementary and middle schools to receive preventive dental services in a classroom setting. Consent forms and program information is provided to students in their First Day of School” packets. All students who return a completed consent form from their parent or legal guardian are eligible to receive the program's preventive dental services. Program staff routinely attend parent events at schools and community health fairs to promote the benefits of dental sealants to local parents, answer any questions which has contributed to an increase in the number of families who participate in the program.
The goal of DOH-Broward's School-Based Sealant program is to provide preventive dental services to the youth of Broward County, many of whom do not receive dental care on a regular basis or at all. This program began providing dental services to children attending Kindergarten through 3rd grade in Broward County's Title I public elementary schools in March 2016. The program was implemented through a grant of $1,271,228 from the Agency for Health Care Administration. It allowed for the purchase of portable dental equipment, instruments, patient forms, and other supplies. In the 2015-2016 school year, 10,453 children received dental services. Participation in the program increased to 27,742 children attending Kindergarten through 7th grades during the 2016-2017 school year, and to 33,472 children in Pre-Kindergarten to 8th grade in the 2017-2018 school year. Throughout the 2018-2019 school year, the program's target is to provide dental services to 60,000 children and teenagers.
To instill dental care as a value point, the management of DOH-Broward's School-Based Sealant program meets with and maintains regular communication with school administrators to discuss the benefits of dental sealants and other preventive dental services. This level of support has led to increased participation in the program. DOH-Broward school health nurses also promote the program while visiting schools. After a dental team finished providing services in a school, the principal receives a summary that includes number of students seen by the dental hygienists, sealants placed, and dental emergencies identified. The school administration and faculty are acknowledged for their participation in increasing access to dental care for children who do not receive dental services on a regular basis. The Broward County School Board Superintendent receives an annual report of services provided.
Any child who received services from the School-Based Sealant program that does not have Medicaid or private health insurance coverage is referred to the Florida KidCare insurance program. KidCare representatives contact the parents of uninsured children to determine if they would like to apply for health insurance and advises them on plans that include dental coverage.
Every child receives an informational card regarding the DOH-Broward pediatric dental clinics, including the ages that can be seen and the phone number the parents can call when they would like to make an appointment for their child to establish a dental home if the child does not have a private dentist. The parents of children who are identified as experiencing a dental emergency, including pain, swelling, or abscesses, are contacted by DOH-Broward's call center to make an appointment.
DOH-Broward supports the oral health goals of Healthy People 2020, and its School-Based Sealant program is contributing to these objectives on a large scale. The objective of reducing of the proportion of children who have tooth decay is accomplished by placing sealants on over 185,000 permanent teeth, providing fluoride varnish treatments, and educating children on oral health. The rate of children who have received dental sealants continues to increase each year as the program expands, and processes are evaluated to further increase the School-Based Sealant program's impact on public health.
The total number of days in the school calendar, as well as each individual school's daily hours, limits the amount of time that can be scheduled to visit all the elementary and middle schools throughout Broward County. To permit more time for the hygienists to be able to provide dental services in the school setting, daily production was analyzed and program improvements were made based on data analysis, suggestions from supervisors, directors, and program hygienists who have experience with daily school schedules.
It was determined that school events and other needs of the school administration periodically slow production so the hygienists are flexible in working around these obstacles. However, a daily occurrence was the hygienists finishing their production before the school day concluded to perform other ancillary tasks. This stoppage occurred so they could travel to DOH-Broward each afternoon to sterilize instruments and deliver their daily paperwork. It also occurred every few days when they completed all treatment at a school and were required to pack their dental equipment into a van and set it up again at their next scheduled school.
Since the 2017-2018 school year, the additional of drivers to set up dental equipment in advance of the hygienists' arrival to each school and have also been utilized to transport the daily paperwork and supplies from the schools to DOH-Broward. The hygienists can sterilize their instruments in autoclaves that are brought to each school along with the rest of the dental equipment. These changes allow the hygienists to continue providing dental services to students throughout the entire school day. The goal has now been raised to 19 students per hygienist each day, which will allow for a greater number of children to participate in DOH-Broward's School-Based Sealant program in the duration of each school year.
To enhance the effect the program has on the youth of the community, the hygienists each have a target of providing dental services to an average of 19 children per school day, which is anticipated to allow for the time to provide dental services to 60,000 children and teens who attend elementary and middle schools throughout Broward County. This production goal was increased from the previous year's target of 16 students per day after forecasting the number of children who would submit consent forms, which was approximately twice as many as the previous years due to the program's expansion into charter schools and non-Title I elementary and middle schools, as well as the limited hours and days of the school calendar. By streamlining processes over the previous school year, the increase in student's seen was determined to be achievable and students who were seen in the program in previous years could have sealant retention checks done, which would allow the hygienists to perform the visits at a faster rate and the students to be out of class for a shorter time span, in addition to the motivation of the staff to provide services to the of children in their community.
The role of the each of the dental hygienists is to provide preventive dental services to an average of at least 19 children per day. Through October 2018, more than 16,000 students have been seen in just 42 school days, which amounted to an average of 380 students per day. This production statistic is a 169% difference from the 225 students per day that were seen during the 2017-2018 school year. This achievement improves numerous children's oral health and increases their overall quality of life.
The target of 19 students per day, the rate of which is measured by dividing the total students seen per month by the number of hygienists who visited schools and again by the number of days they provided services during that month, has been achievable, with an average of 19.73 in September 2018 and 19.20 in October 2018. This production average is a significant increase from the previous school year, in which the hygienists could provide dental services to 15.13 students per day in September 2017 and 15.30 in October 2017. It is also significantly more than the 2016-2017 school year, in which the hygienists saw 12.02 in September 2016 and 12.92 in October 2016. The difference between September 2016 and September 2018 is 164%. At the School-Based Sealant program's inception in March 2016, one of the objectives was for each dental hygienist to provide preventive dental services to an average of 13 children per school day. In September 2016, the average amounted to 9.76 daily, while in October 2016 the average rose to 11.86 per day.
At the end of each month, the hygienists are sent a bar graph that details each one's average, giving them incentive to see more children and stay at the top of the list. In September 2018, the individual production averages ranged from 17.65 to 21.29 students per day, with 85% of the hygienists meeting or exceeding the target of 19 students per day. As a comparison, during the previous school year, in September 2017 the averages ranged from 17.73 to 6.33 students per day, with 31% meeting their goal of 16 students per day. The hygienists also receive individual line graphs throughout the year that show them if their production has increased, decreased, or remained stable throughout the school year. These charts update the hygienists on their production rates on a regular basis and keep them highly involved in the outcomes of the program.
Additionally, the quality of dental services performed by each hygienist is audited at least twice a year by the program's manager and assistant manager, who are both licensed dental hygienists in the state of Florida, as well as DOH-Broward's dental director, who is a licensed dentist. In order to evaluate the rate of sealants that have been retained, the program's management performs random digital audits of the charts of students who have been seen at least twice through DOH-Broward's School-Based Sealant program to determine if particular hygienists have a high rate of sealants that are not retained; throughout these evaluations, negative retention has been found to be random and the rate of retention has remained higher than 80%, which meets the standards of the National Maternal and Child Oral Health Resource Center's Seal America program.
All services rendered are recorded on treatment forms, which the hygienists complete for each child seen. These forms are delivered to the program's data entry staff who enter the data into DOH-Broward's Health Management System (HMS). DOH-Broward utilizes Active Strategy, an analytic program that extracts data from the department's HMS to measure the achievement of program goals. Each month, all program managers meet to discuss each program's progression towards its targets, as well as opportunities for improvement. The School-Based Sealant program's metrics measure the actual to projected number of students, which has met its target for each of the previous 12 months; the percentage of students billed, which is targeted at a minimum of 50% and has been met at 58.96% for the 2017-2018 fiscal year; and the percentage of students sealed, which met its target of 65% of students throughout 91% of the year.
DOH-Broward continually monitors its School-Based Sealant program to utilize opportunities for improvement and expansion that will sustain the program so it can continue to provide preventive dental services to the underserved youth of Broward County. Its primary source of funding is through Medicaid reimbursement of the dental services rendered, but grants and donations are also considered and applied for as a supplement to primary funding. Additionally, community involvement is fundamental to continue to provide these services to existing students each school year throughout their childhood, as well as to expand the program to accommodate additional underserved children who could benefit from accessing preventative dental care that they may otherwise not receive.
Broward County consists of a very transient population, and DOH-Broward's School-Based Sealant program can provide dental services to children who have migrated from other areas. Additionally, over 22,000 births occur annually to residents of Broward County, many of which have a high probability of entering a Kindergarten class of one of Broward County's 195 public or charter elementary schools in the coming years with the potential of becoming students of DOH-Broward's School-Based Sealant program.
Due to its ability to provide outreach to a significant percentage of Broward's youth, the Broward County School Board requested in April 2018 that DOH-Broward's School-Based Sealant program expand from providing preventive dental services in 138 Title I schools to 256 elementary and middle schools, including charter schools, regardless of Title I status. This expansion allows for a larger number of children and teens to can receive dental services in a school setting, as many of the students in these schools also do not have the opportunity to receive dental services from a private dental office on a regular basis. Expanding the number of schools visited by 86% also provides the program with a greater number of students who require sealants and who are enrolled in a Medicaid dental plan, increasing the quantity of preventive dental services to be rendered over a longer period while also allowing the program to break even on its budget.
DOH-Broward's School-Based Sealant program has could reduce costs by arranging for the dental hygienists to primarily provide dental services and perform dental-related tasks, such as sterilization. In the past, they used time that could have been spent on client treatment to move and set up the portable dental equipment themselves. By employing drivers and screeners to provide important yet time-consuming clerical and physical duties at a lower hourly rate than that which the hygienists receive, expenses are reduced and the amount of time available for treatment of students has drastically increased, allowing for a larger number of children to be able to receive preventive dental services throughout the school year. The program continues to evaluate its processes, as well as its students' needs, to increase participation of the target population in future school years.
The 2018-2019 school year has only recently begun, but many avenues have been explored to supplement primary funding. For the second year in a row, United Way has granted $89,248.00 to utilize for the expansion of the program to 45 charter schools that have been classified as Title I, as well as to continue providing dental services at four alternative learning centers that educate at-risk teenagers. A Maternal and Child Health grant of $141,774 was applied to fund the provision of dental services to students who are not insured, which was increased from the $126,411.00 in funds received during the 2017-2018 school year. Funds through the School Health program are also able to be utilized as needed as per the School Health Scope of Work.
To contribute to the sustainability of the program, targets that are related to production and Medicaid billing have been established. A high provision of dental sealants to the program's students increases the amount that can be reimbursed, and so the target is to seal 65% of the students. The average rate of students sealed in October 2017 was 64.22%. Another target is that at least 50% of the students are billed through Medicaid. Approximately 63% of the students seen could be billed through their Medicaid coverage in October 2017. The year-to-date average reimbursement per billed client has a target of $74.75 and the actual average is $79.13. In the 2017-2018 fiscal year, the program broke even on its budget of $1.6 million, with $1.1 million in revenue resulting from Medicaid reimbursements. From the start of the 2018-2019 fiscal year, the program continues to break even due to the highly productive daily schedule of a minimum on 19 students a day, which offsets the salary of the clinicians performing the dental services, as well as through additional grants to supplement the funds for supplies.
To attract the attention of more children, their families, and the overall community towards the beneficial dental services provided by DOH-Broward's School-Based Sealant program and ultimately continually increase participation throughout future school years, a child-friendly brand has been created beginning in the current 2018-2019 school year. An illustrated seal mascot, named Sealy, is placed on the cover of every consent form to draw the eye to the form as soon as it gets sent home to the parents, as well as to get the children excited about the program so they ask their parents to sign them up to participate. This mascot will be placed on the vans that are utilized in delivering equipment and supplies to the schools to promote the program to families of school-aged children while on the road and parked at the front of the schools. The program also created a child-friendly name, Broward Dental SEALS, which uses the tagline Sealing & Educating All Little Smiles” to form the acronym. These promotional efforts have made a significant difference: of the schools that were visited in previous years, elementary schools have had 2018-2019 participation rates of as much as 222% of their participation in the 2017-2018 school year, with middle schools having as much as 350% participation in comparison to the previous year.
The financial benefit that this program provides to the local community is immense when compared to the cost of providing the services. From the program's inception in March 2016 through October 2018, DOH-Broward's School-Based Sealant program has saved taxpayers in Broward County approximately $47.9 million in dental fees by providing the preventive dental services of fluoride varnish applications and sealants, as well as for the prevention of restorations. Through its School-Based Sealant program, DOH-Broward places dental sealants at no cost to the students. On average, sealants cost $44.12 per tooth when applied at a dental office. A total of 185,920 teeth were sealed, and therefore protected from decay, during the approximately timeframe that schools were in session from March 2016 through October 2018. Underserved families throughout the county saved approximately $8.2 million on dental sealants. The combination of sealants and fluoride treatments prevents nearly all incidences of tooth decay. During this period, DOH-Broward also applied 89,327 fluoride varnish treatments. Fluoride varnish costs patients approximately $35 per treatment when applied at a dental office. The School-Based Sealant program saved families of low income nearly $3.1 million in fluoride applications. The average dental restoration (amalgam and resin-based composite fillings) costs $197.09 per tooth. Placing sealants on 185,920 teeth saved taxpayers in our community over $36.6 million in dental restorations through the prevention of tooth decay in the 1st and 2nd permanent molars alone, in addition to the other primary and permanent teeth that are protected by the fluoride varnish applications.