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The Mobile♥Care Health Project: Providing Dental Care in Rural Hawai'i Communities

The Mobile♥Care Health Project: Providing Dental Care in Rural Hawai'i Communities by  Kaye Lundburg, Carol R. Ignacio, Cheryl M. Ramos

Author: Kaye Lundburg, Carol R. Ignacio, Cheryl M. Ramos

Abstract:

This paper reports on the Mobile♥Care Health Project (MCHP), a project of the Office for Social Ministry (OSM) of the Roman Catholic Diocese of Honolulu (referred to subsequently as “Diocese”), which aimed to increase access to dental care for the underserved on the Island of Hawai'i. This paper describes the history of the project, challenges encountered in its development, short and long term goals set and accomplished, and the community-based dental care programs that were established as a result of the MCHP initiative.


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Introduction
Improving oral health has been established as a priority health initiative in the United States (U.S. Department of Health and Human Services, 2003). Strategies employed to achieve this goal include the fluoridation of public water systems, oral health education, evidence-based dentistry, increasing Medicaid benefits, increasing the supply of dentists who participate in Medicaid, and using innovative approaches to deliver dental care. Such approaches include the use of mobile dental units, teledentistry, and the use of non-dental health professionals to provide dental care services to underserved communities. (Cohen, 2009; Colangelo, 2009; Fricton & Chen, 2009).

The need for increased access to dental care is most prevalent for those who experience economic, geographic, cultural, transportation, or medical barriers to care and who live in areas with limited provider availability. When compared to national statistics, the oral health for residents of the State of Hawaii are among the poorest. Those living in Hawaii's rural neighbor islands report the greatest need for improved oral health and increased access to dental services. On the island of Hawai’i nearly 55% of the residents of Hawai'i Island included among the underserved (Hawaii Primary Care Association, 2001).

This paper reports on the Mobile♥Care Health Project (MCHP), a project of the Office for Social Ministry (OSM) of the Roman Catholic Diocese of Honolulu (referred to subsequently as “Diocese”), which aimed to increase access to dental care for the underserved on the Island of Hawai'i. This paper describes the history of the project, challenges encountered in its development, short and long term goals set and accomplished, and the community-based dental care programs that were established as a result of the MCHP initiative.

History
In 1994, the OSM organized and facilitated a community planning process on the Big Island of Hawai'i as a result of learning that a homeless veteran died because he was unable to get dental care for an untreated tooth infection (Okinaka, Ramos, & Ignacio, 2007). At that time the unmet medical and dental needs of the rural poor were identified as a priority concern. Several possible solutions to this problem were discussed and explored but one suggestion rallied the most support as stated by one participant; “we need one of those mobile things that brings medical and dental to where we are”. The concept of a mobile health project was conceived as a result of this community planning process. OSM took the lead in organizing this effort with the funding support of the County of Hawaii, Hawaii Island United Way (HIUW), local foundations, Maryknoll Fathers and Brothers, Sisters of St. Joseph of Carondolet, corporations, and the community. With broad community support, MCHP was underway.

In 1996 the first mobile unit, a thirty-seven foot Winnebago fully equipped medical and dental van, arrived in Hilo. The St. Francis Healthcare System joined OSM to develop the project and to provide clinical oversight. In January of 1997, MCHP began delivering services in West Hawaii from the southermost communities in the Ka'u district to the communities of North Hawaii. In 1999, a second mobile unit was acquired to deliver services to the underserved of East Hawaii communities. It became apparent that the need for access to dental care was not only a critical need on the island of Hawai’i but was also a critical need on other neighbor islands. In 1999 the Maui Oral Health Task Force asked the MCHP to bring mobile dental services to Maui. OSM responded and with the donation of a mobile dental van from HMSA and funding from the County of Maui, MCHP initiated services on the island of Maui in 2000.

Challenges
OSM persevered through many challenges to meet the dental needs of the poor. However, although abundant in faith, OSM lacked knowledge and experience in providing healthcare services and related operating issues. The County of Hawaii awarded the grant for the acquisition of a mobile healthcare unit to OSM with full knowledge and support of the Diocese. However, as OSM prepared to initiate services after two years of planning, support, and encouragement from the administrators of the Diocese, OSM was informed that the van couldn't be operated because the Diocese’s insurance didn’t have a provision for malpractice coverage. Shaken but still determined, OSM contacted Sr. Beatrice Tom OSF, CEO of St. Francis Healthcare System who immediately agreed to partner with the Diocese to provide the necessary clinical oversight.

In 1996, with the mobile van and a clinical partner in hand, OSM faced another challenge. They did not have operating funds to support the MCHP operations and thus began an island-wide van tour to the Catholic parishes on the island of Hawai'i. They attended every weekend mass to share their mission of providing healthcare for the poor and asked parishioners for their financial support. Parishioners responded generously by donating approximately $25,000 for the purchase of supplies and fuel for the van. A parishioner from St. Michael the Archangel Parish in Kona volunteered to become the van driver every weekend for three months. He did not ask for compensation. A very generous grant from the Maryknoll Fathers and Brothers and from the Sisters of St. Joseph of Carondolet provided additional initial operating funds that allowed MCHP to begin providing clinical care to people in need in January 1997 for three days a week.

The need for dental services was voiced strongly by consumers during the planning process of the MCHP but OSM was unprepared for the overwhelming response from those in need. People with acute dental needs began gathering on clinic days and waited patiently to be seen, sometimes waiting for several hours. Many drove 100 miles and farther from their homes on the East side of Hawai'i island to be seen by the dentist providing services on the West side of the island. It was clear that the level of service provided by the small mobile project was far less than the needs of the communities it served. More dentists and more funding were needed to expand services to five days a week. A proposal was submitted and approval was secured from the Federal Bureau of Primary Care to have Hawaii Island designated as a Dental Health Professions Shortage Area (D-HPSA). This was the first D-HPSA designation for a neighbor island county in Hawaii. Maui and Kauai counties have since received D-HPSA designations as well.

OSM met with the State Department of Health Dental Division Chief seeking his support by providing the project with a state dentist and operating funds. He ridiculed the project, saying it was impractical and suggested that the need for dental services on the island of Hawai'i was overstated. It was suggested that OSM go to the Hawaii State Legislature to ask that the State Dental Division be funded to re-open a state dental clinic on the island of Hawai'i. OSM responded by gathering other island advocates and convened a legislative forum in January 1998 to inform legislators of the serious unmet need for dental care on the neighbor islands. At that meeting the Chief of the Dental Division stated that his budget provided direct dental services only on the island of Oahu. The informal “tri-county Oral Health Task Force” then asked the Hawaii Primary Care Association (HPCA) to convene the first strategic Oral Health planning process in 1999.

Partnerships
The HPCA meeting brought together individuals and organizations who committed their resources and became partners in the mission to deliver dental services to the underserved in Hawaii neighbor island communities. St. Francis Healthcare System encouraged staff dentists to travel to the Big Island of Hawai'i to provide dental care. Media attention resulted in increased funding from the private sector for the MCHP, with the HMSA Foundation as the project's flagship supporter. In 1999 the County of Hawaii awarded the MCHP funds to purchase a second mobile van to expand services to communities in East Hawaii. The HDS Foundation, HIUW, and Hawaii Community Foundation (HCF) responded with funds to support this expansion.

The MCHP partnerships included:

  • The mission driven staff and the dentists from Hawaii, Maui and Oahu, that traveled many miles and worked long days to bring dental care to those who had nowhere else to go.
  • The foundations, corporations and community organizations that steadfastly supported this work by providing the operating funding and support.
  • The religious communities and organizations that saw MCHP as an opportunity to extend the mission of Christ in serving the poor.
  • Administrators and legislators in state and county government who supported initiatives for funding and legislation for justice.
  • Parishes and private donors who responded with their financial support.
  • Recipients of MCHP dental services who kept the project grounded in its mission through the sharing of their stories, gratitude, and words of encouragement.

Goals and Accomplishments
For the past twelve years (January 1997 – 2009) the MCHP has been a safety net provider of dental services for the low-income uninsured Medicaid/QUEST2 population on the island of Hawai'i, and on the island of Maui from 2000-2003. Those served include children, the physically disabled, the mentally ill, the impoverished elderly, the recent immigrant, the working poor, the homeless, and the unemployed. Project goals were clearly stated at project start-up and much has been accomplished.

Immediate/Short-Term Goal: Provide direct services
MCHP provided services for over 18,500 patients, at a value of $1.6 million in uncompensated dental care, at clinic sites in Pahala, Oceanview, Honaunau, Kailua, Kawaihae, Kapa'au, Waimea, Hilo and Pahoa on the Big Island, and in Wailuku, Kahului, Hana, Kihei, Lahaina, Pai'a and Keanae on Maui. Until 2003, the MCHP was the only safety net provider of dental care for the underserved on these islands.

Long Term Goal: Systemic Change
In 1997, it was clear that MCHP was an interim response to the immediate acute and urgent dental care needs in Hawai’i. However, what was also needed was a long-term solution to the systemic problems that resulted from years of inadequate funding and the low priority of dental health care in the State of Hawai'i, especially in neighbor island communities. The MCHP and its community partners raised awareness of the needs of the poor for access to oral healthcare with an emphasis on the needs of the neighbor islands. Table 1 outlines the systems-level progress made from 1997 to 2009.

The MCHP supported the development and expansion of dental capacity in Federally Qualified Health Centers (FQHC) and Community Health Clinics (CHC) as a long-term solution to increase access to dental care for the underserved population. The grass roots efforts of community oral health task forces have begun to produce results. Community Health Clinics on Kauai, Molokai, and in Kea'au on the Island of Hawaii are currently providing dental services. The Maui Oral Health Clinic of the Maui Community College (MCC) School of Nursing serves vulnerable populations in a stationary dental clinic and a mobile dental clinic using the van initially donated to OSM by HMSA in the year 2000 (and later transferred to MCC in 2003). These clinics for the underserved are the first on the neighbor islands. Other clinics are currently in operation at Hamakua Health Clinic and West Hawaii Community Health Clinic on the island of Hawaii, and at the Community Clinic of Maui. These clinics are community based, and are situated in identified areas of poverty. Hamakua Health Center received County funding for a new mobile dental van to develop a dental clinic at their sites in Honokaa and Kapa'au. The West Hawaii Community Health Clinic opened a pediatric stationary dental clinic for South Kona in March 2009. The ownership and operation of the two MCHP dental vans was transferred to the two clinics in to support and enable their plan of continued dental expansion in their areas of need. They continue to carry out the MCHP mission of providing access to dental care for the underserved. They collaborate and partner with private and state providers of care to address the total healthcare needs of their patients. It is a mandate from the Bureau of Primary Care that they include dental care in their menu of services and there are federal expansion funds to support this development.

Conclusion
In the beginning the MCHP was envisioned as a five year project. Twelve years have passed and finally the permanent community-based health care facilities, as well as mobile dental units, are delivering much needed dental services in Hawaii communities. When the MCHP began providing medical and dental care for the underserved people of the Big Island of Hawai'i in 1997, one question was frequently asked, that being “Why is the social ministry department of the Catholic Church, the Office for Social Ministry, with no experience in healthcare, involved in this project?” This question led the staff of OSM and the MCHP to reflect on their Catholic faith and the work of Father Damien, one of the greatest servants of the poor in their faith tradition. They wondered if he was ever asked, “Why would a foreigner with no healthcare experience choose to dedicate his life to the people with Hansen’s Disease in Hawaii?” The answer to both questions, they imagined, was the same. It was a matter of putting faith into action, and the belief that all people have dignity and value,and by virtue of this fact deserve basic necessities of food, shelter, and healthcare.

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Table 1. Systems-level Progress.
Year - 1997 There was no unified voice for Oral Health Access on the neighbor islands.

Year - 2009 Today, the neighbor island counties of Hawaii, Maui/Molokai, and Kauai each have an active Oral Health Task Force and an Oral Health Strategic Plan. This tri-county group has been meeting since 1998 to share oral health initiatives on their respective islands, to examine barriers to service and to collaborate on strategies to improve access to care. Policies have been changed and legislation has been passed because of this unified voice. Mobile Care has been a catalyst in the development of this voice.

Year - 1997 There were no (0) CHC Dental Clinics on the neighbor islands of Hawaii, Maui, Kauai, Molokai and Lanai.

Year - 2009 Today CHC Dental clinics on Kauai (2), Molokai (1), Maui, (1) and Hawaii (3) are open.

Year - 1997 There was a critical shortage of dentists serving the low-income population on the neighbor islands.

Year - 2009 Today there are partnerships with a dental residency program and with the US military that place dentists in CHC dental clinics on the neighbor islands.

Year - 1997 Hawaii Dental Licensing was a major barrier in encouraging mainland dentists to volunteer or contract to serve the low-income population in Hawaii in community clinics.

Year - 2009 For 3 years, the Tri-County Oral Health Task Force and the Primary Care Association educated legislators on the need for dental license reform. In 2004 the legislature passed a Community Service Dental License that allows dentists licensed in mainland states to practice in Hawaii in CHCs. Today there are CSL dentists serving in Community Health Dental Clinics and their affiliates on Kauai, Maui, Hawaii, Molokai and Oahu.

Year - 1997 Dental Services for Adult recipients of Quest/Medicaid were limited to Emergency Services.

Year - 2009 The restoration of Adult Dental Benefits for Quest recipients has been a Tri-County Oral Health Task Force and the Primary Care Association goal since 1999. In December 2006 MedQuest expanded the Dental Benefits for Adults to include limited Prevention, Restoration and Dentures.

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Each clinic day, individuals served by the MCHP came in pain and frustration, often presenting symptoms of dental infection and abscess attributed to years of no access to dental care. Each would say “We have no place else to go” , the very same words that were likely voiced by those who faced Hansen’s disease and to who Father Damien brought hope. In the year of Father Damien’s canonization, we reflect on the work of the MCHP and are reminded that what began in faith and in response to a voice saying “we need one of those‘mobile things’ that brings medical and dental to where we are” has resulted in a tidal wave of change in how dental care services are delivered in neighbor island communities of the State of Hawai'i. It is in the spirit of Blessed Damien and Mother Marianne Cope, that the MCHP was conceived and from which great change has come.

References
American Dental Association (2009). Proceedings of the March 23-25, 2009 Access to Dental Care Summit, Council on Access, Prevention and Interprofessional Relations. Retrieved August 8, 2009.

Cohen, L.A. (2009). The role of non-dental health professionals in providing access to dental care for low-income and minority patients. Dental Clinics of North America, 53, 451-468.

Colangelo, G.A. (2009). Innovations to improve oral health care access. Dental Clinics of North America, 53, 591-608.

Fricton, J. & Chen, H. (2009). Using teledentistry to improve access to dental care for the underserved. Dental Clinics of North America, 53, 537-548.

Hawaii Primary Care Association. Oral Health 2001: A strategic plan for oral health in Hawai'i. Retrieved August 4, 2009
http://www.hawaiipca.net/programs/oralhealth/statusoralhealth.

Okinaka, A., Ramos, C.M., & Ignacio, C. (2007). Human Services, In G. Aguiar (Ed) Government in the Countryside: Politics and Policies in Rural America. Dubuque, IA: Kendall/Hunt, 219-231.

U.S. Department of Health and Human Services. (2003). National Call to Action to Promote Oral Health. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental and Craniofacial Research. NIH Publication No. 03-5303, Spring 2003. Retrieved August 8, 2009 http://www.surgeongeneral.gov/topics/oralhealth/nationalcalltoaction.html.


Author

Kaye Lundburg, Carol R. Ignacio, Cheryl M. Ramos Kaye Lundburg, Carol R. Ignacio, Cheryl M. Ramos

Kaye Lundburg, Program Director, Mobile♥Care Health Project, Diocese of Honolulu, Roman Catholic Church of Hawai'i

Carol R. Ignacio, Executive Director, Office for Social Ministry, Diocese of Honolulu, Roman Catholic Church of Hawai’i

Cheryl M. Ramos, Ph.D., Associate Professor, Department of Psychology, University of Hawaii Hilo


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Catherine Hawkins (Kailua Kona) February 04, 2011

Wow! what a beautifully written article! Thank you for sharing it and also thanks for the updates! Congrats to Cheryl on her PH.D. as well (I am sure you have had it for a number of years but I have been out of the loop) Great work by great women! Aloha, Cathie, Jim and Mingxia Hawkins
Nancy Graber Canubida, Psy.D. (Oahu) January 27, 2011

What an inspiring article!I have watched this
miraculous project unfold over the years and continue to be amazed by the perseverance and resourcefulness of all those involved. It has been undergirded by prayer since its inception.
It is wonderful to see it documented so well, and hopefully it can be used as a model for other communities, not only in the United States but throughout the world.

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Keywords: gjcpp, community practice, community psychology, community health, dental care, rural development