Follow up of Access to Public Dental Services in Victoria

Tabled: 28 November 2019

3 Access to care during the transition

While work progresses on the development of new funding models and MoCs for public dental services, it is important that eligible patients can continue to access services and receive the treatment they require.

Our 2016 audit identified some issues with eligible patients not accessing public dental services.

One concerned the way in which CDAs managed their waiting lists. This included placing patients on a waiting list at the time of service entry, with no assessment of their oral health need or risk of deterioration while waiting for care.

We also found that DHSV's collaborative initiatives with CDAs did not effectively address access barriers. Further, we found that CDAs had limited ability to provide a broad continuum of care, including oral health promotion activities.

In this Part, we look at these three aspects of service delivery.

3.1 Conclusion

DHHS and DHSV identified a number of improvements to waiting list management in response to recommendation 3. However, when DHSV piloted improvements made at Bendigo Health (Figure 3A) in other CDAs it found that further work is needed before implementation in all CDAs. DHHS and DHSV also developed a draft action plan to prevent oral disease, which includes developing oral health promotion packages and screening and prevention programs, and workforce regulatory changes. As a result of some of these actions, waiting time for treatment has improved for patients in some CDAs. However, CDAs remain limited in their ability to provide patients with preventative care while the treatment-focused funding model remains in place.

3.2 Delivering services

Our 2016 audit made three recommendations concerning aspects of CDA operations impacting on the delivery of public dental services. These were:

  • improving waiting list management, such as through assessment of patient oral health need and risk
  • enhancing regional collaboration to address access barriers
  • increasing the provision of oral health promotion activities.

Waiting list management

Recommendation 3

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That the Department of Health and Human Services and Dental Health Services Victoria work with community dental agencies to review and improve the current approach to managing waiting lists, including prioritising need and assessing the risk of people placed on the waiting list.

Review of eligibility and priority access criteria

In response to this recommendation, DHHS, in consultation with DHSV, reviewed the eligibility and priority access criteria for the public dental program. This review recommended a number of changes to the criteria for eligibility and priority access for dental treatment at all CDAs including for all Aboriginal and Torres Strait Islander people (regardless of concession card status) and people experiencing family violence. These recommendations reflect current practice at the RDHM, but not in CDAs. DHHS advises that these policy changes are currently being considered.

Waiting list management policy

DHSV identified issues concerning the operation of waiting lists for public dental services, including that:

  • the current waiting list policy and model is outdated
  • the clinical need of patients is unknown at the time of entry to service
  • no preventive interventions are provided to clients either at the time of placement on a waiting list or while waiting.

DHSV developed recommendations aimed at improving waiting list management. These recommendations align with DHSV's VBHC framework, and include:

  • revising waiting list principles (for example, including an oral health assessment and measuring health outcomes)
  • changing the waiting list policy (for example, basing it on patient outcomes)
  • incorporating preventive interventions at the time of placement on a waiting list and while waiting for care
  • improving tools (for example, developing a health assessment tool to prioritise care based on risk determination)
  • increasing use of a skilled workforce, with staff working to the full scope of their practice.
Review of best-practice models

In 2017, DHSV undertook two desktop reviews aimed at identifying examples of best-practice waiting list models. One of these included a review of waiting list approaches used in other jurisdictions. This identified a number of features aligned with VBHC principles, such as assessing a patient's oral health prior to placing them on a waiting list.

The other review looked at successful strategies already used by CDAs that targeted patients at the tail end of their waiting lists. This identified one CDA, Bendigo Health, that operates an 'introductory session' for general dental care patients that is also aligned to VBHC principles, as described in Figure 3A. DHSV have incorporated the introductory session into its new general dental care MoC.

Figure 3A
Case study: Bendigo Health's introductory session for general care patients

A review by Bendigo Health CDA of its general care waiting list indicated that a proportion of patients on the waiting list were not engaged or not ready to engage with the service. It saw education of these patients as important. This provided the impetus for developing an introductory session for all general care patients prior to beginning treatment.

The Bendigo Health model, first implemented in early 2016, consists of an introductory session for all general care patients before treatment begins. Around 20 to 30 people at a time who were at the top of the general care waiting list received a letter inviting them to a group-based introductory session, which ran for around 20 minutes. Patients are provided with information about the service, their rights and responsibilities, care pathways and oral health and hygiene education, such as on teeth brushing and diet.

Following the information session, clients make an informed decision about whether to choose the 'general' or 'emergency only' care pathway. Clients who choose the 'general' care pathway receive the next available dental appointment. Clients who choose the 'emergency only' care pathway receive clinic details for when they have urgent dental needs.

Key successes of the model include:

  • a significant decrease in the longest waiting time from 40 months at the end of 2014–15 to 14 months at the end of 2016–17
  • greater levels of consumer partnership, client focus and shared decision-making
  • improved consumer service and oral health literacy.

The delivery of introductory sessions has changed as a result of regular review and consumer and staff feedback.

The model has continued to be sustainable, with an average general waiting time of 10 months at the end of December 2017, and a further decrease to five months by the end of June 2019.

Source: VAGO.

DHSV worked with Bendigo Health to broaden the implementation of its model to other CDAs. Initially, this involved promoting the model to other CDAs through presentations at annual regional forums in 2017 and 2018.

DHSV advised that it is aware of a number of CDAs that have now incorporated an introductory session into their existing services.

During our visit to one CDA, we observed an introductory session. This CDA reviewed the 17 introductory sessions it delivered between November 2018 and July 2019. Of the 414 patients at the top of the waiting list who received invitations to an introductory session, 55 per cent took up the offer. Nearly all (98 per cent) of these patients opted to start a general course of care, reflecting a commitment to improve their oral health.

Patients' self-reported service literacy and oral health literacy also consistently improved, from 'basic knowledge' before the session to 'confident' after the session. Additional verbal feedback from participating patients includes reports of being more informed and educated about their healthcare options and having a better understanding of good oral hygiene habits (such as correct brushing and flossing techniques).

DHSV waiting list initiative

In February 2018, DHSV began work on a project to further develop and implement the Bendigo Health model with CDAs who have long waiting lists. It plans to eventually rollout this model statewide, making it standard operational practice for all CDAs.

In May 2018, the state government announced an additional $12.1 million in funding in part to help reduce dental waiting lists across the state. Of this, it allocated $5 million to target people on the tail end of CDA general care waiting lists, using the Bendigo Health model. DHSV state that they reviewed waiting lists to identify patients waiting longer than 23 months, which was the SoP target for 30 June 2018. On this basis, DHSV offered 25 CDAs funding to take part in this initiative. CDAs had to implement the Bendigo Health model by the end of September 2018, with all offers of care made by the end of December 2018.

A review of the DHSV initiative shows considerable variability across the 25 CDAs. Some of this is due to differences in the size of CDAs. Variances included the:

  • number of patients on the waiting list at start of the initiative (from 883 to 13 307)
  • number of patients removed from the waiting list (28 to 4 479)
  • reduction in longest waiting time (two to 41 months)
  • percentage of patients who took up offer of care (12 to 54 per cent)
  • number of patients treated (nine to 1 947).

This initiative enabled CDAs to offer care to a total of 28 146 patients. This represents 26 per cent of the patients who were on the general waiting list of the 25 participating CDAs at the start of the initiative. However, only 10 484 (38 per cent) of these patients took up the offer and received treatment. DHSV acknowledges that this result is lower than expected given the demonstrated success of the Bendigo Health model.

DHSV advised that this could be because the initiative targeted patients who had been waiting the longest. As such, these patients may no longer be contactable, or may have already received some form of care during their wait. DHSV's agency relationships team is working with CDAs to implement the introductory session model, as it considers it to be capable of achieving sustainable waiting list management. To achieve this, DHSV needs to identify and address the barriers that limited the success of the pilot of Bendigo Health's introductory session model.

Assessment of patient oral health need and risk

A key component of the new MoC based on VBHC principles is a risk and need assessment of all new patients, the results of which inform a patient's care pathway. DHSV initially developed a rapid assessment tool to enable this assessment. Testing of this tool as part of the general dental care proof of concept at RDHM identified the need for modifications. This subsequently resulted in the development of the Oral Health Questionnaire (OHQ) in early 2019. The OHQ captures the medical, dental and social history of the patient as well as a set of patient‑reported outcome measures that cover aspects of their oral hygiene and habits. As discussed in Section 4.2, the OHQ has progressed through DHSV's collaboration with the International Consortium for Health Outcomes Measurement (ICHOM) working group. Once the standard set of measures are public, the measures will undergo validation testing. When this is complete and the OHQ is available to CDAs, DHSV can determine the extent to which the OHQ helps improve their waiting list management.

Regional collaboration between CDAs

Recommendation 4

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That the Department of Health and Human Services and Dental Health Services Victoria work with community dental agencies to identify where collaboration between regional public dental services could address barriers to access and pilot related projects to test their effectiveness in improving oral health and in identifying resourcing requirements.

DHSV advised us that it established and continues to promote mechanisms to communicate innovative initiatives and practices by CDAs. These include its annual regional and metropolitan CDA forums, and the Public Oral Health Innovations Conference.

In March 2019, DHSV prepared a high-level summary of examples of collaborative initiatives by CDAs aimed at addressing access barriers. Many of these included presentations at annual regional forums between 2016 and 2019. Examples include:

  • West Wimmera Health Service extending its service reach beyond the catchment region to support local communities, including sharing a mobile dental clinic with Wimmera Health Care Group
  • Link Health and Community providing oral health services for residential aged-care residents within their facilities, as part of the Graceful Smiles project
  • Sunbury Community Health Service working with Hepburn Health Service to undertake fluoride varnish applications at kindergartens in partly and non‑fluoridated areas participating in the Smiles 4 Miles program within the Macedon electorate.

DHSV has not actively worked with CDAs to identify potential collaboration opportunities. It also does not regularly review collaborative activities to identify and disseminate key learnings and using these to identify suitable collaborative models for piloting or scaling up.

During our visits to CDAs, we identified examples of collaborations that address access barriers and saw how greater DHSV engagement would be valuable for CDAs. One CDA has worked with a community health service, the regional city council and a multicultural council to meet demand for oral healthcare among its refugee community—a priority access group. This collaboration resulted in the co-design of a culturally appropriate and safe refugee clinic, including on-site interpreters. This model is now an integral part of the CDA's service provision.

Another CDA we visited had collaborated with two smaller CDAs in the region to address access barriers due to their relatively isolated communities, and limited access to local dental services and public transport:

  • From October 2017 to June 2018, it provided a CDA with an oral health screening (by a dentist and dental assistant) and a prosthetist visiting the service on alternative weeks. The screening service focused on a limited exam, with strong emphasis on oral health instruction and preventive education. The prosthetist serviced targeted people who had partial dentures.
  • From March to December 2018, it assisted another CDA with an extended waiting list by providing direct clinical care, which involved sending two oral health therapists twice a week.
Geographical barriers to service access

DHSV itself has developed initiatives and worked collaboratively with organisations to address barriers to service access in regional Victoria. Two key examples include the Royal Flying Doctor Service and teledentistry.

The Flying Doctor Dental Clinic

In 2016, DHSV signed a collaborative partnership agreement with the Royal Flying Doctor Service Victoria and the Australian Dental Association Victorian Branch to establish the Mobile Dental Care Program (known as the Flying Doctor Dental Clinic). The program aims to provide a sustainable mobile model of oral health education, screening and treatment for people living in rural communities with limited access to public oral health services.

Key findings from stakeholder feedback as part of an evaluation of the program during 2017–18 included that the:

  • main strengths of the program were the travel time saved by patients through being able to access a local dental service, the high quality of the service, and the competency of program staff
  • ability to access the program had increased patients' understanding of how to manage their own oral health and improved their health and wellbeing.
Teledentistry

In January 2015, DHHS allocated $369 000 to DHSV for a telehealth program to allow patients to receive specialist advice and advanced care through a clinical alliance between dentists at CDAs and the RDHM. The program focuses on removing barriers to service access for individuals in remote or at‑risk communities and improving health outcomes.

The results of an initial pilot of the program during 2015–16 at four CDAs were positive. Identified program benefits included creation of a patient-centred MoC, and an ability to treat patients near their home and provide more integrated care. These results have informed the progressive rollout of the program across the state. As at 2017–18, 36 CDAs had participated in this program, most of which are located in rural areas.

Oral health promotion

Recommendation 5

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That the Department of Health and Human Services and Dental Health Services Victoria work with community dental agencies to identify how community dental agencies can take greater responsibility for promoting oral health, supported by adequate funding.

Draft action plan to prevent oral disease

DHHS and DHSV collaborated to develop a draft action plan to prevent oral disease (the draft action plan). The draft action plan has four objectives, including that Victorians:

  • benefit from settings and environments that support good oral health
  • have knowledge, skills and resources to improve their oral health
  • have access to oral health promotion programs, screening, early detection and preventive services
  • have improved oral health through policies and practices based on enhanced data and research.

In developing the draft action plan, DHHS and DHSV conducted extensive consultations during 2017–18 through public regional forums, round table discussions and online submissions. They received feedback from over 500 people and key stakeholders, including consumers, oral health staff from CDAs, and representatives from the health, early childhood, education, social services and local government sectors.

The Victorian Oral Health Promotion Advisory Group (formerly the DHSV Population Health Committee) is responsible for oversight and implementation of the draft action plan, as well as development of a four-year work plan.

Our 2016 audit identified a number of barriers to CDAs taking on more responsibility for oral health promotion. Examples include a workforce that is not equipped to deliver oral health promotion activities, and a lack of coordination between oral health and general health services. The draft action plan addresses some of these barriers:

  • Improving oral health literacy will involve initiatives such as the creation of a new workforce of dental assistants with Certificate IV qualifications to assist consumers to manage their own oral health.
  • Oral health promotion programs such as screening, early detection and preventive services will enhance the skills of health, early childhood and social service workers and strengthen referral pathways to oral health professionals.
  • Creating settings and environments will support good oral health and involve partnering with organisations working with at-risk groups, such as aged-care facilities, diabetes educators and maternity services.
Oral health promotion activities by CDAs

All three CDAs that we visited engaged in oral health promotion activities, including established programs such as Smiles 4 Miles. This program, based in early childhood settings, focuses on promoting good oral health habits and healthy eating, as well as increasing access to dental services. CDAs provide a range of other oral health promotion, education and screening services to organisations and groups in different settings. Many of these are undertaken on an outreach basis. Examples include:

  • working with other health professionals/services (such as dieticians, hospital emergency departments, mental health recovery hubs)
  • operating a stall at local supermarkets
  • working with a special-needs dentist at a school for students with intellectual disabilities
  • Aboriginal cooperatives
  • humanitarian settlement programs
  • young mothers' groups
  • agricultural field days/sheep and wool days
  • aged-care facilities
  • housing crisis services
  • local council immunisation sessions and maternal and child health staff.
Oral health workforce regulatory changes

Under the Drugs, Poisons and Controlled Substances Regulations 2017, fluoride varnish is a schedule 4 poison, which can only be applied by registered dental practitioners (dentists, dental therapists, dental hygienists and oral health therapists). DHSV contributed to amending these regulations, and the Drugs, Poisons and Controlled Substances Amendment (Dental Assistant) Regulations 2018 now allows dental assistants to administer fluoride varnish as registered oral health professionals.

Monitoring the impact of this regulatory change will help DHSV understand the extent to which it helps CDAs take greater responsibility for promoting oral health.

Development of oral health prevention tools
Fluoride varnish programs

DHSV worked with a number of CDAs during 2017–19 to pilot fluoride varnish preventive programs and provide oral health screening among preschool and school-aged children. These include:

  • Latrobe Community Health Service
  • Sunbury Community Health and Hepburn Health Service
  • Bendigo and District Aboriginal Co-operative.

The results of completed pilots show good participation by children in screening and fluoride varnish application, and the ability to engage with families to promote important oral health messages. However, these pilots are too short to demonstrate improved oral health outcomes. The workforce regulatory changes discussed below should facilitate improvements to the sustainability of fluoride varnish application.

Oral health prevention packages

DHSV developed content for a number of oral health prevention packages in partnership with other organisations, including:

  • a website ('Supporting Every Smile') that provides information for support workers and service users to promote good oral health in disability services
  • a smoking cessation program ('Smokefree Smiles') that helps oral health professionals provide brief interventions about smoking with patients and facilitates referrals to Quit Victoria's Quitline
  • an online aged-care oral health package to support managing the oral health of older people and aged-care residents.

Monitoring the uptake and effectiveness of these prevention packages will help DHSV understand the extent to which they improve the oral health of the target groups.

Oral cancer screening and prevention program

Funded by DHHS under the Victorian Cancer Plan 2016–20, the oral cancer screening and prevention program aims to help reduce the impact of oral cancer on Victorians. DHSV leads the program in partnership with DHHS, Melbourne Dental School, the Australian Dental Association Victorian Branch and La Trobe University Department of Dentistry.

Piloting of the program, including training for oral health professionals to detect early signs of oral cancer, is happening in 15 sites across Victoria. This will inform the planned rollout of the program to all Victorian oral health professionals.

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