1 Prevent More to Treat Less Next StepsCDHNS Presentation June 3, 2017

2 College of Dental Hygienists of Nova Scotia (CDHNS)

3 AGENDA Introduction Background Data/Needs Assessment highlightsQuestions and Wrap up

4 CDHNS Council Policy EndsIn the best interest of the public, members are regulated, provide excellent care and advance the profession The public is assured of high quality DH care Public recognizes DH value and more people, especially under-serviced populations, have access to DH care and information DH is recognized as primary health care providers by government, etc. Members seek collaboration with other health professionals

5 White Paper: Dental Hygienists Prevent More to Treat LessPromoting health and preventing disease by integrating dental hygienists, at their full scope of practice, into NS’s primary health care system. 13 Recommendations Released October 2014 Presentation to DHW Jan/15

6 Next Steps Project Goal: To explore the potential for taking action on the 13 recommendations White Paper: Lit Review and Jurisdictional Scan Summer 2016:Look for oral health data on NS No surveillance data Used secondary sources with an oral health lens Gather data in one document to support CDHNS decision making and communication

7 Next Steps Project Strategic PlanStrategic Goals : High quality dental hygiene care Increased understanding and awareness of dental hygiene and oral health issues Effective partnerships and integration of oral health More equitable access to oral health care

8 #1 reason children go to OR in CanadaWe can do better

9 Dental Expenditures Most payments for dental care come from private sources (out of pocket, employer-sponsored, private insurance (55%)) Only 6% of all dental expenditure are publicly funded (CHMS) In 2009, it was estimated that Canadians would spend 12.8 billion on dental care (CIHI) Utilization is opposite to expected needs

10 Needs Assessment A process that seeks to identify:the extent and types of existing and potential problems in a community the current system of services available the extent of unmet needs, underutilized resources or shortcomings of the service delivery system

11 Purpose of this Needs AssessmentSupport decision making, priority setting Learn more about the population Identify community wants, needs and assets Support CDHNS strategy development and implementation. Support funding proposal applications To be a stakeholder for public policy

12 Oral Health Needs AssessmentAssoc. of State and Territorial Dental Directors Categories of data: Demographic Oral Health Status Risk Reduction Systems Development/Access

13 1. Demographics Population, Income, Family Composition, Employment, School enrollment, EHV Program 0-4 Population (#, location and % change) Socio-economic status (MDI) # and % of children covered types of insurance

14 NS Demographics DATA SUMMARYVARIABLE NUMBER % DATA SOURCE Population total 921,727 2011 Census > 5 years old 43,985 4.8% 5 to 14 years old 94,235 10.2% 15 to 19 57,440 6.2% 20 to 64 572,705 62.1% 65 to 85 and over 153,370 16.6% (highest in Canada) Canadian average is 14.8% Females 15 to 44 (child- bearing age) 173,115 Family Composition # of Families 270,065 Total lone-parent families 46,730 17.3% Total female led lone-parent families 37,625 13.9% Total children in families 248,885

15 Income Total people in low income, After-tax Low income cut off (LICO)* 64,000 7.0% Statistics Canada 2011, CANSIM Table (via DCS) > 18 13,000 8.0% Statistics Canada 2011, CANSIM Table 18-64 47,000 65+ 4,000 1.9% Employment Status Unemployment rate (Jan-Dec 2015) 8.6% Statistics Canada, Labour Force Survey, CANSIM Seasonally Adjusted School Enrollment Public school students (P-12) 118,152 NS Dept of Education and Early Childhood Development Public Health Programs Births (2015) 7844 DHW Enhanced Home Visiting Program (qualified and accepted program) 2015 368 4.7% of total births in the EHVP

16 78 increasing 29 no change 197 decreasing

17 Community % increase from 2001 to 2011 number 1 Greater Gabarus 166.78 2 Bear River First Nation (Bear River (6)) 100.0 10 3 Grand Mira South 4 Melrose 90.0 19 5 Coxheath 57.5 126 6 Englishtown 55.0 31 7 Wagmatcook First Nation (Wagmatcook (1)) 53.3 69 Big Ridge-French Road 50.0 9 Amiraults Hill 48.1 40 Mahoneys Beach 40.0 56 11 Hemford 21 12 Mount Uniacke 33.3 204 13 Membertou First Nation (Membertou (28B)) 31.9 95 14 Annapolis Valley First Nation (Cambridge (32)) 30.8 17 15 Clayton Park* 30.6 1643 16 Broad Cove 27.8 23 Beaver Bank* 25.4 504 18 Millbrook First Nation (Millbrook (27)) 23.4 79 Pictou Landing 22.0 50 20 Paqtnkek First Nation (Pomquet & Afton (23)) Fairview* 21.2 782 22 Eskasoni First Nation (Eskasoni (3))* 400 Armdale-Northwest Arm* 21.1 448 24 Welshtown 25 New Annan 20.8 29 26 Alton 20.2 101 27 Carleton 19.2 62 28 Tantallon* 18.6 649 Lake George 18.5 32 30 Dartmouth South* 18.4 1204

18 Communities that have increasing 0-4 populations and have 400+ children Community % change Number Clayton Park 30.6 1643 Beaver Bank 25.4 504 Fairview 21.2 782 Eskasoni First Nation (3) 400 Armdale-Northwest Arm 21.1 448 Tantallon 18.6 649 Dartmouth South 18.4 1204

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20 *= 1 or more dentist Central Zone Millbrook First Nation (pop. 184)Preston (pop. 2269) Smith's Corner (West Hants) (pop. 1024) Upper Musquodoboit (pop. 1071) Moser River (pop. 794) Total pop Central Zone= 412, 068 Northern Zone 29. Millbrook First Nation (pop. 841) 30.Indian Brook First Nation (pop. 1099) 31.Debert (pop. 1524) 32.Parrsboro (pop. 2189) 33.River Hebert (pop. 1296) 34.Pictou Landing First Nation (pop. 324) Total pop. Northern Zone = 150, 597 Eastern Zone Eskasoni First Nation (pop. 3314) Mira Gut-Lorraine and area (pop. 1111) Louisbourg (pop. 1023) Membertou First Nations (pop. 910) Grand Mira North (pop. 422) Dominion (pop. 1953) Sydney Mines* (pop. 6358) Florence-Bras D'Or (pop. 2633) Boularderie Island (Victoria) (pop. 807) New Waterford* (pop. 6126) Paqtnkek First Nation (pop. 375) Guysborough* (pop. 1764) Canso* (pop. 1326) Larry's River (pop. 1072) Sherbrook (pop. 1395 Cross Roads Country Harbour (pop. 947) Chapel Island First Nation (pop 485) Waycobah First Nation (Whycocomagh (2)) (pop. 795) Englishtown (pop. 788) Wagmatcook First Nation (Wagmatcook (1))(pop. 512) Margaree (pop. 1866) Dingwall (pop. 1566) Ingonish (pop. 1167) Total pop. Eastern Zone = 163, 217 Western Zone Lake George (pop. 1036) Annapolis Valley First Nation (pop. 222) Cornwallis Park (pop. 1877) Annapolis Royal* (pop. 1607) Port Royal (pop. 806) Milford (pop. 664) Broad Cove (pop. 499) Port Mouton (pop 1153) Medway (pop. 946) Yarmouth* (pop. 7918) Arcadia (pop.1841) Wedgeport (pop. 1748) Carleton (pop. 1297) Quinan (pop. 760) Barrington* (pop. 3741) Cape Sable Island (pop. 3142) Weymouth (pop. 1773) Saulnierville* (pop. 1318) St. Joseph (pop. 1197) Digby* (pop. 3952) Digby Neck (pop. 1628) Barton (pop. 1405) Smith's Cove (pop. 473) Total pop. Western Zone = 194, 501 *= 1 or more dentist

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22 # and % of "most deprivation" communities by Health ZoneTotal Zone Population # of "most deprivation" communities Total population of "most deprivation" communities % of Zone population residing in "most deprivation" communities Central 412, 068 5 5,342 1.3% Eastern 163, 217 23 38,715 23.7% Northern 150, 597 6 7,273 4.8% Western 194, 501 41,003 21.1% Total 920, 383 57 92,417 10%

23 MDI and Access to Care Only 9 of 57 “most deprivation” communities on the MDI have a dentist in their community All First Nation Communities (where data is available) are in “most deprivation” category. Least Deprivation Most Deprivation Population 38% 10% Dentists 46% 5% Dental Offices 40% 7%

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25 Fiscal Year Number of Insured Services Billed Amount Insured Eligible Persons Insured Beneficiaries Accessing the COHP % Insured Persons Accessing the COHP Number of Insured Services per Beneficiary Cost per Beneficiary 2013 /14 215,470 $5,262,008 124,751 52,606 42% 4.1 $100.03

26 2. Oral Health Status Oral Health Survey dataDay Surgery for ECC by DHA IWK utilization IWK outpatients by age and location Self reported barriers to care

27 Data Source Sampling Method Year Age/grade Number of people Caries Categories chosen Caries Experience Un-treated decay Mean DMFT or deft Caries Free Cape Breton DHA: Public Health All students in Public School in CBDHA (by consent) 2014 Grade 6 711 57% 26% 43% 2013 Primary 956 55% 34% 3.1 45% Dept. of Health, Grade 2 Survey (Results by DHA are in Table 2.3) multi-stage stratified random sample 2006 Grade 2 1247 57.3% 25% 2.85 (Range 2.32 to 4.11) 42.7% NS Oral Health Survey Stratified random sample 1996 Grade 1 1343 69.4% 2.5 30.6% 1204 75.6% 1.9 24.4% Grade 9 1142 90.0% 3.3 10.0%

28 TOHAP (The oral health of our aging population survey) Data Source Sampling Method Year Age/grade Number of people Caries Categories chosen Caries Experience Un-treated decay Mean DMFT or deft Caries Free TOHAP (The oral health of our aging population survey) Random sample/Convenience with consent 2008-9 45-65 years & 65+ years 757 (community) 330 (LTC) Total=1087 See results in Table 2.4 Canadian Health Measures Survey (CHMS) stratified random sample 2007-9 6 year olds 5600 of all ages 46.6% 2.52 53.4% Health Status of First Nations On-Reserve in Atlantic Canada (FNIHB) Dental Screenings conducted on-reserve in Atlantic Can. 3-5 year olds 76% 4.5 24% 6-11 year olds 81% 5.1 19%

29 2008-9 TOHAP Results – CariesCommunity Seniors LTC Seniors CHMS 45-65 yrs 65+yrs 45+years 20-79yrs Decayed crown (DT) 0.37 0.20 0.81 % with 1+ DT 16.20% 13.80% 51.00% 20.00% Decayed roots (DR) 0.27 0.26 1.44 % with 1+ DR 10.90% 14.90% 44.40% 7.00% % Edentulous 2.6% 11.6% 40.9% 21.7%

30 New DHW Requirement for LTC: March 2016The LTC licensee shall ensure : 1. An oral health assessment is initiated upon admission 2. Any risked relating to oral health status are documented on admission and referred to appropriate dental professional 3. Daily mouth care plan for each

31 Early Childhood Caries (ECC)Decay of any primary tooth in a child less than 6 years of age and it often requires extensive treatment (fillings, crowns, and extractions) under general anesthesia. ECC may be a painful condition that affects the child’s ability to eat, sleep, communicate and socialize, ultimately influencing optimal growth and development.

32 ECC – A Preventable Disease“They are just baby teeth.” Really? How can we keep kids out of the OR?

33 Guysborough Antigonish Strait 20.1 63 South West Nova 18.9 78 DHA Rate per 1000 Volume Cape Breton 34.5 322 Guysborough Antigonish Strait 20.1 63 South West Nova 18.9 78 Annapolis Valley 12.0 74 Pictou County 43 Colchester East Hants 10.4 South Shore 9.4 33 Cumberland 7.8 18 Capital District 5.4 188 CIHI: 2 year period to

34 Rates of ECC by age (source: CIHI)Rate per 1000 4 to < 5 19.1 3 to < 4 18.3 2 to < 3 10.9 1 to < 2 2.0

35 # of IWK Outpatient & Day Surgery Clients: FY2014-5IWK # Out -patient clinic visits IWK # Day surgery visits (OR cases) 1948 783

36 DHA IWK # Out -patient clinic visits IWK # Day surgery visits (OR cases) South Shore DHA 87 45 South West DHA 46 24 Annapolis Valley DHA 127 72 Colchester East Hants 186 102 Cumberland DHA 26 19 Pictou County DHA 43 21 Guysborough, Antigonish-Strait DHA 39 25 Cape Breton DHA 96 59 Capital DHA 1298 416 Total 1948 783 Fiscal Year

37 IWK : Out patient visits by AgeNumber 0-5 Yrs 864 6-9 Yrs 653 10-12 Yrs 265 13-15 Yrs 184 16-19 Yrs 109 20-25 Yrs 35 26+ Yrs 13 Total 2,123* Includes 175 out of province patients Over 40% are 0-5

38 Early Childhood Caries (ECC)Day surgery use is linked to SES, ethnicity, rurality IWK data shows Colchester East Hants is high for number of outpatient clinic visits and day surgery visits.(after HRM) Within Capital: rate for IWK ambulatory dentistry clinic visits is high in Spryfield, North Dartmouth, Sambro, Halifax Needham, and Preston IWK - long waiting list

39 Early Childhood Caries (ECC)500+ children are waiting for consultation or treatment of a dental issue at the IWK 25-30% of all OR surgical time at the IWK is dedicated to the treatment of dental disease

40 Self reported barriers to careBarriers for Children Barriers for Caregivers Cost (18%) Child uncooperative to too young for treatment (16%) Could not miss work (10%) Cost (35%) No insurance or uncertain of insurance coverage (15%) Could not miss work (8%) Nervous of dentist (8%)

41 3. Risk Reduction Community Water Fluoridation# of public disease prevention programs (FMR, educational, sealants) and # served % of children who use the oral health care system each year and were covered by COHP (preventive services)

42 Community Water Fluoridation51.8% of Nova Scotians have access to community water fluoridation. 67% of the population is served by a water facility. 84 water facilities, 11 are fluoridated Adding CWF to the 5 biggest communities (Truro, Amherst, Bridgewater, Yarmouth and Antigonish) increases the # of Nova Scotians receiving optimally fluoridated water by almost 53,000 people. (51.8% to 57.5%)

43 Community Water Systems Facilities 84 COMMUNITY-BASED PREVENTION PROGRAMS: Fluorides Number % Community Water Systems Facilities 84 Community Water Systems fluoridating 11 13% Population served by all facilities 613, 784 67% Population served by adjusted fluoridation 477,170 51.8% Children receiving fluoride varnish applications (COHI is the only community-based varnish program and is offered by Health Canada to First Nations communities) 9 of 13 communities Children receiving a school based fluoride mouthrinse ( ) 13,323 22% Professional Fluoride treatments paid by MSI N/A

44 (of total payments for Dental Programs)Primary Dental Care Access and Dental Services under MSI - DATA SUMMARY Item Number/$ % Children eligible for Children's Oral Health Program (COHP) 2013/14 124,751 Beneficiaries accessing the COHP 52,606 42% Total MSI payments for Services (services include Physicians, Dental, Optometric, Prescription Drug, and Prosthetic) $905,192,266 Total MSI payment for Physicians' Services $712,629,560 79% Total payment for Dental Services $8,770,502 1% Total payment for Children's Oral Health Program $5,262,008 60% (of total payments for Dental Programs)

45 4. System Development/AccessOral Health professionals workforce # and location of dental offices in NS # and location of independent DH offices description of public resources for dental care Family Resources Centre Locations Early Years Centre Locations Collaborative Care Teams Public Health Offices Community Health Centres

46 Service or Service ProvidersDental Workforce Service or Service Providers Number General Dentists 460 Pediatric dentists 5 Dental hygienists 731(680 practicing) Independent practice DHs 7 Public Health Dental Hygienists 14 Federally employed providers 7 Dental Therapists 1 Dental hygienist 1 Dentist ? COHI Aids Dental Schools 1 Dental hygiene schools

47 Public Dental ProgramsDepartment of Health and Wellness Children’s Oral Health Program Nova Scotia Cleft Palate/Craniofacial Program Maxillofacial Prosthodontics Program Mentally Challenged Program Dental Surgical (In-Hospital) Program Oral Pathology Services Department of Community Services Employment Support and Income Assistance Dental Program

48 Planning and building partnerships

49 Current Status Refugee Clinic (Partners: PH & CHB)Meeting with DEECD : integration of Oral Health into Early Years Centres Seniors in Long Term Care First Nations and Inuit Branch Presentations: FNIHB, DHW, DEECD, CDHNS council and AGM, DCS, Sparkle Fund Board, Community Health Boards Secured some funding & exploring other funding opportunities Lessons: 1. Take action when there are ready and willing partners. This takes time. 2. Actions should align with, and contribute to, the CDHNS Council ENDS 3. Increased involvement of members makes the profession stronger.

50 Integration of Oral Health intoPilot Project Integration of Oral Health into Early Years Centres Proposal for EYCs, PH, & CDHNS partnership Fits with several of the 13 recommendations Funding sources (Sparkle Fund, etc.) Evaluate & use results to advocate for change

51 Further Data Ideas? IWK data – need rates to be comparable, waiting times OR cases other than the IWK Emergency Room visits for dental or oral health issues (standardized coding) Mine dental administrator data (sealant utilization, etc)

52 Questions?