January 14, 2018
Minutes
Minutes
Present: Amy MacMillan, Scot MacDonald, Abbie Tanguay, Margaret Cardoza, Foxfire Buck, Mark Kemmerle, Mary Chris Semrow, Paul Linet, David Cowing, Debbie Dionne, Kim Humphrey, Diane Boas, Jennifer Putnam, Peter Stuckey, Patrick Moore, Lydia Dawson, Vickey Rand. Via Zoom – (Brunswick): Teague Morris. (Winthrop): Cathy Dionne and Cheryl Stalilonis. (Sanford): Brenda Smith. (Auburn): Ann Bentley. Misc. sites: Helen Hemminger, Hillary Steinau, Kathy Adams, and Staci Lamontagne.
Jennifer Putnam introduced herself and welcomed the group. Participants introduced themselves. Minutes from the last meeting were accepted.
Jennifer thanked Senscio Systems, noting that they have very generously covered the cost of lunch for our meetings! For more information on Senscio Systems you can visit their website, or connect with them on Facebook and Twitter.
Featured Speaker: Amy MacMillan, Acting Director, Office of Aging and Disability Services (OADS), DHHS. www.maine.gov/dhhs/oads Topic: Update on dental services.
Amy MacMillan: I’m here today to talk about dental contracts and the overall topic of the crisis system in our state, which dental affects greatly. Thank you for having me here today. Just to clarify, regarding the importance of dental, I’m sure I’m preaching to the choir. The issue is larger than getting dental cleanings or having cavities filled. The largest issue I’ve come across is that individuals with ID/DD are not able to gain access to sedation dentistry. There are some folks with more difficult behaviors who need that service, and there are very few providers who are willing to provide that service in the state. Mark Kemmerle, Cullen, and I were talking after one of your recent meetings, in which there was a parent of an individual who had a serious dental issue while in the emergency room (ER). I don’t think the community at large has all of the information on dental services and funding available within OADS. The situation detailed at one of your recent meetings was a pretty extreme example, but there are issues with access to needed dental services.
To be quite frank, I have dental funds that I cannot find a way to spend. I have $1.2 million in State-funded dental contracts, $1 million of which is spent fully, down to the last cent, by Dr. Praveen Kumar Pavuluru (“Dr. P.”) in Bangor. After accounting for the contract with Dr. P., there is about $200,000 remaining in funding, about 25% of which goes unspent each year. This isn’t a ton of money, but it is money left on the table that goes back into the General Fund if it’s not expended. We have seven contracts in total, including with Dr. P., and money is left unspent every year. When I first came into this position and saw there was unused dental dollars I was shocked because there’s such a significant dental need in this state. To think this money is going back into the general fund when it could be spent frankly blew my mind. As I dug deeper, what I found out is that the Department has a tough time finding willing and able providers. This funding is outside of Medicaid. We do ask providers to bill Medicaid what they can, to be good stewards of tax dollars, but these funds don’t come with the bounds that Medicaid funding does. In researching this, we identified everyone in the state on Sections 21 or 29 who have received sedation dental services in the past few years and identified who provided the service. Come to find out, none of them are providers with whom we contract. We’re going to reach out to those providers to see what we can do to negotiate contracts to increase access to that service.
When we first started looking at this, we kept running into the issue of IV sedation. The root of the problem is that we have an access issue in this state in terms of dentistry overall, then there are a number of providers who aren’t willing to take Medicaid, then the providers who are willing to contract with us are not targeting the service in a way that’s making a big enough difference. It’s a multifaceted issue. I think it’s hard to tell if the money we have now is enough or not because I think the true unmet need is unknown. According to our data, 16% of folks on Sections 21 and 29 have dental listed as an unmet need – but that seems extremely low to me. So that’s one piece of it. There are folks who are possibly self-injuring because they have a dental need that either is unacknowledged, or when it is acknowledged it’s so late that it has become a major issue. I just heard of someone who had an abscess that was infected so badly the infection was in his neck – I can’t imagine the pain he endured. This is unconscionable. So, we’re trying to target those funds. But, we also understand that it’s a hard service to provide.
The other issue, what came up in one of your previous meetings, is the issue of folks being discharged from their residential service provider to the ER, and then not being able to access dental care in the ER. The family I’m familiar with who spoke with you all, that individual was in the hospital and there wasn’t a provider willing to come in and serve him in the hospital – we couldn’t find a dental provider who had rights to do that while he was there. It made so much sense to us at the time – the individual was at the hospital which was equipped to provide sedation and there was space to do the needed procedure. It was very frustrating because it seemed like everything was in place but we couldn’t connect those dots. That member, as you know, ended up going to an out-of-state placement, and this placement wasn’t to treat his dental needs, the need for that residential placement was much greater, but the reality is this individual lost his residential placement, was in pain, not able to communicate it, and then sent to a different state, still in pain, and away from his community. This is not what we’d like to have happen. I understand if someone needs to be served in a higher level of care, but we would like to make sure that anyone having to do that is not entering into that placement in pain or unbalanced in some way medically – that’s our biggest challenge. I can locate providers to do sedation and provide that upfront service, it may take a while, but that is something we can likely achieve. The much bigger issue appears to be the hospital issue, and I’m not quite sure how we’re going to overcome that. Our hospital partners have worked very well with us but it’s a problem that no one knows how to solve – it’s not unwillingness, it’s an issue stuck between three systems, developmental services, dental, and hospital care. There needs to be some broad-reaching collaboration between these three entities. One entity can’t fix the problem on its own. What we’ve seen Dr. P. do in Bangor is amazing, and he’s passionate, but he’s only one person. We could have three Dr. P’s statewide and we’d still have an unmet need. I don’t come today with some kind of solution. And, I specifically didn’t prepare a presentation because I’m hoping to have a conversation about what others feel the issue is and what we can do about it.
Discussion:
Peter Stuckey: It wasn’t that many years ago when there was such a clinic in Portland – it literally evaporated overnight, amid lots of controversy. There were also negotiations with Community Dental about bringing that service back to the Portland area, and they understandably wanted to not just have that narrow scope of care (sedation dentistry), they wanted people to become their patients. I’m trying to understand what happened – we worked hard to get it back on track and I thought we were working in that direction. I’m curious if you’re familiar with that, and if so where did it go off the rails? Because it sounded like the clinic in Portland was very busy. They had the required arrangement, at the time at least; they maintained a certain staffing, both credentialed and patterned, that allowed the clinic to have this as a billable service. I don’t think it was closed because it was unsafe and unregulated. It was effective. I’m wondering if you can speak to this.
Amy: I’m familiar with the Preble Street dental clinic, but not as much with what deteriorated, or the difference in spending between then and now. We still spend a lot of money on dental care. Dr. P. maximizes every cent of funding in his contract. We are providing a lot of dental services, I just don’t think they are as targeted or as spread out geographically as they ought to or could be.
Peter: Dental in general or sedation?
Amy: I’m talking about both, but in the back of my mind I’m thinking sedation, because when I see the unmet needs and the highest need individuals, that’s the need I see most often. This issue is that there isn’t a dentist willing to provide services in the ER setting, and/or the hospital isn’t willing to allow dental to be provided in the ER setting, and then the general lack of accessibility of sedation dentistry statewide.
-It was asked if the Department has data on how many people received services under the dental contracts last year.
Amy: Yes, we do have that data, but I don’t have it with me today. I can certainly provide that, though.
Lydia Dawson – Maine Association for Community Services Providers (MACSP): I think everyone agrees there’s a lot of unmet need around dental services. You seem to be saying there’s a correlation, that people are getting stuck in the ER because of dental issues. I see them as different issues.
Amy: They’re not in the ER because of dental issues, they’re in the ER because their provider discharged them, and then they have a dental issue which prevents another provider from taking them on.
Lydia: That’s interesting because I’ve never seen that with any of our providers.
Amy: This typically happens with higher level cases, often for folks going out of state. I’ve definitely seen this happen; we’re not talking about a hundred people, it’s a smaller number of folks, but when it happens it’s a huge deal. Potential incoming providers thinking they won’t be able to appropriately provide services due to the issues and behaviors stemming from major dental issues. These providers view it as being like discharging someone who’s not medically clear.
Lydia: In that circumstance, when someone is in the hospital with an abscess, what prevents them from accessing that funding to get the dental care in the hospital?
Amy: The hospitals don’t see that as being an emergency service to be addressed in the ER, and they’re not willing to admit the person if the individual doesn’t need a level of care high enough to warrant hospital admission. The other issue is not having dentists with rights who are able to provide services in the hospital.
Mark Kemmerle – Maine Developmental Services Oversight and Advisory Board (MDSOAB): I recently spoke with Dr. P., who treats my son. There isn’t any hospital in Maine currently that is open to having dentistry done in the ER? Could you start with a hospital in one region? Dr. P. said there are three levels of sedation: mild, moderate, and deep. He said they try to treat everyone with mild or moderate sedation, with deep sedation being reserved for people with high levels of anxiety. However, there is another level which is anesthesia – general anesthesia is a much more serious level of sedation and requires hospital care. This is a fourth level of sedation, for someone who requires more than IV sedation, and it doesn’t sound like there are any options for people who need that level of care.
Amy: I don’t know the answer to your question and that’s part of what we’re looking into now: Has there been a person who has received deep sedation in the past few years, and if so who provided that service?
Mark: Dr. P. said that Medicaid billing was time consuming, but it was also very restrictive – Medicaid only covers extractions for people over 21 years old.
Amy: Medicaid will cover more, there’s some language in Section 25 that references pain, but there are few providers who have been successful in getting that covered. This State funding is designed to fills those gaps, between what’s needed and what Medicaid will cover. But I can’t even spend what I have.
Mark: Are the smaller contracts for ordinary dental care?
Amy: That’s how they’ve been established historically. If I had my druthers they would include other things. They are really limited to smaller contracts in the Aroostook County area, Dr. P., and then the one with Community Dental. I don’t think they’re targeted like they should be.
Mark: Is Community Dental working with a hospital?
David Cowing: Community Dental works with Maine Med. As I stated at a recent meeting, and a year or so ago when he presented, Dr. Walawender with Community Dental worked with my son at the Maine Med Scarborough Campus. It was quite a confusing experience. We were able to get a referral to the Community Dental clinic. We brought my son’s dental records, it was confirmed that he needed cavities filled, and we were connected with Dr. Walawender who has some affiliation with Tufts Dental School in Boston. Tufts has a commitment to training dentists in providing services to challenging clients. I presented Dr. Walawender with my son’s story, and Community Dental had a contract, at the time at least, to utilize a surgical room at the Maine Med Scarborough Campus for a half day, two days each month to treat dental patients. Through this, my son received IV sedation; it was successful, and my son received high-quality services. Getting to that point, however, was a challenge – making those connections, making multiple appointments, ensuring paperwork got to where it needed to go, hand-carrying copies of his dental records when they inevitably got lost with different providers, etc. The fact that he had dental insurance as well as MaineCare was helpful because there were multiple ways they could be reimbursed. My son hit the golden sweet spot and was also fortunate to have family that was willing to put the time in and navigate a really complicated system. I assumed that these services were going to expand to meet the need.
Amy: I think many of these conversations need to happen with the hospital systems. This is part of OADS’s strategic planning moving forward. We need to bring Dr. P. to the table with the hospitals and have a conversation about the state of affairs. When someone is in the ER and there’s not a provider who’s willing and able to provide the service, and the feeling is that the individual can’t be served safely in the community, we end up with someone stuck in the ER, taking up a bed, costing the hospital and Medicaid a lot of money, meanwhile the person is suffering. It’s an issue that everyone owns. That’s one of the first steps that needs to be taken – to build those relationships that haven’t existed, at least in my experience.
-A parent stated her son was hospitalized for two and a half months for a psychiatric situation, during which time he needed a medical evaluation, but no hospital was willing to do it. It was left up to the family to figure out what was wrong with him. She had to set up specialist appointments. It turned out he had major dental problems and chronic esophagitis which could’ve been treated in a few days had it been addressed.
Amy: That’s a story for the hospital system. The hospital system is a victim too, as they face capacity and funding losses. All hands should be on deck with this problem; no one entity can fix this. This is a problem, and it’s worth our time and energy to find a pathway for those few who bubble to the top. And, the more we can target our contracts the better positioned we’ll be to prevent those situations from occurring.
Jennifer: Have you had an opportunity to speak with the Maine Hospital Association?
Amy: We have not, but that’s something we hope to have on the horizon this year. We’re in transition currently with the new Administration. That is definitely something I see coming up, and we’ll definitely need help from groups like this to help facilitate that conversation.
Jennifer: What about instead of having unique contracts, setting up a system, some mechanism, where any dentist can access funding needed to meet these needs?
Amy: The struggle with that is largely bureaucracy. I need a mechanism for payment. With Medicaid, providers bill, and then the claim is paid. With State money you need to have a contract. There are some other ways to go about it, and our financial people are looking into those options. That mechanism for payment has been a barrier. If we could find a way to have a fee-for-service type system, that would obviously be much more ideal. I would say if anyone has had success with providers in the past to let us know because we’re open to just about anything at this point. The funding is limited – $47,000 being unspent in the last fiscal year is infuriating, but it’s not that much money in the bigger picture.
-It was asked if State funds can be put towards preventative health. It was stated that it seems like there’s opportunity to educate dentists on how to work with this population and help with preventative oral health.
Amy: I have been thinking about all of the high-level needs – but you’re right it’s not just about putting out the fires and addressing crises, it’s laying the groundwork for the future too. We’re looking to target contracts to providers willing and able to do sedation, but this is definitely a conversation to keep having as the program gets stabilized and we look at the overall Developmental Services budget.
-It was asked who the contracted dentists are in Maine.
Amy: Dr. Praveen Kumar Pavuluru (“Dr. P”), Community Dental, Fish River Rural Health, Dr. Jefferey Dow, Dr. Joseph White, Dr. Richard Raymond, and Steinke and Caruso Dental Care – all of which, except Dr. P and Community Dental, are in Aroostook County.
Teague Morris: I’m looking online at the Maine Oral Health Improvement Plan, written in 2007. I’m curious, has anything been done to update that plan? Does that have anything to do with what you’re referencing?
Amy: I’m very familiar with that, and it’s all interconnected. One of the next steps strategically is to bring this issue to the Hospital Association, the Maine Dental Association, and other pertinent groups. The report doesn’t address these issues directly, but it does address unmet needs, and these groups could help us have those conversations and find willing dentists.
-It was stated that there is transition in the Administration right now. It was asked if, as a Department employee, Amy feels empowered to be able to tackle these larger systems problems, and if she’s optimistic about what the new Administration may bring.
Amy: I am, have been, and always will be empowered about these issues. Anyone who knows me knows that. I think the approach and how we strategically design solutions and communicate those solutions may look different with the new Administration. On the ground, the folks working on this day-to-day, they’re not affected by the politics of this. We employ a lot of social workers – you can’t take the commitment from them, that’s what feeds them. You can’t lose focus of this issue, you can’t brush off someone sitting in the ER for an extended period of time in pain; you can’t walk away from that. The difference will be the style, approach, and communication. I’m optimistic for this population all around because I see all of the pieces starting to fall together, advocacy groups and self-advocates speaking up and playing a big role, which is phenomenal. I think there is a high level of commitment to this population. I will tell you that it is my mission to make changes to our crisis system in this state, which includes dental, in a real way.
-It was stated that a handful of FQHCs (Federally Qualified Health Centers) do dental, and it would be advantageous to have discussions with them as well.
Amy: I hadn’t thought about the FQHC aspect, I’m glad you brought that up. I recently had a meeting with the Director of the University of New England Center for Excellence in Aging and Health. I used a fair amount of the time in that meeting discussing this issue. He’s going to facilitate a meeting with us and the Dean of the College of Dental Medicine to see what the primary needs are, and to identify areas in which we can collaborate.
-A self-advocate thanked Amy for being here and collaborating with the group. She stated that Amy’s willingness to be open and have a dialogue is wonderful. She stated that she is still haunted by memories of friends who endured trauma due to dental issues. She stated that training among doctors and dentists is a problem. She mentioned that often doctors will say “why don’t they just go to a dentist?” when someone presents with pain affiliated with dental issues. This philosophy ought to be examined.
Mark: Cooperative team diagnoses are key. There’s a model that worked for this on the child side when my son was in school and had behavioral issues. They had a group called the Circle of Healing – this was a team, which included a behavioral psychologist, a psychiatrist, an MD, etc. The idea was that all of the medical/dental records were given to the team, and each member looked at them, putting fresh eyes on them, offering different, unique perspectives. One person on the team thought my son’s behaviors could stem from a medication interaction, the medical doctor thought he might be in pain. This approach worked really well and helped get to the root of what was going on. This is a model that works and could perhaps be a model that works for the adult crisis services system.
Amy: This model is similar to programs like health homes and behavioral health homes. We’ve talked about whether there should be a health home for the ID/DD population; however, we’ve found that there aren’t primary care physicians in the state who specialize in this population. Project ECHO is a really cool program, where you have a contract with a provider who specializes in providing a service to a particular population, you call them and explain the situation, and they provide something similar to a consultation. We’ve thought about how we can bring a team together similar to this. The good news is there are models available to allow that to be reimbursed by Medicaid, if that’s a conversation in which this group would like to engage.
-A parent stated that the stigma around serving this population has also been an immense barrier.
Amy: It’s true. It’s similar in the hospitals.
-It was stated that the Circle of Healing model ought to be applied organizationally as well – something like the former Children’s Cabinet, where a group of people who have different expertise get together and figure things out.
Amy: That’s what I’m hoping. One of my goals is to create strategic partnerships.
-It was suggested that the Department look into dental telehealth.
Amy: I think our Medicaid policy is pretty wide open in terms of this.
-It was asked if the group could have Amy’s contact information.
Amy: I would be happy to have my contact information included in the minutes ([email protected]). If people would like follow ups to this discussion please don’t hesitate to reach out.
Jennifer: Thank you for being here today, Amy, this conversation was great. It’s wonderful to have OADS around the table engaging in an open dialogue!
End of presentation.
(Round of applause)
DHHS – Office of Aging and Disability Services (OADS) - www.maine.gov/dhhs/oads
Amy MacMillan: We’re in the process of hiring a new Disability Services Associate Director. Many of you are probably familiar with Emily Kalafarski; Emily has moved on to a different role. We’re just about to hire her replacement. When this position is filled we will hopefully be able to bring him or her to meet this group.
DHHS – Office of Child and Family Services (OCFS) - www.maine.gov/dhhs/ocfs
Luc Nya: We’re all in transition and looking forward to what’s to come. The Public Consulting Group (PCG) final report, which has been discussed previously at this meeting, has been released as well (click here for PCG report).
Disability Rights Maine (DRM) Update:
Foxfire Buck: As July comes closer, we’re rolling out supported decision-making trainings across the state. As we reported last month, DRM is offering upcoming trainings that will provide information about supported decision-making and how it and other less restrictive alternatives are incorporated into the new Probate Code, which goes into effect in July 2019. Additionally, these workshops provide practical information related to the use of self-determination goals (self-advocacy, goal setting, decision-making, and self-awareness) as part of the planning process for youth. (Click here for the dates and locations of the trainings). There’s a new supported decision-making handbook on our website. We’re doing some work around CMS (Centers for Medicare and Medicaid Services) Home and Community Based Services (HCBS) guidelines – these are standards that CMS put out some years ago, with which providers of HCBS must comply by 2022. With the change of the Administration, we’re beginning to look at this.
Federal Update: Congress and the President were unable to come to agreement on another Continuing Resolution, and Federal Departments and Offices not yet funded for FY 19 shut down when the 12/21 CR expired. HUD still awaits FY 19 funding, as it was not among departments funded through minibus spending bills months ago. As such, HUD is operating at FY 18 funding levels until or unless FY 19 funding is agreed upon. However, Congress is still at a stalemate over passing spending bills, largely due to border security.
State Legislature Update:
Jennifer Putnam: MACSP (Maine Association for Community Service Providers) submitted two pieces of legislation this session. One bill would reinvigorate the Section 22 HCBS waiver for children. This would allow for the opportunity to take children with ID/DD out of Section 28 and 65 services and into services that are more broad and comprehensive. This would in turn free up capacity and help alleviate the waitlist for Section 28, which sits at around 400 children waiting for services. There are subsections for the waitlist, Section 28 services for in-home care as well as for a higher level of services. All told, there are hundreds and hundreds of kids waiting for services. The second bill would mirror the crisis services work that’s been done in the Crisis Services Workgroup. One aspect of this would be asking the Department to promulgate rules around crisis services, because they’ve never been promulgated despite being statutorily mandated. Another aspect would be to develop services and corresponding rates to meet the higher behavior needs of folks coming into crisis services in an appropriate fashion – allowing for services to angle up to include more intensive supports before someone gets to crisis, as well as angle down as they’re stepping down out of crisis services.
The Maine Developmental Services Oversight and Advisory Board (MDSOAB) also put forward legislation, reviving a bill from the last session, which would create a mortality review panel. We never received adequate answers from the Department following the release of the Office of Inspector General (OIG) report, which detailed numerous deaths of individuals with ID/DD as well as other systems issues. This bill would seek to cure that moving forward. The MDSOAB also submitted a bill which would strengthen the language regarding the MDSOAB in statute. Currently there are only four appointed members of the MDSOAB, because the previous Governor would not appoint members to the board when terms expired. The MDSOAB cannot be a functioning board, nor can its Executive Director function ably, without sufficient members. There are a lot of wonderful people who come to meetings but are not voting members.
-It was asked how many members the MDSOAB ought to have.
Jennifer: I believe the size of the MDSOAB is supposed to be around fifteen to sixteen members.
-It was asked if there are any updates or changes to the Volunteer Correspondent Program (VCP).
Mark: We hired some part-time help to look at aged and incomplete files, and we’ve done quite a remarkable job breathing life into those files. It’s a two-step process – determining who could benefit from a volunteer advocate, and then matching that person with someone who’s willing to perform that role. The most common situation we see is a direct care worker who has developed a relationship with an individual, who has changed roles in his or her job, but wishes to still be part of that individual’s life. In these cases, the match comes in together as a package. That’s an easy match. The harder matches are when the PCP (Person-Centered Planning) process finds that an individual would benefit from a volunteer advocate, because recruiting volunteer correspondents is the hardest part, and that will likely always be the case – to get freelance volunteers to come in without a pre-made match. However, we’ve processed a fair number of matches recently.
Jennifer: We are looking at different mechanisms than have been used historically. It’s clear there isn’t enough training for case managers regarding identifying this as an unmet need. If you were able to pull statewide data, this wouldn’t emerge as a need.
-A self-advocate stated that this is a wonderful resource and helps create effective connections with the community that otherwise might not occur. It was stated that having the school system be apprised of this program would be especially beneficial. Often when people transition out of the school and into adult services they leave behind those social connections. It was stated that as Maine moves towards supported decision-making, there might be a correlation with the VCP, where the individual has a network of people with whom they can connect.
Mark: I think the program may change a little, but the purpose will stay the same. I think you’re right, it parallels supported decision-making. It’s an unpaid friend. It’s helping someone express their needs in an everyday setting. This is companion advocacy.
Jennifer: It’s interesting that you bring up transition and the VCP. We often speak of transition and the “cliff of no services,” but people also fall off the cliff socially.
-It was asked where more information on the VCP could be found.
Jennifer: If you go to the MDSOAB website there’s a link to the VCP, but we’ll be sure to include a link in the minutes. (Click here for a direct link to the VCP website)
The next meeting will be on February 11, 2019, 12-2pm, Burton Fisher Community Meeting Room, located on the First Floor of One City Center (food court area, next to City Deli), Portland.
Featured Speaker and topic TBD.
Unless changed, Coalition meetings are on the 2nd Monday of the month from 12-2pm.
Burton Fisher Community Meeting Room, 1st Floor of One City Center in Portland (off of the food court).
The Maine Coalition for Housing and Quality Services provides equal opportunity for meeting participation. If you wish to attend but require an interpreter or other accommodation please forward your request two weeks prior to the monthly meeting to [email protected].
Jennifer Putnam introduced herself and welcomed the group. Participants introduced themselves. Minutes from the last meeting were accepted.
Jennifer thanked Senscio Systems, noting that they have very generously covered the cost of lunch for our meetings! For more information on Senscio Systems you can visit their website, or connect with them on Facebook and Twitter.
Featured Speaker: Amy MacMillan, Acting Director, Office of Aging and Disability Services (OADS), DHHS. www.maine.gov/dhhs/oads Topic: Update on dental services.
Amy MacMillan: I’m here today to talk about dental contracts and the overall topic of the crisis system in our state, which dental affects greatly. Thank you for having me here today. Just to clarify, regarding the importance of dental, I’m sure I’m preaching to the choir. The issue is larger than getting dental cleanings or having cavities filled. The largest issue I’ve come across is that individuals with ID/DD are not able to gain access to sedation dentistry. There are some folks with more difficult behaviors who need that service, and there are very few providers who are willing to provide that service in the state. Mark Kemmerle, Cullen, and I were talking after one of your recent meetings, in which there was a parent of an individual who had a serious dental issue while in the emergency room (ER). I don’t think the community at large has all of the information on dental services and funding available within OADS. The situation detailed at one of your recent meetings was a pretty extreme example, but there are issues with access to needed dental services.
To be quite frank, I have dental funds that I cannot find a way to spend. I have $1.2 million in State-funded dental contracts, $1 million of which is spent fully, down to the last cent, by Dr. Praveen Kumar Pavuluru (“Dr. P.”) in Bangor. After accounting for the contract with Dr. P., there is about $200,000 remaining in funding, about 25% of which goes unspent each year. This isn’t a ton of money, but it is money left on the table that goes back into the General Fund if it’s not expended. We have seven contracts in total, including with Dr. P., and money is left unspent every year. When I first came into this position and saw there was unused dental dollars I was shocked because there’s such a significant dental need in this state. To think this money is going back into the general fund when it could be spent frankly blew my mind. As I dug deeper, what I found out is that the Department has a tough time finding willing and able providers. This funding is outside of Medicaid. We do ask providers to bill Medicaid what they can, to be good stewards of tax dollars, but these funds don’t come with the bounds that Medicaid funding does. In researching this, we identified everyone in the state on Sections 21 or 29 who have received sedation dental services in the past few years and identified who provided the service. Come to find out, none of them are providers with whom we contract. We’re going to reach out to those providers to see what we can do to negotiate contracts to increase access to that service.
When we first started looking at this, we kept running into the issue of IV sedation. The root of the problem is that we have an access issue in this state in terms of dentistry overall, then there are a number of providers who aren’t willing to take Medicaid, then the providers who are willing to contract with us are not targeting the service in a way that’s making a big enough difference. It’s a multifaceted issue. I think it’s hard to tell if the money we have now is enough or not because I think the true unmet need is unknown. According to our data, 16% of folks on Sections 21 and 29 have dental listed as an unmet need – but that seems extremely low to me. So that’s one piece of it. There are folks who are possibly self-injuring because they have a dental need that either is unacknowledged, or when it is acknowledged it’s so late that it has become a major issue. I just heard of someone who had an abscess that was infected so badly the infection was in his neck – I can’t imagine the pain he endured. This is unconscionable. So, we’re trying to target those funds. But, we also understand that it’s a hard service to provide.
The other issue, what came up in one of your previous meetings, is the issue of folks being discharged from their residential service provider to the ER, and then not being able to access dental care in the ER. The family I’m familiar with who spoke with you all, that individual was in the hospital and there wasn’t a provider willing to come in and serve him in the hospital – we couldn’t find a dental provider who had rights to do that while he was there. It made so much sense to us at the time – the individual was at the hospital which was equipped to provide sedation and there was space to do the needed procedure. It was very frustrating because it seemed like everything was in place but we couldn’t connect those dots. That member, as you know, ended up going to an out-of-state placement, and this placement wasn’t to treat his dental needs, the need for that residential placement was much greater, but the reality is this individual lost his residential placement, was in pain, not able to communicate it, and then sent to a different state, still in pain, and away from his community. This is not what we’d like to have happen. I understand if someone needs to be served in a higher level of care, but we would like to make sure that anyone having to do that is not entering into that placement in pain or unbalanced in some way medically – that’s our biggest challenge. I can locate providers to do sedation and provide that upfront service, it may take a while, but that is something we can likely achieve. The much bigger issue appears to be the hospital issue, and I’m not quite sure how we’re going to overcome that. Our hospital partners have worked very well with us but it’s a problem that no one knows how to solve – it’s not unwillingness, it’s an issue stuck between three systems, developmental services, dental, and hospital care. There needs to be some broad-reaching collaboration between these three entities. One entity can’t fix the problem on its own. What we’ve seen Dr. P. do in Bangor is amazing, and he’s passionate, but he’s only one person. We could have three Dr. P’s statewide and we’d still have an unmet need. I don’t come today with some kind of solution. And, I specifically didn’t prepare a presentation because I’m hoping to have a conversation about what others feel the issue is and what we can do about it.
Discussion:
Peter Stuckey: It wasn’t that many years ago when there was such a clinic in Portland – it literally evaporated overnight, amid lots of controversy. There were also negotiations with Community Dental about bringing that service back to the Portland area, and they understandably wanted to not just have that narrow scope of care (sedation dentistry), they wanted people to become their patients. I’m trying to understand what happened – we worked hard to get it back on track and I thought we were working in that direction. I’m curious if you’re familiar with that, and if so where did it go off the rails? Because it sounded like the clinic in Portland was very busy. They had the required arrangement, at the time at least; they maintained a certain staffing, both credentialed and patterned, that allowed the clinic to have this as a billable service. I don’t think it was closed because it was unsafe and unregulated. It was effective. I’m wondering if you can speak to this.
Amy: I’m familiar with the Preble Street dental clinic, but not as much with what deteriorated, or the difference in spending between then and now. We still spend a lot of money on dental care. Dr. P. maximizes every cent of funding in his contract. We are providing a lot of dental services, I just don’t think they are as targeted or as spread out geographically as they ought to or could be.
Peter: Dental in general or sedation?
Amy: I’m talking about both, but in the back of my mind I’m thinking sedation, because when I see the unmet needs and the highest need individuals, that’s the need I see most often. This issue is that there isn’t a dentist willing to provide services in the ER setting, and/or the hospital isn’t willing to allow dental to be provided in the ER setting, and then the general lack of accessibility of sedation dentistry statewide.
-It was asked if the Department has data on how many people received services under the dental contracts last year.
Amy: Yes, we do have that data, but I don’t have it with me today. I can certainly provide that, though.
Lydia Dawson – Maine Association for Community Services Providers (MACSP): I think everyone agrees there’s a lot of unmet need around dental services. You seem to be saying there’s a correlation, that people are getting stuck in the ER because of dental issues. I see them as different issues.
Amy: They’re not in the ER because of dental issues, they’re in the ER because their provider discharged them, and then they have a dental issue which prevents another provider from taking them on.
Lydia: That’s interesting because I’ve never seen that with any of our providers.
Amy: This typically happens with higher level cases, often for folks going out of state. I’ve definitely seen this happen; we’re not talking about a hundred people, it’s a smaller number of folks, but when it happens it’s a huge deal. Potential incoming providers thinking they won’t be able to appropriately provide services due to the issues and behaviors stemming from major dental issues. These providers view it as being like discharging someone who’s not medically clear.
Lydia: In that circumstance, when someone is in the hospital with an abscess, what prevents them from accessing that funding to get the dental care in the hospital?
Amy: The hospitals don’t see that as being an emergency service to be addressed in the ER, and they’re not willing to admit the person if the individual doesn’t need a level of care high enough to warrant hospital admission. The other issue is not having dentists with rights who are able to provide services in the hospital.
Mark Kemmerle – Maine Developmental Services Oversight and Advisory Board (MDSOAB): I recently spoke with Dr. P., who treats my son. There isn’t any hospital in Maine currently that is open to having dentistry done in the ER? Could you start with a hospital in one region? Dr. P. said there are three levels of sedation: mild, moderate, and deep. He said they try to treat everyone with mild or moderate sedation, with deep sedation being reserved for people with high levels of anxiety. However, there is another level which is anesthesia – general anesthesia is a much more serious level of sedation and requires hospital care. This is a fourth level of sedation, for someone who requires more than IV sedation, and it doesn’t sound like there are any options for people who need that level of care.
Amy: I don’t know the answer to your question and that’s part of what we’re looking into now: Has there been a person who has received deep sedation in the past few years, and if so who provided that service?
Mark: Dr. P. said that Medicaid billing was time consuming, but it was also very restrictive – Medicaid only covers extractions for people over 21 years old.
Amy: Medicaid will cover more, there’s some language in Section 25 that references pain, but there are few providers who have been successful in getting that covered. This State funding is designed to fills those gaps, between what’s needed and what Medicaid will cover. But I can’t even spend what I have.
Mark: Are the smaller contracts for ordinary dental care?
Amy: That’s how they’ve been established historically. If I had my druthers they would include other things. They are really limited to smaller contracts in the Aroostook County area, Dr. P., and then the one with Community Dental. I don’t think they’re targeted like they should be.
Mark: Is Community Dental working with a hospital?
David Cowing: Community Dental works with Maine Med. As I stated at a recent meeting, and a year or so ago when he presented, Dr. Walawender with Community Dental worked with my son at the Maine Med Scarborough Campus. It was quite a confusing experience. We were able to get a referral to the Community Dental clinic. We brought my son’s dental records, it was confirmed that he needed cavities filled, and we were connected with Dr. Walawender who has some affiliation with Tufts Dental School in Boston. Tufts has a commitment to training dentists in providing services to challenging clients. I presented Dr. Walawender with my son’s story, and Community Dental had a contract, at the time at least, to utilize a surgical room at the Maine Med Scarborough Campus for a half day, two days each month to treat dental patients. Through this, my son received IV sedation; it was successful, and my son received high-quality services. Getting to that point, however, was a challenge – making those connections, making multiple appointments, ensuring paperwork got to where it needed to go, hand-carrying copies of his dental records when they inevitably got lost with different providers, etc. The fact that he had dental insurance as well as MaineCare was helpful because there were multiple ways they could be reimbursed. My son hit the golden sweet spot and was also fortunate to have family that was willing to put the time in and navigate a really complicated system. I assumed that these services were going to expand to meet the need.
Amy: I think many of these conversations need to happen with the hospital systems. This is part of OADS’s strategic planning moving forward. We need to bring Dr. P. to the table with the hospitals and have a conversation about the state of affairs. When someone is in the ER and there’s not a provider who’s willing and able to provide the service, and the feeling is that the individual can’t be served safely in the community, we end up with someone stuck in the ER, taking up a bed, costing the hospital and Medicaid a lot of money, meanwhile the person is suffering. It’s an issue that everyone owns. That’s one of the first steps that needs to be taken – to build those relationships that haven’t existed, at least in my experience.
-A parent stated her son was hospitalized for two and a half months for a psychiatric situation, during which time he needed a medical evaluation, but no hospital was willing to do it. It was left up to the family to figure out what was wrong with him. She had to set up specialist appointments. It turned out he had major dental problems and chronic esophagitis which could’ve been treated in a few days had it been addressed.
Amy: That’s a story for the hospital system. The hospital system is a victim too, as they face capacity and funding losses. All hands should be on deck with this problem; no one entity can fix this. This is a problem, and it’s worth our time and energy to find a pathway for those few who bubble to the top. And, the more we can target our contracts the better positioned we’ll be to prevent those situations from occurring.
Jennifer: Have you had an opportunity to speak with the Maine Hospital Association?
Amy: We have not, but that’s something we hope to have on the horizon this year. We’re in transition currently with the new Administration. That is definitely something I see coming up, and we’ll definitely need help from groups like this to help facilitate that conversation.
Jennifer: What about instead of having unique contracts, setting up a system, some mechanism, where any dentist can access funding needed to meet these needs?
Amy: The struggle with that is largely bureaucracy. I need a mechanism for payment. With Medicaid, providers bill, and then the claim is paid. With State money you need to have a contract. There are some other ways to go about it, and our financial people are looking into those options. That mechanism for payment has been a barrier. If we could find a way to have a fee-for-service type system, that would obviously be much more ideal. I would say if anyone has had success with providers in the past to let us know because we’re open to just about anything at this point. The funding is limited – $47,000 being unspent in the last fiscal year is infuriating, but it’s not that much money in the bigger picture.
-It was asked if State funds can be put towards preventative health. It was stated that it seems like there’s opportunity to educate dentists on how to work with this population and help with preventative oral health.
Amy: I have been thinking about all of the high-level needs – but you’re right it’s not just about putting out the fires and addressing crises, it’s laying the groundwork for the future too. We’re looking to target contracts to providers willing and able to do sedation, but this is definitely a conversation to keep having as the program gets stabilized and we look at the overall Developmental Services budget.
-It was asked who the contracted dentists are in Maine.
Amy: Dr. Praveen Kumar Pavuluru (“Dr. P”), Community Dental, Fish River Rural Health, Dr. Jefferey Dow, Dr. Joseph White, Dr. Richard Raymond, and Steinke and Caruso Dental Care – all of which, except Dr. P and Community Dental, are in Aroostook County.
Teague Morris: I’m looking online at the Maine Oral Health Improvement Plan, written in 2007. I’m curious, has anything been done to update that plan? Does that have anything to do with what you’re referencing?
Amy: I’m very familiar with that, and it’s all interconnected. One of the next steps strategically is to bring this issue to the Hospital Association, the Maine Dental Association, and other pertinent groups. The report doesn’t address these issues directly, but it does address unmet needs, and these groups could help us have those conversations and find willing dentists.
-It was stated that there is transition in the Administration right now. It was asked if, as a Department employee, Amy feels empowered to be able to tackle these larger systems problems, and if she’s optimistic about what the new Administration may bring.
Amy: I am, have been, and always will be empowered about these issues. Anyone who knows me knows that. I think the approach and how we strategically design solutions and communicate those solutions may look different with the new Administration. On the ground, the folks working on this day-to-day, they’re not affected by the politics of this. We employ a lot of social workers – you can’t take the commitment from them, that’s what feeds them. You can’t lose focus of this issue, you can’t brush off someone sitting in the ER for an extended period of time in pain; you can’t walk away from that. The difference will be the style, approach, and communication. I’m optimistic for this population all around because I see all of the pieces starting to fall together, advocacy groups and self-advocates speaking up and playing a big role, which is phenomenal. I think there is a high level of commitment to this population. I will tell you that it is my mission to make changes to our crisis system in this state, which includes dental, in a real way.
-It was stated that a handful of FQHCs (Federally Qualified Health Centers) do dental, and it would be advantageous to have discussions with them as well.
Amy: I hadn’t thought about the FQHC aspect, I’m glad you brought that up. I recently had a meeting with the Director of the University of New England Center for Excellence in Aging and Health. I used a fair amount of the time in that meeting discussing this issue. He’s going to facilitate a meeting with us and the Dean of the College of Dental Medicine to see what the primary needs are, and to identify areas in which we can collaborate.
-A self-advocate thanked Amy for being here and collaborating with the group. She stated that Amy’s willingness to be open and have a dialogue is wonderful. She stated that she is still haunted by memories of friends who endured trauma due to dental issues. She stated that training among doctors and dentists is a problem. She mentioned that often doctors will say “why don’t they just go to a dentist?” when someone presents with pain affiliated with dental issues. This philosophy ought to be examined.
Mark: Cooperative team diagnoses are key. There’s a model that worked for this on the child side when my son was in school and had behavioral issues. They had a group called the Circle of Healing – this was a team, which included a behavioral psychologist, a psychiatrist, an MD, etc. The idea was that all of the medical/dental records were given to the team, and each member looked at them, putting fresh eyes on them, offering different, unique perspectives. One person on the team thought my son’s behaviors could stem from a medication interaction, the medical doctor thought he might be in pain. This approach worked really well and helped get to the root of what was going on. This is a model that works and could perhaps be a model that works for the adult crisis services system.
Amy: This model is similar to programs like health homes and behavioral health homes. We’ve talked about whether there should be a health home for the ID/DD population; however, we’ve found that there aren’t primary care physicians in the state who specialize in this population. Project ECHO is a really cool program, where you have a contract with a provider who specializes in providing a service to a particular population, you call them and explain the situation, and they provide something similar to a consultation. We’ve thought about how we can bring a team together similar to this. The good news is there are models available to allow that to be reimbursed by Medicaid, if that’s a conversation in which this group would like to engage.
-A parent stated that the stigma around serving this population has also been an immense barrier.
Amy: It’s true. It’s similar in the hospitals.
-It was stated that the Circle of Healing model ought to be applied organizationally as well – something like the former Children’s Cabinet, where a group of people who have different expertise get together and figure things out.
Amy: That’s what I’m hoping. One of my goals is to create strategic partnerships.
-It was suggested that the Department look into dental telehealth.
Amy: I think our Medicaid policy is pretty wide open in terms of this.
-It was asked if the group could have Amy’s contact information.
Amy: I would be happy to have my contact information included in the minutes ([email protected]). If people would like follow ups to this discussion please don’t hesitate to reach out.
Jennifer: Thank you for being here today, Amy, this conversation was great. It’s wonderful to have OADS around the table engaging in an open dialogue!
End of presentation.
(Round of applause)
DHHS – Office of Aging and Disability Services (OADS) - www.maine.gov/dhhs/oads
Amy MacMillan: We’re in the process of hiring a new Disability Services Associate Director. Many of you are probably familiar with Emily Kalafarski; Emily has moved on to a different role. We’re just about to hire her replacement. When this position is filled we will hopefully be able to bring him or her to meet this group.
DHHS – Office of Child and Family Services (OCFS) - www.maine.gov/dhhs/ocfs
Luc Nya: We’re all in transition and looking forward to what’s to come. The Public Consulting Group (PCG) final report, which has been discussed previously at this meeting, has been released as well (click here for PCG report).
Disability Rights Maine (DRM) Update:
Foxfire Buck: As July comes closer, we’re rolling out supported decision-making trainings across the state. As we reported last month, DRM is offering upcoming trainings that will provide information about supported decision-making and how it and other less restrictive alternatives are incorporated into the new Probate Code, which goes into effect in July 2019. Additionally, these workshops provide practical information related to the use of self-determination goals (self-advocacy, goal setting, decision-making, and self-awareness) as part of the planning process for youth. (Click here for the dates and locations of the trainings). There’s a new supported decision-making handbook on our website. We’re doing some work around CMS (Centers for Medicare and Medicaid Services) Home and Community Based Services (HCBS) guidelines – these are standards that CMS put out some years ago, with which providers of HCBS must comply by 2022. With the change of the Administration, we’re beginning to look at this.
Federal Update: Congress and the President were unable to come to agreement on another Continuing Resolution, and Federal Departments and Offices not yet funded for FY 19 shut down when the 12/21 CR expired. HUD still awaits FY 19 funding, as it was not among departments funded through minibus spending bills months ago. As such, HUD is operating at FY 18 funding levels until or unless FY 19 funding is agreed upon. However, Congress is still at a stalemate over passing spending bills, largely due to border security.
State Legislature Update:
Jennifer Putnam: MACSP (Maine Association for Community Service Providers) submitted two pieces of legislation this session. One bill would reinvigorate the Section 22 HCBS waiver for children. This would allow for the opportunity to take children with ID/DD out of Section 28 and 65 services and into services that are more broad and comprehensive. This would in turn free up capacity and help alleviate the waitlist for Section 28, which sits at around 400 children waiting for services. There are subsections for the waitlist, Section 28 services for in-home care as well as for a higher level of services. All told, there are hundreds and hundreds of kids waiting for services. The second bill would mirror the crisis services work that’s been done in the Crisis Services Workgroup. One aspect of this would be asking the Department to promulgate rules around crisis services, because they’ve never been promulgated despite being statutorily mandated. Another aspect would be to develop services and corresponding rates to meet the higher behavior needs of folks coming into crisis services in an appropriate fashion – allowing for services to angle up to include more intensive supports before someone gets to crisis, as well as angle down as they’re stepping down out of crisis services.
The Maine Developmental Services Oversight and Advisory Board (MDSOAB) also put forward legislation, reviving a bill from the last session, which would create a mortality review panel. We never received adequate answers from the Department following the release of the Office of Inspector General (OIG) report, which detailed numerous deaths of individuals with ID/DD as well as other systems issues. This bill would seek to cure that moving forward. The MDSOAB also submitted a bill which would strengthen the language regarding the MDSOAB in statute. Currently there are only four appointed members of the MDSOAB, because the previous Governor would not appoint members to the board when terms expired. The MDSOAB cannot be a functioning board, nor can its Executive Director function ably, without sufficient members. There are a lot of wonderful people who come to meetings but are not voting members.
-It was asked how many members the MDSOAB ought to have.
Jennifer: I believe the size of the MDSOAB is supposed to be around fifteen to sixteen members.
-It was asked if there are any updates or changes to the Volunteer Correspondent Program (VCP).
Mark: We hired some part-time help to look at aged and incomplete files, and we’ve done quite a remarkable job breathing life into those files. It’s a two-step process – determining who could benefit from a volunteer advocate, and then matching that person with someone who’s willing to perform that role. The most common situation we see is a direct care worker who has developed a relationship with an individual, who has changed roles in his or her job, but wishes to still be part of that individual’s life. In these cases, the match comes in together as a package. That’s an easy match. The harder matches are when the PCP (Person-Centered Planning) process finds that an individual would benefit from a volunteer advocate, because recruiting volunteer correspondents is the hardest part, and that will likely always be the case – to get freelance volunteers to come in without a pre-made match. However, we’ve processed a fair number of matches recently.
Jennifer: We are looking at different mechanisms than have been used historically. It’s clear there isn’t enough training for case managers regarding identifying this as an unmet need. If you were able to pull statewide data, this wouldn’t emerge as a need.
-A self-advocate stated that this is a wonderful resource and helps create effective connections with the community that otherwise might not occur. It was stated that having the school system be apprised of this program would be especially beneficial. Often when people transition out of the school and into adult services they leave behind those social connections. It was stated that as Maine moves towards supported decision-making, there might be a correlation with the VCP, where the individual has a network of people with whom they can connect.
Mark: I think the program may change a little, but the purpose will stay the same. I think you’re right, it parallels supported decision-making. It’s an unpaid friend. It’s helping someone express their needs in an everyday setting. This is companion advocacy.
Jennifer: It’s interesting that you bring up transition and the VCP. We often speak of transition and the “cliff of no services,” but people also fall off the cliff socially.
-It was asked where more information on the VCP could be found.
Jennifer: If you go to the MDSOAB website there’s a link to the VCP, but we’ll be sure to include a link in the minutes. (Click here for a direct link to the VCP website)
The next meeting will be on February 11, 2019, 12-2pm, Burton Fisher Community Meeting Room, located on the First Floor of One City Center (food court area, next to City Deli), Portland.
Featured Speaker and topic TBD.
Unless changed, Coalition meetings are on the 2nd Monday of the month from 12-2pm.
Burton Fisher Community Meeting Room, 1st Floor of One City Center in Portland (off of the food court).
The Maine Coalition for Housing and Quality Services provides equal opportunity for meeting participation. If you wish to attend but require an interpreter or other accommodation please forward your request two weeks prior to the monthly meeting to [email protected].