Milwaukee Clinic Provides Dental Care to Low-Income and Homeless People as Part of RWJF's Local Funding Partnerships
Staff at the Madre Angela Dental Clinic provided oral health care services to impoverished people in Milwaukee, including:
- Urgent dental care services.
- Dental sealants for children to prevent tooth decay.
- Restorative care, such as dentures to people with significant tooth loss or whose appearance limited their employment options.
- The clinic provided some 13,600 urgent care services over the course of the grant.
- Clinic staff provided more than 4,800 dental sealants to poor children in Milwaukee schools.
- Clinic staff and volunteer dentists provided more than 750 dental appliances, such as dentures, bridges and crowns to low-income people with tooth loss or whose appearance limited their employment options.
RWJF provided a grant of $420,000 to fund this project.
In a 2000 report, the U.S. Surgeon General highlighted what he characterized as a "silent epidemic" of dental and oral disease affecting the most vulnerable citizens in this country poor children, the elderly and many members of racial and ethnic minority groups. Among the report's findings:
- Poor children experience twice as much dental decay as their more affluent peers, and their disease is more likely to be untreated.
- In 1993, Hispanics were least likely to receive dental care (46.2 percent) and whites most likely (64 percent). Dental care among African Americans (47.3 percent) was similar to that of Hispanics.
- Dental sealants, which are applied to teeth to prevent decay, are three times less likely to be found on the teeth of Mexican-American and African-American children than among white children.
In Milwaukee, several Federally Qualified Health Centers (FQHC's) provide oral health care to the poor, but they are focused on Medicaid and insured patients. The closing of a county hospital and community-based health center had made a bad situation worse. In 1999, homeless people in Milwaukee had access to a one-chair clinic staffed by dental residents. Those seeking care put their name in a hat to receive care usually extraction of severely diseased teeth.
Prior Work by the Madre Angela Dental Clinic
The Madre Angela Dental Clinic opened in February 2000 to help put an end to the "dental lottery" in Milwaukee and provide dental treatment for the poorest of the poor people below 100 percent of the federal poverty level and without insurance.
More than 1,000 people received services between February and October 2000. However, systemic oral health problems in the community still existed, such as lack of access to urgent care, the difficulty in providing pediatric preventive care such as sealants and the unavailability of restorative devices such as dentures and crowns.
The clinic is sponsored by Columbia St. Mary's Hospital, and was developed in collaboration with St. Luke's Medical Center, St. Francis Hospital (a general acute care hospital), Marquette University Dental School and the Children's Hospital and Health System of Wisconsin.
In 1987, the RWJF Board of Trustees authorized $8 million to fund a two-year trial of a matching grants program to be called the Local Funding Partnerships program. Many matching grants programs set up by national foundations seek to replicate ideas formulated by the national institution itself. Local Funding Partnerships was to be different. The local community would identify a pressing need, design the strategy for addressing it and put together a funding package that would provide at least one dollar of outside support for every one dollar of RWJF grant money. Each project would have one lead local funder, but additional supporters would be welcomed.
To be eligible, a project would have to fall within the general scope of RWJF's interest in health and health care. But a proposal would not have to meet the kind of specific criteria common to other RWJF programs. Instead of top-down, Local Funding Partnerships would be bottom-up with an emphasis on innovation. RWJF hoped this local "ownership" would ensure sufficient support to keep the project going long after the RWJF grant ended.
From August 2001 through October 2005, staff from the Madre Angela Dental Clinic provided oral health services to impoverished people in Milwaukee. Specifically, the project sought to provide more than 10,000 urgent dental care services, 2,900 dental sealants for children in Milwaukee schools and 800 dental appliances (dentures, bridges, crowns) to people with significant tooth loss or whose appearance limited their employment options. (See Results for more detail).
To accomplish the goals of the project, the project director:
- Hired staff.
- Developed revenue capabilities.
- Utilized the services of two dental residency programs.
- Developed a volunteer program of dentists, hygienists and dental assistants.
- Nurtured the relationship between the clinic's collaborating partners (see Lessons Learned).
- Utilized capital funding from the federal Healthy Communities Access Program to install dental equipment equal in quality to that found in the private practice environment (see Lessons Learned).
Clinic staff utilized a cadre of dental professionals to perform services as volunteers. Initially, staff expected to utilize members from the Greater Milwaukee Dental Association, whose members would volunteer at the clinic four to eight hours per year.
It became clear to staff early on in the grant that a great majority of the association's members were not interested in volunteering. Staff then turned to recruiting a smaller number of "angel volunteers" frequently dentists, also from the Greater Milwaukee Dental Association, who were close to retirement age and who were willing to volunteer four to eight hours every other week.
Throughout the first three years of the project, the clinic utilized the services of two dental residency programs, St. Luke's Hospital and the Marquette University Dental School.
Prior to the start of the fourth year, however, the residency programs were no longer able to work with the clinic due to reimbursement and other financial concerns. The clinic adapted to this loss by decreasing the level of restorative care it provided while increasing the hours of paid dental staff.
The project director replaced the original clinic manager early on in the grant. The original clinic manager lacked dental knowledge and was replaced by a licensed dental hygienist who was more effective because of his dental skills and knowledge of dental practice (see Lessons Learned).
The clinic won several awards, including:
- The Wisconsin Hospital Association's Global Vision Community Outreach Award in 2001. The award recognizes a rural and an urban health care organization that have done an exceptional job of identifying a specific community need, developing a program or service to address the need, and measuring the community benefits derived from the program.
- Finalist designation for the American Hospital Association's NOVA Award in 2002. The NOVA Awards honor effective, collaborative programs focused on improving community health status.
- The Nonprofit Management Excellence Award for Strategic Alliance in 2003. The awards are made by the Helen Bader Institute for Nonprofit Management at the University of Wisconsin-Milwaukee and the Nonprofit Center of Milwaukee. The institute works to improve the leadership and effectiveness of nonprofit organizations through education, research and service.
The clinic also received recognition from:
- Volunteers in Health Care (a national resource center funded by the Robert Wood Johnson Foundation for organizations and clinicians caring for the uninsured) included the clinic as one of three success stories in its report titled, "Success Stories from the Front Lines of America's Health Care Crisis."
- Milwaukee United Way featured the clinic's experience in collaboration in its regionally distributed Resource Guide for Nonprofits." See the Bibliography for details.
Generating Revenue and Funding
The project director reports that development of revenue capabilities was an important strategy for sustaining the project. The clinic works with people with incomes below 100 percent of the federal poverty level and without insurance.
Project staff found that public funding for the clinic, such as the county General Assistance Medical Plan and federal Health Care for the Homeless McKinney Funding, was available to fund services that the clinic provided. All told, the above revenue strategies generated $100,000 per year to support the work of the clinic.
The Greater Milwaukee Foundation, Faye McBeath Foundation, Northwestern Mutual Life Foundation, St. Mary's Hospital Foundation and St. Luke's Medical Center provided $512,000 in matching funds, and the United Way of Greater Milwaukee contributed $130,000 to support this project.
Throughout the grant, the collaborating groups (St. Luke's Medical Center, St. Francis Hospital, Marquette University Dental School and the Children's Hospital and Health System) working with the clinic and Columbia St. Mary's Hospital, the clinic's sponsor, contributed some form of support, including clinic space, employee benefits, administrative services or funding.
The project director reported the following results in a report to RWJF:
- The clinic provided some 13,600 urgent care services over the course of the grant. As the clinic became known to staff of hospital emergency departments and nonprofit organizations serving people in poverty and through word of mouth in Milwaukee, a steady stream of people with urgent oral health care problems, such as swelling, severe pain and bleeding, regularly arrived at the clinic.
- Clinic staff provided more than 4,800 dental sealants to children living in poverty and attending Milwaukee schools. Clinic staff learned that almost all the children attending the Milwaukee public schools are eligible for or enrolled in the county's medical assistance plan, yet they did not have sealants and had poor access to oral health care because so few dentists accept medical assistance coverage. The sealant program provided much needed pediatric preventive oral health care.
- Clinic staff and volunteer dentists provided more than 750 dental appliances, such as dentures, partials, bridges and crowns to poor people with significant tooth loss or whose appearance limited their employment options. This fell short of the original goal, largely because of the level of restorative work that was required for many of the patients to be ready for dentures. Given the level of urgent care needed and the loss of staff from the dental residency programs, the clinic was not able to keep up with the level of restorative dental work that was required to prepare patients for dentures.
- The dental world is not the hospital world. The difference between the two cultures and practices is significant, and understanding the point of view of dentists who volunteer is essential. There was concern among dentists that the clinic environment would be substandard. Even though the population served is poor, to attract volunteer dentists, the equipment cannot be poor and must be equivalent to that of private dental offices. (Project Director/Solberg)
- The clinic manager must have dental knowledge. The original manager was a person with executive director experience who did not have dental knowledge. The project director soon learned that unlike medical clinics, where the manager does not have to be a nurse or doctor, in dentistry it is necessary to have a clinic manager with dental knowledge. The clinic manager for the duration of the grant was a licensed dental hygienist who was effective because of his dental skills and knowledge of dental practice. (Project Director/Solberg)
- Focus time and energy on maintaining a working collaboration. Although Columbia-St. Mary's Hospital sponsored the clinic, clinic staff made a conscious decision to maintain the atmosphere of a freestanding nonprofit organization. This was done to ensure that each of the collaborating organizations (St. Luke's Medical Center, St. Francis Hospital, Marquette University Dental School and the Children's Hospital and Health System) felt that they had a stake in the success of the clinic. The project director reports that understanding what each organization brings to the clinic and what they want to get out of it makes for a successful collaborative process. (Project Director/ Solberg)
- If a niche of care for vulnerable people is clearly identified and communicated, the community will respond in partnership. Several Federally Qualified Health Centers (FQHC's) provide oral health care but they have distanced themselves from care of the truly impoverished and instead have focused on Medicaid and insured patients. The clinic has focused only on people living on incomes under 100 percent of the federal poverty level and has communicated this focus clearly. Foundation support, individual donors and corporate donors have responded to this niche of service. (Project Director)
AFTER THE GRANT
The clinic continues to provide urgent dental care services and dental sealants for children. In addition, it provides restorative care and dental appliances based on available funding. The United Way of Greater Milwaukee continues to fund the clinic, and Delta Dental Plans Association has committed $500,000 for 20062011. The Columbia-St. Mary's Hospital Foundation provides fund-raising and donor solicitation support to clinic staff.
GRANT DETAILS & CONTACT INFORMATION
Collaborative Dental Service Program for Low-Income and Homeless Persons
St. Mary's Hospital of Milwaukee (Milwaukee, WI)
Dates: August 2001 to October 2005
Columbia St. Mary's Hospital is an organization of four hospitals, 28 clinics, a college of nursing, a partnership with the Orthopedic Hospital of Wisconsin, River Woods Outpatient Center and Cathedral Square Urgent Care Center. They have joined together to serve Milwaukee, Ozaukee and Washington counties in Wisconsin.
St. Luke's Medical Center is Wisconsin's largest private hospital. Internationally known for expertise in heart care, St. Luke's also offers care for cancer, digestive diseases and hyperbaric medicine, and houses the Vince Lombardi Cancer Clinic.
Children's Hospital and Health System of Wisconsin is an independent health care system dedicated solely to the health and well-being of children. The 13 entities that make up the health system work to improve the lives of children everywhere through care giving, advocacy, research and education.
Healthy Communities Access Program is a program of the federal Bureau of Primary Health Care. It provides grant funding and technical assistance to a consortia of public and private health care providers as well as social service, local government and other community-based organizations to work together to coordinate and strengthen health services for the uninsured and underinsured in their communities.
General Assistance Medical Plan has been operational in Milwaukee since 1998 and offers health care coverage through a network of community-based clinics. Eligible individuals enroll with a primary care clinic responsible for traditional, managed care gatekeeper functions.
Health Care for the Homeless McKinney Funding. In 1987, the Stewart B. McKinney Homeless Assistance Act, Public Law 100-77, was enacted to provide relief to the nation's rapidly increasing homeless population. The intent of the act was to provide funding for emergency food and shelter, education, and transitional and permanent housing, as well as address the multitude of health problems faced by people who are homeless. Title VI of the McKinney Act added Section 340 to the Public Health Service (PHS) Act, authorizing the Secretary of Health and Human Services, acting through the Health Resources and Services Administration, to award grants for the provision of health care to homeless individuals. The addition of Section 340 to the PHS Act established the Health Care for the Homeless program, the only federal program with responsibility for addressing the primary health care needs of homeless people.
Federally Qualified Health Centers (FQHC's) are nonprofit, consumer-directed corporations that provide care to the underserved and the uninsured. FQHCs include Community Health Centers, Migrant Health Centers and Health Care for the Homeless programs, Public Housing Primary Care programs, and Urban Indian and Tribal Health Centers. There are approximately 722 FQHCs, and 4,059 health center delivery sites in the United States. Federal health center grants, Medicaid, Medicare, private insurance payments and state/local contributions support the health centers.
Delta Dental Plans Association is a dental benefits system made up of independent, affiliated dental service corporations. Delta Dental is a not-for-profit organization with some for-profit affiliates. Delta Dental offers a nationwide package of dental health benefits for a wide range of employers both large and small.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Community Matters. A Review of United Way of Greater Milwaukee's Investment. Milwaukee: United Way of Greater Milwaukee, 2004.
Report prepared by: Barbara Matacera Barr
Reviewed by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: Jane Isaacs Lowe