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Afterword to the Evaluating the Dental Pipeline Program Report: The California Dental Pipeline Program, Phase II

Key words: California dental schools, shortage of dentists, minority student recruitment, community-based dental education

Despite the significant accomplishments of the Pipeline, Profession, and Practice: Community-Based Dental Education program outlined in this report, oral diseases continue to have a disproportionate impact on racial and ethnic minority communities, and even more racial and ethnic minority dentists are needed.¹ Further, most rural areas in California have shortages of dentists, and the state has many low-income urban communities where many racial and ethnic minorities live.² Efforts to expand care to underserved urban and rural communities through safety net facilities such as federally qualified health centers (FQHCs) face challenges in recruiting and retaining dentists because of relatively low salary structures. Many FQHCs also could use practice management improvement.³

In response to these continuing needs, The California Endowment worked closely with the five dental schools in California (Loma Linda University; University of California, Los Angeles; University of California, San Francisco; University of the Pacific; University of Southern California) and the National Program Office at the University of Connecticut and Columbia University to design and implement the California Dental Pipeline Program, Phase II. The ambitious objectives of this program over three years are the following: 1) to double the total number of underrepresented and disadvantaged students admitted to California dental schools; 2) to further integrate cultural competence throughout the dental school curriculum, especially in the operations of the school-based clinics; and 3) to further expand community-based dental education and training opportunities through placements of residents and students and establishment of financial partnerships with FQHCs. The overall goal of the program is to improve access to oral health care for underserved communities throughout California. The University of the Pacific (UOP) Arthur A. Dugoni School of Dentistry has been established as a California Program Office, with program co-leadership from Paul Glassman, associate dean at UOP; Howard Bailit from the National Program Office/University of Connecticut; and Sandra Bolivar, assistant dean of admissions, minority, and student affairs at the University of Southern California School of Dentistry. The California Endowment’s three-year grant of $6,276,449 was made to UOP, with a project start date of September 1, 2007.

	Objectives of the Pipeline Program, Phase II

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Increased Admission of Underrepresented Students
Under the California Dental Pipeline Program, Phase II, California’s five dental schools will continue to work collaboratively to recruit and admit students from groups that are underrepresented in dentistry, with the objective of doubling the total number of underrepresented and disadvantaged students admitted by all five schools by the end of the third project year. Activities will include use of an updated joint recruitment brochure, dozens of joint presentations and outreach activities, annual convenings of college health advisors and academic counselors, and support for predental student associations. The schools also will continue to work with the California chapters of the National Dental Association and Hispanic Dental Association to recruit and mentor underrepresented dental students.

As part of these efforts, the five schools also will continue to jointly operate two postbaccalaureate programs, one in Northern California and one in Southern California, with up to twenty-five underrepresented and disadvantaged students participating per year. Each dental school will recruit undergraduate students who have a demonstrated commitment to pursue dentistry as a career in underserved communities and who were either unsuccessful applicants to dental school on their first attempt or have not yet applied to dental school because of weak academic records and standardized test scores. Students admitted to the one-year postbac program will spend the summer taking advanced coursework in the basic sciences, preparing for the Dental Admission Test, conducting research, and participating in problem-based and group projects. Since 2002, 135 students have completed these two postbaccalaureate programs, with nearly 100 percent succeeding in being admitted to a dental school. The six University of California medical schools have been inspired by the dental schools to better coordinate their own postbaccalaureate programs.⁴

Cultural Competence in Dental Education and Training
The dental schools also will continue activities to further integrate cultural competence into dental education and training.⁵ The knowledge, attitudes, and skills of students and residents to care for diverse patients will be continually assessed as part of the didactic curriculum, including possible application of the Association of American Medical Colleges (AAMC) Tool for Assessing Cultural Competence Training (TACCT).⁶ (Use of the TACCT by dental schools would be consistent with the recent partnership between the AAMC and ADEA to work together in disseminating educational resources for their respective professions.)

In addition, the five dental schools will develop and implement strategies to increase the cultural competence of both school-based and community-based dental clinics that provide care to diverse patient populations. The strategies will include assessing the language skills of staff, students, residents, and faculty members and ensuring the availability of interpretation services. The integration of cultural competence into dental education provides the opportunity for the students to learn about the importance of cultural factors in communication, health beliefs, treatment choices, and oral health maintenance.

Community-Based Dental Education and Training
California’s five dental schools also will continue to increase the time senior dental students and general and pediatric dentistry residents spend in patient-centered community settings. The goal is to increase these community rotations to sixty days from the current average of fifty days. The students and residents will treat an average of eight patients per day. This model of care has already expanded oral health services to underserved communities in the state and exposed the clinics to the latest advances in oral health care technologies and techniques. The students and residents report positive learning experiences and appear more productive in school-based clinics after completing their community rotations. The dental schools will also work to increase the number of community partnerships from approximately seventy sites throughout the state. Despite the success of community-based dental education, dental schools are reluctant to send more students and residents to community settings because of a persistent perception that students are better trained and could be generating revenues for the school at school-based clinics. The community clinics are concerned that supervision of the students takes time away from their dentists for direct patient care and increases operational costs for additional staff, supplies, and equipment to support the students and residents. To address these issues, the California Program Office will establish an incentive fund to support financial partnerships between the five dental schools and a total of up to fifteen FQHCs (up to $54,000 per partnership over the three-year project period). The schools and clinics will be responsible for negotiating how best to enhance and share the revenues the students and residents generate through their rotations at the clinics.

As part of the initial Pipeline program and the planning for Phase II, the dental schools have had extensive discussions around this issue with the U.S. Department of Health and Human Services Health Resources and Services Administration, the California DentiCal program, the California Primary Care Association, several FQHC dental directors, and other key stakeholders. All have agreed on the feasibility of developing mutually beneficial revenue-sharing models and are enthusiastic about the potential such a model could have for both the dental schools and the FQHCs.⁷ Each school will continue to work with its existing community clinic partnerships and focus on developing three of these financial partnerships with support of the incentive fund. By the end of the three years, it is expected that the model will have sufficient evidence of viability to be replicated through additional partnerships without the start-up incentive funds.

As a component of the dental school/FQHC partnerships, the California Program Office will develop an assessment process and organize and train a team of management consultants who will work with the FQHCs to improve the effectiveness and efficiency of their operations. These management consultants will conduct on-site assessments to provide the partnership with a report of opportunities to improve both the operations of the clinic and effectiveness of the partnership. Given that the dental schools have significant expertise in teaching students about best office and operational management practices, the schools can offer this technical assistance to enhance the dental operations at the FQHCs. Also because the dental schools have faculty who train specialists and can offer specialty referrals and consultations, they are interested in exploring collaborative models for providing more specialty consultations to FQHCs, perhaps through emerging telehealth applications. The schools and the California Program Office will then be available to continue to provide ongoing technical assistance and consultations to enhance the efficiency and effectiveness of the clinic dental operations. (Management consulting services may include assistance with improving scheduling systems; balancing emergency versus comprehensive care; data analysis; creating a management manual; education/training of dental staff on operational and management issues; exploration of alternative models of delivering care without such significant reliance on MediCal reimbursements; endodontic training; telemedicine specialty consultations; greater access to other specialty services; and financial management training.)

Oral Health Policy and Systems Change
Finally, to ensure long-term sustainability of these activities, the dental schools in California also will reconstitute an Oral Health Policy Committee to achieve three primary objectives: 1) help coordinate the response of the five schools to policy issues impacting recruitment of underrepresented students, cultural competence, and community-based dental education, which develop over the life of the grant; 2) select two policy issues to promote with key stakeholders⁸ (e.g., enhanced payments to schools for treating DentiCal patients or a state-funded graduate education program for dental residents who provide care to underserved patients at dental schools or community clinics); and 3) identify special research projects to support the objectives of the California Pipeline program. One of the co-directors of the National Program Office, the former dean of the Columbia University School of Dental and Oral Surgery who successfully implemented diversity initiatives at his dental school,⁹ will continue in a consultant role and directly engage the five deans of the California dental schools on a leadership strategy to reinforce their commitment and sustain momentum on these issues.

The California Dental Pipeline program will also enter into three-year subcontracts with two key stakeholder organizations, the California Dental Association (CDA) and the California Primary Care Association (CPCA), to support the schools’ work on oral health policy issues. The CDA and the CPCA also will engage other oral health policy advocates working in California such as the Oral Health Access Council and the Dental Health Foundation.

Evaluation
The California Program Office at the University of the Pacific will work with all five dental schools to continue collecting and reporting key data on outreach, recruitment, admissions, cultural competence education and training activities, community rotations, and implementation of the partnerships with FQHCs. In addition, TCE has awarded a separate contract with the American Dental Education Association (ADEA) to undertake an independent evaluation of Phase II of the California Dental Pipeline Program. This evaluation will expand on the evaluation of the National Evaluation Team at the University of California, Los Angeles, conducted for Phase I and documented in this report. By engaging the national dental education association that oversees the dental schools to conduct the evaluation, this type of monitoring will become an ongoing function of ADEA.

	A Vision for Change

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The California Endowment is proud to make this vital and timely investment in dental education and training that will build on the momentum and accomplishments of the five California dental schools in Phase I of the Pipeline program to make lasting changes in the diversity of dentists and the capacity to meet the challenges of unmet oral health needs in California. Perhaps the most unexpected, yet critical, systems change success of Phase I has been the degree of collaboration among the five dental schools in student recruitment and preprofessional health advisor training, along with their willingness to share best practices, work through challenges collectively, and hold each other accountable for results. This level of collaboration is expected to continue beyond the life of the Phase II grant, as all dental schools will continue to derive benefits from the economies of scale.

The unprecedented collaboration among the five California dental schools has resulted in a larger and better prepared pool of underrepresented students, which begins to approach the critical mass needed to sustain such diversity initiatives.^10,11 In Phase II, that collaboration will be further strengthened with closer working relationships with other key statewide stakeholders such as the California Dental Association and the California Primary Care Association. Phase II truly represents the best in collaboration towards the vital goal of more effectively meeting the challenges of oral health needs in California.

	Author Information

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Mr. Zamora is Statewide Program Associate, The California Endowment, and Mr. Bau is Program Director, The California Endowment. Direct correspondence and requests for reprints to Mr. George Zamora, The California Endowment, 1000 N. Alameda Street, Los Angeles, CA 90012; 213-928-8757 phone; 213-482-9633 fax; gzamora{at}calendow.org.

	REFERENCES

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1. Oral health in America: a report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. At: www.surgeongeneral.gov/library/oralhealth. Accessed: May 25, 2007.
2. Mertz E, Grumbach K, MacIntosh L, Coffman J. Geographic distribution of dentists in California: dental shortage areas, 1998. San Francisco: University of California, San Francisco, Center for California Health Workforce Studies, 2000.
3. Bailit HL, Beazoglou TJ, Demby N, McFarland J, Robinson P, Weaver R. Dental safety net: current capacity and potential for expansion. J Am Dent Assoc 2006; 137(6):807–15.[Abstract/Free Full Text]
4. California Postbaccalaureate Consortium. At: https://meded-postbac.ucsd.edu. Accessed: June 1, 2007.
5. Saleh L, Kuthy RA, Chalkley Y, Mescher KM. An assessment of cross-cultural education in U.S. dental schools. J Dent Educ 2006; 70(6):610–23.[Abstract/Free Full Text]
6. Association of American Medical Colleges. Tool for Assessing Cultural Competence Training (TACCT). At: www.aamc.org/meded/tacct. Assessed: May 13, 2008.
7. Bailit HL, Beazoglou TJ, Formicola AJ, Tedesco L. Financing clinical dental education. J Dent Educ 2007; 71(3):322–30.[Abstract/Free Full Text]
8. Gehshan S. Policy issues in dental workforce diversity and community-based dental education. Los Angeles: The California Endowment, 2004.
9. Formicola AJ, Klyvert M, McIntosh J, Thompson A, Davis M, Cangialosi T. Creating an environment for diversity in dental schools: one school’s approach. J Dent Educ 2003; 67(5):491–9.[Abstract]
10. Grutter v. Bollinger, 539 U.S. 306 (2003) (U.S. Supreme Court’s upholding of University of Michigan Law School’s policy to ensure a critical mass of URM students to achieve the educational benefits of a diverse student body).
11. Sinkford JC, Valachovic RW, Harrison SG. Continued vigilance: enhancing diversity in dental education. J Dent Educ 2006; 70(2):199–203.[Free Full Text]

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