Community of Practice for Dental Providers Serving Children on Medi-Cal Dental: Needs and Progress in Alameda County

ABSTRACT

Background

California has a shortage of dentists able and willing to treat children in the Medi-Cal Dental Program. A dental community of practice (DCOP) model was used in Alameda County to increase provider skills and capacity and to support their Medi-Cal program participation. This paper describes the Alameda County DCOP and the experiences of the participating dental providers.

Methods

Dental providers were invited to join the DCOP and receive program benefits in exchange for accepting children from the Medi-Cal Dental Program in their practice. A mixed-methods study utilizing surveys and focus groups with participating dental providers was conducted, assessing and documenting their experiences, benefits and challenges of participating in the DCOP.

Results

The DCOP program enrolled 169 dental providers and delivered 14 C.E. courses (49 total C.E. units). Additionally, 132 dental providers completed Wave 1 surveys, and 42 providers completed Wave 2. The majority (68%) felt participating in the DCOP increased their capacity to serve children under age 5 in the Medi-Cal Dental Program. Eight focus groups were conducted with 47 dental providers. Focus groups discussed preferred C.E. topics, serving children in the Medi-Cal Dental Program, community dental care coordinators (CDCCs), family oral health education (FOHE), and the emergent theme of building community among dental providers.

Conclusion

Dental providers felt participating in the DCOP helped increase their capacity and confidence to serve low-income children. They also felt there was value in uniting with colleagues in a community dedicated to improving children’s oral health.

KEYWORDS:

• Community of practice
• children’s dental health
• dental public health
• Medi-Cal Dental
• dental workforce

Introduction/Background

California’s children face high levels of tooth decay, and striking disparities persist when comparing children in the Medi-Cal Dental Program to children covered by private insurance.¹ In Alameda County, 70% of children aged 16 months to 5 years participating in the Women, Infants and Children Nutrition Program (WIC) had tooth decay.² In California, dental care utilization among Medi-Cal Dental-enrolled children increased from 29.8% in 2000 to 39.9% in 2013. Despite this increase, 60% of the state’s low-income children were still not accessing annual dental services in 2013.³ However, in Alameda County in 2015, only 33% of individuals aged 0–20 received any dental service in the first year of enrollment, lower than the state average. There are many well-documented barriers to utilizing dental care, one of which is difficulty finding a nearby dental practice that accepts the Medi-Cal Dental Program, as significantly fewer dental practices accept this program compared to private insurance.^4–6 There have been promising increases in the number and proportion of California dental practices that treat children enrolled in the Medi-Cal Dental Program, with now 40% of surveyed practices willing to treat them, up from 24% from a 2010 report.⁷ However, high disease prevalence persists and utilization is still lower than ideal, especially for the most vulnerable children at higher risk and experiencing more disease.

Dentists serving children enrolled in the Medi-Cal Dental Program consistently cite the barriers they face that prevent their participation in the program. A needs analysis conducted within Alameda County found fewer than 50% of dental providers reported feeling adequately trained to manage and treat pediatric dental patients and indicated the need for Medi-Cal provider support at the local level.⁸ This is a difficult, yet vital, safety net role in community health that has historically lacked financial, logistical and local support. Communities of practice (COP) are one way that professions have united in similar circumstances to foster that support.

COPs are defined as “groups of people who share a concern, a set of problems, and a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis.”⁹ A COP has an identity defined by a shared domain of interest and a shared set of competencies. Participation in the COP model has been used successfully by dementia care champions,¹⁰ by clinical instructors to make effective changes in their teaching practices,¹¹ by dental hygiene faculty to improve teaching skills, and within predoctoral dental education.¹² The overall aim of a COP is to raise the level of quality in a specific field of practice to confront a common problem through shared professional knowledge and socialization.¹³ Dentists who serve children in the Medi-Cal Dental Program could benefit from a COP model, as they possess a shared problem, passion for children’s health, and professional community and expertise.

Historically, dentists in small clinical practices serve with one or few dentists, making regular socialization and peer learning with other dentists unlikely and limiting the opportunity for a COP to emerge naturally. Thus, Alameda County sought to create and support its own COP for dentists serving children in the Medi-Cal Dental Program.

To address the health disparities among children in the Medi-Cal Dental Program and provide support to the dental providers who serve that population, the overall vision of the Alameda County Dental Community of Practice (DCOP) was to build a network of providers who are sensitive to the issues of equitable access to care, knowledgeable about barriers to care experienced by Medi-Cal Dental enrollees and proficient in the application of advances in preventive dentistry, motivational interviewing, and interfacing with local and state administrative payment and monitoring systems. The DCOP program was part of a larger Healthy Teeth Healthy Communities (HTHC) Local Dental Pilot Program funded by the Dental Transformation Initiative (described in more detail later in this paper).^14,15

More specifically, the vision of the DCOP was to be achieved by:

1. Identifying barriers, finding solutions and support for dentists who wish to expand their capacity to serve the target population.

2. Supporting dentists in connecting with peers in the community who are serving the target population by creating formal avenues for sharing experiences and learning together.

3. Engaging and motivating more dentists to better serve children from low-income families in our community.

4. Offering training and education to help increase dentists’ clinical and cultural competency to serve the target population.

The objective of this paper is to describe the Alameda County DCOP and the experiences of the participating dental providers.

Methods

DCOP Program Description

The Alameda County DCOP was designed to bring together dental providers on a regular basis through common activities such as continuing education and sharing what they have learned through mutual engagement. The process was structured to enable joint discussions, joint activities, helping one another and building relationships that enable them to learn from one another – in short, a shared practice. Moreover, the joint enterprise organized around a shared responsibility of serving children in the Medi-Cal Dental Program and a recognition that providers are engaged, not as individuals but as part of a community-wide effort.

Alameda County dental providers (dentists, dental assistants, and other dental professionals) were invited to join HTHC and receive program benefits; all dentists in Alameda County received a mailed invitation to attend the inaugural convening of the DCOP. Additional outreach was extended in person at the first three continuing education (C.E.) course convenings as well as in- person office visits by the community dental ambassador and the DCOP program manager to selected offices. Dentists were informed of the overarching goals of the HTHC project and invited to join the DCOP program, which included:

• Free quarterly C.E. courses on topics of relevance to serving children in the Medi-Cal Dental Program, mostly taught by the UCSF School of Dentistry Faculty and other experts.

• Technical assistance and consultation, which was provided by the community dental ambassador and the DCOP program manager. When necessary, assistance was garnered from the Medi-Cal Dental program field staff.

• Support from a specifically assigned community dental care coordinator (CDCC), part of a community-based workforce reflective of the diverse communities in Alameda County, to identify and reach out to community members not currently utilizing dental care, educate about the importance of early dental care, assist community members with finding and making dental appointments, send appointment reminders, and support appointment attendance and continuity of care.¹⁴

• Incentives to private dental providers for a) delivering family oral health education (FOHE)¹⁶ for families of young children ($20 per visit, up to two visits per year) when delivered in concert with fluoride varnish applications; and b) providing dental encounter forms (an additional $10 per patient per year).

• A free pediatric dentistry mentorship program (17 pediatric dentistry specialists agreed to mentor DCOP members, offering support on treatment planning and accepting referrals of complex cases).

• A COP with quarterly face-to-face C.E./social connections with colleagues doing similar work with a shared purpose.

In exchange for the above benefits, DCOP members agreed to serve children in the Medi-Cal Dental Program in their practice and have data collected from the dental encounter form utilized for each visit. The form served as a billing document for FOHE payments and for defining prospective treatment needs and continuity of care. Dentists could choose how many Medi-Cal Dental Program patients they could accommodate, the preferred ages of the patients, and how frequently and which days of the week they could see new patients from the program (usually through referrals from CDCCs doing community outreach).

Survey Methods

Surveys were developed to measure participating dental providers’ demographic characteristics, practice characteristics, current knowledge, current practices and perceived barriers to serving children in the Medi-Cal Dental Program, their sense of community with other dental providers,¹⁷ and their perspective on aspects of support provided by the HTHC program. Wave 2 surveys included additional items that captured beliefs and perceptions about how their practice had changed since joining the DCOP and their perception of DCOP components.

Wave 1 surveys were administered via e-mail upon enrollment to the program and followed up with in-person paper surveys at C.E. events for those members who did not complete the emailed survey. As new providers joined the DCOP, they were emailed the pretest survey. Wave 2 surveys were collected on paper surveys following C.E. events or via emailed survey links after Zoom C.E. events in the final year of the program.

Descriptive analyses of survey data were conducted using Stata software.

Focus Group Methods

Interview guides were developed with the DCOP leadership and evaluation team and designed to elicit feedback on the key components of the DCOP program, including FOHE, C.E., CDCCs, and serving pediatric populations and Medi-Cal Dental Program members.

All DCOP members were invited via e-mail to participate in a 90-minute focus group to discuss their experience in the DCOP and were offered a $75 Amazon gift card as an incentive. For provider and practice types who were slow to sign up, additional personal communication from HTHC and Office of Dental Health leadership was extended to ensure diverse participation. In 2018, a participant invitation was designed around the job types of participants: private dentists, Federally Qualified Health Center (FQHC) directors, FQHC dentists, and non-dentist providers/staff from both private and FQHC practices. Focus groups lasted 90 minutes, were held in person in a central location in the county, provided dinner, and were led by a trained facilitator and co-facilitator. In 2020, focus groups invited dentists only from both private and FQHC practices, and were held via video conference due to COVID-19 pandemic restrictions.

The project was reviewed by the University of California, San Francisco Institutional Review Board (IRB) and deemed “Not Human Subjects Research,” under the category of Quality Improvement/Evaluation Study (IRB Study #18–25323). Informed consent for focus groups was obtained following Alameda County Office of Dental Health protocol.

To help maintain privacy, focus group participants were asked to give only their first names or were assigned a letter and assured that their names and personal information, including clinic names, would not be used when reporting findings. Participants were also asked not to repeat anything they heard in the focus group, which was particularly important in the focus group of dental providers as many already knew each other professionally.

Focus groups were audio-recorded, de-identified, and analyzed by a single researcher using NVivo software. Pre-determined codes were developed to match DCOP program components: FOHE, C.E., CDCCs and serving pediatric populations and Medi-Cal Dental Program members. Emergent codes were also created after several readings of the transcripts. Sample quotes that illustrate the common themes across focus groups are reported below.

Results

The DCOP program enrolled 169 dental providers representing eight FQHCs, a community health center, and 25 private practices. Most providers were from general dentistry practices that provided care for children but had varying levels of experience and comfort in pediatric dentistry, especially for very young children under age 5 or 6. The program delivered 14 C.E. courses for a total of 49 C.E. units. Some of the course topics included:

• Introduction to dental public health, project overview, dental care coordination, role of dentist network (DCOP).

• Behavior guidance: helping children accept dental care.

• Motivational interviewing.

• Science and practice of early childhood oral health care.

• Science of caries progression and caries management strategies and diagnosis/treatment planning: CAMBRA principles.

• Interim caries management and common pediatric dental restorative techniques.

• Practicing more efficiently with more profitability: stainless steel crowns, space maintainers.

• Pediatric anesthetic and behavior management techniques: expanding your comfort zone to include younger patients.

• Oral health care for children with special needs and pregnant women.

• Tobacco, vaping, and oral health: an action guide for dental professionals.

Surveys

Wave 1 surveys were completed by 132 dental providers (Table 1), and 42 of those same providers completed Wave 2 surveys (Table 2). At Wave 1, providers were most confident in their ability to provide FOHE (59% extremely confident), and the vast majority (88%) affirmed their belief that the HTHC and DCOP programs would help improve the health of Alameda County’s children “quite a bit” (36%) or “a lot” (52%). Participants were only slightly confident in their ability to accept public insurance referrals (52%) and provide care to children under age 5 (49%).

Table 1. Baseline DCOP member description (N = 132).

	Number	%
Professional role (n=128)
General dentist	80	63%
Pediatric dentist	8	6%
Dental assistant	31	24%
Dental hygienist	3	2%
Other (specialist, director, other)	6	5%
Practice setting (n=121)
Federally Qualified Health Center (FQHC)	65	54%
Private	47	39%
Both	2	2%
Other Public	5	4%
Other	2	2%

Table 2. Wave 2 provider survey results (N = 42).

Survey Domain	Percent of providers
How has participation in the DCOP affected the volume of Medi-Cal Dental Program patients ages 0–5 seen by your office? (select one)
Increased patient volume	68%
No difference	20%
Decreased patient volume	3%
Other	13%
Which of the following did your community dental care coordinator (CDCC) help you with? (select all that apply)
Recruiting patients	71%
Scheduling patients	69%
Helping patients show up to appointments	63%
Following up with patients after appointments	60%
Program administrative tasks	57%
Getting patients to attend follow-up appointments	54%
Interpretation/translation	49%
Teaching patients what to expect in a dental visit	46%
Navigating Medi-Cal Dental Program	23%
Other	6%
How much has the DCOP helped you with any of these issues? (1 = no help; 5 = a lot of help)	Mean
Free continuing education	4.62
Training on serving kids under age 5	4.14
Getting kids to show up to dentists’ appointments	3.81
Mentoring support from other dentists*	3.83
Language support*	3.37
Resources to navigate Medi-Cal Dental paperwork and billing*	3.32
Access to sedation/general anesthesia support**	2.95

*n = 41; **n = 40.

The majority (68%) of Wave 2 participants reported they believed participating in the DCOP increased their patient population of children in the Medi-Cal Dental Program, including children aged 0–5. They felt CDCCs were helpful in many areas of navigating patient care, especially recruiting, scheduling and supporting patients to attend appointments, supporting attendance of

follow-up appointments, interpretation/translation, and teaching patients what to expect during a dental visit. When viewing the assistance provided by participating in the DCOP, providers expressed they received “a lot” of help in the areas of free C.E., training on caring for children under age 5, getting families to show up to appointments, and mentoring support from dentists.

Focus Groups

Eight focus groups were conducted with a total of 47 participants. Four focus groups were conducted in 2018, each with a specific provider type: private dentists, FQHC directors, FQHC dentists, and non-dentist providers/staff from both private and FQHC practices (n = 36). Four focus groups with FQHC and private dentists were conducted in 2020 (n = 11).

Below, we describe the feedback on the primary components of the DCOP program: C.E. and serving children in the Medi-Cal Dental Program, CDCCs, FOHE, and the emergent theme of community among DCOP members.

Continuing Education and Serving Children in the Medi-Cal Dental Program

Participants felt the C.E. that was focused on serving children in the Medi-Cal Dental Program was extremely valuable. Beyond the benefit of free C.E. credit, the tailored content was useful and immediately implementable in their practice.

For me, the things I found most useful are the types of C.E. courses. Not just for the C.E. units because I mean you can get C.E. units anywhere for any reason. But that the speakers and the topics have been really catered to serve the underserved. So special needs kids, motivational interviewing, things that really impact a low-income community. I’ve been to plenty of C.E.s about doing the perfect porcelain ceramic whatever, but it’s not as valuable in the public health setting as the workshops we’ve gotten through this one. The experiences from all of the senior dentists have been really helpful to me in expanding my knowledge and then how to put it into practice. Because you learn so much at school and then actually being able to put it into practice is really helpful.

Dental providers felt that dental school did not completely prepare them for complex cases that are seen in the safety net setting, so it was a very important benefit to get relevant training to fill in some of those gaps, as illustrated in the focus group conversation below.

Provider 1: “From my personal experience, I started in the public health. I remember I was drawn into public health when I first got a job. And then I started seeing all those, some were pretty complicated cases. I remember, I emailed my professor [from dental school]. I said, ‘You know what, you guys didn’t teach us how to deal with this.’ We were [upset]. They [dental school] taught us all those easy cases … Now when … all 10 teeth are all bad, what do you do with it? I think - ”

Provider 2: Good idea. That’s such a great idea. Yeah, something about really complex treatment planning for another C.E. with complex dental treatment plans and also maybe medically complex. You touch so little on that in [dental] school.

Providers felt the C.E. training increased their skills and confidence to treat young children, especially for treating cavities or performing holding care for young children, which reduces the need to refer to a pediatric dentist who may have a long wait time for an appointment.

I feel like my comfort in operative has increased … kind of going outside my comfort zone so that I can avoid sending people to the operating room. … And not just doing the exams and then refer, exams and refer. But, actually, doing more treatment … So SDF [silver diamine fluoride] and glass ionomer and holding care. Kind of increasing my comfort with using those options. Because I felt like coming out of school, it was either do a definitive something or nothing at all and refer. So if a kid is behaviorally challenging and able to at least tolerate something quick like a scoop and fill then that really helps keep them out of the operating room … I feel like from participating in the C.E.s, I’ve gained more confidence in that kind of dentistry.

Providers especially appreciated the opportunity for hands-on and in-person practice offered in the form of role play during C.E. sessions, practice lap exams with a doll, or the clinical training held at the UCSF dental school.

Especially with those hands-on components … Those teaching the lap-to-lap exams for people who have never done it and the motivational interviewing. And being able to do that without having a person in front of you, I imagine would be much harder.

Participants understood the need for virtual education during the COVID-19 pandemic, but really valued many aspects of in-person education and think that is valuable to return to.

[Zoom breakout rooms] did yield some great conversations, but anything involving anything hands on. There’s no substitute for those in-person classes.

In addition to the clinical care aspects covered in C.E.s, providers appreciated the training focused on motivational interviewing and behavior change.

The motivational interviewing, I found that one was a very helpful C.E. Because as we know and we’ve discussed extensively you can fill the fillings without treating the disease. And you can fill a tooth without actually addressing the problem. So, I’ve been utilizing the motivational interviewing since that C.E. It’s been over a year, I think. That’s really helped getting parents motivated because I often see a family and I see all the siblings and the parents. So if you can at least make those incremental steps. I found that, that even makes things easier because I found that by the time they come back for their recalls, it’s not like I have to start from scratch again. So take all of it, right. It’s the treatment itself, it’s the behavior and modification for the family and everything.

Community Dental Care Coordinators (CDCCs)

Most providers felt that CDCCs were extremely valuable additions to their dental care team. CDCCs were able to spend the necessary time to get appointments scheduled and remind and support patients to attend those appointments.

The [CDCC] is contacting the families and doing follow-up with them because then they’re making their appointments. They come in and then she follows up with them to make sure they get in to get the work that needs to be done. Having her there is awesome.

Our [CDCCs] are really good at following up with our patients and scheduling their appointments, trying to accommodate the schedule for them to come in.

CDCCs also helped make sure that patients attended their recall appointments.

[CDCCs] are really good at making sure the patients don’t fall through the cracks. They’re really on top of getting them into their six-month recalls. They go out of their way to call them and make sure everyone gets seen.

CDCCs had the time to build trusting relationships with patients and increase patient access to the dental care system.

The care coordinators have been doing such a good job. They’re always advocating for the patients. The patients love them. [The patients] feel really comfortable with them and they educate them on oral hygiene. They’re just really easily accessible. It’s really hard to get through to our clinic, but they give them their direct numbers so it’s a lot more accessible for the patients.

CDCCs can extend that trust to dental providers by prepping them about individual needs and preferences of each new patient prior to the visit.

[The CDCC] let us know, for example, if a patient is autistic or if they have any … if they would like to be called certain stuff, we know ahead of time and when we see them, we call them by that and they already start being happy. Little stuff like that, I think, matters.

They also provided needed language translation and interpretation services.

Provider 1: [CDCCs] really go out of their way to help the patient.

Provider 2: “And then if [the patient] can’t speak English, they usually have a coordinator that can help ‘em with whatever language. [The coordinator] will call us and they’ll come in the back with us”. [where the patient is receiving treatment]

The highest satisfaction came from FQHCs that had a large enough patient volume to work with a single CDCC and develop a relationship. Private practices that might be working with a few CDCCs covering their region of the county sometimes felt confusion about who their CDCC was and that it could be disjointed for patients to have a new person speaking to them about their dental care. They also expressed distrust that shared CDCCs were equitably distributing patients across practices.

Family Oral Health Education (FOHE)

FOHE is educational material based on a preset educational inventory emphasizing primary prevention originally developed for the ABCD Program (Access to Baby and Child Dentistry) by Washington State Dental Service. The material was later adopted by Alameda County, for which private practices get an additional $20 per patient visit (up to twice per year) when they provide FOHE in combination with fluoride varnish applications . During the focus group, dental providers reported delivering FOHE to their patients.

[FOHE] is helpful. I mean we explained to the patient that this is a preventative thing and they appreciate it, especially with the small ones. I only had one kid who was two years old and you can teach the mother to catch and straighten this out now. So [you can tell them], don’t worry about it. Don’t worry about it.

FOHE was delivered by different providers in different practices. Some FOHE was given by dental assistants who spoke the preferred language of patients.

So it’s in the clinics, it’s not the doctor … or you can do it chairside, but really it’s the assistants. And … I’m going to tell you, the mainline reason is because the dentists don’t speak the language.

Sometimes education was more of a team approach, often with multiple staff members repeating or reinforcing the educational points throughout the patient visit.

Dentist: “On the first visit, I usually do [FOHE], but on the second I ask my staff [to do FOHE] because [they] really like talking about oral hygiene and diet.”

Community

An emergent theme that came out of the focus groups was the idea of a shared community with other members of the DCOP. This was fostered by meeting in person, having a table-based seating format that encouraged discussion with colleagues at shared tables, and opportunities to talk with other attendees at the C.E. to meet and learn from other providers in Alameda County.

Just having the dynamics at the table to discuss treatment planning phasing and what materials we’re using in our clinic versus another clinic, just having those conversations has been great.

Whenever I sit down at a table at the various C.E.s … picking their brains a lot, and you get to know them, and then kind of through that, a lot of the networking … It’s really cool to see how long a lot of them have been a part of these public health initiatives … It’s really inspiring and it’s made me want to stay in public health rather than go to the private sector.

Providers felt a shared sense of responsibility and purpose.

We all have a common responsibility to our patients and making sure that our population of pediatric patients doesn’t have to wait months and months to see a specialist.

There was a lot of clinical people [at C.E.s] that I didn’t know that worked at the clinic down the street. Now I know them, and so just creating that network of … ‘Hey, we’re all in the same situation.’ … we are all managing those as a whole together, even though we’re all separated by different clinics or just being down the street from one another.

The goal is to increase access to care, especially for pediatrics. And it has as many resources as you guys have. I think of this as a uniquely beneficial program.

They also felt a shared sense of values with other providers who have taken up the mission of providing care for the most vulnerable children.

I feel like I’m kind of an idealist. I like the philosophies behind it. I feel like that aligns with my values and I feel like the dental profession can get quite bombarded with the for-profit mindset and the ‘what’s the next technology, how many implants are you placing’ and less talk about health. As in dental health, as a part of overall health. So, I think that the philosophies of Healthy Teeth Healthy Communities, really expressing community oral health and individual oral health as a benefit to quality of life, I have found that most beneficial … Because I haven’t had the world beat the optimism out of me yet, so the philosophies are very important to me.

Discussion

The DCOP model within the Alameda County Healthy Teeth, Healthy Communities Local Dental Pilot Program created a real-life demonstration of a collective community-wide effort by providers capable of addressing the oral health care needs of the high-risk low-income population of children and youth enrolled in the Medi-Cal Dental Program. Despite the prevailing narrative that dental providers were not capable or simply unwilling to participate in the public insurance program, the DCOP was designed in direct response to the barriers for both providers as well as enrollees enumerated in the legislatively convened Little Hoover Commission (2015) and Report entitled “Fixing Denti-Cal.” In the words of the commission, the program is “broken” beyond fixing and needs to be abolished and rebuilt from scratch. While the Alameda County pilot was not designed to build a new system from scratch or influence reimbursement levels for service, it did develop and implement a pilot that responded to nearly all recommendations asserted by the commission. These recommendations include incentives to motivate dentists’ participation backed by a robust C.E. training and technical assistance program and an extensive case management/care coordination system to conduct “outreach at the community level” to overcome logistical, financial, educational and socio-cultural barriers “to get eligible patients appointments with dentists and keep them and to build a customer-focused program to foster a stronger relationship with providers.”¹⁸

Dental providers greatly valued the opportunity to learn from peers and share their experiences with colleagues. They appreciated the focus on providers who serve children in the Medi-Cal Dental Program, acknowledging the unique barriers they face in serving this high-needs population and recognizing the shared public health mission rather than the profit-driven mission often present in dental education for broader audiences. Providers appreciated the support of the CDCCs, acknowledging the extra support needed by children in the Medi-Cal Dental Program and underscoring previous literature on the value of care coordination.

This study had a major limitation of low participation in Wave 2 survey data collection, making it infeasible to compare attitudes and practices before and after participation in the program. It is possible that low participation in Wave 2 surveys was heavily influenced by COVID-19 restrictions in 2020 and needing to switch to a virtual C.E. format. Previously when participants did not participate in the survey by e-mail, they were given a paper survey at the next C.E. event they attended. This option was not possible in Wave 2 in 2020. Focus group participation was voluntary, and it is possible that those who chose to participate in the focus group were somehow different than the larger DCOP membership. However, the comments from the focus group largely matched what was collected in the survey with the larger group, increasing our confidence in the representativeness of the focus group findings.

Alameda County Office of Dental Health has identified and committed financial resources to continue the DCOP beyond the conclusion of the initial grant funding. It has continued to partner with UCSF and convenes the C.E. program quarterly. Moreover, the county continues to incentivize private dental providers with reimbursement for FOHE. While funding restrictions have limited the CDCC staffing, the Office of Dental Health has retained staff for that function and persists in attempts to expand that function with anticipated state funding. Several of the FQHCs have continued to fund their CDCC staffing, recognizing the return on investment in continuity of care, fewer missed appointments and better health outcomes.

Conclusion

Beyond these individual structural and program components,¹⁴ dental providers felt that serving children on Medi-Cal required additional support and community connection and that the HTHC DCOP helped increase their capacity to serve low-income children. The DCOP was a bold vision transforming the traditional culture of individual dental practices by bringing together providers to learn from each other and feel a shared mission and providing them with the specific skills and support to serve this population. The DCOP model described here provides evidence to promote future collective action of dentists. Dental and policy leaders are urged to create the necessary infrastructure to implement the community of practice as a “best practice” to support dentists and ultimately the communities they are purposed to serve.

Acknowledgment

Healthy Teeth Healthy Communities (HTHC) is a project (Domain 4) of the Local Dental Pilot Program (LDPP) under the Dental Transformation Initiative (DTI), funded by the California Department of Health Care Services (DHCS). The authors thank the leadership and Office of Dental Health of Alameda County for their constant support for this Project. They also thank Bahar Amanzadeh, principal project architect and lead author, Lisa Haefele, and others for their role in writing the grant that supported this work, and Claudia Guerra for assistance with focus group data collection.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The work was supported by the California Department of Health Care Services [Dental Transformation Initiative (DTI)].

Notes on contributors

Kristin S. Hoeft

Kristin S. Hoeft, MPH, PhD, is an associate professor of oral epidemiology and dental public health at the University of California, San Francisco, School of Dentistry.

Yilak Fantaye

Yilak Fantaye, MPH, is with community assessment, planning and evaluation at the Alameda County Health Care Services Agency, Public Health Department.

Benjamin W. Chaffee

Benjamin W. Chaffee, DDS, MPH, PhD, is professor of oral epidemiology and dental public health at the University of California, San Francisco, School of Dentistry.

Suhaila Khan

Suhaila Khan, MD, MPH, PhD, is the past project director of Healthy Teeth Healthy Communities of the Office of Dental Health, Alameda County Public Health Department.

Elizabeth Maker

Elizabeth Maker, DrPH, is Evaluation Manager at the Alameda County Health Care Services Agency, Public Health Department.

Tracey Andrews

Tracey Andrews, RDH, MPH, is a Tobacco Control Program Specialist at the Alameda County Health Care Services Agency, Public Health Department.

Ray Stewart

Ray Stewart, DMD, MS, is professor and chair of the division of pediatric dentistry at the University of California, San Francisco, School of Dentistry.

Ling Zhan

Ling Zhan, DDS, PhD, is a professor and chair of the division of pediatric dentistry at the University of California, San Francisco, School of Dentistry.

Bhavana Ravi

Bhavana Ravi, DDS, MPH, is a general dentist in private practice. She previously served as Training Manager of the Dental Community of Practice within the Alameda County Public Health Department.

Jared Fine

Jared I. Fine, DDS, MPH, is a dental public health consultant and former dental health administrator at the Alameda County Public Health Department.