C.E. Credit. Alternative Pathways in Dentistry: Working at Federally Qualified Health Centers

ABSTRACT

Background

Federally Qualified Health Centers (FQHCs) play a crucial role in providing affordable and high-quality health care services to underserved populations in the United States.

Objective

This article explores promising career options presented by FQHCs, with a specific focus on dental services within community-based health centers. Dental professionals play a significant role by providing much needed dental services for underserved communities by addressing health care disparities. This article also discusses the advantages and challenges of working as a dentist in an FQHC, while outlining the various ways dental professionals can get involved in this health care setting.

Conclusion

By choosing to work in FQHCs, dentists can contribute to improving the oral health and overall well-being of some of the most vulnerable members of their communities. This manuscript presents an overview of FQHCs and discusses roles of a dentist working at an FQHC.

Continuing Education Credit Available: The practice worksheet is available online in the supplemental material tab for this article. A CDA Continuing Education quiz is online for this article: https://www.cdapresents360.com/learn/catalog/view/20.

KEYWORDS:

• FQHC
• Alternate pathways in dentistry
• Community and Public health dentistry

Introduction

Federally Qualified Health Centers, also known as community health centers, serve patients with limited access to health care. FQHCs emerged during the federal anti-poverty initiatives of the 1960s to improve the well-being of low-income Americans. As part of this effort, the Economic Opportunity Act of 1964 created Community Action Agencies, which began offering health care services in their communities. The arrival of Medicaid in 1965 gave rise to the Community Health Center program, which eventually led to the establishment of FQHCs in the 1970s.^1,2 Today, there are over 1,100 FQHCs across the United States and about 180 FQHCs in California.³ These centers deliver interdisciplinary and high-quality comprehensive primary care services with the help of qualified professional staff.

A defining characteristic of FQHCs is their consumer governance mandate, which requires that at least 51% of the governing board must consist of patients of the health center. Furthermore, the board as a whole is required to “represent the individuals being served by the health center.” This dedicated volunteer board convenes monthly meetings and holds responsibilities for annual budget approval, strategic planning, oversight for grants and operations, as well as general clinic operations and evaluation of the health center.⁴ It’s important to note that at each FQHC, payment is determined based on the patient’s ability to pay. FQHCs are a crucial partner for state and county public health programs in achieving service delivery and work very closely with other community-based organizations that address the social determinants of health.

FQHCs as a Safety Net

FQHCs serve as a key part of the safety net for uninsured, underinsured, those insured through Medicaid, and the underserved, immigrant, and vulnerable populations and deliver primary care services in an outpatient clinic setting. FQHCs aim to provide whole-person care through an integrated multidisciplinary care model.²

FQHCs provide health care services while also addressing barriers for care, therefore these entities are located in health professional shortage areas. An FQHC is designated as an urban or rural entity based on definitions in Section 1886(d)(2)(D) of the act.² Health professional shortage areas (HPSA) are designated based on the shortage of primary care services in a specific geographic location to serve the population. Target population refers to the specific group or demographic that an FQHC aims to serve, while the service area population encompasses the broader community or geographic region from which individuals may be drawn from. The state of California, in particular, has seen a significant increase in the number of patients served by FQHCs, with a substantial rise in both medical and dental visits, sites, and employees since 2013.⁵

To address disparities in access to oral health care, the Institute of Medicine and the National Research Council recommend that the HRSA further expand the capacity of FQHCs to deliver essential oral health services.⁶ These centers have expanded their reach and reduced the percentage of uninsured patients. Dental providers specifically have played a vital role in this expansion, providing dental care to a diverse patient population. In 2019, California’s 180 FQHCs served 5.3 million patients and generated 26.4 million patient visits, equating to increases of 40% in patient care and 66% in dental visits over the seven-year review period driven by team-based care and integration of services. California health centers have also expanded from 1,347 delivery sites in 2013 to 1,963 delivery sites in 2019, with the percentage of uninsured patients decreasing from 39% to 19%.⁷

Culturally and Linguistically Appropriate Care

In an attempt to provide care within the cultural context and allow the patient to take an active part in their care, FQHCs are committed to delivering culturally and linguistically appropriate services to all patients. This is achieved by implementing the following practices:

1. Assessing the racial and ethnic diversity of our population.

2. Assessing the language needs of our population.

3. Providing interpretation or bilingual services to meet the language needs of our population.

4. Providing printed materials in the major languages of our population. A health center is required to make translation services available and to post materials in the languages spoken by more than 10% of patients.

5. Recruiting and retaining staff and clinicians who can deliver care to meet the needs of the patients in a culturally sensitive manner.⁸

FQHC regulations reserve certain key functions and responsibilities for the governing board of the health center and play a critical role in the selection and dismissal of the FQHC chief executive officer (CEO) and project director.⁴ The lines of authority are clearly defined, as the board delegates responsibility and leadership to the full-time CEO, who is responsible for appointing, supervising, and retaining the rest of the executive team/C-suite management.

FQHCs provide multidisciplinary care in the areas of medicine, dentistry and behavioral health. All clinical staff, including those providing services on behalf of the FQHC through formal written contracts, must be credentialed and privileged by the FQHC, which may include a formal peer review process. All clinical support staff are also credentialed and privileged periodically.

Finances

FQHC revenue is generated from direct patient care, grants and incentives from the different payers and managed care plans. Following are the revenue streams:

• Section 330 Grants, Health Resources and Services Administration (HRSA) – This grant helps subsidize the cost of providing care to the most vulnerable populations.

• Prospective Payment (PPS) System – These payments are based on the actual costs of care, which allows health centers to ensure adequate reimbursement. With the FQHC model, health centers are incentivized to see these patients through the optimal reimbursement rates. This allows FQHCs to focus on the populations and communities that have traditionally not had adequate access to health care.

• Value Based Care/Alternative Payment Methodology (APM) – In this model, the health centers are reimbursed based on the health outcomes of the population, helping patients improve their overall health by living healthier lives.⁹

• Payer Incentives – These incentives are paid by health plans to the health center program for meeting quality metrics.

Services Offered at FQHC

Required Services

FQHCs are mandated to provide primary care services under the scope of the project as set by the HRSA under the federal Section 330 grant program. Other required services include diagnostic services, health screenings for chronic diseases, coverage for emergencies during and after hours, immunizations, well child services, women’s health, preventative dental services, pharmacology services, community health education and outreach programs.¹⁰ Assistance is also provided with eligibility and addressing the social determinants of health with other health center support staff.

Additional Services

These services include additional dental services including restorative care, oral surgery, behavioral health (mental health, substance use), optometry, recuperative care program services, environmental health services, nutrition, occupational therapy, physical therapy, speech-language pathology/therapy, complementary and alternative medicine, and other additional enabling/supportive services.

Dental Services at FQHCs

Dental clinics are typically co-located with the primary health care centers at FQHCs. Health center dental programs provide diagnostic, preventive, restorative dentistry, rehabilitative, and surgical procedures. The main focus is on the public health principle of health promotion, oral health education, and disease prevention, considering the 2016 Global Burden of Disease Study that reported untreated dental caries in adult teeth (No. 1), severe periodontitis (No. 11), untreated dental caries in baby teeth (No. 17), and severe or complete tooth loss (No. 29) to be among the 30 most prevalent diseases.¹¹

The dental health professional shortage in specific parts of the nation, as of the writing of this paper, impedes timely management of dental diseases, thereby leading to pain and acute dental/oral conditions. Research and policy changes over the past 20 years have made substantial advances in the understanding and treatment of oral diseases and conditions. FQHC dentists are challenged to meet the needs of the community and need to constantly develop innovative ways to provide quality services with limited resources.

Mobile Dental Units

Health centers often utilize mobile dental units (MDU) to provide dental services to their patients as an adjunct to existing dental clinics or as the only access point for dental services. This service delivery helps to address the barriers of transportation and will help reach patients in rural communities. MDUs serve schools, homeless shelters, and other community locations and offer diagnostic, preventative and restorative services for our vulnerable populations. This allows dentists to meet the patients where they are and allows the patients to access services and address their dental needs. The vehicle used for the MDU can be utilized for both medical and dental services, such as vaccinations and well child visits supplemented by fluoride and SDF applications, thereby integrating dental and primary care. As the number of programs and sponsorship have grown, states have increased efforts to regulate these programs.¹²

Teledentistry

FQHCs have led the way to incorporate teledentistry as an alternative modality for the provision of select dental services. Utilizing both synchronous and asynchronous teledentistry, patients can be evaluated by the dentist and their needs addressed.

Unique Nature of Working at a FQHC

The dentist who works at an FQHC is faced with several unique advantages and challenges that are not as frequently encountered in other dental settings. Many of these unique characteristics are shaped in large part by the patient populations that FQHCs strive to serve.

Working with a diverse patient population: According to the HRSA Uniform Data System (UDS) report for reporting period 2022, 29.71% of the nearly 5.3 million California FQHC patients were children under the age of 18 years, 63% were Hispanic/Latino, 37% spoke a language other than English, and 93% of FQHC patients with known incomes were at or below 200% of poverty FPL. The 2022 UDS data five-year summary shows that the percentage of patients who preferred to be served in a language other than English increased slightly from 35.52% in 2019 to 37.16% in 2022. This information provides an opportunity to provide care within a cultural context.

Lack of oral health access leads to inequities, which leads to further health care disparities. Approximately 20% of California communities have a shortage of dentists. Geographic maldistribution of dentists may contribute to poor access to dental care. Two-thirds of dental shortage communities are rural. Communities with higher percentages of minorities, children, and low-income persons also experience a higher need of services but fewer dentists.¹³ The Oral Health Workforce Research Center (OHWRC) study findings indicate a concerning reduction in oral health staffing nationwide at FQHCs. Several patients have gone without a dental visit for years or only visit a dentist when experiencing pain related to the mouth. All these factors lead to patients having high dental treatment needs.

Advantages of Working in an FQHC

Dentists working in FQHCs enjoy numerous advantages, including the opportunity to provide culturally competent, affordable, integrated care to underserved populations. The dental providers are trained with an eye for population health following minimally invasive dentistry principles. More focus is on quality of care, and the quality metrics are reviewed periodically using quality dashboards. Dental team members are mandated to attend training to keep them informed and updated about the populations they serve.¹² Dental providers working at an FQHC provide a full scope of services to meet the needs of the patients, and referral arrangements are in place for patients who need specialty services. There are also opportunities to work with fellow dentists, learn from each other, and build great camaraderie through organizational meetings and team celebrations.

Programs like the National Health Service Corps Loan Repayment Program and the State Loan Repayment Program offer financial incentives for dentists committed to providing care at FQHC settings. Newer graduates practicing in dental provider shortage areas (DPSA) are likely to benefit from loan repayment programs if they are committed to stay for two years or more.

Malpractice insurance provided to the clinical staff is covered through the Federal Torts Claims Act (FTCA). This allows for substantial cost savings for the dentist and the agency. FQHCs offer benefits packages, which include paid time off, holidays and sick leave, retirement savings plans, health insurance, life, disability and other insurance options, reimbursement for professional license renewal fees, continuing education hours and employee assistance programs, with very limited management or operational responsibility. FQHC salaries alone may not keep pace with private practice salaries, however, FQHC compensation packages with benefits added has been found to be quite competitive.

Team-Based Care/Interdisciplinary Care

The team-based care structure of FQHCs helps provide a comprehensive array of health services in an integrated care setting. FQHCs can provide culturally competent high-quality primary care, oral health, behavioral health, and ancillary health services under one roof. The limited health literacy of patients is acknowledged, and efforts are made to improve awareness through patient education. Integrated electronic health records (EHRs) facilitate warm handoffs and referral and clinical consultations within clinics by screening patients for depression, diabetes and hypertension. Pediatric preventive dental services such as topical fluoride application and dental home care education can be integrated into the well child visits. The patient portal interface further helps to improve efficiency, to connect with external health care providers who are treating mutual patients, and to monitor outcomes from clinical interventions. With this structure, there is more collaboration and integration of clinicians across all disciplines who are focused on improving health outcomes for the patients and work as frontlines of the public health care system. Integrated care connects patients with the resources that they need and improves access to care such as the Hub and the Spoke model of care.¹⁴ (Note: These integrated IT platforms can be expensive, which can pose a financial challenge to clinics with more restrictive budgets.)

FQHCs allow for dentists to play different roles such as:

• Working with EHRs allows collaboration with other care team members (physicians, care coordination team, etc.) thereby facilitating whole-person care.

• Mentoring residents, dental students and dental auxiliary staff by supporting student education and training at FQHCs.

• Pursuing a leadership role by taking on administrative roles such as lead dentist, associate dental director, dental director or chief dental officer.

Challenges of Working in an FQHC

The challenges faced by FQHCs are multifactorial, the most significant factors being the workforce shortage, including recruitment and retention, exacerbated by the COVID-19 pandemic. Support staff also need to be trained to provide services in a culturally sensitive manner and to support the dentist in managing complex medical conditions of the patients. The psychological stress and pandemic-related delays in routine dental care have led to an increased burden of dental disease in the community post pandemic, with patients presenting with more invasive dental treatment needs due to delayed treatment.

The lack of opportunities to advance in the dental office setting in the absence of advanced education can lead to dental auxiliary staff switching careers. Some FQHC managements are becoming aware of this stark reality and are exploring various career advancement options like training dental assistants in house and offering tuition reimbursement.⁶

Conclusion

In conclusion, FQHCs are a critical resource in providing equitable health care to underserved populations. With dental diseases taking a significant place among the global disease burden, the team-based care model is forging its way. FQHCs are embodying all these features and are spearheading a revolution in health care in the modern day health care arena.

Through these opportunities, dentists can explore the FQHC health setting and know if it’s an environment they would like to be a part of. FQHCs allow for work-life balance and also provide opportunities for clinicians to wear multiple hats to expand their abilities in teaching or administration. Dental professionals can play a significant role in addressing health care disparities by working in FQHCs, but it is essential to be aware of the advantages and challenges associated with this path. By choosing to work in FQHCs, dentists can contribute to improving the oral health and overall well-being for some of the most vulnerable members of their communities. This is a segment worth exploring.

Disclosure Statement

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

Supplemental data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/19424396.2024.2324954

Additional information

Notes on contributors

Rosa Arzu

Rosa Arzu, DDS, MBA, is the Senior Director of Medical Dental Innovation at Alta Med Health Services, CA. She also has faculty appointment with Tufts University.

Alamelou Radjindrin

Alamelou Radjindrin, BDS, DDS, is the Associate Dental Director at Tiburcio Vasquez Health Center,CA.

Sridevi Ponnala

Sridevi Ponnala, BDS, DDS, MBA, is the Chief Integration Officer at Tiburcio Vasquez Health Center, CA.