HRSA Service Category Title - Harris County's New Web Site!

Service Category Definition - Part A 

� Untargeted 

� Targeted to Rural (North) 

Service Category Definition - Part B 

� Specialty Prosthodontics 

Oral Health (Dental) Pg 

Ryan White Part A/B 2010-2011 Standards of Care 9 

Service Category findings from the 

2008 Houston Area HIV/AIDS Needs Assessment 

Oral Health Care Chart Review FY 2009 

(Harris County PHES – RWGA: August 2009) 

RW Grant Program Summary Report 2009 Ryan White Focus 

Group Report - Dental, December 2009 

Public Comment - Oral Health 42 

HRSA Care ACTION: Increasing Access to Dental Care, August 

2008 

Mouth Full of Problems: A Crisis in HIV Dental Care - AIDSmeds 

September 8, 2009 

Increasing Access to Oral Health Care for People Living with 

HIV/AIDS: The role of dental case managers, patient navigators & 

outreach workers – ECHO, December 2008 

Additional information from Ryan White Grant Administration will be provided at the 

meeting: 

2009 Client Satisfaction 

2009 Service Utilization and Demographics 

4 th Quarter FY10 Outcomes Report 

J:\Committees\Quality Assurance\FY11 How To Best\Workgroups\Workgroup 1 April 20 2010\TOC - WG #1.doc 

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4 

7 

25 

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HRSA Service Category 

Title: (RWGA only) 

Local Service Category 

Title: 

Budget Type: 

(RWGA only) 

Budget Requirements or 

Restrictions: 

(RWGA only) 

HRSA Service Category 

Definition: 

(RWGA only) 


Definition: 

Target Population (age, 

gender, geographic, race, 

ethnicity, etc.): 

Oral Health 

Oral Health 

Unit Cost 

Not Applicable 

Oral health care includes diagnostic, preventive, and therapeutic 

services provided by general dental practitioners, dental specialists, 

dental hygienists and auxiliaries, and other trained primary care 

providers. 

Restorative dental services, oral surgery, root canal therapy, fixed 

and removable prosthodontics; periodontal services includes 

subgingival scaling, gingival curettage, osseous surgery, 

gingivectomy, provisional splinting, laser procedures and 

maintenance. Oral medication (including pain control) for HIV 

patients 15 years old or older must be based on a comprehensive 

individual treatment plan. 

HIV/AIDS infected individuals residing within the Houston Eligible 

Metropolitan Area (EMA). 

Services to be Provided: Services must include, but are not limited to: individual 

comprehensive treatment plan; diagnosis and treatment of HIVrelated 

oral pathology, including oral Kaposi’s Sarcoma, CMV 

ulceration, hairy leukoplakia, xerostomia, lichen planus, aphthous 

ulcers and herpetic lesions; diffuse infiltrative lymphocytosis; 

standard preventive procedures, including oral hygiene instruction, 

diet counseling and home care program; oral prophylaxis; 

restorative care; oral surgery including dental implants; root canal 

therapy; fixed and removable prosthodontics including crowns and 

bridges; periodontal services, including subgingival scaling, gingival 

curettage, osseous surgery, gingivectomy, provisional splinting, 

laser procedures and maintenance. Proposer must have mechanism 

in place to provide oral pain medication as prescribed for clients by 

Service Unit Definition(s): 

(RWGA only) 

FY 2011 Oral Health: Untargeted – Part A 

DRAFT (as of 03-23-10) 

the dentist. 

A unit of service is defined as one (1) dental visit which includes 

restorative dental services, oral surgery, root canal therapy, fixed 







Financial Eligibility: Refer to the RWPC’s approved Financial Eligibility for Houston 

Page 1 of 72

EMA Services. 

Client Eligibility: HIV-infected adults residing in the Houston EMA meeting financial 

eligibility criteria. 

Agency Requirements: Agency must document that the primary patient care dentist has 2 

years prior experience treating HIV disease and/or on-going HIV 

educational programs that are documented in personnel files and 

updated regularly. 

Staff Requirements: State of Texas dental license; licensed dental hygienist and state 

Special Requirements: 

(RWGA only) 


DRAFT (as of 03-23-10) 

radiology certification for dental assistants. 

None. 

Page 2 of 72


DRAFT (as of 03-23-10) 

FY 2011 RWPC “How to Best Meet the Need” Decision Process 

Step in Process: Council 

Recommendations: Approved: Y_____ No: ______ 

Approved With Changes:______ 

1. 

2. 

3. 

Step in Process: Steering Committee 



1. 

2. 

3. 

Step in Process: Quality Assurance Committee 



1. 

2. 

3. 

Step in Process: HTBMTN Workgroup 

Recommendations: Financial Eligibility: 

1. 

2. 

3. 

Date: 

If approved with changes list 

changes below: 

Date: 



Date: 



Date: 

Page 3 of 72

FY 2011 Oral Health: Rural (North) – Part A 

DRAFT (as of 03-23-10) 

HRSA Service Category Oral Health 

Title: (RWGA only) 

Local Service Category Oral Health – Rural (North) 

Title: 

Budget Type: 

Unit Cost 

(RWGA only) 

Budget Requirements or Not Applicable 

Restrictions: 

(RWGA only) 

HRSA Service Category Oral health care includes diagnostic, preventive, and therapeutic 

Definition: 

services provided by general dental practitioners, dental specialists, 

(RWGA only) 

dental hygienists and auxiliaries, and other trained primary care 

providers. 

Local Service Category Restorative dental services, oral surgery, root canal therapy, fixed 

Definition: 






individual treatment plan. Prosthodontics services to HIV-infected 

individuals including, but not limited to examinations and diagnosis 

of need for dentures, diagnostic measurements, laboratory services, 

tooth extractions, relines and denture repairs. 

Target Population (age, HIV/AIDS infected individuals residing in Houston Eligible 

gender, geographic, race, Metropolitan Area (EMA) or Health Service Delivery Area (HSDA) 


counties other than Harris County. Comprehensive Oral Health 

services targeted to individuals residing in the northern counties of 

the EMA/HSDA, including Waller, Walker, Montgomery, Austin, 

Chambers and Liberty Counties. 

Services to be Provided: Services must include, but are not limited to: individual 

comprehensive treatment plan; diagnosis and treatment of HIVrelated 

oral pathology, including oral Kaposi’s Sarcoma, CMV 

ulceration, hairy leukoplakia, xerostomia, lichen planus, aphthous 

ulcers and herpetic lesions; diffuse infiltrative lymphocytosis; 

standard preventive procedures, including oral hygiene instruction, 

diet counseling and home care program; oral prophylaxis; 

restorative care; oral surgery including dental implants; root canal 

therapy; fixed and removable prosthodontics including crowns, 

bridges and implants; 

periodontal services, including subgingival 

scaling, gingival curettage, osseous surgery, gingivectomy, 

provisional splinting, laser procedures and maintenance. Proposer 

must have mechanism in place to provide oral pain medication as 

prescribed for clients by the dentist. 

Service Unit Definition(s): General Dentistry: A unit of service is defined as one (1) dental 

(RWGA/TRG only) visit which includes restorative dental services, oral surgery, root 

canal therapy, fixed and removable prosthodontics; periodontal 

Page 4 of 72

Financial Eligibility: 

Client Eligibility: 

Agency Requirements: 

Staff Requirements: 

Special Requirements: 

(RWGA only) 


DRAFT (as of 03-23-10) 

services includes subgingival scaling, gingival curettage, osseous 

surgery, gingivectomy, provisional splinting, laser procedures and 




Prosthodontics: A unit of services is defined as one (1) 

Prosthodontics visit. 

Refer to the RWPC’s approved Financial Eligibility for Houston 

EMA/HSDA Services. 

HIV-infected adults residing in the rural area of Houston 

EMA/HSDA meeting financial eligibility criteria. 

Agency must document that the primary patient care dentist has 2 



updated regularly. 

Service delivery site must be located in one of the northern counties 

of the EMA/HSDA area: Waller, Walker, Montgomery, Austin, 

Chambers or Liberty Counties 

State of Texas dental license; licensed dental hygienist and state 

radiology certification for dental assistants. 

Must comply with the joint Part A/B standards of care where 

applicable. 

Page 5 of 72


DRAFT (as of 03-23-10) 





1. 

2. 

3. 




1. 

2. 

3. 




1. 

2. 

3. 



1. 

2. 

3. 

Date: 



Date: 



Date: 



Date: 

Page 6 of 72

Service Category Definition - Ryan White Part B Grant 

April 1, 2010 - March 31, 2011 

Local Service Category Oral Health Care – Specialty Prosthodontics (13) 

Amount Available 

Unit Cost: 

To be determined 

Budget Requirements or Maximum of 10% of budget for Administrative Costs 

Restrictions: 


Definition: 

Target Population (age, 

gender, geographic, race, 


Prosthodontics services to HIV infected individuals including but 

not limited to examinations and diagnosis of need for dentures, 

crowns, bridgework and implants, diagnostic measurements, 

laboratory services, tooth extraction, relines and denture repairs. 

General dentistry may be provided only if additional unallocated 

funds are added to the category during the year. 

HIV/AIDS infected individuals residing within the Houston HIV 

Service Delivery Area (HSDA). 

Services to be Provided: Services must include, but are not limited to: fixed and removable 

prosthodontics including crowns, bridges and implants. 

Service Unit Definition(s): A unit of service is defined as one (1) prosthodontics visit. 

Financial Eligibility: Income at or below 300% Federal Poverty Guidelines. 

Client Eligibility: HIV positive; Adult resident of Houston HSDA 

Agency Requirements: Agency must document that the primary patient care dentist has 2 



updated regularly. Dental facility and appropriate dental staff must 

maintain Texas licensure/certification and follow all applicable 

OSHA requirements for patient management and laboratory 

protocol. 

Providers and system must be Medicaid/Medicare certified to ensure 

that Ryan White funds are the payer of last resort. 

Staff Requirements: State dental license. 

Special Requirements: Must comply with the Joint Part A/B Standards of care where 

applicable. 

J:\Committees\Quality Assurance\FY 11 Service Definitions - Part B & SS\2011 Svc Cat Defs - Pt B 04-09-2010.doc 

Page 7 of 72

�� 





1. 

2. 

3. 




1. 

2. 

3. 




1. 

2. 

3. 



1. 

2. 

3. 

Date: 



Date: 



Date: 



Date: 

Page 8 of 72

2010-2011 HOUSTON ELIGIBLE METROPOLITAN AREA: RYAN WHITE CARE 

ACT PART A/B 

STANDARDS OF CARE FOR HIV SERVICES 

RYAN WHITE GRANT ADMINISTRATION SECTION 

HARRIS COUNTY PUBLIC HEALTH AND ENVIRONMENTAL SERVICES (HCPHES) 

TABLE OF CONTENTS 

Introduction………………………………………………………………………………………..10 

General Standards…………………………………………………………………………….........11 

Service Specific Standards…………………………………………………………………......... 21 

Page 9 of 72

INTRODUCTION 

According to the Joint Commission on Accreditation of Healthcare Organization (JCAHO) 2008) 1 

, a 

standard is a “statement that defines performance expectations structures, or processes that must be in 

place for an organization to provide safe, high-quality care, treatment, and services”. Standards are 

developed by subject experts and are usually the minimal acceptable level of quality in service delivery. 

The Houston EMA Ryan White Grant Administration (RWGA) Standards of Care (SOCs) are based on 

multiple sources including RWGA on-site program monitoring results, consumer input, the US Public 

Health Services guidelines, Centers for Medicare and Medicaid Conditions of Participation (COP) for 

health care facilities, JCAHO accreditation standards, the Texas Administrative Code, Center for 

Substance Abuse and Treatment (CSAT) guidelines and other federal, state and local regulations. 

Purpose 

The purpose of the Ryan White Part A/B SOCs is to determine the minimal acceptable levels of quality in 

service delivery and to provide a measurement of the effectiveness of services. 

Scope 

The Houston EMA SOCs apply to Part A, Part B and State Services, funded HRSA defined core and 

support services including the following services in FY 2009/10: 

• Primary Medical Care 

• Vision Care 

• Medical Case Management 

• Clinical Case Management 

• Local AIDS Pharmaceutical 

Assistance Program (LPAP) 

• Oral Health 

• Health insurance 

• Hospice Care 

• Mental Health Services 

• Substance Abuse services 

• Home & Community Based Services (Facility-Based) 

• Early Intervention Services 

• Legal Services 

• Medical Nutrition Therapy 

• Non-Medical Case Management (Service Linkage) 

• Food Bank 

• Transportation 

• Rehabilitation Services 

• Linguistic Services 

Standards Development 

The first group of standards was developed in 1999 following HRSA requirements for sub grantees to 

implement monitoring systems to ensure subcontractors complied with contract requirements. 

Subsequently, the RWGA facilitates annual work group meetings to review the standards and to make 

applicable changes. Workgroup participants include physicians, nurses, case managers and executive staff 

from subcontractor agencies as well as consumers. 

Organization of the SOCs 

The standards cover all aspect of service delivery for all funded service categories. Some standards are 

consistent across all service categories and therefore are classified under general standards. 

These include: 

• Staff requirements, training and supervision 

• Client rights and confidentiality 

• Agency and staff licensure 

• Emergency Management 

The RWGA funds three case management models. Unique requirements for all three case management 

service categories have been classified under Service Specific SOCs “Case Management (All Service 

Categories)”. Specific service requirements have been discussed under each service category. 

1 

The Joint Commission on Accreditation of Healthcare Organization (2008). Comprehensive accreditation manual 

for ambulatory care; Glossary 

Page 10 of 72

GENERAL STANDARDS 

1.0 Staff Requirements 

1.1 Staff Screening (Pre-Employment) 

Staff providing services to clients shall be screened for 

appropriateness by provider agency as follows: 

• Personal/Professional references 

• Personal interview 

• Written application 

Criminal background checks, if required by Agency Policy, 

must be conducted prior to employment and thereafter for all 

staff and/or volunteers per Agency policy. 

1.2 Initial Training: Staff/Volunteers 

Initial training includes eight (8) hours HIV/AIDS basics 

(including one (1) hour HIV/mental health co-morbidity 

sensitivity training), safety issues (fire & emergency 

preparedness, hazard communication, infection control, 

universal precautions), confidentiality issues, role of 

staff/volunteers, agency-specific information (e.g. Drug Free 

Workplace policy). Initial training must be completed within 

60 days of hire. 

1.3 

Standard Measure 

Staff Performance Evaluation 

Agency will perform annual staff performance evaluation 

1.4 Cultural and HIV Mental Health Co-morbidity Competence 

Training/Staff and Volunteers 

All staff must receive four (4) hours of cultural competency 

training and one (1) hour of HIV/Mental Health co-morbidity 

sensitivity training annually. 

• Review of Agency’s Policies and Procedures Manual indicates 

compliance 

• Review of personnel and/or volunteer files indicates 

compliance 

• Documentation of all training in personnel file. 

• Specific training requirements are specified in Agency Policy 

and Procedure 

• Materials for staff training and continuing education are on 

file 

• Staff interviews indicate compliance 

• Completed annual performance evaluation kept in employee’s 

file 

• Documentation of training is maintained by the agency in the 

personnel file 

2.0 Services utilize effective management practices such as cost effectiveness, human resources and quality improvement. 

2.1 Service Evaluation 

Agency has a process in place for the evaluation of client 


compliance 

Page 11 of 72

services. • Staff interviews indicate compliance. 

2.2 Subcontractor Monitoring 

Agency that utilizes a subcontractor in delivery of service, 

must have established policies and procedures on 

subcontractor monitoring that include: 

• Fiscal monitoring 

• Program 

• Quality of care 

• Compliance with guidelines and standards 

2.3 Staff Guidelines 

Agency develops written guidelines for staff, which include, 

at a minimum, agency-specific policies and procedures (staff 

selection, resignation and termination process, job 

descriptions); client confidentiality; health and safety 

requirements; complaint and grievance procedures; 

emergency procedures; and statement of client rights. 

2.4 Work Conditions 

Staff/volunteers have the necessary tools, supplies, 

equipment and space to accomplish their work. 

2.5 

Staff Supervision 

Staff services are supervised by a paid coordinator or 

manager. 

2.6 Professional Behavior 

Staffs comply with written standards of professional 

behavior. 

2.7 Communication 

There are procedures in place regarding regular 

communication with staff about the program and general 

agency issues. 

• Documentation of subcontractor monitoring 


compliance 

• Personnel file contains a signed statement acknowledging 

that staff guidelines were reviewed and that the employee 

understands agency policies and procedures 

• Inspection of tools and/or equipment indicates that these are 

in good working order and in sufficient supply 


• Review of personnel files indicates compliance 


compliance 

• Staff guidelines include standards of professional behavior 


compliance 

• Review of personnel files indicates compliance 

• Review of agency’s complaint and grievance files 


compliance 

• Documentation of regular staff meetings 


Page 12 of 72

2.8 

2.9 

Accountability 

There is a system in place to document staff work time. 

Staff Availability 

Staffs are present to answer incoming calls during agency’s 

normal operating hours. 

3.0 Clients Rights and Responsibilities 

3.1 Clients Rights 

Agency will provide client with written copy of client rights 

and responsibilities, including: 

• Informed consent 

• Confidentiality 

• Grievance procedures 

• Duty to warn or report certain behaviors 

• Scope of service 

• Criteria for end of services 

3.2 Confidentiality 

Agency has Policy and Procedure regarding client 

confidentiality in accordance with RWGA /TRG site visit 

guidelines, local, state and federal laws. Providers must 

implement mechanisms to ensure protection of clients’ 

confidentiality in all processes throughout the agency. 

There is a written policy statement regarding client 

confidentiality form signed by each employee and included in 

the personnel file. 

3.3 

Consents 

All consent forms comply with state and federal laws, are 

signed by an individual legally able to give consent and must 

include the Consent for Services form and a consent for 

release/exchange of information for every individual/agency to 

whom client identifying information is disclosed, regardless of 

whether or not HIV status is revealed. 

• Staff time sheets or other documentation indicate compliance 

• Published documentation of agency operating hours 

• Staff time sheets or other documentation indicate compliance 

• Documentation in client’s record 


compliance 

• Clients interview indicates compliance 

• Agency’s structural layout and information management 

indicates compliance 

• Signed confidentiality statement in each employee’s personnel 

file 

• Agency Policy and Procedure and signed and dated consent 

forms in client record 

Page 13 of 72

3.4 

3.5 

Up to date Release of Information 

Agency obtains an informed written consent of the client or 

legally responsible person prior to the disclosure or exchange 

of certain information about client’s case to another party 

(including family members) in accordance with the RWGA 

Site Visit Guidelines, local, state and federal laws. The 

release/exchange consent form must contain: 

• Name of the person or entity permitted to make the 

disclosure 

• Name of the client 

• The purpose of the disclosure 

• The types of information to be disclosed 

• Entities to disclose to 

• Date on which the consent is signed 

• The expiration date of client authorization (no longer 

than two years or six (6) months to one (1) year from 

last date of service) 

• Signature of the client/or parent, guardian or person 

authorized to sign in lieu of the client. 

• Description of the Release of Information, its 

components, and ways the client can nullify it 

Released/exchange of information forms must be completed 

entirely in the presence of the client. Any unused lines must 

have a line crossed through the space. 

Grievance Procedure 

Agency has Policy and Procedure regarding client grievances 

that is reviewed with each client in a language and format the 

client can understand and a written copy of which is provided 

to each client. 

Grievance procedure includes but is not limited to: 

• to whom complaints can be made 

• steps necessary to complain 

• form of grievance, if any 

• time lines and steps taken by the agency to resolve the 

grievance 

• Current Release of Information form with all the required 

elements signed by client or authorized person in client’s record 

• Signed receipt of agency Grievance Procedure, filed in client 

chart 


compliance 

Page 14 of 72

3.6 

• documentation by the agency of the process 

• confidentiality of grievance 

• addresses and phone numbers of licensing authorities 

and funding sources 

Client Rights and Responsibilities Statement 

Agency has a Client Rights and Responsibilities Statement that 

is reviewed with each client in a language and format the client 

can understand and a written copy of which is provided to each 

client. 

3.7 Client Feedback 

Feedback from clients (or from client caregivers, in cases 

where clients are unable to give feedback) is obtained about 

quality of services annually. 

3.8 Patient Safety (Core Services Only) 

Agency shall establish mechanisms to implement the 

National Patient Safety Goals (NPSG) modeled after the 

current Joint Commission accrediatation for Ambulatory 

Care (www.jointcommission.org) to ensure patients’ safety. 

The NPSG to be addressed include the following: 

• “Improve the accuracy of patient identification 

• Improve the safety of using medications 

• Reduce the risk of Health care-associated infections 

• Accurately and completely reconcile medications 

across the continuum of care 

• Universal Protocol” for preventing Wrong Site, Wrong 

Procedure and Wrong Person Surgery” 

(www.jointcommission.org) 

4.0 Accessibility 

4.1 Cultural Competence 

Agency demonstrates a commitment to provision of services 

• Agency Policy and Procedure and signed receipt of Clients 

Rights and Responsibilities Statement in client record 

• Client feedback mechanism is in place 

• Documentation of clients’ evaluation of services is 

maintained 


compliance 

• Agency has procedures for obtaining translation services 

• Client satisfaction survey indicates compliance 

Page 15 of 72

that are culturally sensitive and language competent for Limited 

English Proficient (LEP) individuals. 

4.2 Client Education 

Agency demonstrates capacity for client education and 

provision of Information on community resources 

4.3 Special Service Needs 

Agency demonstrates a commitment to assisting individuals 

with special needs 

4.4 Program Information 

Broad-based dissemination of information regarding the 

availability of services 

4.5 

4.6 

Proof of HIV Diagnosis 

Documentation of the client's HIV status is obtained at or prior 

to the initiation of services or registration services. 

An anonymous test result may be used to document HIV status 

temporarily (up to sixty [60] days). It must contain enough 

information to ensure the identity of the subject with a 

reasonable amount of certainty. 

Client Eligibility 

In order to be eligible for services, individuals must meet the 

following: 

• HIV+ 

• Residence in the Houston EMA/ HSDA (With prior 

approval, clients can be served if they reside outside 

of the Houston EMA/HSDA.) 

• Income no greater than 300% of the Federal Poverty 

level (unless otherwise indicated) 

• Policies and procedures demonstrate commitment to the 

community and culture of the clients 

• Availability of interpretive services, bilingual staff, and staff 

trained in cultural competence 

• Agency has vital documents including, but not limited to 

applications, consents, complaint forms, and notices of rights 

translated in client record 

• Availability of the blue book and other educational materials 

• Documentation of educational needs assessment and client 

education in clients’ records 

• Agency compliance with the Americans with Disabilities Act 

(ADA). 

• Review of Policies and Procedures indicates compliance 

• Environmental Review 

• Format Agency has a written substantiated annual plan to 

targeted populations 

• Zip code data show provider is reaching clients throughout 

service area 

• Documentation in client record as per RWGA site visit 

guidelines or TRG Policy SG-03 

• Documentation of HIV+ status, residence, identification and 

income in the client record 

• Documentation of ineligibility for third party reimbursement 

• Documentation of screening for Third Party Payers in 

accordance with TRG Policy SG-06 Documentation of Third 

Party Payer Eligibility or RWGA site visit guidelines 

Page 16 of 72

• Proof of identification 

• Ineligibility for third party reimbursement 

4.7 Re-evaluation of Client Eligibility 

Agency conducts annual re-evaluation of eligibility for all 

clients. At a minimum, agency confirms renewed eligibility 

with the CPCDMS and re-screens, as appropriate, for third- 

party payers. 

4.8 Linkage Into Core Services 

Agency staff will provide out-of-care clients with 

individualized information and referral to connect them into 

ambulatory outpatient medical care and other core medical 

services. 

4.9 Wait Lists 

It is the expectation that clients will not be put on a Wait List 

nor will services be postponed or denied due to funding. 

Agency must notify the Administrative agency when funds 

for service are either low or exhausted for appropriate 

measures to be taken to ensure adequate funding is available. 

Should a wait list become required, the agency must, at a 

minimum, develop a policy that addresses how they will 

handle situations where service(s) cannot be immediately 

provided and a process by which client information will be 

obtained and maintained to ensure that all clients that 

requested service(s) are contacted after service provision 

resumes; 

The A gency w ill n otify The R esource G roup ( TRG) or 

RWGA of the following information when a wait list must be 

created: 

An explanation for the cessation of service; and 

A plan for resumption of service. The Sub grantee’s plan 

must address: 

• Action steps to be taken by Subgrantee to resolve the 

service shortfall; and 

• Projected date that services will resume. 

• Client file contains documentation of re-evaluation of client 

residence, income and rescreening for third party payers at 

least annually 

• Documentation of client referral is present in client file 


compliance 

• Documentation of compliance with TRG’s Policy SG-19 Client 

Wait Lists 

• Documentation that agency notified their Administrative 

Agency when funds for services were either low or exhausted 

Page 17 of 72

The A gency w ill r eport to T RG or R WGA in w riting on a 

monthly b asis) w hile a c lient w ait l ist i s r equired w ith t he 

following information: 

• Number of clients on the wait list 

• Progress toward completing the plan for resumption of 

service 

• A revised plan for resumption of service, if necessary 

4.10 Intake 

The agency conducts an intake to collect required data 

including, but not limited, eligibility, appropriate consents and 

client identifiers for entry into CPCDMS. Intake process is 

flexible and responsive, accommodating disabilities and health 

conditions. 

When necessary, client is provided alternatives to office visits, 

such as conducting business by mail or providing home visits. 

Agency has established procedures for communicating with 

people with hearing impairments 

5.0 Quality Management 

5.1 Continuous Quality Improvement (CQI) 

Agency demonstrates capacity for an organized CQI program 

and has a CQI Committee in place to review procedures and to 

initiate Performance Improvement activities. 

The Agency shall maintain an up-to-date Quality Management 

(QM) Manual. The QM Manual will contain at a minimum: 

• The Agency’s QM Plan 

• Meeting agendas and/or notes (if applicable) 

• Project specific CQI Plans 

• Root Cause Analysis & Improvement Plans 

• Data collection methods and analysis 

• Work products 

• Documentation in client record 


compliance 


compliance 

• Up to date QM Manual 

Page 18 of 72

• QM program evaluation 

• Materials necessary for QM activities 

5.2 Data Collection and Analysis 

Agency demonstrates capacity to collect and analyze client 

level data including client satisfaction surveys and findings are 

incorporated into service delivery. Supervisors shall conduct 

and document ongoing record reviews as part of quality 

improvement activity. 

6.0 Point Of Entry Agreements 

6.1 Points of Entry (Core Services Only) 

Agency accepts referrals from sources considered to be 

points of entry into the continuum of care, in accordance with 

HIV Services policy approved by HRSA for the Houston 

EMA. 

7.0 Emergency Management 

7.1 Emergency Preparedness 

Agency leadership including medical staff must develop an 

Emergency Preparedness Plan modeled after the Joint 

Commission’s regulations and/or Centers for Medicare and 

Medicaid guidelines for Emergency Management. The plan 

should, at a minimum utilize “all hazard approach” to ensure 

a level of preparedness sufficient to support a range of 

emergencies. Agencies shall conduct an annual Hazard 

Vulnerability Analysis (HVA) to identify potential hazards, 

threats, and adverse events and assess their impact on care, 

treatment, and services they must sustain during an 

emergency. The agency shall communicate hazards 

identified with its community emergency response agencies 

and together shall identify the capability of its community in 

meeting their needs. The HVA shall be reviewed annually. 

7.2 

Emergency Preparedness Plan 

The emergency preparedness plan shall address the six 


compliance 

• Up to date QM Manual 

• Supervisors log on record reviews signed and dated 


compliance 

• Documentation of formal agreements with appropriate Points 

of Entry 

• Documentation of referrals and their follow-up 

• Emergency Preparedness Plan 


compliance 

• Emergency Preparedness Plan 

Page 19 of 72

critical areas for emergency management including 

• Communication pathways 

• Essential resources and assets 

• patients’ safety and security 

• staff responsibilities 

• Supply of key utilities such as portable water and 

electricity 

• Patient clinical and support activities during 

emergency situations. (www.jointcommission.org) 

7.3 Emergency Management Drills 

Agency shall implement emergency management drills twice 

a year either in response to actual emergency or in a planned 

exercise. Completed exercise should be evaluated by a 

multidisciplinary team including administration, clinical and 

support staff. The emergency plan should be modified based 

on the evaluation results and retested. 

8.0 Building Safety 

8.1 Required Permits 

All agencies will maintain Occupancy and Fire Marshal’s 

permits for the facilities. 

• Emergency Management Plan 


compliance 

• Current required permits on file 

Page 20 of 72

Oral Health Care 

Oral Health care constitute an essential component of primary health care for PLWHA as poor oral health affects adherence to ARV therapy and 

subsequent health outcomes 4 

. Thus, there is the need for coordination of services between medical providers and oral health care providers. 

The Oral health care standards are based on HRSA definition for oral health care, the New York State Health Department AIDS Institute 

guidelines for HIV and Oral Health and other state and local requirements. The RW HIV/AIDS Treatment Modernization Act of 2006 defines 

Oral Health Care as “diagnostic, preventive, and therapeutic services provided by the general dental practitioners, dental specialist, dental 

hygienist and auxiliaries and other trained primary care providers”. The Ryan White Part A/B oral health care services include standard 

preventive procedures, diagnosis and treatment of HIV-related oral pathology, restorative dental services, oral surgery, root canal therapy, fixed 

and removable prosthodontics and oral medication (including pain control) for HIV patients 15 years old or older based on a comprehensive 


1.0 Staff Requirements 

1.1 Continuing Education 

Eight (8) hours of training in HIV/AIDS and clinically-related 

issues is required annually for licensed staff. 

One (1) hour of training in HIV/AIDS is required annually for all 

staff. 

1.2 Experience – HIV/AIDS 

A minimum of one (1) year documented HIV/AIDS work 

experience is preferred for licensed staff. 

1.3 Staff Supervision 

Supervision of clinical staff shall be provided by a practitioner with 

at least two years experience in dental health assessment and 

treatment of persons with HIV. All licensed personnel shall 

received supervision consistent with the State of Texas license 

requirements. 

• Materials for staff training and continuing 

education are on file 

• Documentation of continuing education in 


• Documentation of work experience in 


• Review of personnel files indicates 

compliance 

• Review of agency’s Policies & Procedures 

Manual indicates compliance 

4 

The New York State Department of Health AIDS Institute (2000-2009). Clinical guidelines: HIV and oral health. Retrieved 10/02/2009 from www. 

http://www.hivguidelines.org/Content.aspx?PageID=263 

Page 21 of 72

2.0 Coordination with Primary Care Providers 

2.1 HIV Primary Care Provider Contact Information 

Agency obtains and documents HIV primary care provider contact 

information for each client. 

2.2 Consultation for Treatment 

Agency consults with client’s medical care providers when 

indicated. 

2.3 Health History Information 

Agency collects and documents health history information for each 

client prior to providing care. This information should include, but 

not be limited to, the following: 

• A baseline current (within the last 6 months) CBC laboratory 

test results for all new clients, and an annual update 

thereafter 

• Current (within the last 6 months) Viral Load and CD4 

laboratory test results, when clinically indicated 

• Client’s chief complaint, where applicable 

• Medication names 

• Sexually transmitted diseases 

• HIV-associated illnesses 

• Allergies and drug sensitivities 

• Alcohol use 

• Recreational drug use 

• Tobacco use 

• Neurological diseases 

• Hepatitis 

• Usual oral hygiene 

• Date of last dental examination 

• Involuntary weight loss or weight gain 

Review of systems 

• Documentation of HIV primary care 

provider contact information in the client 

record. At minimum, agency should collect 

the clinic and/or physician’s name and 

telephone number 

• Documentation of communication in the 

client record 

• Documentation of health history 

information in the client record. Reasons 

for missing health history information are 

documented 

Page 22 of 72

2.4 Client Health History Update 

An update to the health history should be made, at minimum, every 

six (6) months or at client’s next general dentistry visit whichever 

is greater. 

2.5 

Comprehensive Periodontal Examination 

Agency has a written policy and procedure regarding when a 

comprehensive periodontal examination should occur. 

Comprehensive periodontal examination should be done in 

accordance with professional standards and current US Public 

Health Service guidelines 

2.6 Treatment Plan 

• A comprehensive, multi disciplinary Oral Health treatment 

plan will be developed in conjunction with the patient. 

• Patient’s primary reason for dental visit should be addressed 

in treatment plan 

• Patient strengths and limitations will be considered in 

development of treatment plan 

• Treatment priority should be given to pain management, 

infection, traumatic injury or other emergency conditions 

• Treatment plan will be updated as deemed necessary 

2.7 Annual Hard/Soft Tissue Examination 

The following elements are part of each client’s annual hard/soft 

tissue examination and are documented in the client record: 

• Charting of caries; 

• X-rays; 

• Periodontal screening; 

• Written diagnoses, where applicable; 

• Treatment plan. 

Determination of clients needing annual examination should be 

based on the dentist’s judgment and criteria outlined in the 

• Documentation of health history update in 

the client record 



• Review of client records indicate 

compliance 

• Treatment plan dated and signed by both 

the provider and patient in patient file 

• Updated treatment plan dated and signed by 

both the provider and patient in patient file 

• Documentation in the client record 



Page 23 of 72

agency’s policy and procedure, however the time interval for 

all clients may not exceed two (2) years. 

2.8 Oral Hygiene Instructions 

Oral hygiene instructions (OHI) should be provided annually to 

each client. The content of the instructions is documented. 

THRESHOLDS 

Measurement thresholds will be set at 100%. 

IV. IMPLEMENTATION & REPORTING 

• Documentation in the client record 

Agencies will be required to adhere to the QA guidelines provided by RWGA, or the Part B administrative agency, as applicable. 

Page 24 of 72

Findings from the 2008 Houston Area HIV/AIDS Needs Assessment 

CORE CORE CORE SERVICES 

SERVICES 

SERVICES 

reported frequently as a barrier. Waiting times were also ranked highly within 

subpopulations, except within the out-of-care and youth. Information-related barriers were 

ranked highly within the out-of-care, women, African-Americans, the recently released and 

substance abusers. 

V 

DENTIST ENTIST VVISITS 

ISITS 

Service category data were collected in the context of their local definitions, rather 

than their official HRSA definitions. Although the differences between the local and HRSA 

definitions are minimal, the Data Collection Workgroup felt the local definition approach 

would promote a realistic assessment of the Houston HSDA Ryan White care system. 

Local definitions for each service category will be included in each summary. A list 

of the official HRSA service category definitions is provided in Appendix C. 

Local Definition 

The local definition of dentist visits is defined as: 

Restorative dental services, oral surgery, root canal therapy, fixed and removable 

prosthodontics; periodontal services includes subgingival scaling, gingival curettage, 

osseous surgery, gingivectomy, provisional splinting, laser procedures and maintenance. 

Oral medication (including pain control) for HIV patients 15 years old or older must be 

based on a comprehensive individual treatment plan. 

CPCDMS/ARIES Service Utilization Data 

Page 25 of 72 

Service utilization information for most services is based on data from the 

Centralized Patient Care Data Management System (CPCDMS) and/or ARIES. The 

CPCDMS is a real-time, de-identified client-level computer database application that allows 

Ryan White-funded providers, as well as non-Ryan White providers, and other users in the 

EMA to share client eligibility information and document service delivery while maintaining 

client confidentiality. Service providers enter registration, service encounter and medical 

update information for each client into the CPCDMS. Client information collected includes 

demographic, comorbidity, biological marker, mortality and service utilization data. Since its 

inception in June of 2000, over 10,000 clients have been registered in the CPCDMS. 

The AIDS Regional Information and Evaluation System (ARIES), implemented in 

February 2005, is also a real-time, de-identified client-level computer database application, 

the ARIES centralizes client data, service details, and agency and staff information to 

maximize the quality of care and services to clients in need. The system was developed 

collaboratively for Part B by the State of Texas, County of San Diego, County of San 

Bernardino, and State of California. Information from the Centralized Patient Care Data 

Management System can be imported into the ARIES system and filtered to produce a 

comprehensive picture of service utilization information on both Part B and Part A-funded 

providers, as well as other users in the EMA/HSDA 

2008 Houston Area HIV/AIDS Needs Assessment

It is important to note that while CPCDMS does represent the majority of PLWHA 

receiving Ryan White-funded services in the HSDA, it is incorrect to assume that all 764 

survey respondents are enrolled in CPCDMS. 

According to the Centralized Patient Care Data Management System (CPCDMS), a 

total of 2,219 unduplicated PLWHA received dentist visits through grants billed to Ryan 

White Part A and Part B. This total represents 12% of the reported 18,109 PLWHA residing 

in the Houston EMA/HSDA. 

Access (Easy versus Hard) 

At the beginning of the client survey, respondents were given a list of core services 

arranged in table format (see Appendix B for copy of client survey). The purpose of the 

core service table was to collect information on access and barriers to the listed services. 

For each HRSA-defined core service, respondents indicated whether they had “some 

difficulty” getting the service, if it was “very easy” to get the service, or if they “did not need” 

the service within the past year. 

The following table shows the level of access to dentist visits reported by all 

respondents. It should be noted that the percentages are based on the sum of 

respondents within each subpopulation that accessed the service (reported difficulty or 

ease). It is also important to remember that the subpopulations are not mutually exclusive 

– in other words, the numbers across the subpopulations do not represent unduplicated 

respondents. For example, an African-American female reporting a mental health symptom 

is included in the Women, African-Americans and Mental Health subpopulations. 

Care should also be taken when making comparisons between subpopulations of 

very small size. The smaller the subpopulation, the more sensitive percentages become to 

changes in the numbers. For example, for very small subpopulations, shifting just one 

response can change percentages by as much as 5 points. It is important not to rely solely 

on such percentages when planning for services – considering both the proportions and 

raw numbers will help ensure a more comprehensive understanding of the results. 

Lastly, it should be emphasized that reports of access to a service does not 

necessarily mean the respondent received the service. In the client survey, respondents 

were asked to report whether they had difficulty getting a service, but the survey did not ask 

as a follow-up whether the respondent ultimately received the service despite the 

difficulties. So, care should be taken not to equate reports of “very easy” or reports of 

“some difficulty” as proxies of service utilization. 


DENTIST DENTIST DENTIST VISITS VISITS VISITS 

Page 26 of 72


SERVICES 

SERVICES 

TABLE 15.1: REPORTED ACCESS TO DENTIST VISITS IN THE PAST 12 MONTHS 

Total who 

attempted 

to access 

* Subpopulations are not mutually exclusive. 

** Percentages may not add up to 100% due to rounding. 

% 

Very 

Easy 

The majority (82%) of all 764 survey respondents reported attempting to access 

dentist visits during the previous 12 months; a total of 138 (18%) said they did not need this 

service. Most subpopulations also reported accessing this service in relatively high 

proportions – Latinos access this service in the highest proportion (90%) compared to other 

groups. However, the subpopulations with the lowest proportions accessing dentist visits 

were substance abusers (79%), the recently released (77%) and the out-of-care (58%). 

Overall, the majority of all survey respondents had an easy time accessing dentist 

visits – 61% said it was “very easy” to get the service. Among the subpopulations, access 

to dentist visits appeared easiest for Latinos (70%), MSM of color (69%) and those in-care 

(64%). 

By far, the out-of-care subpopulation had the highest proportion (78%) of those who 

had some difficulty accessing dentist visits during the past year. Other subpopulations with 

relatively higher proportions of difficulty were youth (65%), women (45%) and the recently 

released (43%). 

Barriers 

Survey respondents that reported “some difficulty” getting a service were asked to 

describe the barriers they experienced. Respondents could choose from a list of common 

barriers, or write their own. The number of possible reported barriers was unlimited, so 

respondents were encouraged to list every barrier they encountered when getting a 

service. It should also be noted that the number of reported barriers does not indicate 

% 

Some 

Difficulty 

% 

No 

Need 

All Respondents (N=764) 626 82% 380 61% 246 39% 138 18% 

Subpopulations* 

In Care 581 85% 370 64% 211 36% 106 15% 

Out-of-Care 45 58% 10 22% 35 78% 32 42% 

Women 197 83% 108 55% 89 45% 41 17% 

Youth 31 84% 11 35% 20 65% 6 16% 

African-Americans 349 81% 214 61% 135 39% 80 19% 

Latinos 127 90% 89 70% 38 30% 14 10% 

White MSM 83 81% 47 57% 36 43% 20 19% 

MSM of Color 179 86% 124 69% 55 31% 29 14% 

Recently Released 92 77% 51 55% 41 45% 27 23% 

Substance Abuse 196 79% 113 58% 83 42% 52 21% 

Mental Health 369 82% 209 57% 160 43% 83 18% 

Homeless 64 72% 42 47% 22 25% 25 28% 

Page 27 of 72 


%

whether the respondent did, or did not, ultimately receive the service – survey respondents 

described the barriers they experienced in the process of getting a service. 

The following table shows the number of barriers reported for dentist visits. The 

numbers in each cell represent how many times respondents faced a certain type of 

barrier. The total reported barriers column on the far right represents the total number of 

barriers reported for each subpopulation. The cells that are shaded and in bold represent 

barriers with the highest number of reports for each subpopulation. 

TABLE 15.2: NUMBER OF REPORTED BARRIERS FOR DENTIST VISITS 

A B C D E F G H I J K M O Q R S 

Total** 

Barriers 

All Respondents 


33 58 74 26 15 17 27 87 43 6 10 5 24 1 4 1 431 

In Care 26 44 63 16 11 8 25 75 33 4 4 3 18 1 3 1 335 

Out-of-Care 7 14 11 10 4 9 2 12 10 2 6 2 6 0 1 0 96 

Women 12 21 27 15 7 10 9 29 21 6 6 0 12 1 1 0 177 

Youth 6 10 5 3 5 1 3 6 4 2 2 0 3 0 1 0 51 

African-Americans 19 36 34 19 8 13 11 49 18 5 8 4 14 0 3 1 242 

Latinos 7 8 12 4 3 2 5 15 6 0 1 0 5 0 0 0 68 

White MSM 5 5 17 1 2 0 8 14 7 0 0 1 1 0 0 0 61 

MSM of Color 7 15 14 3 4 3 5 22 4 0 0 3 7 0 1 0 88 

Recently Released 5 10 14 11 2 4 3 13 6 0 3 4 2 0 1 0 78 

Substance Abuse 11 19 24 9 1 4 4 33 15 2 5 2 7 0 1 0 137 

Mental Health 21 38 55 20 10 13 17 55 32 5 8 2 15 1 4 1 297 

Homeless 8 15 13 12 8 7 6 14 3 3 7 0 0 0 1 1 102 


** Some barriers may not be shown if no respondents reported them as barriers for this service 

Barriers 

A The services are not in my area L People at the agency don't speak my language 

B I don't know where to get the services M My jail/prison history makes it hard to get services 

C I would have to wait too long to get the services N Difficulties with paperwork (volume, confusing process, etc) 

D The services cost too much O Substance abuse 

E I was told I am not eligible to get the services P Was incarcerated/in jail 

F I don't think I'm eligible to get the services Q Personal health issues (too sick, medication resistant, etc) 

G The people who run the services are not friendly R Fear, denial or stigma (internal and/or external) 

H It's hard to make or keep appointments S Homeless/unstable housing 

I It's hard for me to get there T CM left/staff turnover 

J There is no one to watch my kids if I go there U Not enough, resources/funds run out too quickly 

K I'm afraid someone will find out about my HIV V Immigration status 

Overall, there were 431 reports of barriers among respondents who had difficulty 

accessing dentist visits during the past year. The barriers reported most often for dentist 

visits were related to scheduling appointments, getting to locations of services and waiting 


DENTIST DENTIST DENTIST VISITS VISITS VISITS 

Page 28 of 72


SERVICES 

SERVICES 

times. The table below shows 2-3 highlighted barriers reported by subpopulations when 

accessing dentist visits. The intent of this table is to highlight the barriers identified most 

often by respondents – for the full list of barriers, refer to the table titled, “Number of 

reported barriers for Dentist Visits.” 

TABLE 15.3: HIGHLIGHTED BARRIERS FOR DENTIST VISITS BY SUBPOPULATION 

All Respondents 


In Care 

Out-of-Care 

Women 

Youth 

African-Americans 

Latinos 

White MSM 

MSM of Color 

Recently Released 

Substance Abuse 

Mental Health 

Homeless 


Barriers (ranked by number of reports) 

H – It's hard to make or keep appointments (n=87) 

C – I would have to wait too long to get the services (n=74) 



B – I don't know where to get the services (n=14) 





A – The services are not in my area (n=6) 





















D – The services cost too much (n=12) 

Page 29 of 72 

Within all subpopulations, problems making or keeping appointments ranked high 

compared to other barriers. Waiting times were also ranked highly within subpopulations, 

except within the out-of-care and youth. Information-related barriers were ranked highly 

within African-Americans, women, MSM of color, out-of-care and youth. 

2008 Houston Area HIV/AIDS Needs Assessment

Ryan White Part A Quality Management Program–Houston EMA 

CONTACT: 

Oral Health Care Chart Review 

FY 2009 

Prepared by Harris County Public Health & 

Environmental Services – Ryan White Grant Administration 

August 2009 

Carin Martin, MPA 

Project Coordinator–Quality Management Development 

Harris County Public Health & Environmental Services 

Ryan White Grant Administration 

2223 West Loop South, RM 417 

Houston, TX 77027 

713-439-6041 

cmartin@hcphes.org 

Page 30 of 72

Introduction 

Part A funds of the Ryan White Care Act are administered in the Houston Eligible Metropolitan Area (EMA) by the 

Ryan White Grant Administration Section of Harris County Public Health & Environmental Services. During FY 

09, a comprehensive review of client dental records was conducted for services provided between 3/1/07 to 

2/28/08. This review included one provider of Adult Oral Health Care that received Part A funding in the 

Houston EMA. 

The primary purpose of this annual review process is to assess Part A oral health care provided to persons living 

with HIV in the Houston EMA. Ryan White Grant Administration manages the review process and analyzes the 

subsequent data, while the reviews are conducted by TMF Health Quality Institute (TMF), under contract with 

Ryan White Grant Administration. Unlike primary care, there are no federal guidelines published by the U.S Public 

Health Service for oral health care targeting individuals with HIV/AIDS. Therefore, Ryan White Grant 

Administration has adopted general guidelines from peer-reviewed literature that address oral health care for the 

HIV/AIDS population, as well as literature published by national dental organizations such as the American Dental 

Association and the Academy of General Dentistry, to measure the quality of Part A funded oral health care. 

Scope of This Report 

This report provides background on the project, supplemental information on the design of the data collection tool, 

and presents the pertinent findings of the FY 09 oral health care chart review. In addition to this report, the 

reviewed provider will also receive an electronic copy of the raw database in order to facilitate further analysis. 

Also, any additional data analysis of items or information not included in this report can likely be provided after a 

request is submitted to Ryan White Grant Administration. 

The Data Collection Tool 

The data collection tool employed in the review was developed through a period of in-depth research and a series of 

working meetings between Ryan White Grant Administration and the review contractor, TMF. By studying the 

processes of previous dental record reviews and researching the most recent HIV-related and general oral health 

practice guidelines, a listing of potential data collection items was developed. Further research provided for the 

editing of this list to yield what is believed to represent the most pertinent data elements for oral health care in the 

Houston EMA. Topics covered by the data collection tool include, but are not limited to the following: basic client 

information, completeness of the health history, hard & soft tissue examinations, oral hygiene prevention, and 

periodontal examinations. Contact Ryan White Grant Administration for a copy of the tool. 

The Chart Review Process 

Page 31 of 72 

All charts were reviewed by licensed dentist experienced in identifying documentation issues and assessing 

adherence to published guidelines. The reviewer has extensive experience conducting dental chart reviews. The 

collected data was recorded directly onto the tool and this information was entered into a preformatted database. 

Once all data collection and data entry was completed, the database was forwarded to Ryan White Grant 

Administration for analysis. The data collected during this process is intended to be used for service improvement.

The Chart Review Process (cont’d) 

The specific parameters established for the data collection process were developed from HIV-related and general 

oral health care guidelines available in peer-reviewed literature, and the professional experience of the reviewer on 

standard record documentation practices. Table 1 summarizes the various documentation criteria employed during 

the review. 

Table 1. Data Collection Parameters 

Review Area Documentation Criteria 

Health History Completeness of Initial Health History: includes but not limited to past medical 

history, medications, allergies, substance use, HIV MD/primary care status, physician 

contact info, etc.; Completed updates to the initial health history 

Hard/Soft Tissue Exam Findings—abnormal or normal, diagnoses, treatment plan, treatment plan updates 

Oral Hygiene Prevention Prophylaxis, OHI 

Periodontal screening Completeness 

Appointments Kept, Not kept, Practitioner 

The Sample Selection Process 

The sample population was selected from a pool of 2,269 unduplicated clients who accessed Part A oral health care 

between 3/1/08 and 2/28/09. The medical charts of 205 of these clients were used in the review, representing 9% 

of the pool of unduplicated clients. 

In an effort to make the sample population as representative of the actual Part A oral health care population as 

possible, the EMA’s Centralized Patient Care Data Management System (CPCDMS) was used to generate a list of 

client codes to be reviewed. The demographic make-up (race/ethnicity, gender, age, stage of illness) of clients 

accessing oral health services between 3/1/08 and 2/28/09 was determined by CPCDMS, which in turn allowed 

Ryan White Grant Administration to generate a sample of specified size that closely mirrors that same demographic 

make-up. Randomly-generated client codes were categorized in terms of stage of illness, as delineated by CPCDMS, 

in order to allow for assessment of a range of care. 

- Asymptomatic CD4 > = 500 - Symptomatic CD4 200-499 

- Asymptomatic CD4 200-499 - Symptomatic CD4 < 200 

- Asymptomatic CD4 < 200 - AIDS CD4 > = 500 

- Symptomatic CD4 > = 500 - AIDS CD4 200-499 

- AIDS CD4 < 200 

Page 32 of 72 

The lists of client codes were usually forwarded to the reviewer and corresponding agencies 5-10 business days 

before reviews were scheduled to commence.

Characteristics of the Sample Population 

The review sample population was generally comparable to the Part A population receiving oral health care in terms 

of race/ethnicity, gender, age and stage of illness. 1 

It is important to note that the chart review findings in this 

report apply only to those who receive oral health care from a Part A provider and cannot be generalized to all Ryan 

White clients or to the broader population of persons with HIV or AIDS. Table 2 compares the review sample 

population with the Ryan White Part A oral health care population as a whole. 

Table 2. Demographic Characteristics of FY 08 Houston EMA Ryan White Part A Oral Health Care Clients 

Sample Ryan White Part A EMA 

Race/Ethnicity Number Percent Number Percent 

African American 91 44% 1037 46% 

White 109 53% 1186 52% 

Asian 1 1% 20 1% 

Native Hawaiian/Pacific 

Islander 1 1% 4

Findings 

Appointments 

To reduce the number of no-show appointments, the appointment policy at the agency requires patients to call at 

least twenty-four hours in advance if their appointment must be canceled or rescheduled. If a patient fails to follow 

this policy more than twice, they are no longer eligible for regularly scheduled appointments, but instead are 

scheduled for block appointments where groups of patients are scheduled at the same time. While this strategy may 

be employed to encourage appointment keeping, it may also create a barrier to oral health care, particularly among 

clients facing other life challenges that make appointment keeping very difficult. 

At the time of the review, only 6% of records reviewed were for patients who missed more than two appointments. 

This rate has continued to decline in recent years. During the 2008 chart review 17% of reviewed records indicated 

that would be subject to restricted scheduling. 

Unfortunately, this year’s review does demonstrate a marked increase in the racial disparity of those patients 

requiring restricted appointments. Historically, there has been little racial difference among individuals who missed 

more than two appointments. Last year, of those who missed more than two appointments 43% were African- 

Americans. This was slightly less than the percentage that African-Americans represented in the chart review 

sample population. However, this year 83% of patients that missed more than 2 appointments were African- 

American. This is well over their 44% representation in the sample population. 

Additionally, there is also a measure of gender disparity in the restricted scheduling. Fifty percent of those who 

missed three or more appointments were females. However, females represent only 26% of the sample population. 

These results should be interpreted with caution given the small number of clients in the sample population who 

were subject to restricted appointments, and the lack of additional testing to determine whether these differences 

are statistically significant. 

Clinic Visits 

Information gathered during the 2009 chart review included the number of visits during the study period and the 

provider type (dentist, hygienist, prosthodontics, other). Generally, utilization of dentists and hygienists was 

significant. Of the 1,243 oral health care appointments, 80% of the total number of appointments were conducted 

by either a dentist or hygienist. The average number of oral health visits per patient in the sample population was 

six. Ninety-eight percent of review patients had an appointment conducted by a dentist at least once during the 

review period. 

Health History 

Page 34 of 72 

A complete and thorough assessment of a patient’s medical history is essential among individuals infected with HIV 

or anyone who is medically compromised. Such information, such as current medication or any history of 

alcoholism for example, offers oral health care providers key information that may determine the appropriateness of 

prescriptions, oral health treatments and procedures. The form that is used by the agency to assess patient’s health 

history captures a wide range of information; however, for the purposes of this review, this report will focus on the 

assessment of information that is of particular importance among HIV/AIDS patients compared to patients in the 

general population. 

Assessment of Medical History 

� 89% (99%-FY 08) of records reviewed for new patients contained an initial assessment of past medical 

history. Ninety-eight percent of applicable records documented a health history update every 6 months. 

Key highlights are as follows: 

o HIV Associated Opportunistic Infections: 98% (98%-FY 08) of records reviewed documented 

opportunistic infection status. 

o Allergies & Drug Sensitivities: 98% (100%-FY 08) of records reviewed had documentation for 

assessing allergies and drug sensitivities located in a prominently in the chart.

Health History cont’d 

o Alcohol Use: 0% (25%-FY 08) of records reviewed documented an assessment of alcohol use 

during the study period. 

o Tobacco Use: 0% (33%-FY 08) of records reviewed documented an assessment of either smoking 

status or current use of chewing tobacco/snuff during the study period. 

o Street/Illegal Drug Use: 0% (23%-FY 08) of records reviewed documented an assessment of 

recreational drug use during the study period. 

Health Assessments 

o Blood Pressure: 100% of reviewed records documented patient blood pressure at initial visit and 

an update of the patient’s blood pressure every 6 months. Additionally, 100% of applicable records 

documented blood pressure results prior to an applicable dental procedure. 

o Pulse: 100% of reviewed records documented patient pulse at initial visit and an update of the 

patient’s pulse every 6 months. 

o Risk for infection and bleeding: 100% of applicable records reviewed assessed the patients risk 

for infection and bleeding prior to an invasive procedure. 

o Need for Antibiotic Prophylaxis: 100% (99%-FY 08) of records reviewed assessed the patients 

need for antibiotic prophylaxis. 

Patient Medications 

� 100% (100%-FY 08) of records reviewed documented a review of patient medications for either HIV or 

non-HIV medication. 

Primary Care Provider Contact Information 

� 100% (100%-FY 08) of records reviewed contained contact information for a primary care provider. 

Prevention and Detection of Oral Disease 

Page 35 of 72 

Maintaining good oral health is so vital to the overall quality of life for individuals living with HIV/AIDS because 

the condition of one’s oral health often plays a major role in how well patients are able manage their HIV disease. 

Poor oral health due to a lack of dental care may lead to the onset and progression of oral manifestations of HIV 

disease, which makes maintaining proper diet and nutrition or adherence to antiretroviral therapy very difficult to 

achieve. Furthermore, poor oral health places additional burden on an already compromised immune system. 

An intraoral exam was performed in 98% of records reviewed (95%-FY 08). Ninety-eight percent of reviewed 

records documented an extraoral exam of the face, head and neck during the study period (95% in FY 08). Onehundred 

percent of applicable records documented an x-ray (100% in FY 08 review). Ninety-nine percent of 

reviewed records (1% in FY 08 review) documented the clinical chart of teeth was marked and up to date. 

One hundred percent of the records reviewed (97% in FY 08 review) documented a statement by the dentist of an 

annual patient diagnosis. Ninety-nine percent of reviewed records (91% in FY 08 review) contained a subsequent 

treatment plan and/or updates to the treatment plan. One hundred percent of those records documented the 

appropriate treatment was done for condition indicated. 

Four percent of reviewed records contained documentation of the patient’s need to be seen by a specialist. Of 

these records, 78% of applicable records (100%-FY 08) contained documentation that a referral was provided. 

The chart review examined assessed patients for the following oral manifestations associated with HIV: xerostomia, 

LGE periodontal disease, NUP periodontal disease, and candidiasis. Ninety-two percent of assessed records 

documented no pathology for any of these conditions. Three percent of reviewed records (

Conclusions 

Overall, oral healthcare services continues it’s trend of consistent, high quality care. The Houston EMA oral 

healthcare program has established a strong foundation for preventative care. This is demonstrated in the rates of 

intraoral and extraoral exams, 98% for both. The provider has also shown excellent documentation of care with 

100% of applicable records documenting an x-ray (100% in FY 06 through FY 08) and 99% of records containing a 

marked and up to date clinical tooth chart. Additionally, one hundred percent of the records reviewed (97% in FY 

08 review) documented a statement by the dentist of an annual patient diagnosis. Ninety-nine percent of reviewed 

records contained a subsequent treatment plan and/or updates to the treatment plan. This rate is an almost 10% 

improvement over last year’s review finding of 91%. 

This review cycle did suggest a decrease in screening rate for alcohol, tobacco, and recreational drug use (0%-FY 

08). These rates were much improved during last year’s chart review. The rates were 2% for FY 07, and increased 

to 25%, 33%, and 23% respectively for FY 08 However, during the past year the oral health care provider has 

initiated an electronic records system. This may have impacted the chart abstractor’s ability to locate these health 

history elements. 

Similarly, the rate of necessary specialist referrals showed great improvement in FY 08 at 100%, up from 2% in FY 

07. However, FY 09 chart review findings indicate a decrease to 78%. This decrease should be interrupted with 

caution, due to the small number of records that required a specialist referral. The 4% of applicable records 

indicating a need for a specialist, represents nine charts. Of these nine, two did not document a referral. 

Overall, oral healthcare services continues to exhibit excellent performance. We look forward to continued high 

levels of care for our patients in future reviews. 

Appendix A – Resources 

Abel, Stephen N. (and others) eds. Principles of Oral Health Management. Dental Alliance for AIDS/HIV Care, 

2000. HAB00230 

Periodontal Screening & Recording ®: An Early Detection System. (n.d.). Retrieved May 25, 2004, from 

http://www.ada.org/prof/resources/topics/perioscreen/index.asp 

Page 36 of 72 

Heavy Drinking, Drug Abuse Present Health Complications for Dental Treatment. (December 1, 2003). Retrieved 

May 18, 2004 from http://www/agd.org/media/2003/dec/abuse.html

RYAN WHITE GRANT 

PROGRAM 

SUMMARY REPORT 

2009 RYAN WHITE FOCUS 

GROUPS 

December 2009 

Prepared by: 

Carin Martin, MPA 

Project Coordinator-Quality Management Development 

Harris County Public Health & Environmental Services 

Ryan White Grant Administration Section 

2223 West Loop South, RM 417 

Houston, TX 77027 

713-439-6041 

Page 37 of 72

Executive Summary 

The following findings highlight the most frequently discussed topics by focus 

group participants: 

• Most participants are satisfied with transportation benefits provided 

through Ryan White funded bus passes. Many of the participants 

reported an awareness bus passes should be used exclusively for 

transportation to medical appointments. 

• Many of the participants reported experiencing long waits for dental 

care services, particularly general cleaning appointments. 

• Most participants reported receiving their annual Pap screenings as 

scheduled. 

• Many of the participants emphasized the importance of peer 

support/mentoring groups in staying engaged in their own health 

maintenance. 

• Most participants reported substance abuse, depression and/or 

incarceration as barriers to entering care after learning their diagnosis. 

Ryan White Grant Program 

Summary Report on 2009 Ryan White Consumer Focus Groups 

Background 

The Houston EMA (Eligible Metropolitan Area) Ryan White Grant 

Administration office has conducted consumer satisfaction surveys on an 

annual basis since 2003. Since 2008, the Houston Ryan White Grant 

Administration office has conducted focus groups at each of the primary care 

agencies that receive Ryan White funding to augment the consumer 

satisfaction process. The focus groups are conducted to obtain client 

perspectives on a variety of core and support services. 

In Fall 2009, Ryan White Grant Administration, and Harris County Public 

Health and Environmental Services staff conducted a series of focus groups 

with consumers who utilize Ryan White funded core and support services (as 

defined under the Ryan White HIV/AIDS Treatment Modernization Act of 2006). 

The data were collected to obtain additional insight into consumers’ 

perceptions of their experiences with Ryan White funded services. The report 

presents common themes that arose from the four focus groups. 

Methods and Analyses 

Information was obtained on clients perceptions of access to and quality of 

care received through the Ryan White funded agencies in a variety of service 

areas including, primary care, dental care, transportation, and case 

management services, among others. 

Page 38 of 72

The Ryan White Project Coordinator collaborated with agency representatives 

to recruit clients to participate in the focus groups. The focus groups were 

moderated by the Ryan White Project Coordinator. An interpreter was 

present at two focus group sessions to ensure full engagement of Spanishspeaking 

consumer participants. However, no monolingual Spanish 

participants were present at any of the four focus groups. Agencies staff were 

prohibited from participating in the focus group sessions to encourage full 

disclosure of experiences among focus group participants. 

Informed consent forms were obtained from each focus group participant prior 

to each focus group session. There were both English and Spanish versions of 

the informed consent form available to participants. Each focus group session 

was audio taped and transcribed verbatim (to the extent possible). Once the 

focus group sessions were transcribed the audiotapes were destroyed to protect 

the identity of the focus group participants. Focus group participants were 

encouraged to comment however they were informed that it was not necessary 

to respond to every question. 

A thematic analysis was used to analyze the data. Thematic analysis identifies 

patterns in the data and organizes and describes the data in detail (Braun & 

Clarke, 2006) 1. 

It is important to note that focus group results are not 

generalizable to the larger population of consumers who receive Ryan White 

funded services. 

Characteristics of Focus Group Participants 

During the 2009 focus groups, several discussion questions focused on 

women’s health issues, specifically Pap screenings. For this reason, most 

agency staff recruited exclusively from their female client base. However, one 

agency did have mostly male participants. The women in this group indicated 

they were comfortable discussing women’s health issue questions in a mixed 

gender setting. Additionally, there was a mixture of other characteristics 

among focus group participants. There were individuals who had been 

diagnosed as long as twenty years ago as well as newly diagnosed individuals. 

The education and socioeconomic level of participants also varied. For 

example, many participants heavily relied on the Ryan White Program for 

transportation services while a few reported owning their own vehicles. The 

majority of participants were African American. There were several White 

participants. Focus groups consisting of representatives from agency 

consumer councils/support groups tended to voice their concerns more readily 

than others. 

1 

Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in 

Psychology,3, 77-101. 

Page 39 of 72

Dental Services 

Findings 

Consumers were asked if they aware of any recent changes in Ryan White 

Dental services. Those who were aware were asked how the changes have 

affected dental services. 

In an effort to increase access to dental services, at the beginning of FY 2009, 

the Houston EMA began funding a rural oral health care provider. 

Additionally, the Houston EMA’s only untargeted oral health care provider 

relaxed their rescheduling policy regarding missed client appointments. 

• Many of the focus group participants were currently engaged in dental 

care, and most of those individuals were aware of changes in the 

untargeted provider’s rescheduling policy. 

• Participants that were aware of changes in the rescheduling policy were 

universally pleased with its impact on access to dental services. 

• One participant stated she had already benefited from the more flexible 

policy, and that she felt the dental provider were more understanding of 

the fact things arise in day-to-day scheduling that make keeping every 

appointment difficult for someone living with HIV/AIDS. 

• A number of participants that had not been aware of the new policy 

commented that they would make an effort to engage in oral health care 

services again. 

• Most participants were not aware of the new oral health care provider. 

The exception to this were patients who received primary medical care 

through the same agency that provides rural oral health care. 

• Many focus group participants reported long waits for dental care 

appointments. One participant commented that she completed her 

prerequisite x-ray appointment with the untargeted dental provider and 

was told she would be contacted when an appointment was available 

for a cleaning. She followed-up for a year. After a year on the waiting 

list, she was seen for a cleaning, and told that her x-rays had expired 

and needed to be completed again. Participants reported the wait time 

at the rural dental provider to be approximately 30 days. 

Page 40 of 72

Conclusions 

The information obtained through these focus groups provided valuable 

insight on consumers’ perceptions of their access to care and experiences with 

service providers. Issues such as patient mental health, substance abuse, 

stigma, the importance of social support networks and access to medical and 

dental appointments were common themes discussed across focus groups. 

One of the most notable topics discussed was the profound negative effect 

depression and/or substance abuse has on patient retention in medical care. 

Depression and substance abuse were given as the chief reasons why patients 

were out of care for extended periods of time. This information further 

confirms the importance of mental health and substance abuse screenings for 

all patients that enter the care system. Mental health and substance abuse 

service availability and referral follow-up are equally important aspects of 

overcoming barriers to retention in care. 

The importance of a support network was also a sentiment that was expressed 

across all focus groups. This appeared to be particularly true for patients that 

were new to HIV medical care. Participants indicated that in-clinic support 

groups were not only excellent resources for information on how to navigate 

the care system, but also a network for friends with similar life experiences. 

Many consumers comments that the “support groups” were like family, 

always available and helpful. 

In addition to treatment adherence and retention in care issues, access to 

dental services continues to be a significant concern. Many participants were 

aware of increased flexibility with our untargeted dental providers 

rescheduling policy. Participants also believe that this change enhances their 

access to oral health care. However, appointment availability due to system 

capacity appears to be a growing problem. 

Linkage to and retention in primary medical care is a central focus of quality 

improvement for HIV-positive individuals on both a local and national level. 

The information provided in the 2009 Houston EMA focus group offers 

excellent insight on what areas have the potential of making the greatest 

impact on this issue. 

Page 41 of 72

Public Comment 

for How to Best 

Meet the Need 

Oral Health 

Workgroup 

Page 42 of 72

Monday Tuesday Wednesday Thursday Friday Week Totals 

Hyg Pts Seen 16 19 15 17 19 86 

Hyg Apts 

Scheduled 

20 20 18 20 20 98 

Hyg No Show 4 1 3 3 2 13 

X/E Pts Seen 8 20 0 16 6 50 

X/E Apts 

Scheduled 

9 18 0 18 9 54 

X/E No Show 2 0 0 3 3 8 

Gen Pts Seen 20 27 19 24 26 116 

Gen Apts 

Scheduled 

0 

0.00 

205 

4.10 

20 27 17 25 23 112 

Gen No Show 5 5 1 2 0 13 

Length of General Waiting List in Weeks 

Pros Pts Seen 21 9 15 13 10 68 

Pros Apts 

Scheduled 

25 10 17 13 9 74 

Pros No Show 5 1 2 0 0 8 

Number of Individuals Currently on Pros Waiting List 

PVC/Implant 

Pts Seen 

PVC/Implant 

Apts Sched. 

PVC/Implant 

No Show 

Weekly Tally February 1-5 

Number of Individuals Currently on Hygiene Waiting List 

Length of Hygiene Waiting List in Weeks 

Number of Individuals Currently on X/E Waiting List 

Length of X/E Waiting List in Weeks 

Number of Individuals Currently on Gen Waiting List 

Length of Pros Waiting List in Weeks 

1 0 2 0 0 3 

1 1 2 0 0 4 

0 0 0 0 0 0 

Number of Individuals Currently on PVC/Implant Waiting List 

226 

1.95 

0 

0.00 

363 

Page 43 of 72


Length of PVC/Implant Waiting List in Weeks 

Perio Pts Seen 0 0 8 0 0 8 

Perio Apts 

Scheduled 

Perio No 

Show 

121.00 

0 0 7 0 0 7 

0 0 1 0 0 1 

Number of Individuals Currently on Perio Waiting List 

Length of Perio Waiting List in Weeks 

Pts Seen 331 

Apts 

Scheduled 

349 

No Show 43 

No Show Rate 12.32% 

Total Number of Individuals Currently on Waiting List 

3 

0.38 

797 

Page 44 of 72


Hyg Pts Seen 20 15 18 20 20 93 

Hyg Apts 

Scheduled 

20 15 18 20 19 92 

Hyg No Show 3 2 2 3 1 11 

X/E Pts Seen 17 14 0 17 1 49 

X/E Apts 

Scheduled 

17 18 0 18 0 53 

X/E No Show 0 4 0 1 0 5 

Gen Pts Seen 16 22 22 20 19 99 

Gen Apts 

Scheduled 

14 24 18 19 18 93 

Gen No Show 2 2 0 1 2 7 

Pros Pts Seen 29 10 19 11 12 81 

Pros Apts 

Scheduled 

28 11 17 12 14 82 



PVC/Implant 

Pts Seen 

PVC/Implant 

Apts Sched. 

PVC/Implant 

No Show 

Weekly Tally February 12 








1 1 2 1 0 5 

1 1 2 1 0 5 

0 0 0 0 0 0 


0 

0.00 

238 

4.86 

252 

2.55 

7 

0.09 

350 

Page 45 of 72



70.00 

Perio Apts 

Scheduled 

0 0 7 0 11 18 

Perio No 

Show 

0 0 0 0 2 2 


3 


Pts Seen 345 

Apts 

Scheduled 

343 

No Show 31 



Number of New Intakes 

0.17 

850 

9 

Page 46 of 72


Hyg Pts Seen 20 20 18 20 20 98 

Hyg Apts 

Scheduled 

19 20 18 20 20 97 

Hyg No Show 1 1 2 3 2 9 

X/E Pts Seen 19 16 0 16 7 58 

X/E Apts 

Scheduled 

18 18 0 18 9 63 

X/E No Show 2 2 0 2 2 8 

Gen Pts Seen 16 21 15 24 21 97 

Gen Apts 

Scheduled 

16 25 16 21 21 99 

Gen No Show 3 5 3 0 4 15 

Pros Pts Seen 32 14 17 12 10 85 

Pros Apts 

Scheduled 

29 15 20 12 9 85 



PVC/Implant 

Pts Seen 

PVC/Implant 

Apts Sched. 

PVC/Implant 

No Show 









0 0 2 2 0 4 

0 0 2 2 0 4 

0 0 0 0 0 0 


0 

0.00 

273 

4.71 

296 

3.05 

0 

0.00 

351 

Page 47 of 72



87.75 

Perio Apts 

Scheduled 

0 0 8 0 7 15 

Perio No 

Show 

0 0 2 0 1 3 


3 


Pts Seen 355 

Apts 

Scheduled 

363 

No Show 43 




0.23 

923 

8 

Page 48 of 72


Hyg Pts Seen 20 19 15 19 19 92 

Hyg Apts 

Scheduled 

20 20 16 20 20 96 

Hyg No Show 2 5 1 3 4 15 

X/E Pts Seen 5 14 0 14 0 33 

X/E Apts 

Scheduled 

9 20 0 18 0 47 

X/E No Show 4 6 0 4 0 14 

Gen Pts Seen 21 27 17 34 26 125 

Gen Apts 

Scheduled 

0 

0.00 

182 

5.52 

20 26 18 34 23 121 

Gen No Show 4 0 0 1 1 6 

Pros Pts Seen 26 11 17 10 11 75 

Pros Apts 

Scheduled 

30 10 17 10 11 78 

Pros No Show 7 0 2 1 0 10 



PVC/Implant 

Pts Seen 

PVC/Implant 

Apts Sched. 

PVC/Implant 

No Show 








1 0 3 0 1 5 

1 0 3 0 1 5 

0 0 1 0 0 1 


281 

2.25 

0 

0.00 

352 

Page 49 of 72



Perio Apts 

Scheduled 

Perio No 

Show 

70.40 

0 0 9 0 10 19 

0 0 0 0 4 4 



Pts Seen 345 

Apts 

Scheduled 

366 

No Show 50 




3 

0.20 

818 

13 

Page 50 of 72

February Tally 

Week 1 Week 2 Week 3 Week 4 Month Totals 

Patients Seen 331 345 355 345 1376 

1421 

Appointments Scheduled 

349 343 363 366 

No Show 43 31 43 50 167 

No Show Rate 12.32% 9.04% 11.85% 13.66% 11.72% 

Total Number of Individuals 

Currently on Waiting List 

797 850 923 818 818 

Number of New Intakes 18 9 8 13 48F 

Page 51 of 72

INCREASING ACCESS TO DENTAL CARE 

You cannot be healthy without oral health 

—Oral Health in America: A Report of the Surgeon General 1 

Access to oral health care for all people living with HIV/AIDS (PLWHA) 

remains a critical—and unmet—goal. Uninsured PLWHA are three times 

more likely to have untreated dental and medical needs than are PLWHA 

with private insurance. Moreover, oral infections, mouth ulcers, and other 

severe dental conditions associated with HIV infections go untreated more 

than twice as often as other health problems related to the disease. 2 

DID YOU KNOW? 

HRSA-supported community health centers in 2006 provided oral 

health services to some 2.6 million patients. 

Approximately 108 million Americans lack dental insurance. 3 

More than 500 medications can lead to xerostomia or “dry mouth,” 

which can lead to dental decay, periodontal disease, and oral 

candidiasis (thrush). 4,5,6 

�� Please visit our Web site at www.hrsa.gov 

ONLINE RESOURCES 

Page 52 of 72 

AUGUST 2008 

Big Barriers: High Costs 

HIV Dental Health Issues 

Transporting Health 

Taking It to the Streets 

HRSA Part F Dental Programs 

http://hab.hrsa.gov/ 

treatmentmodernization/dental.htm 

SPNS Oral Health Initiative Evaluation 

Center 

www.hdwg.org/echo/front 

Oral health in America: A report of the 

Surgeon General 

http://silk.nih.gov/public/ 

hck1ocv.@www.surgeon.fullrpt.pdf 

HIV Screening in Dental Settings: The 

Role of Salivary Diagnostics 

www.nationaloralhealthconference. 

com/docs/presentations/2007/0430/ 

Jennifer%20Cleveland%20%20Salivary 

%20Diagnostics%20Potential%20 

Benefits%20of%20HIV%20Testing% 

20in%20Dental%20Settings.pdf

2 

DIRECTOR’S NOTES 

When the media covers HIV disease, its impact on 

dental care and access to oral health services is rarely 

discussed. As health care professionals, however, we know 

all too well that oral health problems are often the first 

manifestations of HIV disease. For HIV-positive persons 

who don't know their status, dentists can have an important 

role as diagnosticians. For PLWHA who do know their 

status, providers must be ever vigilant in linking people to 

dental providers and preventing oral health problems. 

Dental care in the United States is a luxury many 

people cannot afford. In fact, 108 million Americans are 

without dental insurance. But for PLWHA, the lack of 

proper oral health care can be devastating. Weakened 

immune systems can make PLWHA more susceptible to 

oral infections and dental problems can interfere with 

nutrition and absorption of life-saving HIV medications. 

HIV providers across the country are addressing new 

oral health issues as they arise—and persist. These may 

include “meth mouth,” or the need for more implants and 

denture work, as PLWHA continue to age with the disease. 

This is why the linkages providers create with one another 

are so essential to creating the comprehensive care PLWHA 

need if they are going to get healthy—and stay that way. 

Deborah Parham Hopson 

HRSA Associate Administrator for HIV/AIDS 

HRSA CAREAction 

Publisher 

U.S. Department of Health and Human Services 

Health Resources and Services Administration, HIV/AIDS Bureau 

5600 Fishers Lane, Room 7-05 

Rockville, MD 20857 

Telephone: 301.443.1993 

Prepared for HRSA/HAB 

by Impact Marketing + Communications, www.impactmc.net 

Photography 

Cover: a patient at the San Francisco Native American Health Center’s 

pediatric dental facility. © See Change, www.see-change.net 

P. 7, Project coordinator Henry Boza of the Miami Dental Access 

Project. © See Change, www.see-change.net 

Additional copies are available from the HRSA Information Center, 

1.888.ASK.HRSA, and may be downloaded at www.hab.hrsa.gov. 

Page 53 of 72 

In addition to common oral health problems, 

such as caries (decay) and gingivitis, 

PLWHA have a high incidence of rare oral health 

issues (see Table 1) because of their weakened 

immune systems. 7 Dental problems can also 

impede food intake and nutrition, 8 leading to 

poor absorption of HIV medications and 

increasingly impaired immune function, particularly 

because all antiretroviral medications are 

given in relation to food intake. 9 

Poor oral health conditions can also interfere 

with social functioning and limit educational 

and career opportunities as a result of the 

disfigurement and odor caused by decayed 

teeth and gum disease. 10 Completing the circle, 

reduced quality of life related to oral health is 

associated with poor clinical status and reduced 

access to health care. 11 

These data are not news to most providers 

of HIV/AIDS care to the uninsured. Yet, the 

unmet need for oral health services and the 

incidence of entirely preventable oral health 

problems among underinsured PLWHA remains 

persistent. In fact, even people who have medical 

insurance, whether or not they have HIV/ 

AIDS, may have limited or no dental benefits. 

Providers who are most successful at helping 

PLWHA transcend barriers to good oral 

health are applying perhaps one of the most 

important lessons learned—and relearned— 

since the Ryan White HIV/AIDS Program was 

adopted: Eliminating health disparities often 

isn’t about doing just one thing; instead, it is 

about meeting PLWHA “where they are” and 

helping them address the specific barriers they 

face. 

Big Barriers Extract High Costs 

HIV-positive people face challenges in maintaining 

oral health that go beyond remembering 

to brush and floss their teeth. First among 

them may be fear. As much as 20 percent of the 

American population does not regularly visit 

the dentist because of anxiety, and an estimated 

8 to 15 percent of Americans avoid 

dental treatment entirely because of this fear. 12 

A more systemic issue is that the number of 

oral health professionals per capita is declining. 

The number of practicing dentists in the United

States has remained stagnant at around 150,000 since 

1990, although the U.S. population has grown significantly 

since then. 13 The diminishing availability of dentists 

exacerbates the shortage of dentists who are experienced 

in treating—or willing to treat—PLWHA. 

“The number of dentists providing dental care to 

HIV-positive patients is inadequate. Consumers consistently 

identify oral health as one of their top unmet 

needs,” according to Mahyar Mofidi, project director of 

the Ryan White HIV/AIDS Program Part F Community- 

Based Dental Partnership Program. 

PWLHA are among the 108 million Americans without 

dental insurance—a number 2.5 times greater than 

the number of Americans who lack medical insurance. 

14,15 Fewer and fewer people have dental insurance 

for a host of reasons, including lack of health literacy, 

inadequate coverage from public programs, loss of dental 

insurance after retirement, and employer insurance 

plans that do not cover dental care. This lack of insurance 

is interwoven with many familiar problems for 

PLWHA, such as the inability to pay for care and unmet 

needs for essentials like transportation, housing, and 

child care. 

As Steven Toth of the University of Medicine and 

Dentistry of New Jersey (UMDNJ) explains, poor oral 

health carries a stigma. “We had a patient who was very 

embarrassed about his smile,” says Toth.“When we saw 

him for the first time, he had maybe two teeth. We were 

able to give him back his smile, and now his teeth are 

reflective of his personality.” 

HIV-Specific Dental Health Issues 

PLWHA can develop the same oral health problems as 

HIV-negative people. But some conditions are seen 

almost exclusively in people who are HIV positive (see 

Table 1, page 4). In fact, more than one-third of PLWHA 

have oral conditions resulting from a weakened 

immune system. 20 Oral lesions from candidiasis (thrush), 

oral hairy leukoplakia, herpetic ulcers, and Kaposi’s sarcoma, 

for example, are often among the first symptoms 

of HIV infection. 21 

Bacteria are the culprits behind the two most common 

oral health conditions affecting everyone, regardless 

of HIV status: dental caries and periodontal disease. 

22 These bacterial infections that begin in the 

mouth can potentially inflict great harm to the heart, 

brain, and other organs if not treated, particularly in 

PLWHA with severely compromised immune systems. 23 

In addition, antiretroviral medications taken by 

many PLWHA may cause a reduction in salivary secretions 

called xerostomia, commonly referred to as “dry 

mouth,”which predisposes people to caries, periodontal 

disease, and oral candidiasis. 24,25 In fact, more than 500 

medications can lead to dry mouth, and approximately 

30 percent of PLWHA have moderate to severe dry 

mouth. 26 

Saliva neutralizes acids in the mouth from food and 

drink and helps prevent microorganisms from adhering 

to teeth; in the absence of sufficient saliva, acids and 

pathogens have deleterious effects on teeth and gums. 27 

Fortunately, dry mouth is easily treated with artificial 

“The number of dentists providing dental care to HIV-positive patients is inadequate. 

Consumers consistently identify oral health as one of their top unmet needs.” 

In addition to large-scale issues, such as cost of services 

and access to care, smaller, more personal ones play 

a significant role in oral health. People with substance 

abuse problems, for example, have an increased incidence 

of poor oral hygiene. Some illicit substances 

increase cravings for sugary foods and drinks which, 

over time, can erode teeth. 16,17 Drugs like ecstasy and 

crystal methamphetamine make users more susceptible 

to tooth grinding and cause dry mouth. The corrosive 

properties of methamphetamine can lead to decayed 

oral tissue and severe damage, causing teeth to break, 

rot, and discolor. 18,19 

Page 54 of 72 

saliva products or sugar-free citrus candies, such as 

lemon drops, which stimulate saliva production. 28 

Steps can be taken to prevent many other oral 

health care issues that disproportionately affect PLWHA. 

Along with regularly brushing and flossing, PLWHA 

should limit smoking and alcohol intake—both of which 

are strongly associated with oral cancers, which have a 

poorer patient prognosis than other types of cancer. 29 

Finally, PLWHA should receive dental examinations 

every 6 months. It is preferable if examinations are 

conducted by providers familiar with the particular conditions 

associated with decreased immune function. 

(continued on bottom of page 4) 

3

4 

TABLE 1. ORAL HEALTH PROBLEMS COMMON AMONG PLWHA 

Condition 

Aphthous stomatitis 

Caries 

Herpes simplex 

Human papilloma 

virus (HPV) 

Linear gingival 

erythema 

Kaposi’s sarcoma 

(KS) 

Necrotizing 

ulcerative 

periodontitis 

Oral candidiasis 

Oral hairy 

leukoplakia 

Periodontal disease 

Description/Cause 

Also known as canker sores, this condition is characterized by red sores that can be topped 

by a yellow-gray film and are usually found on the tongue or inside of the cheeks and lips 30 

Tooth decay caused by bacteria 31 

Oral Health Care—A Consumer Priority 

Oral health care is considered a core medical service 

under the Ryan White HIV/AIDS Treatment Modernization 

Act. The Ryan White HIV/AIDS Program tackles oral 

Viral infection that causes red sores (“fever blisters”) on the roof of the mouth or on the lips 32 

Virus associated with genital and other warts and one of the most common sexually transmitted 

infections; can produce serious and hard-to-treat lesions in the mouths of PLWHA 33 

Inflammation of the gingiva, the tissue surrounding the neck of the tooth; unique among 

people with compromised immune systems 34 

Cancer that causes red or purple patches of abnormal tissue to grow under the skin; in the 

lining of the mouth, nose, and throat, or in other organs 35 

Severe form of periodontal disease (see definition below) in which the gums pull away from 

the teeth and form pockets that are infected; if not treated, the bones, gums, and connective 

tissue that support the teeth are destroyed 36 

A fungal (yeast) infection of the mouth also known as thrush; one of the most common 

opportunistic infections among PLWHA, usually appearing when CD4 counts fall below 300 37 

White, hairlike growth that usually appears on the side of the tongue or the inside of the 

cheeks and lower lip; caused by the Epstein-Barr virus 38 

Page 55 of 72 

Chronic bacterial inflammation of the gums, ranging from gingivitis, in which gums become 

red and swollen and can bleed easily, to serious disease that results in damage to the bone 39 

health care on several fronts. In addition to Part F dental 

programs, Ryan White Parts A and D address oral health 

care and, in 2006, provided approximately $43 million for 

oral health care services for nearly 70,000 people.

Currently, three specific dental programs exist within 

the Ryan White HIV/AIDS Program: the Community- 

Based Dental Partnership Program, the Dental Reimbursement 

Program, and the Special Projects of National 

Significance (SPNS) HIV/AIDS Oral Health Care Initiative. 

The sections that follow describe each program. 

Community-Based Dental Partnership Program 

The Community-Based Dental Partnership Program provides 

dental care and provider training in community 

based settings.The program aims to increase oral health 

services for PLWHA in underserved communities and to 

provide hands-on training for dental school students 

and residents in treating PLWHA. The training is particularly 

valuable, according to Mofidi, because it is “important 

for the students to see how dental care fits into 

overall health of PLWHA.” 

First funded in 2002, this program supports 12 

grantees serving 11 States. In 2006, more than 4,300 HIVpositive 

patients received dental care through this program 

in a total of 22,000 patient visits—about five visits 

per patient, per year. 40 

Dental Reimbursement Program 

The Dental Reimbursement program is the oldest Ryan 

White HIV/AIDS Program dental initiative. It reimburses 

schools of dentistry and oral hygiene for a portion of the 

costs of providing dental care to PLWHA. In 2006, 65 

schools received reimbursements totaling more than 

$22.9 million.This program has served more than 32,000 

PLWHA and helped train more than 11,000 dental students 

and residents in 2006. 41 

SPNS HIV/AIDS Oral Health Care Initiative 

The Health Resources and Services Administration, 

HIV/AIDS Bureau, Special Projects of National Significance 

(SPNS) HIV/AIDS Oral Health Care Initiative is 

funded through Part F of the Ryan White HIV/AIDS 

Program. Launched in 2006, the 5-year, multisite initiative 

is developing, implementing, and evaluating innovative 

models of oral health care around the country. 

Fifteen demonstration sites are being funded in both 

urban and nonurban areas where oral health services do 

not exist or are inadequate to meet current demand. 

The Oral Health Care Initiative includes an evaluation 

and technical assistance center—the Evaluation 

Center for HIV & Oral Health (ECHO) at the Boston 

University School of Public Health. ECHO implements 

and coordinates the multisite evaluation of the initiative, 

gathers data, and shares lessons learned across the 

Page 56 of 72 

15 demonstration sites. In addition, it coordinates the 

provision of technical assistance through presentations 

and trainings by leading experts in HIV oral health care. 

ECHO also coordinates semi-annual grantee meetings 

to bring grantees together to share their experiences 

and lessons from the field, and learn from each other’s 

experience in delivering oral health care and evaluating 

their service models. (For more information about ECHO, 

visit www.hdwg.org/echo/.) 

Transporting Clients, Transporting Care 

Ann Ferguson is a nurse at the AIDS Care Group in 

Chester, Pennsylvania, a SPNS Oral Health Care Initiative 

grantee.“Part of the problem for our patients,” she says, 

“is the barriers imposed by providers and the general 

fear and anxiety associated with dental care.” She points 

out other issues too, such as the need for ancillary services. 

“We are impressed on a weekly basis by the transportation 

needs associated with this program,” says 

Ferguson. The AIDS Care Group utilizes a van with a 

Global Positioning System (GPS). “It has already logged 

20,000 miles on this grant alone.” 

Cindee Shapiro echoes the need for transportation 

among her clients. Shapiro is vice president of the AIDS 

Resource Center of Wisconsin (ARCW) in Green Bay, 

another SPNS Oral Health Care Initiative site. About 60 

percent of ARCW clients require transportation assistance. 

Shapiro says that providing this assistance has 

raised clients’ awareness of ARCW’s other services. For 

example, she says,“ARCW is experiencing a doubling of 

food disbursed through its Green Bay food pantry since 

the dental clinic initiated services in April 2007.” 

The HIV Alliance of Lane County in Eugene, Oregon, 

expected to transport clients all over its 63,000 squaremile 

service area when it wrote its SPNS Oral Health Care 

Initiative grant application.“We had thought one shuttle 

would be fine,” says Dental Program Coordinator 

Amanda McCluskey,“but that has not been the case.” 

Instead, the HIV Alliance is finding that opening 

satellite clinics “is a great way to build capacity and get 

involvement in our clinics,” says McCluskey. One satellite 

clinic has opened so far; three more are expected to 

open this spring, and another two or three over the summer. 

The clinics offer cleaning and preventive care from 

hygienists, and dentists perform services ranging from 

extractions to denture work. 

“Partnerships have been the key to the project’s 

success,”says McCluskey.“We are partnering with dental 

hygiene programs, federally qualified health centers, 

community health departments using spaces that 

5

already exist,” she explains. “So we are replicating our 

model across the State to give clients greater access.” 

Taking It to the Streets 

Hurricane Katrina devastated the dental school at 

Louisiana State University (LSU) in New Orleans and 

damaged half of all the dental practices in Orleans 

Parish. Charity Hospital, which had a large, 28-chair 

dental clinic, was lost. 

Dental services for city residents after the hurricane 

were set up in a military tent in a parking lot with a 

single dental chair, recalls Janet Leigh, chair of oral 

medicine and radiology at the LSU School of Dentistry 

and principal investigator for the Oral Health Initiative 

project called “Smile Again, New Orleans!” The services 

were then moved to the city’s convention center to 

allow for increased space. The program moved again, 

this time to a vacant department store building, before a 

final move to its current location in the Medical Center 

of Louisiana at New Orleans. 

The SPNS grant has provided Leigh’s program with a 

mobile unit that can be moved around to areas with 

potential patients but no public transportation services. 

The project believed the van’s dental services would 

attract people already infected with HIV and others at 

risk who were unlikely to have been tested or have 

accessed care even before the storm. 

Sure enough, “The van has helped channel HIV 

patients into the medical care they need,” says Leigh. It 

also has helped rebuild the HIV outpatient oral health 

clinic from three to five chairs. The project has partnered 

with Covenant House, a shelter for runaway and troubled 

youth; St. Anna’s Episcopal Church, an African 

American parish that regularly offers HIV testing; LSU 

Behavior Science, an inpatient psychiatric and addiction 

program; the Louisiana Office of Public Health; and the 

New Orleans AIDS Task Force. These partnerships 

demonstrate the repeated success HRSA-funded programs 

have had in maximizing limited resources 

through relationships and referral systems with community 

based organizations. 

Partnering for Lasting Results 

The UMDNJ began providing oral health care services to 

PLWHA in 1989, and its oral health care services for 

PLWHA have been supported by the Ryan White 

HIV/AIDS Program for years. Jill York, director of the 

UMDNJ’s Special Services Dental Unit, says that the unit 

served 616 unduplicated oral health care patients in 

2007, accounting for 2,634 patient visits. This success 

6 

Page 57 of 72 

was achieved through a partnership with Access One, an 

AIDS service organization serving three counties. 

York says that the partnership helps fulfill UMDNJ’s 

goal of improving both access to care and primary 

health care for PLWHA. At the most fundamental level, 

the partnership is successful because it works for all the 

players: It creates access to patients for UMDNJ’s Special 

Services Dental Unit, and it helps Access One serve its 

clients. 

The partnership also provides opportunities to train 

dental students and medical students, who do a rotation 

through the unit’s clinical sites. York is hoping to develop 

a national model for oral health care in Ryan White 

programs within 5 years and is now conducting followup 

interviews with former students to see how they 

have implemented what they learned in the program. 

“We had a great chance to inspire them,”she says,“so we 

want to see how many people are serving the underserved, 

particularly HIV patients.” 

More than one-half of all the HIV patients seen at 

UMDNJ are between 45 and 64 years old. 42 The high percentage 

of older PLWHA served in the program demonstrates 

how aging with HIV is changing the landscape 

not only of primary care but also of dental care. 

Partnerships like those spearheaded by the UMDNJ 

Special Services Unit are occurring across the country. A 

longtime collaboration between the University of 

Louisville’s Community-Based Dental Partnership 

Program and Ryan White-supported physicians and 

social service care coordinators has been the foundation 

of its excellent patient care and educational opportunities 

for dental students, according to Program Director 

Theresa Mayfield. The oral health portion of the program’s 

Ryan White grant supports its collaboration with 

two clinics—one urban and the other rural. “We have 

taught the staff of these clinics, and they have embraced 

the need for their clients to receive oral health care,”says 

Mayfield. “It is just as important for them to coordinate 

for those services as for housing and other services.” 

The embrace has been mutual, because medical 

providers have realized the value of coordinating their 

services with the social service providers. “It takes the 

joint effort of medical providers and people doing social 

services to make it seamless,” says Mayfield. “You can’t 

do it if you don’t have everybody onboard.” 

The WINGS Clinic, a Ryan White-supported outpatient 

medical clinic for PLWHA at the University of 

Louisville, is not just a close partner of the university’s 

dental program—it is just down the hallway in the same 

building. “Proximity at the school has been mutually

eneficial,” says Clinic Program Director Deborah Wade. 

“It has meant that if WINGS Clinic patients have dental 

emergencies, or are in pain, we can just walk them right 

next door,” adds Wade. “The beauty of that is we have 

their records and can tell the dentist their CD4 count, 

viral load, whether they’ve been adherent to their medications, 

and any background information they might 

need as they deliver oral health care.” 

Likewise, Wade says the dentists “have trained all our 

medical providers on how to do a visual screen at a 

medical appointment.” As a result, a medical patient in 

the WINGS Clinic who might be experiencing a dental 

issue can get an initial assessment in the medical clinic. 

It provides a seamless approach to then refer the patient 

for dental care. “Now we are pretty much set on autopilot,” 

says Wade. “We have all our medical providers do 

oral screens as a routine part of each medical visit.” 

This collaboration of the WINGS Clinic and the Ryan 

White oral health programs has helped educate both 

PLWHA and medical providers about the connection 

between oral health and general health. “Now we are all 

speaking the same language and can communicate better 

about patients’ oral health care needs,” says Wade. 

Page 58 of 72 

The Miami Dental Access Program (MDAP) and Louisiana’s “Smile Again, New Orleans!” are two Oral Health Initiative projects using 

a mobile van to expand HIV/AIDS dental care into urban communities. MDAP’s Henry Boza is shown above with a prospective client. 

At Matthew 25 AIDS Services in Henderson, Kentucky, 

Cyndee Burton, the nurse-administrator and cofounder, 

says the partnership with the University of 

Louisville dental school “has been a Godsend for us.”The 

agency has been able to use the relatively small amount 

of dental care funding it had before to provide transportation 

for dental clients, taking them to either 

Louisville or nearby Elizabethtown, Kentucky, for the 

specialized care they cannot receive in Henderson. 

Clients who receive regular dental care have been 

transformed by these important services. In a State 

where more than 40 percent of the adult population 

experience the loss of more than 5 teeth, receiving 

dental care can literally be life changing. 43 

“We have one guy who, when he first came in, would 

hang his head because his teeth were so bad,” recalls 

Burton. “He was a meth user and had gone through 

treatment and gotten out. He immediately started volunteering 

at our clinic, but I noticed he always did things 

in the background. You could never get him to smile.” 

That all changed when the patient was referred to the 

dental clinic.“He now has the most beautiful teeth, and 

he is also one of our leading volunteers,” she marveled. 

7

8 

REFERENCES 

1 U.S. Department of Health and Human Services (HHS). 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. 

2 Agency for Healthcare Research and Quality (AHRQ). Dental 

problems go unresolved in many HIV patients. April 6, 2001. Rockville, 

MD: AHRQ. Available at: www.ahrq.gov/news/press/pr 2001/ 

dentalhivpr.htm. Accessed April 7, 2008. 

3 Centers for Disease Control and Prevention (CDC). Public health & 

aging: Retention of natural teeth among older adults—United States, 

2002. MMWR. 2003;52:1226-9. Available at: www.cdc.gov/mmwr/ 

preview/mmwrhtml/mm5250a3.htm. Accessed April 4, 2008. 

4 Project Inform. Dealing with drug side effects: Dry mouth. 2008. 

Available at: www.projinf.org/info/sideeffects/11.shtml. Accessed 

April 6, 2008. 

5 Abel S, Reznick D. New York/New Jersey AETC and Southeast AETC. 

Current trends in HIV oral health care. Unpublished presentation to 

staff of Health Resources and Services Administration, HIV/AIDS 

Bureau, March 28, 2007. 

6 Public Broadcasting Service (PBS). Frontline: the meth epidemic: How 

meth destroys the body. 2006. Available at: www.pbs.org/ 

wgbh/pages/frontline/meth/body/. Accessed April 6, 2008. 

7 Epstein JB. Oral malignancies associated with HIV. J Can Dent Assoc. 

2007;73:953-6. Available at: www.cda-adc.ca/jcda/vol-73/issue-10/ 

953.pdf. Accessed April 9, 2008. 

8 Gennaro S, Naidoo S, Berthold P. Oral health and HIV/AIDS. MCN 

Am J Matern Child Nurs. 2008;33:50-7. 

9 School of Dentistry, Louisiana State University Health Sciences 

Center. HIV+ Outpatient Clinic: Overview. 2007. Available at: 

www.lsusd.lsuhsc.edu/patient/hiv_clinic1.htm. Accessed April 9, 

2008. 

10 Abel & Reznick, 2007. 


12 Fischler MS. A tooth fairy’s gift: freedom from fear. New York Times. 

June 16, 2002. Available at: http://query.nytimes.com/gst/fullpage. 

html?res=9A00E7DE173CF935A25755C0A9649C8B63&sec=&spon= 

&pagewanted=all/. Accessed April 11, 2008. http://jada.ada.org/cgi/ 

content/abstract/118/5/591 

13 TARGET Center, HRSA, HAB. Ryan White National TA call: Oral 

health and HIV. Call summary and Transcript. October 25, 2007. 

14 CDC, 2002. 

15 HHS, 2000. 

16 McGrath C, Chan B. Oral health sensations associated with illicit 

drug use. Brit Dent J. 2005;198:159-62. 

17 PBS, 2006. 

18 McGrath & Chan, 2005. 

19 PBS, 2006. 

20 National Institute of Dental and Craniofacial Research (NIDCR). 

Mouth problems and HIV. 2007. Available at: www.nidcr.nih.gov/ 

NR/rdonlyres/D8E70B65-6F27-46BC-8043-30C309508B5F/0/ 

Page 59 of 72 

MouthProblemsAndHIV.pdf. Accessed April 6, 2008. 

21 Gennaro et al., 2008. 

22 NIDCR, 2007. 

23 Renvert S, Pettersson T, Ohlsson O, Persson GR. Periodontal 

bacteria linked to heart disease. J Periodontology. 2006;77:1110-9. 

Available at: www.joponline.org/doi/abs/10.1902/jop.2006.050336 . 

Accessed April 11, 2008. 

24 Project Inform. Dealing with drug side effects: Dry mouth. 2008. 

Available at: www.projinf.org/info/sideeffects/11.shtml. Accessed 

April 6, 2008. 

25CNN. Oral thrush. August 20, 2007. Available at: www.cnn.com/ 

HEALTH/library/DS/00408.html. Accessed April 7, 2008. 


27 Brosky ME. The role of saliva in oral health: strategies for prevention 

and management of xerostomia. J Supportive Oncol.2007; 

5:215-25. Available at: http://www.oralcancerfoundation.org/dental/ 

pdf/mgmnt_of_xerostomia.pdf. Accessed April 11, 2008. 

28 NIDCR, 2007. 

29 Kerawala C. Oral cancer, smoking and alcohol: A patient’s perspective. 

Brit J Oral Maxillofacial Surg. 1999; 37:374-76. 

30 NIDCR, 2007. 

31 U.S. National Library of Medicine, National Institutes of Health 

(NLM). Health topics: Dental cavities. March 18, 2008. Available at: 

www.nlm.nih.gov/medlineplus/ency/article/001055.htm. Accessed 

April 7, 2008. 

32 NIDCR, 2007. 

33 Cheah PL, Looi LM. Biology and pathological associations of the 

human papillomaviruses: a review. Malays J Pathol. 1998;20:1-10. 

34 Southeast AIDS Training and Education Center, Emory University 

School of Medicine. Linear gingival erythema. In Clinical management 

of the HIV-infected adult. Available at: www.seatec.emory.edu/ 

clinicalprotocols/chpt5/LinearGingivalErythema.htm. Accessed April 

4, 2008. 

35 NLM. Health topics: Kaposi’s sarcoma. March 31, 2008. Available at: 

www.nlm.nih.gov/medlineplus/kaposissarcoma.html. Accessed 

April 6, 2008. 

36 NLM. Health topics: Gum disease. March 14, 2008. Available at: 

www.nlm.nih.gov/medlineplus/gumdisease.html. Accessed April 6, 

2008. 

37 NIDCR, 2007. 

38 NIDCR, 2007. 

39 NLM, March 14, 2008. 

40 HIV/AIDS Bureau (HAB). Health Resources and Services Administration. 

Ryan White HIV/AIDS Treatment Modernization Act: Dental programs. 

n.d. Available at: http://hab.hrsa.gov/ 

treatmentmodernization/dental.htm. Accessed April 9, 2008. 

41 HAB, n.d. 

42 University of Medicine and Dentistry of New Jersey. Ryan White 

HIV/AIDS data report. 2006. Unpublished data. 

43 CDC, 2002.

y David Evans 

Mouth Full of Problems: A Crisis in HIV Dental Care 

AIDSmeds September 8, 2009 

Too few people with HIV get the routine oral health care they need to stay healthy. The teetering economy, experts 

say, might make the situation a whole lot worse. 

Not accessing dental care can be deadly. In early 2007, a 12-year-old boy named Deamonte Driver from suburban 

Washington, DC, died of an infection that had spread from an abscess in his mouth to his brain. His family’s 

Medicaid had lapsed because of a technicality, so he didn’t get care until his mother took the by then very ill boy 

into an emergency room. Experts say an $80 tooth extraction, if done early enough, could have saved his life. 

Though Driver’s HIV-status was never reported, and there hasn’t been wide press coverage of a similar story 

involving an openly HIV-positive person, David Reznick, DDS, head of the HIV Dental Alliance in Atlanta, says 

that all the necessary ingredients to create such a tragedy are already in place—and could be getting worse. 

People with HIV are simultaneously more likely than their HIV-negative counterparts to have more frequent and 

more serious oral health issues, while being less likely to have the funds and insurance to cover necessary 

procedures. The public support that is available for providing clinical oral health care to people with HIV, Reznick 

says, is drying up as various states confront catastrophic budget crises. “We’re just not seeing enough [funding] 

increases to take care of the people we already serve,” Reznick laments, “So it’s an overwhelming need and no 

resources to pay for it.” 

Open Wide 

Page 60 of 72 

People rarely think—at least until their face is horribly swollen and they’re immobilized with pain—that oral health 

care can have much of an impact on their overall well-being. According to Reznick, however, a neglected mouth 

can lead to more than localized tooth pain: Tooth and gum infections can spread to other parts of the body, and 

mouth pain can cause people to go without necessary nutrition—and even cause them to forgo their HIV 

medications. 

“If you’re in an extraordinary amount of pain, you’re not going to be able to take your medications,” he explains. “If 

you don’t have any teeth to chew with, how are you going to get the nutrition you need to stay healthy?” 

Reznick also has concerns about chronic inflammation from untreated periodontal disease. A growing number of 

studies are illuminating the role of inflammation in a variety of non-AIDS-related health problems such as 

cardiovascular disease. The link between gum and heart disease has been proposed in HIV-negative people, and 

some evidence suggests it to be true. 

For all of these reasons, preventive dental care can have a tremendous influence on a person’s overall well-being. 

Unfortunately, many people with HIV don’t know or understand the importance of regular preventive dental care. 

According to the Health Resources and Services Administration (HRSA), people with HIV who are uninsured are

three times as likely to have untreated dental needs as people with HIV who have insurance. HRSA also states, 

“Moreover, oral infections, mouth ulcers and other severe dental conditions associated with HIV infections go 

untreated more than twice as often as other health problems related to the disease.” 

Roadblocks to Care 

Reznick says that HIV stigma and cultural habits against seeking dental care are two big reasons that people fail to 

go to the dentist regularly even when they have coverage or access to a dentist through public or private benefits. 

But even among people who want to go to a dentist as often as is recommended—at least once every six months for 

a thorough cleaning and checkup—lack of insurance or comprehensive public benefits can mean going without. 

Given the severe budget woes of most states right now, publicly funded dental care is not expanding sufficiently to 

meet the growing epidemic. In fact, in many areas it is shrinking. 

In most cities and towns, the only options for people without dental insurance are oral care programs covered by the 

Ryan White CARE Act or Medicaid. Ryan White, however, has been essentially flat-funded for several years, and 

Medicaid dental coverage, already stingy in many states, is beginning to disappear. “Without the Ryan White 

dollars, there’s minimal access,” Reznick says. “With states that had adult benefits through Medicaid who have lost 

them, it’s caused a gigantic crunch.” 

“We’re struggling to keep up with the need,” Reznick explains, “because people are living longer, and more people 

are getting tested and entering into the system of care. So we’re literally booked through until November, and I have 

eight dental chairs and over three full-time dentists and three hygienists, and we’re having a very difficult time 

meeting the need.” 

Reznick hopes that policymakers and people living with HIV understand the consequences of too-little access to 

good oral health care. Aside from the pain and illness it will almost certainly cause, Reznick contends, it will also 

end up costing more money in the long run. He is hoping for increases, rather than additional cuts, to services. 

When people don’t get preventive care, Reznick says, “they end up in the emergency department, and that’s going 

to cost the public a whole lot more than if they would have kept the benefits in place.” 

© Copyright 1996 - 2009 HIVdent.org. All Rights Reserved.� 

Page 61 of 72

Increasing Access to Oral Health Care for People Living with HIV/AIDS: 

The role of dental case managers, patient navigators and outreach 

workers 

By Carol Tobias, MMHS; Tim Martinez, DDS; Helene Bednarsh, BS, RDH, MPH; 

Jane E. Fox, MPH 

While it is common 

to find HIV case 

managers working 

in medical settings 

or social service 

organizations, the 

concept of dental 

case management 

is relatively new. 

Introduction 

In 2006 the HIV/AIDS Bureau of the Health Resources and Services 

Administration (HRSA) funded the Innovations in Oral Health Care 

Initiative as a Special Project of National Significance (SPNS). The goal of 

this five-year initiative is to expand access to oral health care for HIV-positive 

underserved populations in both urban and rural areas across the country. 

Nine of the fifteen demonstration sites included in this initiative employ a 

dental case manager, patient navigator or outreach worker as part of their 

program model. 

Case management has been part of the continuum of HIV care in the US 

since the early days of the epidemic and was mandated as a service by the 

Ryan White CARE Act of 1990 to ensure service coordination and continuity 

(Fleishman, 1998). Although there is some variation in the key functions 

of case managers across case management programs, the Centers for Disease 

Control and Prevention (1997) have identified six core tasks that form the 

basis of most of HIV case management programs. These core tasks include: 

1. 

2. 

3. 

4. 

5. 

6. 

Client identification, outreach, and engagement; 

Medical and psychosocial assessment of need; 

Development of a service plan or care plan; 

Implementation of the care plan by linking with service delivery systems; 

Monitoring of service delivery and reassessment of needs; and 

Advocacy on behalf of the client (including creating, obtaining, or 

brokering needed client resources). 

BU School of Public Health, Health & Disability Working Group 

December 2008 

Page 62 of 72 

1

Increasing Access to Oral Health Care for People Living with HIV/AIDS 

While it is common to find HIV case managers working in medical settings 

(medical case management) or social service organizations (psychosocial case 

management), the concept of dental case management is relatively new. Most 

of the programs that use dental case managers or related personnel such as 

patient navigators or outreach workers [hereafter all referred to as dental 

case managers unless otherwise noted] as part of the SPNS initiative do so, 

in large part, to increase access to and retention in oral health care. This 

report describes the emerging concept of dental case management and how 

it is implemented in community settings to expand access to oral health care. 

Sections include: 

• 

• 

• 

• 

• 

• 

• 

Methods 

Methods 


December 2008 

The importance of oral health care for people living with HIV 

Barriers to care for people living with HIV 

The role of dental case managers 

How dental case managers improve access to care 

How dental case managers are different from HIV case managers 

How the dental case manager role can be incorporated into other 

practices 

In June 2008 the Evaluation Center for HIV Oral Health (ECHO), the 

multi-site evaluation and technical support center for the SPNS Oral Health 

Initiative, convened a focus group with demonstration site staff who function 

as dental case managers to learn more about their roles. Nine individuals 

participated in the focus group, six of whom had a formal title or role as a 

dental case manager, patient navigator or outreach worker. The other three 

individuals, two of whom were research assistants and one of whom was 

a research hygienist, participated in the focus group because some of their 

functions overlapped with the case managers or outreach workers. 

The six core participants worked at three large urban sites (two in San 

Francisco and one in New York) and three rural sites (Eugene, OR; East 

Texas; and Green Bay, WI). We also received written materials from three 

additional case managers who work in rural locations (Chester, PA; Cape 

Cod, MA; and Middletown, CT). 

Page 63 of 72 

2


Dental case 

managers are 

critical in helping 

patients overcome 

the fear, stigma 

and other barriers 

that inhibit patient 

access to oral 

health care. 

The importance of oral health care for people living with HIV 

While good oral health habits are important for all people, they have 

particular significance for people living with HIV. Many of the first signs 

of HIV infection may occur as oral manifestations that can be identified 

during a routine oral examination by a dentist or hygienist. A review of the 

patient’s medical history and risk assessment in conjunction with an oral 

lesion may prompt the dental team to refer the patient to an HIV testing site 

or a medical provider for a comprehensive work-up. This referral is especially 

important for patients who do not know their HIV status. 

On the other hand, if a person is aware of their HIV status and oral 

manifestations are present, this could indicate a change in the immune 

system or a failure of the current drug regimen. People may find that treatable 

conditions such as gingivitis or early periodontitis can become serious quickly 

if the immune system is weak. In addition, medications prescribed to treat 

HIV can cause a reduced salivary flow and lead to dry mouth or xerostomia. 

Without adequate saliva, which contains protective enzymes, cavities or other 

infections may occur. If not treated, oral health complications can make 

it difficult to chew or swallow, which in turn can impact nutritional status 

or the ability to take HIV medications (Cherry-Peppers, 2003) . This close 

and interdependent relationship between physical health and oral health 

is reflected in the Presidential Advisory Council on HIV/AIDS report on 

Achieving an HIV-Free Generation: Recommendations for a New American 

HIV Strategy, which recommends that “Oral health be part of core services 

available under the Ryan White CARE Act” (DHHS, 2005). 

Barriers to care for people living with HIV 

Access to oral health care is problematic for many Americans, especially those 

living with HIV. With nearly half of all expenditures for dental care coming 

straight out of peoples’ pockets (Badner, 2005), and most of the HIV-positive 

clients served by Ryan White programs living close to or below the poverty 

level, the presence or absence of dental insurance has a major impact on access 

to care. For most low-income individuals, the only source of dental insurance 

is the Medicaid program; yet only 60% of people who receive Medicaid 

benefits live in states that cover adult dental care (Freed, 2005). Even with 

Medicaid dental benefits, people often have difficulty finding dentists that 

will accept Medicaid payment, and Medicaid dental benefits vary from state 

to state. 

In addition to the financial issues, people living with HIV face a host of other 

barriers to care, including provider shortages (particularly in rural areas), 

unwillingness to treat, other competing needs, stigma, discrimination, or 

fear of going to the dentist. Unmet needs for oral health care among people 

living with HIV are substantially higher than the unmet oral health needs 


December 2008 

Page 64 of 72 

3


Dental case 

managers are able 

to address barriers 

to oral health care 

in a way that other 

HIV-care providers 

cannot. 

in the general population (Marcus, 2000), and higher than unmet needs for 

medical care (Heslin, 2001). Racial and gender disparities also play a role in 

access to care, as African Americans, Hispanics, and women are less likely to 

receive dental care than other people living with HIV (Dobalian, 2003). This 

underscores the importance of developing interventions that address both 

the structural and the personal/cultural barriers to oral health care for people 

living with HIV. 

Another significant barrier to care is the overall lack of awareness about the 

importance of regular dental care and the relationship between oral health 

and physical health for people living with HIV. This is not just a barrier for 

individual patients, who may have never received routine dental care, it is also 

a barrier for health care providers and HIV case managers who do not fully 

understand the role of oral health in the continuum of HIV care. Thus, HIV 

case managers may not include dental care on their screening instruments or 

make routine referrals to dental care, or doctors and nurses may not think to 

ask patients about their use of dental services. 

In the context of the SPNS Oral Health Initiative, where financial barriers 

to care were addressed through grant funding, dental case managers play an 

important role in addressing many of the other barriers to oral health care. 

The role of dental case managers 

Nine of the fifteen oral health demonstration programs employ staff as 

dental case managers (6), patient navigators (2) or outreach workers (1). In 

practice, many of the functions of these staff overlap. For example, all staff, 

regardless of title, play an important role in client recruitment, appointment 

scheduling and making sure clients have a way to get to the appointment. In 

addition, all staff provide some level of patient education about the nature of 

the care they will receive, and are instrumental in following up any missed 

appointments. Another common function is coordination with (and referral 

to, if necessary) other services such as HIV case management, medical care, 

or support services. Finally, all of the dental case managers are part of a 

team that helps educate other providers in the continuum of HIV care on 

the importance of oral health care and how to refer their patients to dental 

services. While the above-mentioned functions are common across programs, 

both their methods of implementation and other functions may be unique to 

a particular patient population or differ based on the location of the program. 

Each dental case manager activity is described below with the results from the 

focus group used to illuminate the range of activities. 

Patient recruitment. A key case management activity is to encourage 

patients to come in to receive oral health care. Dental case managers are 

critical in helping patients overcome the fear, stigma and other barriers 

that inhibit patient access to oral health care. The work involved in patient 


December 2008 

Page 65 of 72 

4


I…mostly give them support 

to try to come to the [dentist] 

appointments. Once they get 

over that fear, they start going 

in on their own. ….we kind of 

team up to see …-do they need 

an escort or do they need more 

appointment reminders? Do 

they have a phone…? One of the 

things we are running into is the 

….fear of pain. 


December 2008 

recruitment and appointment scheduling varies greatly across sites. 

Most of the dental case managers receive new patients through 

referrals from other health or social service providers; the patient has 

already decided to seek dental care. Thus, the recruitment work is 

actually conducted by building and maintaining relationships with 

referral providers rather than with patients directly. However, in two 

urban sites that employ patient navigators or outreach workers, these 

staff are more directly involved with patient recruitment, actually 

doing the work of talking patients into coming to see the dentist, 

helping to allay their fears, and offering to accompany new patients 

on their first visit to the dentist. In both of these circumstances, the 

patient navigator and outreach worker are connected to large HIV 

service organizations with a reasonably accessible patient population 

that is not already receiving dental care. 

I…mostly give them support to try to come to the [dentist] appointments. 

Once they get over that fear, they start going in on their 

own. ….we kind of team up to see …-do they need an escort or do 

they need more appointment reminders? Do they have a phone…? 

One of the things we are running into is the ….fear of pain. 

Transportation and scheduling. Dental case managers who work 

in rural communities that provide services over a broad geographic 

area spend much more time arranging or coordinating transportation 

for their patients than those who work in urban programs. Some 

programs offer gas cards as an incentive for patients to come in for 

care, while others use a van to pick patients up and bring them in 

to the clinic. Still other programs help arrange car-pools, or try to 

arrange Medicaid-financed transportation. With patients coming 

to the dental clinic from far distances, the dental case managers also 

face scheduling challenges. They may need to schedule a patient 

for a large number of procedures on a single day, or they may need 

to coordinate the dental visit with a same-day appointment for 

medical care and/or HIV case management services. There are some 

circumstances in which a patient may need to be scheduled for an 

appointment in the afternoon and a subsequent appointment the 

following morning. This type of situation requires additional effort 

by the case manager to locate and/or book lodging accommodations 

for the patient. 

….we have a lot of people….with no driver’s license…. in rural 

areas it is needed because we don’t have a massive transportation 

system here…..One of the other things we are doing….is….setting 

up satellite clinics around the state because it’s not practical for us 

to drive three hours to pick somebody up for a dental appointment. 

Page 66 of 72 

5


I accompany patients to the 

dentist office if they want me to. 

That means going in with them 

and explaining exactly what 

is going down….and why the 

dentist is doing that….because 

at times the patient doesn’t like 

to ask the dentist…..[they feel] 

more comfortable with asking me 

questions which I love to answer. 


December 2008 

Visit accompaniment. Two of the urban programs are more likely 

to serve immigrant populations that have limited experience with 

dental care. These programs offer visit accompaniment services 

to help ensure that patients attend their appointments or follow 

through on a referral to dental specialty services. A third urban 

program serves a population that is largely homeless, many of 

whom have mental health or addiction co-morbidities; this 

program also offers visit accompaniment services to help get their 

new patients in the door for care. 

I accompany patients to the dentist office if they want me to. 

That means going in with them and explaining exactly what 

is going down….and why the dentist is doing that….because 

at times the patient doesn’t like to ask the dentist…..[they feel] 

more comfortable with asking me questions which I love to 

answer. 

Visit explanations. Both urban and rural program staff spend 

a significant amount of time, particularly with new patients, 

explaining what they should expect when they come in for a visit. 

This explanation serves several purposes. First, it helps to ease 

people’s minds if they are worried about the visit, and it may also 

reassure them that the providers they will see are comfortable 

treating people with HIV. Second, when the patient arrives for the 

appointment, the dental case manager can introduce her/himself 

as someone the patient has already spoken with on the phone. 

When I used to work in the front office I dealt with a lot of 

patient finances and translating for patients. So when it came to 

translating for Spanish speaking patients I was already explaining 

the treatment plans because the dentist wasn’t able to do 

that. So having the patient relationship beforehand…helped 

me a lot because I built trust with a lot of patients whether they 

were HIV positive or not. 

Referrals and translation. Other functions of the dental case 

managers at the point of entry into care include enrollment in 

benefits, particularly dental benefits if these are available, referrals 

to other services, and, in some cases, translation. 

Retention services. Retention in dental care begins at the first 

visit when the case manager works to build a relationship with 

the patient and explains what to expect during the visit. This 

relationship is key to patient retention, as the dental case managers 

Page 67 of 72 

6


We have seen within a few 

months, when they get teeth, 

when they get the partials, they 

are able to eat better and they 

start gaining weight…. 


December 2008 

check in with patients following their appointments: “How did it 

go?” “Do you have the supplies you need?” “Do you want me to 

go over what is happening next?” “How are you feeling now?” All 

of the case managers provide appointment reminders just prior to 

the next appointment, and all follow up with any individual who 

misses an appointment. In the typical dental setting, if a patient 

fails to show up for an appointment, nothing is done to follow up 

to find out why. Instead, the patient’s name is likely to go onto a 

no-show list, and if it appears more than two or three times, the 

patient may be told to go elsewhere for care. Several of the SPNS 

oral health programs with high patient caseloads also had no-show 

policies, but they also used missed appointment follow-up as an 

opportunity to educate patients about the wait for services and 

how advance notice of a missed appointment helps the dental 

office accommodate other patients. In addition, most programs 

are willing to accommodate patients as walk-ins if they are unable 

to keep appointments. 

Patient education. All of the case managers provide some level 

of oral health education, but the level of education depends on 

the clinical background of the staff. Most can explain how HIV 

affects the mouth, and things to watch for, as well as basic oral 

hygiene techniques. Two of the case managers/navigators are 

dental assistants by training, and they are able to provide more 

comprehensive education about specific dental procedures and 

follow-up care. All of the non-clinical case managers expressed 

an interest in receiving more oral health education themselves in 

order to share information with their patients. In contrast, the 

case managers who are dental assistants by training expressed an 

interest in learning more about specific case-management skills. 

“Many…..don’t know how to brush their teeth; don’t know that 

you need to floss. We have a patient [whose] front teeth were 

perfect but behind the teeth was terrible because they learned 

that you only brush from one side. So education, education …it 

makes a difference cost-wise also.” 

Collaboration with HIV case managers. Another way in which 

dental case managers improve access to care is through their 

collaboration with HIV case managers and medical- and supportservice 

providers. Dental case managers can help keep oral health 

on the radar screens of other providers by providing resources 

and support materials, promoting oral health assessment as part of 

comprehensive case management, and training HIV case managers 

to advocate for oral health services for their clients. 

Page 68 of 72 

7


My best experience …..a lot of 

people haven’t had teeth for years 

or haven’t been able ….to smile 

for years. So the opportunity to 

have that experience is really big 

for a lot of people, and [it’s a 

relief to] just take care of pain…. 


December 2008 

Background and Qualifications. The formal qualifications for 

dental case manager positions vary across programs. Two of 

the case managers are trained dental assistants and most have 

a bachelor’s degree. However, several of the positions have no 

formal education requirements, but require state-specific HIV 

training and experience with case management or in human 

services. Most of the case managers have a minimum of five years 

experience working in HIV care settings or other human services 

such as drug treatment, homeless services or domestic violence 

shelters. Two of the positions require a valid driver’s license. 

How dental case managers improve access to care 

Dental case managers are able to address barriers to oral health 

care in a way that other HIV-care providers cannot. Most HIV 

case managers have a large patient caseload and a series of service 

areas to address, many of which may be more pressing than oral 

health care. Oral health often gets pushed to the bottom of the 

list, if it is on the list to begin with. Dental case managers enable 

HIV case managers to focus on other issues within a client’s 

service plan without sacrificing access to oral health care. They 

arrange transportation, coordinate appointments, provide patient 

education and assistance with follow-up care, and help make sure 

that people return for their appointments. These are activities that 

few HIV case managers can undertake. And in most busy dental 

clinics, dentists, hygienists and dental assistants do not have the 

time to do all of this either. 

“We have seen within a few months, when they get teeth, when 

they get the partials, they are able to eat better and they start 

gaining weight….” 

“My best experience …..a lot of people haven’t had teeth for years 

or haven’t been able ….to smile for years. So the opportunity to 

have that experience is really big for a lot of people, and [it’s a 

relief to] just take care of pain….” 

“The best experience is being able to treat those patients…that 

are coming from so far away and haven’t gone to a dentist in 

so many years because of…access, insurance ….it is really nice 

to have them come in and treat them and for them to feel good 

about themselves.” 

Page 69 of 72 

8


I got a job that is just awesome. 

You know you can give someone 

a set of dentures who hasn’t had 

any for ten years and has not had 

any teeth and…..they hug you. 


December 2008 

“I got a job that is just awesome. You know you can give someone 

a set of dentures who hasn’t had any for ten years and has not 

had any teeth and…..they hug you.” 

How dental case managers are different from HIV case 

managers 

Unlike HIV case managers, dental case managers do not conduct 

comprehensive psychosocial or health assessments, nor do they 

develop, implement and monitor treatment plans. This is 

typically the work of the clinical members of the oral health team, 

the dentist and the hygienist. Thus, the work of an HIV case 

manager is much more comprehensive than the work of a dental 

case manager. HIV case managers have to address a broad range 

of issues, many of which are immediate needs for their patients 

and are not typically related to dental care. Dental case managers 

perform fewer tasks per patient and as a result can serve a higher 

volume of patients than an HIV case manager can. In addition, 

their education role is different – they focus mainly on dental care 

rather than on the broader spectrum of HIV care. 

In contrast, while an HIV case manager, under the best of 

circumstances, may make a referral to dental care, they are not 

able to follow up to make sure the patient gets the care he or she 

needs. This is something that the dental case manager can do 

– arrange the transportation, accompany patients to visits, and 

provide the one-to-one attention a patient needs. For dental case 

managers, dental care is at the top of the list rather than at the 

bottom; they make sure it is available and accessed. 

“…the regular HIV case managers have so many things to do.” 

How the dental case manager role can be incorporated into 

other practices 

Nearly all of the dental case managers involved in this 

demonstration wore multiple hats. For example, all played 

an important role in program evaluation, recruiting study 

participants, conducting patient surveys and entering data. Some 

of the staff also drove mobile vans, or functioned as receptionist/ 

front desk staff. In addition, the outreach workers conducted 

outreach for other services and the dental assistants assisted with 

the dental care. Despite wearing these multiple hats, the case 

managers involved in the SPNS initiative served between 150 and 

300 patients, depending on the severity of patient needs and the 

Page 70 of 72 

9


You can affect the culture of 

care so that you can convince 

patients it’s really less costly and 

more beneficial if you go [to 

the dentist] when there aren’t 

problems, go routinely rather 

than wait until you are in pain. 

You have the time to do that 

[affect the culture of care] that a 

regular case manager would not 

have the time to do. 


December 2008 

scope of their other duties. Thus, it is quite possible that some of 

the functions described above as dental case management could be 

incorporated into the roles of other dental clinic staff, especially 

receptionists, clinic coordinators, schedulers, translators or dental 

assistants. 

Within larger organizations, such as AIDS Service Organizations 

or HIV clinics that provide both medical and dental care, some 

of the functions described above could be picked up by HIV case 

managers if they are given the time to do this. In organizations 

that have multiple case managers, one case manager could be 

dedicated to oral health. Ryan White nurse case managers could 

be trained to provide basic oral hygiene education and include 

oral health as part of their clinical assessments. 

Ultimately, many of the tasks performed by dental case managers 

are non-reimbursable services and the position or functions 

must be funded from general revenue or grants. However, it can 

be argued that if the patient education, tracking and retention 

functions result in a reduced no-show rate, the position may 

pay for itself through additional visit revenue. In clinics where 

the dental case manager is a clinician, such as a dental hygienist, 

certain patient education services may be billable services. Clinic 

billing personnel can review all third party payer reimbursement 

codes to identify any codes that are associated with chair-side 

patient education as a possible source of revenue. Finally, a case 

can be made that the provision of oral hygiene education and early 

treatment for conditions such as periodontal disease reduces longterm 

costs for dental care. This is a strong argument for including 

access to and retention in care services in capitated oral health 

care programs where long-term cost savings can help finance 

the functions necessary to ensure the provision of early care and 

treatment. 

“….You can affect the culture of care so that you can convince 

patients it’s really less costly and more beneficial if you go [to the 

dentist] when there aren’t problems, go routinely rather than 

wait until you are in pain. You have the time to do that [affect 

the culture of care] that a regular case manager would not have 

the time to do.” 

Page 71 of 72 

10


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Badner VM. Ensuring the oral health of patients with HIV. J Am Dent 

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Centers for Disease Control and Prevention. (1997, September). HIV 

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http://www.cdc.gov/hiv/pubs/pcml/pcml-doc.htm 

Cherry-Peppers G, Daniels CO, Meeks V, Sanders CF, Reznik D. Oral 

manifestations in the era of HAART. J Natl Med Assoc. 2003;95(2 Suppl 

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Department of Health and Human Services, Presidential Advisory 

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Freed JR, Marcus M, Freed BA, et al. Oral health findings for HIVinfected 

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Utilization Study. J Am Dent Assoc. 2005;136(10):1396-405. 

Heslin KC, Cunningham WE, Marcus M, et al. A comparison of unmet 

needs for dental and medical care among persons with HIV infection 

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December 2008 

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