Oral Health Screening for All at Life Academy SBHC
Native American Health Center, Oakland
Students in Oakland face harsh odds:
- Homicide is the leading cause of death among youth;
- 26% of children are living in poverty; and
- 30% are dealing with depression-related feelings.
Given these overwhelming realities, clinic leaders knew that “selling” the importance of oral health to school administration and teachers might be a challenge.
Why would school leaders and teachers focus on dental screening when there are so many other difficult issues to address?
Framing oral health as an equity issue was the chosen approach, given that many of the school’s students had never even seen a dentist.
Schoolwide dental screenings were launched when Native American Health Center (NAHC) received a grant focused on integrating oral health into primary care. Originally, dental screenings started at one SBHC and then expanded to three other sites; dental screenings are now in seven NAHC health centers, including Life Academy.
At the outset, the goals of the schoolwide dental screening were simple:
- To screen and varnish as many youth as possible.
- To identify youth with high-risk of dental decay.
- To connect youth with follow-up dental care and ultimately a dental home.
In the beginning, teachers were somewhat suspicious, but NAHC’s staff, and particularly the dental director, worked hard to earn teachers’ trust, even offering dental screenings for teachers.
Over time, the screening results illustrated an overwhelming need, and teachers and school leaders came to understand that children from low-income families are disproportionately affected by poor access to dental care. Their buy-in for the schoolwide dental screenings would be instrumental to its success.
Screening large numbers of students requires good organizational skills and a well-defined process.
SBHC staff broke down their process into three phases:
- implementation, and
- case management.
Preparation involved making sure everyone was on the same page, having all the supplies there on time, and logistics.
The first year, SBHC staff chose to do the screenings in February in honor of Oral Health Month. Once the dates were selected, they formed and prepared their team. SBHC staff recruited extra support from the NAHC dental department and developed a formal partnership with the UCSF dental and nursing schools to have hands-on support on screening days.
Staff then coordinated dates, times, and location with the school administration. School administrators were most amenable to the schoolwide screenings taking place during PE class, and the school gym was used to allow for enough space. SBHC staff met with teachers and other school staff to review logistics.
To simplify and speed up the approval process, staff chose to use an opt-out consent form so that parents would only need to sign if they did not want their child to participate. They identified which students were Medicaid patients in advance so they could bill for those screenings and varnish applications.
Staff also launched an outreach/media campaign. Outreach was essential to get the word out and included development of a poster that would appeal to teens with a message to “Check Your Smile.”
Finally, SBHC staff ordered and prepared the supplies, which included clipboards and pens, gloves, gauze, varnish, masks, hand sanitizer, and goody bags.
Implementation of the schoolwide screening involved good set-up of the area and preparation for a fast and furious flow of students.
On screening day, with hundreds of students expected, having extra staff was extremely helpful and required a clear process flow and defined roles.
For example, it was very helpful to have one staff person be in charge of crowd control and another give instructions to students. Both of these staff members worked in the waiting area, managing the flow of students to the dentists and protecting the privacy of the students being screened.
The set-up in the gym included a waiting area and a screened area (for privacy) for the dentist and a “recorder” to document the clinical notes and complete the screening tools.
Recorders are individuals without special training who transcribe the dentist’s screening observations on the bottom of the screening forms.
For example, the dentist will note aloud whether there is previous history of decay, current decay, and so on, and the recorder makes notes accordingly. Recorders help maintain the flow of a fast-paced screening event by relieving the dentist of documentation responsibilities.
After the dentist visit, the student is sent to a varnisher.
Varnishers can be a dentist, dental hygienist or other health care professional, and their role is to apply fluoride varnish—a highly concentrated form of fluoride applied to the tooth’s surface as a type of topical fluoride therapy.
SBHC staff found that getting the right staff ratios was very important on screening days; the ideal ratio is one recorder for every dentist, and three varnishers for every one dentist, or five varnishers for every two dentists.
This set-up and staff support plan kept the dental screening running smoothly and efficiently.
Case management was the most challenging part of the dental screening process.
To identify high-risk students, the SBHC developed a case management tool in which students could be classified on a scale of 1 to 4 (1=no decay, 2=some suspicious areas, 3=urgent but not in pain, and 4=urgent and in pain).
From the screening, 17% of students were identified as needing urgent care, meaning they received a classification of 3 or 4 on the screening tool. While all screenings get some sort of follow-up, such as a letter home about the screening results, students identified with urgent needs require a more intensive approach.
In addition to notification of their caregivers, the SBHC also worked to identify any insurance coverage and schedule a follow-up appointment.
For students with no existing coverage, staff assisted with insurance enrollment.
Follow-up appointments were scheduled with providers in the SBHC, the NAHC main dental clinic, or other community dental health providers.
Screening During 9th Grade Clinic Visits at Fremont Tiger Clinic
La Clínica de la Raza, Oakland
Fremont High School is an urban public high school located in the Fruitvale District of East Oakland, California, and the school has had an onsite SBHC operated by La Clínica de la Raza for 21 years.
The Fremont Tiger Clinic is part of the school culture. Clinic staff wear school jerseys, participate in school events, and act as adult allies for students.
The SBHC is centrally located in the high school, allowing students more opportunity to drop in for small needs. The clinic has good recognition, and there is widespread belief that the SBHC is providing value to students.
Each year for the last several years, the Fremont Tiger Clinic has held a 2-day event targeting every 9th grade student in the school. Functioning like a schoolwide screening, this annual registration drive allows the SBHC to establish connections with approximately 130 students annually.
These relationships pay off in the years to come as students feel comfortable and willing to return to the SBHC for clinic services. The annual screening event allows staff the opportunity to assess all incoming students’ health needs and register them as patients in the clinic.
The goals are to have every 9th grade student come through the clinic, meet a provider, and complete a brief screening.
Like any schoolwide screening, the Tiger Clinic 9th grade adolescent screenings require a well-defined process that includes preparation, implementation, and follow-up.
Preparation for the 2-day screening begins with coordination. Clinic staff work with administration and teachers to establish dates and plan event logistics. Two weeks before the event, SBHC staff work with 9th grade teachers to visit the classroom to do a 30-minute presentation.
Staff explain the upcoming screening drive, when all 9th graders will be doing a tour of the clinic and receiving a brief provider visit. They describe the services offered at the SBHC and ask all students to complete pre-registration paperwork, including minor consent and Family Planning, Access, Care and Treatment (FPACT) enrollment forms. Students complete and return all pre-registration paperwork during the classroom visit to save time on screening day.
After the classroom visits, SBHC staff use administrative time to process all student registration paperwork. Entering new patient registration information, activating FPACT, and screening for student insurance eligibility requires about 20 minutes per student.
SBHC staff also prepare by enlisting additional clinical staff (often borrowed from other La Clínica sites) to help with the screening. Before the students arrive, staff assemble student gift bags with free goodies (i.e., water bottles, pens, stress balls, granola bars, and condoms) and set up the clinic for an easy, comfortable flow.
Implementation involves moving all 9th graders through the clinic and screening them for services. SBHC staff call students to the health clinic in groups of five to eight. When they arrive in the health center, they are welcomed with juice and snacks and seated in the waiting area to complete a brief screening questionnaire. The intention is to “normalize” the clinic so that students will feel comfortable returning. During the clinic visit, each 9th grade student receives a brief (15 minute) individual visit with a provider, such as a family nurse practitioner, health educator, or mental health clinician.
The visit includes an overview of SBHC services, confidentiality, and mandated reporting so that students have a clear understanding of their patient rights. Students then receive a sexual health screen and a SSHADESS assessment. The SSHADESS assessment includes questions about Strengths, School, Home, Activities, Employment, Drugs, Emotions, Suicidality, Sexuality, and Safety (including violence, abuse, and self-harm). After the basic screening is completed, students are given an opportunity to ask questions and offered goody bags before they are sent back to class.
Follow-up after the 9th grade registration event requires staff to review each case individually to identify health needs. All screenings are reviewed by a medical provider to ensure that clinical or psychosocial concerns are addressed and flagged for follow-up.
Each year, about one-third of the students screened need immediate services. For these students, SBHC staff work to schedule follow-up appointments in the SBHC or give referrals to other providers as needed. Billing and insurance information is reviewed for each student; those with no existing coverage are offered help with insurance enrollment.
After the screening, SBHC staff members thank teachers and school administrators for their support and report back on population health data collected.
Partnerships Are Key
Among the many lessons learned, the most important is the value of partnerships. Staff at Life Academy SBHC said this is true for school-based health in general, but shared that they learned it again and again with their oral health initiative. The collaboration with the NAHC dental department and with the UCSF dental and nursing students allowed the SBHC to reach greater numbers of youth and train new professionals in the value of oral health integration into school-based health. At Fremont Tiger Clinic building strong partnerships with school staff is a key priority because they control access to the classroom. Teachers and administrators can be important allies if they understand how the screening process improves access and ensures that poor health is not a barrier to learning.
Screenings Can Be Institutionalized & Increase Patient Engagement
The annual dental screening process has become significantly easier and is now part of the routine at Life Academy. While the grant has ended, the SBHC continues to do the annual screenings with great success. Students, teachers, and administration know what to expect and value the services being provided. While the very early planning stages of the dental screening required SBHC staff to figure out how to “sell” oral health, over time the dental screenings were appreciated and became a gateway to other SBHC services for students. At Fremont High, the screening drive has become routine at the school, and the patient population is steady as a result. Year after year, the screenings increase awareness about the clinic services and serve as a cost-effective approach to engaging more patients and building sustainability.
Schoolwide Screenings Provide an Opportunity for Health Career Exposure
One of the biggest surprises was youth interest in dentistry and health care as career options. During schoolwide screenings, youth were very curious not only about fluoride varnish but also about the people who applied it. As students were exposed to nurse practitioners in training, dentists, medical assistants, and physicians, the screening became an introduction to a variety of health professions. Life Academy for Health and Bioscience is a “health pathways” school and offers a unique class on becoming a medical assistant. After the screening, Life Academy added a component to their medical assistant class that focuses on oral health and fluoride application. The dental screening continues to inspire interest in dental and health careers.
This information is adapted from the Population-Wide Screenings in Schools Guide: A publication of UCSF and Family Health Together. We are grateful to our partners at ETR for funding and the UCSF School of Nursing for creating this content: Naomi Schapiro, RN, PhD, CPNP; Emily Green, RN, PhD; Victoria F. Keeton, PhD, RN, CPNP-PC; and Ivette Gutierrez, M.A.
We would also like to acknowledge Alameda County Center for Healthy Schools and Communities, Oakland Unified School District, La Clínica de la Raza, Native American Health Center, Lifelong Medical, Karen Gersten-Rothenberg, and Joanna Bauer for their contributions to this toolkit.
Photo credit: Randall Ann Homan