Dentist and RDHAP team up to deliver care

With many adults challenged to access oral health services, some dentists and registered dental hygienists in alternative practice (RDHAPs) team up to try to fill the gap.

Two such dental professionals have been working together in Humboldt County for nearly 20 years. Darla Dale, RDHAP, and Wilmer Hechanova, DDS, met in 1996 at a class on hospital-based dentistry. Both share a passion for using dentistry to positively impact their local communities, so the two began building a partnership to provide care for the children and special-needs patients who fall through the cracks in the sparsely populated county in which they live and work.

Dale has been involved in dental case management for 19 years and has been an RDHAP for more than 10 years. Hechanova has worked as a dentist at Pelican Bay State Prison for the last 17 years. While he finds his work there rewarding, he utilizes the RDHAP model of care to connect with his community outside of the prison’s walls.  

Twice a month, Hechanova takes a day off of work to treat children and special-needs patients at St. Joseph Hospital in Eureka. His patients are referred to him from Dale, who spends her time routing patients in need for appropriate care after her scope of practice as an RDHAP has been reached. An RDHAP’s scope of practice includes dental hygiene services permitted under general supervision and the settings where an RDHAP can provide dental hygiene services without dentist supervision such as residences of the homebound, schools, residential facilities and other institutions and dental health underserved areas (known as DHPSAs) as defined by the Office of Statewide Health Planning and Development.

Dale is contracted with the Redwood Coast Regional Center to provide dental coordination and preventive services. She also provides on-site dental hygiene care with her mobile dental hygiene business. It is here that she gets to know the patients and caregivers of the patients she will send Hechanova’s way.

“Darla is well-acquainted with all of the patients and so she is the one who coordinates and arranges the appointments with these patients who may have cerebral palsy, autism or another form of disability. She cleans their teeth and assesses them and when patients need dentistry beyond the scope of the hygiene practice then that is where I step in,” said Hechanova, who moved to Humboldt County to provide care at an Indian clinic and then Pelican Bay after working in private practice for 11 years in Southern California. “Darla gives me a rundown on a case, knows the history. It is very freeing for me because I don’t have to worry about the scheduling or follow-up, I just get to help the patient.”

Hechanova provides fillings, crowns, prophys and even full-mouth extractions at St. Joseph Hospital (the hospital provides the space and all of the supplies). For children, he sees such significant decay that he will often perform full-mouth rehabs.

“Dr. Hechanova supports me in this 100 percent, and you really have to have that relationship with a dentist to do this kind of work,” said Dale, who finds her work challenging and “different every day.”

The RDHAP model of care is rewarding for those who participate, but can be difficult when dealing with funding and reimbursements.

“The Denti-Cal situation is very frustrating, it leaves big burdens on dental care,” Dale said.

Typically, if the services she is providing aren’t covered through Denti-Cal, she will attempt to connect with various foundations or track down a specialist who provides services through Denti-Cal, but those are few and far between in Humboldt County. The most difficult care to get covered is extractions — third molar extractions especially, she said.

“There is one oral surgeon in Humboldt County who accepts Denti-Cal, but he is three hours away,” Dale said. “For root canals, there are two specialists in the county, but they do not accept Denti-Cal.”

The Denti-Cal program currently fails to provide access to care due to glaring oversight issues and extremely low reimbursement rates.

A recent state audit of Denti-Cal reveals fewer than half of California's children enrolled in the program received dental care in 2013. The audit also points out that current provider reimbursement rates for the top 10 children’s dental services paid in California are a mere 35 percent of the national average. Denti-Cal rates have not increased since 2000-2001, and the program was further impacted by the 10 percent rate cut on certain services in 2013, with pediatric dental being one of the only services for children included in the cut.

CDA is advocating for immediate improvements to the program, specifically for the state to establish criteria that allow for a legitimately accurate assessment of true access to timely care and substantially increase Denti-Cal reimbursement rates starting this year.

Hechanova bills Denti-Cal for the services he provides at the hospital, and sometimes he gets reimbursed and sometimes he doesn’t. He openly admits he couldn’t make a living doing this as a day-to-day job.

“I am not doing it for my livelihood. If I was running a practice seeing only Medi-Cal patients, treating nursing home patients, I wouldn’t be able to make ends meet,” he said.

But for a dentist who is looking for a new challenge and a way to take on some extra work to help out in their community, the RDHAP model may be an option for them.

“One thing about doing this kind of work, if anything, it is a change of pace from the routine in the office. You can break out of the routine of your private practice and connect and give back to the community,” Hechanova said. “It is a great way to get involved. If a person has that desire for community service, then they should do it.”

According to Hechanova, a benefit to working with an RDHAP is that it provides a consistent pipeline of patients who typically show up for their appointments.

“The no-show rate is almost zero,” Hechanova said. “The case management is simple because all I have to do is provide the best dentistry I can and then I am done. Darla does all of the follow-up.”

Dale, who refers patients to two other dentists in Humboldt County in addition to Hechanova, said there are RDHAPs in every county in California and hopes more dentists will be willing to connect with them so more underprivileged children and adults with disabilities receive the oral health care they need.

“I encourage the dental community, if they are inclined, to connect with an RDHAP to collaborate because it makes everyone’s job easier,” Dale said. “It makes it easier if there is a dentist to refer to and it makes it easier for the dentist to line up patients. It could be a wonderful relationship throughout California.”

An RDH must have a bachelor’s degree and a valid registered dental hygiene license, have practiced dental hygiene for a minimum of 2,000 hours during the immediately preceding 36 months, and complete 150 hours of coursework in an approved RDHAP program to become an RDHAP.

For information about insurance when participating in an RDHAP model, contact the TDIC Service Department at 800.733.0633.

For more information about working with an RDHAP, or other alternative models of dental care delivery, contact Gayle Mathe.