D402 Task 1 Community Health Evaluation Example

A Toothache Ends in the Emergency Department: Barriers to Dental Care for Low-Income Adults in a Composite Rural County and an Evaluation of the Resources Meant to Reach Them

Student Name

Leavitt School of Health, Western Governors University

D402: Community and Public Health, Task 1

Course Instructor

Month Day, Year

A Toothache Ends in the Emergency Department: Barriers to Dental Care for Low-Income Adults in a Composite Rural County and an Evaluation of the Resources Meant to Reach Them

The Community Health Issue

Tamarack, a composite county with roughly 37,500 residents and no city larger than 9,000, depends on a meat packing plant, two nursing homes and its schools for jobs, and many working adults earn too much for full public assistance but too little to buy private dental insurance. Last year the county hospital's emergency department recorded 1,140 visits for dental pain, abscesses and other nontraumatic dental conditions, and most were made by adults between 20 and 49 who were uninsured or covered by Medicaid. Many were repeat visits by the same patients.

The pattern is not unique to Tamarack. In a study of Oregon hospitals, dental problems accounted for 2.5% of emergency visits and were the second most common discharge diagnosis among adults aged 20 to 39. Uninsured patients were more than five times as likely as commercially insured patients to make such a visit, and 56% of visits ended with an opioid prescription and 56% with an antibiotic, at an average hospital cost of $402 (Sun et al., 2015). A systematic review found that rural adults had higher odds of emergency visits for dental conditions than urban adults (Akinlotan & Ferdinand, 2020). An emergency department can relieve pain and treat infection, but it cannot fill a cavity or save a tooth, so the problem returns.

This paper treats emergency dental visits as a community health issue: a sign that residents cannot reach ordinary dental care. It identifies the barriers that keep low-income adults in Tamarack from that care, evaluates four existing resources against those barriers and recommends ways to connect them.

Barriers to Accessing Dental Care

Cost and coverage come first. The composite state's Medicaid program covers only emergency dental services for adults, which in practice means extractions, and many working adults in the county have no dental coverage at all. Dental care stands out nationally in this respect: across age, income and type of insurance, more people report financial barriers to dental care than to any other kind of health care (Vujicic et al., 2016). For a plant worker, a root canal and crown can cost more than a month's wages.

Distance and supply are the second barrier. The county has six practicing dentists, all in the county seat, and only two accept Medicaid. Residents of the eastern townships live up to 50 miles away. The community health center's dental clinic uses a sliding fee scale, but its wait for a new adult patient is about three months.

Work schedules are the third. Plant shifts begin at 5 a.m. or end at 11 p.m., hourly workers lose pay for time off, and not one dental office in Tamarack sees patients after 5 p.m. or on a Saturday. The emergency department, by contrast, is always open.

Transportation is the fourth. Tamarack runs no buses on regular routes, and its dial-a-ride van must be booked two days ahead, which does not suit a sudden toothache.

Fear and distrust are the fifth. Community health workers report that many adults remember painful extractions or being turned away for unpaid bills, and some expect that a dental visit will only end in losing a tooth. These experiences make people wait until pain forces an emergency visit.

Evaluation of Existing Resources

Four resources in or near the county are intended to help. The matrix below shows which barriers each one reduces, and the discussion that follows explains the ratings.

The community health center's dental clinic is the county's strongest resource because it offers real treatment at a price people can pay. Its weaknesses are capacity and hours: a three-month wait and weekday schedule mean that the people most likely to use the emergency department are least able to get in.

The annual free dental day, run by a volunteer dental association at the fairgrounds, treats about 300 people in a single Saturday. It is well attended and generous, but it mostly provides extractions and cannot offer follow-up. A person who waits all year for the event and loses a tooth has been helped with pain, not with dental health.

The emergency department is the resource people actually use, because it is open and cannot turn them away. It is also the least suitable. It treats pain and infection with medication and sends the patient home with the underlying problem unchanged, which explains the repeat visits.

The health department's three community health workers are the least visible resource but the one best placed to address the barriers the others ignore. They already help residents apply for benefits and book the county van, and they are trusted in the townships. At present, however, dental care is not part of their work, and no one refers emergency dental patients to them.

Remaining Gaps

Taken together, the resources leave three gaps. No resource offers treatment outside weekday hours. No resource links an emergency visit to ongoing care, so each emergency visit is a missed chance. And the state's emergency-only Medicaid benefit keeps covered adults in a cycle of extractions rather than repair. Research supports the importance of that last gap: after Medicaid expansion, dental emergency visits fell in expansion states that included adult dental benefits, but not in states with emergency-only or no dental coverage (Giannouchos et al., 2023).

Recommendations: Connecting What Already Exists

The county does not need a new program as much as it needs its current resources to work together. First, the hospital and the community health center should create an emergency department referral route: when a patient is treated for dental pain, the discharge nurse sends a referral to a community health worker, and the clinic holds four urgent adult appointments each week for these patients. Second, the clinic should open one evening a week, staffed by a rotating dentist and hygienist, so that shift workers can attend without losing pay. Third, the community health workers should add dental navigation to their role: calling each referred patient, booking the clinic and the van, enrolling eligible patients in the sliding fee scale and following up after the first visit. Fourth, the free dental day should partner with the clinic so that every patient leaves with a scheduled follow-up appointment rather than a pamphlet.

A health and human services professional at the health department would coordinate these steps and track the results, using emergency dental visits, repeat visits and completed clinic appointments as measures. Over the longer term, the county's public health board should join advocates in asking the state to add a preventive and restorative adult dental benefit to Medicaid, since the evidence suggests that coverage, not just access, determines whether emergency visits fall.

Conclusion

A toothache treated in the emergency department is a symptom of a community problem: dental care that exists on paper but not within reach of working adults in a rural county. Tamarack's resources each remove one or two barriers, and none removes them all. Linking the emergency department to the clinic through trusted community health workers, and opening the clinic when people can come, would turn separate resources into a route to care.

References

Akinlotan, M. A., & Ferdinand, A. O. (2020). Emergency department visits for nontraumatic dental conditions: A systematic literature review. Journal of Public Health Dentistry, 80(4), 313-326. https://doi.org/10.1111/jphd.12386

Giannouchos, T. V., Reynolds, J., Damiano, P., & Wright, B. (2023). Association of Medicaid expansion with dental emergency department visits overall and by states' Medicaid dental benefits provision. BMC Health Services Research, 23, Article 625. https://doi.org/10.1186/s12913-023-09488-3

Sun, B. C., Chi, D. L., Schwarz, E., Milgrom, P., Yagapen, A., Malveau, S., Chen, Z., Chan, B., Danner, S., Owen, E., Morton, V., & Lowe, R. A. (2015). Emergency department visits for nontraumatic dental problems: A mixed-methods study. American Journal of Public Health, 105(5), 947-955. https://doi.org/10.2105/AJPH.2014.302398

Vujicic, M., Buchmueller, T., & Klein, R. (2016). Dental care presents the highest level of financial barriers, compared to other types of health care services. Health Affairs, 35(12), 2176-2182. https://doi.org/10.1377/hlthaff.2016.0800