Chapter 11. Connecting All the Pieces: Strategies for Sustainability

Chapter Description This chapter guides the reader through a process of using information that has been collected as a result of reading the other chapters to develop an integrated action and sustainability plan for a community project or program. All of the pieces should frame a portrait of your project.

Chapter Overview

How do you assure that your coalition, project or program continues to exist and meets a community need? Building sustainability is a long-term process that can't wait until funding is threatened. Potential supporters want to contribute to endeavors that reflect sound fiscal management and planning, not ones that are always in crisis mode. They are interested in programs that can document their effectiveness using valid evaluation methods and measures.

Self-Assessment: Where is the Community at this Stage?

By now you should have reviewed all of the chapters and completed as many of the worksheets as possible. Inevitably the information from the worksheets represents fragments that need to be analyzed and summarized. Although there may still be unanswered questions or gaps, assembling all of the information into a usable framework will clarify what still needs to be done. This is the same process you would engage in to develop a strategic plan, a sustainability plan or a comprehensive proposal for funding. Complete the self-assessment to document where the community is in the cycle of addressing oral health issues for young children and their families.

Assembling the Pieces

Step 1 . Go back and revisit/revise the Statement of Need from Chapter 1 if you developed one. You have probably added to it based on information from the other chapters. Is it clear, concise and compelling? Does it tap into the readers' logic and emotion? Does the Statement of Need accurately summarize the oral health issues, describe the barriers and show how poor oral health impacts children, their families and the community? Describe and document sources of information carefully. How does your community compare to nearby towns or other rural areas?

Step 2 . Try to think of a catchy name for the project or coalition if it doesn't have one. Name recognition is an important marketing tool. Some examples used by others include Healthy Smiles, Healthy Teeth; Access to Baby and Child Dentistry (ABCD); Healthy Kids, Healthy Teeth, Open-Wide, Smile Savers, Into the Mouths of Babes, Teeth for Tots.

Step 3 . Articulate the Mission and Vision that was developed for the oral health coalition or project in Chapter 2 and who the community partners are. Do you have a diverse group of committed organizations and people? What sets the project apart from similar endeavors? Why might it serve as a model for other communities? Describe how the community would be improved if all the planned strategies are implemented. Describe the ability and commitment of the community to carry out the project. List coalitions and collaborations, and unique contributions of each partner. Describe why these alliances will result in a successful and effective effort and what strategies you will use to assure sustainability. Develop letters of collaboration/agreement/support to document these relationships. Include a few examples of past and current achievements and how much collaborative planning has already occurred.

Step 4 .Create a table of Goals, Objectives and Evaluation Strategies —both long-term and short-term. Refer back to the examples in Chapter 2. Make sure they are measurable and include a realistic timeframe. Include the Evaluation methods and measures for each objective. Have you included both process and outcome-focused objectives?

Step 5 . Construct a project table or spreadsheet to include the following:

•  A sequential list of methods/activities to accomplish the objectives

•  Rationales for why each method was chosen and how each responds to the needs that are articulated: check for feasibility and age appropriateness, and make sure they are based on current scientific knowledge

•  Resources that are needed (human and otherwise) and how they will meet the needs

•  Responsible parties for implementing each activity: make sure they have enough time and the appropriate training to be effective

•  Major deadlines: think about contingencies if deadlines are not met.

Try drafting a logic model to visually show how program resources and activities are linked to program products and outcomes.

Step 6. Develop a timeline chart or table by month (or by week, depending on your overall timelines) to show how the activities and evaluation strategies will flow.

Step 7. Develop an itemized budget table with columns for potential sources of funding, including in-kind contributions from community organizations, and a column for justification for why each item is needed.

Now you should have a package of materials that can form the basis of a plan to use to 1) submit grants, 2) communicate with partners, 3) leverage in-kind resources, 4) market ideas, and 5) think about how to assure a steady flow of resources to maintain and enhance programs.

Implementing Programs

Many California communities have assembled oral health coalitions and initiated oral health projects with the assistance of First 5 funding and other resources. The Rural Smiles online Resource Guide is the result of just such a partnership. To learn what oral health projects for young children have been funded and implemented in California communities, view the project descriptions categorized by county by clicking on the Resource tab on the homepage. The final report of a unique rural program that received outside funding is also featured here.

Because of the First 5 focus on children ages 0-5 and their families, a number of communities have initiated infant oral care programs that emphasize early preventive efforts and establishment of a medical and dental home. These programs have been successful in involving partners such as private practices of health professionals and dental professionals, federally funded or nonprofit community clinics, WIC programs, CHDP programs, Early Head Start/Head Start programs, hospitals, public supported and other preschools, childcare/day care programs, and others. These efforts reinforce the relation between oral health and general health as well as the importance of health for school readiness. Review the Resources section for articles and online education programs related to oral health programs for infants and young children.

Planning for Sustainability

Developing a sustainability plan will help community members and others visualize the entire project and what is needed. Review and approval of such a plan will increase community buy-in and support. It also helps to attract new volunteers and supporters. It serves as a road map, with associated stop signs and intersections to reassess your progress and direction.

Once you have secured resources and implemented projects, plan to look at sustainability issues as least once a year . Analyze what your mix of funding is and what the potential is for maintaining or increasing resources in each category. A Framework for a Funding Sustainability Plan is provided. Make sure you consider what you need for short-term support (in the next year), intermediate support (1-3 years) and long-term support (more than 3 years). Building productive relationships with funders takes continued effort over time. This function should not be delegated to one person, but be a responsibility of all the partners of the coalition or project advisory committee. Share decisions and workloads.

A good policy strategy when developing or sustaining any program is to involve local public officials in various ways. If the project continues to demonstrate that it is truly meeting a community health need in an effective and efficient manner, there is always a possibility of becoming a line item in a local health agency budget.

If the program has been successful in reducing the need for oral health services for young children, then maybe you can expand services into another age group or focus, e.g., target schoolage children or take a family approach to involve siblings and parents. Doing so may open up additional avenues for support and garner additional partners.

Review the reasons why people have committed to the oral health coalition or project. How do they benefit? What will keep them engaged and feeling that they make a difference in the oral health of families? As programs mature, turnover in staff and volunteers will inevitably occur. Although such turnover may have consequences in continuity of activities, it also provides an opportunity to involve new people with new ideas and skills. Even small changes will show people that the project is dynamic and is capable of responding to future societal and economic changes.

Soliciting, listening to and incorporating feedback from staff, volunteers, recipients of services and other community members is an important part of any sustainability strategy. Summarize all feedback, both positive and negative, and strategize how to make meaningful improvements. Carefully document how well your program is meeting its objectives. Celebrate your successes publicly and show how you are responding to the feedback received and any deficiencies discovered through other evaluation information. Recognize the diverse contributions that have helped make the project successful—not just through financial support, but through volunteers and in-kind donations. Acknowledge community businesses and service organizations that helped. Ask how partners have used information about the project or coalition in their own organizations or agencies. Use the public education and media information in Chapter 7 to select the best way to feature accomplishments and celebrate the community's involvement.

Summary

Readers are asked a number of questions in the self-assessment to determine how much progress a community has made in designing and implementing strategies to address oral health issues for young children and their families. Steps are given to compile and assemble information into a usable action plan for sustainability. Readers are referred to a number of resources as well as descriptions of First 5 related oral health programs in California counties.

American Academy of Pediatrics. Policy Statement. Oral Health Risk Assessment Timing and Establishment of the Dental Home. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/5/1113

Association of Clinicians for the Underserved. Early Childhood Caries Prevention Training. http://www.clinicians.org/oralhealth/eccp_training.htm . Overview of a project that trained 50 primary care clinicians and patient educators.

French, Melody. Final Report to the American Academy of Nurse Practitioners Foundation . Implementation of an Infant Oral Health Clinic in a Rural Primary Care Setting . June 2004.

From Protocols to Policy: Consensus Conference to Increase Children's Access to Early Preventive Dental Services .2003. http://www.dentalhealthfoundation.org/documents/CCReport.pdf

Oral Health and Health in Women: A Two-Way Relationship. National Maternal and Child Oral Health Resource Center . http://www.mchoralhealth.org/PDFs/WomensFactSheet.pdf

Ramos-Gomez F, Jue B, and Bonta CY. Implementing an infant oral care program. J California Dent Assoc. Oct 2002, pg 752-61. http://www.cda.org/member/pubs/journal/jour1002/infant.html

Sanchez OM and Childers NK. Anticipatory guidance in infant oral health: Rationale and recommendations. American Family Physician . Jan 1, 2000. ( http://www.aafp.org/afp/20000101/115.html )

Sustainability

Afterschool Alliance . Sustainability Tools. http://www.afterschoolalliance.org . They have a good template for a formal sustainability plan.

An excellent summary of examples of state efforts to improve oral health and access is part of an appendix to Elements of Effective Action to Improve Oral Health & Access to Dental Care for Connecticut's Children and Families , and can be viewed at http://www.cthealth.org . Efforts are categorized as 1) Workforce, 2) Safety Net, 3) Dental Enterprise Zones and Expanded Access Programs, 4) Community Integrated Service Systems Program, 5) Extramural Training of Students, 6) Child Oral Health Needs Assessment, 7) Dental Resources Assessment and Geographic Information Mapping, 8) Medicaid (the majority of the suggestions), 9) Disease Management, 10) Public Education Efforts, 11) Political and Community Interventions.

National Senior Service Corps Conference. Building Strategic Partnerships in Rural Communities. June 2002 . http://www.sustainabilityonline.com provides examples of how to use AmeriCorps members to leverage resources and includes examples of sustainability plans. Their 2001 conference proceedings on the same website are also very useful.

State of Washington Department of Health. Community Roots for Oral Health: Guidelines for Successful Coalitions . Olympia , WA , 2000. ( http://www.doh.wa.gov/cfh/OralHealth/manuals/Roots/Roots.html ). There is a good section on funding and sustainability.

Sustainability Toolkit: 10 Steps to Maintaining Your Community Improvements , is available through the Center for Civic Partnerships. An overview is available at http://www.civicpartnerships.org/files/sustainabilitytoolkit.pdf .The toolkit includes examples and stories from around the country; activities to complete (included on a CD ROM); sample plans, timelines and completed activities; tips and resources. Cost is about $80.

Title XIX (Medicaid) Funds and Federal Financial Participation (FFP): How to Utilize these Funds and the FFP Funding Mechanism to Enhance Oral Health Activities at the Maternal, Child and Adolescent Local Programs, MCHB, CDHS and Office of Dental Health, Alameda County PHD, May 2004.

Online Continuing Education Resources for Practitioners

Open-Wide: Oral Health Training for Health Professionals. National Maternal and Child Oral Health Resource Center . http://www.mchoralhealth.org/OpenWide/index.htm

This is an online series of four self-study modules designed to help health and early childhood professionals working in community settings (for example, Head Start and WIC staff) promote oral health for infants and young children. Modules cover 1) Tooth decay, 2) Risk factors for tooth decay, 3) Prevention of tooth decay and 4) What to do and how to do it.

Isman BA and Newton RN. Planning Guide for Dental Professionals Serving Children with Special Health Care Needs. Los Angeles, CA: University of Southern California University Affiliated Program, Children's Hospital Los Angeles . 2000. Sixty-page manual for dental team members in California that can be downloaded from http://www.mchoralhealth.org/PDFs/OHguide.pdf . This manual promotes a framework for dental professionals to communicate and work with families to ensure that appropriate, quality oral health care is provided both at home and in the dental office. The manual contains six sections on the following topics: (1) preparation for dental visits, (2) oral assessment and prevention, (3) determination of specialized treatment techniques, (4) indicators of quality dental care, (5) linking with community resources, and (6) bibliography and other resources. Handouts with color photos of oral conditions and anticipatory guidance messages are available for health professionals and can be downloaded or ordered from http://www.nohic.nidcr.nih.gov . The lists of resources in this manual are not updated. The manual will be revised in 2005 and converted to an online resource guide, but will not be specific to California .

Dept of Pediatric Dentistry. Access to Baby and Child Dentistry: A Manual for Dental Providers. Seattle , WA : University of Washington , 2001. The aim of this 88-page manual is to provide a chairside guide for clinicians who intend to implement effective preventive and early intervention oral health therapies for infants and toddlers. Section topics include Bright Futures in Practice: Oral Health; Examination of infants and toddlers; Family oral health education; Prevention of dental disease; Treatment guidelines for pre-cooperative children and pregnant women; Restorative dentistry; Initial assessment and management of infection and trauma; and How to make a referral. Appendices include handouts for parents and ABCD dental program benefits, program tips, articles, newsletters, and where to order products. Can be downloaded from http://www.dental.washington.edu/pedo/allpages/abcdfeb23-01.pdf . Also see the ABCD website at http://www.abcd-dental.org .

Office of Oral Health. Early Childhood Caries: A Medical & Dental Perspective. Phoenix : Arizona Dept of Health Services, 2002. Online continuing education course for dental providers and medical providers on early childhood caries and its management. The interactive program presents information, followed by practice in the form of multiple-choice and true/false questions, and a post-test that requires 80% score or higher to receive CE credits. Includes case studies and references, resources, weblinks. Takes two hours to navigate through the whole program, but can do it in stages. Costs $30 for 2 CEUs or CMEs. http://www.pc.maricopa.edu/dental/online.htm

Oral Health for Family Physicians. 2004. This curriculum resource developed by Society of Teachers of Family Medicine, provides goals and objectives for training primary care physicians in the area of oral health. The curriculum is organized by ACGME Competencies. Available online at: http://fammed.musc.edu/fmc/data/Oral_Health.htm .

A Health Professional's Guide to Pediatric Oral Health Management. 2004. National Maternal and Child Oral Health Resource Center . Seven online self-contained manuals on topics such as oral conditions and abnormalities, oral injuries, prevention, non-nutritive sucking habits, and working with young children and children with special health care needs. Includes a self-assessment quiz and references for each chapter. http://www.mchoralhealth.org/PediatricOH/index.htm

Healthy Smile, Happy Child: Early Childhood Caries Prevention
Maternal and Child Health, Nevada Bureau of Family Health Services, 2002. This training aid/kit contains materials on early childhood caries prevention and fluoride varnish, including a brochure, anticipatory guidance curriculum, and presenter manuals. The 74-page anticipatory guidance curriculum includes schedules (prenatal to 24 months) and resources for oral health care. The accompanying presenter manual includes class objectives, an outline, and participation notes, as well as camera-ready copies for making 43 Power Point slides and a post-training evaluation form. A separate 22-page manual provides information for health care providers on fluoride varnish application, as well as parent information and consent forms in English and Spanish. Download most materials from http://health2k.state.nv.us/oral/caries.htm .

Evaluation