Chapter 5. Approaches to Screening, Referral
and Case Management
This chapter will describe ways to establish coordinated
screening, referral and case management systems to help assure
that children receive the oral health care they need in a
timely and appropriate manner. Considerations for performing
oral health screenings, and the differences between screenings,
epidemiologic surveys and dental exams are discussed. Various
referral and case management models are presented, including
sample scopes of work, reimbursement issues, and ways to track
and monitor care.
The fields of health and education include many types of
screenings-developmental, hearing, vision, language. All are
attempts to assess a child's development and identify those
children with other than routine needs who should be referred
for more in-depth examination and care.
|Dental screenings are widely
used for this purpose, to triage those children who have
routine needs, those who are at high risk for developing
problems, and those who have obvious disease that requires
treatment. Children can then be referred for routine preventive
care and regular examinations as well as restorative or
other care. The process and data collection instruments
for most health screenings are more standardized than
those for dental screenings. Sometimes screenings or "oral
health surveys" are done primarily to gain an overall
understanding of the oral health status of a particular
population for purposes of planning and allocation of
resources. It is important to keep these two purposes
in mind when determining how to conduct screenings.
Screenings are different
than epidemiological surveys, such as the Basic Screening
Survey, which require a sampling framework and other research-oriented
A dental screening
is not the same as a clinical dental examination. Dental
examinations are performed by dentists and should result
in a diagnosis and an individualized plan for care.
Screenings are not effective and should not be undertaken
unless there is a referral network of professionals to provide
the needed care and there is a way to track which children
A common complaint
in many communities is that dental screenings are performed
on a regular basis, but children with identified restorative
needs may not be able to access care, resulting in the
same needs being observed over a number of years.
This is where "case management" is valuable. Social
workers, nurses and other health professionals have been providing
case management in public health and school settings for over
70 years. Case management responsibilities are now performed
by many different professionals in inpatient, outpatient,
community and health insurer settings to coordinate resources.
The population to be served, the type of services needed,
and the available healthcare settings often determine what
type of professional background a case manager needs. Highly
specialized, complex care such as that provided for children
with cleft lip/palate will require someone with more clinical
expertise, while case management of families who do not speak
English in a rural town and are not familiar with community
services might best be provided by a bilingual lay advocate
whom the families trust. Choosing the appropriate model and
staff are crucial to the success of any screening, referral,
and case management program.
Determine what screening, referral and case management processes
already exist in your community. Many of these may be informal
processes that were created by a dedicated nurse from the
local health department or a Head Start Health Specialist.
You may need to interview a number of people to find this
information. Use the Screening/Referral/Case
Management Self-Assessment form to help guide your search.
After you complete the self-assessment, discuss the findings
with your oral health coalition or other group to determine
if a more formal system would enable more children to have
a true "dental home."
Screening, Referral and Tracking
Screening provides a snapshot of a population at a particular
point in time to identify oral health needs and ways to meet
those needs. Let's look at the purposes in more detail.
1. Identify populations at high risk for dental problems
- nutritional factors: inappropriate feeding practices, frequent
use of snacks or beverages with high refined sugar content
- poor oral hygiene: infrequent tooth cleaning or brushing
- medical conditions: conditions that affect the immune system
(e.g., HIV infection), craniofacial disorders (e.g., cleft
lip/palate), or that require frequent hospitalizations or
multiple medications (e.g., kidney problems)
- behaviors that interfere with home oral care or professional
dental care or put the child at risk for child abuse: e.g.,
- beginning stages of dental decay (white spot lesions) or
gum tissue problems
o inability to access professional dental care for exams or
treatment due to lack of finances, lack of providers, etc.
- poor overall coordination or hyperactivity resulting in
2. Triage to establish needs and priorities for allocation
of resources, maybe using the following categories:
- need regular exams, anticipatory guidance and preventive
- need further examination for definitive diagnosis and possible
care other than preventive measures
- need further examination and treatment in a timely manner
- need immediate examination and care for advanced disease
or other condition
- Differentiate between those with a dental home and
- Money for direct care vs. money for preventive supplies
vs. money for supportive services such as transportation to
- Type and level of effort of workforce, e.g., DDS and/or
RDH, DA, case manager
- Analyze for gaps in resources or to advocate for more
How and Where to Perform Screenings
Screenings can occur in most any setting as long as there
is an adequate source of light and somewhere for the child
to sit or recline, sometimes in a parent's lap. This includes
Head Start programs, WIC sites, child care centers, health
fairs, family resource centers, home visits, well child clinics
or other medical clinics. Screenings can also be conducted
for pregnant women seen in parenting classes, prenatal clinics
or in other settings.
screenings in dental offices is a waste of valuable resources
and time. Dental office settings should primarily be used
for diagnostic, treatment, and some preventive procedures.
For screenings, examination gloves are optional, but should
be used if there will be any contact with saliva. To gain
access to the mouth, a small (not adult size) disposable tongue
blade can be used or a small toothbrush that you give to the
child after the screening (one with a rubber handle can be
used to help prop open the mouth.) The latter is sometimes
more helpful if there is food debris that obscures your view.
Oral screenings on young children usually only take 1-3 minutes.
Screening older children and adults takes a bit longer.
must be obtained from parents/caretakers prior to performing
an oral screening.
This can be accomplished by sending home a permission slip
for signature (active consent) or by sending home a notice
of the screening and asking those who don't consent to the
process to send in a note stating so (passive consent). Examples
of consent forms are included in the Basic Screening
Survey, and can be easily modified. Some include questions
for parents to answer about access to dental care, home oral
care practices, or feeding practices that might place a child
at high risk for dental problems. After the screening, send
a letter home noting the screening findings for each child,
with an appropriate recommendation for seeking care and having
a dental home. Emphasize in the letter that the screening
does not take the place of a dental examination.
Incorporating Risk Assessment Questions
Asking a few key questions can help determine a child's risk
for dental disease and other oral problems. Some high risk
factors include: primary caregiver has active dental decay,
child uses bottle that contains sweetened beverages, frequent
between-meal snacks, medications that contain high amounts
of sugar or that promote dry mouth, and inadequate oral hygiene.
Examples of protective factors include appropriate use of
fluorides, good oral hygiene, regular dental check-ups, primary
caregiver has good oral health. Two examples of risk assessment
questionnaires are at http://www.cdafoundation.org/journal/jour0303/consensus.htm
Collecting and recording the screening information in a consistent
manner is important, especially if you are trying to categorize
children to allocate resources and make appropriate referrals.
If many agencies or individuals are performing screenings,
then using the same form will allow aggregation or comparison
of data. Again, there are examples in the Basic Screening
Survey that can be modified. Make sure everyone is clear on
the definitions of terms and categories. For example, if you
intend to track children with suspected cases of Early Childhood
Caries (versus any other pattern of decay that is evident),
decide on a definition such as "obvious caries on at
least one of the upper front teeth." Looking for and
tracking oral injuries of the soft and hard tissues is important
for anticipatory guidance with parents around oral injury
prevention, or in cases of suspected child abuse.
Communicating with Parents
is important that families understand the purpose and
limitations of screening and what follow-up is recommended
for further examination and care.
Most screening/referral programs provide a letter back to
parents that describes what occurred at the screening and
a general description of the child's oral health status (e.g.,
appears health, possible areas of dental decay) and what follow-up
is recommended (e.g., routine examination and preventive care
in dental office; needs dental treatment as soon as possible
to reduce infection.) View examples
of letters from screenings (need examples). Include contact
information for questions, referrals or case management. This
is also an opportunity to include oral health education information
on specific topics.
Analyzing Results of Screenings
Analyze the screening data to see if they answer the questions
that prompted your screening. For example, if you discover
that most children in your preschool program don't have any
immediate needs but could benefit from better oral hygiene
care and preventive measures, you might decided to allocate
resources to purchase toothbrushes and paste. Then you could
schedule onsite fluoride varnish applications when parents
can be present. Or if a number of children need dental treatment
and parents don't have reliable transportation, you might
allocate some funding to purchase transportation vouchers.
Oral health screening data can be shared with other agencies
in your community in a format that graphically displays the
children's level of need; this helps document the need when
advocating for additional funding.
Referral and Tracking
In many rural areas, an informal referral system exists because
families and professionals in small towns know each other
and interact on a more personal basis. Although this works
well in some communities, it may not work where there are
seasonal fluctuations in the population or where dental providers
do not participate in public financing programs such as Medi-Cal
or Healthy Families. Negotiations with providers and a definite
process for referrals and tracking of care are needed. Incentives
and community recognition often go far in sustaining provider
Once a referral system is established, it usually requires
frequent updating. The goal of a viable referral system is
to have enough providers to meet anticipated needs in a timely
manner and to establish "dental homes" for all children
and their families. Dental homes should be accessible and
provide continuous, comprehensive, family centered, coordinated,
compassionate, and culturally effective dental care and promote
oral health. Waiting lists often are needed, so priorities
based on level of urgency for the care are important to document.
you recommend that a child be seen for care, make sure
that you have a tracking system to follow up on that recommendation,
both with the parents and with the dental provider who
sees the child.
This means documenting when appointments are scheduled, if
appointments are kept, reasons why appointments are not kept,
if the child's care is completed, and what the recall interval
is. Some programs have developed standard referral forms
that include a portion to return after care is provided.
This sends a clear message to the dental provider that a response
is expected, and promotes two-way communication. Any problems
that occur around missed appointments, other specialty referrals,
etc. can also be shared via this mechanism.
Tracking systems vary in their sophistication. They can include
color-coded cards, reminder stickers on patient records, spreadsheets,
or computerized databases. Some automated tracking systems
generate patient reminders, letters, and topical information.
Situations that create gaps in these systems include missed
appointments, delays in pre-authorizing care, specialty referrals
where paperwork is lost or the results of the care are not
sent to the referring provider, or families move and don't
notify the office. Effective tracking systems should have
cross-checks, tickler files or alerts to prevent or manage
Case management is a process used by a health professional
or care coordinator to manage health care needs of families.
Case managers make sure that families get needed services,
and track their use of facilities and resources. They try
to identify individuals at high risk for problems and assess
opportunities to coordinate care to optimize health outcomes.
Case managers can provide a variety of valuable services:
- implementing an active outreach system to underserved
- handling requests for screening or care from community-based
groups such as Head Start
- explaining benefits and services to providers
- responding to provider problems with families, paperwork
- establishing a family's eligibility for services or
- providing information, answering questions and helping
people make decisions about services
- helping families complete paperwork to obtain services
- making and following up on referrals to dental providers
- finding additional funding for individual cases if
needed; interfacing with other agencies
- helping families find interpreters
- determining potential barriers for parents and problem-solving
to reduce the barriers
- arranging for transportation or child care assistance
or payment during dental appointments
- scheduling appointments and coordinating with other
health or social service appointments if possible
- explaining the importance of oral health and answering
some common oral health questions
- reviewing responsibilities and rights of patients and
of dental providers
- managing paperwork so that everyone has what they need
- coordinating with families to facilitate follow-up
on recommendations and routine care
- checking with families and providers to determine if
there were any problems
- helping to prioritize and allocate resources
- generating reports to providers or agencies
essence, case managers act as ombudsmen-playing an advocacy
role, as well as a coordinator of care and a liaison between
families, providers, and funders.
View a scope of work for a comprehensive care coordinator
position in a regional center program in the program examples
section. Where funding and staff are limited, case management
services that address oral health in an integrated way with
other health services are probably most cost-effective and
help assure that health needs are being addressed in a comprehensive,
coordinated way. If this is not an option because of dedicated
grant funds for oral health or because of large potential
dental caseloads, then a separate case management system may
Some potential beneficial outcomes from case management include:
1) lower missed appointment rates, 2) increased future self-reliance
and confidence of families, 3) increased knowledge of oral
health, dental benefits and services available, 4) improved
provider understanding and respect of families and young children,
5) improved timeliness of referrals and receipt of care, 6)
increased adherence to recommendations and follow-up care,
7) reduced barriers to care, 8) increased numbers of dental
professionals providing care to young children and pregnant
women, 9) decreased prevalence of dental diseases, especially
at advanced levels requiring urgent care, 10) reduced costs
for dental care over the long run.
Examples of Programs
- Spokane Regional Health District received funding
from the March of Dimes to provide oral screenings for low-income
pregnant women seen by public health nurses. They have created
a referral system with Eastern Washington University Dental
Hygiene Program, focusing on care for periodontal disease.
Contact: Oral Health Program Supervisor, 509-324-1550.
- Hawaii's Medicaid program contracts with a local private
sector case management service to work with dentists and Medicaid
recipients to help them understand Medicaid benefits and how
to utilize them appropriately. They also coordinate specialty
appointments, transportation and translators (when needed)
and help place people with dentists when they have difficulty
finding accessible/willing Medicaid providers. Contact: Dr.
Mark Greer, 808-832-5700.
- Red River Valley Dental Access Project is a collaborative
effort with public, private and philanthropic groups to improve
access to dental care. It offers case management to a referral
network of dentists in 25 counties in eastern North Dakota
and western Minnesota. Social service and housing agencies
identify clients in need of service. The project offers oral
health screenings and education to programs that serve low-income
families, such as Head Start. Multiple funding sources are
used. Contact 701-364-5364; view website at http://www.rrdentalaccess.com.
- Plumas County conducted a dental case management program
in 2001 through a Rural Health Services Small Grants Program.
View the case study. Twenty-four of the 105
individuals served were ages 0-5.
- Lassen Oral Health Task Force began a case management
and tracking system using volunteer coordinators and providers.
As the caseload increased and the need for a toll-free number,
office space and record storage became crucial, they documented
the effectiveness of the system and successfully acquired
funding for a case manager and donated office space from a
community health center.
- Anderson Center for Dental Care in San Diego initiated a
Healthy Smiles for Children with Disabilities program to help
families improve and maintain oral health for their children
ages 0-3 with autism or other disabilities. The program is
funded by the California State Council on Developmental Disabilities.
overview and an example of an
oral health assessment and plan provide more details and
contact information.Anderson Center also received grant funding
from First 5 Commission of San Diego to implement "Welcome
Baby Teeth." Physicians and staff receive in-office
training, parent education materials, referral resources,
and care coordination services to incorporate oral health
screening into regular check-ups. Screenings also are conducted
at Head Start and State-funded preschools. This curriculum
will be adapted for the statewide First 5 Oral Health Education
and Training Project, administered by the Dental Health Foundation.
For more information on the Welcome Baby Project, contact
Jan Ferree, Program Coordinator at 858-576-1700 x 4802.
- The Center for Oral Health for People with Special Needs
at the University of the Pacific School of Dentistry has developed
a community-based system for oral health care for persons
with developmental disabilities. One component of this program
includes dental coordinator positions at eight or more state-contracted
regional centers to provide case management, education and
training. For more details see http://www.pacificspecialcare.org/factSheet.htm
and a position
- Donated Dental Services Program. In this program,
volunteer dentists agree to accept a certain number of needy
patients each year who are disabled, medically compromised
or elderly to treat in their offices where they can work more
efficiently with their own equipment, supplies, and staff.
Although the focus generally is on older patients, this could
be a resource for young children with special health care
needs. In each state, at least one program coordinator is
responsible for determining that applicants are eligible and
have no other way of paying for dental care. Communicating
between offices and patients is also a major responsibility.
The coordinators play a case management role, verifying patients
have reliable transportation, reminding them of appointments,
and resolving problems that may arise. Coordinators also arrange
for specialists and laboratory services when necessary. To
find further information about the DDS program in a specific
state, go to http://www.nfdh.org/DDS.html.
- El Dorado California Care Program/ East and West Slope
Offices: Case management and dental care is offered through
the county public health department; http://www.sacdhhs.com/cms/download/pdfs/pub/pub_source_eldorado.pdf
- Alameda County Health Department received funding for a
national demonstration program called Healthy Kids, Healthy
Teeth (HKHT): Case Management and Care Integration for children
ages 0-5. Modeled after the Washington ABCD program , the
program assists families in accessing dental care, provides
education about dental visits, removes some barriers to care,
tracks children's progress through the dental system, encourages
appropriate use of dental services, and provides linkages
to other health programs such as health insurance, well child
exams and WIC. There are four program components: 1) recruitment,
enrollment and case management, 2) dental and medical provider
training, 3) provider incentives for participation, and 4)
outcome evaluation. For information, contact Dr. Jared Fine
What are some ways to determine if your screening, referral,
tracking, and case management systems are effective? Consider
the following methods and outcome measures.
- Examples of methods: family satisfaction surveys, provider
interviews, case manager interviews, time and effort analyses,
cost analysis, oral health data analysis
- Some outcome measures: improved oral health status
of individuals/groups one year after screening, % of children
who have a dental home, % of children completing recommended
care, % of providers participating in referral system, in-kind
efforts or donations such as transportation, # of case management
hours spent/child or family, % of families who kept scheduled
appointments, families reporting high level of satisfaction
with care and with case management process.
Use evaluation information to improve your program and to
justify its continuation or expansion.
- Summers S et al. Practical infection control in oral
health surveys and screenings. JADA. 125:1213-17, 1994. Available
as an appendix to the Basic Screening Survey at http://www.astdd.org/docs/BSS_Manual_Appendix.pdf.
- Case Management Basics: http://www.cyberchalk.com/nurse/courses/nurseweek/nw2210/c1/.
This course covers eight chapters. Although not focused on
oral health, it does provide a good overview of the goals
and strategies of case management. The course includes references,
review questions and a posttest.
- ADA. State Innovations to Improve Dental Access for
Low-Income Children: A Compendium, http://www.prnewswire.com/mnr/ada/11207/#;
this a compilation of data drawn from each state's Medicaid
and State Children's Health Insurance Program. Some examples
of case management are given.
What did you learn or accomplish as a result of reading this
chapter? Did it help you to organize your thoughts about what
types of screening, referral and case management systems would
be appropriate in your community? Were the resources and examples
helpful? Go to the feedback form for Chapter 5 and tell us what was useful or not useful