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2013 Model Practices (Public)

Application Name: 2013 Model Practices (Public) : Clark County Health Department : Clark County Dental Health Initiative
Applicant Name: Ms. Beth Willett
Application Title:
Clark County Dental Health Initiative
Please enter email addresses you would like your confirmation to be sent to.
Practice Title
Clark County Dental Health Initiative
Submitting LHD/Agency/Organization
Clark County Health Department
Head of LHD/Agency/Organization
Anthony S. Lockard
Street Address
400 Professional Avenue
Practice Contact Person
Anthony S. Lockard
Public Health Director

Email Address

Submitting LHD/Agency/Organization Web Address (if applicable)

Provide a brief summary of the practice in this section. This overview will be used to introduce the model or promising practice in the Model Practices Database. Although this section is not judged, the judges use it to get an overall idea about your practice. You must include answers to the following questions in your response:

• Size of population in your health department’s jurisdiction
• Who is your target population/audience, what is the size of your intended population/audience for this practice and what percent of your target population did you reach?
•Provide the demographics of your target population (i.e. age, gender, race/ethnicity, socio-economic status) 
• Describe the nature and gravity of the public health issue addressed
• List the goal’s and objective(s) of the practice and clearly link them to the problem or issue the practice is addressing.
• Describe the potential public health impact of the practice, and the likely effectiveness of the practice being implemented as intended, and the ease of adoption of the practice by other LHDs.

In your description, also address the following
• When (month and year) the practice was implemented.
• Briefly describe how the practice was implemented, what were major activities, and any start-up and in-kind costs and funding services.
• Outcomes of practice (list process milestones and intended/actual outcomes and impacts.
• Were all of the objectives met? 
• What specific factors led to the success of this practice?

The Clark County Dental Health Initiative (CCDHI) is a population-based primary prevention intervention. The CCDHI began in January 2008 and is a program to reduce dental caries in the youth of Clark County, Kentucky. On December 25, 2007, the New York Times published an article placing Kentucky last in the nation for dental health of its children. The decay rate was 50 percent, the highest in the nation. In response, collaboration between the private sector, public agencies, and local philanthropy formed. Clark County has a population of 35,613 and is served by one health department. The target population of this program is students preschool through fifth grade. There are approximately 2,877 in this population - 54 percent male, 46 percent female. The race/ethnic breakdown is 84 percent Caucasian, 6 percent African American, 6 percent Hispanic/Latino, and 4 percent Asian, American Indian, or two or more races. To date the practice has reached an average of 94.4 percent of the intended population. 43 percent of students are eligible for Free or Reduced lunch and 26 percent live below the federal poverty level. The public health issue addressed is oral health of children. Tooth decay has implications to overall health status, including quality of life, illness, chronic disease, and nutrition status. Upon implementation of CCDHI, 54 percent of children enrolled in Medicaid or KCHIP received dental services. 2008 baseline data collected from local sixth grade students revealed a 50.42 percent rate of tooth decay. Goals and objectives: 1) twice-annually apply Enamel Pro Series Amorphous Calcium Phosphate (ACP) Fluoride Varnish on preschool through fifth grade students’ teeth, 2) annually provide all students in Clark County Public Schools with a new toothbrush and toothpaste, 3) perform oral exams annually and provide an assessment report to parents, 4) conduct the Decay, Missing, Filled, Sealants survey on all sixth graders annually, and 5) institute an oral health education program in the schools. These goals will impact the public health issue of high decay rate among school children by providing free fluoride varnish which is proven to impact the rate of tooth decay. The practice will increase oral health in the community. This program was implemented when one local dentist took an interest in the issue and recruited other dentists and community members to volunteer. The major activities include a volunteer dental team visiting each school twice annually to apply varnish and perform dental assessments on students. The assessment allowed for parental access to information and resources for oral health. The Clark County Community Foundation granted CCDHI $12,000 per year for five years to implement this practice. All start-up funds were used to purchase ACP Fluoride Varnish, toothbrushes, toothpaste, dental supplies, and printing of materials. In-kind costs totaled $32,460.40, which included the volunteer hours from dentists and hygienists, dental education kits, and assessment forms. The average cost of a fluoride application in a dental office is $40, which gave this project a healthcare value of $186,800 in its first year. Thus far all objectives have been met. Factors contributing to success: Start-up funding from a local foundation, commitment of private sector dentists to ensuring children receive dental services, and volunteer dentists and community volunteers. The outcomes of this practice demonstrate the impact a population-based primary prevention intervention can have an oral health.

Overflow: Please finish the response to the question above by using this text area.  Please be mindful of the word limits.

To date, there has been a 77 percent decrease in the number of sixth grade students presenting with tooth decay. An instrumental milestone and factor in the success was the decision to make this program mandatory for all Clark County preschool and elementary students. In year one, this was an opt-in program, requiring a signed parent release for students to receive fluoride varnish. After seeing the success of the practice and ease of implementation in schools, the School Superintendent changed the program to an opt-out program. This decision increased the percentage of target population receiving fluoride varnish application from 86 percent in year one to 96 percent in year two. This program could be easily implemented by other communities. Fostering partnerships with private-sector dental providers, dental insurance providers, and dental supply companies is the key for other communities to successfully replicate this program. An unintended outcome for this program was the development of “KY Smiling Schools Oral Health Project”. This is modeled after CCDHI, and will result in the program being replicated in 16 counties in Eastern KY, reaching an estimated 25,000 children. This outcome is a major milestone for CCDHI, and demonstrates the ease of replication in other communities.
You may provide no more than two supplement materials to support your application. These may include but are not limited to graphs, images, photos, newspaper articles, etc.
Describe the public health issue that this practice addresses. (350 word limit)
Worldwide, dental decay and caries remain a major public health issue. In 2007, Kentucky was identified as having the highest rate of tooth decay in the nation among children. According to the Oral Health in America Report, tooth decay is the most common disease during childhood, more common than asthma and hay fever. Dental decay can affect overall health status, including quality of life, illness, chronic disease, nutrition status, and social interaction. In addition, the learning process for children can be interrupted due to oral pain and lost school time. Over 51 million school hours are lost each year to dental illness according to the Oral Health in America Report. The theme of this report was “safe and effective disease prevention measures exist that everyone can adopt to improve oral health and prevent disease.” Dentists, dental hygienists and the local public health system can play a major role in disease prevention in a given community. The CCDHI introduces a safe and effective prevention practice that addresses tooth decay and barriers to childhood preventative dental services. Administering free fluoride varnish in schools addresses access to care plus challenges parents might face, such as taking time off work, cost, and transportation.
What process was used to determine the relevancy of the public health issue to the community? (350 word limit)
In developing the Clark County Dental Health Initiative, baseline data was collected from 361 sixth grade students in the Clark County School System in the spring of 2008. These students were assessed with the Decayed, Missing, Filled, Sealant survey, a national standard for evaluating the dental health of a specific group. In total, the assessment revealed 50.4 percent of these students had decayed teeth. This data matched the New York Times article from late 2007, stating Kentucky had a 50 percent rate of decay among children. In addition, Clark County is designated as a Health Professional Shortage Area for primary care, dental care, and mental health.
How does the practice address the issue? (350 word limit)
This practice addressed the issue of dental decay in school-aged children by using the evidence-based practice of applying fluoride dental varnish two times a year. In particular, the purpose of using Enamel Pro Series ACP fluoride varnish is to increase fluoride uptake and increase remineralization of tooth enamel. Both of which will decrease the rate of tooth decay. Fluoride varnish is safe and can be applied in a very short time. The application does not require a dental visit, and can be performed in most settings. According to the American Dental Association (ADA), fluoride varnish is the only topical fluoride treatment recommended for children less than six years of age. Additionally, the inclusion of an objective to develop a school oral health education program will increase the number of students brushing and flossing their teeth daily, and increase preventive dental health services for children in Clark County.
Does this practice address any of the CDC Winnable Battles? If yes, select from the following
Please list any evidence based strategies used in developing this practice. (Provide links or other materials for support)
The American Dental Association recommends fluoride varnish 2 times a year for moderate-risk patients and recommends fluoride varnish as the only acceptable topical application for children less than six years of age. This practice follows this recommendation by applying fluoride varnish twice annually to children aged 3 years through fifth grade. According to the National Guideline Clearinghouse, the American Academy of Pediatric Dentistry recommends when a dental home is not established, periodic applications of fluoride varnish may be effective in reducing early childhood tooth decay. This includes applications performed by trained non-dental healthcare professionals. KIDS COUNT data revealed in 2008, 46 percent of children enrolled in Medicaid or KCHIP did not receive dental services, possibly indicating a high number of children without a dental home. The Institute for Clinical Systems Improvement recommends preventive services for children and adolescents. Dental and periodontal disease is listed as a preventable disease or condition, with specific prevention recommendations from birth to age 18. Preventive services that have been shown to be effective and provided whenever possible include fluoride to prevent decay and caries, oral screening as a risk assessment tool, and counseling on preventive oral health care. All of these recommended preventive services are included in this practice.
Is the practice new to the field of public health? If so, answer the following questions.

What process was used to determine that the practice is new to the field of public health? Please provide any supporting evidence you may have, e.g. literature review.

How does this practice differ from other approaches used to address the public health issue?
Is the practice a creative use of an existing tool or practice? If so, answer the following questions.
What process was used to determine that the practice is a creative use of an existing tool or practice?  Please provide any supporting evidence you may have, for example, literature review.
A literature review of evidence concerning fluoride varnish and specifically Enamel Pro Series ACP Fluoride Varnish was conducted to determine that this is an inventive use of an existing practice. Under ideal conditions, calcium and phosphate ions dissolve from tooth mineral into saliva, a process called demineralization. These ions naturally come back to teeth through remineralization. When the balance between demineralization and remineralization is disturbed, dental decay and caries are formed. A disruption to this process is caused by changes in mouth pH, which in turn is caused by oral bacteria, and frequent intake of acidic or sugary foods and beverages. In response to the prevalence of oral decay worldwide, a chemist and researcher at the American Dental Association Foundation Paffenbarger Research Center in Maryland studied ways to increase the rate of remineralization. In 1991, Ming S. Tung Ph.D. found remineralization can occur quickly with the use of amorphous calcium phosphates, or ACP, when combined with fluoride. The calcium and phosphate ions begin to remineralize the lesion and restore the tooth’s surface. For this reason, Enamel Pro Series ACP Fluoride Varnish was developed and approved by the Food and Drug Administration in 2006. Further research conducted in 2008 by Dr. Tung and J. Torres found that treatment with calcium-phosphate-fluoride significantly reduced dentin permeability (which is necessary for restoration of early caries lesions), and fluoride varnish alone did not produce similar results. Considering this, Enamel Pro Series ACP Fluoride Varnish is an inventive use of an existing tool for oral health.

What tool or practice (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, etc.); did you use in a creative way to create your practice?  (if applicable) (300 word limit total)
a. Is it in NACCHO’s Toolbox; (if not, have you uploaded it in the Toolbox)?
b. If you used a tool or practice to implement your practice, how was your approach to implementing the tool unique and innovative for your target area/population?


How does this practice differ from other approaches used to address the public health issue? 

The use of fluoride varnish has long been a successful preventive dental health practice. The CCDHI practice differs and improves upon this in several ways. The use of a new fluoride varnish made with ACP is an innovative use of a known preventive dental practice. ACP works by enhancing the natural healing abilities of saliva, and helps prevent decay through a process of remineralization and an increase in the uptake of fluoride. The FDA approved ACP for use in fluoride varnish and the Enamel Pro Series ACP fluoride varnish become available for public use in 2006. The compounds in ACP have been found to have the highest mineral formation rates, and can easily transform to tooth mineral. The combination of fluoride and ACP creates a synergistic effect, with the ACP optimizing the effects of the fluoride and the fluoride promoting the remineralization properties of the ACP. According to research by Drs. Schemehorn et al. this varnish has been found to release more fluoride and promotes more fluoride uptake by the enamel when compared with conventional fluoride varnishes containing the same amount of fluoride. For these reasons, the CCDHI practice differs from the traditional practice of using fluoride varnish alone, by using an innovative product which may remineralize tooth enamel and provide increased uptake of fluoride.
If this practice is similar to an existing model practice in NACCHO’s Model Practices Database (www.naccho.org/topics/modelpractices/database), how does your practice differ? (if, applicable)
A literature review of Model Practices was conducted during October 2012 to determine how the CCDHI practice differs from other approaches to this public health issue. There were several similar approaches: 2012 Lake Children's Dentistry program, 2012 School Based Oral Health Program in Chicago, and the 2012 Young Children Priority One Dental Program in Nebraska. The CCDHI differs from these in several ways. First, the CCDHI program was staffed solely by volunteer dentists and community members. Second, the program is inexpensive to operate, being funding by a local philanthropy foundation at $12,000 a year, plus in-kind services totaling $32,460.40. The Nebraska program in its first year cost $57,000 and reached 522 children. In its first year, the CCDHI applied varnish to 2,728 children, and 6,000 students received a new toothbrush and paste, all for a total cost of $44,460.40. Thirdly, this program serves all grades in the local elementary schools rather than just a single grade. Rather than using a mobile dental unit, the practice is conducted either in the classroom, school library or gymnasium. The practice takes only 2 school days to complete, and the dental teams only interrupt each class for a total of 10-20 minutes. Lastly, this practice provides ACP fluoride varnish for five consecutive years. The use of the ACP fluoride varnish is an innovative use of a preventive dental product because it is designed to increase remineralization of weakened tooth enamel. No previous Model Practice has used this type of dental product.
Who were the primary stakeholders in the practice?
The primary stakeholders in this practice are the school-aged children in the Clark County Public School system, the Clark County Public Schools and the Board of Education, the Clark County School Health Program, the Winchester Clark County Dental Association, the Clark County Community Foundation, the Clark County Health Department, the Bluegrass Community and Technical College- Lexington campus, the University of Kentucky College of Dentistry and Premier Dental Supply.
What is the LHD's role in this practice?
The LHD's role in this practice has been to serve as the fiscal agent for the grant funding awarded to conduct this program for five consecutive years. To maximize use of the grant funding, all supplies were ordered by the LHD using its tax exemption status. The LHD printed all materials needed by the dentists and uses the LHD's School Health Program to facilitate the program in the schools. The School Health nurses have been instrumental in planning the logistics of the application days, and all nurses have been trained in varnish application, so as to assist in day-of activities.
What is the role of stakeholders/partners in the planning and implementation of the practice?
The planning and implementation of this practice was possible through a unique partnership of the private dental sector and local philanthropy. These two stakeholders agreed to work together to decrease the dental decay rate among children in the community. These stakeholders gained the support of the LHD and local school system prior to implementation of the practice. The LHD agreed to serve as the fiscal agent for the practice and leverage its relationship with the local school system for collaboration and facilitating the process. The local school system gained parental support by sending informational material home with students explaining the public health issue concerning their children’s oral health. To implement the practice successfully, many dental materials and supplies were needed to reach the practice’s objectives. By leveraging existing relationships between local dentists and local community members with dental industries, the products were obtained through donations or discounted pricing. Premier Dental Supply provided the Amorphous Calcium Phosphate (ACP) fluoride varnish at a discounted rate and has used this practice for evaluation of the product. Comments and feedback from the dentists, volunteers and students are given yearly to the company and modifications to the ACP fluoride varnish have been made because of this practice. The modifications due to feedback have included the color, grittiness and mouth-feel of the varnish.

What does the LHD do to foster collaboration with community shareholders?
Describe the relationship(s) and how it furthers the practice's goals.

The LHD furthered the practice’s goals by fostering collaboration with the local school system. A formal relationship previously existed with the Clark County Public School System through the School Health program. Using this established relationship, the LHD was able to facilitate the process and collaborate with Clark County Public Schools to institute this program. The School Health nurses were instrumental in planning the logistics of the application days and worked with the volunteer dentists to ensure a successful intervention. Additionally, the LHD was able to further the practice’s goals by bringing state-wide recognition to the practice when the Public Health Director nominated the practice for an award from the Kentucky Public Health Association. The CCDHI received the 2011 Group Award as the outstanding public health project in the state. Additionally, volunteerism in the schools has increased due to this program, as has public awareness of the role of the LHD in the community.
Describe lessons learned and barriers to developing collaborations.
There were several lessons learned and barriers encountered to developing collaborations for the Clark County Dental Health Initiative. In the beginning of this practice, an initial barrier was collaboration with the principals and teachers at the individual schools. The teachers had to be convinced by educating them about ease of process and potential positive outcomes that are relevant to student achievement. Class time was a second barrier as it is limited and teachers are under pressure to cover all mandatory curriculums, so initially principals and teachers were hesitant to give time to the practice. The dental teams visit each school, simultaneously on the same school day. The total class time for the practice is about 10-20 minutes. The applications can be done in the classroom setting or if a school chooses, the library or gymnasium can be used for applications and exams. After the first year of the practice, the principals and teachers realized the minimal time required out of class for this practice, and were in favor of the practice. The dentists report now that the teachers are first in line for varnish application! An important lesson learned during the course of this practice was to use an opt-out policy for student participation, rather than an opt-in policy. In the first year, 15 percent of opt-in parent sheets were not returned, and thus those students did not receive varnish application. After the success of the first year, the Superintendent of the school system decided to make this a mandatory program for all students, and required an opt-out parent form to be turned in to exempt a child from varnish application. This change in practice format increased the number of students receiving varnish application to 95.8 percent of the total target population, an increase of 11.9 percent from the first year. Another lesson learned is importance of education for collaborators in order for them to be participants and funders. Education is also important for community members to engage them in volunteer roles.

Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.

Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).

List up to three primary objectives for the practice. For each objective, provide the following information:  (750 word limit per objective)

• Performance measures used to evaluate the practice: List the performance measures used in your evaluation. Depending on the type of evaluation conducted, these might be measures of processes (e.g., number of meetings held, number of partners contacted), program outputs (e.g., number of clients served, number of informational flyers distributed), or program outcomes (e.g., policy change, change in knowledge or attitude, change in a health indicator)
• Data: List secondary and primary data sources used for the evaluation.  Describe what primary data, if any were collected for each performance measure, who collected them, and how.
• Evaluation results: Summarize what the LHD learned from the process and/or outcome evaluation. To what extent did the LHD successfully implement the activities that supported that objective? To what extent was the objective achieved?
• Feedback:  List who received the evaluation results, what lessons were learned, and what modifications, if any, were made to the practice as a result of the data findings.


• Performance measures used to evaluate the practice: List the performance measures used in your evaluation. Depending on the type of evaluation conducted, these might be measures of processes (e.g., number of meetings held, number of partners contacted), program outputs (e.g., number of clients served, number of informational flyers distributed), or program outcomes (e.g., policy change, change in knowledge or attitude, change in a health indicator)
• Data: List secondary and primary data sources used for the evaluation.  Describe what primary data, if any were collected for each performance measure, who collected them, and how.
• Evaluation results: Summarize what the LHD learned from the process and/or outcome evaluation. To what extent did the LHD successfully implement the activities that supported that objective? To what extent was the objective achieved?
• Feedback:  List who received the evaluation results, what lessons were learned, and what modifications, if any, were made to the practice as a result of the data findings.

Objective 1:

A long-term performance measure for CCDHI is the decay rate among sixth grade youth in Clark County. This long-term outcome is being evaluated using the Decayed, Missing, Filled, Sealants (DMFS) survey. The evaluations are being performed on all sixth grade students during the spring school term, and are conducted by volunteer dentists from the Winchester Clark County Dental Association. In spring 2008, per the DMFS survey, Clark County sixth graders had a 50.42 percent decay rate. After the first year of the CCDHI practice, sixth graders showed an 11 percent decrease in decay rate. At the end of year four, sixth grade students showed an 11.24 percent decay rate, a decrease from baseline of 77 percent. The results from the DMFS survey were reported to the Clark County Community Foundation, the Clark County Health Department, the Winchester Clark County Dental Association and the Clark County Public School System. These results have also been shared with Premier Dental Supply and May Consulting for their internal evaluation of the Amorphous Calcium Phosphate Fluoride Varnish.

Overflow (Objective 1): Please finish the response to the question above by using this text area.  Please be mindful of the word limits.

Objective 2:

A short-term performance measurement for CCDHI practice is the number of school-aged youth receiving preventative and restorative dental services. According to the DMFS surveys, the number of dental sealants seen in sixth graders has increased by 144 percent after four years of the CCDHI practice. Additionally, according to the KIDS COUNT Mobile Data Center, 54 percent of children enrolled in Medicaid or KCHIP received dental services in 2008, which was the first year of the practice. In 2010, this oral health indicator has increased by 16.7 percent. This may be an indication that the dental exam forms being sent home and follow-up with parents is increasing the likelihood a child is getting to a dentist for dental services. These evaluation results have been shared with the Clark County Community Foundation and the Clark County Health Department.

Overflow (Objective 2): Please finish the response to the question above by using this text area.  Please be mindful of the word limits.

Objective 3:
The number of volunteer private-sector dentists and the number of community volunteers is a quantitative measure for process evaluation. In year one of this practice, 7 local private-sector dentists volunteered their time to provide oral exams and fluoride varnish application. By year four, this number had increased to 17 dentists. In year one, 80 community volunteers helped in the schools on the two dental application days. By year four, this number had increased to 127 trained community volunteers. Additionally, the regional campus of the Bluegrass Community and Technical College has begun using this practice as an opportunity for its dental hygiene and dental assisting students to gain practicum experience. Anecdotal evidence of the effectiveness and intended duplication of this practice is seen through a former volunteer now at Tulane University, writing a grant to replicate this practice in schools, hopefully reaching 5,000 students.

Overflow (Objective 3): Please finish the response to the question above by using this text area.  Please be mindful of the word limits.

What are the specific tasks taken that achieve each goal and objective of the practice?
The objectives of this practice were achieved by creating community partnerships, each with specific tasks geared toward reaching the goals. The Clark County Community Foundation provided the funding to purchase the Enamel Pro Series ACP fluoride varnish for 3,000 students and reviewed yearly data to evaluate the success of the practice. The Winchester/Clark County Dental Association provided volunteer dentists and dental hygienists to be a part of seven dental teams to work in the schools. A training program was developed by these dentists to train community volunteers and school nurses in varnish application. This Association also led the dental teams, performed oral exams, applied fluoride varnish, and completed the dental surveys. The dentists and hygienists provided oral health education to the schools during separate visits. Community volunteers attended on-site application training, and worked with the dental team to conduct the applications. The LHD managed the grant funds, maintained financial records, ordered and printed needed supplies, and is responsible for publishing the data collected in this practice. The Clark County School System and the School Health Program worked with the dental teams to develop a letter of explanation of the program for the parents, distributed the dental exam forms to classrooms in preparation of application days, distributed the toothbrushes and paste to all students, instituted the dental health education curriculum, and prepared the school for visits from the dental team. The local school system also sent home the oral dental exam form to parents, and provided follow-up with those parents of children with tooth decay, to ensure the children received restorative dental care. The CCDHI formed relationships with several industry partners, including Premier Dental Supply, Proctor and Gamble, Delta Dental Plan of Kentucky and Darby Dental Supply. These industries supplied the dental materials either in-kind or at a discounted rate. To gain further community support, the local newspaper - The Winchester Sun - promoted and followed the practice through articles and wrote educational pieces about dental health for the entire community.
What was the timeframe for carrying out these tasks?
Several of the implementation tasks were accomplished prior to the beginning of the 2007-2008 school year and once the relationships were established, the products and services have been continually provided for each new year. The forms and dental products are ordered in the month of July, prior to the start of a new school year. Most products are delivered directly to each individual school, to minimize volunteer time needed for material distribution. The fluoride varnish application training is conducted at the school sites, once in the fall term and once in the spring term. This training is for all returning and new volunteers. The application days occur once each in the fall term and spring term, and the data is collected from the sixth grade students during the spring term. All of these tasks require only one school day to complete. The original funding for the CCDHI is for 5 years, and school year 2012-13 will be the fifth year of the practice.
Please provide a succinct outline of some basic steps taken in implementing your practice.
1. Design CCDHI practice a. Met with Public Health Director to discuss practice development, fiscal responsibilities, and facilitation of practice in schools b. Met with local School Board for permission to enter schools to apply dental varnish c. Met with school principals for development of oral health educational program d. Met with School Health Program nurses to discuss role e. Met with Director of Student Services f. Met with Family Resource Center(s) for distribution of toothbrushes/paste g. Obtain annual list of students for each school h. Discuss role of media with local newspaper 2. Develop a budget a. Negotiate price of dental materials with suppliers 3. Secure grant funding from Clark County Community Foundation a. Appoint LHD as fiscal agent 4. Develop parent information letter and dental health survey a. Distribute to parents at beginning of 2008 school year 5. Preliminary count of number of volunteers and supplies needed 6. Recruit and train Dental Teams 7. Opt-in permission form sent home and returned 8. Order dental supplies and oral health education kits 9. Application Day - Fall Term 2008 a. Conduct varnish application training b. Complete oral exams and ACP Fluoride Varnish application 10. Follow-up a. Send home exam forms to parents of children exhibiting tooth decay b. Make follow-up phone calls to those parents c. In one month, repeat follow-up phone calls 11. Application Day - Spring Term 2009 a. Conduct Decayed, Missing, Filled, Sealant (DMFS) survey on sixth grade students b. Second-round of fluoride varnish application 12. Data and annual reports distributed to all stakeholders 13. Repeat steps 8-12 twice each school year

What were some lessons learned as a part of your program's implementation process?

There were several lessons learned in the program’s implementation process. First and foremost, delegation of responsibilities is important as to not exhaust one or two key community partners. Flexibility should be given to the Dental Team Leaders to directly communicate with their assigned school. The Team Leader and the school should have the authority to change the application date if needed without authority of the Project Director. The first year of this program, all materials were delivered either to the Project Director or Dental Team Leaders. This was cumbersome for getting those materials to the schools prior to application day. Starting in year two, all program and application materials were delivered to the schools. The responsibility of the organization of the school application day should be delegated to the school nurse or other school employee who is an expert on the layout of the school and day-to-day class processes. Allowing principals some flexibility in the design of the oral health education program in their school can increase the buy-in and engagement in a particular school. Lastly, and most importantly, sharing the data from the oral exam with the students during the application visit can increase the students’ interest and engagement with the program and with their own oral health.
Provide a breakdown of the overall cost of implementation, including start-up and in-kind costs and funding services.
1. Implementation Costs for CCDHI practice a. Funding Source: Clark County Community Foundation i. $12,000.00 1. Purchase of Enamel Pro Series ACP Fluoride Varnish 2. Purchase of dental supplies: gloves, masks, toothbrushes, toothpaste b. In-kind: $1,500.00 i. Purchase of 3,000 toothbrushes c. In-kind: $11,440.00 i. 11 volunteer dentists, 16 hours each at rate of $65 per hour d. In-kind, start-up: $10,920.00 i. Director of CCDHI, 168 hours at rate of $65 per hour e. In-kind: $7,800.40 i. 49 dental volunteers, 16 hours each at rate of $10 per hour f. In-kind, start-up: $500.00 i. Delta Dental Plan of Kentucky- 20 dental educational kits for schools g. In-kind, start-up: $300.00 i. Department of Community Outreach University of Kentucky- forms 2. Total Costs a. Grant funding: $12,000.00 (each year for five consecutive years) b. In-kind: $32,460.40 (has increased due to increased number of volunteers each year) i. Start-up: $11,720.00
Is there sufficient stakeholder commitment to sustain the practice?  Describe how this commitment is ensured.
Due to the enormous community response and the decreased rate of tooth decay in Clark County’s youth from this program, we believe there is sufficient stakeholder commitment to sustain the practice. The Public Health Director is committed to continuing service to the program by serving as a fiscal agent and leveraging resources and relationships with primary stakeholders. The Winchester Clark County Dental Association will continue to serve as the lead agency for program direction, recruitment of volunteers and recruitment of local dentists. The Clark County Community Foundation recognizes the impact this grant award has brought to the community, and will continue to be a stakeholder and will work with the community to discover new avenues of resources as needed in the coming years.
Describe plans to sustain the practice over time and leverage resources.
The CCDHI practice will be sustained over time beyond the original objectives of the practice. In 2011, due to the positive oral health outcomes found through this practice, the Governor and First Lady of Kentucky, Steve and Jane Beshear, made this practice a priority for underserved children in Eastern Kentucky Appalachian counties. The state implemented the “KY Smiling Schools Oral Health Project” through funding from the Appalachian Regional Commission Grants for Distressed Counties and general funds from the state. This project will focus on providing ACP fluoride varnish treatments and outreach to children and families in at-risk schools in 16 counties. This program, replicating the pilot program CCDHI, is predicted to provide preventive oral health services for 25,000 children. Although this program does not include Clark County at this time, it is possible it could expand statewide as success is measured. In addition, the Clark County Community Foundation takes requests for proposals annually and will be approached for further funding and possibly matching funds. Possible match sources include the LHD, city and county governments (the county Fiscal Court has its own foundation), public school district, interested individuals, several local private foundations, and the new Clark Regional Foundation for the Promotion of Health. Also, the private, public, and philanthropy sectors of the local public health system are working together to discover ways to leverage existing resources.
Practice Category Choice 1:
Practice Category Choice 2:
Access to Care
Practice Category Choice 3:

Please Describe:

Population-based Primary Prevention
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Colleague from another public health agency

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