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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Part 3 - Professional Services

Chapter 2 - Dental

Title Section
Introduction 3-2.1
    General 3-2.1A
    History of Dental Services 3-2.1B
    Operational Philosophy 3-2.1C
    Goals 3-2.1D
    Objectives 3-2.1E
Program Organization 3-2.2
    Headquarters Administrative Level 3-2.2A
    Area Administrative Level 3-2.2B
    Service Unit Administrative Level 3-2.2C
    Standing Committees 3-2.2D
    Interagency Relationships 3-2.2E
Program Operations 3-2.3
    Personnel Administration 3-2.3A
    Program Standards 3-2.3B
Program Resources 3-2.4
    Resource Allocation 3-2.4A
    Contract Resources 3-2.4B
Program Reporting 3-2.5
    Dental Data Reporting System 3-2.5A
    Resource and Patient Management System 3-2.5B
    IHS Fluoridation Data System 3-2.5C
Program References 3-2.6

Appendices Description
Appendix 1 Objectives

3-2.1  INTRODUCTION

  1. General.  This chapter provides a general orientation to the Indian Health Service (IHS) Dental Program.  More detailed information may be found in the Oral Health Program Guide for the Indian Health Service.
  2. History of Dental Services.  Although the IHS as part of the United States Public Health Service originated in 1955, the history of health services for Native Americans had its origins in the late 1700s under the Department of War.  These health services were aimed primarily at controlling infectious diseases.  By the mid-1800s several treaties promising medical care for Native Americans had been ratified, and responsibility for the delivery of care had been assumed by the Bureau of Indian Affairs (BIA) in the Department of the Interior.  Dental services were initiated in 1913 with the employment of five itinerant dentists who traveled among the various Indian reservations, providing services primarily for the relief of pain.  In 1932, Dr. Frank Cady, a Public Health Service (PHS) dental officer, was assigned to the Indian program and began to organize the delivery of dental services.  By identifying schools as a community locus at which dental equipment could be located on either a temporary or permanent basis, he initiated the program’s early focus on school-aged children.  This emphasis on school children was later formalized as program policy which lasted until the late 1970s, when emphasis was redirected to family oriented care.

    The 1950s saw the establishment of the IHS and with it the assignment of additional PHS dental officers, the building of permanent health facilities, formal training programs for Indian dental assistants, and an emphasis on the use of topical fluoride treatments to prevent dental decay.  As working conditions improved and more adequate staff housing became available in the 1960s, it became relatively easier to attract dentists to the IHS.  Automated data collection was initiated to replace the very labor intensive manual system used to plan, monitor, and evaluate the Dental Program.  The 1970s stressed the refinement of the clinical program, with particular emphasis on productivity and the use of expanded function dental auxiliaries.  The number of new facilities and staff greatly expanded during this time but the increase in services capacity was unable to offset the rapid growth of the Indian population  During the 1970s, staff development programs were initiated to improve staff retention and to ensure that dental personnel were adequately trained to provide efficient and effective care.  During this period, the IHS was among the first to develop and implement a system to evaluate the quality of dental services.  In the absence of adequate resources and a steady increase in the demand for more adult care, there was a gradual shift from limiting services to school children to a focus on the family unit.  New legislation required the IHS to assist tribes that wished to operate their own health programs.
  3. The 1980s were notable for a marked emphasis on disease prevention activity.  This included use of the Community Oriented Primary Care (COPC) approach to the delivery of dental services.  The COPC emphasizes the use of epidemiological data to plan and evaluate programs and has proven to be a valuable conceptual framework that incorporates many of the delivery modes used by the Dental Program in the past.  It differs in its emphasis by stressing the use of available data to select, for each community, the approach, or combination of approaches, that best addresses local oral health problems.  It further promotes the sharing of information with the community to educate consumers and obtain their assistance in planning and implementing health care systems.  Efforts to apply the COPC model to the IHS Dental Program were strengthened by the findings of oral health surveys of various Indian communities.  Although tooth mortality had been stabilized by an active treatment program, the prevalence of oral disease had not declined as it had in the U.S. population at large.  By the mid-1980s renewed emphasis on fluoridation had dramatically increased the number of American Indians and Alaska Natives (AI/AN) with access to fluoridated water.  During the 1980s, emphasis on the application of pit and fissure sealants resulted in significant increases in use of this preventive treatment as well.  The 1990s are viewed as a decade in which significant gains in oral health are expected to result from these efforts.

  4. Operational Philosophy.  Oral problems common to AI/AN are similar to those found in the general population:  dental caries, periodontal disease, malocclusion, trauma, oral clefts, and tumors.  However, the prevalence of dental caries in Native Americans, unlike that of the general population, has remained high well into the 1980s.  Furthermore, the Native American population has a much higher proportion of untreated disease.  Many Native Americans live in isolated areas where private dental care is unavailable or very limited.  Except for State Medicaid programs (which have very limited dental benefits), few Indian people are financially able to independently obtain private dental care.

    The mission of the IHS Dental Program is to protect and promote oral health and prevent oral disease among all Indian beneficiaries.  The following principles underlie this stated mission:

    Oral health is an essential component of total health.  It is a major contributor to complete physical, mental, and social well-being, not just the absence of oral disease and infirmity.

    All people should have the opportunity to achieve sound oral health.  The promotion and protection of oral health is important to sustain community development and contributes to the quality of community life.

    All people should have the right and responsibility to participate individually and collectively in the planning and implementation of their oral health care.

    The reduction of oral conditions that may be handicapping to the human experience, the protection of oral health, and the prevention of oral disease requires the cooperation and special abilities of many individuals and organizations.  Dental professional participation is an essential element in the planning, organization, implementation, and evaluation of high quality oral health programs.

    Specific Dental Program Professional Responsibilities fall into the following areas:
    1. ACCESS:  To promote access to oral health services of high quality for all Indian people.

      Because resources available to the IHS are inadequate to provide dental treatment to all Native Americans who desire it, prevention of oral disease must pervade most Dental Program activities.  Resources should be directed toward activities that most effectively prevent the deterioration of oral health among the greatest number of people for the longest period of time.  Fluoridation of its water supply is the most important preventive dental activity that a community can perform for its people.  Drinking water supplies should be tested for natural fluoride ion content and corrective action taken to adjust the concentration to a range compatible with dental caries prevention.  More detail regarding the water fluoridation policy of the IHS and description of other recommended preventive methods may be found in the Oral Health Program Guide for the Indian Health Service.

      Dental care should focus on the family unit wherever possible.  This family-oriented program should strive to develop within individuals a sense of responsibility for their own oral health and to seek appropriate care themselves and their families.

    2. SERVICE:  To protect and promote oral health and to prevent oral disease by providing professional services according to scientifically and technically sound methods.  These services must also be practical, socially acceptable, and in accordance with dental public health priorities.

      Within the resource limitations of the IHS, patients should receive the dental services they desire, insofar as such care is within the bounds of professional ethics. The corrective treatment of gross dental defects that have accumulated in the population through many years would require more resources than are currently available to the IHS. Therefore, a system of priorities exists to guide health personnel in delivering oral health services. Clinical services priorities are based the following hierarchy:
      1. Emergency services are of the highest priority.
      2. Examination and determination of the dental services required by the patient should precede the provision of treatment.
      3. Preventive services should be provided before corrective services.
      4. Services which arrest and/or remove active disease.
      5. Services which correct the effects of disease or address other defects of the oral cavity and related structures.

        Further details regarding the specific priorities of clinical services may be found in the Oral Health Program Guide for the Indian Health Service.

    3. RESEARCH:  To promote the development of new knowledge that is relevant to the improvement of the oral health status of AI/AN people.  Although the primary mission of the IHS is service, limited research aimed at improving the health of Native Americans and the health delivery system serving them is conducted.

      Such research efforts should be coordinated to ensure maximum gain in relevant knowledge and conservation of scarce resources.  When appropriate, collaboration with other government agencies and interested parties is encouraged.  Further details regarding the research priorities and approaches may be found in the Oral Health Program Guide for the Indian Health Service.
    4. EDUCATION:  To promote a high level of understanding, capability and action in oral health promotion and disease prevention by individuals and communities, support organizations, and staff.  The benefits of oral health will be promoted to American Indian communities.  The promotion of high ethical standards within the dental profession is considered to be the responsibility of every dental officer in the IHS.

      Oral health education must be considered in all aspects of the dental program.  Desired levels of utilization and program effectiveness cannot be achieved unless there is understanding and active participation in program activities by those receiving and providing oral health education services.  The demand for dental care requires IHS and tribal dental staff to spend a majority of time providing clinical services.  However, in addition, dental staff must also focus on the provision of effective oral health messages to patients and the community.  Dental staff should identify and coordinate other available resources to assist in the delivery of oral health education in an effort to develop individual and community responsibility in oral health.  Important resources to consider include tribal health committees, tribal leaders, public health nurses, health educators, other medical staff members, community health representatives, and environmental health personnel.
    5. MANAGEMENT:  To monitor oral health status and promote high quality management of dental resources, including the utilization and improvement of information and personnel, financial, materiel and organizational resources.

      The dental program should be conducted in a manner which promotes mutual understanding, dignity, and respect between the Native American people served and the IHS. Dental staff will promote the active participation of Native American community representatives and support tribal contracting initiatives in planning, coordinating, implementing, and evaluating resources available for their dental program.

      Staff development activities should be an integral part of the IHS dental program.  The competence of dental staff and the profession of dentistry should be advanced through staff participation in professional organizations, public speaking, professional writing to advance ideas and publish pertinent findings (research), and continuing education.

      Further details regarding the management of resources, staff development, and support for Indian self-determination may be found elsewhere in this chapter as well as in the Oral Health Program Guide for the Indian Health Service.
    6. GENERAL:  To promote the IHS mission of improved health status, increased self-determination and advocacy through activities in support of the overall program.  Dental staff should be mindful of, and contribute to, the overall health mission of the IHS.  Opportunities for collaboration and mutual support should be pursued to the benefit of individual and community health.
  5. Goals.  The health goal of the IHS dental program is to minimize the adverse effects of oral disease on the well being of AI/AN people by raising their oral health status to the highest possible level.  The service goal is to provide comprehensive dental care to the demand population.
  6. Objectives.  The principal or “enterprise” objective is to prevent dental caries and limit the severity of periodontal diseases in the AI/AN population.  Specific goals and time lines are described in Appendix I.

3-2.2  PROGRAM ORGANIZATION.  The IHS is organized around three major administrative levels.  Headquarters operations include general oversight; budget justification, allocation and monitoring; and policy development.  Headquarters offices are located in Rockville, Maryland and Albuquerque, New Mexico, and a limited number of other sites.  Management of field functions is accomplished regionally in 11 “Area Offices.” In turn these regional components are further divided into “service units” which are the points of health care delivery in the IHS.  Similar to the service units are health care facilities operated by tribes under contracts authorized by Public Law (P.L.) 93-638, “Indian Self-Determination and Education Assistance Act,” enacted January 4, 1975.  Tribal contractors do not fall within the formal organizational structure of the IHS, but are bound by the terms of their 638 Contracts.

The line of authority in the IHS is from the Director, IHS, to the Area Director to the Service Unit Director.  Each level of administration has staff to perform the work objectives of the unit.  Distinct components of the dental program exist at each administrative level and, while no formal line authority exists among Headquarters, Area, and Service Unit Dental staff, a close technical and consultative relationship exists.

  1. Headquarters Administrative Level

    1. Functional Responsibility.  The Headquarters Dental Program consists of two distinct, but complementary components:  the Policy and Resources Development Section located in Rockville, Maryland, and the Field Support and Program Development Section located in Albuquerque, New Mexico.

      The Policy and Resource Development Section is responsible for the:  (1) development of policy for oral health programs; (2) development of resource opportunities; (3) formulation, monitoring, and evaluation of dental resource utilization; and (4) development of liaison and advocacy relationships within IHS, and other Federal and State programs which may impact the oral health of Native American people.

      The Field Support and Program Development Section is the principal provider of technical assistance to IHS and tribally managed programs in areas of staff development, information management, prevention, and community-based health promotion, and is responsible for:  (1) planning, implementation, and evaluation of staff development and continuing dental education for dentists and dental auxiliaries; (2) organizing recruitment of professional staff for the dental program; (3) monitoring and evaluating the IHS Dental Data System and coordinating implementation of the dental portion of the master IHS data system, the Resource and Patient Management System (RPMS); and (4) developing and coordinating applied research in areas of oral disease prevention, health promotion, and cultural and behavioral aspects of oral health status and services delivery.

      Headquarters Dental operations are assigned 18 positions.  The proportion of positions assigned to each location is modified over time to meet current programmatic needs.  Approximately 40 percent of staff are now located in Rockville and 60 percent in Albuquerque.
    2. Relationship to Areas and Service Units.  The Headquarters relationship to Area and service unit dental personnel is a technical, consultative one.  Support is provided through (1) resource utilization monitoring; (2) personnel system support; (3) staff development activities; (4) recruitment; (5) data system monitoring and development; (6) research evaluation and support.  Interaction is via telephone, memorandum, electronic bulletin board, meetings and formal program reviews.  Headquarters dental staff work in conjunction with Area Dental Officers to develop policy on major issues affecting the Dental Program.
    3. Relationship to Tribal Groups.  The Headquarters relationship to tribal groups is a consultative one. Support is provided through exchange of information about the oral health needs of specific communities and resource requirements to support those needs.  Communication is via telephone, letter, or meetings.
  2. Area Administrative Level

    1. Functional Responsibility.  Staff assigned to the Area Dental Program are the principal advisors and consultants to the Area Director, to the service unit dental chiefs within an Area, and local tribal groups concerning oral health and dental program issues.  Responsibilities include planning, coordinating, implementing, and evaluating the clinical and community dental activities within the Area so that resources are used to meet the oral health needs of Native American people in the most effective manner possible.  Carrying out this responsibility requires:  (1) equitable distribution of resources within the Area; (2) monitoring the utilization of these resources; (3) facilitation of staff development and training for dental personnel within the Area; (4) evaluation of the quality of clinical and community dental services provided within the Area; and (5) development of liaison and advocacy relationships within IHS and other Federal and State programs which may have a positive impact on the oral health of Native American people.
    2. Staffing.  Dental program activities at the Area level are the responsibility of the Area Dental Officer.  Additional staff may include Deputy Area Dental Officer, Assistant Area Dental Officer, Area Prevention Officer, administrative assistant, and clerical staff.  However, the staffing of the 11 Area dental programs is varied.  The presence of support staff in the Area dental program is often determined by factors which distinguish one Area from another.  Each Area is organizationally unique.  Some are more traditional in nature, with authority centralized within the Area office while others may be largely decentralized with virtually the entire program encompassed in tribal contracts.  Most programs, however, represent some mix of these two situations.

      In response to different and varying roles of each Area dental program, IHS Area managers have staffed and structured local area dental programs to fit the specific requirements of each Area.  As local area needs change, it can be anticipated that the staffing of the Area dental programs will also change.

    3. Relationship to Headquarters and Service Units.  The Area relationship to Headquarters and service unit dental personnel is a technical consultative one.  Support is received and provided through: (1) resource distribution; (2) resource utilization monitoring; (3) personnel system support; (3) staff development activities; (4) recruitment; (5) quality assurance functions; and (6) support of health promotion and disease prevention initiatives.  Interaction is via telephone, memorandum, electronic bulletin board, meetings, and formal program review.
    4. Relationship to Tribal Groups.  The Area relationship to tribal groups is a technical and consultative one.  Support is provided through exchange of information about the oral health needs of specific communities and resource requirements to support those needs.  For tribes operating contracted dental programs, Area dental staff may provide feed back through program review.  Other communication is via telephone, letter, or meetings.
  3. Service Unit Administrative Level

    1. Functional Responsibility.  Staff assigned to the Service Unit Dental Program are the principal advisors and consultants to the Service Unit Director concerning oral health and dental program issues.  Responsibilities include planning, coordinating, implementing, and evaluating service unit clinical and community dental activities within the framework of the Area program so that the oral health needs of Native American people are met in the most effective manner possible.  Carrying out this responsibility requires: (1) the delivery of high quality clinical and community dental services which address the needs of the community; (2) monitoring the utilization of service unit dental resources; (3) ongoing staff development for dental personnel within the service unit; (4) evaluation of the quality of clinical and community dental services provided within the service unit; and (5) development of liaison and advocacy relationships within the service unit and the community to integrate dental activities with the full complement of other health care programs to have a more positive impact on the health of Native American people.
    2. Staffing.  Dental program activities at the service unit level are the responsibility of the Chief, Dental Unit.  Additional staff may include: Deputy Chief, Dental Unit; Chief, Dental Unit-Satellite; Staff Dental Officer, Dental Assistant Supervisor, Dental Assistant, Dental Hygienist, and clerical staff.

      The staffing of each service unit dental program is a function of the size of the population served and the clinical facilities available.  Service Units may contain one or more facilities and may be IHS or tribally managed.
    3. Relationship to Headquarters and Area.  The Area Dental Officer (ADO) provides technical and consultative support to the service unit dental program.  The ADO assists service unit staff in interpreting and implementing Dental Program policy.  Support is received through: (1) resource distribution; (2) resource utilization monitoring; (3) personnel system support; (4) staff development activities; (5) recruitment; (6) quality assurance functions; and (7) support of health promotion and disease prevention initiatives.  Communication is via telephone, memorandum, electronic bulletin board, meetings and formal program review.
    4. Relationship to Tribal Groups.  The service unit relationship to tribal groups may be a consultative one for programs operated in traditional IHS settings or, in tribally managed settings, service unit staff may be employed and/or supervised by the tribal organization.  Support is provided through the delivery of curative and preventive dental service and the exchange of information about the oral health needs of the community.

  4. Further information on specific organizational structures and billet descriptions of the positions referenced herein may be found in Sections II and IV of the Oral Health Program Guide for the Indian Health Service.

  5. Standing Committees.  The IHS operates in a decentralized environment with considerable authority delegated to areas and service units.  The various elements of the dental program function within the overall line management structure of the IHS.  This structure is well suited to respond to the needs of local program managers and the service population but central direction and support are essential if programmatic oral health goals are to be achieved.  Six standing committees are in place to consider issues over broad functional areas of the dental program.  These committees serve as a clearing houses for input, feedback, and evaluation of issues relative to their respective areas of responsibility.  Committees are composed of Headquarters, Area, and service unit dental representatives as appropriate.

    1. The Resources Analysis Committee is charged with addressing issues related to identification of oral health program resource requirements, development and allocation of such resources, the use of alternative resources, and the updating of program documentation in the Oral Health Program Guide of the Indian Health Service Sections I and III (management).
    2. The Staff Development Committee examines issues related to personnel recruitment, retention and career development.  The committee develops mechanisms to increase staff, capabilities and morale: and thereby, more efficiently address the oral health needs of Native American populations.  The committee is also responsible for updating program documentation in the Oral Health Program Guide of the Indian Health Service Sections IV and V.
    3. The Research Committee provides technical support and evaluation of proposed and ongoing oral health research within the IHS to assist professionals in pursuing knowledge and to facilitate scientific inquiry that will have the greatest impact on the oral health of Native American people.  To this end, the Committee maintains an agenda that identifies research needs as well as ongoing projects.  It encourages collaboration among IHS and qualified non-IHS investigators to further oral health gains for AI/AN.  The committee is also responsible for updating program documentation in the Oral Health Program Guide of the Indian Health Service Section VIII.
    4. The Services Delivery Committee addresses issues related to support of clinical services delivery.  Its scope of activities include quality assurance, standard dental clinic plans, master equipment lists, objectives and strategies for efficient and effective care delivery, specialty consultation and updating program documentation in the Oral Health Program Guide of the Indian Health Service Sections III (Direct and Contract Health Services (CHS), VII, and IX.
    5. Oral Health Promotion Disease/Prevention CommitteCommittee develops standards and provides guidance for Health Promotion Disease/Prevention (HP/DP) Programs.  The committee coordinates HP/DP activities on a national level and offers technical support to areas, service units, and tribal programs in planning, implementation, and evaluation of HP/DP programs.  The committee is also responsible for updating program documentation in the Oral Health Program Guide of the Indian Health Service Sections II and IX.
    6. The Dental Professional Specialty Group (DPSG) pursues improved data, collection and analysis.  Its scope includes the current dental data reporting system, use of standard codes and nomenclature, development and evaluation of computer software related to the RPMS, and updating program documentation in the Oral Health Program Guide of the Indian Health Service Section III on Management Information Systems (MIS).

    Selection of the Committee Chairmen is the responsibility of the Chief, Dental Services Branch (DSB), IHS.  Committee Chairmen are, in turn, responsible for selection of other committee members.

    Each committee addresses issues deemed appropriate by the committee chairman or as assigned by the Chief, DSB, IHS.  Committee recommendations are submitted to the Chief, DSB, who obtains input from area dental officers or other appropriate individuals.  Recommendations requiring further staff work are returned to the committee chair prior to issuance of finalized documents.

  6. Interagency Relationships.  The IHS Dental Program has a predominantly clinical orientation.  Periodically, however, the opportunity arises for collaboration with organizations which may have differing missions but mutual areas of interest.  These interagency relationships may be long standing, ongoing agreements, or arrangements of more limited duration to facilitate accomplishment of some short term objective.

    The IHS may enter into joint projects with other agencies of the Federal Government, tribal governments, State health departments, academic institutions, voluntary or proprietary institutions, or international health agencies.  These joint ventures offer the opportunity to exchange information and share expertise with other parties, ultimately enabling the IHS to carry out its mission in a more effective way.

    Examples of such relationships include interagency agreements with the Centers for Disease Control (CDC), National Institutes of Health (NIH), Administration for Children, Youth and Families (ACYF Headstart program); collaboration with the World Health Organization; and memorandums of agreement with numerous tribal governments and dental schools.

3-2.3  PROGRAM OPERATIONS

  1. Personnel Administration

    1. Staffing.  Dental staff vacancies are filled by qualified persons from within the IHS dental program, tribal dental programs or by recruitment outside these programs.  Selection factors are described in Section IV of the Oral Health Program Guide for the Indian Health Service and regulations of the Office of Personnel Management and the PHS Commissioned Corps.  Absolute preference is given to qualified Indian candidates.  Training programs are available to allow dental officers to pursue the qualifications necessary to be selected for career development positions of increasing responsibility.

      1. Staffing Ratios.  Staffing ratios for clinical dentists may be determined by consulting Section III of the Oral Health Program Guide for the Indian Health Service.

        These ratios consider the oral health and treatment needs of the community served by a dental facility.  They represent a balance of dentists and support staff that will allow the most efficient application of available resources to oral health needs.

        To ensure maximum efficiency of each dental provider, there should be a support staff of dental specialists, educators, administrators, dental auxiliaries and dental hygienists available to aid direct care providers.  The Oral Health Program Guide for the Indian Health Service and the Indian Health Service Facilities Planning Manual provide criteria for the optimal number of supporting staff consistent with the number of clinical dentists and the oral health needs of the population served.
    2. Recruitment.  To varying degrees recruitment of new dentists to the IHS is the responsibility of all dental staff.  The PHS Recruitment Program works in conjunction with all PHS program components needing dental manpower.  In the IHS, scholarship programs for AI/AN aspiring to health careers as well as loan repayment opportunities for officers willing to serve in hard-to-fill locations are a significant benefit to the recruitment and retention of health professionals.  The Dental Program participates in both of these programs which contribute substantially to maintaining an adequate staff of dental officers in the IHS.

      1. Dentists.  Recruitment programs are carried out by the IHS at dental schools throughout the nation with the intent of promoting application to the IHS by newly graduated dentists.  Vacancies for dentists are advertised by IHS Area Personnel Branches, the IHS dental program, tribal dental programs and the Division of Commissioned Personnel.  Selection is made from a list of qualified applicants and is competitive within the context of Indian preference regulations.
      2. Dental Auxiliaries.  Dental assistants, dental therapists, dental laboratory technicians, and dental clerical personnel assume a broad scope of responsibility in the IHS and contribute substantially to the effectiveness of the dental program.  Graduates of the IHS dental training programs are specifically trained to meet these responsibilities and are preferred.  The IHS does not possess the training capacity, however, to meet its entire need for dental auxiliary staff and welcomes applications for employment from individuals meeting requirements for specific positions.
      3. Dental Hygienists.  Dental hygienists in the IHS have a broad scope of responsibilities in providing clinical and community preventive services and organizing health promotion activities.  Vacancies for these positions are advertised by Area Personnel Branches or specific contracts are solicited by the IHS Contracting Officers in the Commerce Business Daily.
      4. Secretarial and Administrative Assistants.  Applicants for these positions are recruited by the IHS Personnel Branch.  Job requirements vary depending on responsibilities.
    3. Staff Development.

      1. Credentialing

        1. Licensure.  State Licensure is a requirement for dentists and dental hygienists employed by the IHS.  The commissioned corps requires that dental officers be licensed in a State within 1 year of reporting to duty.  Commissioned officers who report to duty without a dental license will provide care by standing orders under a licensed dentist until they obtain one.  Civil Service employees must possess a dental license at the time of employment.  Tribally hired dentists and hygienists must possess a license from the State in which their facility is located.
        2. Certification.  Dental assistants may be certified by the American Dental Assistant Association (ADAA) and dental laboratory technicians may receive the credential of Certified Dental Laboratory Technician.  While the IHS does not require these credentials as terms of employment, individuals are encouraged to pursue them.

          The Patient-Consumer Radiation Health and Safety Act of 1981 requires that all dental assistants who take dental radiographs be certified to do so.  The IHS has an established certification process which dental assistants who are not certified by ADAA must complete to demonstrate competency in dental radiography.  This credential must be maintained by annual recertification.
      2. Career Development

        1. Commissioned Corps Billet System.  A billet describes the responsibilities and duties required of the commissioned officer serving in a particular position, e.g., staff dental officer, chief, dental unit-complex, etc.  Since many dental positions are similar across the PHS, a system of Standard billets is used to avoid duplication and to ensure fair consideration of officers across all agencies.  This system also allows officers the opportunity to more easily identify positions of interest while pursuing their chosen career track which may span multiple PHS agencies.

          The IHS uses the PHS Standard Billets plus a few agency-specific ones that pertain only to positions with the IHS.  This billet structure provides dental officers and commissioned dental hygienists the opportunity to develop careers along specific career tracks.  Three tracks: 1) clinical management, 2) administration, and 3) clinical specialty practice are defined in the “Personnel Policy for Utilization of Commissioned Corps Officers in the Indian Health Service Dental Program.”  This document is included in the Oral Health Program Guide of the Indian Health Service.

          This policy permits the IHS to meet program personnel needs and encourages career development of dental officers in an organized and rational fashion.  Consideration of officers for change of assignment is defined in predictable cycles so that personal planning may more easily be accommodated.

        2. Civil Service.  Dental assistants are commonly employed via the civil service system and make up a valuable career force in the IHS.  Senior dental assistants help to provide continuity to a community dental program, as dental officers move on to assume additional responsibility or to meet other program needs.  In the civil service system, dental assistants can progress from the GS-2 grade through GS-7 with opportunities for expanded functions and dental assistant supervisory roles available in larger clinic settings.

          Dentists may be employed through the civil service system with grades ranging from GS-11 to GS-15.  Dental hygienists may be employed through the civil service system with grades ranging from GS-5 to GS-12.  Both career tracks require assumption of additional responsibilities, the provision of more complex clinical services and acquisition of additional training for promotion to higher grades.

        3. Tribal Employed Personnel.  Employed personnel career development opportunities for tribally hired personnel are determined by each tribal organization.  IHS dental staff are available to consult with tribes wishing to establish career development opportunities for dental employees.
      3. Continuing Education.  Continuing education is an integral part of the IHS staff development program.  A large portion of both short-term and long-term training is provided in-house by IHS personnel.  The IHS staff development centers are located in many IHS Areas and have responsibility for advanced general practice residency training, dental assistant training, and the development of short-term training courses.  These locations are frequently staffed with specialty-trained practitioners who have Area- or IHS-wide responsibility for development of training activities.

        1. Short term training.  The IHS Dental Program sponsors a variety of short dental continuing education courses each year.  These typically cover a range of topics which include clinical topics for dentists and dental assistants, management, interpersonal relations and health promotion/disease prevention.  This training is intended to improve the skills of dental personnel so that they may more effectively perform their jobs.

          Training needs assessments are conducted each year by Area training coordinators.  Training nominations are solicited from supervisors for all dental staff members, and courses are then developed in order to meet the most critical needs.

          The level of funding available to support training is determined annually and is drawn from recurring and non-recurring resources.  Local managers with funds control responsibility must, therefore, make a funds availability determination for each submitted training nomination.
        2. Long-Term Training.  Long-term training opportunities, both in-service and out-of-service, are sponsored by the IHS dental program in dental general practice, dental public health and clinical dental specialties.  The number and types of training positions available each year vary, depending on program needs, and availability of funds.  Each of these training programs is preparatory for one of the designated IHS dental career tracks.  Selection is competitive and, of those applicants meeting the criteria, Indian applicants receive preference.  Criteria for selection for long-term training are published annually, and individuals who wish to be considered for a specific training position should make application to the IHS Dental Branch.
      4. Further information on staff development in the IHS dental program may be found in Section V of the Oral Health Program Guide for the Indian Health Service.

      5. Standards of Performance.  Standards of performance are a written understanding between employee and supervisor regarding the specific accomplishments to be performed by the employee during a specific time period.  The IHS has mandated use of standards of performance for its employees.  Civil service employees are evaluated according to the requirements of the Employee Performance Management System (EPMS) or the Performance Management and Recognition System (PMRS) for supervisors.  It is the responsibility of each supervisor to ensure that standards accurately reflect the requirements of each position and that they are measurable and attainable.
      6. Commissioned Officers’ Effectiveness Report.  Each commissioned officer is evaluated annually using the Commissioned Officers' Effectiveness Report (COER).  Each officer must complete Section 1 and submit the form as directed. This process is generally initiated in September of each year, although a COER may be completed at any time by the supervisor.  The rating officer should ensure that he/she reviews the COER with the officer being evaluated and that a copy is forwarded to the Chief, Dental Services Branch, IHS.  The officer must also be provided a copy of any other comments added to the COER by other reviewing officials.

        The standards of performance of the officer may be used by the supervisor as a basis for completing the COER but are not to be submitted through channels with the completed COER.
    4. Program Standards

      1. Eligibility.  The determination of patient eligibility is made in accordance with established criteria (see IH Manual Part 2).  Eligibility for care should not be confused with priorities for care.
      2. Schedule of Services.  The oral health care provided by the IHS has been arranged into levels that reflect priorities for the provision of care.  Higher priority services relieve pain and prevent the further deterioration of the dentition while lower priority services are generally rehabilitative in nature, and often must be deferred so that more Indian people may have access to basic services.

        The Schedule of Oral Health Services is subdivided into six levels of care plus those services which are excluded from consideration.  Level I services (emergency) are considered the most necessary services and Level VI services (complex rehabilitation) the most elective.  Lower levels include those services which are the least costly in terms of manpower or dollars yet have the most long term benefit.  The provision of services necessary to treat the emergency situation is considered mandatory and is the first level of service.  Those services which prevent the onset of disease are of higher priority than those intended to contain the disease or correct damage caused as a result of oral diseases.

        The schedule of services is based upon six assumptions.  1) Services provided are based upon the demand care concept.  Those persons requesting care will be served, limited only by the resources available.  2) The schedule of services is applicable for groups as well as for individuals.  3) Limited resources will force the prioritization of services.  4) Services based on public health principles, especially the prevention of oral disease and early intervention in the disease process are most cost effective.  5) The schedule of services will be accepted by the persons being served.  6) As additional funds become available, the schedule permits an orderly, consistent, and equitable increase in the levels of service.

        The specific levels of care are as follows:
        1. Emergency dental care.  Those services necessary for the relief of acute conditions and defined by the patient to be of an emergent nature.
        2. Preventive dental care.  Those activities which prevent the onset of dental disease.
        3. Secondary dental care.  Those procedures which intervene early in the dental disease process.
        4. Limited rehabilitation.  Those services which restore the oral structures to improved form and function.
        5. Rehabilitation.  Rehabilitative services requiring more provider time, skill, or expense than those in level IV.
        6. Complex rehabilitation.  Those services considered most complex often requiring delivery by a specialist.

        For a list of specific services included in each level consult Section III of the Oral Health Program Guide for the Indian Health Service.

        The schedule of services is intended to serve as a guide for: 1) dentists salaried by the Federal Government or tribal groups; 2) fee-for-service dentists; 3) administrators of tribal dental programs; 4) administrators of third party payment programs; and 5) IHS contract care personnel.  Local administrators may use the schedule of services as a guide to develop a dental care delivery system sensitive to the needs and desires of the community while maintaining assurances that the most cost effective services are being provided.

        Any schedule of service must allow flexibility in the method of its implementation.  Certain differences in patient conditions can modify the application of the schedule.  Factors such as age of the patient, the condition of the remaining oral structures, the prognosis for success, the motivation of the patient, existing medical conditions and a host of other conditions may dictate the provision of lesser priority services to an individual.  Isolated exceptions may be permitted based on the clinical judgment of the provider; however, repeated authorization of such exceptions will diminish the community effectiveness of the schedule of services.

      3. Program Effectiveness and Efficiency Standards.  To accomplish its mission, a program such as the IHS must use its limited resources well.  Insofar as standards for service quality can be met, increased productivity results in gains in service.  Furthermore, to be accountable to Indian people, Congress and taxpayers, the IHS Dental program must be able to describe and quantify the existing need for services in the population as well as the services provided, and further to evaluate whether the observed quantity of services are reasonable given the resources used to produce them.

        Three measures of workload are used to describe dental services.  The least sensitive measure is a count of patient visits.  Because of the variability of types of dental services, a count of patient visits does not permit ready comparison between facilities and is not commonly used to evaluate dental productivity.  A more sensitive measure of dental clinic workload is a count of dental services provided.  This information is more sensitive than patient visit data, because it accounts for variability in the number of services provided to each patient.  Services data do not, however, account for the fact that different services may take differing periods of time to complete.  Further, increasing sensitivity requires the weighting of each service to account for the time taken to perform it.  The time weighted measures of dental productivity are referred to as service minutes.  By conducting productivity studies, the IHS dental program has determined the average time taken to perform a full range of dental procedures and, on the basis of those studies, assigned a time-weighted value to each clinical dental procedure performed.  Service minutes have been the standard measure of dental workload used by the IHS, since the late 1960’s.  They provide a measure of workload to which provider, facility, and area productivity may be compared over time.

        These standards are also used to plan for the staff required in new or expanded facilities as well as for evaluation of clinical productivity.  For a list of annual productivity standards for the full range of IHS staffing configurations consult Section III page III-79 of the Oral Health Program Guide for the Indian Health Service.

      4. Health Promotion/Disease Prevention Standards.  Evidence from the oral health status survey conducted by the IHS in 1983-84 indicates that Native American children have a greater prevalence of dental caries as well as untreated dental caries than does the general population of U.S. school aged children.  Likewise, periodontal disease, though less accurately quantified, is a significant health problem for a large proportion of adults visiting IHS clinics.

        The reasons for the prevalence of these preventable conditions remaining high in the Native American population are not fully understood.  However, the following factors should collectively be considered as playing a contributory role:

        • Lack of adequate access to curative and preventive oral health services.
        • A historical lack of continuity in community based dental disease prevention efforts.
        • Generally low oral health priority or awareness in Native American populations consistent with low socioeconomic status.
        • Dietary practices conducive to promotion or oral diseases.
        • Lack of personal disease preventive behaviors (self-care) that promote improved oral health.

        In recognition of the persistently high levels of dental diseases in the Native American population, IHS has made significant and increasing efforts to implement and extend dental disease prevention programs, and remains committed to the prevention, early intervention, and treatment of disease.

        1. Community Oriented Primary Care.  A significant component in preventing diseases with major behavioral relationships is the involvement of individuals and communities in their own health decisions.  Programs that involve the community in the decision-making process promote increased individual health responsibility and, therefore, have a better chance of effecting or contributing to long term, positive health outcomes.  In keeping with this, the IHS dental program has adopted the major tenets of the COPC.  It is an epidemiologically-based model with the following elements:

          1. A service program actively engaged in primary care.
          2. A defined community for which the program has accepted responsibility for health care.
          3. A management process by which the program, with the participation of the community, identifies and addresses the major health problems of the community.

          The process, in turn, consists of four functional steps:

          • defining and characterizing the community,
          • identifying the community health problems,
          • modifying the health care program, and
          • monitoring the effectiveness of program modifications.

          Applying the COPC model to dental diseases and the strategies known to prevent or control them affords a real opportunity to improve health status of entire communities.
        2. Standards for Health Promotion/Disease Prevention.  The responsibility for the development or modification of standards in HP/DP resides with the Oral HP/DP Committee.  The Committee’s recommendations are reviewed by the Chief, DSB, IHS, with input from the Area Dental Officers.  Like other areas of health care, techniques for the prevention of oral disease on both the patient and community level are continually evolving in light of research findings and technological advancements.  Program standards must also evolve to reflect these changes.

          Program activities in HP/DP are both community and clinic based.  Areas of emphasis include community water fluoridation, pit and fissure sealants, school fluoride mouthrinse programs, prevention of baby bottle tooth decay, prevention of periodontal disease, reduction of risk to oral cancer because of tobacco use, and the promotion of self-care practices.  Guidance for tribal and service unit programs is given by the Area Dental Officer (ADO) or the Area Dental HP/DP Officer.  On an IHS-wide basis, guidance is found in Section II of the Oral Health Program Guide for the Indian Health Service.  Section XI of the document contains standards for HP/DP activities and is titled “IHS Dental Program Quality Assessment Document.”  The HP/DP related standards are found in both the Community Involvement and Technical Quality of Care area.
      5. Research.  The goals of research are the development of new knowledge, the corroboration of previous non-definitive studies, and the identification of the utility of applications of existing knowledge to new, broader, or unique situations/applications.  While the IHS is not primarily a research oriented agency, there is both opportunity and need to investigate areas that have potential positive impact on the oral health status of Native Americans and to positively affect the way oral health care is delivered.  In this light, it seems prudent to base the development of a dental research agenda on fundamental principles of public health.  In concrete terms, this means prioritizing research opportunities in terms of their relative probability of benefiting the oral or general health of the largest possible number of Native Americans in the shortest amount of time, at the least cost to the program and in a manner most acceptable to the communities involved.  These are certainly complex criteria to balance, and outside assistance will frequently be needed.  In the Dental Program’s history, prospects for building collaborative research relationships with outside research institutions have never been brighter.  Examples of potential collaborators include dental schools, public health schools, and Federal agencies such as the CDC and the NIH.

        At this point in the development of the IHS Dental Research Agenda, five broad categories of investigation have been identified.  Although not mutually exclusive, they provide a useful structure for classifying research activities:

        1. Studies of the effectiveness and efficiency of alternative regimens for the treatment of caries, periodontal disease, and malocclusion.
        2. Studies of the effectiveness and efficiency of HP/DP interventions addressing oral diseases and conditions.
        3. Qualitative and quantitative descriptive and analytical studies of oral health status, and its determinants.
        4. Clinical trials of chemotherapeutic agents for preventing/controlling oral disease.
        5. Other studies with IHS dental program criteria.

          Each dental research protocol must be approved by the Area Dental Officer, Area Research Committee, Area Director, IHS Dental Research Committee and IHS Research Committee in accordance with IHS procedures.  The mechanisms for design, support, and approval of research activities is described in the Indian Health Manual, Part 1, Chapter 7 and Section VIII of the Oral Health Program Guide for the Indian Health Service.

          Prior to publication, manuscripts should be submitted for review and approval to the IHS Research Committee through the appropriate Area Research Committee and the IHS Dental Research Committee.

      6. Quality Assurance.  It is the responsibility of each oral health provider serving Native American people to provide the highest quality of care possible.  Moreover, the IHS has a responsibility to systematically review the quality of care provided by both direct and contract providers.

        The quality assessment process must address a broad scope of issues to accurately gauge the quality of a dental program.  In development of a dental quality assurance program, the IHS has included measures of the quality of clinical dental services, as well as standards to assess the needs of the population at large.  Criteria have been developed that address the technical quality of dental care, dental program management, and community involvement, using both direct and indirect methods of assessing quality of care.

        In addition to evaluation by IHS dental standards, dental programs also participate in accreditation surveys conducted by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) and are evaluated by the ambulatory care standards of that organization.

        The overall responsibility for implementing quality assurance in the IHS resides with the ADO.  The Chief, Area Contracting Branch is responsible for evaluation of tribally contracted programs and health care provided by other contractual means.  The responsibility for evaluation of the dental components of these contracts may be delegated to the Area Dental Officer.

        The quality of Area dental programs is assessed during Area Program reviews.  These reviews are the responsibility of the Chief, DSB, and are conducted in each area every 2-3 years.  Review topics include access to oral health services, preventive services, clinical care services, management, and staff development.

        For more specific information on the quality assurance process and a complete listing of IHS quality of care criteria consult Section IX of the Oral Health Program Guide for the Indian Health Service.

      7. Standards of Care.  In order to deliver dental services of consistent quality, standards of care are established for dental programs that serve Indian health programs.  Those standards are:

        1. All dentists and dental hygienists must be graduates of schools accredited by the American Dental Association.
        2. All dentists and dental hygienists providing clinical care must be licensed in a State in accordance with section 3-2.3A(3) of this chapter.
        3. Care provided must meet standards defined in Section IX of the Oral Health Program Guide of the Indian Health Service.  Additional standards applicable to all health professionals may be used by the local facility in the granting of clinical privileges.
        4. The IHS and tribally employed dentists are directly responsible for all services provided to patients under their care, including that portion of care which may be delivered by auxiliary personnel.
        5. Diagnosis, treatment planning, and intraoral procedures performed for the fabrication of dental prostheses procured outside IHS/tribally operated facilities must be performed by a licensed dentist.

          Adherence to these standards by programs providing dental services to Native Americans will assist in the consistent delivery of quality oral health services in all dental settings serving Native Americans.

      8. Tort Claims.  Under the Federal Tort Claims Act of 1946, P.L. 79-657, 28 U.C.S. 1346(b), 2671-2680; the United States waived its sovereign immunity and assumed liability for negligence of Federal employees acting within the scope of their official duties.  An amendment known as the “Drivers Act” (SB2679) provided that the only remedy available to aggrieved persons would be against the United States for personal injury or property damage caused by a Federal employee.

        The Indian Self-Determination Act, P.L. 93-638, invoked Federal tort liability coverage for civilian employees assigned either on detail or on leave without pay to Indian Tribes under the Intergovernmental Personnel Act and, similarly, tort liability coverage for PHS Commissioned Officers assigned or detailed under Section 214(d) of the PHS Act of 1944, as amended, 42 U.S.C. 215(d).

        Federal tort liability coverage has also been extended to tribal employees working in health care settings operated under a tribal 638 contract with the IHS.

        For further information on coverage under the Tort Claims Act consult Section III of the Oral Health Program Guide for the Indian Health Service.

    3-2.4  PROGRAM RESOURCES

    1. Resource Allocation

      1. Line item budget.  The organization and delivery of health care by the IHS reflect its origins in treaties, laws subsequently enacted by Congress, and judicial rulings.  Services to Native Americans were first authorized by the Snyder Act of 1921.  This Act links IHS services to congressional appropriations by providing for the use of “such monies as Congress may from time to time appropriate, for the benefit, care, and assistance of Indians.”  Additional authorization language for a dental program within the IHS may be found in Title II of the “Indian Health Care Improvement Act of 1976,” P.L. 94-437.  Each year’s appropriation act for the IHS specifies funding for a dental program.

        As a matter of Department policy, IHS resources are “residual” to other health care delivery and payment mechanisms.  Individual entitlements for such programs as Medicare, Veterans Administration, and private insurance are used first.  This policy maximizes the resources available for health care for all eligible Native Americans.

        Resources are provided annually to the IHS by Congress, by line item budget.  Funds to support the provision of dental services have historically been accorded such congressional line item status.  In so doing, Congress often provides guidance regarding allocation of certain portions of these funds, e.g., staffing for new facilities.  Allocation of funding to Areas is directed by the Chief, DSB, IHS, subject to approval by the Director, IHS, after consideration of formal Area requests for funding.

        The dental line item budget provides the majority of funding for Dental Program Operations.  However, the Hospitals and Clinics, Contract Health Services (CHS) and Direct Operations budgets also support a portion of dental activities.  The CHS resources are generic funds provided to Areas and service units to supplement the direct care program.  These may be used to supplement the direct care program.  These may be used to purchase service on a fee-for-service, fee-for-clinic, capitation, tribal contract or other basis.  Priorities for services provided with these funds follow the IHS Schedule of Services (Section III of the Oral Health Program Guide of the Indian Health Service).  The Hospitals and Clinics budget contains funding to support some additional clinical dental positions while Direct Operations budget contains funding for many of the dental administrative positions in the IHS.
      2. The Dental Resource Allocation Methodology.  The Dental Resource Allocation Methodology (DRAM) is an allocation formula which may be used to assess relative need for resources and performance of dental program components at the Area or service unit level, and to provide a more equitable and optimum distribution of Direct program and CHS resources.

        This methodology may be used as an alternative to the historic “base plus” method of distributing program resource increases or decreases.  It may also be used to redistribute a portion of a program component’s base budget in order to more equitably distribute resources.  The exact applications of the DRAM may vary from year to year.

        The DRAM consists of two modules: unmet need and performance.

        1. Unmet Need.  The unmet need module identifies the resource requirements necessary to annually provide treatment for the incidence of all emergency, preventive, and restorative conditions (Level I-III).  This module also identifies resources required to reduce the backlog of restorative and rehabilitative services (Level IV-VI), at a specified rate annually.  The module promotes equity among IHS Areas and is based on data obtained from periodic or ongoing IHS oral health surveys.  Area utilization rates and average costs of services delivery for each Area are also utilized.

          These data are used to calculate the cost of delivering the services needed to address newly occurring disease and a portion of the backlog of disease.  This amount is compared to all the dollars available (dental, hospitals & clinics, and CHS) for the Area’s dental program.  From this comparison, deficiencies for each Area are defined and a basis for relative need established.
        2. Performance.  The performance module consists of four components.  These factors may be weighted to independently contribute to the overall allocation to each Area.

          1. Productivity is measured as the average service minutes provided per full-time equivalent position (FTE) by area.  Service minute data are obtained from the dental data system, and FTE data are obtained from personnel records and confirmed by each respective ADO.
          2. Cost Containment is measured as the average cost to provide one service minute.  Service minute data are obtained from the dental data system, and cost data are obtained from the IHS cost accounting system and confirmed by each respective ADO.

            These first two measures combine to give an overall indication of program efficiency.  Their inclusion is based on the premise that clinical programs that are efficient are better able to meet the demand for dental services.  The intent is to direct more resources to those Areas with greater overall efficiency by identifying a portion of funds that will encourage programs to provide the highest volume of quality care that is appropriate to its circumstances.
          3. Population penetration is expressed as the proportion of the 3 year clinic user population which has access to dental care on an annual basis.  The 3 year user population is determined from the patient registration system and the count of dental users obtained from the dental date system.  The inclusion of this module is intended to provide incentives to make wide access to dental care available to the eligible population.
          4. Fluoridation of community water systems is the most effective public health measure which can be employed to control the high rate of dental caries among Native Americans. The prevention module creates incentives for Area/service units to improve the effectiveness of their water fluoridation program by rewarding Area/service unit compliance with the IHS fluoridation policy.

            The effectiveness of water fluoridation depends on consistently maintaining the fluoride level within the appropriate range.  Because of the small size (often accompanied by a lack of full-time water plant operators) and isolation of many systems serving AI/AN, the IHS policy, established in 1980, requires, as a minimum, sampling at weekly intervals.  The prevention module of DRAM incorporates both frequency of reporting and maintenance of appropriate fluoride levels.  The reliability of the data increases with the frequency of reporting.  For example, for two systems reported to be within range for a given month, there is a greater degree of certainty that the system reporting each week has maintained consistent levels of fluoride than the one that reported only once for the month.

      3. Resource Requirement Methodology.  The computerized Resource Requirement Methodology (RRM) is used by the DSB to provide a comprehensive and systematic process for determining resource requirements (personnel and contract dollars) necessary to provide effective, efficient, and acceptable health care service.  Within this broad purpose, the specific objective of the RRM is to enable dental program managers to make more rational decisions about present and future manpower requirements based on standards, criteria and quantitative data.  The RRM provides a mechanism that allows each facility/service area, service unit, tribe or Area to be compared on the same relative scale.  The RRM also provides critical supportive data utilized for Congressional appropriation hearings.

        During fiscal year (FY) 1983, the dental program initiated an Oral Health Survey to determine the oral health status and treatment needs of patient care utilizers from selected locations in each Area of the IHS.  These data and official IHS population data are formula variables used to calculate the dental program's RRM profile.  For a more detailed discussion of the RRM and formula variables, refer to Section III of the IHS Oral Health Program Guide of the Indian Health Service.
    2. Contract Resources

      1. Contracts under P.L. 93-638 (Indian Self-Determination Act).  The Indian Self-Determination Act (P.L. 93-638) and Indian Self-Determination and Education Assistance Act Amendments of 1988 (P.L. 100-472) provide a mechanism that enables Indian tribes to assume the management and operation of their health programs through contracts with the IHS.  The resources available under the terms of these contracts are the same as resources that would otherwise have been provided for the direct operation of the program, if operated by the IHS.  The tribal organizations are expected to provide their respective service population with at least the same level of dental services that were provided by the IHS-operated program serving the same eligible population.  The tribal organization may choose to deliver these services directly with their own dental staff or by contracting with individual dentists or dental groups to provide the care.  A Memorandum of Agreement (MOA) under P.L. 93-638, Section 105(b), may be used to assign PHS Commissioned Officers to a tribal organization (see example of MOA in the Oral Health Program Guide of the Indian Health Service, Section III).

        Public Law 93-638 also amended the Intergovernmental Personnel Act (IPA) to enable Tribal organizations to participate in IPA mobility assignments for civil service employees.
      2. Contract Health Services.  The CHS funds are used to augment the direct care dental program and allow for the provision of those services that would otherwise not be available because of lack of clinical specialists or excessive demand.  Contract services are purchased through the private sector and may vary, depending on the unique needs of the site where services are required.  For example, contract services may be provided in an IHS facility or a private dental office, and the contract may be with a single provider, dental service corporation such as a Delta Dental Plan or another fiscal intermediary (FI).

        When funding is not available to pay for fabrication of a dental prosthetic appliance by a commercial laboratory when the clinical treatment is being provided in an IHS or tribal facility, the dental clinic staff may act as an intermediary for purchase of the appliance by coordinating and facilitating payment by the patient to the source laboratory.  This payment shall be made via a money order or bank check acquired by the patient and made payable in the exact amount of the purchase to the source laboratory.  Cash or personal checks are not to be handled or accepted by clinic staff.

        When a patient fails to make normal adaptation to the prescribed dental prosthesis and the appliance must be remade, such appliance may be replaced at IHS expense, provided that the patient is eligible for CHS.

        Where direct care facilities are unavailable, contract services may be the sole mechanism by which dental care is provided.  A CHS-eligible beneficiary has been legally defined in the 42 Code of Federal Regulations (CFR), Part 36, Subpart C, as one who lives on, or near, a reservation to which he/she is a member, or the person has a close economic or social ties with the tribe or tribes.

        For details on contract health care regulations and contract requirements, refer to section III of the Oral Health Program Guide of the Indian Health Service, the CFR, or Part 2 Chapter 1 and 3 (Contract Health Services) of the Indian Health Manual.

        1. Procurement of Dental Services.  Dental services are provided in IHS/tribal clinics by federally employed dentists, tribally employed dentists, or on a contractual basis by dentists from the private sector.  Services provided outside IHS/tribal facilities are purchased from private practitioners.  The IHS may procure dental services on an open market basis, or enter into negotiated contracts or provider agreements either with individual dentists or with a dental service corporation, e.g., a Delta Dental Plan, that administers prepaid dental care programs for the public on a group basis.

          Delta Dental Plans, created and endorsed by organized dentistry at the State level, are nonprofit organizations designed to provide a predetermined and specific package of dental services to defined groups.

          Under the terms of agreement with a Delta Dental Plan, a participating dentist agrees to be bound by certain uniform requirements including the pre-filing of usual, customary and reasonable fees on a confidential basis with the Plan.  The Plan then is able to make payment directly to the participating dentist for the services provided on the basis of the provider’s usual fees, i.e., the fee ordinarily charged to all patients, as long as that fee has been determined to be within the customary range of Fees charged by other dentists of similar training and experience in a given geographic area.

          The advantages of entering into a contract with a Delta Dental Plan are the control of costs of contract dental services, elimination of the need to negotiate numerous individual provider agreements and contracts, the provision of claims processing as part of the contract, and the ability to review the dental care provided under the terms of the contract.

          For a detailed discussion of services provided by Delta Dental Plans, IHS and tribal contractual responsibilities with Delta, and a guide for preparing a Request for Contract (RFC), refer to section III of the Oral Health Program Guide of the Indian Health Service.
        2. Dental Claims Processing  Historically the processing of dental claims (HRSA-57) for payment has been accomplished by dental and CHS staff at the service unit and Area level.  Areas with Delta Dental contracts have had the claims processing performed by Delta.

          For those IHS Areas not processing dental claims through a dental service corporation such as Delta Dental, the Dental Services and CHS Branches are processing dental claims using the same FI that handles claims processing for the IHS medical CHS.  This contract permits centralized processing of CHS claims, but allows a certain degree of flexibility to Area programs.

          Precedence has been established for using FIs for claims processing by State Medicaid programs and the Department of Defense.  The IHS also has statutory authority (P.L. 99-272) to use an FI agent for CHS procurement.

          In FY 1987, the IHS entered into a contract with the New Mexico Blue Cross and Blue Shield (NMBCBS) to act as the FI agent to process medical claims for IHS programs nationwide (participation of tribal contracted programs is not mandatory).  In FY 1989 the contract with NMBCBS was modified to include dental claims processing and review for those Areas without existing Delta Dental Plan contracts.  As evaluations are conducted to determine the most effective method of procuring contract dental services, the amount of CHS funds, and the type of FI used by the IHS may change over time.
      3. Urban Programs.  Funding for urban Indian health care programs is authorized by “The Indian Health Care Improvement Act,” P.L. 94-437.  The IHS funding is provided through “Buy Indian” contracts. State, local, and private funds are also important sources of revenue for urban programs.  Dental services are provided either directly or by a referral service in many of the urban Indian programs.  Most programs provide some dental care that, at the minimum, stresses preventive and dental health education services; a few include more comprehensive dental services provided by the program’s own staff.  The IHS Dental Program serves a consultative role for urban programs.  Program specifications and requirements are defined by contractual scope of work, and dental consultation is coordinated with respective project officers and Area contracting officers.
    3-2.5  PROGRAM REPORTING

    1. Dental Data Reporting System.  In 1969, the Council on Dental Care Programs of the American Dental Association (ADA) developed the Uniform Code on Dental Procedures and Nomenclatures.  The Uniform Code established simplified reporting procedures to facilitate third-party claims administration and reimbursement, data tabulation, and the accumulation of service statistics by grouping of similar dental procedures.  A companion piece to the Uniform Code, the Attending Dentist’s Statement (ADS), is accepted as a reimbursement request by the major commercial insurance companies and Delta Dental Plans.  The Code and ADS have become the standard method both for reporting services provided, and for requesting remuneration from third-party carriers throughout most of the country.  In 1976, the IHS Dental Branch revised its existing data reporting system to conform to the national standards established by the Uniform Code on Dental Procedures and the ADS.

      The DSB uses four forms in its reporting system:

      • The Patient Service Record (HSA 42-1)
      • Services Provided, Dental Progress Notes (HSA 42-2)
      • Purchase Order for the Report of Contract Dental Care (HSA-57)
      • Record, Clinic and Doctor Identification (HSA 42-2 - page 2)

      The Patient Service Record form (HSA 42-1) is used for the collection of demographic data, the medical history, oral diagnosis, and the recommended treatment plan for each dental patient receiving care.

      The Services Provided, Dental Progress Notes form (HSA 42-2) is used to report either direct or contract dental services provided to the patient and for recording progress notes.  This form serves as the legal documentation of care and must be signed by the attending dentist.

      The Purchase Order for the Report of Contract Dental Care form (HSA-57) is used when care is provided to eligible AI/AN by contract referral to privately practicing dentists.  This form serves as a purchase order, a patient record, report of contract dental care provided, and an invoice for payment.

      The Record, Clinic, and Doctor Identification form (HSA, 42-2 page 2) is used to submit data for computer processing.  It serves as the cover sheet for each packet of HSA 42-2 and HSA-57 forms to be processed, and identifies the type of program (Direct or Contract), the dentist’s identification by social security number and the Area, service unit, and facility location that produced the data.

      Dental Data Reporting System forms are to be submitted on a weekly basis for each dentist providing care at each location.  These forms are submitted to the data entry contractor, and should be sent to:
      Uincor-ADP
      P.O. Box 15291
      Fort Worth, Texas 76119

      After the data are processed by the Data Processing Services Center (DPSC) in Albuquerque, New Mexico, statistical reports are printed and distributed monthly, quarterly, and annually, depending upon the type of report and its intended use.  The service reports listed below are distributed to IHS Headquarters and Area Offices by DPSC.  Distribution of appropriate reports to field locations then made from the Area level.  The reports organize the dental services provided by each program based upon the following characteristics:

      Indian, Non-Indian patients

      IHS Direct or Contract Programs

      Tribal/638 Direct or Contract Programs

      Non-IHS (Urban) Direct or Contract Programs

      Dentist Level Services (summary by levels of care)

      Dentist Services Report (lists all types of services provided)

      Level of Services Report

      Dental Services Report

      Each of the Service Reports are identified as to the geographic subdivision and level of program management.

      For a more detailed description of the data reports, and use of the dental data reporting documents, refer to the Oral Health Program Guide of the Indian Health Service and the IHS Dental Data System User's Manual.
    2. The Resource and Patient Management System.  The RPMS is an integrated information system designed to respond to current and future IHS information needs for management, administration, and patient care applications.  This system provides a structure within which all future automated data processing (ADP) systems can be developed to ensure that the IHS maintains an integrated information system, while allowing for maximum development and tailoring of discipline-specific systems at the local level.

      The primary function of the RPMS is to integrate patient and cost data into a single ADP system that supports all disciplines, and programs, while at the same time collecting and storing a core set of health and cost data that cuts across disciplines and facilities.  By merging cost and workload data, the local dental manager will have the information necessary to make alternative decisions for charting future courses of action.  Also, the DSB will be able to optimize resource management and use workload data to improve the planning, implementation and evaluation of COPC programs.

      Basic information requirements or core data elements for the dental program include data on financial costs associated with dental program activity, dental workload projections/forecasts, patient health status, treatment and management data, and CHS data.  For a detailed description of these data elements and sources, refer to the IHS Dental Services Branch Automated Data Processing Strategic Plan.

      The dental component of the RPMS system is the Dental Data Software (DDS).  This computer software provides for the entry of dental treatment data at the facility where the services are provided and for the timely use of those data by IHS clinical and administrative personnel in the management of IHS dental programs.  This system enables local dental programs to electronically manage a broad range of detailed information for many applications, including: patient followup, referral, quality assurance, utilization review, third-party billing, productivity, and access to care.
    3. IHS Fluoridation Data System.  The Director, IHS, the Office of Environmental Health and Engineering (OEHE), and the DSB actively promote the fluoridation of community water systems serving AI/AN.  Under the authority of the Indian Sanitation Facilities Act (P.L. 86-121), the IHS purchases and installs fluoridation equipment, usually in conjunction with the construction or improvement of community water systems.  In accordance with IHS authority, completed facilities are transferred to an Indian tribe, an Alaska Native village or other entity in accordance with an MOA that sets forth the responsibility to operate and maintain the facility.  The IHS then provides these entities technical assistance and training in operational procedures and maintenance.

      To ensure proper function of a water system, regular analysis of the fluoride levels in community water systems is required once a water fluoridation program is initiated.  The IHS uses the following forms in its Fluoride Reporting Data System:

      • Fluoridation System Add/Delete Forms
      • Weekly Fluoride Analysis Report Form
      • Fluoride Maintenance and Repair Report Form

      Local programs will report the required data on a weekly or monthly basis using any of several options:

      • submission of completed data forms directly to the IHS Area office or IHS key entry contractor, or
      • submission of formatted records from data entered into local RPMS database, or
      • submission of formatted records from a local non-RPMS database.

      If forms are submitted in IHS key entry contractor, they should be sent to:
      Unicor-ADP
      P.O. Box 15291
      Fort Worth, TX 76119

      Specific guidelines for the IHS fluoridation program are found in Section II of the Oral Health Program Guide of the Indian Health Service.

      Evaluation of the water fluoridation system is based on data submitted to the IHS Fluoridation Data System.  This System provides source-specific and system-specific fluoride information by service unit, Area, and Headquarters categories from three sources:

      • The annual OEHE Sanitation Facility Data System Reports
      • The Monthly IHS Fluoridation Surveillance Data Reports
      • The Quarterly IHS Fluoridation System Maintenance and Repair Data Reports

      The annual OEHE Sanitation Facility Data System (SFDS) Report provides information as to whether fluoridation equipment on any particular water system included in the report is present and, if not, if it is required.  It provides information as to whether defluoridation equipment is present or not and, if not, whether it is required.  Also, information as to whether optimal fluoride levels (monthly concentration averages) have been maintained for at least 8 out of the last 12 months, is included.  This system tracks all community water systems, including school water systems that have been included in the Fluoridation Data System.  Since this report also indicates the number of homes served by systems, it is possible to estimate the number of individuals served by a system, and thus the number of persons served by optimally fluoridated water (either naturally occurring or adjusted).  This report lists systems in alphabetical order with their associated Environmental Protection Agency unique system identifier numbers, as well as by Area and service unit.

      The monthly IHS Fluoridation Surveillance Data Report provides tabulated information on fluoride compliance.  The key indicator is mean fluoride level achieved.  A tolerance of 0.1 ppm below and 0.5 ppm above optimum is considered as an acceptable compliance range.  A monthly mean fluoride concentration for each community water system is then calculated and compared against optimum and acceptable ranges for that system.

      Systems that fall within acceptable range or outside acceptable range are so grouped and identified.  Systems that fail to report during any part of a month are identified as non-reporters.  Systems that have fluoridation equipment present but have never reported are designated inactive.

      The Quarterly IHS Fluoridation System Maintenance and Repair Report provides information as to the maintenance and repair activities that have occurred during the previous quarter and the year to date for systems and sources included in the IRS Fluoridation Surveillance Data System.  Specific repair, maintenance, and preventive maintenance activities are reported by category of activity (a key to activity types is listed on the reverse side of the Fluoridation System Input Form).  The dates of the activities and the organizational representative, i.e., tribal, IHS, other, performing the activity are also indicated.  Thus, it, is possible to compare fluoridation levels provided as reported to the Fluoridation Surveillance Data System with specific fluoridation maintenance and repair activities as reported in the IHS Fluoridation System Maintenance and Repair Report.  These data permit evaluation of the adequacy and appropriateness of individual maintenance and repair activities.  It is also possible to determine the amount of involvement of community water works personnel in the operation and maintenance of the fluoridation equipment.

      Detailed instructions on the submission of the above forms may be found in Section III of the Oral Health Program Guide of the Indian Health Service.

    3-2.6  PROGRAM REFERENCES

    Oral Health Program Guide of the Indian Health Service

    Clinical Specialties Manual

    Annual IHS Dental Program Hearings Document

    IHS Facilities Planning Manual

    Policy for Utilization of Commissioned Corps Personnel in the IHS Dental Program

    Allocation of Resources in the Indian Health Service, April 1988

    Schedule of Services Report, 1988

    IHS Dental Services Branch Automated Data Processing Strategic Plan.


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