Late last month, the Gardetto Family Community Dental Clinic opened in Milwaukee with a goal of becoming a dental home for about 400 to 500 patients with cognitive or physical disabilities.
The clinic, located at the St. Ann Center for Intergenerational Care-Bucyrus Campus, will serve both adults and children from Wisconsin who are referred by dentists or doctors. It’ll also accept Medicaid patients. Dr. Russell Dunkel, dental clinic director, said the biggest challenge facing people with disabilities in need of dental care is access.
“Access to care for people with disabilities is really out of control, unfortunately,” he said.
Dunkel and Laura Cherek-Laabs, director of dental services, recently spoke with Wisconsin Health News about the clinic and the lack of dental providers who accept the patients.
WHN: What was the lead-up to opening this clinic?
LC: This all started out when I started volunteering at our Stein campus, which is outside Milwaukee. And I realized that nobody was brushing the teeth of adults with disabilities. Not even their caretakers. So I started a program called Smiles for Sister Lucille, and started brushing everyone’s teeth. But everybody needed dental work and that’s when I realized there was no place to send out clientele here at St. Ann’s. That means that there’s no place for anybody in the Milwaukee area to get dental home care, a place where you just don’t go to get your tooth pulled, a place where you get cleanings and X-rays. At that same time, they were building this building. I approached the president, Sister Edna Lonergan, and talked to her about building a three-chair dental clinic to serve specifically this population.
That’s when the ball started rolling and we approached the Department of Health Services. We got a grant from them. We basically just requested a lot of requests for proposals and wrote a bunch of grants and worked with Delta Dental closely on the budgeting and how to keep this place sustainable. And we are continuing writing grants because we have to raise at least $150,000 a year to keep this clinic sustainable. And there’s such low pay from the state’s Medicaid fee schedule. Once we got the funding, we started going, looking at equipment and that whole process took three years.
WHN: What services do you provide for this population? Is this a local or statewide focus?
RD: Our focus is for the entire state. One of the drawbacks is I think we’re the only clinic right now that’s specifically set up in the state of Wisconsin to handle this population. I don’t believe there’s any other clinic in the state that I’m aware of. UnityPoint Health-Meriter closed their clinic about a year and half ago. They were taking people for basically operating room procedures. We’re currently in the process of negotiating on working with one or two hospitals in this area so we can do the same thing because there is no place for people to go. Some patients have to go to the Mayo Clinic in Minnesota. It’s the closest they can go to get treatment in the operating room. So we’ve opened it up not just to the Milwaukee County area but anybody in the state.
LC: At this point, since we don’t have hospital privileges yet, it’s not in our patient’s best interest to offer any kind of conscious sedation or IV sedation. We’re not in a hospital setting. A this point we do what’s called prescription sedation where someone will get a sedative an hour before they get here, a sedative when they get here and then we’ll use nitrous oxide. The services that we provide are the main services that you would see in any general practitioner’s office: X-rays, cleanings, fillings, crowns, root canals, dentures, extractions.
RD: Literally, the only thing we won’t be doing would be orthodontic treatment and probably implants. But anything else under the purview of dental treatment, we’ll be able to do.
WHN: Meriter’s clinic had a residency program. Are you considering starting a similar program?
RD: I don’t know if it would be exactly what Meriter had, but basically I’ve been in communications with Dr. Lori Barbeau, who is the medical director at Children’s Dental Center of Children’s Hospital of Wisconsin. We’re looking at approaching them in the future to consider doing that…That’s something we’re looking at in the future. How soon that would be to happen, it’s hard to say. But there’s talk about doing something like that. It would probably be something with Children’s Hospital, possibly Marquette University. But at this time we haven’t approached Marquette. Right now it’s between ourselves and Children’s Hospital.
WHN: How many do you plan to serve?
LC: Being open right now at two days a week for clinical with the dentist chair, hopefully moving up to four days a week, we were aiming at being a dental home to about 400 to 500 clients a year. Meaning that once we hit our maximum – 400 or 500 – then we couldn’t take any more clients. We would be full. We don’t want this to be a revolving door, like “Oh you have a toothache, we’re going to pull your tooth. See you the next time you have a toothache.” Our goal is to get them in dental health. You can’t be completely healthy if you have decaying teeth and periodontal disease. So we’re trying to stop this problem, which is just going to grow and grow, especially with baby boomers. Once they start getting a little older and having dementia or Alzheimer’s, this kind of issue is going to get bigger. We’re trying to keep these people in dental health so there are not a whole bunch of dental emergencies.
WHN: Why are there so few providing these services?
RD: Basically, access to care comes in obstacles that are presented to the practitioner. The state, unfortunately, does not make it easy to become a Medicaid provider. It’s an enormous amount of paperwork that you constantly keep having to go through, even to get qualified. And then when you do, they’re literally paying you anywhere from $0.20 to $0.30 on the dollar. You can’t build a practice on it. Basically, when you’re looking at individuals that requires double the amount of time possibly to do the same treatment as someone else, you’re really losing out. It makes it almost impossible financially for practices to even consider doing that because of those two obstacles, the paperwork and the enormous amount of detail and the things that you have to go through to get approval and to get someone covered. And then when you finally do, you’re paid so little. And the bottom line is that as a business in private practice you can’t run in the red and stay open. That’s one of the problems we’re looking at, trying to get a higher reimbursement rate for these people who require additional care and procedures.
WHN: What else needs to be done to address the dental care needs of patients with special needs in the state? What gaps do you see and how can they be closed?
LC: Before we were opening this clinic, I always approached dentists and said, “If you could just serve one or two people with disabilities and take those two clients on forever.” If every dentist in the state would do that, we’d have much less of a problem than we have now. Unfortunately, because of all the major obstacles, becoming Medicaid providers, it’s very confusing, very time consuming, very costly. And it’s very hard to do if you take on all Medicaid patients like we’re doing. It would be easier if all private dentists agreed to take one or two people a year. We understand that those one or two people a year would lose them money but hopefully they’d have enough money from their standard clients that they see every day. We have run into problems with dentists who were willing to see clients but literally didn’t have the space in their office. They don’t have room for wheelchairs, they’re not ADA-certified. That’s sometimes a problem. And other problems are, and to put it very bluntly, some people are afraid. They’re afraid because they don’t have the proper training to see someone with disabilities because they don’t know how that person is going to act any given second.
RD: I’ve been in meetings with Dr. Barbeau about setting up mini-residencies, something along those lines, basically to get people past their comfort zone and eventually get them better trained so they feel more comfortable with these patients. If they can see one or two patients a month in their practice, if we can get several practitioners looking at that, we can start reducing the numbers of people that are out there who just have no care at all and have nowhere to go.
WHN: Where do you plan to go from here?
RD: One of the things we’re looking at is hopefully we have another doctor who will be working here on Tuesdays and Thursdays, and I’d be doing the Mondays and Fridays. We’re looking at bringing in other doctors here at the clinic, even if their office wasn’t accessible, to bring them as volunteers to work here. There’s a couple of people who have expressed interest. Then there’s where the problem comes in with the state making it more difficult to try and bring volunteers in. When I was working at Bread of Healing, that wasn’t quite an issue because it was a different scenario. I could just bring in a dentist, have them fill out a form, send it to the state and it was done. Well it’s a different scenario here. They have to become a Medicaid provider, which creates another problem of here’s more paperwork we have to go through to have someone who’s willing to volunteer that doesn’t want to spend hours going through all this paperwork in order to do so. They want to help, but you don’t want to make it so cumbersome so they can’t do it.