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Transportation Problems and Dental Care of Nursing Home Residents
ART ICLES
Transportation problems and dental care of nursing home residents Roger Simpson, MA, DD Marsha Cunningham, RDH, MS Robert Glenn, DDS, MS Jane fakobsen, MA
Nursing home residents may not receive adequate oral care because they have a problem getting to the dental office and dentists h ave difficulties providing treatm ent at the home. Some solutions are recommended.
nadequate transportation has been cited as a major barrier to dental services for the elderly by the ADA Council on Dental Health and Health Planning.1 In addition, a survey2 of Iowa dentists and nursing home administrators identified transportation as a problem for them and for residents in obtaining dental care. The public also expressed an awareness of the transportation needs of the elderly in a public opinion survey that showed nearly 80% of the respondents favored public transportation of the elderly to get health care.3
Analysis of needs of elderly The elderly, especially those in nursing homes, present some unique oral health needs. As a group, the elderly make the most frequent use of the health care sys tem.4 Anderson5 reports “morbidity in creases with age,” and many elderly pa tients have several undiagnosed medical problems. W ith regard to oral health needs, approximately 50% of the elderly (those older than 65 years) have lost all 178 ■ JADA, Vol. 106, February 1983
their teeth; periodontal disease affects 90% or more of those aged 73 to 79 years; and the oral hygiene index ranges from 1.9 for women aged 75 to 79 years to 2.5 for men aged 65 to 74 years.6 Approxi mately 1 m illion persons are in nursing homes, representing (at any one time) about 5% of the US population.7Approx imately 60% or more have immediate dental needs, and their last visit to a den tist was six years ago, but the average age of their dentures exceeds ten years. Types of emergencies reported by nursing home administrators include: toothaches; bro ken dentures; edema and infection; and loose teeth.2 A nursing home adminis trator reports that “transportation is a primary problem of the elderly,” and af firms that transportation decisions are part of the (dental health care) planning process.”8 Murray8 reports that a survey of nursing home residents in Dubuque found 61% who thought they needed den tal care. Furthermore, the Iowa code rec ognizes the transportation problem for some home residents and states “trans portation arrangements shall be made
when necessary for the resident to be transported to the dentist’s office.”9 In summary, “the oral health problems of the elderly and chronically ill or disabled in nursing homes are considered to be far more serious than oral health problems among the rest of the population, includ in g th e e l d e r l y o u t s i d e n u r s i n g facilities.” 10
Transportation modes and access Freedman5 has identified four methods for providing oral care to nursing home residents: care delivery in the home, with a complete dental unit provided; transfer of the resident to the dental office; hospi tal care; and mobile van delivery systems by which the dentist goes to the nursing home. Most elderly patients are unable to provide their own transportation to the dental office and less than 50% are ambu latory. Most are women: 70% are older than 70 years; only 10% have a spouse; 50% have no close relatives or friends; and 60% have no visitors. The Iowa survey2 discovered that only
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Three major models of transportation represent the possible solutions to transportation problems. First, the residents can go to the dental office. Second, the dentist can go to the resident in the home. Third, institutions, such as dental schools, can go to the homes, thus fulfilling their mandates to combine teaching with service. 10% of the residents can .travel alone to the dental office. A n escort would be needed by 50%, whereas 20% would need to receive treatment in the residence, and 10% are considered to be too frail to re ceive dental care. In solving the transpor tation problem, more than 90% of the nursing homes had taken residents to dental offices and 65% had dentists come to the homes. Still, 16% of the facilities reported that virtually all of their resi dents (99%) needed an escort to go to the dentist. Paying privately for transportation could be a problem for a considerable number of residents because 20% of the homes reported their residents need den tal care but are ineligible for Title XIX and do not have personal money for dental care.2 As a result of the survey on nursing homes and dentists, it was recommended that “alternative methods need to be ex plored for the dental care delivery to LCF (nursing homes) residents who need es corts or cannot travel,” 2 Three major models of transportation (Illustration) represent the possible solutions to the transportation problems. First, the resi dents can go to the dental office. Second, the dentist can go to the resident in the home. Third, institutions, such as dental schools, can go to the homes, thus fulfill ing their mandates to combine teaching with service.
Discussion Residents of homes visiting the dentist To determine the current status of trans porting the resident to the dental office, a 10% sample telephone survey11 was made of Iowa nursing homes inquiring about: — whether the home owned a van, mini-bus, or car for transporting resi dents; — finances for purchase and mainte nance of such transportation; availability of public transportation; — modes of transportation generally used to get residents to the dental office; and — whether dentists come to the nursing
homes to provide dental care. The sample was generally representa tive of the size and location of homes in Iowa, so that extrapolation to other homes in Iowa seems valid. Of the homes sur veyed, 67% do not own transportation vehicles. Of these, 37% do not believe that one is needed, whereas 25% believe such a vehicle would be useful. Most do not plan to get a vehicle and, of those who re sponded, 14% identified lack of funds as the reason. Most depend on some mode of public transportation and also on friends and relatives to provide the transporta tion. Staff members in 80% of the homes are expected to take responsibility for transporting residents, as required, via their private vehicles. Regarding public transportation, 16% depend on public transit systems and 58% depend on vans or rides through the county or regional transportation systems supported by var ious funds including boards of super visors and state and federal funds. Those homes that do have vehicles constitute about a third of the total homes. Funds for purchase come from a variety of sources; however, most homes depend on the operating budget of the institution. A few homes had fund drives to purchase the vehicles while others received special gifts. Most homes supported the ongoing costs out of the operating budget; how ever, one home made direct charges to residents who use the vehicle. Escorts who go with patients were either staff (79%), family and friends (88%), or volunteers (13%) (some homes responded more than once). The adminis trators and nursing directors made sev eral comments that they are increasingly encouraging families to become more active in the resident’s life, including ar ranging dental visits and providing transportation. This approach seems to be meeting with some degree of success. Alexander8 has identified, for the pa tient and the home, some of the problems associated with transporting the resident to the dental office. These include: weather conditions that can make it hazardous to take the elderly from the homes; the number of residents (in skilled nursing facilities) who would need trans portation by ambulance; the cost of the home providing a van or car, and the
number of poorer residents who can ob tain Title XIX support; the emotional and social instability of some residents; the difficulty in transferring some frail, though mobile, persons who cannot tol erate long trips, nor move easily about the streets and navigate stairs and unfamiliar passages with safety; the physical limita tions such as incontinence of some ambu latory persons; the hindrance of some available transportation lacking lifts or having steps impossible for the elderly to navigate; the difficulty of arranging ap pointments so that the resident w ill be treated on time, and so escorts can end their shifts on time; and, frequently, the lack of convenient parking near the den tal office. Though the nursing homes depend on families and friends to transport resi dents, and report some success in this re gard, there are difficulties to be overcome. There is the basic matter of educating the family and friends regarding the impor tance of taking the resident for dental care. Many regard it as an extra effort they are not ready to undertake. When told that a resident's dentures are broken, a family might reply: Well, can’t you just glue it together with some of that easy-on ce m ent?8 Relatives can become hostile when the administrator or nurse insists on doing something about oral health care. Some do not wish to be responsible for the additional expense.
Dentists visiting nursing homes A second solution to the transportation problem of the nursing home resident is for the dentist to go to the home. The den tist can do this alone, carrying some basic equipment and a few supplies. The den tist can go also in a van, which, if well equipped, can take almost all equipment, supplies, and personnel needed for a full range of dental care. The surveys did re port that most of the homes have dentists who make personal visits upon request, and most dentists in the survey stated that they have a concern for the oral health care of the residents. Many go even if they find it inconvenient and nonprofitable.2 However, Glenn3 says having dentists go to the homes has not been productive and “Dental care in nursing homes is practi-
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cally nonexistent.” Reasons he cites as deterrents include: time constraints on when the resident can be seen; need to as semble accurate information on the pa tients’ general physical condition; need for cooperation by the home personnel in gaining access to the resident; and com munication with the patient and coopera tion with the family to obtain consent and receive payment. Although the Iowa sur vey disclosed that 32% of the dentists contacted are willing to be consultants to nursing homes, only 54% of the homes report they have such consultants. A few dentists are going to nursing homes with enough equipment, supplies, and adequate staff to provide extensive, in-home dental care. This is as yet a small number and complete information about the extent of this development is not available. Yet examples can be cited in which attempts are being made and re sults seem positive. Freedman5 says the mobile van deliv ery system is a method he strongly advo cates and uses. His van, called the “Geriatric Tooth Fairy,” contains porta ble equipment (dental chair, delivery sys tem) that can be carried by one person, stored in a panel truck or van, and moved through the entrances of homes, down corridors, and into rooms where service can be provided. It uses the water and electrical systems of the home, and air is provided by a small compressor. A porta ble case contains hand tools and supplies ordinarily needed. With the cooperation of the nursing home staff, he has found this system to be both manageable and profitable as a means of dental care deliv ery by the private practice dentist, He rep resents one dentist in a large metropolitan area (Chicago) successfully providing this kind of transportation as the answer to dental care delivery to nursing home residents. Murray,8 a dentist from Dubuque (a town of 62,000), has been working from a smaller van to take dental care to nursing homes in that area. His equipment in cludes a portable chair and delivery sys tem and supplies. His support staff in cludes his four auxiliaries. He reports the effort will continue as long as a number of the homes welcome the service and coop erate in care delivery, He notes it is not very profitable financially, but he and his staff receive tremendous personal satis faction from grateful residents and help ful home staff, The National Foundation of Dentistry for the Handicapped (NFDH) is a public, nonprofit corporation based in Denver. NDFH operates several dentistry vans, each equipped with portable dental ap paratus. This is called a homebound pro gram because it serves handicapped and elderly persons who are homebound. Ac cess to the services of the homebound 180 ■ JADA, Vol. 106, February 1983
Residents of nursing homes — Residents provide transportation: -go alone; with escort — Friends, relatives provide transportation — Homes, staff provide transportation: vans, cars — Public transportation: vans, buses — Taxis, ambulance
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Transportation models
program can occur in three ways: — H o m e b o u n d patients (or their families) may contact the NFDH coor dinator. — Nursing homes may contact the NFDH coordinator seeking treatment for dental needs. — Private practitioners may contact the NFDH coordinator to be scheduled to treat new patients or homebound patients from private practice, The NFDH coordinator develops a schedule, matching patients with den tists (and vice versa) and organizing the daily route by geographic location. The program has a high rate of use and is usu ally booked several months in advance. The homebound program is staffed by one full-time person, who serves as the dental assistant, laboratory technician, maintenance person, driver, and equip ment manager. Local dentists contract to use the porta ble equipment for a use fee, which is 20% of the dentist’s usual fee for the procedure performed. The use fee offsets the cost of disposable supplies, gas for the truck, and use of the equipment. There are currently several such programs, in the planning stages, across the country. Funding for implementation, purchase of equipment, and operating expenses must be secured independently of the NFDH.
Dentists ■Dentist provides transportation: -goes alone; -has van with staff, supplies, equipment
Institutions an d dental schools providing care This third model for taking care to nurs ing home residents is one that has a considerable history, with varied results.1 This approach depends on the traditional teaching and service functions of educational institutions. For example, the department of preven tive and community dentistry at the Uni versity of Iowa operates a mobile dental unit for nursing home residents. The mobile unit is a 25-foot trailer that contains a dental operatory, including a labo ratory and X-ray machine. The unit also has two portable dental chairs and other equipment that can be moved inside a nursing home facility. The program is staffed by a dentist who is a full-time fac ulty member, a certified dental assistant, and a part-time dental hygienist. Two to three senior dental students are assigned to the program on a rotating basis. This geriatric mobile dental unit is op erated as an extramural program of the college of dentistry. The program provides a valuable educational experience for senior dental students in treating nursing home residents who have an ac cumulation of dental problems because of their inability to seek and receive regular dental care. Thus, while providing a
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needed service to the residents, the dental student w ill become familiar with deliv ering care outside of the office and under less than ideal conditions. The original refinishing and equipping of the unit was accomplished through the aid of the Heritage Agency on Aging, the Hawkeye Area Community Action Pro gram, and a federal geriatric curriculum development grant from the Health Re sources A dm inistration, Health and Human Services. The program is cur rently self-supporting.
Conclusions and recommendations On the basis of a 1979 survey of dentists and nursing homes, and a 1981 telephone survey of nursing homes, it is evident that transportation is a problem that must be solved if nursing home residents are to receive adequate and regular oral care and dental treatment. Three solutions and examples of their use are identified. In transporting a resi dent patient to the dentist, the nursing homes depend on the goodwill of family and the volunteer efforts of friends and staff. Residents are primarily taken by private car. Elderly persons who have special needs and who depend on the in i tiative of others may be frustrated by this mode of access to care. Though a few den tists are making efforts to take treatment services to the patients, few are doing it. For those who do, overhead expenses are considerable. Few dentists have been ad equately trained in geriatric dentistry or to provide health care treatment to the el derly. Although several institutions, such as dental schools, are developing mobile units, these are mostly demonstration units and they cannot reach large num bers of nursing home residents who need care. In view of the studies mentioned, some recommendations can be made.
One recommendation concerns dental and medical education. Students should be educated by working in nursing homes and with homebound patients and be familiar with the modes of transportation. Dental students and practicing dentists should be encouraged to consider pur chasing portable equipment as individu als or on a shared arrangement as an al ternate to the traditional private office mode. The second recommendation involves transportation planning. Government and private transportation planning en tities should consider persons with spe cial needs for dental and medical care. A third recommendation involves state codes which need to specify the nursing home’s responsibility in transportation and allow for recovery of expenses in volved, making a tax credit available to nursing homes for purchase, operation, and maintenance cost of such vehicles. Likewise, family and friends who provide such transportation and escort assistance should receive a tax credit for expenses involved, including the cost for time spent in such endeavors. Nonprofit nurs ing homes should urge their funding sources to give a priority to transportation service for dental care. Federal codes are also involved. Efforts should be made to amend Title XVIII (Medicare) to provide for reimbursement for dental expenses for the elderly. The last recommendation concerns guidelines for dentists and physicians. Guidelines should be developed by nurs ing home associations and departments of health concerning transportation prob lems and needs of the elderly, so that den tists and p h y s ic ia n s can im p ro v e scheduling and time control. As these transportation models are im proved and extended, and the foregoing recom m endations stu d ie d and im plemented, it is reasonable to expect
some significant advance in the oral health care of the elderly. This should re sult in improvement of the quality of life for each elderly community. CTat'
Dr. Simpson is assistant professor, departments of family dentistry, and preventive and community den tistry; Ms. Cunningham is assistant professor; Dr. Glenn is assistant professor; and Ms. Jakobsen is bio statistician, department of preventive and commu nity dentistry, College of Dentistry, University of Iowa, Iowa City, 52242. Address requests for reprints to Dr. Simpson. 1. ADA Council on Dental Health and Health Plan ning. Manual on comprehensive dental care access programs; a guide for dental societies. Chicago, American Dental Association. 1981, p 3. 2. Hayden, H., and others. Surveys of Iowa dentists and nursing homes regarding dental care of the el derly and Title XIX. Monograph. Department of Pre ventive and Community Dentistry and Iowa Geron tology Center, College of Dentistry, University of Iowa, Iowa City, 1979, pp 20, 22, 23, 31. 3. East Central Iowa Council of Governments. Re gional transit development plan. Coralville, Iowa, 1981, pp 111-115. 4. Special report on aging. US Department of Health, Education, and Welfare, Public Health Ser vice. NIH pub. no. 80-1907,1980, p 1. 5. Simpson, R., and others. Geriatric dentistry. Pro ceedings, Preventive and Community Dentistry, and Gerontology Center, University of Iowa, Iowa City, 1978, pp 7, 45-48. 6. Lotzkar, S. Dental care for the aged. J Public Health Dent 37(3):201,1979. 7. Ettinger, R. Patient assessment, management and treatment modifications. Dental Care in nursing homes. In Simpson, R., and others. Geriatric den tistry. Proceedings, University of Iowa Preventive and Community Dentistry and Gerontology Center, 1978, pp 34, 45-48. 8. Simpson, R., and others. Dental care in nursing homes. Monograph. Preventive and Community Den tistry, College of Dentistry, University of Iowa, Iowa City, 1979, pp 13,15. 9. Iowa rules and regulations setting minimum standards for health care facilities, Sept 27,1976, pp 79,87. 10. ADA Council on Dental Health and Health Planning. Oral health care for the geriatric patient in a long-term care facility. Chicago, American Dental As sociation, 1981, p 6. 11. Simpson, R.; Cunningham, M.; and Jakobsen, J. A nursing homes survey on transportation for dental care. Proceedings, University of Iowa, Preventive and Community Dentistry. 1981.
Simpson-Others ; TRANSPORTATION PROBLEMS AND CARE OF NURSING HOME RESIDENTS ■ 181
Transportation problems and dental care of nursing home residents Roger Simpson, MA, DD Marsha Cunningham, RDH, MS Robert Glenn, DDS, MS Jane fakobsen, MA
Nursing home residents may not receive adequate oral care because they have a problem getting to the dental office and dentists h ave difficulties providing treatm ent at the home. Some solutions are recommended.
nadequate transportation has been cited as a major barrier to dental services for the elderly by the ADA Council on Dental Health and Health Planning.1 In addition, a survey2 of Iowa dentists and nursing home administrators identified transportation as a problem for them and for residents in obtaining dental care. The public also expressed an awareness of the transportation needs of the elderly in a public opinion survey that showed nearly 80% of the respondents favored public transportation of the elderly to get health care.3
Analysis of needs of elderly The elderly, especially those in nursing homes, present some unique oral health needs. As a group, the elderly make the most frequent use of the health care sys tem.4 Anderson5 reports “morbidity in creases with age,” and many elderly pa tients have several undiagnosed medical problems. W ith regard to oral health needs, approximately 50% of the elderly (those older than 65 years) have lost all 178 ■ JADA, Vol. 106, February 1983
their teeth; periodontal disease affects 90% or more of those aged 73 to 79 years; and the oral hygiene index ranges from 1.9 for women aged 75 to 79 years to 2.5 for men aged 65 to 74 years.6 Approxi mately 1 m illion persons are in nursing homes, representing (at any one time) about 5% of the US population.7Approx imately 60% or more have immediate dental needs, and their last visit to a den tist was six years ago, but the average age of their dentures exceeds ten years. Types of emergencies reported by nursing home administrators include: toothaches; bro ken dentures; edema and infection; and loose teeth.2 A nursing home adminis trator reports that “transportation is a primary problem of the elderly,” and af firms that transportation decisions are part of the (dental health care) planning process.”8 Murray8 reports that a survey of nursing home residents in Dubuque found 61% who thought they needed den tal care. Furthermore, the Iowa code rec ognizes the transportation problem for some home residents and states “trans portation arrangements shall be made
when necessary for the resident to be transported to the dentist’s office.”9 In summary, “the oral health problems of the elderly and chronically ill or disabled in nursing homes are considered to be far more serious than oral health problems among the rest of the population, includ in g th e e l d e r l y o u t s i d e n u r s i n g facilities.” 10
Transportation modes and access Freedman5 has identified four methods for providing oral care to nursing home residents: care delivery in the home, with a complete dental unit provided; transfer of the resident to the dental office; hospi tal care; and mobile van delivery systems by which the dentist goes to the nursing home. Most elderly patients are unable to provide their own transportation to the dental office and less than 50% are ambu latory. Most are women: 70% are older than 70 years; only 10% have a spouse; 50% have no close relatives or friends; and 60% have no visitors. The Iowa survey2 discovered that only
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Three major models of transportation represent the possible solutions to transportation problems. First, the residents can go to the dental office. Second, the dentist can go to the resident in the home. Third, institutions, such as dental schools, can go to the homes, thus fulfilling their mandates to combine teaching with service. 10% of the residents can .travel alone to the dental office. A n escort would be needed by 50%, whereas 20% would need to receive treatment in the residence, and 10% are considered to be too frail to re ceive dental care. In solving the transpor tation problem, more than 90% of the nursing homes had taken residents to dental offices and 65% had dentists come to the homes. Still, 16% of the facilities reported that virtually all of their resi dents (99%) needed an escort to go to the dentist. Paying privately for transportation could be a problem for a considerable number of residents because 20% of the homes reported their residents need den tal care but are ineligible for Title XIX and do not have personal money for dental care.2 As a result of the survey on nursing homes and dentists, it was recommended that “alternative methods need to be ex plored for the dental care delivery to LCF (nursing homes) residents who need es corts or cannot travel,” 2 Three major models of transportation (Illustration) represent the possible solutions to the transportation problems. First, the resi dents can go to the dental office. Second, the dentist can go to the resident in the home. Third, institutions, such as dental schools, can go to the homes, thus fulfill ing their mandates to combine teaching with service.
Discussion Residents of homes visiting the dentist To determine the current status of trans porting the resident to the dental office, a 10% sample telephone survey11 was made of Iowa nursing homes inquiring about: — whether the home owned a van, mini-bus, or car for transporting resi dents; — finances for purchase and mainte nance of such transportation; availability of public transportation; — modes of transportation generally used to get residents to the dental office; and — whether dentists come to the nursing
homes to provide dental care. The sample was generally representa tive of the size and location of homes in Iowa, so that extrapolation to other homes in Iowa seems valid. Of the homes sur veyed, 67% do not own transportation vehicles. Of these, 37% do not believe that one is needed, whereas 25% believe such a vehicle would be useful. Most do not plan to get a vehicle and, of those who re sponded, 14% identified lack of funds as the reason. Most depend on some mode of public transportation and also on friends and relatives to provide the transporta tion. Staff members in 80% of the homes are expected to take responsibility for transporting residents, as required, via their private vehicles. Regarding public transportation, 16% depend on public transit systems and 58% depend on vans or rides through the county or regional transportation systems supported by var ious funds including boards of super visors and state and federal funds. Those homes that do have vehicles constitute about a third of the total homes. Funds for purchase come from a variety of sources; however, most homes depend on the operating budget of the institution. A few homes had fund drives to purchase the vehicles while others received special gifts. Most homes supported the ongoing costs out of the operating budget; how ever, one home made direct charges to residents who use the vehicle. Escorts who go with patients were either staff (79%), family and friends (88%), or volunteers (13%) (some homes responded more than once). The adminis trators and nursing directors made sev eral comments that they are increasingly encouraging families to become more active in the resident’s life, including ar ranging dental visits and providing transportation. This approach seems to be meeting with some degree of success. Alexander8 has identified, for the pa tient and the home, some of the problems associated with transporting the resident to the dental office. These include: weather conditions that can make it hazardous to take the elderly from the homes; the number of residents (in skilled nursing facilities) who would need trans portation by ambulance; the cost of the home providing a van or car, and the
number of poorer residents who can ob tain Title XIX support; the emotional and social instability of some residents; the difficulty in transferring some frail, though mobile, persons who cannot tol erate long trips, nor move easily about the streets and navigate stairs and unfamiliar passages with safety; the physical limita tions such as incontinence of some ambu latory persons; the hindrance of some available transportation lacking lifts or having steps impossible for the elderly to navigate; the difficulty of arranging ap pointments so that the resident w ill be treated on time, and so escorts can end their shifts on time; and, frequently, the lack of convenient parking near the den tal office. Though the nursing homes depend on families and friends to transport resi dents, and report some success in this re gard, there are difficulties to be overcome. There is the basic matter of educating the family and friends regarding the impor tance of taking the resident for dental care. Many regard it as an extra effort they are not ready to undertake. When told that a resident's dentures are broken, a family might reply: Well, can’t you just glue it together with some of that easy-on ce m ent?8 Relatives can become hostile when the administrator or nurse insists on doing something about oral health care. Some do not wish to be responsible for the additional expense.
Dentists visiting nursing homes A second solution to the transportation problem of the nursing home resident is for the dentist to go to the home. The den tist can do this alone, carrying some basic equipment and a few supplies. The den tist can go also in a van, which, if well equipped, can take almost all equipment, supplies, and personnel needed for a full range of dental care. The surveys did re port that most of the homes have dentists who make personal visits upon request, and most dentists in the survey stated that they have a concern for the oral health care of the residents. Many go even if they find it inconvenient and nonprofitable.2 However, Glenn3 says having dentists go to the homes has not been productive and “Dental care in nursing homes is practi-
Simpson-Others : TRANSPORTATION PROBLEMS AND CARE OF NURSING HOME RESIDENTS ■ 179
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cally nonexistent.” Reasons he cites as deterrents include: time constraints on when the resident can be seen; need to as semble accurate information on the pa tients’ general physical condition; need for cooperation by the home personnel in gaining access to the resident; and com munication with the patient and coopera tion with the family to obtain consent and receive payment. Although the Iowa sur vey disclosed that 32% of the dentists contacted are willing to be consultants to nursing homes, only 54% of the homes report they have such consultants. A few dentists are going to nursing homes with enough equipment, supplies, and adequate staff to provide extensive, in-home dental care. This is as yet a small number and complete information about the extent of this development is not available. Yet examples can be cited in which attempts are being made and re sults seem positive. Freedman5 says the mobile van deliv ery system is a method he strongly advo cates and uses. His van, called the “Geriatric Tooth Fairy,” contains porta ble equipment (dental chair, delivery sys tem) that can be carried by one person, stored in a panel truck or van, and moved through the entrances of homes, down corridors, and into rooms where service can be provided. It uses the water and electrical systems of the home, and air is provided by a small compressor. A porta ble case contains hand tools and supplies ordinarily needed. With the cooperation of the nursing home staff, he has found this system to be both manageable and profitable as a means of dental care deliv ery by the private practice dentist, He rep resents one dentist in a large metropolitan area (Chicago) successfully providing this kind of transportation as the answer to dental care delivery to nursing home residents. Murray,8 a dentist from Dubuque (a town of 62,000), has been working from a smaller van to take dental care to nursing homes in that area. His equipment in cludes a portable chair and delivery sys tem and supplies. His support staff in cludes his four auxiliaries. He reports the effort will continue as long as a number of the homes welcome the service and coop erate in care delivery, He notes it is not very profitable financially, but he and his staff receive tremendous personal satis faction from grateful residents and help ful home staff, The National Foundation of Dentistry for the Handicapped (NFDH) is a public, nonprofit corporation based in Denver. NDFH operates several dentistry vans, each equipped with portable dental ap paratus. This is called a homebound pro gram because it serves handicapped and elderly persons who are homebound. Ac cess to the services of the homebound 180 ■ JADA, Vol. 106, February 1983
Residents of nursing homes — Residents provide transportation: -go alone; with escort — Friends, relatives provide transportation — Homes, staff provide transportation: vans, cars — Public transportation: vans, buses — Taxis, ambulance
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Transportation models
program can occur in three ways: — H o m e b o u n d patients (or their families) may contact the NFDH coor dinator. — Nursing homes may contact the NFDH coordinator seeking treatment for dental needs. — Private practitioners may contact the NFDH coordinator to be scheduled to treat new patients or homebound patients from private practice, The NFDH coordinator develops a schedule, matching patients with den tists (and vice versa) and organizing the daily route by geographic location. The program has a high rate of use and is usu ally booked several months in advance. The homebound program is staffed by one full-time person, who serves as the dental assistant, laboratory technician, maintenance person, driver, and equip ment manager. Local dentists contract to use the porta ble equipment for a use fee, which is 20% of the dentist’s usual fee for the procedure performed. The use fee offsets the cost of disposable supplies, gas for the truck, and use of the equipment. There are currently several such programs, in the planning stages, across the country. Funding for implementation, purchase of equipment, and operating expenses must be secured independently of the NFDH.
Dentists ■Dentist provides transportation: -goes alone; -has van with staff, supplies, equipment
Institutions an d dental schools providing care This third model for taking care to nurs ing home residents is one that has a considerable history, with varied results.1 This approach depends on the traditional teaching and service functions of educational institutions. For example, the department of preven tive and community dentistry at the Uni versity of Iowa operates a mobile dental unit for nursing home residents. The mobile unit is a 25-foot trailer that contains a dental operatory, including a labo ratory and X-ray machine. The unit also has two portable dental chairs and other equipment that can be moved inside a nursing home facility. The program is staffed by a dentist who is a full-time fac ulty member, a certified dental assistant, and a part-time dental hygienist. Two to three senior dental students are assigned to the program on a rotating basis. This geriatric mobile dental unit is op erated as an extramural program of the college of dentistry. The program provides a valuable educational experience for senior dental students in treating nursing home residents who have an ac cumulation of dental problems because of their inability to seek and receive regular dental care. Thus, while providing a
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ARTICLES
needed service to the residents, the dental student w ill become familiar with deliv ering care outside of the office and under less than ideal conditions. The original refinishing and equipping of the unit was accomplished through the aid of the Heritage Agency on Aging, the Hawkeye Area Community Action Pro gram, and a federal geriatric curriculum development grant from the Health Re sources A dm inistration, Health and Human Services. The program is cur rently self-supporting.
Conclusions and recommendations On the basis of a 1979 survey of dentists and nursing homes, and a 1981 telephone survey of nursing homes, it is evident that transportation is a problem that must be solved if nursing home residents are to receive adequate and regular oral care and dental treatment. Three solutions and examples of their use are identified. In transporting a resi dent patient to the dentist, the nursing homes depend on the goodwill of family and the volunteer efforts of friends and staff. Residents are primarily taken by private car. Elderly persons who have special needs and who depend on the in i tiative of others may be frustrated by this mode of access to care. Though a few den tists are making efforts to take treatment services to the patients, few are doing it. For those who do, overhead expenses are considerable. Few dentists have been ad equately trained in geriatric dentistry or to provide health care treatment to the el derly. Although several institutions, such as dental schools, are developing mobile units, these are mostly demonstration units and they cannot reach large num bers of nursing home residents who need care. In view of the studies mentioned, some recommendations can be made.
One recommendation concerns dental and medical education. Students should be educated by working in nursing homes and with homebound patients and be familiar with the modes of transportation. Dental students and practicing dentists should be encouraged to consider pur chasing portable equipment as individu als or on a shared arrangement as an al ternate to the traditional private office mode. The second recommendation involves transportation planning. Government and private transportation planning en tities should consider persons with spe cial needs for dental and medical care. A third recommendation involves state codes which need to specify the nursing home’s responsibility in transportation and allow for recovery of expenses in volved, making a tax credit available to nursing homes for purchase, operation, and maintenance cost of such vehicles. Likewise, family and friends who provide such transportation and escort assistance should receive a tax credit for expenses involved, including the cost for time spent in such endeavors. Nonprofit nurs ing homes should urge their funding sources to give a priority to transportation service for dental care. Federal codes are also involved. Efforts should be made to amend Title XVIII (Medicare) to provide for reimbursement for dental expenses for the elderly. The last recommendation concerns guidelines for dentists and physicians. Guidelines should be developed by nurs ing home associations and departments of health concerning transportation prob lems and needs of the elderly, so that den tists and p h y s ic ia n s can im p ro v e scheduling and time control. As these transportation models are im proved and extended, and the foregoing recom m endations stu d ie d and im plemented, it is reasonable to expect
some significant advance in the oral health care of the elderly. This should re sult in improvement of the quality of life for each elderly community. CTat'
Dr. Simpson is assistant professor, departments of family dentistry, and preventive and community den tistry; Ms. Cunningham is assistant professor; Dr. Glenn is assistant professor; and Ms. Jakobsen is bio statistician, department of preventive and commu nity dentistry, College of Dentistry, University of Iowa, Iowa City, 52242. Address requests for reprints to Dr. Simpson. 1. ADA Council on Dental Health and Health Plan ning. Manual on comprehensive dental care access programs; a guide for dental societies. Chicago, American Dental Association. 1981, p 3. 2. Hayden, H., and others. Surveys of Iowa dentists and nursing homes regarding dental care of the el derly and Title XIX. Monograph. Department of Pre ventive and Community Dentistry and Iowa Geron tology Center, College of Dentistry, University of Iowa, Iowa City, 1979, pp 20, 22, 23, 31. 3. East Central Iowa Council of Governments. Re gional transit development plan. Coralville, Iowa, 1981, pp 111-115. 4. Special report on aging. US Department of Health, Education, and Welfare, Public Health Ser vice. NIH pub. no. 80-1907,1980, p 1. 5. Simpson, R., and others. Geriatric dentistry. Pro ceedings, Preventive and Community Dentistry, and Gerontology Center, University of Iowa, Iowa City, 1978, pp 7, 45-48. 6. Lotzkar, S. Dental care for the aged. J Public Health Dent 37(3):201,1979. 7. Ettinger, R. Patient assessment, management and treatment modifications. Dental Care in nursing homes. In Simpson, R., and others. Geriatric den tistry. Proceedings, University of Iowa Preventive and Community Dentistry and Gerontology Center, 1978, pp 34, 45-48. 8. Simpson, R., and others. Dental care in nursing homes. Monograph. Preventive and Community Den tistry, College of Dentistry, University of Iowa, Iowa City, 1979, pp 13,15. 9. Iowa rules and regulations setting minimum standards for health care facilities, Sept 27,1976, pp 79,87. 10. ADA Council on Dental Health and Health Planning. Oral health care for the geriatric patient in a long-term care facility. Chicago, American Dental As sociation, 1981, p 6. 11. Simpson, R.; Cunningham, M.; and Jakobsen, J. A nursing homes survey on transportation for dental care. Proceedings, University of Iowa, Preventive and Community Dentistry. 1981.
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