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Promoting Oral Health Care for People with HIV Infection

January 2004

ACKNOWLEDGMENTS

This booklet would not have been possible without the participation of many people at community-based organizations, hospitals, dental schools and community health centers who lent their time and expertise during the preparation of this document. In particular we wish to acknowledge the generous assistance from individuals at the following organizations:

Albany Medical Center
David Drohan, DDS

Bronx Lebanon Hospital Center
Paul Gates, DDS; Cheryl Stolarski, DMD; Iris Santiago

Brooklyn Hospital Center, The PATH Center
Dan Sendzik; Leonard Berkowitz, MD; Harry Dym, DDS

Columbia University School of Dental and Oral Surgery
Georgina Zabos, DDS; Sandra Burkett, DDS

Erie County Medical Center
Stuart Fischman, DMD

Harlem United Community AIDS Center, Inc.
Patrick J. McGovern

Joseph P. Addabbo Jr. Family Health Center
Rosa Rodriguez

Montefiore Medical Center
Barry Zingman, MD; Judy Schrager, RN; Jorge Rodriguez, MPA; Joan Grcevic, DDS; Lila Nikkah, DDS; Fleur Wheeler, RDH

Saint Barnabas Hospital
Dara Rosenberg, DDS

State University of New York Stony Brook School of Dental Medicine
Barbara Berentsen, RDH; Fred Ferguson, DDS; Sharon Nachman, MD

Westchester Medical Center
Peter De Lisi, DDS; Giovanni Boiano, DDS; Anthony Alessi, DMD; Rosanne Scallion, Elfreda Darrien, Keri Gallagher-Tone

Woodhull Medical and Mental Health Center
Sheldon Stachel, DDS; Peter Sherman, DDS; Yusaf Afacan, MD; Maria Pineiro

Photographic Credits:
Dr. Victor Badner, Kimberly L. Collins, Dr. Peter Delisi, Dr. David Drohan, Jennie B. Epstein, and Dr. Olapeju Simoyan

Special thanks to Dr. Victor Badner, the principal consultant, and Dr. Olepeju Simoyan for their active participation in this project.

INTRODUCTION

The purpose of this booklet is to provide health care practitioners and administrators with practical advice for initiating and maintaining a high standard of HIV oral health care for their patients.

The HIV/AIDS epidemic continues to pose enormous challenges in the United States, both for the communities most affected, and for the health care professionals who serve these communities. Highly active antiretroviral therapy has made HIV/AIDS a chronic, manageable disease.1 Inadequate oral health care, however, can undermine the success of treatment by exacerbating existing medical conditions, compromising adherence to an antiretroviral treatment regimen, and diminishing quality of life.

Oral disease occurs disproportionately among individuals from low socioeconomic levels and among those who are most vulnerable because of poor general health.2 Most reported cases of HIV occur in communities where levels of oral health care utilization are among the lowest in the nation. This is associated with lack of access to care and lower education levels.3 Improving oral health within these communities will require changes at a number of levels. Medical care providers will require a better understanding of the relationship between oral disease and general health, and patients living with HIV will need to better appreciate the importance of oral health in general health and well being.

This booklet offers guidance to individuals and health care organizations that currently provide or are planning to initiate oral health care services for people with HIV/AIDS. The best practices included in this booklet reflect creative solutions to the challenges that arise in providing quality oral health care, ranging from attracting and retaining patients in care to approaching oral health care delivery in a multidisciplinary manner. These best practices have been compiled from a series of face-to-face and telephone interviews with clinicians and administrators working in hospitals and community health centers across New York State.

This booklet is divided into several sections:

The Importance of Oral Health: This section explains why oral health care is a critical component of high quality HIV primary care. Key recommendations developed by the New York State Department of Health AIDS Institute regarding routine oral health care for HIV-infected patients are included.

Best Practices with Case Studies: This second section describes practices that have been demonstrated to be effective in improving oral health care delivery at facilities across New York State. Best practice topics include increasing patient knowledge and access to information, improving access to dental services, improving patient outreach, encouraging patients to schedule and keep their appointments, facilitating information management, and utilizing staff resources effectively. The accompanying cases describe in greater detail strategies that different institutions have utilized to overcome barriers.

Quality Improvement: This section includes examples of quality improvement activities that institutions may adopt to attract greater numbers of HIV-infected clients into dental care.

Resources and Tools: Resources and training information to assist sites in delivering high quality oral health care are presented within this section.

We hope the insights and perspectives included here will inspire readers to develop new programs or to improve existing services within their settings. The response of those who use this manual will assist us in improving how we promote quality of care. Please address any comments or suggestions to:

Oral Health Policy Liaison
HIV Guidelines Program
Office of the Medial Director,
AIDS Institute, New York State Department of Health
5 Penn Plaza, New York, NY 10001
or use the “Contact Us” link at www.hivguidelines.org.

Bruce D. Agins, MD, MPH
Medical Director
AIDS Institute
New York State Department of Health

Stephen N. Abel, DDS, MS
Oral Health Policy Liaison
AIDS Institute
New York State Department of Health

I. THE IMPORTANCE OF HEALTH FOR HIV-INFECTED PATIENTS

Oral health is integral to general health. Good oral health care is especially important for people living with HIV/AIDS for the following reasons:

  • Oral manifestations are common in people with HIV infection. By some estimates, more than ninety percent of HIV-infected patients will have at least one HIV-related oral manifestation in the course of their disease.4
  • Oral lesions may herald decline in immune function. For example, untreated HIV-infected patients with oral candidiasis have been shown to progress to an AIDS diagnosis within a two-year period.5
  • Controlling a focal infection within the oral cavity may eliminate adverse consequences such as systemic infections.
  • Poorly functioning dentition can adversely affect quality of life. For example, oral pain or discomfort may cause patients to avoid eating resulting in weight loss, which may be especially distressing for HIV-infected patients concerned about wasting.
  • Oral pain and difficulty in swallowing (dysphagia) can be unrecognized barriers to successful treatment adherence, illustrating the importance of close coordination between the oral health and medical teams.
AIDS Institute Clinical Guideline Recommendations

The Dental Standards of Care Committee of the New York State Department of Health AIDS Institute has developed recommendations for delivering comprehensive quality dental care in a multidisciplinary approach with medical and social support providers. This document, entitled Oral Health Clinical Guidelines, documents the following recommendations:

  • Oral health should be integrated into the HIV care plan and coordinated between the oral health and medical teams.
  • An oral health practitioner should perform a well-documented, hard and soft tissue examination that includes a complete head and neck examination at the initial and recall visits.
  • HIV primary care providers should document that all patients under care are referred annually to an oral health provider or that the patient is actively under the care of an oral health provider.
  • The medical team should encourage all patients to follow the recommendations of their oral health providers.

- AIDS Institute: Oral Health Care for People With HIV Infection6

II. BEST PRACTICES IN ORAL HEALTH CARE

The oral health care providers and administrators interviewed for this booklet have identified best practices in the provision of oral health care for people living with HIV/AIDS which include:

  • Increasing patient knowledge through education
  • Increasing access to oral health care
  • Improving information management
  • Utilizing a multidisciplinary approach to oral health care

Best practices are summarized and are followed by one or more detailed examples from a specific facility illustrating model practices. Not all examples will apply to every facility. However, the best practices outlined below represent a menu of options that can be tried, and when appropriate, adapted for your facility.

Increasing Patient Knowledge Through Education

Empowering patients with knowledge is associated with adherence to a variety of medical recommendations, including those for HIV. Providers should ensure that each patient has the information needed for reasoned decision-making.7 The following are examples of educational efforts that some facilities use to enhance patients’ understanding about the importance of oral health:

  • Develop simple fact sheets at a range of literacy levels and in languages used by your patient population which emphasize:
    • The importance of oral health care for those infected with HIV,
    • What to expect during an oral health exam; and
    • The importance of follow-up care
  • Make oral care brochures in multiple languages available to illustrate techniques on self-examination, flossing and brushing.
  • Turn dental and clinic waiting rooms into “education rooms” by playing educational videotapes that promote oral health care.
  • Create a lending library of oral health-oriented education videos that clients may take home and watch. These resources are available from dental professional organizations such as the American Dental Association.
  • Provide critical prevention messages at the onset of therapy. Empower patients to prevent disease recurrence by combining professional care with good self-care. This includes training patients to check their mouths for any changes such as the development of red or white areas. Use models, brochures, drawings, and diagrams to visually reinforce messages. Additionally, teach patients how to reduce the incidence of caries through oral hygiene techniques and dietary intake. Hygienists can distribute toothbrushes and floss, instruct patients on their proper use and assist them in developing strategies to incorporate self-care into daily routines.
  • Conduct patient group education sessions. Include oral health topics in patient HIV support programs. Invited guest speakers and/or health educators can address existing groups of patients being treated within your facility. Utilize faculty from dental schools, schools of dental hygiene, or other local resources to participate in the program. Guest speakers can provide useful information about patients’ health issues in general and oral health care in particular.
  • Offer smoking cessation counseling. Smoking compromises oral health, delays wound healing, accelerates breakdown of the periodontal attachment and is prominently associated with oral and pharyngeal carcinoma. Anti-smoking messages should be delivered in the context of oral disease prevention. Patients should be informed about the risk of oral cancer from smoking and facilities should offer counseling and treatment to promote smoking cessation. Further information can be accessed on the American Dental Association website at www.ada.org
  • Educate the community about the importance of oral health care by distributing literature and presenting informal lectures. These can be offered to the community-at-large at health fairs, schools, youth groups or other venues that bring people from the community together.
  • See Section IV for resources related to patient education and access to information.

    Focus on Patient Education:

    Westchester Medical Center

    Westchester Medical Center has developed a multidisciplinary, focused program that offers both inpatient and outpatient care. This AIDS Care Center serves Westchester County and the six surrounding counties of the Mid-Hudson region. Westchester’s dental program, established in 1992, is an integral component of the AIDS Care Center, offering comprehensive and emergency dental treatment to over 300 HIV-infected clients annually.

    Westchester’s dental program prides itself on conducting extensive education programs for HIV-infected persons. The following are key components of program activities:

    Patient Education Materials

    Patients seen in the dental department are educated about the signs and symptoms of infections associated with HIV and what can be done to maintain oral health through diet and oral hygiene. A patient education brochure entitled “A Guide to Dental Care for the HIV-Infected” was developed by staff members and is an especially useful resource for this purpose (see Section IV, Printed Resources for Health Professionals and Consumers).

    Community Patient Education

    The dental staff provides oral health education sessions at many community-based social service agencies throughout the Hudson Valley region. Through question and answer sessions, clients build a better understanding of the importance of oral health in their general health. Subsequently, many schedule dental appointments at Westchester Medical Center. Additionally, Westchester Medical Center invites groups of people with HIV from local community-based organizations to the Center for HIV education updates. The dental director reviews the dental brochure with them and encourages participants to schedule appointments for oral health care.

    Improving Access to Dental Care

    Oral Health in America: A Report of the Surgeon General2

    “There are profound and consequential oral health disparities within the U.S. population. Social, economic, and cultural factors and changing population demographics affect how health services are delivered and used, and how people care for themselves. Reducing disparities requires wide-ranging approaches that target populations at highest risk for specific oral diseases and involves improving access to existing care.”

    There are a number of practices that facilities can implement to improve access to oral health care. Methods for achieving greater access include:

    • choice of treatment site location
    • flexibility when scheduling appointments
    • co-location of oral health services with medical or other services
    • networks of community-based dentists
    • satellite clinics in convenient locations
    • family-centered service models
    • transportation/escort services and childcare

    All of the approaches described in the best practice case studies involve responding to the unique needs of the community served, from methadone maintenance treatment clients to residents of rural communities. These sites made efforts to bring oral health care to the communities they serve.

    Access to safe, appropriate oral health services is of particular concern for children who are HIV-infected. Pediatric dentists or services should be made available to these children either on site or through referral. Because providing dental care to children presents unique challenges, those facilities not able to do so on site should develop a network of linkages within their community of pediatric dentists able to offer this care. Offering transportation and/or escort services for dental appointments may be especially effective in ensuring that HIV-infected children receive appropriate dental care.

    The following suggestions come from several oral health care programs that have made efforts to increase access to care for their HIV-infected patients:

    • Ensure that all HIV primary care team members and their patients can find and access nearby dental facilities when oral health services are not available on site. Utilization of oral health services has been shown to increase when patients can access care near their homes. The New York State Department of Health has published an HIV oral health directory of sites funded to provide oral health care to patients with HIV disease (see Section IV, HIV Oral Health Resource Directory).
    • Offer transportation or fares to and from oral health services, or provide case management escorts to and from appointments. A Metrocard or the encouragement of a case manager can be helpful in getting a patient to visit the dentist.
    • Make oral health care available at times that are convenient for the population served, such as early mornings, evenings, weekends, or at times when patients are coming to the clinic for medical care. Build time into the dental program’s schedule for walk-in appointments.
    • Use reminder tools to help patients remember appointments. Examples include associating appointments with certain milestones or times of the year, sending reminder letters, which should be available in multiple languages, or making confirmation phone calls prior to the appointment.
    • Offer safe and appropriate childcare either on-site or through a local community- based organization. This issue is of particular concern to single parents. Clinics that provide childcare when HIV-infected parents are undergoing treatment can eliminate a major barrier to making dental appointments and receiving care.
    • Train front-desk staff to be sensitive to the needs of the patient, including asking patients for their scheduling preferences and appropriately handling HIV-related information. Facilities should provide training on HIV confidentiality issues to all staff members.
    • Allow patients to choose their place of treatment among the various sites at a facility, if multiple sites exist. Patients may, for example, choose a mainstream clinic or a location that is designed exclusively for the care of HIV-infected patients.
    Following Up on Missed Appointments

    Clinics should have a policy in place to contact patients who have missed their appointment. Assign staff to follow up with patients who require rescheduling.

    Determine why a patient is repeatedly missing appointments. Barriers can frequently be overcome once understood by the staff. For example, patients who have no transportation or are unable to leave elderly parents or young children at home often need assistance to assure they can keep their appointments.

    Develop linkages with community-based case management programs to address needed support services that can facilitate patients receiving consistent dental care.

    A Model of Convenience to Care for Patients and Their Families:
    Woodhull Medical and Mental Health Center, Paul Paroski Center

    The Woodhull Medical Center has been providing care to people living with HIV since the early 1980s. Woodhull’s team approach to HIV care includes physicians, dentists, pediatricians, nurses, social workers and community liaisons all working together to administer high quality treatment.

    In 1993, four dental treatment rooms within the general dental clinic were set aside for the care of HIV patients. Initially, all dental services were located separately from the general medical clinic. It soon became apparent that many dental patients were dissatisfied with the inconvenience of having to leave the HIV Center to access dental care and with the insensitivity towards their HIV status displayed by some staff of the dental clinic. Woodhull addressed these and other patient concerns in the following ways:

    Choice of locations

    In 1994, concerns from patients and providers resulted in the establishment of a second dental service which was physically integrated into the HIV program. Currently, this integrated HIV facility provides over 1,200 oral health visits annually. HIV/AIDS patients are now able to obtain oral health care either at the general dental clinic or in the smaller, integrated HIV care facility.

    Fast-tracking appointments

    To streamline the process of making appointments, HIV patients who prefer the general dental clinic are given appointments more quickly than the general population. Not only are emergency cases seen on a same-day basis, but Woodhull’s electronic referral and communication lines are so well established that non-emergent dental care can often be obtained on the same day.

    Family-focused services

    To further reduce barriers to care, Woodhull has also eliminated the inconvenience of separate treatment sites for the family members of HIV/AIDS patients. Family members are welcome to receive care in the HIV clinic. The family-friendly Center also provides a playroom for clients’ children with puzzles, coloring books, toys and furniture appropriate for different age groups.

    In many aspects of its daily operation, Woodhull Medical Center stands as a model of patient- and family-centered care for HIV-infected patients and their families.

    Bringing Care into the Neighborhoods:
    Montefiore Medical Center, Community Dentistry Division

    Montefiore Medical Center (MMC) is located in a community in the Bronx that has one of the highest incidence rates of HIV infection in New York State. Access to dental care in the Bronx is especially limited, with several localities designated as Federally Qualified Dental Health Professional Shortage Areas. Montefiore has developed one of the largest dental departments in New York State, providing oral health care to HIV-infected patients in multiple locations including: hospital-based dental facilities, HIV-focused integrated dental/medical facilities, community-based drug treatment programs, homeless shelters and community health centers. To increase access to dental care, Montefiore has established dental services within a broad network of community-based organizations and offers appointments at times which are convenient for the target population.

    For some patients, one obstacle to accessing dental care is an ongoing concern that they will be discriminated against or denied appropriate care at facilities not specifically dedicated to the care of HIV-infected individuals. The dental program at MMC’s Infectious Disease clinic addresses this concern by integrating its services with those of the HIV medical team. Patients’ familiarity with team members and scheduling personnel, and the use of patient service representatives to escort patients to and from dental appointments, increases patients’ use of dental services at this facility.

    Initially, Montefiore provided community-based facilities, such as shelters, drug treatment centers and nursing homes, with opportunities to work together in the design of HIV primary care/oral health programs that matched the needs of their client base. Designing successful programs required collaboration between the health care team from an academic medical center and the administration of community-based agencies.

    Unique to these programs is the availability of Montefiore oral health staff during hours that are convenient to the populations served by the community agencies. For instance, the dental program that is located within a methadone maintenance program opens early to provide morning dental appointments when the clients arrive for their daily methadone. At the dental facility that has been established within a homeless shelter, access to care is available in the early evening hours when clients arrive.

    All aspects of preventive, restorative and prosthodontic care, along with simple extractions, are performed at each of the satellite facilities, while parenteral sedation for the many apprehensive patients and for those undergoing more complex procedures is performed at the local Montefiore dental clinics.

    Montefiore successfully brings oral health to the hard-to-reach populations within the Bronx by:

    • Co-locating services throughout the community
    • Meeting the scheduling needs of the clients
    • Offering integrated dental services in the medical clinic for patients most comfortable receiving care in that setting

    Developing Community Partnerships:
    We Care – Columbia University School of Dental and Oral Surgery

    Established in 1999, Columbia University’s We Care program offers preventive and early intervention dental services at four community-based HIV/AIDS medical programs in Manhattan, effectively bringing dental care to the people it serves. A mobile dental team provides direct dental services on-site to the following affiliated community-based organizations:

    • Women and Children Care Center (Babette’s Place), which provides medical and supportive services for women with HIV/AIDS and their children.
    • Harlem United Community AIDS Center, Inc., which offers medical and supportive day treatment services to adults with problems including homelessness and substance abuse.
    • Safe House, a residential program, which provides a temporary home, supportive services and medical referrals to homeless adolescents with HIV/AIDS.
    • Project Renewal, a non-profit provider of homeless services.

    The oral health care team of We Care consists of a dental school faculty attending, a dental fellow and a dental assistant. Portable equipment is stored at the various sites and is used in spaces that are shared with other medical specialties. Storage space is provided on-site for bulk materials and supplies; sterilization of equipment is performed at the Columbia University School of Oral and Dental Surgery.

    We Care staff actively recruit patients in the waiting rooms and communal areas of the community-based organizations where it offers services. Additionally, the dentists promote their program to all staff and health providers within the agencies.

    Once a client elects to become a dental patient, the following services are offered:

    1. Education about appropriate oral health self-care
    2. Distribution of toothbrushes, toothpaste and floss
    3. Periodic oral examinations
    4. Early intervention and preventive care services (i.e. sealants, fluoride treatments, interim restorations)
    5. Follow-up appointments in local dental clinics for comprehensive dental services such as restorative and prosthodontic care.

    The rise in the number of patients who have accessed dental care services through the We Care program speaks to its success. Prior to the establishment of the program in 1999, only 15% of the clients at these participating agencies had an annual dental visit. Presently, the percentage is over 50%. Thus, through developing close partnerships with community agencies, Columbia University has effectively promoted and improved the oral health of Manhattan’s underserved populations.

    Bringing Oral Health Care to a Rural Setting:
    Albany Medical Center and the Mid-Hudson Care Center

    The Albany Medical Center (AMC) serves the dental needs of many HIV patients in the northeast region of New York State. Current strategies to improve access at this site include the establishment of an HIV satellite clinic for rural consumers, co-location of dental and medical services, and close collaboration between the academic and community-based facilities.

    AMC provides services at its rural satellite clinic, the Mid-Hudson Care Center in Kingston, New York, 55 miles from Albany Medical Center. Because no major health care institutions are located in the area surrounding Kingston, AMC elected to establish HIV medical and oral health care services at this community site. All patients seen by the medical team at Mid-Hudson Care Center are referred to the dental service for treatment.

    The Mid-Hudson site provides dental care on a limited basis (three Mondays per month), requiring close coordination with the parent institution in Albany. While routine preventive, restorative, and prosthetic dental services are provided in Kingston, more complicated procedures are referred to Albany. When a patient is referred to AMC for treatment, the same treatment team from Mid-Hudson provides the care at AMC, retaining the advantage of interpersonal relationships that have been established. In these cases, the dentist transports the dental charts from the Mid-Hudson site to Albany, assuring seamless provision of care.

    The relationship between Albany Medical Center and the Mid-Hudson Care Center is a model dental partnership between an urban and a rural region. As the incidence of HIV disease continues to rise in rural settings, successful models of delivering HIV care in these and other hard-to-reach communities become increasingly important.

    Focus on Pediatric Oral Health Care:
    State University of New York at Stony Brook Dental School

    The State University of New York at Stony Brook Dental School (SUNY Stony Brook) has a long history of providing services to HIV-infected patients on Long Island in New York State. Since 1990 SUNY Stony Brook has been addressing the oral health care needs of HIV-infected pediatric patients through a Ryan White-funded dental program.

    As a response to the high number of pediatric HIV operating room procedures for extensive oral rehabilitation in the 1990′s, the dental program shifted its focus. SUNY Stony Brook’s mission now focuses on prevention, recognizing that HIV-infected children are particularly susceptible to caries, in part as a result of taking sugar-based medications. Furthermore, the dental program, originally located within the University Hospital Center, was moved to the Dental School to offer greater comfort and confidentiality to young patients and their families and caregivers.

    Stony Brook’s pediatric dental program plays an active role in improving access to pediatric oral health care throughout Long Island. Not only does the program coordinator arrange appointments and facilitate the children’s visits, but often arrangements are made for transportation and/or escort services free of charge. Through effective teamwork among primary medical care providers, social workers, maternal/child health workers and dentists, HIV-infected children treated within SUNY Stony Brook receive routine outpatient dental care.

    AIDS Institute Clinical Guideline Recommendation

    The primary care provider should perform an initial dental screening at approximately 12 months of age in HIV-infected children. Preventive information and anticipatory guidance regarding bottle-feeding, eruption sequence, and infant oral hygiene should be given to parents at this time. By 24 months of age, children should be referred to an oral health care provider.

    - AIDS Institute, Criteria for the Medical Care of Children and Adolescents With HIV Infection8

    Managing Information to Improve Care

    Thorough, accurate and definitive documentation ensures the effectiveness of an oral health program and facilitates monitoring quality of care. The following strategies facilitate the use of information to provide continuity of care:

    • Forms completed by patients should be written at a reading level that is appropriate for the population. Medical history, release of information and informed consent forms should be available in multiple languages. Documentation of all forms signed by patients should be maintained within the patient file. (Copies of release of information and other HIV-related forms can be accessed through the New York State Department of Health AIDS Institute website’s Order Form)
    • The dental chart should contain all necessary information relevant to a patient’s oral care. Pertinent information includes:
      • Medical history
      • Dental history
      • Identification of chief complaint
  • Radiographs
  • Drug and lab prescriptions
  • Correspondence
  • Consultation and referral reports
  • A sequenced treatment plan individually designed to address patient needs
  • Documentation in the record should be arranged in a manner that provides quick access to key information and lends itself to easy review by third parties.

    • Implement a system to document dental and medical communication. Dental visit and consultation reports rarely make their way into medical charts. Some programs have overcome this barrier to effective communication by implementing carbonless medical record inserts and consultation forms that can readily be placed in the medical and dental charts.
    • Revise the medical chart and progress notes to include an oral health referral section. This has been implemented by several facilities as part of quality improvement activities.

    Following are two examples of well-designed dental and medical forms. The dental treatment plan form used by St. Barnabas Hospital in the Bronx has a particularly functional layout. The medical annual examination flow chart used by Brooklyn Hospital Center effectively integrates oral health care into routine health maintenance documentation.

    Medical annual examination flow chart used by Brooklyn Hospital Center (Acrobat PDF)

    Dental treatment plan form used by St. Barnabas Hospital (Acrobat PDF)

    Multidisciplinary Models of Care

    Strong collaboration between oral health practitioners, medical providers and social service support staff is critical in order to achieve optimal health care outcomes. Practices utilized by clinics throughout New York State follow.

     

    Suggestions for Building a Team to Address Oral Health Issues
    Make medical staff aware of the importance of oral health in comprehensive HIV primary care. Staff meetings and in-service conferences should be used to reinforce the importance of regular oral examinations for people living with HIV/AIDS. All medical care providers should be made aware of oral health referral sources for patients under their care.

    Train all members of the primary health care team to perform an initial oral exam. Dental staff can instruct the medical team to recognize early signs and symptoms associated with oral disease. The Agency for Healthcare Research and Quality has recommended that all primary care clinicians should be trained to regularly perform oral cancer examinations on high-risk persons. Medical staff should be supplied with the necessary tools (mouth mirror, gauze and an appropriate light source) in order to conduct a proper oral examination.

    Utilize case managers to promote oral health care. The availability of case managers, volunteer workers or peer counselors was frequently cited as a factor contributing to the best practices in oral health care for people living with HIV/AIDS. These providers can:

    • Serve as intermediaries between medical providers, dental providers and patients by interpreting care recommendations
    • Remind patients of upcoming appointments
    • Act as patient advocates for achieving improvements and expansion of oral health services in a broader range of settings

    Encourage nurses and health educators to play important roles in reinforcing oral health messages. Dentists can train other providers about oral health issues which they can then share with patients. Suggested topics include:

    • The oral side effects of HIV medications (e.g., xerostomia, ulcerations)
    • The importance of preventive oral health care
    • The relationships between oral health and systemic health

    Consider including dental providers in HIV/AIDS patients’ care conferences. The dental provider should function as a member of the HIV primary health care team. By including dentists in case conferences and clinical rounds, the dental provider may become more aware of physical and psychosocial factors that are impacting the patient’s response to oral care. Alternatively, the dentist may provide additional insights to members of the HIV team on reasons, such as dental pain, that might contribute to patients’ non-adherence to drug therapy.

    Several strategies for building and utilizing a multidisciplinary team approach to oral health care services are found across New York State. A model multidisciplinary approach is found at Joseph P. Addabbo Jr. Family Health Center in Queens, New York.

    A Multidisciplinary Approach to Dental Care:
    Joseph P. Addabbo Jr. Family Health Center

    The Joseph P. Addabbo Jr. Family Health Center (Addabbo) is a large community health clinic in Far Rockaway, New York. Personnel include advanced general dental residents, general dental attendings, dental specialists, dental assistants, a peer counselor and a case manager.

    The program offers a multidisciplinary team approach. Not only do health professionals coordinate their services with each other, but staff members from all disciplines work together to ensure quality of care. Close coordination exists among all departments. An example of how Addabbo has achieved success in implementing a multidisciplinary approach is the fact that the support staff of the medical clinic (clerks and peer counselors) physically escort patients to the dental clinic for their initial dental appointment. These staff members have engendered a trusting relationship with the patients both at the clinic and through social events. Their presence at the first dental visit provides patients with the necessary reassurance to overcome the fears that have previously kept many from seeking non-emergent care.

    Addabbo is a family-oriented facility that prides itself on its “small-town community” environment; for example, everyone, from clerks to doctors to patients, is on a first-name basis. In addition, Addabbo holds community-wide events such as health fairs and barbecues where patients become better acquainted with the providers, peer educators and each other. These activities also ensure that all staff have opportunities to interact, even if they do not work directly together at the clinic.

    Addabbo promotes a respectful, caring atmosphere for its clients, inspiring positive interactions at every turn. Close working relationships among the medical, dental and social support divisions have led to virtually all of their HIV-infected clients receiving treatment within the Addabbo dental program.

    III. QUALITY IMPROVEMENT

    Facilities can implement a number of practices to enhance the quality of their clinical services and to improve access to care. Principally, a quality improvement program fosters optimal clinical care for patients. Additional benefits from the program include improvements in systems of care delivery and enhanced communication throughout the organization. Examples of quality improvement projects addressing oral health issues that were conducted at Brooklyn Hospital and Nassau University Medical Center follow.

    A Model Method for Increasing Dental Referrals & Appointments:
    The PATH Center at Brooklyn Hospital

    Background

    The Brooklyn Hospital Center has been providing health care to residents of the northern and central Brooklyn community since 1845. The hospital center’s network includes two hospital campuses and three off-site health centers. The Program for AIDS Treatment and Health (PATH) is the hospital network’s HIV outpatient service.

    PATH provides services at the Downtown and the Caledonian Campuses of the hospital. The oral health initiative described here focuses on Caledonian, where 60% of PATH patients receive care but where, until recently, no on-site dental service existed.

    Methodology

    Initiated in 1998, PATH’s ongoing Performance Improvement (PI) process involves the quarterly review of 48 randomly selected medical records, surveyed with a tool that consists of 40 indicators. Among the indicators are “Patients Referred for Oral Health Care” and “Patients Receiving Annual Oral Health Exam.” The PI Committee noted that the percentage of patients receiving referrals and exams was low. In December 2000, the hospital began a QI process to specifically improve oral health care for HIV positive patients.

    The PATH Center followed a process using the acronym “FOCUS”. It is described as follows:

    Find an Opportunity for Improvement

    Data showed that during the period from July 1997 to June 1998, only 27% of patients were being referred for oral health care and only 18% of referred patients kept their appointments. In December 2000 the QI team set two goals to be achieved by June 30, 2002:

    • Increase the percentage of patients referred for annual oral health care to 90%.
    • Increase the percentage of referred patients receiving oral health care to 75%.

    Organize a Quality Improvement (QI) Team

    A multidisciplinary QI team was formed consisting of:

    Chief of ID Medicine
    PATH Director
    Senior Staff Nurse
    Operations Manager
    Chief of Oral Surgery
    Dental Residents

    Clarify the Existing Process

    The QI Team reviewed how patients were being assessed for oral health needs and how and where they were being referred for exams.

    Understand the Process Variations

    Through brainstorming, the QI Team identified the process variations—where the process of referral and receiving care required improvement. Barriers included the following:

    • House staff serving in the PATH Clinic lacked adequate orientation on the importance of oral health care for HIV-infected patients.
    • For most PATH patients, oral health services were not available near their homes.
    • Documentation of oral health care was not easily visible in the medical record.

    Select Improvement Measures

    Based upon the above analysis, the QI Team selected and implemented four interventions. They were:

    • Incorporate an oral health segment into the orientation for house staff rotating onto PATH. Information was added to the orientation packet and to the presentation given monthly to the residents by the Director of Clinical Services.
    • Use a rubber stamp to highlight dental notes in the medical record so providers and reviewers could locate the information readily.
    • Recruit a dental hygienist for the PATH Clinic to perform oral health screenings on-site.
    • Create an HIV Dental Clinic at the Caledonian campus location thereby providing dental services closer to many patients’ homes.

    Results

    These interventions resulted in a significant improvement in the percentage of patients referred for oral health care and the percentage that actually received services, as the following graphs illustrate.

    patientsreferred.jpg

    patientsreceiving.jpg

    By September 30, 2002, 88% of patients received an annual oral health referral. Of those, 100% had received services.

    Conclusions

    • A coordinated, multidisciplinary team approach can improve oral health care delivery for HIV-infected patients.
    • Incorporating a dental clinic into the HIV program setting improves access and the likelihood that patients will accept oral health services. Co-locating a dental provider in the medical clinic to perform triages also promotes the acceptance of dental services by patients.
    • For teaching institutions, orientation of house staff is a critical link in ensuring that patients receive oral health services.

    A Comprehensive Approach to Increasing the Number of Patients Receiving Dental Care:
    Nassau University Medical Center

    Background

    The Nassau University Medical Center (NUMC) is part of a 1,500 bed health care system that includes a 615-bed tertiary care teaching hospital, an 889-bed skilled nursing facility, a 40-bed correctional center infirmary and six community health centers. HIV outpatient services are provided at the NUMC Designated AIDS Center and at three community health centers (Freeport, Hempstead, and New Cassel-Westbury).

    Methodology and Improvement Goals

    In 1998, a random review of 50 HIV outpatient clinic charts documented that only 12% of patients were referred for dental services, and only 4% received dental services within the past year. NUMC AIDS Program staff decided to develop a quality improvement project to increase the percentage of patients referred for dental care to 60% and increase the percentage of patients receiving dental examinations to 20%.

    Quality Improvement (QI) Team:

    A multidisciplinary team was created to oversee this project. The members included the:

    • Medical Director of HIV Outpatient Services
  • Head Nurse for the HIV Clinic
  • HIV Case Manager
  • HIV Clinic Registrar
  • Nicholas A. Rango HIV Clinical Scholar, Project Coordinator
  • Clarifying the Existing Process and Selecting Improvement Measures

    The QI team reviewed the current mechanism for dental referrals and identified the following problems:

    • Clinic staff was unaware of the importance of oral care as a component of comprehensive HIV care.
    • Providers and patients were unaware of the dental resources within the community.
    • The progress note had no specific area to document discussion of dental services.

    After reviewing the current process and identifying barriers experienced by providers and patients, the following measures were initiated:

     

    Initiated Measures
    • Training was provided to HIV Clinic staff about the importance of dental services for patients.
    • Flyers were prepared for patients highlighting the importance of oral health care. Clinic nurses distributed the flyers at the intake assessment.
    • A list of local dental providers in Nassau and Suffolk Counties was developed for distribution to the patients.
    • The clinic progress note was revised to include a specific area for documenting counseling about oral health.
    • Individualized “intensive” counseling emphasizing the importance of dental care was provided to the patients by the NUMC team, assisted by staff and students of the SUNY Farmingdale School of Dental Hygiene. 
    • Monthly QI meetings were implemented to provide feedback to the staff on compliance with the project.

    Results

    dentalreferral.jpg

    The Dental Improvement Project resulted in a significant increase in documentation of the number of patients being referred for dental services and receiving dental services. The initial rate of referral for annual dental examination has increased from 12% to 95%. This improvement has been sustained over several years. In 2002, 70% of patients at NUMC received a dental examination, up from 4% since 1998.

    Conclusions

    A QI approach to identifying and eliminating barriers to care was successful in increasing the number of patients receiving dental services. These improvements were achieved through:

    • staff and patient education
    • identification of dental resources
    • improving the medical record and
    • implementing a multidisciplinary approach to assure that patients with HIV receive routine oral care.

    References

    1. Hogg RS, Rhone SA, Yip B, et al. On viral load-driven antiviral therapy. AIDS 1998;12:279-284.

    2. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

    3. Marcus M, Freed JR, Coulter ID, et al. On unmet need for oral treatment among HIV-positive medical patients. Am J Public Health 2000;90:1059-1063.

    4. McCarthy, GM. Host factors associated with HIV-related oral candidiasis. A review. Oral Surg Oral Med Oral Pathol 1992;73:181-186.

    5. Nielson H, et. al. Oral candidiasis and immune status of HIV-infected patients. J Oral Pathol (med), Mar 1994, 23(3) p 140-143.

    6. AIDS Institute, New York State Department of Health. “Oral Health Care for People with HIV Infection—HIV Clinical Guidelines for the Primary Care Practitioner.” December 2001.

    7. Weiss L, et al. HIV-related knowledge and adherence to HAART. AIDS Care 2003;15:673-679.

    8. AIDS Institute, New York State Department of Health. “Pediatric and Adolescent HIV Guidelines – Chapter 16. HIV Clinical Guidelines for the Primary Care Practitioner.” December 2002.

    IV. RESOURCES AND TOOLS

    The information presented in this section is intended to provide clinicians and administrators with additional resources for:

    • Locating clinical education and professional development related to oral health and HIV
    • Obtaining printed educational materials for themselves and their patients
    • Utilizing on-line resources for more in-depth information on oral health care in the HIV-infected population
    • Securing financial assistance available to facilities and consumers to cover oral health services
    • Identifying facilities offering dental care in communities throughout New York State to increase patients’ access to an oral health provider

    Local, Regional and Statewide Training Resources for Health Professionals

    New York State Department of Health AIDS Institute:
    The HIV Clinical Education Initiative (CEI)

    http://www.nyhealth.gov/nysdoh/aids/clinician.htm

    The CEI was established to expand HIV clinical expertise among clinical providers within a wide range of community-based settings by providing on-site training. The CEI also provides phone consultations on clinical management and post-exposure prophylaxis. For information and to contact one of the nearest CEI Centers in New York State, call The New York State Department of Health AIDS Institute, Office of the Medical Director, (518) 473-8815.

    New York State Department of Health AIDS Institute:
    The Nicholas A. Rango HIV Clinical Scholars Program

    The Nicholas A. Rango HIV Clinical Scholars Program is a fellowship-type program designed for physicians, physician assistants, nurse practitioners and dentists who are seeking hands on training in HIV clinical care and the public health aspects of the epidemic. The program strives to recruit clinicians who have the skills and commitment to provide leadership in the rapidly changing field of HIV medicine. Oral health is an integral component of the curriculum for all HIV Clinical scholars. The oral health-training component of this program is based out of Bronx-Lebanon Hospital Center. For further information, contact the Nicholas A. Rango HIV Clinical Scholars Program at the New York State Department of Health AIDS Institute, Office of the Medical Director, (518) 473-8815.

    The New York/New Jersey AIDS Education and Training Centers (AETC) Program

    www.nynjaetc.org

    The NY/NJ AETC program assists health care professionals to provide high quality services and care to persons with HIV. The NY/NJ AETC is capable of designing a training program tailored to the needs of an institution or the geographic region it serves. To discuss training needs call the NY/NJ AETC program at Columbia University at (212) 305-8291.

    The Westchester Medical Center’s Annual HIV Dental Conference

    This conference has trained hundreds of dentists, dental hygienists and dental assistants on the principles of oral health management for persons with HIV. For additional information call the AIDS Care Center at Westchester Medical Center, (914) 493-7700.

    Printed Resources for Health Professionals and Consumers

    1. For Health Professionals

    New York State Department of Health AIDS Institute: Oral Health Care for People with HIV Infection. HIV Clinical Guidelines for the Primary Care Practitioner

    www.hivguidelines.org

    These clinical guidelines are intended to assist in providing all members of the primary health care team with important clinical information regarding oral health. This publication can be downloaded at the website. Requests for sample copies and order forms for clinical guidelines and other educational materials are available by phone at (518) 474-9866 in Albany or (212) 268-6164 in NYC or by e-mail at hivpubs@health.state.ny.us. Publication #9450, 2001.

    New York City Department of Health HIV Resource Library

    www.nyc.gov/html/doh/html/ah/ah.shtml
    This library was established by the New York City Department of Health, Bureau of HIV Program Services, in order to provide current and comprehensive HIV-related information to health care providers in the New York City area, staff and clients of publicly funded community-based organizations, and the general public. The collection consists of books, periodicals, a videotape collection and special information packets. The library is located at 225 Broadway, 23 Floor, New York, NY 10007. To register for courses, call (212) 693-0774 between 10 am and 4 pm Monday to Friday.

    Dental Alliance for AIDS/HIV Care:
    Principles of Oral Health Management for the HIV/AIDS Patient

    www.aidsetc.org/pdf/curricula/Princ_Oral_Health_HIV.pdf

    This consensus monograph was developed by nationally and internationally recognized leaders in the dental community who are on the front lines of HIV clinical care and social support issues.

    To order call (888) 275-4772 and request inventory code #HAB 00230 or download.

    Academy of Oral Medicine: Clinician’s Guide to the HIV-Infected Patient

    http://aaom.com

    This monograph, developed by the Academy of Oral Medicine (AAOM), includes information on HIV epidemiology, pathogenesis, oral manifestations and treatment planning for patients with HIV disease.

    Order forms are available online.

    Printed Resources for Health Professionals and Consumers

    2. For Consumers

    New York State Department of Health AIDS Institute: Oral Health is Important. A Guide for Caregivers of Children with HIV Infection

    This easy-to-read pamphlet provides useful oral health education for caregivers of children with HIV. Requests for sample copies of this and other educational materials are available by phone at (518) 474-9866 in Albany or (212) 268-6164 in NYC or by e-mail at hivpubs@health.state.ny.us. Publication # 9290, February 2001.

    Westchester County Medical Center AIDS Management Program:
    A Guide to Dental Care for the HIV-Infected

    This consumer brochure provides guidance on self-examination for oral lesions along with daily oral hygiene techniques. A copy of this brochure may be requested by phone from the Ryan White Dental Clinic at Westchester Medical Center at (914) 493-7785.

    Web-Based Resources for Health Professionals

    New York State Department of Health AIDS Institute

    www.hivguidelines.org

    This website has been developed as a central, on-line resource that equips clinicians and administrators who provide services to people with HIV infection with current, state-of-the-art tools to ensure delivery of the highest quality HIV clinical care. These tools include clinical guidelines, prevention guidelines, examples of best practices and quality improvement information and software.

    The AIDS Education and Training Centers (AETC) National Resource Center

    www.aidsetc.org

    The National Resource Center is a web-based HIV/AIDS training resource that supports the training needs of the regional AETCs through coordination of HIV/AIDS training materials, rapid dissemination of late-breaking advances in treatment and changes in treatment guidelines, along with critical review of available patient education materials.

    HIVDENT

    www.hivdent.org

    This coalition of health care professionals is committed to assuring access to high quality oral health care services for people living with HIV disease. This site disseminates state-of–the-art treatment information and includes extensive information on the oral aspects of HIV disease.

    American Dental Association

    www.ada.org

    This website provides information on practice management, government issues and scientific affairs as they relate to HIV disease and oral health. Additional resources for patients and consumers include informational videos and brochures on oral health.

    Dental Alliance for AIDS/HIV Care

    www.critpath.org/daac

    This association of dental health care workers and other concerned professionals was organized to provide improved clinical oral care for patients with HIV disease.

    AIDSinfo

    www.aidsinfo.nih.gov

    A service of the U.S. Department of Health and Human Services, AIDSinfo is a central resource for current information on federally and privately funded clinical trials for AIDS patients and others infected with HIV. As the main dissemination point for federally approved HIV treatment and prevention guidelines, AIDSinfo provides information about current treatment regimens for HIV infection and AIDS-related illnesses.

    Centers for Disease Control and Prevention (CDC)

    www.cdc.gov

    CDC serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and education activities designed to improve the health of the people of the United States. The CDC website has extensive information related to HIV/AIDS disease, treatment and prevention.

    Financial Resources for Institutions Providing Dental Care

    New York State HIV Uninsured Care Programs: ADAP and ADAP Plus

    The New York State Department of Health AIDS Institute has established the HIV Uninsured Care Programs to provide access to medical services and medications for eligible New York State residents with HIV/AIDS. The ADAP formulary consists of more than 400 medications for HIV-related illnesses. ADAP Plus covers a full range of HIV primary care outpatient services including oral health treatment.

    For information regarding client and facility eligibility contact:

    New York State Department of Health
    HIV Uninsured Care Programs
    (518) 459-1641 or (800) 542-2437

    Department of Health & Human Services
    Health Resources and Services Administration
    HIV/AIDS Bureau

    • Dental Reimbursement Program of the Ryan White CARE Act

    This program provides grants to accredited dental schools, postdoctoral dental education programs and dental hygiene education programs to help cover the uncompensated costs of providing oral health services to patients with HIV infection.

    • Community Dental Partnership Program of the Ryan White CARE Act

    This newly established program provides support to dental and dental hygiene schools to partner with community-based organizations. The goals of the program are to provide oral health services to people with HIV in rural and urban unserved and underserved areas, and to train additional numbers of dental providers to deliver quality oral health care to people with HIV disease.

    For information on the Dental Reimbursement Program or the Community Dental Partnership Program contact:

    Division of Community-Based Programs
    HIV/AIDS Bureau
    Parklawn Building, Room 7A-30
    5600 Fishers Lane
    Rockville, MD 20857
    (301) 443-0493

    HIV Oral Health Resource Directory

    This directory, organized by borough in New York City and by region in New York State, is intended for use as a referral tool for providers and individuals seeking oral health services for HIV-infected patients. Among the many reported reasons why people with HIV do not access dental care is the fact providers and consumers are unaware of sites that offer oral health services. Through this directory, individuals may find venues for care previously unknown to them and providers may become more knowledgeable of oral health referral sites in their regions.

    Every attempt has been made to list facilities that receive funding through the Ryan White Care Act. It may be necessary to contact the site prior to the patient’s arrival in order to determine the intake policy of the facility. Within New York City, it may be helpful to look at sites in several boroughs since some sites serve clients from neighboring localities.

     

    New York City – Borough of Bronx
    North Central Bronx Hospital
    1400 Pelham Parkway S.
    Bronx, NY 10467
    (718) 918-3422 (P)
    (718) 824-4547 (F)

    Montefiore Medical Center

    111 East 210th Street
    Bronx, NY 10467
    (718) 918-3418 (P)
    (718) 824-4547 (F)

    Montefiore Medical Center
    @ Jacobi Medical Center

    1400 Pelham Parkway S.
    Bronx, NY 10461
    (718) 918-3422 (P)
    (718) 842-4547 (F)

    Montefiore Medical Group
    Comprehensive Health Care Center

    305 East 161st Street
    Bronx, NY 10451
    (718) 579-2500, Ext.104

    Montefiore Medical Center
    @ North Central Bronx Hospital

    3424 Kossuth Avenue
    Bronx, NY 10467
    (718) 519-3300

    Montefiore Medical Center
    @ Van Etten Hospital

    Morris Park & Seminol Avenues
    Bldg. #5, Room 3C15
    Bronx, NY 10461
    (718) 918-3422

    Morrisania Diagnostic
    and Treatment Center

    1225 Gerard Avenue
    Bronx, NY 10452
    (718) 960-2945 (P)
    (718) 960-2609 (F)

    St. Barnabas Hospital
    183rd Street & 3rd Avenue
    Bronx, NY 10457
    (718) 960-6498 (P)
    (718) 960-3663 (F)

    Bronx Lebanon Hospital Center
    Bronx Care Dental @ Selwyn

    1650 Selwyn Avenue, #10B
    Bronx, NY 10456
    (718) 960-2018 (P)
    (718) 960-2022 (F)

    Bronx Lebanon Hospital Center
    Bronx Care Dental

    1770 Grand Concourse
    Bronx, NY 10457
    (718) 901-8400, 8401, 8402 (P)
    (718) 901-8150 (F)

    Bronx Lebanon Hospital Center
    Bronx Care Dental @ Poe Clinic

    2432 Grand Concourse
    Bronx, NY 10458
    (718) 817-7920 (P)
    (718) 817-7908 (F)

    Bronx Lebanon Hospital Center
    BMACU Dental Clinic

    1309 Fulton Avenue, Suite 537
    Bronx, NY 10456
    (718) 579-7528 (P)
    (718) 579-7519 (F)

    Bronx Lebanon Hospital Center
    Bronx Care Dental @ Findlay Plaza

    Daughter of Jacob
    1175 Findlay Avenue, 2nd Floor
    Bronx, NY 10457
    (718) 901-6440,6442 (P)
    (718) 901-6464 (F)

    Bronx Lebanon Hospital Center
    Bronx Care Dental @ Ogden Avenue

    1067 Ogden Avenue
    Bronx, NY 10452
    (718) 466-3225 (P)
    (718) 466-3223 (F)

    Bronx Lebanon Hospital Center
    Bronx Care Dental @ Hunts Point

    882-886 Hunts Point Avenue
    Bronx, NY 10474
    (718) 860-8020 (P)
    (718) 860-8010 (F)

    Bronx Lebanon Hospital Center
    Skilled Nursing Care Facility

    1265 Fulton Avenue
    Bronx, NY 10456
    (718) 579-7097 (P)
    (718) 579-7519 (F)

    Lincoln Medical & Mental Health Center
    234 East 149th Street
    Bronx, NY 10451
    (718) 579-5692 (P)
    (718) 579-4781 (F)

    Montefiore Medical Group
    Williamsbridge Family Practice

    3448 Boston Road
    Bronx, NY 10469
    (718) 547-6111

    Montefiore Medical Group
    South Bronx Children Health

    871 Prospect Avenue
    Bronx, NY 10469
    (718) 991-0605

    Montefiore Medical Group
    Castle Hill Family Practice

    2175 Westchester Avenue
    Bronx, NY 10462
    (718) 829-6770

    Montefiore Medical Group
    Comprehensive Health Care Center

    Jarrett Place
    1516 Jarrett Place
    Bronx, NY 10461
    (718) 405-8040

    Montefiore Medical Group
    University Avenue Family Practice

    105 West188th Street
    Bronx, NY 10468
    (718) 563-0757

     

    New York City – Borough of Brooklyn
    St. John’s Family Health Center
    1740 84th Street
    Brooklyn, NY 11214
    (718) 232-3666, Ext. 281 (P)
    (718) 236-0810 (F)

    Brookdale University Hospital & Medical Center

    1 Brookdale Plaza
    Brooklyn, NY 11212-3198
    (718) 240-6282 (P)
    (718) 240-6682 (F)

    Brooklyn Hospital Center
    121 DeKalb Avenue
    Brooklyn, NY 11201
    (718) 250-8616

    Kings County Hospital Center
    451 Clarkson Avenue, Ground Floor, Room E1100
    Brooklyn, NY 11203
    (718) 245-4915 (P)
    (718) 245-3577 (F)

    Long Island College Hospital
    339 Hicks Street
    Brooklyn, NY 11201
    (718) 780-4630 (P)
    (718) 780-2981 (F)

    Lutheran Medical Center
    150 55th Street
    Brooklyn, NY 11220
    (718) 630-7177 (P)
    (718) 630-6823 (F)

    St Vincent’s Catholic Medical Centers of New York
    Pierre Toussaint Family Health Center

    1110 Eastern Parkway
    Brooklyn, NY 11213
    (718) 735-1900, Ext. 111 (P)
    (718) 735-4531 (F)

    St Vincent’s Catholic Medical Centers of New York
    St Francis Family Health Center

    333 Knickerbocker Avenue
    Brooklyn, NY 11237
    (718) 381-5600 (P)
    (718) 456-1068 (F)

    St Vincent’s Catholic Medical Centers of New York
    St. Mary’s Hospital Dental Clinic

    170 Buffalo Avenue
    Brooklyn, NY 11213
    (718) 221-3107 (P)
    (718) 221-4527 (F)

    St Vincent’s Catholic Medical Centers of New York
    St. Peter Claver Family Health Center

    1061 Liberty Avenue
    Brooklyn, NY 11208
    (718) 827-5009 (P)
    (718) 827-5359 (F)

    St Vincent’s Catholic Medical Centers of New York
    Sister Thea Bowman Family
    Health Center

    1205 Sutter Avenue
    Brooklyn, NY 11208
    (718) 647-2600, Ext. 144 (P)
    (718) 348-9430 (F)

    Woodhull Medical &
    Mental Health Center

    760 Broadway
    Brooklyn, NY 11206
    (718) 963-8312 (P)
    (718) 630-3244 (F)

    Wyckoff Heights Medical Center
    374 Stockholm Street
    Brooklyn, NY 11237
    (718) 963-7174 (P)
    (718) 963-7653 (F)

     

    New York City – Borough of Manhattan
    Columbia University
    School of Public Health

    Vanderbilt Clinic, 8th Floor
    630 West 168th Street
    New York, NY 10032
    (212) 305-6793 (P)
    (212) 305-7134 (F)

    Mount Sinai Hospital
    1 Gustave L. Levy Place,
    Box 1187
    New York, NY 10029
    (212) 241-4584 (P)
    (212) 996-9793 (F)

    NENA Comprehensive
    Health Services Center
    279 East 3rd Street
    New York, NY 10009
    (212) 477-8509 (P)
    (212) 473-4970 (F)

    St. Luke’s Comprehensive
    Health Services Center
    114th Street & Amsterdam
    New York, NY 10025
    (212) 523-3173 (P)
    (212) 523-4695 (F)

    New York Medical College
    1901 First Avenue, # 1105
    New York, NY 10029
    (212) 423-8977 (P)
    (212) 423-8495 (F)

    New York University
    College of Dentistry
    345 East 24th Street
    New York, NY 10010
    (212) 998-9885 (P)
    (212) 995-4844 (F)

    Roosevelt Hospital Center
    59th Street & 10 Avenue
    New York, NY 10019
    (212) 523-6389 (P)
    (212) 523-6703 (F)

    William F. Ryan Community
    Health Center
    110 West 97th Street
    New York, NY 10025
    (212) 749-1820, Ext. 931

    St. Vincent’s Midtown Hospital
    Spellman Dental Center
    415 West 51st Street, 3rd Floor
    New York, NY 10019
    (212) 459-8327 (P)
    (212) 549-8061 (F)

    St. Vincent’s Midtown Hospital
    Family Health Center

    350 West 51st Street
    New York, NY 10019
    (212) 631-2955

    North General Hospital
    Dental Clinic

    1879 Madison Avenue
    New York, NY 10035
    (212) 423-4322 (P)
    (212) 423-4669 (F)

    Harlem Hospital
    16 West 137th Street
    New York, NY 10037
    (212) 939-2890 (P)
    (212) 939-2885 (F)

    Bellevue Hospital Center
    27th Street & First Avenue
    New York, NY 10016
    Adult: (212) 522-3221
    Pediatric: (212) 562-6537

     

    New York City – Borough of Queens
    Peninsula Hospital Center
    5115 Beach Channel Drive
    Far Rockaway, NY 11691
    (718) 734-2776 (P)
    (718) 734-3126 (F)

    New York Hospital
    Medical Center of Queens
    56-45 Main Street
    Flushing, NY 11355
    (718) 670-1060 (P)
    (718) 445-1769 (F)

    St Vincent’s Catholic Medical Centers of New York
    St. Dominic Family Health Center
    114-49 Sutphin Boulevard
    Jamaica, NY 11434
    (718) 322-6110 (P)
    (718) 322-6103 (F)

    St Vincent’s Catholic Medical Centers of New York
    Dental Administrative Office
    88-25 153rd Street
    Jamaica, NY 11432
    (718) 558-6958 (P)
    (718) 221-3973 (F)

    St Vincent’s Catholic Medical Centers of New York
    St. Joseph’s Program for the Disabled
    79-11 Parsons Boulevard
    Flushing, NY 11366
    (718) 558-6200 (P)
    (718) 558-6315 (F)

    Jamaica Hospital Medical Center
    Dental Department
    8900 Van Wyck Expressway
    Jamaica, NY 11418
    (718) 206-6980 (P)
    (718) 206-8709 (F)

    Long Island Jewish Medical Center
    Dental Department
    270-05 76th Avenue
    New Hyde Park, NY 11040
    Adult: (718) 470-7110 (P)
    Pediatrics: (718) 470-3110 (P)
    (718) 347-4118 (F)

    New York City – Borough of Staten Island
    St Vincent’s Catholic Medical Centers of New York
    Bailey Seton Hospital
    Dr. Richard Bailey Dental Center
    75 Underhill #3
    Staten Island, NY 10305
    (718) 818-5811
    Staten Island University
    Hospital Center
    Dental Center
    475 Seaview Avenue
    Staten Island, NY 10305
    (718) 226-9080

     

     

     

     

     

    New York State
    Ryan White Region: Rochester
    University of Rochester
    Strong Memorial Hospital
    601 Elmwood Avenue
    Rochester, NY 14642
    (716) 275-5688 (P)
    (716) 256-3154 (F)
    University of Rochester
    Eastman Dental Center
    625 Elmwood Avenue
    Rochester, NY 14620
    (716) 275-5688 (P)
    (716) 256-3154 (F)
    Ryan White Region: Northeast
    Albany Medical College
    Ryan White Dental Service

    47 New Scotland Avenue, A-158
    Albany, NY 12208
    (518) 262-4730 (P)
    (518) 262-8460 (F)
    Ryan White Region: Mid Hudson
    Mid-Hudson Care Center
    142 Aaron Court
    Kingston, NY 12401
    (845) 339-6755 (P)
    (845) 339-1014 (F)
    Middletown Community Health Center
    10 Benton Avenue
    Middletown, NY 10040
    (845) 343-8838 (P)
    (845) 343-7017 (F)
    Ryan White Region: Lower Hudson
    Hudson River Healthcare
    1037 Main Street
    Peekskill, NY 10566
    (914) 734-8803 (P)
    (914) 734-8804 (F)
    Westchester County Medical Center
    Macy Pavilion, Ward 24, Room 2068
    Valhalla, NY 10595
    (914) 493-1172 (P)
    (914) 493-1806 (F)
    Ryan White Region: Long Island
    Catholic Charities
    Diocese of Rockville Center
    333 North Main Street
    Freeport, NY 11520
    (516) 623-4420 (P)
    (516) 623-9621 (F)

    Nassau County Medical Center
    2201 Hempstead Turnpike
    East Meadow, NY 11554
    (516) 572-8804 (P)
    (516) 572-5379 (F)

    Research Foundation of SUNY
    School of Dental Medicine
    Stony Brook, NY 11794
    (516) 632-8919 (P)
    (516) 632-7130 (F)

    Brentwood Health Center
    1869 Brentwood Road
    Brentwood, NY 11717
    (631) 853-3495

    Riverhead Health Center
    300 Center Drive
    Riverhead, NY 11901
    (631) 852-2691

    TriCommunity Health Center
    1080 Sunrise Highway
    Amityville, NY 11701
    (631) 854-1024

    Ryan White Region: Buffalo
    Erie County Medical Center
    Dental Clinic
    462 Grider Street
    Buffalo, NY 14215
    (716) 898-3351 (P)
    (716) 898-3704 (F)