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June 27, 2024
In November 2020, Martha’s Vineyard Hospital (MVH) Dental Clinic, the only clinic on the island accepting Massachusetts Medicaid (MassHealth), closed, worsening health care disparities for the Wampanoag Tribe of Gay Head (WTGH). For many tribe members, including elders, removing local access to oral health care highlighted broader issues of limited provider availability, geographical isolation, and the challenges of traveling off-island for care.
Lauren E. Gritzer, DDS, MPH, a dental public health resident at UCSF School of Dentistry, was spurred to action.
“Driven by a desire to enhance access to health care and address the specific health needs of the tribe, who have historically faced significant inequities, I was compelled to undertake a needs assessment project,” she said. “It is essential for properly planning community-based initiatives.”
Gritzer completed the assessment last year and earned the Leverett Graduate Student Merit Award for Outstanding Achievement in Dental Public Health. Her poster was on display at the recent National Oral Health Conference in St. Louis.
“This recognition underscored the potential of our project to bring meaningful change, especially for underserved communities like the WTGH,” she said. “Winning this award also increased the visibility of the project’s findings and recommendations, paving the way for broader policy changes and the implementation of similar health initiatives in other communities.”
Below, Gritzer shares more about the project and the next steps.
Briefly, how did you go about the research?
The Wampanoag Community Needs Assessment (WCNA) aimed to comprehensively understand the oral and overall health needs of the WTGH, addressing challenges from individual to policy levels. It focused on evaluating oral health care access and utilization, identifying barriers, and developing targeted interventions to enhance health outcomes for the tribe. Martha’s Vineyard (MV) is considered a Health Professional Shortage Area by the Health Resources and Services Administration, with a score of 11. The WCNA was conducted using a comprehensive mixed-methods approach, combining qualitative and quantitative techniques to thoroughly understand the tribe’s healthcare needs.
How did you better understand the tribe’s needs?
Collaboration with stakeholders was essential. Key stakeholders such as the chairwoman, tribal chief, tribe council, and community members ensured the assessment was informed by those with a deep understanding of the tribe’s needs. To further our understanding and build trust, we attended tribal powwows. These gatherings allowed direct engagement with tribe members, providing vital insights for tailoring our approach to the tribe’s specific needs and values.
We also:
- Ensured we had an understanding of community assets and available resources
- Reviewed previous needs assessments done from 2016 to 2019
- Conducted stakeholder interviews with 14 individuals
- Completed a concept mapping exercise to visually explore the issues
- Conducted a self-reported survey with questions from sources such as NHANES and PHQ-2
- Conducted a medical billing code analysis to assess expenditures and identify common health issues
- Considered the ethical implications of our work to ensure we maintained trust and integrity
What were the results of the needs assessment? What did you find?
- Access and Transportation Issues: Ninety-one percent (91%) of WTGH reported having an oral health issue in the last year. In terms of WTGH adults, 73% encountered challenges in accessing oral health care, primarily due to lengthy wait times (39.7%) and high costs (34.9%). Regarding the children of WTGH, 76.5% faced access issues, notably the absence of a pediatric dentist and lengthy waits for appointments, each affecting 44.4%, alongside transportation difficulties.
- Service Availability and Insurance Challenges: Participants noted the closure of the MVH dental clinic and the absence of a dentist at the island’s federally qualified health center as major barriers. The closure of the only clinic accepting public insurance underscored the tribe’s reliance on external health facilities. Stakeholder interviews revealed general dissatisfaction with local oral health service availability and quality.
- Economic Factors and Insurance Complexities: Many faced upfront payment issues and delays in the tribe’s medical reimbursement system, with 57.1% finding it somewhat or not convenient.
- Community and Cultural Engagement: There is a need to emphasize cultural competence in health services and develop programs sensitive to the cultural specifics of the WTGH.
- Concept Mapping Results: Key themes from concept mapping included limited availability of services, accessibility and transportation issues, difficulties using insurance, lack of a centralized database, tribal/national policy, and health-related self-sufficiency.
Did anything surprise you about the research?
The closure of the MVH dental clinic significantly worsened access issues, highlighting the community’s heavy reliance on off-island services and exposing a vulnerability in the health care infrastructure. Transportation and geographical isolation also emerged as major barriers, with nearly half of adults and children citing them. Service gaps across all age groups, coupled with the absence of essential services like a resident dentist, severely hindered comprehensive care. Additionally, insights into cultural engagement underscored the need for culturally competent care, emphasizing its crucial role in improving effectiveness and fostering community trust.
What recommendations did you offer?
Through concept mapping, self-reported surveys, and analysis of medical billing codes, we identified seven key priorities to enhance health-related self-sufficiency within the WTGH community: access to care, transportation, streamlined reimbursement systems, implementation of an electronic health records system, health literacy materials, a coordinated referral system, and utilization of medical records applications. Additional recommendations included fluoridating the area of the island occupied by the tribe.
Could you highlight one or two recommendations and share a bit about why you chose them?
Two standout recommendations from the WCNA are the development of a portable oral health clinic and the implementation of a community-based clinical education (CBCE) program. These initiatives were chosen for their ability to directly address access barriers and improve healthcare delivery for the WTGH community.
With the MV hospital dental clinic closure, for example, there’s an urgent need for a flexible solution to bring oral health services directly to the tribe. A portable oral health clinic allows for on-site care at homes and community locations, minimizing travel barriers. It’s especially beneficial for elders with mobility issues, ensuring they can access oral health treatments conveniently.
The recommendation to implement a CBCE program involves formalizing partnerships between tribal health services and dental schools. This initiative was chosen for its dual benefit of improving access to care while enhancing oral health education. Dental students and residents can provide supervised care. This exposure enhances students’ skills and cultural competence, preparing them for diverse health care settings. Engaging students in CBCE encourages future health care providers to consider community health careers, potentially leading to sustained improvements in underserved areas.
Both recommendations aim to strengthen the health care infrastructure for the WTGH by integrating educational and community resources. This scalable solution could benefit other Native American tribes with similar challenges, inspiring broader adoption across different tribal settings. By addressing the tribe’s unique challenges, these initiatives lay the groundwork for comprehensive healthcare solutions benefiting other Native American communities.
What are the next steps to put the recommendations into action?
To implement the WCNA recommendations, structured steps are in place, focusing on partnership establishment, formal agreements, and program implementation. Program design, implementation, and evaluation methods have been finalized, with all equipment acquired for the portable oral health clinic. The pending step is the signing of the memorandum of understanding by the Harvard School of Dental Medicine, marking the final stage before launching the initiatives.
More broadly, what are the implications of your research for the future of dental care? Can you say more about the need to “go to the patients”?
The research conducted for the WTGH has broad implications for the future of oral health care, especially for aging and vulnerable populations. With a substantial portion of the WTGH being elders, the study emphasizes the need to tailor care delivery to meet the needs of aging individuals. This population often experiences mobility issues, higher rates of chronic conditions, and increased vulnerability to oral health and health problems. The concept of “going to the patients” involves delivering health care services directly to the homes or community settings where elderly and vulnerable populations reside, reducing transportation barriers and providing care in a comfortable, familiar environment. This approach has shown success, particularly with geriatric and special needs populations, highlighting its effectiveness. Implementing mobile and portable clinics equipped to offer comprehensive oral health care is a practical solution that can be replicated in various rural and isolated communities. These clinics, along with mobile health technologies, provide a flexible approach to health care tailored to the specific needs of different populations, addressing disparities in access to care.
The findings from this research could inform policy decisions to enhance health care accessibility for underserved populations. This might involve funding mobile health units, incentivizing providers to work in underserved areas, and improving infrastructure to support mobile health care delivery. Integrating mobile services into the health care system requires systemic changes to ensure their support and integration into existing networks and reimbursement systems.
How did your perspective on the Wampanoag Tribe (and the health of that community) change from before the project to after the project?
Initially, my understanding of the WTGH’s health needs and cultural aspects was limited and shaped by broad stereotypes. Through direct interactions with WTGH members and key stakeholders, as well as participation in community events like powwows, I gained a nuanced understanding of the tribe’s unique cultural practices, values, and health concerns.
After the project, I developed a deeper appreciation for the complexities of health care delivery in isolated settings. With this understanding, my future work in public health will focus on advocating for community-specific, culturally sensitive health care models that can be adapted to communities that have issues with access to care.