The Seattle Transitional Grant Area (TGA) Ryan White HIV/AIDS Program (RWHAP) Part A program developed a referral-based oral health model in which Lifelong, a community-based organization, serves as the administering agency between the RWHAP and oral health care providers. When RWHAP providers refer people to Lifelong, dental navigators connect them with dentists. Lifelong has a large network of dentists that facilitates scheduling appointments as quickly as possible.
Seattle, WA
People with HIV often struggle to access oral health care, which can lead to painful dental disease, tooth loss, and other medical conditions. These issues impact individuals’ well-being and their ability to work and engage in community activities. Many RWHAP providers do not have co-located oral health services and, therefore, need to refer clients to external dentists. However, there is a shortage of dentists willing to serve clients with lower incomes, especially Medicaid beneficiaries.1 Discrimination in oral health practices against people with HIV, although unlawful, may also affect potential partnerships.2
RWHAP providers in the Seattle area use various strategies to identify whether their clients have oral health needs. Providers may detect issues in their physical exams, and comprehensive assessments for care planning often include questions on oral health.
RWHAP providers connect clients to Lifelong dental navigators when they identify oral health care needs. Lifelong provides RWHAP case managers with complete information about dentists in the network and the types of clients they can best serve based on health care coverage accepted and location. In addition, Lifelong makes sure the first appointment is scheduled during a conference call with the client and dentist. This reduces stress on clients and ensures that their service access is seamless. Clients may also contact Lifelong directly to request services. Dentists are selected based on their geographic location, client health care coverage status, need for specialty care, and language spoken.
Lifelong dental navigators provide CD4 count, viral load, and the name and contact information of the RWHAP provider to dentists. The dental navigator also shares whether the client has any fears that need to be addressed or taken into consideration. Clients are also instructed to take a list of their medications, identification card, health care coverage cards, and updated labs to their appointments.
Lifelong dental navigators enter all referrals into a data management system to facilitate follow-up, including the client's health status and related information from the RWHAP medical care provider. They also follow up with the dentist to confirm whether the client attended the appointment and document oral health care provided. This information is also entered into the system. While Lifelong dental navigators serve as liaisons, RWHAP medical and oral health care providers may communicate with each other directly.
Of over 1,600 clients receiving dental navigation services in 2021, 88% were virally suppressed.
| Category | Information |
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| Evaluation data |
The Seattle TGA tracks services provided by RWHAP-funded subrecipients, including oral health non-medical case management (dental navigation), in its internal data management system. Subrecipients also report clinical outcomes into this system. |
| Measures |
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| Results |
In 2021:
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- Extensive referral network. Based on their capacity and experience serving people with HIV, Lifelong developed a robust network of oral health care providers to accept referrals. When identifying oral health care providers, Lifelong casts a wide net, including reaching out to accredited dental and dental hygiene schools, residency programs, and dental service organizations, which are growing as they acquire more individual private practices. Dentists are also approached for participation in the network based on gaps in coverage by both service type and geographic area.
- Agreements with providers. Dental providers sign a memorandum of understanding to demonstrate ability to participate in referrals and data sharing and an estimated number of clients to be seen monthly. These providers also have contracts with the Seattle TGA RWHAP Part A program to fund dental care, as that is the mechanism through which dental claims are paid.
- Set fee schedule. Lifelong, the Seattle TGA RWHAP Part A program, and the Washington State Department of Health (DOH) together developed a fee schedule for oral health services delivered by participating dental providers.
“Lifelong focuses on having a large network, incorporating as many dental providers as possible given the size of the client population and the desire to connect clients to services as soon as possible.”
Health care coverage and the Seattle TGA RWHAP Part A program cover the cost of oral health care within the model. A RWHAP Part A fee schedule ensures that oral health care providers are paid consistently and within the scope of the RWHAP Part A budget. A $3,000 cap on client-level expenditures also promotes sustainability; however, the cap may be overridden with RWHAP Part A approval, based on client need and medical necessity. RWHAP Part A covers the cost of the dental navigation services provided by Lifelong.
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Oral health care providers in the network should have a welcoming, stigma-free environment. Simply asking about dentists’ experience with working with people with HIV can provide important insight.
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Lifelong originally sent out postcards as reminders for appointments they had scheduled. However, the agency stopped doing so at the request of the oral health care providers, as they sometimes rescheduled client visits directly without notifying Lifelong.
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When creating dental partnerships, providers should leverage the dependability of RWHAP funding as an incentive for partnerships. Dentists often “don’t get RWHAP” and need to be educated on the program, an important part of Lifelong’s role as Administering Agency.
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Lifelong does not have a shared dataset with oral health care and RWHAP Part A-funded medical providers. Therefore, dental navigators play a key role in acquiring the information, entering data into the local data management system, and sharing relevant information across the care settings. Standardized templates help make sure the information gathered is useful and comprehensive. Dentists are aware which information is entered into the database and shared.
- Kaiser Family Foundation. (2018). Providers & Service Use Indicators. Retrieved from kff.org/state-category/providers-service-use/health-professional-shortage-areas
- Sears B, Cooper C, Younai FS, Donohoe T. HIV discrimination in dental care: Results of a discrimination testing study in Los Angeles County. Loyola of Los Angeles Law Review. 2012;909–962.
