Rethinking oral healthcare for the homeless
By Primary Care Journal-
Rates of dental decay have improved over the past 40 years but high levels of decay still remain in certain cohorts of the community. Individuals who fall under the umbrella of ‘hard-to-reach’, such as homeless people, are very unlikely to attend a general dental practice.
Dental care for people who find themselves homeless is essential but accessing it seems to be far more difficult than accessing medical care. Homeless people have similar levels of dental disease to the housed population with much higher levels of untreated disease. To manage pain, some clients who are not accessing dental services often end up misusing drugs or misusing their prescribed medications.
Several years ago, Revive Dental Care started to become involved in providing dental services to homeless people in Manchester. We shared a building with a medical clinic called Homeless Medical Service Unit that operates a homeless service. Dickensian is how I would describe the state in which many patients suffered oral health and dental disease in this clinic. We decided to pilot a service for these hard-to-reach patients and our local Clinical Commissioning Group (CCG), Manchester PCT, awarded us a small contract.
The commissioners were keen that patients did not use the dental service purely for emergencies but hoped that their general levels of oral health could be improved by encouraging patients to make follow-up appointments for further treatment. It was hoped that by removing patients from pain, their trust would increase and make them more likely to attend for further preventive treatment.
It soon became obvious that there was an acute need for dental provision to support GPs in their work with the homeless. If a patient attended the medical clinic in dental pain, the medical reception directed them to us.
In terms of how the outreach service developed, practice manager Jo Dixon explains: "Initially, we worked just with homeless patients but our service grew to cover a variety of other vulnerable groups in Manchester. We now work with Manchester Action on Street Health and we provide support to sex workers, mental health charities, asylum seekers and refugee groups, all of whom may find it difficult to access treatment in a standard dental practice. Homeless patients often don’t attempt to access dental care for a variety of reasons, including confusion on where and how to access care."
Many service users attend A&E for treatment of an acute swelling as self-medication often controls their pain. Oral pain often means they find eating harder too. Working with care groups to fast track these patients has been a real success.
Jo continues: "We now also work with a new Manchester drug service called “RISE” as well as hard-to-reach groups support networks such as www.cornerstonecds.org.uk, www.justlife.org.uk and www.thewellspring.co.uk. Rather than a patient having to hunt for a dentist, our dental team goes to the patient. We offer a pop-up dental practice within drop-in establishments, where clients feel comfortable, to inform them how to access dental services and to dismiss some of the myths about dentists."
A ‘pop up’ dental surgery
Developing our pop-up mobile dental surgery has really engaged with the patients and failure rates have considerably reduced. If a patient attends one of the shelters in pain, the shelter contacts us and coordinates getting the patient to us for treatment. We can treat the patient on the day that we see them. Engagement with hard-to-reach patients and then building their trust is key to successful outcomes. We had to find ways of modifying our service delivery to match patients’ needs.
Hard-to-reach patients may have communication problems, especially if they are suffering with psychological issues. This alone may have been what has stopped them accessing dental services in the past. Patients often feel misunderstood and alienated owing to their situation. Support workers help to remind patients to attend for treatment which is really important when we have their involvement.
Lowering the boundaries
Gaining consent can be critical for patients who need a helping hand in attending appointments. We have a no de-registration policy so patients can come back at any time, even if they miss appointments. A hard-to-reach dental service has to understand that patients have multiple issues within their lives. Their lives are often chaotic, and dentistry might not be a priority for them. As a result, treatment may have to start and stop several times.
To build trust, the team visits 10 local charity bases. They deliver oral hygiene training and giving out simple oral health packs. Once we establish a level of trust, we encourage patients to come to our clinics. Here, we can assess their oral health and plan treatments.
Revive Dental Care funds and supports a team of dental nurses in their training as oral health educators. These roles are now quite sought after in the practice. Each team member realises how important this role is. They are the ones who are delivering vital oral health messages to patients and that will have such an impact on their health going forward.
After the engagement programme started, patients have been more likely to attend second and third appointments. Understanding where patients are on their journey towards rehabilitation is key. Not all patients want the same thing. Some may not be ready to engage, some may need pain relief. Others need new smiles and are ready and willing to engage to make that happen.
It became clear that some patients had had a bad dental experience in the past. Dental practices will turn patients away due to lack of benefits or a home address so individuals may have only attended a practice when in acute pain and never had a normal conversation with a dentist when they were not suffering from oral pain. Many of the patients we see are in pain daily due to chronic underlying infections. Their medication often masks their symptoms. We see between 10 and 18 patients at every pop-up session. There will always be at least one individual experiencing a raging toothache.
Faye Greenhalgh is the project manager for our community outreach dental service. She has worked at Revive for 12 years and was involved in setting up the project in 2013.
"Getting hard-to-reach patients to come to appointments can be challenging, especially if they are at quite a distance from where they are staying," Faye says. "We can’t rely on traditional methods like phone calls, texts and emails. We must consider our approach – even how we dress has an impact on people perceive us. Dressing less formally makes us seem more approachable. However, we also have to be prepared to be very firm when we need to be. Especially if patients attend appointments under the influence of drugs or alcohol. The mindset needs to be completely different from traditional dental practice."
We urge any practices considering running a homeless dental service to get in touch with local services that already work with vulnerable groups. Working closely with local public health agencies and CCG partners will also ensure you are offering the best value to the widest patient base. No matter the size of your local area, you’ll be surprised by the number of vulnerable people who need help. It is important to remember how easy it is for people to become homeless. You never know the backstory of any patient you meet.
The clinics themselves and levels of patient attendance are very different from the standard dental practice. You have to be prepared to be really flexible. Failure rates are obviously higher and you need to be prepared to persevere.
Hard-to-reach groups often have very low expectations so being involved with reinstating their pride and dignity is hugely rewarding.