With more than 1.1 million people in the United States living with HIV infection and almost one in six (15.8%) unaware of their status, expanding access to oral health care for uninsured and underinsured HIV-positive clients is a challenge faced by the safety net, including academic institutions.1,2  Increasing numbers of mostly impoverished people of color, particularly women and those without dental insurance, are less likely to receive adequate oral health care.3 The HIV Cost and Services Utilization Study, conducted by a consortium of private and government institutions centered at the RAND Corporation, is a rich source of information regarding access to care for HIV-positive people. It was the first comprehensive U.S. survey of health care use among a nationally representative sample of HIV-positive people who were receiving care for their HIV infections. The original study was active from September 1994 to October 2000 and found that 58% of participants who completed the initial interview reported that they did not receive regular dental care.4 More recent studies covering specific U.S. regions have reported similar findings; today it is estimated that 64% of people living with HIV do not visit a dentist regularly.5

Although a cure is not in sight, widespread use of highly active antiretroviral therapy has made HIV a chronic, manageable disease. Because of its effects on the immune system, HIV is a disease that affects all aspects of one’s health.6  One of the earliest findings of the HIV epidemic that still holds true today is that various oral health conditions manifest as a result of a diminished immune system. Twenty-eight percent of people living with HIV/AIDS (PLWH) exhibit at least one HIV-related oral health problem throughout the course of their disease.6 Once HIV antiretroviral therapy has begun, these manifestations usually decrease.7 However, PLWH who have persistent or reoccurring oral lesions, tooth decay, and periodontal disease may experience a decline in their overall health and diminished efficacy of antiretroviral therapy. These problems can be caused by compromised nutritional intake, poor absorption of HIV medications, and decreased adherence to treatment regimens.

The federal government recognizes the special needs of PLWH and has several programs in place in order to fill the gaps in the oral health management of this population.  In fiscal year 2014, the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB) allocated $16.4 billion in funding for health care services and treatment for PLWH.  During this period, the Ryan White HIV/AIDS Program received $2.4 billion—which represents the largest HIV-specific discretionary grant program nationally.8  Planning models have estimated that PLWH living in the United States require 1.9 to 3.4 dental visits per year.9

Background

The HRSA administered Ryan White HIV/AIDS Program funds community and state-level projects to deliver HIV primary care and support services, covering HIV medications and outpatient care. The Ryan White HIV/AIDS Program has funded dental care since its inception in 1991, both as a primary care service program as well as under its HIV oral health initiatives. The Community-Based Dental Partnership Program (CBDPP) is one of multiple HIV-focused oral health programs first funded in 2002, over a decade after the Ryan White HIV/AIDS Program’s commencement. The CBDPP represents an evolution in the Ryan White HIV/AIDS Program’s efforts to expand the Nation’s capacity to deliver oral health care to PLWH.  The program funds eligible dental schools to increase access to oral health care for unserved and underserved HIV-positive populations, and to train new generations of dental providers through education and clinical experiences to manage health needs of PLWH. 

Funded by HAB since September 2002, Rutgers School of Dental Medicine (RSDM) and Access One, Inc. are one of the 12 CBDPPs nationwide.  The RSDM, located in Newark, is the only dental school in the state of New Jersey.  The CBDPP operates out of three RSDM community based dental centers in the southern region of the state.  These state-of-the-art facilities offer patients high quality, comprehensive oral health care and serve as a training facility for predoctoral, postdoctoral, and community oral health providers. The partner organization, Access One, Inc., is a non-profit AIDS service organization founded in 1998. They are committed to providing medical and dental referral services, case management, and social services to individuals infected with HIV/AIDS.

After eight years of continuous funding, RSDM realized that population based planning would be instrumental in strengthening and sustaining achievement in the CBDPP.  RSDM developed a strategic map that illustrated a plan by which the community based dental centers could improve performance of its goals. The outcomes from the planning process suggest that other institutions can use the strategic map, tailoring it to their respective establishments to better their own programs.

Partnership response: actions taken

Nationally, New Jersey ranks fifth in terms of cumulative cases of HIV/AIDS.   As of June 2013, there were over 78,000 cases reported, of which minorities account for 76% of adult/adolescent cumulative HIV/AIDS cases. Currently, there are more than 37,000 PLWH in the state. Of these cases, minorities account for 78%.10 

As RSDM sought to improve the delivery of oral health services to this population, many different models and action steps for strategic planning were considered.  Ultimately, RSDM utilized a ten-step process presented by John M. Bryson in his publication Strategic Planning for Public and Nonprofit Organizations. The ten steps are reproduced below.11

Step 1: Initiate and agree on a strategic planning process. The purpose of the first step is to            develop among key internal decision makers and external leaders an initial agreement about the overall strategic planning effort and main planning steps.

Step 2: Identify organizational mandates. The formal and informal mandates placed on the          organization consist of the various “musts” it confronts—that is, the various requirements, expectations, and constraints it faces.

Step 3: Clarify organizational mission and values. An organization’s mission, in tandem with its    mandates, provides the organization’s most important justification for its existence. It   also points the way toward the ultimate organizational end of creating public value.

Step 4: Assess the internal and external environment.  The planning team explores the environment inside the organization to identify strengths (S) and weaknesses (W) and the environment outside the organization to identify the opportunities (O) and threats (T) the organization faces (SWOT).

Step 5: Identify the strategic issues facing the organization. The strategic issues are fundamental policy questions or critical challenges affecting the organization’s mandates, mission and values, service level and mix, clients, users or payers, cost, financing, structure, processes, and management.

Step 6: Formulate strategies to manage the issues. A strategy can be defined as a pattern of purposes, policies, programs, actions, decisions, or resource allocations that define what an organization is, what it does, and why it does it.

Step 7: Review and adopt the strategies. Once strategies have been formulated, the planning team may need to obtain an official decision to adopt them and proceed with implementation.

Step 8: Establish an effective organizational vision. The organization develops a description of what it should look like once it has successfully implemented its strategies and achieved its full potential.

Step 9: Develop an effective implementation process. The changes called for by the adopted         strategies must be incorporated throughout the system for these strategies to be brought to life and for real value to be created for the organization and its stakeholders.

Step 10: Reassess strategies and strategic planning process. Once the implementation process has been under way for some time, the organization reviews the strategies and strategic planning process, as a prelude to a new round of strategic planning.

As RSDM engaged in the ten-step strategic planning process for the CBDPP, there were several positive outcomes realized. The most obvious benefit was the promotion of strategic thinking, acting, and learning, especially through dialogue and strategic conversation between RSDM and Access One, Inc. The decision making processes was improved and organizational effectiveness was enhanced, producing efficient broader societal systems. Thus, strategic planning directly benefited all stakeholders involved.

Conclusion

By developing a long-range strategic response plan for expanding access to dental care, RSDM aimed to develop a model for oral health care in programs servicing PLWH.  Figure 1 summarizes the RSDM and Access One, Inc. approach developed in response to strategic issues. A strategic response plan was constructed using the Strength – Weaknesses – Opportunities – Threats (SWOT) approach. This project accomplished three important tasks: to clarify the outcomes that the program wished to achieve, to select the broad strategies that will enable the program to achieve those outcomes, and to identify ways to measure progress.

A key component to the RSDM response is that the changes implemented constitute moderate programmatic modifications to existing operations, rather than more extreme organizational transformations.  Most importantly, these planning components lead directly to improved service access and increased provider capacity.  The integration of strategic management into the CBDPP facilitates forward thinking, capacity building, goal identification, achievement, increased public support, increased funding, and greater accountability. The result is improved outcomes for RSDM, Access One, Inc., PLWH, and HRSA.