ATTACHMENT A

CALIFORNIA STATE UNIVERSITY LOS ANGELES

PROJECT: DENTAL TRANSFORMATION INITIATIVE (DTI) LOCAL DENTAL PILOT PROGRAM (LDPP)

SECTION 1 LEAD ENTITY AND PARTICIPATING ENTITIES

Overview

The Rongxiang Xu College of Health and Human Services (RXHHS) of California State University, Los Angeles (Cal State L.A.) in collaboration with the Herman Ostrow School of Dentistry of the University of Southern California (USC) is pleased to submit this application for an LDPP Domain 4 project. The proposed pilot program for the Los Angeles Basin builds on Cal State L.A.s philosophical commitment to community service, engagement and the public good, the College of Health and Human Services interdisciplinary (human and social service) expertise, and the Herman Ostrow School of Dentistry of USCs long history of serving underserved communities. The proposed program seeks to implement an interprofessional whole child and whole community approach to increase the proportion of children and young adults (0-20) who receive preventive dental services, establish positive oral health habits in families, increase continuity of dental care, and provide other health and social services to support these goals. The whole child and whole community approach aligns with best practices in the delivery of health and human services that acknowledge that social, educational, psychological and cultural contexts inform help seeking behaviors and capacities to sustain health promotion behaviors. This orientation is enriched by a service delivery stance that recognizes that families and communities present with multiple strengths that provide the foundation for positive collaborations with care-giving and healthy delivery systems. This LDPP integrates state of the art practice in dental care with a theoretical orientation that is fundamentally respectful and collaborative in the design and delivery of all interventions.

The Lead Organization for this application is Cal State L.A.s Rongxiang Xu College of Health and Human Services (RXHHS), which will be responsible for coordinating the LDPP and will serve as the single point of contact for the Department of Health Care Services (DHCS) and the Centers for Medicare and Medicaid Services (CMS). RXHHS will leverage its strong disciplinary programs in Child and Family Studies, Communication Disorders, Public Health, Nutritional Science, and Nursing; our strong connection with the networks of community based child and family serving organizations; and our diverse and talented student body to succeed in these efforts.

Demographic Description of Cal State L.A. and RXHHS

Cal State L.A. is situated in a rich and unique environment that is home to the largest Latino community in the nation and at the doorway to one of the largest Asian and Asian American communities in the nation. The University service area includes African-American communities, as well as the second largest urban American Indian and Alaskan Native population in the nation. Cal State L.A. is a federally designated Hispanic Serving Institution (HSI), an Asian American and Native Pacific Islander Serving Institution (AANAPISI), and Minority Serving Institution. Fifty-seven percent of students at Cal State L.A. identify as Hispanic/Latino, 15% as Asian American, 9% as White, and 4% as African American. Eighty-two percent of students who attend Cal State L.A. are first-generation college students. Most of our students are local to the communities surrounding Cal State L.A., with 86% coming from Los Angeles County or other Los Angeles metro areas. According to data from 2016, 6,334 undergraduate and graduate students are enrolled in RXHHS, making it the largest college on campus. In our college, 62.2% of students identify as Hispanic/Latino, 16.7% as Asian American, 7.9% as White, 4.1% as African American, 1.8% as two or more races, and 0.06% as American Indian and Alaskan Native. Within the college, 76% of students are female. The students who will participate in training activities

reflect the demographics of the communities adjacent to the university and articulate strong motivations to work within their home communities.

RXHHS Academic Programs

RXHHS faculty have demonstrated excellence in teaching, scholarship, and service to the community. RXHHS is composed of seven units; five academic units will participate in the efforts outlined in this proposal. These include the Department of Child and Family Studies, Department of Communication Disorders, Department of Public Health, School of Kinesiology and Nutritional Science, and the School of Nursing. Child and Family Studies maintains robust educational pipeline partnerships with local community colleges and with disciplinary and professional organizations, such as a regional partnership with Child Life Specialists and networks of early childhood education providers and professionals. The Department of Communication Disorders maintains a Speech and Language Clinic, which serves primarily children and addresses articulation, phonology, language, cognitive, voice, fluency, and hearing disorders, as well as three Child Language Labs. Their Speech and Language Pathology MA program places students in schools and hospitals across LA County. The Department of Public Health maintains contracts with over 60 Los Angeles area organizations at which students undertake internships and gain valuable work experience. The department also runs an annual health policy conference and will be opening a new graduate program in Urban Community Health in Fall 2017. Kinesiology and Nutritional Science have generated over $12 million in grants over the last eight years. This school houses the Coordinated Dietetics Program, which is one of only three of its kind in California and the only one offered at a public institution. It is accredited by the Accreditation Council for Education in Nutrition and Dietetics. The School of Nursing is ranked #23 in the top 50 nursing schools in the Western United States and in the top 100 in the U.S. according to the US Nursing Schools Almanac.

In addition to providing high-quality disciplinary training, each of the involved disciplinary units have extensive fieldwork and internship training programs in place, which leverage and expand the universitys extensive connections with community partners. Additionally, RXHHS units have partnered with government and educational entities to produce several community health and professional development training projects. Examples include a project to provide professional development training and social work field education services to the County of Los Angeles, Department of Children & Family Services and a CaPROMISE grant to improve the provision and coordination of services and supports for child SSI recipients and their families.

Administrative Leadership Team

The Program Director, Dr. Rita Ledesma, has been a lifelong resident of the communities surrounding Cal State L.A. and has developed strong and lasting relationships with several community organizations serving underserved or at-risk populations due to low-income, substance abuse, involvement in dependency court, and people with developmental disabilities. These organizations include El Nido Family Centers, United American Indian Involvement, Inc., East LA Community College, and the USC University Center for Excellence in Developmental Disabilities at Childrens Hospital Los Angeles. She brings over 30 years of experience as a social work practitioner-scholar, working within the American Indian and Latino communities in Los Angeles County. In particular, Dr. Ledesma has a strong record of engagement with American Indian and Latino child and family serving organizations and leadership in policy and advocacy groups. Dr. Ledesma is a Licensed Clinical Social Worker (CA) and an enrolled member of the Oglala Lakota Tribe, Pine Ridge Reservation.

Dr. Ledesma currently serves as RXHHS Associate Dean of Diversity and Student Engagement. Prior to this, she

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served as Department Chair of Child and Family Studies, during which time she developed the departments successful peer mentorship program, Pathways to Graduation, which received competitive funding from the University. Before her tenure in Child and Family Studies, Dr. Ledesma was part of the School of Social Work, where she was instrumental in the development of the Master of Social Work Program and served as first director of field education. Throughout her career, she has been instrumental in developing several community-campus interventions. For example, with the Pat Brown Institute at Cal State L.A., she developed the Health Policy Outreach Center, which received support from the California Endowment and the Wellness Foundation and established partnerships with 60 health and social service agencies in East/Northeast Los Angeles and West San Gabriel Valley. She served as Co-Principal Investigator on an STEM intervention project, Pueblo Science, which was funded by the National Science Foundation. Pueblo Science was housed in the East Los Angeles community and involved a partnership with several local agencies. Dr. Ledesma was Co-Principal Investigator on an educational pipeline initiative pilot program that was funded by the Kellogg Foundation. She also directed the Partnership for Academic Learning and Success (PALS) Peer-Mentoring Program for several years. Dr. Ledesma received a Social Work Leadership Award to conduct research in the urban American Indian Alaska Native community from the Soros Foundation, Open Society Institute, Partnership on Death in America. In her role as Associate Dean, Dr. Ledesma has the opportunity to promote and lead College wide initiatives that support health equity, student engagement, and collaborations/partnerships that contribute to the greater good of the region.

The Associate Director for Cal State L.A. for this project, Dr. Ashley Munger, contributes a wide variety of research, clinical, and teaching skills to address the exigencies of community-based and programmatic research. These include training and experience with curriculum and program development, program evaluation, and experience working within diverse communities. Previously, Dr. Munger was involved in basic and community intervention research through a statewide collaboration between the School of Public Health at the University of Maryland, College Park and the University of Maryland Extension Food Supplement Nutrition Education Program. Furthermore, Dr. Munger trained and practiced as a couple and family therapist, developing clinical skills in systems-thinking, relationship building, problem-solving, and group facilitation. These skills will enable her to effectively communicate and coordinate program components. Additionally, she has considerable training in university teaching, including areas such as general best practices, diversity and inclusion in the classroom, scholarship of teaching and learning, service learning, and online course design, which will be leveraged to ensure high-impact learning and experiences for student interns.

Associate Director, Roseann Mulligan, D.D.S., M.S., is the Associate Dean of Community Health Programs and Hospital Affairs for the Herman Ostrow School of Dentistry of USC, Chair of the Division of Dental Public Health & Pediatric Dentistry, and Charles M. Goldstein Professor of Community Dentistry. She is a recent recipient (2016) of the American Assoc. for Dental Research, Jack Hein Public Service Award. Additionally, Dr. Mulligan received the Harold Berk award (2014) from the Academy of Dentistry for Persons with Disabilities. She brings expertise in providing dental services to a wide array of special populations that are frequently underserved and a whole-family approach to the LDPP, including, general dentistry and dentistry for special populations which includes individuals with intellectual and physical disabilities and those with complex medical conditions. Dr. Mulligan serves as the Principal Investigator of USCs Childrens Health and Maintenance Program (CHAMP), a five-year oral health prevention, education, and dental home project serving children 0-5 years of age funded through First 5 LA. Dr. Mulligan will be the lead for the USC Team in this collaboration.

Description of the Program and Efforts Undertaken by Lead Entity

Childrens oral health is connected to a wide variety of outcomes throughout a childs lifespan. Poor oral health is associated with school absence and poor academic performance, reduced growth and poor quality of

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life (American Academy of Pediatric Dentistry, 2014). Unfortunately, for families with many needs competing for time and financial resources, oral health may be difficult to prioritize. Even among families who are eligible for dental health services through Medi-Cal, the utilization rate for Denti-Cal fee-for-service ranges from an average of 27% for children 0-3 to 52% for children 6-18. (Barzaga, 2015). Additionally, multilevel factors including environmental and social determinants have been shown to influence oral health. For example, family-level factors (e.g., social support; parents beliefs, behaviors, and health; and family culture) and community-level factors (e.g., physical and social environments and availability of resources) indirectly impact childrens oral health (Fisher-Owens et al., 2007). Unfortunately, very few existing programs have sought to consider the whole child or whole family and address these contextual factors that influence oral health.

This project integrates the expertise and experience of two major universities, in partnership with a broad range of child and family serving organizations, to connect families to dental homes and to promote dental health in vulnerable populations. Program activities will intervene with conditions that undermine oral health status by adopting a multidisciplinary service delivery approach that is attentive to culture, responsive to the social ecology and focused on strengths and capacity. The USC team brings a strong record of success in advancing the dental health of children and youth that is complemented by the Cal State L.A. teams record of success in advancing the whole child and whole family approach. Each team elevates the achievements of the other by endorsing a shared value for integrated service delivery systems, while specializing in distinct scopes of practice. The USC team will assume primary responsibility for dental health screening activities, and the Cal State L.A. team will implement educational and intervention strategies to support oral health, as both entities focus on continuity of care, interdisciplinary training of students, agency staff and community members. We expect that emerging professionals, who participate in field and practicum training experiences, will adopt an approach to practice that is more complex and useful to the communities where they will practice. We anticipate that these activities will stimulate interest in the field of oral health and career opportunities related to oral health amongst program participants.

The project seeks to promote oral health by addressing the complexity of issues associated with lack of access to dental care among children aged 0 to 20 who are Medi-Cal eligible in the LA Basin through the following Specific Aims:

Aim 1: Increase access to dental health care for underserved populations by 1) deploying mobile care teams to the community to provide oral health screenings and 2) connecting children and their families to local dental homes for continuity of care using an interdisciplinary approach

Aim 2: Identify contextual barriers to childrens oral health by 1) assessing families existing resources, capacities and challenges concerning oral health; 2) developing and implementing protocols to assess families values, attitudes, knowledge, and behaviors related to oral health and 3) integrating this knowledge in the design and delivery of program interventions

Aim 3: Increase access to dental health care for children/youth in the urban American Indian Alaska Native urban community by 1) complementing the goals of Aim 1 through specialized outreach and recruitment strategies; 2) hiring designated staff to strengthen these efforts and 3) integrating best practice knowledge from Indian Health Service protocols

Aim 4: Utilize findings from the assessment referenced in Aim 2 by 1) developing Individualized Oral Health Care Plans, 2) creating education materials on various topics of relevance to the population that are congruent with the cultural and developmental contexts of the audience, 3) delivering educational content to target audiences utilizing an interdisciplinary team approach, 4) delivering oral health

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educational materials individually and to community groups, and 5) utilizing mobile technology to engage families to practice what they have learned about oral health

Aim 5: Increase the involvement of professionals in related fields (child development, education, and general health care) in raising awareness among their clients of the importance of preventative and regular maintenance of oral health care in children, youth and young adults by 1) developing strategies to educate practitioners about the importance of oral health and its link to general health and wellbeing and 2) educating healthcare providers (pediatricians, OB/GYNs, primary care physicians, nurses, nutritionists, etc.) to deliver and incorporate oral health care into primary care

Aim 6: Disseminate findings from this project to appropriate consumer, professional, and legislative audiences

The above Aims will be met through the collaborative efforts of the Cal State L.A. Rongxiang Xu College of Health and Human Services (RXHHS) and The Herman Ostrow School of Dentistry of USC using the following methods. Each entity has a scope of responsibility and accompanying administrative support that is integrated in the design and delivery of comprehensive multidisciplinary interventions that address oral health using the lens of the whole child, whole family and whole community. The RXHHS-USC partnership will develop and implement an interdisciplinary approach to oral health promotion and dental disease prevention that is strengths based and culturally focused. This approach will include the production of culturally attuned and developmentally sensitive protocols for investigating the factors that influence oral health outside of the scope of dental care. The knowledge gleaned from this process will inform the development of interdisciplinary dental health promotion intervention and materials which will encourage families to engage in small, specific behavior changes concerning dental health care and other factors that influence oral health, such as cultural beliefs, demographic considerations, parenting behaviors, nutrition and access to dental care system.

RXHHS will recruit, train, and supervise undergraduate student interns from multiple disciplines who will serve as members of Bridge Teams. (See Section 3.) These interns will participate in an interdisciplinary training program that extends across the academic year. During this time, interns will be sent out to participating entities in the community in order to gather information and implement oral health promotion educational interventions; to assess the conditions that undermine capacities to maintain and sustain dental health; and to implement interventions (under the supervision of the RXHHS discipline faculty) that mitigate these conditions. Following completion of the internship program, interns will be hired as student assistants in order to ensure continuity of training, intervention activities, and evaluation of efforts. RXHHS will employ promotoras (oral health educators) who will work closely with Bridge Teams and support the community based oral health activities.

The Herman Ostrow School of Dentistry will provide dental faculty (dentists, hygienists) who will supervise dental students who will be deployed to the community as part of the Bridge Team to provide oral health screenings. USC will also utilize its School of Social Work interns for Bridge Team participation. Intra-oral digital cameras will be used as an oral health education tool to improve oral health knowledge, promote awareness of the need for care and reduce childrens dental fear and anxiety. When needed, geo-mapping technology will be used to locate appropriate dental homes for children and their families at community partner clinics. Through the Herman Ostrow School of Dentistrys current large-scale dental health service project, CHAMP, a large network of dental homes to which families can be referred has already been

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established. Additionally, in collaboration with RXHHS, USC will provide training for dental and non-dental professionals to improve their knowledge and skills in all aspects of pediatric and prenatal oral health care and to develop dental health promotion materials.

To complement the efforts of the Bridge Teams, a mobile application will be developed. Mobile applications have been successful in promoting positive health behaviors (Philips, 2003). The application developed for this program will be modeled on successful efforts undertaken for tobacco cessation programs and other public health initiatives (Pike, 2015). Use of this application will help to continue the programs relationships with each family by reinforcing education provided on site; providing small, specific behavioral nudges for families to engage in activities that promote oral health; and permitting the program to collect ongoing data concerning each family's connection to dental homes and continuing oral health. All data collection will comply with relevant privacy laws and regulations.

Lead Entity Decision Making Process These efforts above will require coordinating multiple participating and subcontracting entities in order to ensure program success. As the lead entity, Cal State L.A. and its personnel will serve as point of contact and provide appropriate reports to DHCS and the Centers for Medicare and Medicaid Services (CMS).

Within Cal State L.A., the Dean of the Xu College of Health and Human Services (RXHHS) is the direct supervisor of the proposed Program Director (Rita Ledesma), who also serves as the Associate Dean for Diversity and Student Engagement in the College. The College is housed in the Universitys Division of Academic Affairs. Academic Affairs, one of the largest units within the University, is under the leadership of the Provost and Vice President for Academic Affairs, Dr. Lynn Mahoney. As noted above, the Xu College of Health and Human Services is home to 7 Departments and Schools and 4 Institutes. Dr. Ledesma is authorized to serve as lead for this proposed project and is responsible for ethically and effectively leading the project. The Program Director is expected to adhere to the policies and procedures associated with effective grant management within the University. The Dean and other University leaders and offices, such as the University Auxiliary Services, are available to monitor, guide and consult with the Program Director to ensure the successful achievement of the proposed project goals. The Program Director must abide by the administrative procedures that inform management of grants and contracts on behalf of the University. All managers within the University complete mandatory trainings offered by the Chancellors Office to develop knowledge about and awareness of the policies that govern supervision of employees, Title IX provisions, sexual harassment issues, and the responsibilities of supervisors. The College fiscal management office will work with the University Auxiliary Services to support program operations. Dr. Ledesma and the projects Associate Directors, Ashley Munger from Cal State L.A. and Dr. Mulligan from USC, are committed to standards of ethical behavior, best practices and confidentiality requirements associated with each discipline.

RXHHS will also coordinate all project components and facilitate communication among all entities. Mechanisms for continuing communication and monitoring are built into the project, and include the development of a Leadership Team, a Program Operations Committee, an Interprofessional Development and Coordination Committee, and an Advisory Board. Meetings held by the Committees and Advisory Board will be documented via meeting minutes that will be distributed to the Leadership Team and available for review to others upon request. RXHHS will be responsible for directing and coordinating these efforts. (See Section 1.4)

Final decisions will be made by the Program Director after receiving input and guidance from the Associate Directors and the various Committees.

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1.1 Lead Entity and Contact Person

Type of Entity CSU campus Contact Person Alma P. Sahagun Title Executive Director Telephone (323) 343-5366 Email Address asahag@cslanet.calstatela.edu Mailing Address Cal State L.A. University Auxiliary Services, Inc.

5151 State University Drive, GE 314 Los Angeles, CA 90032-4226

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mailto:asahag@cslanet.calstatela.edu

1.2 Participating Entities

Organization Name and Address

Description of Organization

Contact Name, Title, Telephone and Email

Role in LDPP

Herman Ostrow At 119 years old, the Roseann Mulligan Subcontractor School of Herman Ostrow School of Charles M. Goldstein Professor A. Provides outreach Dentistry of Dentistry of USC has Community Dentistry, Associate community services: University of educated thousands of the Dean, Community Health caries risk assessment, Southern worlds most talented and Programs and Hospital Affairs, oral health screenings California trusted dental

professionals. The School is an international leader in dental and craniofacial research and a pioneer in serving populations who lack access to dental care. A cornerstone of dental care experience for School students is community engagement. As of 2016, the School has 21 dental service sites. Working in FQHCs, at the Union Rescue Mission dental clinic, through urban outreach efforts and mobile dental vans, the School serves underserved areas throughout the state. It provided care to 79,000 patients in 2015 - and the number continually rises. Service in action not only in theory. Developing culturally diverse dental professionals in the hugely multi-cultural L.A. area is a necessity that the School takes seriously. It is a benchmark of ethnic, racial and academic diversity. The class of 2020

Chair Division of Dental Public Health & Pediatric Dentistry 1149 S. Hill St, Suite H550 Los Angeles, CA 90015 (213) 740-1084 mulligan@usc.edu

and education to children, oral health education for caregivers, dental home referrals; B. Provides direct patient care at University Clinics serving as Dental Home; C. Enhances and delivers professional and interprofessional education to health professionals focusing on the inclusion and integration of oral health as an important part of overall health.

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is an example of diversity in action, with 188 dental students and 40 dental hygiene students representing 34 different majors, 7 ethnicities and 17 nations.

Childrens The USC University Center Barbara Yoshioka Wheeler, PhD. Subcontractor Hospital Los for Excellence in Associate Professor of Clinical A leader in the field of Angeles Developmental Disabilities, Pediatrics Keck School of developmental USC University based at Childrens Medicine of University of disabilities within the Center for Hospital Los Angeles and Southern California western U.S. Will Excellence in affiliated with the USC Associate Director, USC consult on Developmental Keck School of Medicine, University Center for Excellence interdisciplinary training, Disabilities is a nationally recognized in Developmental Disabilities education and technical (UCEDD) leader in developing and Childrens Hospital Los Angeles assistance. Will also

implementing quality 4650 Sunset Blvd. serve as an advocate in services for infants, Los Angeles, CA 90027 the public arena to children, youth and adults Wheeler, Barbara strengthen systems and with, or at risk for, BWheeler@chla.usc.edu services for individuals behavioral, developmental, and families impacted by physical, and/or special special developmental, health care needs and their behavioral and/or health families. care needs. - serves 5,000 children/ yr.

El Nido Family Founded in 1925, El Nido Liz Herrera, LCSW Community Agency Centers Family Centers mission is Executive Director Provides access to client

to empower families in 10200 Sepulveda Blvd. populations in program low-income communities Suite 350 sites who will receive of Los Angeles County to Mission Hills, CA 91345 LDPP interventions: break the cycle of poverty, (818)830-3646 preventive dental care, child abuse, violence, health promotion academic failure, and teen activities, assessment pregnancy through and response to the non-outstanding educational, dental issues that youth development, health intersect capacities to and therapeutic services. access and sustain El Nido provides behaviors/practices that community based social support dental health services in some of the and engagement with most underserved dental home. communities in Los Angeles County including: Pacoima and surrounding communities, South Los Angeles, Compton, and the

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Antelope Valley. Last year, 10,298 individuals were served by El Nido Family Centers; 80% of whom live at or below the poverty line; the agency is the largest provider in the state of services to adolescent mothers and fathers. - serves 10,278 persons/yr.

Kaiser Doing well in school can Kaiser Permanente Educational Community Agency Permanente send a student on a lifelong Outreach Program Provides access to client Educational trajectory for success. The 4141 Maine Ave populations in program Opportunity Educational Outreach Baldwin Park, CA 91706 sites who will receive Program Program (EOP) provides

education and support services in the San Gabriel Valley section of Los Angeles County. The focus of EOP is to provide programs and activities that improve school performance, promote family communication, teach skills that are needed to meet various life tasks and alleviate stress, create opportunities for the development of leadership skills for both youth and their parents so that they can address issues that have an impact on their community, and increase awareness of professional opportunities in the health field for young people. In 2015, EOP provided services to 1,428 participants with 928 participants under the age of 20. Program growth anticipated for FY 16-17.

Ruth Padilla - King, LCSW (626) 814-6400

LDPP interventions: preventive dental care, health promotion activities, assessment and response to the non-dental issues that intersect capacities to access and sustain behaviors/practices that support dental health and engagement with dental home.

East Los Angeles College

East Los Angeles College empowers students to achieve their educational

Julie Benavides, Vice President of Special Services/Special Programs

Community Agency Provides access to client populations in program

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goals, to expand their East Los Angeles College sites who will receive individual potential, and to 1301 Avenida Cesar Chavez LDPP interventions: successfully pursue their Monterey Park, CA 91754 preventive dental care, aspirations for a better 323-265-8650 health promotion future for themselves, their activities, assessment community and the world. and response to the non-ELAC has been serving the dental issues that Monterey Park community intersect capacities to since 1945. More than access and sustain 40,000 students are behaviors/practices that enrolled every semester support dental health and offer career- and and engagement with transfer-oriented courses dental home; specialized and programs that range outreach to students who from Administration of are under age 20 and to Justice and Nursing to students who are Chicana/o Studies and parents. Chemistry. Over 23,000 students were enrolled at ELAC in 201516, which includes and approximately 25% are younger than 20 years old. The non-traditional student population includes many students who are also parents.

California State Cal State L.A. is a Ron Vogel, Dean Community Agency University Los university dedicated to Rongxiang Xu College of Health Provides access to client Angeles engagement, service, and and Human Services populations in program Division of the public good. Founded 5151 State University DR sites who will receive Student Affairs in 1947, the University Los Angeles CA LDPP interventions:

serves more than 27,000 90032 preventive dental care, students and 247,000 (323) 343-4600 health promotion distinguished alumni, who rvogel@calstatela.edu activities, assessment are as diverse as the city we and response to the non-serve. Located in the heart dental issues that of Los Angeles, Cal State intersect capacities to L.A. has long been access and sustain recognized as an engine of behaviors/practices that economic and social support dental health mobility. Led by an award- and engagement with winning faculty, the dental home; specialized University offers nationally outreach to students recognized programs in under age 20 and science, the arts, business,

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criminal justice, children of student engineering, nursing, parents. education and the humanities. The Cal State L.A. student population includes 7,000 students who are under the age of 20 and includes many students who are parents.

Clnica Clnica Msr. Oscar A. Sandra Rossato, Executive Dental Home Monseor Oscar Romero is a 501 (c)(3) Director Will provide direct A. Romero nonprofit Federally 123 S. Alvarado Street patient care, serving as a

Qualified Health Center Los Angeles, CA 90057 dental home on this (FQHC) with three clinic (213) 989-7700 project. sites located in the Pico- srossato@clinicaromero.com Union and Boyle Heights neighborhoods of Los Angeles. They provide comprehensive medical services, dental care, and health education to low-income men, women and children of all ages living in Los Angeles County. Health care is a human right and Clnica Romero works to ensure access to it for all people regardless of their ability to pay.

Childrens The Children's Dental John Blake, DDS Dental Home Dental Health Health Clinic is a 501(c)(3) Exec. Dir./Dental Dir. Will provide direct Clinic non-profit organization 455 E. Columbia St. #32 patient care, serving as a

serving c hildren and young Long B each, CA 90806 dental home on this adults, ages 0-21, in the (562) 933-3141 project. Greater Long Beach and jblake@cdhc.org South Bay areas who are economically disadvantaged or have issues in access to care. They are dedicated to providing quality basic and specialty dental treatment, as well as preventive services. - serves 10,000 children/yr.

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Public Health The PHFE WIC Program is Kiran Saluja, MPH, RD Community Agency Foundation WIC the largest local WIC Executive Director Provides access to client (PHFE) agency in the country, PHFE WIC Program populations in program

serving a pproximately 4% 12781 Schabarum Ave. sites who will receive of the nations total and Irwindale, CA 91706 LDPP interventions: 23% of Californias total (626) 856-6650 ext. 202 preventive dental care, WIC participants. 250,000 kiran@phfewic.org health promotion clients are served monthly activities, assessment

at 62 sites. Eighty-four and response to the non-percent of the clients dental issues that served by PHFE WIC are intersect capacities to Latino, 6% are African- access and sustain American, 3% are behaviors/practices that Caucasian, 6% are Asian support dental health and 1% are American and engagement with Indian and Alaskan Native. dental home. WIC serves pregnant, breastfeeding, and postpartum women, infants and children under the age of five who are low to moderate income (up to 185% of the federal poverty level) and at nutrition risk. WIC gives vulnerable population the best possible start by providing nutrition education and healthy foods during c ritical stages of development so children achieve optimal nutritional status. PHFE is the nations premier catalyst for advancing program and support services to optimize population health. The 9 sites involved in project serve 48,384 persons/yr.

USC School of Founded in 1970 as a Theda Douglas Community Agency Early Childhood teaching school for future Assoc. Vice President Provides access to client Education early-childhood USC Government Partnerships populations in program (USC SECE) professionals, the USC and Programs sites who will receive

School for Early Childhood (213) 821-2746 LDPP interventions: Education (USC SECE) thedadou@usc.edu preventive dental care,

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has served more than 4,700 health promotion neighborhood children activities, assessment from 4,200 families. By and response to the non-providing comprehensive, dental issues that high-quality early intersect capacities to childhood education access and sustain services to children and behaviors/practices that their families in South Los support dental health Angeles and cultivating and engagement with parental involvement, USC dental home. - SECE seeks to create positive change in the community now and in the future. - serves 500 children/yr

Para Los Nios Founded on Skid Row in Martine Singer, CEO Community Agency 1980, Para Los Nios is a 500 Lucas Ave Provides access to client nonprofit social services Los Angeles, CA 90017 populations in program and education organization (213) 413-1466 sites who will receive dedicated to the success of Msinger@paralosninos.org LDPP interventions: L.A.s neediest children preventive dental care, and families. With six early health promotion education centers and three activities, assessment charter schools serving and response to the non-some 2,000 low-income dental issues that children (ages 6 months to intersect capacities to 14 years), Para Los Nios access and sustain places education at the c ore behaviors/practices that of its mission to break the support dental health cycle of poverty. The and engagement with organization provides a dental home. comprehensive social services model that incorporates: high-quality education, family support & mental health services, parent engagement and community building opportunities. - serves 7,500 children/yr

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Boys & Girls The mission of the Los Calvin Lyons, CEO Community Agency Club of Metro Angeles Boys & Girls Club 800 S. Figueroa Provides access to client Los Angeles is to inspire and enable all Los Angeles, CA. 90017 populations in program Consortium youth, especially those who (323) 221-9111 sites who will receive

need us most, to realize LDPP interventions: their full potential as preventive dental care, productive and responsible health promotion members of the activities, assessment community. This growing and response to the non-consortium of clubs dental issues that currently serves 1500 intersect capacities to members and their families access and sustain within Los Angeles County behaviors/practices that with the expectation that it support dental health will grow to include 11 and engagement with clubs. dental home. - serves 1,500 children/yr.

To Help For more than four Clifford Shiepe Dental Home and Everyone decades, T.H.E. (To Help Pres. & CEO Community Agency Health & Everyone) Health and 3834 Western Ave. Provides access to client Wellness Wellness Centers has been Los Angeles, CA. 90062 populations in program Centers improving the wellbeing of CEO@tohelpeveryone.org sites who will receive

in-need, underserved (323) 730-1920 LDPP interventions: communities in Los preventive dental care, Angeles by providing health promotion access to high-quality activities, assessment healthcare and dental care and response to the non-and for all, regardless of dental issues that ability to pay, while being intersect capacities to mindful of the diverse access and sustain cultural, social and behaviors/practices that economic factors that make support dental health up the foundation of the and engagement with community. dental home.

Montebello Montebello Unified is the Susanna Contreras Smith Community Agency Unified School third-largest school district Superintendent Provides access to client District in Los Angeles County. In 123 S Montebello Blvd populations in program

the school year just begun, Montebello, CA 90640 sites who will receive it welcomed 53,000 LDPP interventions: students to the appropriate preventive dental care, educational level of health promotion schooling from transitional activities, assessment kindergarten to adult and response to the non-school, with 87% receiving dental issues that

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free & reduced lunch intersect capacities to support. 96% of the district access and sustain students are Hispanic or behaviors/practices that Latino Partnering with support dental health Family Healthcare Center and engagement with of Los Angeles to provide dental home. family health care at Bell Gardens High School is a new and growing initiative. - serves 53,000 students/yr. (87% receive free or reduced lunch)

Family In California, parent-to- Yvette Baptiste, PhD Community Agency Resource parent support is offered Executive Director Provides access to client Network of LA through a network of 47 1000 S. Fremont Ave. populations in program County Family Resource Centers Suite 6050, Unit 65 sites who will receive

(FRCs). These centers have Alhambra, CA 91803 LDPP interventions: a common mission of (626) 300-9171 preventive dental care, providing services to health promotion

families of children age activities, assessment birth 3. However, many and response to the non-centers have expanded dental issues that their mandate beyond the intersect capacities to 0-3 population and serve access and sustain families of children of all behaviors/practices that ages and special needs. support dental health FRCs are directed and/or and engagement with staffed by parents of dental home. children with special needs. FRCs strive to reflect the diversity of their community and can accommodate cultural and language needs through bilingual/ bi-cultural paid and unpaid staff. In LA County, there are 10 FRCs which can serve as a gateway to eligible populations for this grant. - serves 50,000 persons/yr

Fiesta Fiesta Educativa was Irene Martinez, MSW Community Agency Educativa, Inc. founded in California in Executive Director Provides access to client

1978 to inform and assist 2310 Pasadena Ave. populations in program Latino families in Suite 213 sites who will receive obtaining services and in Los Angeles, CA 90031 LDPP interventions:

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caring for their children (323) 221-6696 preventive dental care, with special needs. Fiesta imartinez@fiestaeducativa.org health promotion Educativa was formed by activities, assessment

family members and and response to the non- professionals who dental issues that recognized the need to intersect capacities to provide assistance and access and sustain advocacy to these Spanish- behaviors/practices that speaking families. FEI support dental health provides the following and engagement with services: (1) Assist dental home; specialized families gain knowledge, outreach to access key resources and children/youth who have understand their developmental fundamental rights; (2) disabilities. Influence the advancement and rehabilitative potential of Latinos with special developmental needs; (3) Increase the consciousness of professionals about the unique cultural characteristics and needs of Latino children and their families; (4) Expand and develop culturally sensitive programs and services. In Los Angeles County, approximately 2000 clients were served in 2015 with 50% of the clients below the age of 20 years old

Fuerza This community-based Ana Trujillo, Exec. Director Community Agency (Familias parent organization has 1340 E. McWood St. Provides recruitment Unidas En been in existence for 30 West Covina, CA 91790 sites for initial encounter Respuesta al years and is dedicated to ana@fuerzainc.org with targeted Sindrome de serving the Latino, (626) 277-6316 population. Assist the down y otras Spanish-speaking families project in identifying Alteraciones) with children with eligible families and

disabilities that due to their disseminating cultural, socio-economic information on project and language barriers are services in the

underserved. Of the 500+ community; specialized families in Fuerza, outreach to approximately 120 families children/youth who have have children with

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disabilities 0-20 who are developmental Medicaid eligible. disabilities. - serves 120 families/yr

United Established in 1974, the Jerimy Billy, MBA Community Agency American United American Indian Chief Executive Officer Provides access to client Indian Involvement, Inc. (UAII) is 1125 West 6th Street, Suite 103 populations in program Involvement, a 501(c)3 private, non- Los Angeles, CA sites who will receive Inc. profit organization offering (213) 202-3977 LDPP interventions:

a wide array of health and preventive dental care, human services to health promotion American Indians/Alaskan activities, assessment Native (AIAN) living and response to the non-throughout Los Angeles dental issues that County. UAII has grown intersect capacities to from a small community- access and sustain based organization behaviors/practices that providing social services to support dental health AIAN living in the Skid and engagement with Row area within the City dental home; will assist of Los Angeles, to a with specialized multidisciplinary outreach to urban comprehensive service American Indian Alaska center meeting the multiple native families in the needs of AIAN region. countywide.

UAII operates under Federal guidelines established by the Department of Health and Human Services Indian Health Service when determining eligibility for program services.

- serves 761 persons/yr (145 children)

Centro de Nios Centro de Nios y Padres Maria Andrade Moberg Community Agency y Padres (Center for Young Director Provides recruitment

Children and their Centro de Nios y Padres sites for initial encounter Families) has proudly 5151 State University Drive with targeted served Los Angeles and Los Angeles, California 90032 population. Assist the neighboring communities Ph. 323-343-4420 project in identifying with a staff dedicated to Fax: 323-343-6115 eligible families and providing families the disseminating skills and knowledge to information on project

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support their children in services in the their continuing education. community; specialized Early Intervention outreach to Specialists (Lead Teachers) children/youth who have and certified and trained developmental assistant staff offers special disabilities. skills, to young children and their families, including the ability and experience to work with infants and toddlers who are identified with the following types of disabilities:

autism spectrum disorder (ASD)

low incidence disabilities (visual impairments, physical disabilities, deaf and hard of hearing)

medically fragile severe multiple

disabilities developmental

delays at risk for delays

- serves 60 families per month; in FY15-16, 114 unduplicated children received services

Visionary The Visionary Youth Robert Hernandez, MSW Community Agency Youth Center, Center seeks to service Director Provides access to client Hollywood vulnerable youths, in the 5030 Santa Monica Blvd. populations in program Community East Hollywood Los Angeles CA 90029 sites who will receive Housing Community, who are at 323 454-6221 LDPP interventions: Corporation risk for variety of preventive dental care,

adolescent social issues health promotion stemming from violence- activities, assessment

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and response to the non- dental issues that intersect capacities to

access and sustain behaviors/practices that

support dental health and engagement with dental home.

related trauma. The mission is to uplift youth from the negative impacts of trauma and violence exposure by establishing a holistic youth center focused in creating generation change, fostering resiliency, and empowering youth to build thriving communities.

- serves 50 clients and interacts with 400 residents under the age of 20

Dental Homes The primary role of all Dental Home participating entities is to treat the oral needs of project participants identified during oral health screenings at participating Community Agency outreach sites. Bridge Team members, Benefits Enrollment Specialists and Social Work Interns will work closely with the Dental Home participants in scheduling appointments and exchanging information on patient progress.

Expectations of Dental Home partners include: Adherence to the goals of the project; Treatment of all project participants referred to dental clinic in a timely manner; Provision of patient specific treatment data for each project participant on a

quarterly basis; Maintenance of all necessary patient care and reporting documentation; Allowance of time for staff training regarding the project, data management and

reporting, as well as periodic updates; Allowance of posting of project promotional and educational materials; Participation of dental staff in dental continuing education events; Provision of feedback to project leadership, regarding project processes, successes, and

opportunities for improvement, through participation in the projects Advisory Board.

Community Agencies The Community Agency participating entities are the outreach sites where the initial contact with families in the target population will occur. These community agencies are well established and trusted resources within each locale and represent the points of contact with the families to be served by the project. Bridge Teams will visit these sites to recruit families into the program and provide services to the families on site at the agency.

Expectations of Community Agency outreach sites include: Adherence to the goals of the project; Provision of inside space for Bridge Teams to meet/recruit potential project participants;

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Program Director Associate Directors (LT)

Project Operations Committee (POC)

Interprofessional Development and

Coordination Committee (IDCC)

Informatics and Data Management Center

(IDMC)

Office of Community Resources Navigation

(OCRN) Advisory Board

(AB) 3 Bridge Teams

(BT)

Community Organizations Denti-Cal and Medicaid Managed Dental Plans 1 Mini Bridge Team

(BT) Dental Homes

Allowance of time for staff training regarding the project, the importance of oral health and periodic project updates;

Posting of project promotional and educational materials; Provision of feedback regarding to project leadership, regarding project processes,

successes, and opportunities for improvement, through participation on the Advisory Board.

1.3 Letters of Participation Letters of participation from the organizations listed above are attached in Exhibit A.

1.4 Collaboration Plan: To facilitate regular communication and prevent silos, the project will be managed through the structure of 6 separate but interrelated entities: the Leadership Team (LT), the Program Operations Committee (POC), the Interprofessional Development and Coordination Committee (IDCC), the Informatics and Data Management Center (IDMC), the Office of Community Resources Navigation (OCRN), and the Advisory Board (AB).

Figure 1: Project Administrative Structure

The IDCC, OCRN, and the IDMC report to the POC. Cal State L.A. leads the POC and coordinates the ABs efforts. The PIs provide the required and definitive administrative supervision and scientific expertise to

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conduct this community dental public health pilot project properly and efficiently. Each entitys roles in data collection and analysis, communication, and sustainability is described below.

1) Leadership Team: This Leadership Team includes the Program Director and Associate Directors and will meet weekly, prior to the Program Operations Committee, and will set the agenda for the POC. This group is responsible for the overall success and direction of this collaborative project. Weaving together robust interdisciplinary efforts from two local universities, this project has the potential to improve the welfare of many vulnerable Los Angeles residents. Ultimate decision-making authority rests with the Program Director from the Lead Entity (Dr. Ledesma of Cal State L.A.).

2) Program Operations Committee: The Program Operations Committee (POC) is comprised of the Program Director and Associate Directors, as well as key faculty from both Cal State L.A. and USC with expertise in oral health, public health, child development, social work, nursing, nutrition, epidemiology, biostatistics and bioinformatics. The committee will meet weekly and oversee the project through completion. Three meetings per month with take place via teleconferencing, and one meeting will occur in-person. For the first 6 months of the project timeline, the POC will be in charge of developing the project protocols and setting up the needed operational infrastructure. After this period, the POC will continue to meet weekly to monitor implementation, identify and address challenges, and modify the project protocols as needed to ensure that the project is efficiently and effectively achieving the state pilots goals. POC will be in charge of analyzing progress reports based on the established goals and relevant data (See Section 4.1). The POC will identify areas of weakness, adjust the project protocols and implement additional trainings as needed. Data output to inform POC decisions will be produced by the IDMC.

The Committee will also explore opportunities for sustainability. Both Universities have strong experience in applying for federal, state and local government grants and have raised millions of dollars to sustain their profiles of community health projects (Health Policy Institute & American Dental Association, 2015). The Directors believe that the proposed projects Bridge Teams (described in section 3.1) have the potential to tap into the reimbursement money of Denti-Cal/Medi-Cal working as s an extension of dental home partners, and/or as a dental plans partner. The Leadership Team also considers the possibility of developing further partnerships with Local Government Agencies through this pilot and securing their funding with matching federal funds for the future. This mechanism, known as MAA (Medi-Cal Administrative Activities), is currently being pursued by USC as a part of its CHAMP program by partnering with Los Angeles County.

3) The Interprofessional Development and Coordination Committee (IDCC): The IDCC will be led by expert faculty in professional and interprofessional education from Cal State L.A. and USC. The IDCC will: Develop appropriate instruments (curriculum, student rotations and internships, students/interns

evaluation) for all students and interns involved in this project from both universities; Develop several multi-level and multi-disciplinary educational track programs that provide

progressive, year-long, continuing education courses for dental professionals and professional education for non-dental healthcare professionals using didactic lecturing and hands-on workshops; topics include childrens oral health and its impact on development throughout developmental periods, including prenatal, infancy, adolescence and early adulthood and will consider both dental and non-dental factors influencing oral health;

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Evaluate existing education materials that promote oral health and construct new materials that are attentive to the linguistic, cultural and literacy profiles of the target populations.

In the first 6 months of the project timeline, the IDCC will develop training materials, an implementation strategy, and an evaluation plan. Thereafter, the IDCC, in consultation with our Assessment Coordinator, will routinely evaluate the quality of curriculum and training materials, interprofessional education, professional and community presentations, printable brochures and posters, and the website (and its traffic). IDCC will conduct this evaluation through informal processes (such as reflective writing assignments that are routinely submitted by students participating in the Bridge Teams), or formal feedback questionnaires administered by IDCC to the target audiences or participants. IDCC will use these tools to improve the quality of these different products in order to achieve the desired impact. To accomplish these goals, the IDCC will meet weekly (in person or by teleconference). The committee will be responsible for ensuring the availability of the educational programming and materials beyond the life of the project. Thus, these activities will promote sustainability as community partners will have continuing access to the referral services and educational programs/materials developed as a result of these endeavors.

The weekly meeting strategy is modeled after the highly successful USC CHAMP Program for both the POC and the IDCC. The weekly meetings (actual or virtual) allow for much faster decision-making and implementation of corrective actions.

4) The Informatics and Data Management Center (IDMC): IDMC will manage, analyze and summarize all collected data. IDMC will be staffed by experts in bioinformatics

and biostatistics who are capable of providing technical assistance, advanced data management and statistical analyses, and recommendations related to the improving data quality. IDMC will monitor individual, team, and entity performance and compare performance to benchmarks set by POC in the project protocol. In cases of poor performance or deviation from protocols, POC will take appropriate actions, such as additional protocol training, communication or team building exercises, or even a recommendation to the Project Director for termination if needed. IDMC will support the submission of progress reports to DHCS in intervals agreed upon.

The project will use an innovative communication platform (described in Section 3.2) that will facilitate communication among the project stakeholders by enabling sharing of data, reports and resources at different levels while complying with best practices for maintaining patient confidentiality. This platform will be maintained by USC after the end of the grant to provide project community stakeholders with the resulting learning experiences and needed resources to develop other relevant or advanced projects.

5) The Advisory Board (AB): The Advisory Board (AB) will meet bi-monthly with the primary purpose of soliciting feedback directly from the communities being served. The AB will serve as a point of contact for coordination and support of participating entities. This board will include selected representatives from the Lead Entity, the projects POC and IDCC Committees, but will consist primarily of members from the projects participating Community Agencies, participating Dental Homes, and individual community representatives (such as parents and foster parents, legal guardians, teachers and social workers) who will be invited to join the Boards regular meetings. At these bi-monthly meetings, the AB will identify and discuss the project advancements and challenges, develop appropriate strategies to advance the project and overcome obstacles, identify potential service gaps, ensure proper communication among all leading and participating entities, review quality control and progress reports, and ensure that the activities conducted and the materials developed are culturally appropriate.

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During the meetings, members will be provided adequate opportunities to voice their concerns, as well as brainstorm and develop recommendations that align the project goals with the goals of all participating entities, share resources, and explore opportunities for cooperation, expansion, and pursuing sustainability projects. The AB will have the ultimate power to make the decision about partnership termination whenever performance falls below the expected. All decisions and recommendations of the AB will be brought to the POC for discussion and implementation if appropriate.

Cal State L.A. will ensure in these monthly reviews that all participating entities are informed and compliant with the State's requirements for this pilot project. Participating entities that are not represented at the advisory board meetings will be sent bi-monthly memos, updating them on the states requirements for the project, the progress of the project, and the activities of the Advisory Board. Dr. Munger will serve as point of contact for all participating entities, with help from support staff.

6) The Office of Community Resources Navigation (OCRN): OCRN is an office established by USC and staffed by social work interns and the Community Services Navigator through the USC CHAMP Project. OCRN will tap into its already established broad network of community stakeholders in Los Angeles County. These staff members are trained to navigate local social and medical systems, provide families with appropriate and culturally competent resources in a timely manner, and support families in their utilization of these resources. OCRN will utilize a Task Management System and Call Center developed by the IDMC (described in Section 3.2). OCRN will collect data concerning relevant metrics, described in Section 4.1, which will be entered into the projects data management system. Minimization of silos can be facilitated by this administrative structure that promotes information sharing through regular meetings and additionally utilizing the methods below:

Orientation and training sessions to address professional and academic silos focusing on the need to share information and provide constructive feedback between the various parts of the project;

Regularly scheduled peer-to-peer Bridge Team member problem-solving sessions. These teams will meet to discuss programmatic and individual client needs at the conclusion of each site visit day;

A single, centralized client-centered data management system, developed and managed by the Informatics and Data Management Center, which will allow the various professions (nursing, dental, social work, etc.) and team members to document client interactions, etc. and to review these interactions with the other professions;

Specific, pre-set client benchmarks/goals applicable across all disciplines.

Sustainability The infrastructure of the pilot is necessary to launch the project. However, not all components of the pilot will need to be sustained following the end of the pilot. After the pilot is established and operations are running, a part of the executive level as well as staff needed for the reporting/analytical purposes may be able to be reduced. The extent of any potential clinical interventions provided by the Bridge Teams as well as the clinical operations of Dental Home partners will depend on actual and projected financial returns and will be thoroughly analyzed throughout the projects duration so that efficient and productive strategies to continue providing these services will continue after the pilot is completed.

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At the same time, the pilot places strong emphasis on activities in the served communities that, once initiated and bought-into by the families and staff at Community Agencies, can continue on their own. These activities include the train-the-trainer approach to oral health education for the major community stakeholders, integration of oral health topics in the non-dental curriculums of Cal State L.A. programs, development of reusable informational materials and ongoing mobile app usage. In addition, collaboration of the two major Universities on this project will open new opportunities for educational/research/services grants, fundraising activities and other local and federal funding. Lastly, families who integrate good oral health knowledge and practices will pass those to the next generation.

SECTION 2: GENERAL INFORMATION AND TARGET POPULATION

Target Population Determination and Number to be Served

In 2011 USC completed a needs assessment of underserved children in L.A. County. As a result of this study, we determined that the highest oral health care needs were in the inner city SPAs where high density minority populations are located. These findings and the experience of Cal State L.A. and USC in their outreach efforts in the local communities informed us in choosing to focus on the geographic areas that make-up SPAs 3, 4, 6 and 8. Cal State L.A. and USC are located in these SPAs and have firsthand experience in recognizing and working to address the needs of their neighbors. Other participating entities (Community Agency outreach sites and Dental Home partners) were chosen based on current partnerships with Cal State L.A. and USC, and their established presence in the areas to be served and the populations which they currently serve.

We chose the number of children to be served (32,400) based upon our analysis of the available funding and our experience with the USC CHAMP project in providing similar services to underserved children. Reaching this number of children and their families may seem ambitious; however, by building upon the strategies that our CHAMP teams have honed in reaching nearly 50,000, age 0 to 5 year old children, we feel it is achievable and will make a significant impact on the entire family, including siblings. The 0-20 year old participant focus allows us to build upon and expand the personal contacts we have with individuals and families, offering expanded services/resources.

2.1 Geographic Area and Target Population Needs

Community Needs and Project Significance

The focus of this project is Service Planning Areas (SPAs) 3,4,6,8 which represent some of the poorest areas of Los Angeles County. Persons, who are Latino, African American, Asian Pacific Islander and immigrants, represent very large sectors of these communities. American Indian and Alaska Native children and families reside in these communities as well. Dental caries (or cavities) is the most common childhood illness in the nation, accompanied by challenging societal economic and social burdens (Little Hoover Commission, 2016). The psychosocial effects of poor oral health impact childrens health, social wellbeing, academic performance and quality of life (American Academy of Pediatric Dentistry, 2014). In California, 55% of children ages six to eight years have untreated tooth decay, more than twice the national average for this age group (California Healthcare Foundation, 2009). In 2007, the Center for Oral Health (then known as the Dental Health Foundation) estimated the prevalence of untreated dental caries among kindergarten and 3rd

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grade students in Californias elementary public schools to be at 28%.

Based on the data presented in Figure 2 below, this project focuses its effort on areas of greatest economic hardship in Los Angeles County. This County core also represents what has been referred to as the dental desert of Los Angeles, with the lowest percentage of dental services in comparison to the population need in LA County. This inter university, interprofessional project brings critical wellness resources to the most vulnerable segment of our county. The provision of these resources will be enhanced by a programmatic orientation that highlights and embraces the strengths, cultural inheritances and capacities of the target communities while building partnerships for health and well-being.

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Figure 2: Economic Hardship Index by City/Community and SPA, Los Angeles County

(County of Los Angeles Department of Public Health, 2015)

The Project Design and Comprehensive Plan Cal State L.A. and USC have incorporated the theoretical models of Whole School, Whole Community, Whole Child (WSCC) and the Accountability Health Community Model (AHC) (described further in Section 3.1) to guide this pilot project with the goal of creating a comprehensive and innovative program that promotes oral health among children 0-20 years of age in Los Angeles County. This pilot project is designed to yield favorable outcomes related to DTI Domains 1-3. We have learned that multiple factors and social hazards affect a familys capacity to engage with oral health care services. Therefore, we have designed the project

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using interdisciplinary bridge teams to help families overcome barriers that prevent them from participating in care. The Bridge Teams provide oral health screenings, oral health and nutritional education, behavioral and child development education, and resource navigation for family needs such as food, shelter, safety counseling and resources.

The following concepts are incorporated in this project:

Core Concepts: 1. Recognize and address oral health disparities. 2. Establish dental homes as soon as the first tooth erupts. 3. Develop Interprofessional Education (IPE) and Collaborative Practice (CP). 4. Emphasize oral health as an essential part of overall wellness. 5. Promote oral health using multi-dimensional approach.

1. Recognize and Address Oral Health Disparities Disparities in oral health continue to persist in the United States with alarming rates of dental caries among vulnerable children (Dye et al., 2015). According to CDC, persons who are non-Hispanic Black, Hispanic, and American Indian and Alaskan Native generally have the poorest oral health among the racial and ethnic groups in the United States. The greatest racial and ethnic disparity among children aged 24 years and aged 68 years is seen among children who are Mexican American and non-Hispanic Black (Childrens Oral Health, 2016). Nationally, the percentage of children and adolescents aged 5 to 19 years with untreated tooth decay is twice as high for those from low-income households (25%) compared with children from higher-income households (11%) (Disparities in Oral Health, 2016).

The most recent study that examined the caries status of vulnerable children in Los Angeles County was conducted by the USC team in 2011 (Mulligan et al., 2011). This study focused on a random selection of WIC centers and Head Start programs and a proportional-to-size, clustered by age group, a random sample of elementary and high schools (schools were included in the sampling frame if at least 50% of the enrolled students were from a minority racial or ethnic group and at least 62% of the enrolled children of the school were eligible for the free and reduced meals programs). As a result of the oral exams performed, the estimated prevalence of untreated dental caries specifically among three groups of unprivileged children in Los Angeles County (ages 25, 68 and 1416) was estimated to be 73%, with 44% having frank cavities and 29% having white lesions, which are the precursors of cavities (Mulligan et al., 2011). This data is much higher than the national average for children. For example in 2011-2012, 10% of children aged 2-5 and 20% of children aged 6-8 years old in the US had untreated tooth decay (CDC, 2016b). Access to dental care is limited for the majority of the beneficiaries of the Denti-Cal, Californias Medicaid dental program for the vulnerable (Little Hoover Commission, 2016). Half of Californian children (over 4.5 million children) are eligible for Denti-Cal, but only half of those children see a dentist annually (Little Hoover Commission, 2016). Thus it is not surprising that the uninsured and MediCal beneficiaries represented in 2007 nearly twothirds of all hospital emergency visits for dental reasons (California Healthcare Foundation, 2009), and that 9% of Los Angeles children seeking needed dental care at a medical office or hospital emergency room due to lack of access to dental care (Mulligan et al., 2011).

Certain populations within the overall group of vulnerable children in LA County are of special interest in this project, specifically American Indian and Alaskan Native (AIAN) and children and youth with developmental and intellectual disabilities. The AIAN population suffers from the poorest oral health of any population in the

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United States, with staggering rates of untreated tooth decay among children, and untreated tooth decay and periodontal diseases among adults. Pre-school -aged AIAN children have four times more untreated tooth decay than white children (43% vs. 11%) (The Pew Charitable Trusts, 2015). In Los Angeles County, only 0.2 % of the AIAN population seeks dental care in public health clinics (Cabezas, 2016).

It is relevant to mention to that AIAN population is young and growing at rate that is almost two times as fast as the total U.S. population (Norris, Vines, & Hoeffel, 2012). California has the largest share of the AIAN population and Los Angeles metropolitan region has the second largest AIAN population in the nation (Norris, Vines, & Hoeffel, 2012); still there is no a specific geographic home for the community. Ledesma (2007) reports that AIAN children and families experience similar vulnerabilities as other poor children and families in the region, but that the AIAN experience is invisible outside of their community in comparison to the high visibility of other racial and ethnic groups in the region. Further, the dispersed AIAN services across the region render these services challenging and inaccessible. Members of the community are often disconnected from reservation-based health, educational, social and cultural support systems. The Annie E. Casey Foundation (2008) notes that urban AIAN children and families experience a host of social, economic, educational and health vulnerabilities that compromise life opportunities and undermine health status. A health status brief (US Department of Health and Human Services Office of Minority Health, 2016) reports on specific challenges for urban AIAN community members and notes that this group has less access to hospitals, Indian Health Service providers, and tribal health programs. These conditions exacerbate the vulnerability status of children and families and fuel the risk factors that result in dental caries and dental disease across the lifespan.

Developmental disabilities (DD) are defined as a group of conditions due to an impairment in physical, learning, language, or behavior areas. Developmental disabilities, which typically start during childhood and last throughout the lifespan, may impact day-to-day functioning (Facts About Developmental Disabilities, 2015). Approximately 15% of children aged 3 to 17 in the U.S. has one or more developmental disabilities, which include conditions such as Attention-Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), cerebral palsy, hearing loss, intellectual disability, vision impairment, and other developmental delays (Boyle, 2011). Children with developmental disabilities may face particular physical, psychological, behavioral, or economic barriers to oral health, such as difficulty with transportation to dental clinics because of physical, economic, or behavioral reasons; a prioritization of other medical exigencies over oral health; behavioral issues that complicate office visits and treatment; fear and anxiety about visiting the dentist; etc. (Slack-Smith, 2010; Lehl, 2013). The caregivers of children and youth who have developmental disabilities may experience additional challenges in accessing and sustaining dental care. These challenges may include surmounting language barriers and establishing relationships with dental providers, who are attuned to their specific needs and concerns.

Children with developmental disabilities are identified by the American Academy of Pediatric Dentistry (AAPD) as a group with Special Health Care Needs (SHCN) (2012). In the 2011 Institute of Medicine Report, Improving Access to Oral Health Care for Vulnerable and Underserved Populations, people with SHCN were identified as having poorer oral health than the general population (Institute of Medicine & National Research Council, 2011). Low-income children with SHCN may be particularly at risk of not receiving preventive services. Many with SHCN rely on government funded health care to meet their medical and dental needs; however, research indicates that children with SHCN who are enrolled in Medicaid are less likely to receive needed preventive dental care than children with SHCN who were not enrolled in Medicaid (Kenney, 2009). This could be due in part to factors outside of access to care. For example, for children with SHCN, family poverty was found to be associated with greater caregiver burden, defined as the time and financial

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demands associated with caring for a child with disability that constrain the parental social role, (McManus, et al., 2011) and less preventative dental use (Chi et al., 2014).

This LDPP directs program activities to vulnerable children and their families who reside in Los Angeles Countys dental desert, in particular American Indians and Alaska Natives and children with developmental and intellectual disabilities. This focus is enriched by a perspective that incorporates attention to cultural and social variables that intersect help-seeking and health sustaining behaviors and that are respectful of family/community strengths and capacities.

The proposed project is unique in its capacity to address the issues that are summarized, because this partnership of two major universities leverages experience, wisdom and resources in an integrated program design. This capacity is strengthened by a commitment to deliver culturally attuned services and dental health promotion activities in the second largest AIAN urban community and to build university-community partnerships with a historically underserved population. The LDPP intends to integrate recommended best practices from Indian Health Service as well as build on the wealth of practice wisdom of AIAN practitioners in the urban community. There is also the opportunity to disseminate best practices to other AIAN urban communities via the knowledge gleaned from this partnership.

This LDPP seeks and integrates the knowledge of faculty and providers, who are experts in this field and who can strengthen outreach and intervention strategies. Project Associate Director, Dr. Mulligan, and participating entity, Childrens Hospital Los Angeles, have extensive expertise concerning the delivery of health care for children with disabilities, assets that will be leveraged in the proposed project.

2. Establish Dental Homes for children by the time the first tooth erupts Leading health and oral health organizations, including the American Academy of Pediatrics (AAP), American Academy of Pediatric Dentistry (AAPD), American Dental Association (ADA), California Dental Association (CDA), and American Association of Dental Public Health Dentistry (AAPD), recommend a first dental visit by age 1 (Agency for Healthcare Research and Policy, 2015). Research has shown early intervention leads to better oral health and lower cost for families and society (Casamassimo, 2009). While few very young children (1.5%) are seen by the dentist at the recommended age of 1 for a dental check-up, the majority (89%) of young children are seen by pediatricians and primary care providers for well-baby visits (Health Professions Network Nursing and Midwifery, 2010). Physicians and nurses can act as a first line of defense against this most common childhood disease and help link those children to proper dental homes, if they are provided with the right information and training. Additionally, enhancing the clinical skills of dental professionals through continuing education will enable them to be willing and ready to provide dental services for very young children and improve access to care for this population.

We are proposing a community-based oral health promotion program that combines health education by inter-disciplinary teams that incorporate cultural and contextual understandings into their interactions with beneficiaries. This model has been more effective than alternative methods that solely focus on interventions, such as those that aim to promote access to fluoride, improve children's diets or provide oral health education alone, which have shown only limited impact according to a recent systematic review (de Silva, 2016).

3. Develop Interprofessional Education (IPE) and Collaborative Practices (CP) IPE & CP have been proposed and advocated by the World Health Organization (WHO), as well as other

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national and international health organizations, for improving team-based patient care and enhancing population health. According to the WHO, Interprofessional Education (IPE) is defined as when two or more professions learn about and with each other to enable effective collaboration and improve health outcomes. Collaborative Practice occurs when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, families, and communities to deliver the highest quality of care across settings. IPE is essential to the development of CP (Health Professions Network Nursing and Midwifery, 2010). Therefore, our focus in this proposal is expanding the knowledge and activities of other non-dental disciplines in improving oral health practices at the community level (e.g., teaching nurses and other health professionals to apply fluoride varnish, encourage drinking fluoridated tap water, and provide anticipatory guidance health checks), the family level (e.g., changing parental feeding practices and establishing family routines that promote oral health), and the individual level (e.g., empowering teenagers through helping them develop plans to overcome barriers to well-being and self-care). The development of interdisciplinary training curricula that draws on the expertise and scholarship of RXHHS and USC faculty will enhance these efforts. In particular, faculty knowledge and scholarship about the role of the cultural inheritance and the contexts that shape developmental processes for children, youth, family and communities will enrich pedagogy and curriculum.

In order to measure the success of interprofessional education (IPE), we will assess how IPE impacts the client experience (vertical integration), and how IPE improves interprofessional collaborative efforts (horizontal integration). IPE can affect a range of outcomes, such as learners attitudes toward one anothers professions, collaborative behavior, and overall quality of client care (Reeves, 2008). Evidence proves that on the whole, IPE is well-received and helps participants to develop knowledge and skills for collaborative working, including an understanding of roles and responsibilities (Thistlethwaite, 2012).

4. Emphasize that Oral health is an essential part of overall wellness Oral and general health are intertwined. Poor oral health makes it difficult to eat, speak, and be employed. For children, poor oral health can make it difficult to learn due to pain, discomfort, or social stigma. Accordingly, oral health affects individuals selfesteem, psychological and social wellbeing, income level, interpersonal relations, and quality of life (U.S. Department of Health and Human Services, 2000). Additionally, just this month (Sept. 2016) the World Dental Federation (DFI) launched a new definition of the term oral health, designating oral health as an integral part of general health and well-being (Burger, 2016). According to this definition, oral health is:

Multi-faceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex;

A fundamental component of health and physical and mental wellbeing, which exists along a

continuum and is influenced by the values and attitudes of individuals and communities;

Reflective of the physiological, social and psychological attributes that are essential to quality of life and are influenced by the individuals changing experiences, perceptions, expectations and ability to adapt to circumstances.

This definition emphasizes that oral health does not occur in isolation, but is embedded in the wider framework of overall health and well-being. Our project is an integrative and collaborative approach in line with the new definition of oral health by FDI, designed to improve oral health and related quality of life among children and youth.

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5. Promote oral health using a multidimensional approach Children and their families are nested within broader contexts that may promote or hinder their oral health; oral health and dental care are inextricably linked to a variety of societal, community, family interpersonal, and individual factors (Patrick et al., 2006; Fisher-Owens et al., 2007). For example, family-level factors (such as social support; parents beliefs, behaviors, and health; and family culture) and community-level factors (such as the physical and social environments and the availability of resources) indirectly impact childrens oral health (Fisher-Owens et al., 2007). A 2011 report from the Institute of Medicine, currently known as the Academy of Medicine, entitled, Advancing Oral Health in America, made multiple recommendations known as the New Oral Health Initiative (Institute of Medicine, 2011). Recommendations of particular interest to this project include:

Improving oral health literacy and cultural competence; Enhancing the role of non--dental healthcare professionals; Promoting collaborations among private and public stakeholders.

Therefore, an interdisciplinary, multilevel approach is needed to truly address oral health. Such an approach will be utilized in this project. The approach is based on the Whole School, Whole Community, Whole Child (WSCC) model (described further in Section 3)developed by the Centers for Disease Control. WSCC has 10 components: (1) Health Education; (2) Nutrition Environment and Services; (3) Employee Wellness; (4) Social and Emotional School Climate; (5) Physical Environment; (6) Health Services; (7) Counseling, Psychological and Social Services; (8) Community Involvement; (9) Family Engagement; and (10) Physical Education and Physical Activity. By addressing the multiple needs of vulnerable children and their families based on this model, reductions in contextual barriers and see improvement in engagement, adherence and compliance in oral health and overall health should be seen.

Target Population: Our target population is Medicaid eligible, vulnerable children 0-20 years old residing in the County of Los Angeles Service Planning Areas (SPAs 3, 4, 6, 8). These SPAs represent the highest poverty levels in the County and the County has the highest poverty rate in the state as shown in Figure 2 above.

26% of Los Angeles County children (about 526,500) live below the po