Improving access to affordable health care has been a long-term priority for The Duke Endowment. This includes oral health – an often neglected but vitally important part of overall health. According to the U.S. Health Resources and Services Administration (HRSA), affordability and access are challenges for many in North Carolina – especially since all of the state’s 100 counties had shortages of dental health professionals in 2022. That makes affordable dental prevention and treatment inaccessible for many, leading to dental issues escalating into crises. According to HRSA, 76,000 North Carolinians sought emergency department care for dental issues in 2019.
In May 2013, oral health advocates and leaders came together to form the North Carolina Oral Health Collaborative (NCOHC) with the mission of improving oral health access across the state. The effort has been supported by Blue Cross and Blue Shield of North Carolina Foundation (Blue Cross NC Foundation), DentaQuest (now CareQuest Institute for Oral Health) and The Duke Endowment. What began as a simple education and awareness initiative has grown into a trusted partner and advocate for oral health access in North Carolina. As a long-term partner and supporter, The Duke Endowment has witnessed the power of sustained collaboration to help NCOHC evolve into a respected and effective engine for policy change.
A Decade of Collaborative Funding
The Duke Endowment and Blue Cross NC Foundation were early partners to NCOHC and committed to a decade of funding to help establish the new organization and become a powerful voice to address oral health disparities. In 2013, DentaQuest offered an opportunity for organizations to create statewide collaboratives. Blue Cross NC Foundation convened collaborative partners to develop a grant application from North Carolina, and the NCOHC was born. The Endowment’s commitment began in 2016, with three, three-year grants. Blue Cross NC Foundation also committed support, ultimately funding a concurrent 10-year period. That long-term relationship proved vital to helping the collaborative navigate the challenges and transitions of growth as well as identify and act on opportunities with partners across the state.
Evolving Support Empowers Grantees – and Funders
The Collaborative’s early years focused mostly on education – both providing education about oral health care in local communities and listening to those communities to inform NCOHC members about problems and potential solutions. During the early years, the Endowment and Blue Cross NC Foundation were active partners in the collaborative, helping to shape its agenda and encouraging it to build its advocacy capacity. As the years passed and NCOHC matured, both funders gradually transitioned to a more hands-off approach, empowering other collaborative members and staff to fully embrace their leadership roles.
As our friend and colleague Katie Eyes, vice president, program and strategy at Blue Cross NC Foundation, explained, “Coalitions can be challenging in that they bring folks together with different orientations and experiences toward a shared goal. The commitment of funders to be at the table and support evolution allows stakeholders to work through differences and identify areas of alignment so they can take action together.”
This work was new to both The Duke Endowment and Blue Cross NC Foundation. By co-funding and engaging with NCOHC members, we were able to learn together and determine where our respective funding strategies needed to align closely and where they might exist as different, but coordinated, activities.
“Co-funding in this way creates more confidence to innovate and find new ways to address an intractable challenge,” said Eyes. “Both of our boards were very interested in addressing this challenge and partnering gave us the confidence that we weren’t going it alone.”
Building Allies for Policy Change
Part of NCOHC’s growth was learning to navigate relationships with other groups to find a path to a shared goal. One such goal was increasing access to dental sealants. By learning from other states, leaders at the NCOHC identified increasing access to preventive services in schools as an opportunity for impact. Other states leveraged the dental hygienist workforce to perform certain preventative care activities that are included in their training and experience – such as screenings, cleanings and the application of sealants – without the onsite presence of a licensed dentist. However, hygienists’ ability to deliver these services in North Carolina was restricted by policy. At the time, North Carolina had one of the most restrictive practice acts in the country and had recently earned a failing grade in a state-by-state report card from Pew Charitable Trust.
Years of ongoing communication and the leadership of respected dentist Zachary Brian at NCOHC helped build support among multiple partners, including the North Carolina Dental Society, to broaden the ability of hygienists in public health to provide preventive care in places beyond a dentist’s office, such as in schools or other community spaces. The NC practice act was updated in 2020 to be more aligned with other states. This policy change was a significant factor in the impact of the two funders’ school-based oral health initiative that has expanded access to preventative oral health care, performing 130,000 preventative services to more than 7,000 children every year since 2018.
While the policy win was a great milestone, we realized that as funders we would need to support NCOHC’s efforts to help practitioners understand and implement the new practices. NCOHC provided training on the technical aspects of the rule, helping practitioners become confident that they were acting within new parameters and applying new rules appropriately.
Continuing Policy Efforts
Over the past decade, NCOHC has become recognized across the state as a neutral convenor and a trusted voice. Today, NCOHC continues working to increase access to care and to advance its policy agenda in support of that goal. It is recognized as a leading voice for oral health in North Carolina. Currently, NCOHC is implementing recommendations from the state’s Oral Health Medicaid Transformation Work Group, a task force funded by the Endowment that includes 80 dental professionals and advocates dedicated to expanding access to care. The recommendations include increasing Medicaid reimbursements for dental care, further clarifying the new guidance that arose from changes to the Practice Act, building the dental workforce and promoting minimally invasive, cost-effective preventative procedures such as the application of silver diamine fluoride, which halts the progression of tooth decay.
“We’re constantly thinking about the work that needs to be done and the problems we’re going to solve,” said Crystal Adams, MA, CDA, RDH, director of NCOHC. “We want to continue building the infrastructure that keeps our relationships alive with providers and communities. When it comes to sustainability, we let the work lead. There are some great policies in other states that we can apply in North Carolina to improve oral care for millions of residents, especially in underserved and rural communities.”
