January Session, 2011
House of Representatives, April 4, 2011
The Committee on Human Services reported through REP. TERCYAK of the 26th Dist., Chairperson of the Committee on the part of the House, that the bill ought to pass.
Be it enacted by the Senate and House of Representatives in General Assembly convened:
Section 1. (Effective from passage) (a) For purposes of this section: (1) "Advanced dental hygiene practitioner" means a licensed dental hygienist who (A) is authorized to perform all services set forth in section 20-126l of the general statutes, pursuant to a collaborative management agreement, and (B) has presented documentation to the Commissioner of Public Health establishing that the licensed dental hygienist has graduated from a master's degree program in advanced dental hygiene practice from an institution of higher learning accredited by the Board of Governors of Higher Education in accordance with the provisions of section 10a-34 of the general statutes. Any such master's degree program accredited by the Board of Governors of Higher Education shall include a curriculum that incorporates advanced dental hygiene practice competencies as adopted by the American Dental Hygienists' Association; (2) "collaborative management agreement" means a written agreement between an advanced dental hygiene practitioner and a dentist, licensed in accordance with the provisions of chapter 379 of the general statutes, that outlines a mutually agreed upon relationship in which the advanced dental hygiene practitioner and the dentist agree to the parameters of practice provided by such advanced dental hygiene practitioner; and (3) "public health facility" means an institution, as defined in section 19a-490 of the general statutes, a community health center, group home, school, preschool operated by a local or regional board of education, or a head start program.
(b) The Commissioner of Social Services, in consultation with the Commissioner of Public Health, shall establish an advanced dental hygiene practice pilot program in public health facilities located in the city of Bridgeport. Under such program, an advanced dental hygiene practitioner may provide services as described in this subsection. The advanced dental hygiene practitioner may:
(1) Formulate an individualized care plan based on scientific rationale, evidence-based standards of care and practice guidelines in collaboration with the patient and a multidisciplinary health care team;
(2) Administer local anesthesia;
(3) Diagnose and treat oral diseases and conditions within the advanced dental hygiene practitioner scope of practice;
(4) Provide diagnostic, educational, palliative, therapeutic, prescriptive and minimally invasive restorative oral health services including: (A) Preparation and restoration of primary and permanent teeth using direct placement of appropriate dental materials; (B) temporary placement of crowns and restorations; (C) placement of preformed crowns; (D) pulpotomies on primary teeth; (E) direct and indirect pulp capping in primary and permanent teeth; and (F) placement of atraumatic temporary restorations;
(5) Prescribe, dispense and administer the following drugs within the parameters of the collaborative management agreement and within the scope of practice of the advanced dental hygiene practitioner: (A) Analgesics, (B) anti-inflammatories, and (C) antibiotics;
(6) Perform nonsurgical extractions on primary teeth that are mobile or exfoliating;
(7) Place and remove sutures;
(8) Prevent or intercept potential orthodontic problems and parafunctional habits by early identification of such problems, space maintenance services and appropriate referral to other health care professionals;
(9) Provide temporary reparative services to patients with defective prosthetic appliances;
(10) Consult, collaborate and coordinate care with other health care professionals;
(11) Provide referrals to patients as needed for further dental procedures or other health care needs;
(12) Utilize emerging technologies in assessment, evaluation, diagnosis, prognosis, intervention and prevention of disease or conditions that impair oral or systemic health and wellness; and
(13) Use electronic technology to transfer digital radiography, photography, clinical assessment data and fiber optic imaging in collaboration with other health care professionals when warranted for the health of the patient.
(c) The Commissioner of Social Services, or the commissioner's designee, shall (1) coordinate the provision of advanced dental hygienist practitioner services in public health facilities that participate in the pilot program in the city of Bridgeport; and (2) establish rates of payment for the provision of such services.
(d) A collaborative management agreement entered into in accordance with the provisions of this section shall be in writing, signed by the parties to the agreement and maintained by the advanced dental hygiene practitioner at the public health facility where such practitioner is providing services and shall be available for inspection upon the request of the Department of Public Health and the Department of Social Services. A collaborative management agreement shall minimally include: (1) A description of the supervisory relationship between the advanced dental hygiene practitioner and the licensed dentist; (2) specific protocols for prescribing, administering and dispensing medications, including, the types of medications to be prescribed, administered and dispensed and the conditions and circumstances under which such medications are to be prescribed, dispensed and administered; and (3) an emergency protocol that addresses situations under which the following shall occur: (A) Consultation with a licensed dentist or other health care provider; (B) transfer of patient care to a licensed dentist or other licensed health care provider; (C) the provision of emergency care; (D) methods for disclosing the relationship covered by such agreement to the patient; and (E) methods for reviewing patient outcomes.
(e) Nothing in this section shall be construed to: (1) Allow an advanced dental hygiene practitioner to practice beyond the parameters of the collaborative management agreement with the collaborating licensed dentist; or (2) prevent a licensed dentist from providing advanced dental hygiene practice services.
(f) Each advanced dental hygiene practitioner, who provides direct patient care services as part of the pilot program shall maintain professional liability insurance or other indemnity against liability for professional malpractice. The amount of insurance that each such person shall carry as insurance or indemnity against claims for injury or death for professional malpractice shall not be less than five hundred thousand dollars for one person, per occurrence, with an aggregate of not less than one million five hundred thousand dollars.
(g) Each insurance company that issues professional liability insurance, as defined in subsection (b) of section 38a-393 of the general statutes, shall, on and after January 1, 2014, render to the Commissioner of Social Services a true record of the names of persons issued professional liability insurance for the practice of advanced dental hygiene, of cancellations of and refusals to renew such professional liability insurance policies and the reasons for such cancellations or refusal to renew said policies for the year ending on the thirty-first day of December next preceding.
(h) The pilot program shall commence on or before January 1, 2014, and shall terminate not later than January 1, 2015.
(i) The Commissioner of Social Services, in consultation with the Commissioner of Public Health, shall report, in accordance with section 11-4a of the general statutes, to the joint standing committees of the General Assembly having cognizance of matters relating to public health and human services not later than July 1, 2015, concerning the results of such pilot program. The report shall include, but not be limited to: (1) Recommendations to expand the pilot program to other geographic areas of the state; (2) a timeline for expansion of the pilot program; and (3) recommendations for policies and procedures to permit advanced dental hygiene practitioners to provide the services described in subsection (b) of this section on a state-wide basis.
This act shall take effect as follows and shall amend the following sections:
The following Fiscal Impact Statement and Bill Analysis are prepared for the benefit of the members of the General Assembly, solely for purposes of information, summarization and explanation and do not represent the intent of the General Assembly or either chamber thereof for any purpose. In general, fiscal impacts are based upon a variety of informational sources, including the analyst's professional knowledge. Whenever applicable, agency data is consulted as part of the analysis, however final products do not necessarily reflect an assessment from any specific department.
OFA Fiscal Note
The bill allows dental hygienists to perform additional services after meeting certain requirements, and establishes a pilot program in Bridgeport. This is not anticipated to result in a fiscal impact to the Department of Social Services as the bill does not change client eligibility under state or federal benefit programs.
The Out Years
The bill requires the pilot to begin no later than January 1, 2014 and end by January 1, 2015.
OLR Bill Analysis
This bill creates a pilot program in Bridgeport that allows a dental hygienist with an advanced degree who works in a “public health facility” to perform a broader scope of services than is otherwise allowed by law. The Department of Social Services (DSS) commissioner must, in consultation with the Public Health Department (DPH) commissioner, establish the program and coordinate services in participating facilities. DSS must develop payment rates for advanced hygienist services. The program must begin before January 2, 2014 and end by the following January 1.
EFFECTIVE DATE: Upon passage
ADVANCED PRACTICE DENTAL HYGIENIST
Scope of Practice
Under current law, a dental hygienist can clean teeth and gums by scaling, root planning, and polishing; apply sealants; administer certain local anesthetics (after completing special course and clinical work); chart oral conditions; assess dental hygiene; plan treatments; and collaborate in implementing an oral health care regimen. A hygienist must practice under a dentist's general supervision unless she or he works in a public health facility. The law defines a public health facility as a hospital, nursing home, residential care home, home health care agency, outpatient surgical facility, school infirmary, mental health facility, among other institutions; community health center; group home; school, publicly operated preschool, and a head start center.
The bill permits an advanced practice dental hygienist (APDH) working in a public health facility (defined the same way as under current law governing dental hygienists) in Bridgeport to, among other activities:
1. collaborate with the patient and a multidisciplinary health care team to formulate an individual care plan for a patient based on evidence-based standards of care and practice guidelines;
2. administer any kind of local anesthesia (it is not clear whether the APDH must complete the same course and clinical work as a dental hygienist must to administer local anesthesia);
3. diagnose and treat oral diseases within the APDH scope of practice;
4. provide diagnostic, educational, palliative, therapeutic, prescriptive, and minimally invasive restorative oral health services including: (a) preparing and restoring primary and permanent teeth using direct placement of appropriate dental materials, (b) temporarily placing crowns and restorations and placement of preformed crowns, (c) performing pulpotomies on primary teeth, (e) direct and indirect pulp capping in primary and permanent teeth, and (f) placing atraumatic temporary restorations;
5. prescribe, dispense, and administer analgesics (which include opioids), anti-inflammatories, and antibiotics within the parameters of a collaborative management agreement with a licensed dentist;
6. perform nonsurgical extractions on loose primary teeth;
7. place and remove sutures;
8. prevent or intercept potential orthodontic problems and parafunctional habits by early identification, space maintenance services (using a device to keep a space open if a child loses a primary tooth before the permanent tooth is ready to come in), and referral to other health care professionals;
9. provide temporary reparative services to patients with defective prosthetic appliances (e.g., bridges, crowns, implants, dentures, and partial dentures);
10. consult, collaborate, and coordinate care with other health care professionals; and
11. make referrals as needed for further dental procedures or other health care needs.
The bill specifies that it does not prohibit a licensed dentist from performing any of these activities.
Collaborative Management Agreements
Under the bill, an APDH must practice within a scope defined by a written collaborative agreement between the hygienist and a licensed dentist. The agreement must, at a minimum, include:
1. a description of the supervisory relationship between the APDH and the licensed dentist;
2. specific protocols for prescribing, administering, and dispensing medications, including, the types of medications covered and the conditions and circumstances under which they are to be prescribed, dispensed, and administered;
3. an emergency protocol that addresses (a) consultations with and transfer of patient care to a dentist or other health care provider, (b) the provision of emergency care, (c) how to disclose to the patient the relationship between the APDH and the collaborating dentist, and (d) ways to review patient outcomes.
The APDH must keep the agreement at the facility where he or she works and make it available to DSS and DPH upon request.
APDH Education Requirements
In order to participate in the pilot program, a dental hygienist must show DPH that he or she has a master's degree in advanced practice dental hygiene from a college or university that is accredited by the Board of Governors of Higher Education. The master's program must include a curriculum that incorporates the American Dental Hygienists' Association's competencies for APDHs.
The bill requires an APDH who participates in the pilot program to carry the following minimum amounts of malpractice insurance: $500,000 per person, per occurrence and $1.5 million in aggregate. These are the current limits for all dental hygienists. It requires insurance companies to give DSS the names of any APDH whose malpractice policy it cancels or refuses to renew and the reasons for its decision.
The bill requires DSS and DPH to report on the pilot program's results by July 1, 2015. The report must contain recommendations (1) to expand the program and a timeline for doing so and (2) for policies and procedures to permit APDHs to perform the expanded scope of practice statewide.
American Dental Hygienists' Association Competencies
The association's curriculum contains five domains in which APDHs must attain competency. These are (1) provision of primary oral healthcare, (2) healthcare policy and advocacy, (3) management of oral healthcare delivery, (4) translational research (using sound scientific methods and accessing evidence-based information when making decisions and providing patient care), and (5) professionalism. Each domain involves demonstrating competence in specific areas. The curriculum contains nearly 60 specific competencies.
OLR does not analyze most special acts. But we are analyzing this bill, which would become a special act if enacted, because of the unique way in which it expands a health profession's scope of practice.
Human Services Committee