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Creating

Your�Collaborative Agreement

April 2020

Welcome to this online tutorial. I’m Deb Jacobi, Policy Director at Apple Tree Dental. I am a licensed dental hygienist and member of the Collaborative Dental Hygiene Practice Advisory Committee. I want to thank Dr. Colleen Brickle, Dean of Health Sciences at Normandale Community College, for asking me to help with the tutorial and even more for her dedication to dental hygiene and visionary leadership in oral health.

This photo of me with Ann Battrell, Chief Executive Officer of the American Dental Hygienists Association is my reminder to urge you to join ADHA. ADHA is working across the country to expand our ability to practice dental hygiene to the full extent of our education and expertise. Our membership supports their efforts. Please also consider joining the AAPHD, SCDA, the American or Minnesota PHA, MOHC, and other professional groups working on the issues of importance to you.

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Collaborative Agreement Template - July 2019

Available at: http://www.normandale.edu/departments/health-sciences/dental-hygiene/minnesotas-21st-century-dental-team-toolkit/dental-hygiene-in-community-settings-collaborative-dental-hygiene-practice

Before we begin

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Collaborative Dental Hygiene Practice Authorization

First enacted in Minnesota Statutes in 2001, 150A.10 Subdivision 1a, created a “Limited Authorization for Dental Hygienists” with a goal to expand access to care for populations experiencing barriers to the traditional delivery system.
Commonly referred to as Collaborative Dental Hygiene Practice (CDHP) or simply “Collaborative Practice”.
Revisions made in 2003, 2005, 2007 and 2017 expanded and clarified CDHP. Future changes may occur.

Before we step through the template, let’s look at the legal authorization for CDHP.

The original and ongoing purpose of the authorizing Statute was and remains that too many Minnesotans are unable to access dental care in the traditional delivery system. This leads to untreated disease as well as increased dental and health care costs.
Perhaps reflecting initial hesitancy about a new approach, CDHP began as a “limited authorization”. Subsequent legislation has expanded and clarified the Statute to strengthen its potential impact.
It is reasonable to expect future changes as the dental team advances, so please keep yourself up to date.
In addition to regulatory changes, the science and practice of dental hygiene is evolving. As I speak, Minnesota is responding to COVID-19. Post-pandemic changes in how we delivery dental care will also impact CDHP – perhaps making it even more vital to improving oral and overall health by bringing timely preventive services to people that reduce their need for restorative treatment.

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Collaborative Dental Hygiene Practice Authorization

has entered into a collaborative agreement with a licensed dentist that designates authorization for the services provided by the dental hygienist; and
has documented completion of a course on medical emergencies within each continuing education cycle.

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Collaborative Dental Hygiene Practice Regulation

Legal Authorization: Minnesota Statutes, �Chapter 150A.10, Subd. 1a
Minnesota Board of Dentistry “rules” guide the implementation of the statutes
Minnesota Health Care Programs, insurance companies and managed care organizations set coverage and payment policies

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Collaborative Dental Hygiene Practice Responsibilities

Patients’ best interest
Best Practices
Collaboration with dental professionals and community partners

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Types of Agreement

Dental Hygiene Collaborative Agreement
Dental Therapy Collaborative Management Agreement

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Collaborative Practice Authorization for Dental Hygienists and �Dental Assistants in Community Settings�

In accordance with Minnesota Statutes, Chapter 150A.10, Subd. 1a, a dental hygienist licensed under this chapter may be employed or retained by a health care facility, program, or nonprofit organization to perform dental hygiene services listed in Minnesota Rules, part 3100.8700, subpart 1, without the patient first being examined by a licensed dentist.

In accordance with Minnesota Statutes, Chapter 150A.10, Subd. 2a, a dental assistant licensed under this chapter may be employed or retained by a health care facility, program, or nonprofit organization to perform dental assistant services listed in paragraph (2)(b) without the patient first being examined by a licensed dentist. The dental assistant will enter into a collaborative agreement with a licensed dentist, which must be part of a collaborative agreement established between the licensed dentist and dental hygienist that authorizes the services provided by the dental assistant.

The services to be provided by the dental hygienist or dental assistant in community settings must conform with current statutes, however a collaborating dentist may note limitations of the scope of practice in the template below.

Now, let’s step through the July 2019 CA Template. This slide shows the opening paragraphs of the Template.

The phrase ”employed or retained by” means that with a Collaborative Agreement, a Minnesota licensed dental hygienist may volunteer for, contract with, or work as an employee of a health care facility, program, or nonprofit organization to provide services within their legal scope of practice prior to a dental examination.
“Licensed” and “licensed under this Chapter” means holding a license in good standing from the Minnesota Board of Dentistry.
With a goal to support CDHP and access to care, the statute language shown in the second paragraph was enacted to authorize licensed dental assistants as team members in community settings.
For both licensed dental hygienists and licensed dental assistants, the CA may include limitations to their legal scopes of practice if that is determined to be advisable for the specific circumstances of the CDHP.

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Collaborative Agreement Dentist Name: (Print) _____________________________________

Minnesota Dentist License Number: _____________________________

Primary Dental Practice Address: _______________________________

Email: __________________________ Phone: ____________________

Signature: ___________________________________Date: ___________

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Collaborative Agreement Dental Hygienist Name: (Print) ______________________________________

Minnesota Dental Hygienist License Number: ___________

Email: _______________________ Phone: _________________

Signature: ______________________________Date: ________

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Collaborative Practice Settings Served Through this Collaborative Agreement: �(attach a separate sheet to include additional settings)

Organization/Community Setting Name: i.e. school name, health care facility name, etc. ____________________________________________________________________________

Address: ____________________________________________________________________________

Email: ___________________________________ Phone: _____________________________

Population being served in this setting, e.g. age, community group, non-profit, etc. ____________________________________________________________________________

Best Practice:

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Describe Age- And Procedure-specific Standard Collaborative Practice Protocols:

1. Medically compromised patients: �Example: Medical histories are reviewed by the dental hygienist and dental assistant at each appointment. Patients with complex medical histories will be discussed with the collaborating dentist to determine if the patient may proceed with the appointment and/or to identify necessary treatment modifications.

Several sections of the Template cover age- and procedure-specific standard collaborative practice protocols. Some are required in statute. Others are Best Practices. All protocols should be customized for your specific Collaborative Dental Hygiene Practice.
Statute requires that the Collaborative Agreement include “consideration for medically compromised patients and medical conditions for which a dental evaluation and treatment plan must occur prior to the provision of dental hygiene services”. You may also include specific conditions or diseases when you will postpone care until after an examination has been completed.
This requirement could include consultation with other interprofessional team members in addition to the collaborating dentist. For example, the school nurse might serve as a resource in a school-based program. In a Long-Term Care setting, it might also include the nursing staff.

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Describe Age- And Procedure-specific Standard Collaborative Practice Protocols:

2. Procedure to obtain consent:�Example: In Head Start or school-based programs, consent forms sent home to parents with other school information. The school nurse receives returned forms.

Statutes require that the Collaborative Agreement must include: “copies of consent to treatment form provided to the patient by the dental hygienist.”
The Collaborative Agreement should describe how forms are distributed and tracked, as well as the types of consent.
For example for a Head Start or school-based program, consent forms and the instructions for their return might be sent home to parents with other school information.
Determining who is responsible for receiving, tracking and documenting the responses should be planned in advance and included in this section of the Collaborative Agreement.
In some situations, passive consent, meaning that the screening will be done unless consent is formally denied, might be allowed for a visual screening while active consent is required for the provision of preventive services.
Statute also requires that consent forms must include a ‘statement advising the patient that the dental hygiene services provided are not a substitute for a dental examination by a licensed dentist.”
This requirement may be less relevant if the Collaborative Dental Hygiene Practice is utilizing Teledentistry as the patient will receive an examination by an off-site dentist.

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Best Practice:�

Risk-based care: Periodontal risk protocol

Example: Follow and document periodontal classification in the patient record according to American Academy of Periodontology.�

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Best Practice:

Risk-based care: Caries risk protocol�Example: Caries risk assessment will be performed using an “evidence-based approach to preventing and managing cavities at the earliest stages.”

CAMBRA https://dentistry.ucsf.edu/research/cambra;
American Academy of Pediatrics (AAP) Oral Health Risk Assessment Tool https://tinyurl.com/yxcrclls
PREDICT, Advantage Dental, University of Washington) https://tinyurl.com/y3ncnzdt

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Describe Age- And Procedure-specific Standard Collaborative Practice Protocols:

4. Dental sealant protocols:�Example: Identify standard procedures to determine need, materials being used, and the protocols followed to determine referral. Describe a plan for follow up care to assure efficacy of the sealant placement. The dental assistant may place sealants following determination of need by the dental hygienist and based upon authorization criteria of the collaborative agreement dentist.

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Best Practice:

5. Other protocols (if applicable):

Fluoride varnish
Silver diamine fluoride
Teledentistry
Radiographs
Glass ionomer temporary restorations*

*requires Restorative Expanded Functions training

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Describe Age- and Procedure-Specific Standard Collaborative Practice Protocols:

6. Dental records: �Describe where patients’ dental records will be stored and the electronic dental record system being used by the program.

Documentation must include medical & dental history review, special considerations, treatment provided, outcomes, patient response to treatment and referrals or actions taken.

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Best Practice:

7. Emergency response: �Describe familiarity with the community setting’s emergency response plan and equipment available. Include the most recent date of completed medical emergency training by the dental hygienist and dental assistant.

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Describe Age- and Procedure-Specific Standard Collaborative Practice Protocols:

8. Protocol for referrals:

Example: When the need for urgent or routine follow up care is identified the dental hygienist and/or designated program staff will:

detail findings verbally and in writing
assist with referrals to partnering dental facilities, expediting urgent care needs
document all correspondence with patients, parents/legal guardians/family members in the patient’s dental record

Statute states that “When the patient requires a referral for additional dental services, the dental hygienist shall complete a referral form and provide a copy to the patient, the facility if applicable, the dentist to whom the patient is being referred, and the collaborating dentist if specified in the collaborative agreement. A copy of the referral form shall be maintained in the patient's health care record.”

Statute goes on to say that “The patient does not become a new patient of record of the dentist to whom the patient was referred until the dentist accepts the patient for follow-up services after referral from the dental hygienist.”

Beyond that specific Statutory language, care coordination is a Best Practice. It is our professional responsibility to develop effective linkages to needed care beyond the scope of Collaborative Dental Hygiene Practice. Developing relationships with multiple general dentists and specialists is in our patients’ best interest and an important professional obligation.

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Best Practice:

9. Quality assurance plan: �Example: Patient care review will be performed by the collaborating dentist on a quarterly basis to monitor referrals and treatment completion.

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Registering the Collaborative Agreement:

Describe a plan for submitting initial registration and collaborative agreement updates to the Minnesota Board of Dentistry https://mn.gov/boards/dentistry/current-licensee/collaborative-agreements/: �____________________________________________________________________________________________________________________________________________________________

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Annual Review:

The collaborative agreement will be reviewed annually by the collaborative agreement dentist, dental hygienist and dental assistant. A signed, updated copy of the collaborative agreement will be provided to each community site served by the dental hygienist and dental assistant.

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Normandale 21st Century Dental Team website > Collaborative Dental Hygiene Practice section > Helpdesk� �http://www.normandale.edu/mndentalteam

Still have question(s)? �Contact the Help Desk!

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This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $1,660,032 with zero percentage financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.”��

Thank you and good luck in your endeavors!