What Changed In The Ecosystem?

From 2009 to 2022, the Blue Cross NC Foundation funded 59 grantee partners for a total of $9.8M. In addition to funding in the form of multi-year grants, equipment grants, planning grants, and COVID-19 emergency grants, the Foundation also provided grantee partners with direct capacity-building support, opportunities for networking and convening, and thought leadership.

Today, there is a more fortified infrastructure to expand access, increased coordination among diverse partners, policy wins, and increased awareness and recognition of oral health as a health priority.

Strengthened infrastructure to expand access to care

Blue Cross NC Foundation’s targeted funding and responsive partnership enabled grantee partners to strengthen and expand operations at rural clinics, safety-net clinics, and other community sites. Grantees reported buying necessary equipment and receiving technical support to adopt streamlined and data-driven practices for more sustainable health center operations.

Technical support, offered in collaboration with grantees, fostered peer learning and better outcomes. This further helped grantees shift from a model of urgent care services towards one that prioritized comprehensive and preventive dental care. More sustainable revenue enabled grantees to maintain operations and offer vital oral health services to communities.

“We were able to shift from an urgent care facility to a comprehensive/ preventive care program.

We have stable and sustainable programming due to these funds.”

Blue Cross NC Foundation grantee

“We had access to equipment that financially we would never be able to afford. Since we received the equipment that is the most sustainable outcome because you can use it for years to come.”

Blue Cross NC Foundation grantee

Increased workforce capacity

Forty-seven percent of grantee partners leveraged funding to improve the capacity of the dental workforce, both current and future. Notably, the Foundation supported fellowships to train future clinicians and provide the opportunity to explore the impact of different social determinants of health, and design & implement  results-oriented programs in communities.

“One of the most important long-lasting changes as to increase our capacity to train Fellows to apply a results oriented framework to their practice to achieve measurable outcomes providing immediate impact on vulnerable communities.”

Blue Cross NC Oral Health grantee

Increased access to care

Because of strengthened infrastructure and increased workforce capacity, clinics and providers were also able to expand their reach and serve more individuals at more locations. This was done by expanding evidence-based models like school-based oral health programs and implementing innovative & newer models like teledentistry.

“There is a lot more effort to get services to where they are needed rather than having folks come to the dental office, particularly for the kids.”

Blue Cross NC Foundation grantee

Significant efforts were also made by the Foundation and grantee partners to prioritize and increase oral health access through school-based services as a critical avenue to reach uninsured and low-income students. In fact, in addition to screening and preventive services, some school-based clinics are also reliably offering complex & comprehensive treatment services.

Together, these efforts contributed to reducing the burden of dental diseases and strengthening the oral health infrastructure to continue delivering services in a timely manner.

“With the help of Blue Cross Blue Shield Foundation, we moved into a school-based program in 2014. It was just with one school and the next year was for three schools. The next year was with the entire county and the next year was with another county. So now we’re in 18 schools…

It is an area where our needs, our mission, and the mission of Blue Cross Blue Shield have intersected in the school-based program.”

Blue Cross NC Foundation grantee

Why does infrastructure matter?

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A strengthened oral health infrastructure at-large supports better availability and accessibility to oral health services by populations that were previously underserved, especially rural communities, children, and medicaid-eligible individuals.

With improved capacity and infrastructure, clinics can not only serve more individuals, but also increase their revenues, in-turn supporting their viability, expansion, and sustainability of many clinics, and ultimately the oral health ecosystem.

Additionally, a combination of efforts like equipment purchase and clinic operations coaching help unlock both immediate and longer-term sustainable impact on access to care.

Finally, a targeted focus on prevention of dental diseases among children through school-based programming, is evidenced to support long-term health & well-being of individuals, reduce costs to the broader health care system, and manage the burden on a oral health service ecosystem that is still further strengthening to be able to serve everyone in NC.

Collective action through a more coordinated and expanded ecosystem

One of the most significant changes in the oral health ecosystem is the expansion of new partnerships and improved coordination. Since 2009, the Blue Cross NC Foundation has played a pivotal role in connecting partners through intentional efforts to spur shared learning, facilitate co-action, and forge partnerships through grantmaking. From the outset, the Foundation’s oral health work was collaborative — engaging 26 leaders and other funders in strategy conversations before making any grants.

In the early days of the portfolio, from 2010-2011, the Foundation connected and coordinated partners from public health departments, academic institutions, and clinics. In 2012, the collaboration strategy expanded to include school districts, more emphasis on convening for shared learning, and the inception of a North Carolina Institute of Medicine (NCIOM) taskforce.

“Everybody now works together on things that no one ever thought these groups would work together on, and that has made a difference in terms of policy. And I think just setting the overall tone for collaboration of what we can accomplish outside of policy, is set a tone that, okay, we might be able to actually make change.”

Ecosystem partner

In 2016, the Foundation partnered with other funders to seed the North Carolina Oral Health Collaborative, which has been foundational in connecting and coordinating oral health partners and community members to advance policy change.

In the past five years, the Foundation has continued to convene cross-sector actors and build momentum among peer funders for increased funding for oral health access and equity in North Carolina.

“The Oral Health Collaborative has a lot to do with the communication between stakeholders of all varieties — not just providers, not just organizations that represent beneficiaries, not just advocacy groups, not just funders. Collaboration is better now than it has ever been.”

Ecosystem partner

The North Carolina Oral Health Collaborative was a gateway for sustainable oral health change

There is widespread consensus that the North Carolina Oral Health Collaborative was transformational in increasing the involvement and coordination of actors within the oral health space.

The Collaborative was able to include and elevate the voices of various actors within the ecosystem to promote effective change. Evaluation data demonstrated that grantees and ecosystem actors alike were deeply impressed with how the Collaborative mobilized folks and achieved sustainable change.

“The Collaborative has more capacity than other advocacy organizations to singularly focus on oral health. And then they were able to tap in and leverage different actors for different pieces of the work.

NC Child and MomsRising could really lift up child and family issues. The Dental Hygiene Association really looking at workforce issues. Partnership with the universities and the dental schools look at how to grow a bigger pool of oral health professionals and make sure they are in service in the right way.

I see [the Collaborative] as this coordinating body that really effectively partners and leverages what other folks have to offer.”

Blue Cross NC Foundation grantee

Why does coordination matter?

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An expanded, well-coordinated ecosystem enabled collective action towards shared goals in service of a stronger oral health care system in NC.

The inclusion of new actors from across different disciplines and areas of expertise allowed for a broader and deeper understanding of issues at-hand, and devise solutions that are innovative, responsive and effective. The Foundation strategically co-created mechanisms and offered support for grantees to deepen partnerships with other actors in the ecosystem. These partnerships were critical for grantee partners to identify shared opportunities, coordinate efforts, spur shared learning, and access additional resources.

Additionally, seeding the North Carolina Oral Health Collaborative proved to be a very effective mechanism to bring together ecosystem actors on a regular basis, engage in collective action, and represent diverse voices. Overtime, the strengthened ecosystem enabled actors to find common ground across a diversity of perspectives (including with policymakers), which ultimately contributed to policy wins and adoption.

Ultimately, the collective strength of the Collaborative and its ability to leverage change in a way that no single entity can, was and will continue to be key to sustainable improvements in the oral health care ecosystem in North Carolina.

Increased recognition of oral health attracts more funding to generate solutions

Oral health is increasingly recognized as a priority in North Carolina, exemplified by sustained funding, momentum among partners, and collaboration in service of future policy and administrative changes. While there is much more work to be done to sustainably strengthen the oral health ecosystem in North Carolina, more entities are paying attention to the issue, and partners feel more empowered and supported in their oral health work.

The Foundation and its grantees (mainly the Collaborative) made a concerted effort to recognize and address prevalent narratives and mental models (i.e., ingrained patterns of thinking and behaviors) that hindered a shared vision and meaningful progress across the state.

I think the Board’s upfront commitment to this for five plus years and $10 million, that was a big thing for us to be able to say. It wasn’t just like, ‘Hey, we’re going to pilot our work in this and see if we feel like there’s something there that we can do.’

It gave Blue Cross NC the credibility in spaces to say we’re doing this.

Foundation Staff

By engaging new partners with common interests, the Foundation helped break down silos and address oral health issues across disciplinary boundaries.

A vital step in this direction was recognizing the role and the power of dentists and professional associations in the ecosystem. Data showed that the NCOHC succeeded in using tact and strategy to build inroads and productively engage critical professional associations. Ecosystem partners recognized the value of finding common ground to make incremental progress toward complementary interests. Interviewees reported feeling invigorated by the possibilities of “no longer being stuck.”

“We now have a partner who is an advocacy group focusing on children.

They’ve been brought into the Collaborative so that the common interest that they have in children’s health, and now includes children’s oral health.

There has been an effort to engage the Latino community also.”

Ecosystem partner

Now, there is a fertile ground for strong collaborative, productive relationships between various partners, momentum from significant policy wins, and ongoing investments in oral health that can be leveraged to further advance the oral health agenda in NC.

…there’s definitely mutual respect between the Dental Society and the NCOHC, and each year we’re seeing changes made… Policy changes made. So we’re no longer stuck, I guess, we’re moving forward.

Ecosystem partner

Why does recognition matter?

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An increased recognition of oral health as a priority can bring more funders and partners into the realm of oral health, as well as strengthen non-monetary assets (knowledge, capacity, experience etc.) necessary to enact change. 

The Foundation’s substantial, early investments proved its commitment and fostered credibility, which signaled the importance of the oral health work to other funders. In fact, the foundation funded several grantees in collaboration with other funders in NC further enhancing the recognition of oral health, and directing more funding and support to oral health partners in NC. With more funders in the mix, grantees can diversify their funding, and oral health work can be better continued and sustained.

The Foundation leadership’s presence in the oral health discourse also added visibility and created urgency. The Foundation continued to build steady momentum by ‘showing up’ in a spirit of curiosity and insistence that there exist different paths to the oral health problems prevalent in NC. This persistence by the Foundation supported the diversification of partners, expansion of the ecosystem of actors, and created opportunities for successes that had otherwise been challenging to achieve.

Ultimately, very few funders fund oral health work specifically. But the Foundation has demonstrated that with some intention, spirit of collaboration, and humility (and a relatively small amount of money), a difference can be made.

Achieved policy wins for lasting impact

Taken together, the Foundation’s support to strengthen infrastructure, improve capacity, increase coordination, and increase recognition of oral health as a priority all contributed to key policy changes that are transforming the way oral health services are administered in North Carolina. These policy changes were activated by, advocated for, and achieved through strategic and intentional efforts by the Collaborative, various partners (both oral health and non-oral health focused), grassroots organizations, and community members, among many others. There were intentional efforts to bring lived experiences to the forefront by leveraging organizations that already specialize in this space and building the capacity of clinically-focused organizations to participate in policy advocacy work.

A key policy win was Senate Bill 146, a landmark piece of broad-ranging legislation, being signed into law in North Carolina on July 23, 2021.

Firstly, this law, codifies teledentistry in NC law. Having been used extensively to maintain access to oral health services during the COVID-19 pandemic, this law helps set standards for continued, safe, and effective implementation of this model in the post-pandemic era. In the absence of or inability to get to brick-and-mortar dental clinics, teledentistry can be invaluable in delivering timely care.

The general statute around Practice Act; that is a significant change. I would say three or four changes that have happened, I feel like from 2020 to 2021, just in that two year timeframe, those have been a huge successes for the North Carolina Oral Health Ecosystem. Like I said, still work to be done, but no one thought those things would ever be pushed through.

Ecosystem partner

This law also expands the scope of practice for dental hygienists by allowing them to administer local anesthesia. This is a significant win for North Carolina, as one of only 6 remaining states in the U.S. that did not have this provision. It was game-changing in increasing the efficiency of dental teams, reducing costs, and ultimately increasing access to care. In the same vein, the law also clarifies existing provisions related to dental hygienists practicing in community settings under limited supervision from a practicing dentist.

Because of COVID there were some regulations that were passed or relaxed to give people more access and a virtual environment. And I think that’s a tipping point for other change that can happen. And so I think’

there’s momentum here that it would be difficult to walk away from it at this point.”

Foundation Staff

Another regulation change that was successfully championed was the ability to use fluoridated toothpaste in childcare settings, with parent/guardian’s consent but without needing a prescription. This allows for better access to this evidence-based method for protecting teeth from decay in young children.

One thing we worked on was like tooth brushing and childcare. We got a regulation changed so that fluoride toothpaste could be used in childcare settings without a doctor’s note, which had been the prior policy.

Blue Cross NC Foundation grantee

One of the Foundation’s key contributions to these policy wins was elevating efforts to bridge lived experience with policy advocacy work. By collecting and honoring stories of community members’ experiences with the oral health care system in NC, grantees were able to start calibrating policy priorities of dental professionals with the needs of communities and direct beneficiaries. Furthermore, with the Foundation’s support, the Collaborative also identified, trained, and built the capacity of oral health providers to serve as “clinical champions” informing and supporting policy advocacy work.

Ultimately, there was consensus that these policy wins contributed to meaningful changes in access care, and to building momentum for future co-action for change.

Why does policy matter?

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Advancing policy change, although one of the most complex changes to achieve in a system, is also one of the most effective ways to bring forth change across the whole system.

With the Foundation’s support, under the leadership of the Collaborative, diverse entities across the oral health ecosystem in NC worked together to identify and strategize policy priorities and achieve significant policy changes. These policy changes tend to have a cascading effect on various elements of the system, when implemented effectively.

For example, revisions to rule 16-W which relate specifically to public health hygienists working in dental access shortage areas, increased increased workforce flexibility to provide preventive care in certain settings, thereby opening doors for school-based oral health programs.

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