Board of Health
November 15, 1999
To: Policy and Finance Committee
From: City Clerk
Subject: Review of the Expanded Municipal
Non-Mandatory Dental Program
Recommendations:
The Board of Health recommends the adoption of:
(1) Option (3) embodied in Recommendation No. (1) of the joint report dated November 9, 1999, from the Medical
Officer of Health and the Commissioner of Community and Neighbourhood Services, as amended, viz.
"Option (3): funds to the amount of $2.4 million be included in the 2000 Public Health operating budget to
annualize the cost of $1.6 million and provide additional funding of $800,000.00 to support the nine dental teams
required to meet the estimated dental treatment needs of 12,500 eligible low-income seniors and children in the City
of Toronto"; and
(2) Recommendations Nos. (2), (3) and (4), viz.
"(2) the age eligibility of seniors seeking dental treatment in the municipally funded, non-mandatory dental
treatment program be standardized at 65 years, although clients in Etobicoke aged 55 to 65 already receiving dental
care should continue to be eligible for services;
(3) Public Health collaborate with the community to develop partnerships for the provision of municipally funded
non-mandatory dental treatment services in areas of the City where these services are not currently available; in
particular:
(a) that Public Health consult with the Rexdale community and staff of the Rexdale Community Health Centres to
examine the feasibility of partnering to provide municipally funded non-mandatory dental services for low-income
residents in the target groups defined by Toronto Public Health; and
(b) that Public Health staff continue to collaborate with staff at Weston Collegiate to utilize the Weston Collegiate
dental facilities to provide municipally funded non-mandatory dental services for the low-income residents in the
target groups defined by Toronto Public Health; and
(4) this report be referred to the Budget Advisory Committee for consideration during the 2000 operating budget
process."
Background:
The Board of Health on November 15, 1999, had before it a joint report (November 9, 1999) from the Medical Officer of
Health and the Commissioner of Community and Neighbourhood Services respecting a review of the expanded
municipally funded, non-mandatory dental treatment program; and amended the recommendations to read as follows:
(1) the Board of Health recommend to the Policy and Finance Committee, one of the following options for maintaining the
expanded municipally funded, non-mandatory dental treatment program:
Option (1): funds to the amount of $800,000.00 be added to the 2000 operating budget for Public Health to support three
dental treatment teams in strategically located clinics across the city. These teams would serve up to 4000 eligible
low-income seniors and children across the City;
Option (2): funds to the amount of $1.6 million be included in the 2000 Public Health operating budget to annualize the
cost to support the six current dental teams in maintaining expanded operating hours in clinics strategically located across
the City of Toronto, with particular emphasis on clinics outside the former City of Toronto. These teams would be able to
serve up to 9,000 eligible low-income seniors and children across the City;
Option (3): funds to the amount of $2.4 million be included in the 2000 Public Health operating budget to annualize the
cost of $1.6 million and provide additional funding of $800,000.00 to support the nine dental teams required to meet the
estimated dental treatment needs of 12,500 eligible low-income seniors and children in the City of Toronto;
(2) the age eligibility of seniors seeking dental treatment in the municipally funded, non-mandatory dental treatment
program be standardized at 65 years, although clients in Etobicoke aged 55 to 65 already receiving dental care should
continue to be eligible for services;
(3) Public Health collaborate with the community to develop partnerships for the provision of municipally funded
non-mandatory dental treatment services in areas of the City where these services are not currently available; in particular:
(a) that Public Health consult with the Rexdale community and staff of the Rexdale Community Health Centres to examine
the feasibility of partnering to provide municipally funded non-mandatory dental services for low-income residents in the
target groups defined by Toronto Public Health; and
(b) that Public Health staff continue to collaborate with staff at Weston Collegiate to utilize the Weston Collegiate dental
facilities to provide municipally funded non-mandatory dental services for the low-income residents in the target groups
defined by Toronto Public Health; and
(4) this report be referred to the Budget Advisory Committee for consideration during the 2000 operating budget process.
The Board of Health also had before it a communication from Ms. Anne Dubas, President, Local 79, Canadian Union of
Public Employees, advising that Local 79 is very concerned about the proposal to use fee-for-service practitioners and
non-profit organizations to provide services to residents who did not have access to them in the past; and urging the Board
to expand the community-based dental clinic model.
Dr. Sheela Basrur, Medical Officer of Health, gave a presentation to the Board of Health in connection with the foregoing
matter.
The following persons appeared before the Board of Health in connection with the foregoing matter:
- Mr. Roy Barriffe, on behalf of the Caribbean Canadian Seniors, and filed a submission with respect thereto;
- Mr. Mohammed Yusuf, on behalf of the Somali Canadian Association, and submitted comments and a petition containing
550 names requesting that a dental care clinic be set up in the Rexdale area;
- Mr. Krishna Sachi, on behalf of Mr. V. Jeevarathnam, Sri Lankan Seniors Tamil Association, and filed a submission with
respect thereto;
- Ms. Ernestine Van Marle, Board Member, Rexdale Community Health Centre; and
- Ms. Bonnie Doucette, Etobicoke resident.
City Clerk
Trudy Perrin/lm.03
c. Medical Officer of Health
Commissioner of Community and
Neighbourhood Services
Ms. Anne Dubas
Interested Parties
(Report dated November 9, 1999, addressed to the
Board of Health, from the Medical Officer of Health
and Commissioner of Community Services)
Purpose:
To provide the Board of Health and Community Services Committee with a review of the expanded, municipally funded,
non-mandatory, Public Health dental treatment program in order to inform the 2000 budget process.
Financial Implications and Impact Statement:
In 1999, Toronto City Council approved funds of $800,000 for the expansion of the municipally funded, non-mandatory
dental treatment program. Funds will be required in 2000 if the expansion of the program for low-income seniors and
children is to be maintained. The level of funding is contingent on the level of service approved by Toronto City Council,
ranging from $800,000 to $2.4 million.
Finance staff have been consulted regarding this report.
Recommendations:
It is recommended that:
(1) the Board of Health recommend to City of Toronto Council, one of the following options for maintaining the expanded
municipally funded, non-mandatory dental treatment program:
Option 1: funds to the amount of $800,000 be added to the 2000 operating budget for Public Health to support three dental
treatment teams in strategically located clinics across the city. These teams would serve up to 4000 eligible low-income
seniors and children across the City.
Option 2: funds to the amount of $1.6 million be added to the 2000 Public Health operating budget to support the six
current dental teams in maintaining expanded operating hours in clinics strategically located across the City of Toronto,
with particular emphasis on clinics outside the former City of Toronto. These teams would be able to serve up to 9,000
eligible low-income seniors and children across the City.
Option 3: funds to the amount of $2.4 million be added to the 2000 Public Health operating budget to support the nine
dental teams required to meet the estimated dental treatment needs of 12,500 eligible low-income seniors and children in
the City of Toronto.
(2) the age eligibility of seniors seeking dental treatment in the municipally funded, non-mandatory dental treatment
program be standardized at 65 years, although clients in Etobicoke aged 55 to 65 already receiving dental care should
continue to be eligible for services;
(3) Public Health collaborate with the community to develop partnerships for the provision of municipally-funded
non-mandatory dental treatment services in areas of the City where these services are not currently available. In particular:
(a) that Public Health consult with the Rexdale community and staff of the Rexdale Community Health Centres to examine
the feasibility of partnering to provide municipally funded non-mandatory dental services for low-income residents in the
target groups defined by Toronto Public Health;
(b) that Public Health staff continue to collaborate with staff at Weston Collegiate to utilize the Weston Collegiate dental
facilities to provide municipally funded non-mandatory dental services for the low-income residents in the target groups
defined by Toronto Public Health.
(3) this report be referred to the Budget Advisory Committee for consideration during the 2000 operating budget process.
Background:
Prior to amalgamation, 4 of the 6 former municipalities offered varying levels of municipal non-mandatory dental
treatment services while 2 offered no services. This service distribution can be broken down as follows:
North York - 70 fixed and 28 portable school clinics providing basic dental treatment for elementary school children up to
grade 6 during the school year.
York - 3 school clinics providing basic dental treatment for elementary school children during the school year.
Toronto - 9 community based clinics operated full time, providing basic dental treatment for low-income children up to
grade 8, ESL high-school students, low-income high school students with emergency or urgent treatment needs, seniors
and high risk mothers enrolled in other Public Health programs.
Etobicoke - One part-time dental clinic, located in the Etobicoke Civic Centre, providing basic dental treatment to
low-income seniors, age 55 and older.
East York - No treatment services.
Scarborough - No treatment services.
During the 1998 budget cycle, the Budget Committee requested staff to report back on the options available to the City to
harmonize the dental program and the costs of such options. At its April 26, 1999 meeting, City Council approved funds of
$800,000 to expand the dental program for children and seniors by extending the hours of the current dental clinics, with
particular emphasis on enhancing access for clients outside the former City of Toronto. In addition, Council requested that
a Dental Task Force report back on the options for dental service delivery for low-income seniors and children. The Dental
Task Force report will be considered by the Board of Health at its November 15, 1999 meeting.
Council also requested that the Commissioner of Community and Neighbourhood Services and the Medical Officer of
Health report on the successes and failures of the expanded municipally funded, non-mandatory dental treatment program,
prior to the end of 1999. This report outlines those successes and challenges, and informs the 2000 budget process in
determining the continuation of funding for the expanded dental program.
As well, Council requested that the City Auditor review and make recommendations on how best to determine eligibility
for Toronto residents who utilize the dental treatment program. The report from the Auditor is forthcoming.
Comments:
Since May 1, 1999, all clinics in the City of Toronto removed pre-existing residency requirements such that eligible
low-income children and seniors who reside anywhere in the City of Toronto, can now go to any of the municipally funded,
non-mandatory dental treatment clinics and receive basic dental services. Basic dental care includes oral examinations,
x-rays, cleaning, scaling, fillings, extractions, root canal therapy, and dentures.
To respond to the increased demand for services, additional temporary staff were hired over the period June 1st to August
31st, 1999. To date 6 dentists, 7 dental assistants and 5 dental clerks have been hired for a total cost of $167,616., for
salaries and benefits for the period May 1st to September 22nd, 1999. In addition, $20,994. was spent to purchase dental
supplies, dental instruments and furniture as well as to repair and maintain the dental equipment during that same period.
The total actual expenditure for the municipally funded non-mandatory expanded program for the period May 1st to
September 15, 1999, is $188,610.00. (See Attachment 1.) Project costs until year end, 1999, are $525,000.
Staff were placed in clinic locations as follows: 2398 Yonge Street, 95 Lavinia Avenue, West Mall-Etobicoke Civic
Centre, 726 Bloor Street and 235 Danforth Avenue. To minimize waiting time and maximize service efficiency, clients are
referred to other clinics when these clinics are operating at capacity.
Tables 1 and 2 show the number of clients, procedures and clinic visits completed during the period May 1st to September
15, 1998, (prior to the expansion of the municipally funded, non-mandatory dental treatment program) as compared to May
1st to September 15th, 1999, (after the expansion of the municipally-funded non-mandatory dental treatment program in the
South and West Regions). There were 878 clients treated in the expanded program during this period. Of these, 406 were
children, and 472 were seniors who received basic dental services.
To serve these clients, staff from the previously established program, were required to reorganize their practices, orient
new staff, and explain program objectives to clients who are not eligible for services but who are trying to access the dental
program. While there was a 10 percent decrease in the number of clients seen from the former City of Toronto, the number
of dental procedures performed on these patients only decreased by 2 percent, while the number of client visits increased
by 10 percent. This indicates that staff gave priority to clients with the most serious conditions.
Table 1
Pre and Post Expansion Services provided by Public Health
in the Municipally Funded, Non-mandatory Dental Treatment Program
for the period May 1st to September 15th, 1998 and 1999
Former City of Toronto
The breakdown of clients utilizing the expanded program who reside in areas outside of the former City of Toronto, is as
follows:
The clinics with the highest utilization rate are as follows: 94 Lavinia Avenue, where residents primarily from the West
Region of the City receive dental services; 2398 Yonge Street where residents primarily from the North Region of the City
receive dental services and 235 Danforth where residents primarily from the East Region of the City receive dental
services. These clinics are booked 5 to 10 weeks in advance and some clinics have waiting lists. In particular, the clinic
located at 235 Danforth, primarily serving clients from East York and Scarborough, has a waiting list of 51 patients.
As eligible clients became aware of the expanded dental program, the number of clients accessing care increased by 50
percent to 100 percent each month. If this level of service demand continues, with current resources supporting six dental
teams, the number of eligible clients that can be served is estimated at 9,000 per annum.
Attachment 2 shows the locations of all community based dental clinics. Those clinics with the highest utilization by
clients who reside outside the former City of Toronto are highlighted.
Attachment 3 contains copies of correspondence received from some clients who reside in areas outside of the former City
of Toronto. The consistent messages are appreciation for the high quality of service received and the desire to see the
program expanded to the locations across the City.
There are an estimated 30,000 low-income children and 12,000 low-income seniors in the City of Toronto in need of dental
care. Assuming a 60 percent utilization rate, 25,000 people would be seeking care each year. At a more conservative 30
percent utilization rate, 12,500 low income children and seniors would be seeking dental treatment per annum. These
estimates are based on Statistics Canada Census Data and analysis of Public Health dental treatment service utilization
patterns.
The expanded municipal dental treatment program has only just become fully operational. Staff had to be hired and trained
and be in a position to inform people of the City's expanded capacity. It is therefore too early to accurately predict service
utilization patterns over time. However, based on current professional capacity where each dental team has a dentist, a
dental assistant, some clerical support and basic materials, it is estimated that each team could treat 1,200 to 1,500 high
need clients annually. Hence at a 30 percent utilization rate, 9 dental teams would be required to meet the needs of the
estimated 12,500 (based on an average 1,350 clients per year, per team) at an estimated cost of $2.4 million. The cost per
team is approximately $265,000.
Option 1: An estimated $800,000 would cover the salaries, benefits, overhead and material costs for 3 dental teams to serve
about 4,000 low income children and seniors per annum.
Option 2: An estimated $1.6 million would cover the salaries, benefits, overhead and material costs for the current
expanded hours with 6 dental teams serving approximately 9,000 clients in the existing dental clinics.
Option 3: An estimated $2.4 million would cover the salaries, benefits, overhead and material costs for 9 dental teams to
serve the estimated 12,500 low income seniors and children eligible for treatment, assuming a utilization rate of 30 percent.
While the expanded dental treatment program has harmonized eligibility across the city, many clients from former
suburban municipalities must travel long distances to receive service. To enable those eligible clients to obtain services
closer to home, minor re-configuration of the dental clinic space in Etobicoke and the preventive dental clinic in
Scarborough could be done to offer the full range of basic dental services and maximize the efficiency of these clinics. In
addition, these changes are necessary to address outstanding health and safety issues for clients and staff. Staff, and where
feasible, equipment, could be transferred from locations in the former City of Toronto to enable those sites to provide basic
dental services. This reallocation of resources could be done within the current budget.
It is Public Health's understanding that for several years, residents of the Rexdale Community have identified the need for
access to affordable dental services in their community. In the spring of 1999, Public Health staff met with staff from the
Rexdale Community Centre who indicated an interest in establishing a partnership with the City of Toronto to provide
dental services for clients in that area. In September 1999, the Rexdale Community Centre held a dental care symposium to
consult with residents and dental professionals on strategies to improve access to affordable dental care services in the
community. It is recommended that Public Health continue to participate in these discussions and report back to the Board
of Health on the feasibility of such a partnership.
The expansion of existing partnerships between Public Health and other agencies is also under review. In the former City
of York, Public Health had an arrangement where dentists employed by the City of York would utilize the dental facilities
at Weston Collegiate (which are normally used to train certified dental assistants) to provide dental services for seniors in
the community. This arrangement was beneficial to the students in the dental assistant program who gained chairside
experience. Weston Collegiate has offered to expand this arrangement. Public Health staff will collaborate with Weston
Collegiate to maximize the benefit of this arrangement to the community.
The issue of the age of eligibility for the seniors dental program needs to be resolved. At present, seniors age 55 in the
former municipality of Etobicoke are eligible for dental services if they meet established income criteria. The age for
eligibility in the other areas of the City was set at 65 years. It is necessary that this disparity be rectified. If the Board of
Health chooses to increase the age eligibility requirement from 55 years to 65 years in the former City of Etobicoke, there
would be a loss of service for these residents. However, reducing the age eligibility requirement from 65 years to 55 years
would be an enhancement to services in the other areas of the City, and would lead to increased utilization of the dental
program.
From a health perspective, reducing the age of eligibility is advantageous as it allows early stabilization of the oral health
of seniors, leading to increased retention of the clients' own natural dentition and a positive impact on their general health
and well being. However, this would place an increased demand on the current available resources. To accommodate this,
Public Health would have to further prioritize access to dental services within the eligible groups. The result would be a
lengthening of the waiting period between appointments and longer waiting lists. At this point, given the resource pressures
for the program, it is recommended that the eligibility requirement be 65. However, those clients in Etobicoke age 55 - 65
who are currently receiving dental care should continue to be eligible for these services. The standardization of age
eligibility for seniors would apply to new clients only.
One of the major challenges experienced by Toronto Public Health dental staff in implementing Council's harmonization
directive was a lack of management support for the program, which resulted from the freeze on management positions for
the dental program. As a result, staff were unable to fully implement the expanded municipally funded, non-mandatory
dental program. Staff should be recognized for the inordinate number of overtime hours they have worked to implement
the expanded dental program. This situation however, is not sustainable. It is therefore necessary to stabilize the dental
management structure to ensure effective program delivery, and evaluation of the mixed model approach to service
delivery being recommended by the Dental Task Force, subject to City Council approval.
This report outlines the current status, successes and challenges facing the expanded municipal, non-mandatory dental
program. While it has been challenging for staff in the former City of Toronto to make the adjustments necessary to
accommodate the increased patient flow to existing clinics, the expansion of the program has proceeded uneventfully.
Eligible clients from areas outside of the former City of Toronto now have increased access to basic dental services and
have expressed satisfaction with the quality of service. The expanded program has therefore been successful in
harmonizing client eligibility and enhancing access to dental services for Toronto residents, regardless of where they reside
within the City.
Continuing delivery of an expanded dental treatment program for eligible low income children and seniors, using current
dental facilities, is recommended until issues pertaining to the method of service delivery in other areas of the city are
resolved. It is important for City of Toronto Council to approve a level of funding appropriate to meet the need and demand
for services for eligible low income children and seniors for dental care.
Dr. Hazel Stewart
Tel. 416-392-0442 ext. 87027
Fax. 416-392-0713
Dr. Sheela V. Basrur Shirley Hoy
