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military duty, the Veterans Administration is in an unusually favorable position to attract and retrain these veterans. Such a program would provide benefits to the veterans involved by assuring them of employment in work they have enjoyed and for which they are especially prepared, and to the Veterans Administration Dental Service which needs their talent.

Therefore, it is recommended that the Veterans Administration immediately establish recruitment and training programs for dental auxiliaries, with special emphasis on veterans who have had experience as dental auxiliaries during their military service.

opmental state to experiment with and demonstrate the utilization of multiple assistants with expanded functions. Already, it has shown that a dentist and dental auxiliaries working as a team at several chairs can provide increased dental service of high quality at lower unit cost. Diagnosis, treatment, prescription, and other procedures requiring full professional expertise must be reserved for the dentist. However, other selected duties, beyond those generally assigned at present, must be properly and effectively delegated to trained auxiliaries.

Dental students exposed to the TEAM concept in Veterans Administration hospitals are learning how to manage a team of auxiliaries working in a suite of operatories and taking part in new experiments. For example, the dental hygienist, with the necessary additional training, is being used to serve as a periodontal therapist, again expanding manpower potential. Dental students trained in the TEAM concept who are being graduated from dental schools are already utilizing auxiliary personnel trained in companion programs and, with some other innovations, are putting many of these practices into operation in the community.

The council believes that there is a failure to fully and effectively utilize auxiliaries in the Veterans Administration Dental Service at present.

Therefore, it is recommended that the Veterans Administration should set an immediate priority for the full utilization of auxiliaries in its facilities to increase the efficiency, practicability, and economy of its dental service; and that staffing patterns be developed to ensure that by 1975 the TEAM approach to dental health care is fully operational in all Veterans Administration dental services.

Developing research as an integral activity: Research activities of the dental service should not be isolated from the mainstream of other biomedical or health service research in the Veterans Administration. Oral research facilities should be a resource to be shared with and appropriately utilized by all other related services. Research programs should be directed toward solving oral health problems that are particularly related to the conditions that are most prevalent among the part of the population represented by Veterans Administration beneficiaries.

Such research may be concerned with a wide range of activities. It may, for example, be devoted to the further study and development of preventive techniques and the early detection of disease; or it could include studies of the epidemiologic characteristics of oral conditions and diseases, correlations between oral and systemic disease, or the study of bone and the effect of disease and aging on the oral tissue. The Veterans Administration Dental Service is in a unique position to undertake such studies and to make these kinds of correlations.

Other areas of investigation relevant to the mission of the dental service, as described in this document, include research in the use of expanded functions of auxiliary personnel, equipment design, and utilization, and economic implementation of various health care delivery systems. High priority should be given to the development of improved biomaterials for tissue replacement. The dental service might also provide treatment facilities that can serve as the interface between work relating to prostheses and research in biologic materials.

Therefore, it is recommended that support be provided to the dental service for immediately expandi its research and development activities and that those activities be directed to

Increasing training programs for auxiliaries: If the Veterans Administration adopts the TEAM approach for oral health care, it will become the country's largest single employer of dental auxiliaries, including assistants, hygienists, and new ancillary personnel who are qualified to perform expanded functions. Therefore, the Veterans Administration must undertake the expansion of its own or the development of new cooperative training programs. Since such individuals have a greater tendency to remain nearer to their homes than dentists and physicians, such training centers should be established throughout the country. Also, because numbers of veterans serve as dental auxiliaries during their

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ward the solution of oral and related health problems that are most prevalent in the patients in the Veterans Administration system, but which have direct applicability to the private sector.

than one Veterans Administration hospital is involved, plans should be developed to have one advanced dental educational program under the dental school's aegis with residents in a common program. Where feasible, dental residents from other community hospitals in the region should be included in the same program to facilitate the rotation among all of the institutions involved. For example, a dental school with an accredited advanced education program in oral surgery might have residents rotating through a Veterans Administration general hospital, a Veterans Administration psychiatric hospital, a community pediatric hospital, and an active city hospital with an emergency service. Under such a program, the Veterans Administration residents would receive the broadest possible experience. This is, in effect, regionalization of educational and health care service that can enhance efficiency and economy.

Therefore, it is recommended that Veterans Administration hospitals expand cooperative programs for patient care and residency training programs for dental students with dental schools and hospitals in the private sector.

Enhance collaboration between Veterans Administration hospitals and other teaching hospitals and educational institutions: The primary function of the Veterans Administration hospital system is the provision of patient care, and this responsibility must continue to be maximized both qualitatively and quantitatively.

Since educational activities have demonstrated a direct relationship to quality care, dental schools affiliated with Veterans Administration hospitals have a long history of helping to improve the quality of dental patient care. Conversely, these affiliations have proved advantageous to the dental education programs of the schools. Members of the faculty of dental schools have provided much of the biomedical and dental science education, both at the hospitals and at the schools in intern and residency programs in Veterans Administration hospitals. However, as already noted, the clinical facilities of the schools have not been fully utilized for dental treatment of veteran patients.

In view of the shortage of facilities and manpower to deliver oral health care, the current potential of these relationships appears to have serious limitations in terms of service. Therefore, consideration should be given to fuller collaborative use of the facilities of these affiliates. Provisions should be made for an increased number of veterans to receive treatment in dental school clinics as needed, and for an increased number of dental students to be assigned to Veterans Administration hospitals to help deliver oral health service under supervision of the Veterans Administration dentists and faculty members. The Veterans Administration also should develop collaborative efforts with other com munity hospitals in dental patient care to utilize those that are best qualified in each disci in pline or specialty for the benefit of all patients.

Recognized dental specialties of Veterans Administration dental training programs are generally affiliated with the dental schools of the region. These affiliations should be expanded in the best interest of the Veterans Administration hospitals, the residents in training, and the schools themselves. Since the programs are primarily teaching programs, the educational responsibility must, of necessity, be centered in the accredited school. In regions where more

Understanding, acceptance, and support of the Veterans Administration Dental Service: It is imperative that understanding, acceptance, and support of the mission and activities of the Veterans Administration Dental Service be developed. Only in this way can patients, whether hospitalized or ambulatory, have full confidence that they are receiving high-quality care by thoroughly trained and competent staff working in well-equipped facilities. Similarly, only with recognition of the major role played by the Veterans Administration Dental Service in dental education and research can recognition be achieved at the professional, congressional, and community level.

The establishment of an understood and accepted identity for the Veterans Administration Dental Service in these areas is an integral part of the total goal of the Veterans Administration's Department of Medicine and Surgery and consistent with its need to be included as an integral part of the country's total health care system. With the advent of some type of national health program, the options open to veterans for dental care, like other health services, could become many and varied. Also, with the options for available support to dental schools becoming more and more limited along with availability of research funds, it is important that the actual and potential Veterans Administration support be recognized and understood. Only by becoming closely integrated with the community it serves, and collectively a national resource for health care, can the Veterans Administration health care system and its dental service be assured that it can continue to serve not only veterans but their families and neighbors by cooperatively working with the institutions that serve them, as well.

Therefore, it is recommended that a strong public and professional educational program be implemented to educate the public about the mission, activities, and potential of the Veterans Administration Dental Service.

. Demonstrations of model care systems: It has been pointed out that the magnitude, scope, and diversity of the Veterans Administration health care system make it an ideal base for new and improved methods of delivery of dental care. By demonstrating innovative approaches in this effort, the Veterans Administration Dental Service could make an invaluable contribution to ward helping to solve national oral health care problems.

Therefore, it is recommended that the dental service immediately embark on a series of studies and demonstrations to develop and test new ways of delivering care to patients and to improve the use of dental manpower and facilities.

If some or all of the recommendations are adopted, the council also suggests that there be periodic review and assessment of their value. This supports the realization of the council that these recommendations should not be considered as a rigid plan, but rather as a flexible pattern on which additional future programs and activities can be developed.

In order to serve effectively, the Advisory Council on Dentistry believes that it must be involved in such continuing efforts, including the evaluation effort, so that it can continue to make meaningful revisions to the recommended programs and study and suggest other areas of action.

During the forthcoming period of rapid changes in the nation's health care policies, the role of the council should be reappraised. In this regard, consideration should be given to broadening the composition of the Advisory Council on Dentistry to ensure that it is more representative of all aspects of dentistry, as well as integrated with other areas of health care activities. In addition, better coordination of overall planning would encourage closer ties between the Advisory Council on Dentistry and other advisory bodies of the Veterans Administration's Department of Medicine and Surgery, especially the Special Medical Advisory Group.

To carry out such expanded functions and fulfill its responsibilities, the Advisory Council on Dentistry should be kept fully informed of all health care activities of the Veterans Administration and of the operation of its existing and developing programs. Mechanisms such as more frequent council meetings, representation on the Special Medical Advisory Group, inclusion in conferences, briefings, and site visits are all encouraged.

Role of the Advisory Council on Dentistry in the future: The Advisory Council on Dentistry presents this report to the Chief Medical Director through the Assistant Chief Medical Director for Dentistry and asks that, if appropriate, it be forwarded to the Administrator of Veterans Affairs.

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I enjoyed the opportunity of appearing before your committee and was greatly pleased at the interest you evidenced in the Veterans Administration dental program and your knowledge of the recommendations made by the Dental Advisory Council.

I have prepared and returned the material from the hearing with necessary correc tions and additions. In answer to your specific questions included with your letter of April 24, I can give the following:

Where would you recommend we cut the 197 4 budget for D. M.&S. ? I do not believe that we can afford to make cuts in the D. M.&S. program as there are veterans who are entitled to even more care than can be provided by the present budget.

The other VA programs. I believe that we must consider the veterans benefits as a debt of the nation resulting from our military activities and hope that the nation can see fit to provide for those who served their country in this capacity.

I believe I expressed myself at the hearing that the general feeling I have observed among my colleagues and associates is that we should reduce our military spending and our spending in foreign programs and concentrate on domestic programs at the present time.

For the first time since World War II there is a potentially reduced level of funding for VA medical research programs. In Fiscal Year 1973 the VA appropriation for medical and prosthetic research was 76.8 million and in Fiscal Year 1974 the requested appropriations amount is 71 million. What do you be

lieve the level of funding for VA research programs should be in Fiscal Year 1974? I believe that in order to maintain the present level of research in the Veterans Administration, which in the long run may reduce the cost of care of veterans and others, the minimum for FY 1974 should be 88 million dollars.

By what percentage do you estimate the research funding must increase in FY 1974 just to maintain program levels. I have used the figure of approximately 5.5%. Although this is low, we are struggling along with this at our university level in hopes of maintaining the present level of activities and simply meeting inflationary costs.

If I can be of any further help, I shall be pleased to respond.

Again thanking you for your deep interest in our programs.

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