Stuart Rubin’s dental office fits into 10 carefully stocked plastic bins that are strapped to a metal trolley as needed and wheeled from his SUV to a patient’s front door.
His daughter, Lindsay, also a dentist, has her own portable office, set up exactly the same way. There are two more mobile offices used by three other dentists who work with them.
"I have it very well organized," says Lindsay Rubin, who has packed each bin with the tools needed for procedures ranging from routine cleanings to fillings or extractions, and even X-rays. Every tool is in its place, so that any dentist using the equipment can find what is needed with ease.
The Rubins have a traditional dental office in Maplewood, but for their Dental Home Services practice, they travel with mobile equipment that enables them to perform every procedure imaginable in a patient’s living room, bedroom or dining room. "We can adapt to every situation," Stuart Rubin says. With the help of laptop computers, iPads and smart phones, they have access to patients medical records, instant X-rays and more in home settings. Working on patients who are sometimes in wheelchairs or hospital beds, they fix broken incisors, remove or crown compromised molars, make molds for dentures or fix them.
The father-daughter dental team is among what is expected to be a growing number of health care professionals, including doctors, nurses, psychologists, dieticians and others who make house calls. An aging baby boomer population, in which many have multiple health conditions, is increasing demand for in-home care.
But home care is not new for Stuart Rubin. He began home visits about 15 years ago, after his father-in-law had a disabling stroke and required home-based medical care. "It opened my eyes to how hard it was to get help in," he says. "You don’t think of it if it doesn’t happen to you."
Rubin, 61, thought he might help by taking his practice on the road. "I said, ‘Let me give it a try on Wednesdays, I don’t need to be playing golf.’ "
Demand for his home dental visits exploded. His mobile dental team now serves patients at numerous private homes, more than 100 New Jersey assisted living facilities and a few New York residences, he says. To serve all those patients, Stuart and Lindsay Rubin work a six-day week.
Lindsay Rubin, 29, joined the practice two years ago and trains all the dentists on proper equipment use and on caring for patients with challenging medical conditions, including Alzheimer’s, which is a specialty for the practice.
"We definitely schedule accordingly," she says when asked about managing what is, effectively, a statewide practice. Efficient scheduling also enables Lindsay and her parents to have social lives, she says. She and her father work alternating schedules in the office, each doing two days a week there and four days a week on the road. "I can still have Saturday night," she says.
During a recent visit to patients at the Sunrise assisted living community in the Lincroft section of Middletown, Lindsay Rubin pointed an X-ray gun at Ann Fallon’s right jaw. She joked that the tool, with its space-age shape, makes her feel like the ray-gun-toting Looney Toons character Marvin the Martian. Within seconds, a digital image of Fallon’s teeth appeared on the screen of a laptop computer Rubin had set up on a nearby chair. Within minutes, the exam was over.
The sound of a dentist’s drill may or may not be less menacing in your living room when you’re being treated in your recliner, but for Fallon, who uses a wheelchair, in-home treatments are certainly more convenient.
"It’s always a hassle if my son has to take off work to take me to a dentist or the doctor," she says. "It’s nice that they come to you."
Stuart Rubin says the cost of the dentist coming to you is the same as that in an office visit, but with a mileage charge. "As far as insurance, it’s just like a regular office visit," he says. Sometimes, the travel cost, typically about $85, is also covered by insurance.
While some physicians are examining opportunities for so-called concierge care in which home visits are a luxury available to any patient willing to pay a premium, most home care visits now serve those for whom it is difficult or impossible to leave home. Lindsay Rubin says their practice serves the occasional caregiver, but rarely anyone who could easily make a trip to their office. "There’s just such a high demand from the patients we do see," she says.
And their services appear to be rare. Officials at the American Academy of Home Care Physicians, which offers physician referrals online, said only Stuart Rubin and a San Francisco dental practice are listed among its members.
Arthur Meisel, executive director of the New Jersey Dental Association, says few dentists venture into home care because dental exams require lots of tools, proper lighting and equipment that make examinations difficult in a home setting. “It's not like a physician going to someone's house with a tongue depressor and saying 'stick out your tongue'; it's far more involved than that.” However, given the need among those who are less mobile, overcoming such obstacles is obviously possible for dentists like Rubin. “I'm sure there are appropriate means of providing care when it is necessary,” he said.
Rubin and others anticipate increased demand for home care with what has been dubbed the "silver tsunami," referring to a time when the majority of baby boomers are senior citizens. "We see how bad it is already," he says.
House calls: an affordable solution
Home care providers also include mental health professionals. Jeffrey Axelbank of Highland Park has worked with patients who don’t leave their home because of chronic pain, for which he addresses any psychological roots. In other cases, it’s patients who could leave home, but fear doing so. "The goal is to help them get out of the house, to help them to come to my office," he says. "By going there, I can begin to establish a relationship and trust, and that will help to lower their anxiety."
The patient-doctor relationship is part of the appeal of home care, as it was in the days when traveling doctors carried only a little black bag. Union County physician Douglas A. Ballan says those relationships matter, and after seeing one too many patients brought in on a stretcher, he formed House Calls of NJ in 2008. In this part-time practice, he offers home visits every day of the week and strives for a better bedside manner.
"When I was seeing patients in an office, there were sometimes patients who were too sick to come to the office. So basically, they went without care and they got too sick and ended up going to the hospital," Ballan says.
That is exactly the situation that organizations such as the American Academy of Home Care Physicians hope to prevent. The nonprofit group has worked since 1984 to increase home-based primary care to the frail elderly. House calls, the group believes, are a solution to rising medical costs when quality, low-cost care is provided in the homes of those with several chronic conditions. With such care offered more frequently, troubles could be caught early, keeping those patients out of emergency rooms and hospitals where more expensive treatment can cost thousands. According to the organization, every medical tool typically used in an office visit can now be brought into the home. That technology also can help doctors keep many patients out of nursing homes, the group says.
Home health care will be a particular issue for New Jersey, which has been listed among states with the highest Medicare costs and the worst outcomes for those with multiple health conditions.
The notion that home visits can improve health care is now being tested as part of the Independence at Home Demonstration, a three-year research program tied to the Affordable Care Act. The Centers for Medicare and Medicaid Services is working with about two dozen medical practices across the nation to test the effectiveness of delivering primary care at home.
While no New Jersey providers are participating in the demonstration, the goal is to determine if home care will improve outcomes for Medicare beneficiaries with multiple chronic conditions. The program’s test, which runs through 2015, also will reward health care providers who deliver "high quality care while reducing costs."
In the meantime, another hurdle is trying to get insurance companies to understand the importance of home care, Ballan says. "It’s too bad that they are worried about cost effectiveness when the issue is really helping people," he says. "Cost effectiveness is not supposed to be the goal. Taking care of people, that’s the goal."
The American Academy of Home Care Physicians offers physician referrals online at aahcp.org.
Beyond individual doctors, Robert Wood Johnson Home Visit Service offers care to those living within a 25-mile radius of its New Brunswick facility. Call 888-784-5773 for details.
Eatontown-based Visiting Physician Services covers Ocean, Monmouth, Middlesex, Somerset, Union, Essex, Passaic and Bergen counties. See Visiting-Physician.com.
Various New Jersey locations of the Visiting Nurse Association are a link to health care providers who make house calls. Begin at vnaa.org/Find-a-Provider.
Urgent Care House Calls, formed by two former emergency room physicians, offers traveling concierge care. A basic house call is $250, follow-ups are $195. Evening and weekend surcharges range from $95 to $195, with additional charges for travel time over 30 minutes. Details at UrgentCareHouseCalls.net.
Kimberly L. Jackson may be reached by e-mail
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