When Elizabeth Brooks looks up to see Dr. Eugene A. Steinberg come into the "examining" room to begin her checkup, she hasn't been sitting on a hard, tissue-covered doctor's table for an hour.
She has been relaxing in her own living room, watching television, with her family around her. For Steinberg, black bag in hand, has just walked into Brooks' home on Buffalo's East Side.
Steinberg parks his black bag on the living room floor and places his hand on her shoulder, asking "How are you today, young lady?"
Brooks, 83, known as the Hat Lady to church friends and Gramma Lizzie to her great-grandchildren, manages a slight smile and says she's OK. That small exchange is Steinberg's first way of checking on Brooks, who suffered a stroke and has diabetes and arthritis.
Welcome to house calls revisited.
Steinberg, who lives in Getzville, has joined an emerging medical practice called Home Care. The way he does it is to work in conjunction with other doctors; he doesn't have an office and only does house calls. He also combines up-to-date technology with old-fashioned caring to see people who have become too old, too sick or too anxious to risk venturing out.
Nationwide, at least on a small scale, doctors have begun venturing out of their offices and back into people's homes, fueled by a burgeoning elderly population and increased Medicare payment for home visits. Over the last four or five years about 1.5 million house calls were billed annually to Medicare, according to figures from the Maryland-based American Academy of Home Care Physicians.
After having treated elderly patients as medical director of the Buffalo Veterans Administration home care program for many years, Steinberg last spring began a private practice called House Call Physicians: Consultants in Home Care Medicine.
"Once in your lifetime you have a chance to achieve a dream," said the 50-year-old Steinberg. "I think this is my chance."
His patients are grateful that he's taking the risk.
"It's been more personal and more thorough with Dr. Steinberg," said Gloria Threatt, Brooks' daughter and a nurse, referring to the care her mother is getting from him.
Now, Threatt doesn't have to take off from work for doctor's visits or see her mother get nauseous from the motion of the wheelchair van that would take her to a doctor's office. Steinberg maintains an informal arrangement with local physicians. He acts as the primary care doctor when he visits patients in their homes and they take over when they see the patient in their offices or at a hospital.
Steinberg maintains an informal arrangement with local physicians. He acts as the primary care doctor when he visits patients in their homes and they take over when they see the patient in their offices or at a hospital.
So far, he's seeing about 40 patients and also works in nursing homes, at least until he reaches an optimum number, about 300 patients. "I'm not there financially yet," he said.
With the number of elderly members of the population growing and many remaining in their homes, this is a much needed service, gerontologists say.
"We're dealing with the toughest patients," said Steinberg, who treats patients in an area that stretches from Niagara Falls to Lackawanna. "It's not something you can do in your spare time."
'The need is so intense'
Also providing in-home care to the frail elderly locally is Home-Link Medical Service, which employs four nurse practitioners who see approximately 250 patients in Erie and Niagara counties. It was started in 1998 by Donna Keith-McCain, a nurse practitioner, who previously ran Mobile Nurse Practitioners.
"The need is so intense," said Keith-McCain. "Many haven't been to a doctor in years, maybe 40 or 50 years. I think it's fear of loss of independence, fear of treatments, fear of medicine, period. They've never been and they are not going."
Frequently she gets referral calls from senior service agencies about people who need immediate attention, she said. "They always ask why it took so long to find us," she said.
Some patients are seen regularly, while others are monitored with visits once or twice a year, she said.
Every three months, patient records are reviewed by a physician with the Elder Medical Service.
With improved technology and miniaturization of equipment, medical personnel can now do procedures in the home that were once reserved for hospitals and clinics: EKGs, sonograms, X-rays, MRIs, ultrasounds, IV infusion and transfusions.
And they offer instruction to family members on interim care.
"We just learned, one thing at a time," said Wanda Threatt, Brooks' granddaughter.
During his visit, Steinberg asks Brooks' family about how she is eating and how her spirits are, as well as reporting to them on test results and discussing medication. Seeing a patient in her own environment offers clues that he would never get in a clinical setting, he said.
"In a doctor's office, you see them all dressed up, in a vacuum," he said. At home, he can pick up other cues, such as seeing whether prescriptions have been filled and how the person uses a walker.
"You can even do things like spotting a salt shaker on a bedside table when someone is supposed to be on a salt-free diet," he said.
Steinberg spent a year researching the feasibility of operating this kind of practice locally, consulting with Detroit's Dr. Eric Baron, a pioneer in the movement.
Steinberg's car, stocked with road maps, a cell phone, a pager and stacks of paperwork, is his mobile office. While his medical assistant, Jeannie Birkby, drives from one patient to the next, he completes paperwork and answers phone calls.
Some bumps in the road
House calls all but disappeared with the advent of specialization, managed care, and a reduction in Medicare reimbursement, according to Constance Row, executive director of the 12-year-old American Academy of Home Care Physicians. In the mid-1960s when Medicare was instituted, organizers saw no need for house calls and set reimbursement rates so low that doctors seldom stopped to see patients at their homes.
But interest has reawakened as Medicare rates were raised in recent years. Payment now ranges from $36 to $132 per visit, depending on the complexity of treatment, Steinberg said.
Though studies done in affiliation with Harvard Medical School show that home care significantly lowers costs, it's also true that some doctors have found that it's not profitable to operate this way.
"The financial trend certainly has improved," said Row, "but it's still not where it should be."
For now, doctors are experimenting with different ways of doing house calls. There are still some of the "old-fashioned" house calls being made by doctors who have "grandfathered" in long-time patients. Some doctors practice in conjunction with nurse practitioners, some through a contracted service to an HMO. Others maintain their traditional practice and see a smaller number of patients at home, perhaps limiting it to one day a week.
As desirable as it may seem, there are road blocks to making house calls, said Charles R. Cimasi of Cynergy Consulting Services, a local health care management consultant who researched the concept. He found that doctors have concerns about safety in some neighborhoods, about productivity in a practice that's limited to eight or 10 patients a day, and the challenge of prioritizing calls and arranging efficient routes.
"It's certainly socially desirable," said Cimasi, "but the economics of it are challenging."
Dr. Joanne Schwartzberg, director of aging and community health at the American Medical Association in Chicago, calls the resurgence of house calls "a very positive trend" and predicts that the practice will pick up.
"We have a group of people both under and over 65 who are homebound and cannot get out easily, so they have limited access to medical care and greatly benefit from house calls," she writes on WebMD.
"It's still a relatively novel concept and quite frankly a lot of people are not enamored of it," said Row of Home Care Physicians, "But, fortunately, we do have some pioneers out there sort of showing how it can be done and meeting the needs of the community."
As to why Steinberg is willing to be on the road, he answers that he found out early in his medical career that caring for the elderly was his forte. And the best place to treat them is where they feel most comfortable, right at home.
"It's in my blood," he said, as he picked up his black bag on the way to his next call.