ON THE ROAD AGAIN
ON THE ROAD AGAINBremerton native Michelle Caldier saw a need in dentistry that wasn’t being met and found a solution: she took her show on the road.
To hear Michelle Caldier tell it, she’s a dentist because she liked toys as a kid, and she chose mobile dentistry over a traditional practice because she likes to sleep in. Well, that may be part of it, but like any dedicated dentist, her motivations are more sophisticated than that. She’s good natured and articulate, and likes to poke fun at her own foibles when she tells her story. Why did she choose a career in dentistry? She tracks it back to the pediatric dentist she loved, the guy who gave her a toy after every visit. And why a geriatric, mobile dental practice that cris-crosses Puget Sound to a different nursing home every day of the month? Because geriatric patients aren’t early risers, of course — and Caldier will be the first to tell you she likes to sleep in. All kidding aside, sleeping in is important to Caldier, who was voted class clown and most likely to be fashionably late in dental school. But she’s outgrown the clownish ways, and has a practice as sophisticaed as any private practice in a stick-built structure. She’s heard the criticisms of mobile dentistry and scoffs at all of them; that the standard of care is lower than a traditional practice’s, and that follow up care for mobile patients is non-existent. This is her life’s work, and she’s ardent and passionate about it — but more than that, she’s developed a model that tackles previous problems about mobile dental practices head on. She’s achieved a standard of care equal to that a patient would receive in any private practice and her goal is to bring that same level of care to each and every nursing home in the state. It’s a smart service she’s organized —nursing homes contract with her at varying rates, depending on whether their residents will pay directly or bill Medicaid, or some mix thereof. They then assign a staff member who schedules with Caldier and her team, leaving her to attend to what she does best – bringing careful, compassionate dental care to a geriatric population she reveres — people who desperately need dental care and who might otherwise never receive it. Some of the nursing homes she sees have rooms with donated dental chairs, others rely on her to bring hers to them. With some 25 nursing homes from as far north as Marysville clear down to Des Moines, and from downtown Seattle as far east as Redmond, Caldier has reached the maximum work load with the equipment she currently owns, but that’s only driving her desire to expand more. Her equipment includes a van to carry the traditional dental chair and carts she’s modified with wheels, and a treasure trove of state of the art mobile dental equipment. She has a driver and assistant who serve as an advance team, arriving on location early and getting all the equipment set up. Set up and break down each take an hour, and Caldier typically has ten appointments scheduled in advance of arriving, making for long days on the road, but it’s rewarding work for this woman who counts her grandparents among her favorite people in the world. Her current equipment is an exponential jump from what she started with. Her Aseptico hand unit has excellent suction, fiber optics and a supplied evacuation container. The water supply is a simple bottle attached to the unit that is easily refilled. The only downside, she notes, is that the unit is noisy — unlike a traditional office, she has to have the air compressor in the same room. Lighting is enhanced with a head unit by Designs for Vision. Her X-ray unit is hand held Aribex — at just 8 pounds, it is a truly portable unit that has its own shield to protect both patient and operator. Before it came out on the market, Caldier used large portable units that had to be plugged in and were very top heavy, so if they were positioned incorrectly they’d fall over on the patient. She remembers one such unit “It was top of the line and incredibly unwieldy and the operator had to go around the corner to trigger the gun.” Ever the skeptic, Caldier devised her own test for the modern portable unit she now uses and found no residual radiation after a quarter of use. Still she, her assistant, and the patient all don lead aprons whenever they use the Aribex unit, just to be safe. Her practice is also wired — when she’s onsite she has direct, remote access to all her office computers so they can do chart notes, prescriptions and everything else onsite. Having top of the line portable equipment is vital to Caldier, who uses her family as the measure for the standard of care she gives, saying, “In all honesty I treat everyone as though they were family, and the equipment I use is the same stuff I use when I work on my family. And I feel like it is the best standard of care that I could possibly bring into the nursing home setting today.” As for the critisism about mobile units and the lack of follow up, Caldier insists it doesn’t apply to her model — she shares a symbiosis with the nursing homes, who are required by law to provide access to dental care. They have the training to tackle anything that might arise once Caldier has left, and she’s only a phone call away should something come up that needs immediate attention. She attends to emergent care as it arises, and also has two colleagues who work with her a couple of days a month, further widening the net of care she’s established. She’s able to see a high number of Medicaid patients because her overhead is much lower than a traditional practice’s, and because she charges the homes who retain her services a varying rate depending on the type of billing. She uses a whip-smart billing coordinator well versed in the vagaries of state’s procedures, pays careful detail to what the system will and won’t pay, follows the billing requirements religiously, and knows everything about pre-authorization for dentures. And, like most dentists in Washington state, she’s a little apprehensive about Provider One, but she’s on it. Still, her practice is not without it’s peculiarites. Nearly all of her patients are medically challenged and require some assistance just to get in the chair. And, many or most of those she and colleagues Dr. Shane Ness and Dr. Thomas Vo see have some level of Alzheimers or dementia, which can make appointments interesting. Caldier says “A lot of times they have a shorter attention span, so you have to pace your visit. And for some, I will have to talk throughout the appointment to distract them. I’ve even anesthetized a patient, only to have them run away — when that happens I’ll see someone else until they’re ready to return. You have to be very flexible.” Plus, Caldier maintains strong relationships with other skilled care facilities like Harborview and Seattle Special Care Dentistry to handle the truly tricky cases – like those requiring possible transfusions, and those where a patient’s dementia is so severe that the only options are general anesthesia or no care at all. In those cases, Caldier encourages the family to direct the care, saying “I will give the families the option to be referred out and go under general anesthesia or do nothing. Of course, with medically complex patients, general anesthesia can be very dangerous, so for some of my patients their families opt to do nothing for the time being. The other option is to wait a year, because sometimes patients with dementia actually get more cooperative over time.” However, the tough reality is that for some of these people the standard of care becomes more about infection control and pain management. If Caldier and her team can’t clean their teeth, take care of the cavities or extract an infected tooth because a patient is uncooperative or too medically complex, they’re forced to refer patients out, something she estimates happens only about two percent of the time. And for a woman working with geriatric patients, there are additional quirks. Caldier remarks, ”I have to have a good sense of humor, to be sure. Since there were no female dentists in their day, some of my geriatric patients think I’m lying or pretending to be the dentist. It ends up being a good thing though, because they assume I’m just prepping for a male dentist and let me do my thing. It takes a lot of worry out of the situation for them. Then, as I’m wrapping up, I tell them the dentist had to cancel.” Other than that, Caldier insists hers is like any practice, again with her family as the standard of care model. “It’s pretty much comparable to what I would do in a private practice, the only difference is that I do very few crowns, and no bridgework because it isn’t what I would want for my family – obviously, I wouldn’t treatment plan a nice $3,000 case on someone who is 97, because I have to look at the potential benefit to them. I don’t do as much crown and bridge work as a comparable private practice,” and, she says with a laugh, “I haven’t done any implants and no ortho.” She sets aside a few days a month for denture adjustments, which she can do on her own, without an assistant. Caldier’s business is so good she’s not even in the phone book and she’s still regularly contacted by nursing homes hoping to get added to the growing waiting list. For now, though, she’s tapped the limits of her equipment. She formed a non-profit and tried to get funding this past year, but was rejected because she doesn’t see enough patients to qualify. So for now, her goal is to purchase more equipment and have dentists “adopt” nursing homes. As she sees it, she would provide the equipment, they would see the patients of a particular nursing home one or two days a month, and in return they’d receive a stipend for their work – something comparable to the pay they’d get working in a public clinic setting. Caldier’s goal, she says, “is to get it so that all the nursing homes have someone who can come in and provide the same level of care that they would be able to give in their private practice. The key is to ensure that you have the equipment and the proper lighting and all the wonderful stuff you need to make it work.” Since each set up costs about $200,000 including the van, the ramp, and all of the equipment necessary for a mobile practice, Caldier has her work cut out for her. Still, she’s up to the challenge — her ultimate goal is to have every nursing home in the state taken care of, and she’s not giving up the fight.