Dr. Bruce Ruben working on a patient.Too often accessibility in medical facilities is either an afterthought, poorly executed from the beginning, or not even considered. This not only results in inadequate or unequal care for wheelchair users, but also discourages those in need of treatment from making an appointment in the first place. What is needed is a truly functional model of accessibility that begins with a caring, patient-centered viewpoint resulting in a blueprint for comprehensive access designed from the inside out.

Fortunately, that model — perhaps the only one of its kind — exists. Encompass HealthCare and Wound Medicine, an outpatient wound care facility in West Bloomfield, Mich., is a shining example of well-thought-out accessibility, staffed and run by people who really care about their patients. Founder and medical director Dr. Bruce Ruben explains what lies at the heart of his clinic: “Freedom is what I was really striving for with Encompass HealthCare,” he says. “I didn’t want there to be any barriers for patients to endure in order to obtain treatment. Quadriplegic and paraplegic patients have enough medical challenges in their lives. Access to the care in the first place shouldn’t be one of them.”

When you approach the clinic, the first thing you see is a long awning in front of the entrance — not unlike what you can find at upscale restaurants or first-class hotels — with plenty of space if you are waiting for a ride and want to stay out of the rain. But what makes a real impact on new patients is what they encounter when they pass through the automatic doors. The clinic has 48-inch-tall walls in the front treatment cubicles of the office that lengthen the lines of sight for wheelchair users.

Treatment cubesAccording to Ruben, there is an important psychology behind the design. “Shorter walls are simply less intimidating for wheelchair users than being surrounded by four, full-size walls. They give the outer office an open and airy feeling. Wheelchair users feel more in control since they can see more of what’s going on around them.” Each treatment cubicle has its own height-adjustable recliner-style exam chair and necessary supplies. When more privacy is needed — for instance, when an ischial wound is the problem — traditional treatment rooms are nearby.

“The open design also provides a sense of community, particularly when we’re busy,” says Ruben.

“When you go inside, right away you notice it is very open, and the people are warm and friendly, more so than other medical facilities I’ve been to,” says Ron Elkin, 45, a T6 para who has had infusion therapy and flap surgery under Ruben’s care. He says the atmosphere is calm and relaxed. “You might be greeted by two certified therapy dogs that are Ruben’s personal dogs.”

And the infusion center is more than a sterile environment for treating infections. “This is the only doctor’s office I’ve ever been to where they offer to make you lunch!” says Elkin. “The lady who runs the infusion center has her own little café with a menu, and there is a nearby kitchenette. You go in for infusion therapy and she asks if she can make you something — coffee, a grilled cheese sandwich, protein shake, toast. Once she fixed me a ham sandwich. What makes this place so unique is the people really seem to care, and everything they have or do seems to flow out of that.”

Care by Design
The caring atmosphere is no accident. It comes directly from Ruben’s philosophy of patient-centered care. “You have to hire the right personalities to work together, and the training is every day,” says Ruben. “If I had to put it in just two words, they would be ‘passion’ and ‘compassion.’ To do what we do every day, seven days a week, passion and compassion have to be deep in your DNA. When a patient experiences that in you, all the psychological barriers come down. They know you care, that you’re on their side and that they’re not alone in their goal to heal their wound or to overcome an underlying condition preventing that wound from healing.”

Dr. Bruce Ruben working on a patient.For those who know him, Ruben’s philosophy is not merely academic. It comes naturally from a man who loves what he does. “This guy is a wonder guy,” says Thomas Durkee, a 72-year-old T11 incomplete para. “You go in his office and you feel like it’s a club. There is a definite camaraderie. And he knows what he is doing, treats you like a regular guy. I’ve been to a lot of different doctors. He has a chair you sit in and get weighed. Rehab doctors don’t even have this. The guy has poured himself into this thing to take care of people. He makes you feel great, does his job, and all his employees are nice.”

It may sound too good to be true, but the results the clinic gets are proof that the patient-centered model really works. Encompass HealthCare is gaining a reputation as a wound care clinic that succeeds where other treatment facilities give up. Kathy Best knows this all too well. She became severely depressed when no one seemed to be able, or even willing, to tackle a difficult wound. One doctor even told her that she would most likely have to go to a nursing home and would probably die there within five years.

Fortunately, she heard about Encompass HealthCare and went there. What happened next has been covered in greater detail in a previous story in New Mobility (“New Model for Wound Care,” April 2013). The short version is Dr. Ruben took her as a patient and restored her health and her sense of well-being. “Everything is fine with my health now,” she says. “All is fine, I’m shopping, driving, going out with girlfriends. I’m back to myself prior to how sick I was. Just two years ago I was way, way down in the dumps. I am so happy that I am so well. I stop people on the street and tell them I’m happy!”

Care When and Where It is Needed
You would think that results like this would mean long waits to get into the clinic, but the goal of the staff seems to be to get you in for evaluation and treatment as soon as possible, unlike many medical facilities or doctors’ offices where you must set an appointment weeks or even months in the future. This is where the concept of accessibility begins. When you need wound care, you need it now. Often the appointment at Encompass HealthCare happens the same day you call or the next day, which can mean the difference between having a minor infection spiral out of control — and maybe even lose a limb — or healing up a wound efficiently. And it is all done in an outpatient setting that keeps you out of the hospital.

Ora Smith is a Vietnam vet who became a diabetic as a result of being exposed to Agent Orange. He sometimes has to use a wheelchair. It was November 18, just before Thanksgiving, when he went to see Ruben, who suggested he start IV infusions to get rid of infection in his toe right away. He began having IV treatments at the clinic seven days per week immediately. “Do I have to come on Thanksgiving?” asked Smith.

“Well, the germs don’t know it’s Thanksgiving,” answered Dr. Ruben.

People coming from out of town are welcome to stay at the Encompass Home, which is a fully accessible alternative to a motel room. In many cases, insurance will pay for the stay.

People coming from out of town are welcome to stay at the Encompass Home, which is a fully accessible alternative to a motel room. In many cases, insurance will pay for the stay.

If coming to the clinic is a hardship, treatment can, and often does, happen in your home. “It’s the same when they come to your house for care,” says Elkin. “Dr. Ruben came to see me and brought his dogs. Every time I have called them with a problem they have called back right away and they tell me to come in the next day, or they will come to you. Other places I have to wait three weeks or more before they can see me. If you have an infection, that is definitely not going to work well for you.”

Erik Zeck, 33, was injured in March 2012 at the T11-12 level. Like many people with newer injuries, he developed a sore on his backside that required downtime in bed, lying on his side or his stomach, for three months or longer. A stem cell graft would cut that time down by four to six weeks, but Zeck’s insurance would not pay for it, and he could not afford it. The graft material has a life of about one hour after the package has been opened, but often there is more material than is needed for one patient. “Dr. Ruben set it up so when he did a similar treatment at the clinic, his assistant drove the extra stem cell material to my home immediately,” says Zeck.  “When Dr. Ruben finished doing the graft at the clinic, he drove to my home right away and used the rest of the stem cell graft to close up my wound, so I could gain four to six weeks of my life back at no cost to me. And this was on a Saturday.”

The treatment that works best is not always confined to the latest materials and procedures. Often more is needed — personal attention, education, nutrition counseling, advice, or encouragement. “When he was done,” adds Zeck, “he asked my parents to leave the room and he had a heart to heart talk with me. I was depressed, overwhelmed with this sudden tragedy in my life, and he told me that I would be OK and this would not define me. He is such a unique person who is perfectly placed to help people.”

Going the Extra Mile
The treatments available at Encompass HealthCare are not limited to infusion therapy, wound debridement, grafting and other traditional wound care modalities. Ruben is board certified in infectious disease, internal medicine, and undersea and hyperbaric medicine. The clinic has three individualized hyperbaric chambers to speed healing when an oxygen-rich environment is needed. When Best was being treated at the University of Michigan Medical Center, she had to go outside the hospital to get wound care dressings and treatment, including having to be driven downtown to go to a separate hyperbaric treatment center, where many people were treated in one very long common chamber.

“They put a plastic bag over your head, and you are sitting side by side with many people. The whole thing is pressurized and you have one screen to watch while you get your treatment, which can last a couple of hours or more. They had a video and you watched a movie. At Encompass you have your own environment, no bag over your head, and there are three screens, one for each chamber, so you get individualized choice. It’s more comfortable. My ears did not bother me like they did in the group chamber. I had to have tubes put in my ears because the pressure was bothering me there.”

A new twist at Encompass is a dedicated area where Ruben does minimally invasive venous ablation surgery. Part of wound healing has to do with not only adequate circulation to the wound area, but also management of edema, which often is related to venous insufficiency. The venous ablation procedure selectively seals off veins that are not working properly, which results in redirecting blood flow to healthy veins and reducing edema.

In the same building with Encompass, on the same floor, flap surgery can be done at The Lakes Surgical Center, so everything needed for complete wound care is available in one outpatient location.

Another unique part of the overall design of the clinic is the inclusion of a first-class roll-in shower. “We have patients with urinary catheters and colostomies,” says Ruben. “Sometimes, those systems can fail, and for the patient, it can be very embarrassing. But we’re all very caring and professional about it when those things happen, and we’re well-equipped to help people clean up quickly. We always have fresh towels and scrubs should the need arise.”

There is one drawback with this leading edge wound care clinic: There is only one of them. But true to form, that is being addressed in a thoughtful and practical manner. No, there is no mega-chain of similar clinics on the drawing board, but Ruben has just recently added a separate building not far from the clinic — the Encompass Home — also completely accessible, for people from outlying areas or other states to come and stay while they get treatment. There is no need to rent a costly motel room. The Encompass Home is licensed and certified, which means insurance can pay for it, and it is designed for wheelchair accessibility

[see below].  Best of all, it is not a hospital. If the atmosphere is anything like what prevails in the clinic, it will feel a lot like a family visit.

Certain quotations from Dr. Ruben have been adapted with permission from WoundSource (www.woundsource.com), Providing Barrier-Free Treatment for Disabled Patients, by Rob Striks (Kestrel Health Information, Inc., 2014). © Kestrel Health Information, Inc. 2014.

Learn more about Encompass HealthCare: www.encompasshealthcare.com/wound-care/

To take a video tour of the clinic, visit: www.youtube.com/watch?v=pvA-gip-GDE&feature=youtu.be

A Model of Efficiency

How does Encompass HealthCare and Wound Medicine deliver all the elements of comprehensive wound care so efficiently? We asked Dr. Bruce Ruben what the secret was.

“Each technician in my office is primarily stationed in a specific area, but in a patient-centered model, all of us can and do all the specific treatments, with the exception of certain physician-only modalities,” says Ruben. “Examples of physician-only procedures are surgical debridement, grafting, and ultrasound-guided venous access. However,” he says, “IV administration of antibiotics, hyperbaric oxygen therapy, compression therapy wraps, total contact casting, scheduling, etc., can all be done proficiently by everyone. All of us can cook and all of us, including myself, can assist in hygiene issues when they arise.”

He points out that only IV antibiotics are administered seven days a week, with every other specific physician or technician interaction carried out weekdays, most commonly. “Of course, when certain emergencies arise, they are attended to on any of the days or late evenings without a hitch. Mostly,” he stresses, “it’s about good communication and a mutual team effort by all of us who have the passion and compassion to do what we do.”

The Encompass Home was previously owned, operated and licensed as a group home by a home care company as a transition home for people with SCI. It was already modified and staffed by certified nurse assistants. “I was well-acquainted with them and worked with them in the past,” says Ruben. “The CNAs simply stayed with the home, only now under my employ. They primarily assist with all activities of daily living requirements of the residents.”