The Transitions program is all about house calls.
The Transitions staff recently visited Louis and Lois Alfeld in their San Carlos townhouse. Louis has dementia. His wife, Lois, takes care of him. Transitions palliative care nurse Wyatt Knapp wants to see how well Louis is tracking things.
"Do you know where we are today?” Knapp asks.
"Yeah, right here," responds Louis.
"Perfect! I like that answer. That is a perfectly acceptable answer," Wyatt said.
Knapp talks with Lois about dementia, and what she can expect.
“You know, with dementia, we wax and wane, right? So we have good days and bad days," Knapp said. "But overall, as long as he’s staying stable, I think he probably has more good days than bad days.”
“Oh yes, oh yes," Lois nods.
Lois said she has noticed some changes.
"His way of trying to explain to me what he needs, what he wants, is becoming, I think, more difficult," she tells Knapp.
“And that can cause for him more anxiety and more frustration," Knapp replies. "As those communication things become more difficult, that’s when patients often start displaying signs of anxiousness, or even agitation.”
Knapp said that there will come a point when Louis’s decline will happen more rapidly.
“That’s where I feel like I’m waiting for the next shoe to drop,” Lois said.
“But that’s why we’re here, right? ‘Cause when that shoe drops," Knapp said.
“That’s why I’m so glad I have you in the background, if not right here, at least in the background," Lois said.
Program launched
The Transitions program was launched in 2007. The program's chief medical officer, Dr. Daniel Hoefer, came up with the idea, after years of observing a reoccurring problem with many of his elderly patients.
Those who had heart failure, dementia and other serious health issues would reach a point when they would frequently go in and out of the hospital.
Hospital care can be disruptive, expensive and dangerous. Studies show about one-third of elderly patients over 70 leave the hospital in worse shape than when they arrived.
Hoefer thought there has to be a better way.
“I said, ‘well, let’s create a proactive program,'" Hoefer recalled. "And in the proactive program you say, I know where you are in the natural progression of your illness. And you’re at the point where you’re going to start to use the hospital as a tool to manage exacerbations of a predictable medical condition. We’ve eliminated that.”
Proactive care, patient education
Transitions provides proactive care and patient education, all in a patient’s home.
“This is one of the fundamental constructs of our program: stop bringing patients to care, and start bringing care to patients," Hoefer said.
Sharp Hospice Care Vice President Suzi Johnson helped Hoefer start Transitions.
She said the program addresses a long-neglected group: people who are in the pre-hospice phase of life.
“People live a long time with chronic illness, a long time," Johnson explained. "And we have not really been well prepared to think about how we care for the aging over a period of time. This program helps manage people over a period of time.”
Johnson and Hoefer recently had a study on Transitions published in the journal of the American Geriatric Society.
It showed on average, Transitions saved just under $20,000 per patient at the end of life, compared to patients who went the hospitalization route.
Lois Alfeld knows there will come a day when she can no longer take care of her husband at home. Nonetheless, she tries to stay positive, and even get a few laughs in here and there.
Lois says her husband can no longer recognize their children. He frequently asks what their names are.
“And when I tell him that our oldest son is named after him, but he’s not a junior, he’s Louis Alfeld. And he will say, ‘That’s the same as mine!’", she said, laughing. "And he’s even asked me, too — ‘Who’s his daddy?’"
According to a study in the American Journal of Public Health, an estimated $280 billion was spent in 2011 caring for people in their last year of life.
