My husband Dave has become a bit of a celebrity in our neighborhood. Each day he walks from our home and over to the beach; we live 1-1/2 blocks from Boston Harbor. As long as the weather is good and no snow on the ground, he walks. His gait is slow, and his trusted quad cane keeps him steady. His eyes cast downward to spot trouble because of the condition of some city sidewalks. When he looks up, there are always neighbors with a friendly wave and kind words of encouragement. He has chatted with most of the people along his usual routes. They all marvel at his dogged determination to keep on keeping on despite having had a stroke in 2014.

Recently, Dave met a gentleman named Nate. Nate was doing some repair work at his mother-in-law's home. He paused and walked over as Dave approached, curious to know more about why he walked with a cane. Dave told him he had a stroke and the floodgates opened. Nate unburdened himself of the current situation he and his family faced. Dave related the story to me upon his return. It troubled him because Nate's 80-year-old mother-in-law suffered a stroke.

A couple days later, Dave asked me to take the walk with him. I was happy to oblige because it was the first warm spring day. As we got further down the street, Nate called out "Hey Dave," as he stepped off a ladder. Nate sauntered over as Dave introduced me, "I want you to meet my wife...." The first words out of Nate were "I heard about you ... you are a nurse, right?" Over the next 10 min, I got the Reader's Digest version of what he had previously told Dave.

Normally, I avoid telling people I'm a nurse, but the cat was out of the bag. I watched pent-up stress start to release from Nate's face. I politely listened as red flags began popping up. It was like an episode of The Price is Right, with my own private ding, ding, ding alarms going off. I asked whether they had any support services to help. His answer, "Not now. She had someone, but they stopped coming. My wife is doing her best, but she is exhausted. No one else in the family (e.g., other siblings) helped out. She's trying to work her full-time job and take care of her Mom and that is a full-time job too. My daughters and I pitch in, but I feel like we are all drowning. I mean, she can't even get to the toilet without someone helping." Nate also shared that his wife was beginning to snap at him, "She apologizes right away, but that never used to happen before. We feel helpless."

I had all I could do to keep from going into full case manager mode at this point, but I restrained the impulse. I didn't launch an assessment conversation because I had no standing in the situation. Clearly, a neighbor was in need of help, so I asked whether he would mind me giving a couple suggestions. His rigorous nod was all I needed. It took only a few minutes to offer basic suggestions:

1. Call the primary care provider and the last in-home provider and ask them to come back and reevaluate the situation. Nate made it sound like his mother-in-law was making more progress but still needed strengthening to be more independent. Perhaps, it was time to assess whether additional therapy would be beneficial.

2. Call the city's Elder Services office to learn more about available support services. Our city offers a wide range of services as well as referrals to other services.

3. Call the regional Elder Service Council. In our area, services such as Meals on Wheels are coordinated at the regional level.

4. Call the local VNA to ask about hospice and palliative care services. Depending upon the family situation, it might be an option to request a hospice evaluation. I specifically noted that hospice does not equal "giving up." I mentioned it required certain commitments that the family may not be ready to make. The only way to learn was to have someone come for an evaluation.

I realized that these options will not solve the entire situation. By the look on Nate's face, there was a flicker of hope. It wasn't hope that his mother-in-law would return to her prestroke self. It was hope that there were things he could do.

After a few more of Nate's questions, I stepped back and excused myself to finish my walk. As I went on my way, I was struck by how little this family understood about access to care and resources. I realized that over the previous 6 months, there were acute care, rehabilitation, and home care admissions. Sadly, Nate and his family felt there was nowhere to turn. By his tone of voice and fatigued appearance, Nate was nearing the end of his ability to cope.

Our health care system has been focused on transition of care from acute hospital to home setting. Skilled nursing facility readmission penalties are set to begin in 2019 as part of the Skilled Nursing Facility Value-Based Payment system (Medicare.gov, 2018). Home Health Value-Based Purchasing (HHVBP) model rolled out in nine states in 2016 (Medicare, 2016). It is anticipated that initiative will become a mandate for every home care agency by 2022 (Home Care Home Base.com, n.d.). Eventually, there will be value-based financial risk across the entire care continuum. Although my neighbor may not have tripped any of the 20 measures associated with HHVBP, if this situation remains unchecked, she will likely experience an acute event requiring an ambulance ride to the nearest emergency department.

There are two main issues in play here. Despite the promise of Value-Based Purchasing initiatives, our system still has large cracks and people are falling through. Second, there is a human toll that is exacted on every patient and family caregiver falling through these cracks. His mother-in-law is already compromised, but both Nate and his wife, who are in the 50-60 years age range, are on overdrive, trying to balance full-time jobs in addition to this burgeoning home care crisis. It is putting their personal health in jeopardy. At what point will one or both of them require care because of the constant stress? Where is the quality measure for that?

I am sure that there were well-meaning providers launched into soliloquy of discharge instructions and handed over reams of paper outlining transition of care plans. That paper was a small part of the many documents handed over to the patient/caregiver as they leave one care setting for another (or for home). Eventually, all verbal instructions are forgotten. All the paper ends up on the kitchen counter, a desk, or bureau to gather dust and never again picked up. These pages and the talking are meaningless when someone needs help and has no idea where to turn.

Have we overengineered the transition process? Have we created a monster that overrelies on a little talk and a lot of documents? Have we lost sight of the human factor as we check off all our transition of care task boxes? I don't know the answers to these questions. What I know is that Nate and his family feel helpless, isolated, and had no idea where to turn for help. To my way of thinking, this is an example of a major failure in transition planning. This is a ticking time bomb that is not a blip on anyone's radar-yet.

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