This post is the first in a series of articles focused on design thinking and aging. In future posts, we will explore the use of personas in designing solutions for seniors. We will also address problems identified by seniors themselves.
Last week, the ACCESS Health Singapore team attended a DesignSingapore forum titled Rethinking Health and Wellness for the Elderly. Among the fresh perspectives and opinions shared at the forum, one point really stood out to us: Often, designers who design products for seniors view seniors as isolated individuals. In reality, the elderly live and interact with others in their families and communities, such as family members and health professionals. They engage others in their external environment multiple times throughout the day: when getting coffee, seeing their neighborhood doctor, seeing specialists at hospitals, visiting community centers, going to the supermarket, and even through online sites and discussion boards. Behind these interactions, or touchpoints, lie many higher level entities that share an active interest in the wellbeing of the elderly, such as ministries or charities.
This learning point came from applying design thinking and ethnography to aging. One principle of design thinking is that all design activity is social in nature. Ethnography aims to explore social phenomena from the point of view of the subject, in this case seniors. At the forum, videos were shown of interviews with various seniors and their caregivers. These seniors and caregivers were asked what challenges they faced in daily living. Beyond these answers, researchers also followed the seniors on their daily activities, like cooking and exercising, in true ethnographic fashion.
In one clip, a frail senior was shown cooking for himself. His legs are weak so he sits on his wheelchair at the stove. But this position is often low and awkward. Upgrading to an adjustable height chair could make cooking easier for him.
One woman interviewed in the video had left her job to care for her father full time. Even while providing fulltime care, she said, there are moments when she cannot be there, physically, to catch her father if he falls. Such personal examples peppered the forum, turning abstract issues into real and moving stories.
When we think of the people, places, and organizations seniors interact with, many opportunities come to light. One senior featured in the video had lost his leg to amputation due to diabetes. After being fitted with a prosthetic, he still found it tiring to navigate his neighborhood. He told the interviewers that he was truly glad to receive a motorized personal vehicle from a welfare organization. Some limitations remain. Narrow corridors and places without ramps are inaccessible to him. However, he is now able to take public trains and go shopping, everyday tasks that would have been nearly impossible before. The motorized vehicle has improved his quality of life. In this case, an organization found a solution that has allowed this senior to engage more with the people and places around him.
Engaging ethnography and design thinking for the elderly may seem unconventional. But some researchers acknowledge the benefit of taking into account social and environmental aspects of aging. A recent BMJ article reviewed existing ideas and concepts of Successful aging refers here to physical, mental, and social wellbeing in older age. The authors found that traditional conceptions of successful aging focused largely on individual bodily health. For example, the Activities of Daily Living scale tests a senior’s ability to complete a basket of self care tasks. These tasks include feeding, toileting, and grooming.
The authors found in their review that psychosocial and external factors are important to successful aging too. Yet, the authors found that these factors are underrepresented in traditional models of successful aging. For example, the Activities of Daily Living scale does not measure social activities such as holding a conversation or enjoying a sport outdoors. The authors wrote, “[Successful aging] is clearly not simply a physiological construct, so it seems intuitive that psychosocial components should be included in otherwise biomedical models of [successful aging].” The authors concluded that conventional models for aging can benefit from including social and external components of seniors’ lives.
Design thinking and ethnography can be applied at all levels of the ecosystem surrounding seniors. Consider seniors, the people they interact with, the people and places they engage with, and the organizations that help support them. Imagine a senior living out a typical day in this environment. What gaps and opportunities do you see? Are there any potential collaborations between organizations? We feel these added perspectives will help craft more targeted, efficient products and solutions to help seniors.
US House of Representatives Votes to Repeal Medicare Sustainable Growth Rate and Strengthen Medicare Access
We at ACCESS Health have been watching the news closely for the last two weeks. The issue of interest was the vote by the United States (US) House of Representatives on March 26 to repeal the Medicare sustainable growth rate formula and to “strengthen Medicare access by improving physician payments and making other improvements.” The bill can be viewed here.
This event is noteworthy in a few ways. One is that the 392 to 37 vote reveals overwhelming bipartisan support for these changes. Another is that, if passed by both houses of Congress, the bill would change the US healthcare payment system significantly. The bill still needs to be passed by the Senate.
If passed, how will the bill affect healthcare in the US? First, the bill repeals the sustainable growth rate formula used by Medicare. The sustainable growth rate formula pegs provider reimbursements to economic growth, as measured by gross domestic product (GDP). In place of the sustainable growth rate formula, the bill proposes value based payment models such as accountable care organizations and bundled payment. Accountable care organizations link doctors, hospitals, and other health professionals together to develop tailored care plans for Medicare patients. These care plans encompass the entire care process, matching the appropriate service to patients’ needs and reducing duplication of efforts. The bundled payment system reimburses care providers based on expected costs for specific clinical issues. This prevents unexpectedly high costs for patients.
Presently, the US healthcare system uses a fee for service model to pay providers. This means providers are paid for each individual service or operation, regardless of necessity or efficacy. As described in Forbes, “[Fee for service] actually rewards providers financially when patients suffer complications or infections, and pays them more if [providers] order unnecessary tests or procedures.”
Changing this system would remove incentives for healthcare providers to push large numbers of services on patients. Replacing fee for service with value based payment models could improve patient outcomes while reducing costs.
In the future, the high percentage of GDP spent on healthcare in the US may fall. According to World Bank data, the United States spent nearly eighteen percent of its GDP on healthcare in 2012, the highest in the world. GDP savings on healthcare would allow higher spending in other areas, such as education.
However, it is still too early to tell whether the bill will pass the Senate. In addition, there are still many challenges to the change. Many healthcare providers still cling to fees for services models of payment. It is also challenging to define key performance values for providers. Will providers aim to reduce readmission rates or improve life expectancies of patients? At this point, performance values are not standardized. Nevertheless, the strong bipartisan support for the bill shows a consensus that the existing sustainable growth rate model is undesirable.
This movement represents a move toward a capitation payment system, which pays providers a set amount for each patient, regardless of service type. Capitation systems are used by countries like Italy, the United Kingdom, and Denmark. In addition to the US, fee for service is used in countries like Japan, Germany, and Canada.
Interestingly, China has used the fee for service system since the 1980s. China has experienced healthcare cost increases, poor quality, and a questioning of medical ethics. These factors have led to experimental healthcare reforms, since the 2000s. City and local governments were encouraged by the central government to redesign the healthcare system, with wellbeing of patients as a main goal. China tried bundled payment systems, with some success. Jining saw a thirty three percent reduction in expenditure, while Shanghai saw a seven to twelve percent reduction in cost per outpatient visit. However, these initial results are not conclusive of the superiority of a capitation system. China continues to experiment with and review healthcare reforms.
If the US moves forward with the repeal of the sustained growth rate for Medicare, other countries facing challenges with fee for service healthcare models may follow suit. The ripples of this bill are potentially larger than domestic US healthcare policy. What do you think of these policy developments? Tell us your thoughts by leaving a comment.
Lee Kuan Yew, the founding prime minister of Singapore, passed away on Monday morning. As the first prime minister, Mr. Lee helped shape many policies in the formative years of independence. As the Singapore population matured, aging became an issue of concern for Mr. Lee. He shared some personal views on aging at a forum in 2010, when he himself was close to ninety.
Mr. Lee said, “I think the most important single lesson I learned in life was that if you isolate yourself, you’re done for. The human being is a social animal – he needs stimuli, he needs to meet people, to catch up with the world.”
Mr. Lee also said, “You must have an interest in life… If you’re not interested in the world and the world is not interested in you, the biggest punishment a man can receive is total isolation in a dungeon, black and complete withdrawal of all stimuli, that’s real torture.”
Indeed, part of aging well is maintaining social support and engagement in activities. Population trends in Singapore indicate that, in the future, many more elderly will be single and living alone. We must create opportunities to help these elderly avoid isolation.
How can this be done? Many are thinking of solutions. The ACCESS Health Singapore team spoke to a professor in architecture. She explained to us that simply adding a small space to common corridors for residents to sit and mingle can draw them out of their flats. Eventually, she said, the residents may venture down their blocks and into the community.
There must be other ways to help our elderly age well. People from all sectors are thinking of novel ways to make a difference in the Singapore silver industry, a promising development. Mr. Lee’s advice was for individuals to take an interest in the world and to avoid isolation. How we can help is to think of creative ways to encourage these individuals to do so.
Perhaps then we can live out Mr. Lee’s wish, “Have a purpose driven life and finish well, my friends.”
ACCESS Health studies good examples of elder care in Sweden. In a series of group interviews, the Swedish team of ACCESS Health meets with a group of senior citizens to understand their needs. In this interview, the participants discuss technology, share their views on Swedish healthcare, and tell us about their experiences as informal caregivers. When they learned about the work of ACCESS Health, the participants volunteered for the focus group. The focus group participants live in the city of Eskilstuna, one hour southwest of Stockholm.
The blog post of this week is an extract from a group interview conducted on December 31, 2014 with Gudrun Bergström, eighty six, Gujje Byström, eighty nine, Inga Brehmer, eighty eight, and Ingrid Svahn, eighty five.
This is an insightful and fun read! Enjoy!
Inga Bremer (IB): My name is Inga Bremer. I am eighty eight years old. I am interested in technology. I own an iPad. I own a Doro telephone. [Doro is a company that developed a simplified mobile telephone for older users.] My Doro is easy to use. My Doro telephone is not a smartphone. Dora does develop smartphones for older consumers right now. I also own a laptop. I own other technical devices at home, such as a dishwasher and a washing machine. I also have a small automatic vacuum cleaner so that I do not need to vacuum constantly. I have three large flat screen televisions with over fifty channels. I would call myself mildly interested in technology.
Gudrun Bergström (GB): My name is Gudrun Bergström. I am eighty six years old. I love technology. I am handicapped. I have poor eyesight. Technical solutions help me live with my sight impairment. I do not own a smartphone. I own a Doro telephone.
I have one of the newest stationary computers that you can buy. I use a magnifying software program that helps me increase the size of the text of the documents on my computer. I own an external hardware product. This hardware product helps me to magnify texts and images so that I can read and see the images better. This program is called Zoom Text.
I wear a watch that reads the time for me out loud. That is a great device. I have hearing aids. I also have three televisions. I use my three televisions. I have connected my television in the kitchen with an external hard drive so that I can record programs and store them.
Sofia Widen (SW): Do you record a lot of television programs?
GB: Yes. It allows me to watch them when I want to watch the programs. It took some time to figure out how to record programs. Learning is a gradual process.
I buy technology products. The booklet with instructions is written in a small text. This is problematic. It is difficult for older consumers to read small text. I can read instructions with my magnifying program. My dream is that doctors will find a way to operate a new sight nerve into my eyes so that I regain my sight. We are not there yet.
SW: Do you use your computer to browse websites?
GB: I browse a lot of different websites. I disapprove of some things that people write on Facebook.
SW: Do you have a Facebook account?
GB: Of course. I am on Facebook.
SW: Are you active on other social media sites?
GB: No. I am not interested in blogging or in tweeting. I use Skype. I Skype with my family. I have a wireless internet connection in my apartment.
IB: We should have spoken before you, Gudrun. You have so many devices.
GB: I love technology. My husband was not interested in technology. I installed devices at home. I learn about new products. I want to buy them. More people my age ought to take an interest in technology. Technology can help the elderly.
Ingrid Svahn (IS): Technology is in your nature. Either, you understand technology or you do not.
GB: I disagree. Look at the young who adopt technology. Are they born with an ability to absorb technology quickly? I do not think so. The young set aside time to learn how to use the technology.
IS: My name is Ingrid Svahn. I just turned eighty five. My husband knew everything about technology. I never needed to learn. My husband passed away a few years ago. I use modern technology. I am not interested in technology. I had a computer. I threw it out when it crashed.
SW: What did you use your computer for?
IS: I served on the board of an organization. I used my computer to type out the minutes from our board meetings. I have a smartphone. I use my smartphone sometimes.
SW: How do use your smartphone?
IS: I play games. I like Alphabet and Scrabble. I will say, though, that like other retirees, I do not have time to play all these games. Many retired people I know say they are busy. I also feel that I am busy all the time. I also own televisions. I use a dishwasher and a vacuum cleaner.
I use a pen for my touchscreen smartphone. I do not have Wi-Fi. I access the internet through the mobile network. Other family members discuss what kind of technology I need. They discuss whether I should install Wi-Fi or not. I do not know how the discussion will end. I might buy a tablet.
GB: I recommend a tablet. Tablets are great. You can carry it around. You can carry a mobile phone of course. I would not compare the two products. A tablet is helpful for my reduced sight. I prefer a larger tablet.
Gujje Byström (GBO): I am eighty nine years old. I am not interested in technology. I own one television. I watch eleven channels. I dislike watching television during the day. I record my programs. I watch them in the evening.
From the left, Inga Brehmer with her Doro telephone and her tablet. In the middle, Gudrun Bergström, with her Doro telephone and her tablet. To the right, Ingrid Svahn with her smartphone.
GBO: I use hearing aids. I use a walker. The walker helps me when I shop. I can carry a lot of bags. I hang them on my walker. People pestered me to get a walker. I think it is wise to wait until you really need a walker before getting one. You become dependent on your walker. I could not manage to carry my groceries without my walker.
I prefer to use a cane. I have a beautiful cane. I like my cane. I have had hip and knee surgery. After my surgery I decided to get a cane. There are flowers on my cane.
IB: I have a cane. My doctor prescribed the cane, so I obtained it for free. We buy technology such as canes and walkers. We buy them because we want nicer versions. In Sweden, you obtain technical aids from your doctor or from your municipal care organization. The devices are almost free or charge. You pay up to a fixed sum every year. This is a low sum. If you pay the fixed sum, you can obtain all devices that you need.
GB: We can discuss if you always obtain all the devices and all the aids that you need. I have a friend who requested two walkers. She was refused those two walkers. She wanted one robust walker for outside use in the snow. She wanted a smaller walker for use inside her apartment.
I returned the walker I was given for free. I bought my own walker. Look at my walker. I can lift it. It is light. [Gudrun demonstrates. She brings out her walker to the focus group.]
GBO: Those walkers are expensive. You made an investment.
GB: I can carry up to seven bottles of wine with this walker!
SW: Can you use the walker with thin wheels outside in the snow?
GB: If it is that snowy I do not go outside. There is no reason for me to leave the house when I cannot walk on the streets. Most Swedish cities are not accessible to the elderly in the winter. Too much snow and ice on the pavement prevents the elderly from leaving their houses.
Södermanland County Council hands out two types of walkers: one with large wheels and one with smaller wheels. Rules vary from county to county because regional governments are autonomous. The number of aids that you can obtain from each county varies.
GBO: The design of certain walkers can hurt your shoulders. I experience pain in my shoulders because of the way I walk and what I carry. I never experienced pain in my shoulders before. I have experienced pain in all other parts of my body before. I never suffered pain in my shoulders before.
You will soon be able to read the entire interview, posted on the ACCESS Health website here.
This blog post introduces Care Company TioHundra in Norrtälje, Sweden. This is a unique model of integrated care in Europe. I have had the opportunity to interview Peter Graf, Chief Operating Officer of TioHundra. Peter Graf talks openly about the challenges and the many opportunities that TioHundra faces. I have also had the opportunity to interview members of the staff and managers throughout the organization. Through these interviews, I have gained an understanding of the different parts of the company. I will tell you about my impressions of TioHundra in a series of blog posts. You can access the full interviews and all relevant background information from this case study on the ACCESS Health website.
An older person with multiple diseases often requires care from several healthcare and care providers. This elderly patient may travel to a local hospital for treatment. It is not uncommon that up to sixty people from various care organizations are involved in the care of an older individual with complex care needs. Patients with complex care needs require the services of both the county healthcare providers and the local municipal care organizations. As individuals in Sweden age, and as more people live with multiple diseases and have complex care needs, counties and municipalities realize the need for greater care coordination. Care coordination to meet the needs of the elderly is one of the greatest challenges in Swedish healthcare, witnessed by the large effort of the previous center right coalition government to improve care coordination in the program “The Most Ill Elderly” from 2010 to 2014. The previous government allocated over four billion Swedish kronor to improve the coordination of care for the most ill elderly. TioHundra shows that their model of integrated care already works well. During the program The Most Ill Elderly, TioHundra received funding based on the results they displayed in their work for the most elderly ill. These results included a reduction in unsuitable medication for the elderly and shorter wait times in the emergency room, among other areas.
Elsewhere in Sweden, regional governments manage the healthcare provision while local governments provide homecare and social care. Well defined areas of responsibility ensure that each provider in healthcare and in social care can focus on a range of services. In theory, the specialization of each level of government ensures that citizens obtain the healthcare and homecare they need. In practice, the division of responsibilities causes delays in service delivery, and at times, it compromises the quality of care. Regional and local governments use different communications systems, have distinctive work cultures, and use individual terminologies. Older frail patients, among other groups, suffer when healthcare providers fail to communicate effectively across organizations. TioHundra overcomes many problems of care coordination. Instead of coordinating care across organizations, TioHundra merged multiple care providers, now operating as one large healthcare and care system. This merger entails one of the largest regional reforms of Swedish healthcare since the Nobel Reform in 1992.
Care Company TioHundra is a public healthcare company that provides integrated care in Norrtälje, a city one hour north of Stockholm in Sweden. TioHundra operates an emergency hospital, six primary healthcare clinics, and a home healthcare organization for patients who are unable to travel to obtain care. It also manages social care and homecare organizations. The company runs nine nursing homes and it has 3,500 employees, including healthcare professionals and administrative staff.
To improve the quality of healthcare and to overcome the care coordination problems of regional and local administrations, Norrtälje and the Stockholm County Council established TioHundra in 2006.
The guiding philosophy of TioHundra is to construct an integrated healthcare system. The objective is to be the leader in integrated care in Sweden, and to be the number one choice of care provider in Norrtälje. The management approach centers on constant improvements. Managers and employees at all levels of the company identify areas for improvement, suggest new routines, and implement changes. The idea is to constantly improve service delivery and employee satisfaction.
Improved Care, Lower Cost
The ability to turn around negative operating results of previous years into a positive net result helped to convince politicians in the region that TioHundra improves the quality of care while lowering the delivery costs. Results from the employee survey show that the company employs a more satisfied workforce in 2014 than in 2013.
TioHundra manages to overcome certain problems of care coordination that persist in other regions and in other municipalities. Formal and informal channels of communication improve the transfer of information between different departments. Patient data is shared throughout the organization with the help of read only functions in patient journals. Weekly meetings of the management team foster an atmosphere of cooperation. Where disagreement occurs, the meetings serve as an arena for constructive debate.
TioHundra obtains one pool of financial resources from municipal and county taxes. Elsewhere, counties raise taxes for healthcare while municipalities raise separate taxes for social care. Budget silos prevent counties and municipalities to coordinate care in other parts of Sweden. One level of government is sometimes reluctant to deliver a service it considers to be the responsibility of the other level of government. The organizational structure of TioHundra allows this problem to be overcome through a lateral integration of caregivers from the county and the municipality.
In summary, TioHundra is a unique healthcare company. There are no other companies like TioHundra in Sweden. Few similar care organizations exist elsewhere in the Nordic countries. TioHundra reported a balanced budge for the first time in 2014. It also marked a year where management recorded improvements in employee satisfaction. TioHundra delivers healthcare of high quality at relatively low costs. The company has reduced the number of medications per older patient, reduced the prescription of unsuitable medications for the elderly, and it has shortened emergency room wait times for this patient group.
It remains to be seen how the integrated care model of TioHundra evolves. A transition in 2015 away from a focus on balancing the budget, towards operational and organizational changes is already noticeable. This is a young company with an eager management team. If the quality of care improves dramatically, and if the costs of healthcare can be contained in Norrtälje, other counties and municipalities may look into adopting the model of TioHundra.
 De mest sjuka äldre
I spent two days participating in a conference in Stockholm on the topic of welfare technology. Welfare technology is a term that encompasses a wide range of information and communications technologies, alarms, aids, devices in the home, and other technologies that help the elderly or people with disabilities. The official definition states,
“Welfare technology is the knowledge and the use of technologies that can contribute to increased safety, activity, participation, and independence for people with disabilities and their families. Welfare technology can also support independent living, and it can prevent or supplement healthcare and social care needs. Welfare technology can help to improve resource utilization and quality in the welfare sector, and it can be economically viable.”
This conference was the first in Stockholm on the theme of welfare technology. I hope it will become a permanent and annual event.
The conference featured panel debates, lectures, and a round table discussion. Companies showcased their latest products. Economists lectured on the economics of technology in healthcare and social care. Lawyers described the legal framework and the regulation of technology. Participants exchanged ideas and networked.
As a researcher for ACCESS Health, I immersed myself in the latest thinking on welfare technology. I examined how the fusion of a bicycle, a computer game, and a chair can improve the health of the elderly. Read about the company that has developed this bicycle that allows a biker with poor balance to cycle in a three dimensional environment of his or her choosing.
The idea of the bike is to stimulate more exercise. Equipment like this can turn exercise into an enjoyable experience for those who have suffered injuries and face months of painful rehabilitation. It can also encourage exercise in those who feel uncomfortable at a normal gym. Several municipalities in Sweden purchase the bikes, and the spinoff product, a treadmill that comes with a rounded screen to create the illusion of outside walking. This treadmill takes the person into a three dimensional reality. It works like a game. When the person looks to the left, the picture moves to the left. The user experiences a simulation of taking a stroll outside. The images are developed with Google street view. The tablet on the treadmill allows the user to play a quiz game while strolling in the forest. The questions are viewed on the large curved screen. The answers are recorded on the tablet. Developers believe that the gamification of exercise can enhance the user experience for the elderly.
The municipalities allow elderly citizens to come to community centers and to keep physically active. Perhaps we are witnessing the infancy of gyms with equipment developed for people over the age of seventy. This age group can benefit from exercise that strengthens muscles and trains the heart. Most public gyms do a poor job of installing exercise equipment and designing facilities that suit the needs of the elderly. I have been pleased to observe that developments in this area already benefit active older citizens.
I looked at the newest products on the market for safety alarm watches for patients who suffer from dementia, such as watches with positioning systems and alarms. I examined intelligent beds, which hold sensors in the mattress. The sensors notify caregiver personnel or are connected to your computer at home. The sensors highlight where there is pressure in the bed so that a caregiver can make adjustments and help the user avoid ulcers, which are a common result of pressure and poor blood circulation in certain areas of the body. The economists who participated in the conference, including Dr. Åke Dahlberg, calculate that these sorts of devices are so cost effective that the payer or user breaks even within one year of use. These calculations factor in the costs of treating an ulcer, which may demand that a patient visit a hospital twice a week.
The intelligent bed is an innovation produced at the Health Technology Center in Halland, in the south of Sweden. The bed is just one of many new technologies in the field of homecare and elder care that shows how patients can use smart technologies at home to prevent diseases and ulcers. These images display what nursing homes of the future may look like. The sensor, which goes under the mattress, can record your breathing and your pattern of sleep. To the right, a computer screen is visible. Doctors can use the data remotely to check up on you in the middle of the night and decide if you may need assistance at home.
You can read more about welfare technology in my upcoming case studies on the ACCESS Health website. I will shed light on the legal aspects of the use of technology in elder care. I will also examine the ethical aspects and discuss the economics behind the introduction of more technology in sectors like homecare, which largely center on personal meetings between caregivers and patients. This is an exciting area of development and shows promising results already. Patients, caregivers, and society at large stand to benefit from the technological advances in this sector. On the other hand, these technologies must be developed with the users in mind. The users are the healthcare staff, the homecare personnel, and the patients. A careful examination of patient needs and user friendliness for all of these groups must precede any introduction of technology in elder care and homecare. Far too many applications are developed without the involvement of the relevant consumers.
Previous waves of technology in these sectors illustrate that technology is powerful, and it will find users and needs for its applications. Previous waves of technology show that, in some areas, technology comes first and needs of the users come second. Developers apply technology from other fields to the elder care sector. This technology may not always be aligned with the needs of the users. The needs of the users must be the point of departure. Ideally, technology is not adopted from other fields; it is purposely constructed for older consumers, for caregivers, and for relatives. This is why the debate around technology is so important. The lecturers at the welfare technology conference stressed that they wanted to see technology that aligns with the needs of the users.
The previous generation of safety alarms for older people illustrates the point that technology does not meet the needs of users. The previous generation of safety alarms was connected to landline telephones. These alarms were a great invention for those who needed help at home. An older person who fell at home could use the alarm to contact a caregiver. The caregiver could come to the house and assist the person after the fall. However, the safety alarm could not be used on the balcony or outside of the house or apartment because it relied on the landline telephone. Sweden is introducing digital safety alarms on a large scale right now. The introduction has caused difficulties in many parts of the country, including disruptions in the signals to homecare personnel. Despite these difficulties, many municipalities are examining new digital alarms. In this process, some municipalities are introducing digital alarms that cannot be brought outside. The use of these types of alarms is a mistake. They confine the elderly to their apartments instead of encouraging an active lifestyle, which requires leaving the house.
Some new safety alarms, which often come in the form of watches to wear on the wrist, have Global Positioning System (GPS) technology built in, which allows a caregiver to turn on the navigation in his or her phone and navigate to the users, wherever he or she may be. The user can also talk into the watch and reach a caregiver, just like you would talk with someone on a mobile telephone. The image below illustrates a safety alarm with a positioning system and a clip on battery charger to ensure that the user does not lose the alarm when he or she charges the battery. Older versions of these watches must be taken off to be charged. A person with a cognitive impairment might easily forget to put the watch back on. Of course, the user must accept that he is traced when he wears the watch with a positioning system.
The new technology raises issues of privacy, data storage security, and surveillance of our elderly loved ones. Are we reducing or increasing their freedom with these alarms? As with any technology in the elder care sector, we must look at alternative solutions. No technology is perfect. Some technologies improve quality of life. If a technology has the potential to improve quality of life, we ought to examine the technology carefully.
In the case of wearable alarms with positioning systems, we either prohibit our loved ones from leaving the house alone because we are afraid that our elderly who suffer from dementia will become disoriented and wander off, or we allow these people to leave the house with a portable and traceable alarm system. Some people will be inherently skeptical of these technologies, perhaps more so in the wake of national programs on mass surveillance. There are arguments on both sides of this debate that need to be examined further, but the technologies show great potential.
The other ethical aspect we must think about carefully is consent. How do we obtain consent from users with cognitive disabilities? Is consent from relatives enough to allow the use of a safety alarm outside? It is impossible to offer one answer for all users and for all relatives. We must develop national guidelines that caregivers can follow. At each developmental stage, we must allow public lawyers to evaluate the legal implications of each technology. This will take time. We must be patient.
We must also allow individual caregivers and family members to decide what is best for their loved ones. What works for one user may be completely inappropriate for another user. Perhaps the user is bothered by a large safety alarm watch, scratching to take it off. In this case, I would think it wise to find other solutions. The elderly, like all of us, have different preferences. Common sense in the use of technologies will allow us to incorporate technology into sectors such as elder care and homecare. At the conference for welfare technology, nurses, lawyers, developers, and other participants raised these issues for debate.
Telia Healthcare, one of the largest telecom companies in Sweden, brought four showrooms to the technology fair in Stockholm. The product range HomeCare includes sensors in your bed. This bed is equipped with sensors in a pad that goes underneath the mattress. The pad warns if the patient lies still for too long or needs assistance to rise up. This pad is intended for use in care homes to guide the staff to the patient when the patient needs assistance. The blood pressure device on the bedside table can measure blood pressure and blood oxygen saturation. This information can be linked to patient records.
The sensors send signals via the Telia Healthcare application to caregivers or to the user. It is up to family members or users to decide where the text messages go. The bed below is equipped with a lamp gradually adapts to your sleeping pattern. It turns on a light in the morning to help you wake up. In cold, dark countries like Sweden, this may be a welcome device, although its healthcare application seems limited.
A smart sensor at the front door of a person’s house can notify a caregiver if the user leaves his or her house and wanders off. The text message alert, combined with a traceable and wearable alarm, like the safety alarm watches discussed above, helps the caregiver to locate a person that may have gotten lost. Technologies like this could help an aging population to live at home for longer. They can also improve the sense of well being and safety for users and for family members. Telia intends to sell these products to public caregiver organizations in the spring of 2015. Municipal organizations develop new guidelines on public procurement, which includes data encryption for this type of product.
The small white sensor in the top left corner of the medical cabinet will send a notification if the cabinet has not been opened for a certain amount of time. The scales in the images below send weight information to your computer or to your caregivers, via Bluetooth. Fluctuations in weight are an early sign of declining health in patients suffering from chronic obstructive pulmonary disease, for example. The text message alert will act as a reminder for you to take your medication or visit your doctor before you develop more serious symptoms. All of these technologies will help patients with chronic diseases to live at home for longer in the future. The scales for home use stores information on patient weight. The scales can notify caregivers if a patient collects additional fluids, which is an indicator of rising blood pressure. The scales send the information via Bluetooth to the caregiver’s mobile telephone.
Now, Telia is just one of many companies entering the growing market of homecare devices. It remains to be seen whether these specific products serve the needs of these patients, or whether Telia must improve or change their products. Telia runs pilot studies with several Swedish municipalities where they evaluate their products.
Telia installs cameras for use at home during the night, when someone might otherwise need to visit the person to check that everything is in order. Several municipalities in Sweden work with eHomecare. eHomecare uses a camera that is switched on for a few minutes at a time throughout the night to check that the user is alright. This type of technology replaces short visits by homecare personnel in the middle of the night, and several users prefer a camera to personal visits. My upcoming interviews with the managers of eHomecare in Västerås stad will be posted on the ACCESS Health website.
In summary, the welfare technology conference stimulated important debates on technology for the elderly. I will keep you up to date on this important topic in future blog posts and in my case studies. I hope to see technologies that benefit the elderly. I want to see more companies that involve all users early on in product development. As one participant in the conference put it, “only when all groups benefit from the technology, including the doctors, the patients, the caregivers, and the relatives, can we expect large scale adoption.” One final reflection comes to mind the day after the technology conference. Many municipalities had representatives at the conference. Few county councils were present. If counties and municipalities want to stay up to date on the latest technology, this conference is a good starting point!
In my previous blog post, I described the work of the Mobile Team for the Elderly in Uppsala, Sweden, a municipality of two hundred thousand. In this blog post, I will discuss some of the tangible benefits of the Mobile Team to the municipality, to patients, and to patients’ families.
Before I get started, I want to explain how healthcare and government is managed and financed in Sweden. Sweden is organized into municipalities. Several municipalities comprise each county. Uppsala County includes eight municipalities, including a municipality called Uppsala municipality (see the maps below). Uppsala County manages healthcare provision for all citizens in the county. The County Council in Uppsala is the payer of healthcare in the county. An autonomous government governs each Swedish municipality. Municipalities are responsible for social care for the elderly. The Mobile Service offers healthcare to the elderly, thus touching on the responsibility of both Uppsala municipality and Uppsala County. The Mobile Emergency Team serves the elderly only in Uppsala municipality, not the entire county.
Since the establishment of the Mobile Team in September 2011, fewer older patients visit the emergency room at Uppsala University Hospital. The Mobile Team started as a pilot project, which became a permanent unit in Uppsala, in January 2014.
Uppsala University Hospital is the only hospital with an emergency room in Uppsala County. Uppsala University Hospital is a public hospital financed by county taxes. Fewer visits to the emergency room thus save costs for the county. One visit to the emergency room is assumed to cost the county hospital 2,500 Swedish kronor (350 US dollars). In a conversation with the Mobile Team, one of the team’s two physicians, Magnus Gyllenspetz, explained to me that Uppsala County saves costs if the team makes three home visits per day. The savings come from reductions in the number of ambulance trips and the number of treatments provided in the hospital.
The total yearly cost of the Mobile Team is 3.5 million Swedish kronor (five hundred thousand US dollars). Uppsala County saves 2.5 million Swedish kronor (350,000 US dollars) on reduced outpatient treatments of the elderly alone. The largest savings are in the area of reduced hospitalizations for this group. Estimates for 2012 indicate that the Mobile Team saves Uppsala County over nine million Swedish kronor (1.2 million US dollars) annually on inpatient treatments for the elderly, excluding the costs of the Mobile Team.
Without the Mobile Team, an estimated 460 patients would have traveled to Uppsala University Hospital for treatment during the pilot phase, from September 2011 to January 2014. These 460 patients are “avoidable inpatients,” patients who can avoid a stay in hospital with treatment or social care assistance at home.
Apart from the economic benefits, patients like the Mobile Team. Fewer patients need to travel to the hospital. Fewer patients need to wait in emergency rooms. Fewer relatives worry about the health of their elderly loved ones. Fewer relatives must take time from work to help their relatives get to the emergency room. The Mobile Team cares for the ill residents in nursing homes. Because ill nursing home patients are the responsibility of the Mobile Team, the nurses in the nursing home are able to continue to care for all of their patients. If the nurse from the nursing home had to travel with the resident to the emergency room, then that nurse could not care for other patients.
Considering all the benefits, why is there only one Mobile Team with this setup in Sweden? Why do some older patients who need urgent care still travel to the emergency room? Is the Mobile Team too good to be true? How can we explain the fact that there is only one Mobile Team financed by a municipality and a county in Sweden?
There are many answers to these questions. Some older patients feel safer in emergency rooms. Most patients want the freedom to choose where to obtain treatment, at home or in emergency rooms, and some older patients feel safer in emergency rooms. People do not like to be told what kind of healthcare is best for them. Some simply do not know about the Mobile Team. Healthcare personnel follow routines. Some employees of the county do not work with the Mobile Team simply because it is not part of their routine. In my conversation with the five members of the Mobile Team, they expressed a desire to develop a new promotional strategy that would help the team reach out to more patients and partner organizations in the county.
The Mobile Team in Uppsala became a permanent unit one year ago, on January 1, 2014. I hope that other municipalities will establish Mobile Teams in the future, as more people become aware of the many benefits a Mobile Team can bring.
This is a happy thought for the New Year.
Happy New Year to all readers!
 “Final Report on the Mobile Emergency Team for the Elderly, 2013”. Author of the report: Swedish Association of Local Authorities and Regions (Slutrapport för projekt kring de mest sjuka äldre Mobila hembesöksteamet i Uppsala, SKL)