Health-Based Technology in the Home: Why it Matters, Why Now

Laurie M. Orlov

In the past 5 years, technologies have been developed that can support families and seniors to age in place more independently. Many of these technologies can be recommended and supported by professional geriatric care managers (PGCMs). This article provides a background of why this has happened and a brief overview of the categories of technologies that are of interest to PGCMs.

Why Are In-Home Technologies So Important?

The future Medicare and Medicaid funding crisis combined with the aging of the baby boomers results in a situation where technology, with its resulting lower costs, can help improve care and deliver it where it will be most useful – in the home. PGCMs, like all health care professionals, will need to become informed and participate in the nationwide effort to lower cost and improve care for seniors.  PGCMs will use all means at their disposal, including technology, to help families in the midst of a changing landscape as:

• Boomers and seniors will stay longer – and frailer -- in family homes.  Nursing home occupancy has been declining for the past 10 years, and assisted living growth has stalled following the collapse of real estate markets, shrinking retirement portfolios, and worsening job prospects for older Americans. Nationwide today there are only 3 million units of independent, assisted and skilled nursing care, despite 39 million seniors (age 65+).  The net result of this trend towards ‘aging in place’ is that many more frail seniors with chronic conditions will stay in their current homes longer than was previously believed. And some seniors may move in with family members – who may be ill-prepared to care for them.
• Cost crises and government investment are fueling expanded offerings. Although the initial and apparent focus of health IT investments appears to be electronic medical records (EMR) and personal health records (PHR), government infusion of cash will be the catalyst for innovation in numerous adjacent health-related technologies – particularly those that seamlessly interface with EMR and PHR software. So with PHR, for example, vendors are appearing who sell related disease management software and services that consumers may want to use even after the technology is no longer covered by Medicare post-hospitalization benefits.
• Home health technologies have evolved and cost reductions are proven. With more than 17,000 patients participating in a study of care coordination/home telehealth, the Veterans Health Administration published results in 2008 that were conclusive about the benefits of delivering the ‘right care in the right place at the right time.’  With coordinated care by case managers and a variety of technology enablers, participants’ bed days of care dropped 25% and hospital admissions 19%. The cost of $1600 per year per patient was substantially less than primary care costs of $13,121 per year or market nursing home care at the time of the study of $77,745 per patient per year

Home Health Tech Extends the GCM Toolkit and Reach.
The world of PGCMs extends well beyond their numbers. This is a direct result of their role as a coordinator of delivery of senior-related services to fill a wide variety of family needs. This includes referrals for assistance with legal, financial, care, health-related issues and help locating assistive devices, social and psychiatric services, and technology assistance.   A PGCM may initially be engaged under dire circumstances, not the least of which often is a family member’s perception that an elderly parent is unsafe continuing to live in their own home. Technology categories that are relevant for geriatric care managers include in-home monitoring, medication monitoring and management, and internet-based services. Examples of these and other important categories are described in the remainder of this article.

Health Monitoring, Tracking, and Information Storage
Because a large proportion of PGCM time is spent with seniors with chronic conditions or who have recently been released from the hospital, technologies for monitoring and managing health information are required.

• Telehealth monitoring devices.  PGCMs may become involved with medically frail clients who require remote monitoring.  Frequently, remote health monitoring by health care professionals is offered during the initial period of time after a client has been discharged from the hospital or rehabilitation facility, but it may also be offered to those who live at home and are suffereing from chronic diseases such as diabetes, hypertension, chronic heart failure, and chronic obstructive pulmonary disease (see Table 1).  Telehealth devices such as Intel’s Health Guide, Viterion, or Bosch’s Health Buddy are examples of such devices which are placed in the home with diagnostic devices that check blood pressure, glucose levels, or weight, for example.  The information collected by these devices is transmitted over telephone lines or the internet to telehealth monitoring professionals (perhaps including the PGCM). If a particular reading is outside of recommended parameters, the professional is notified and the patient is contacted for follow-up.
• Tools for storing health information.  PGCMs may use a computer to record notes and specific health information of a client. To make this more efficient, PGCMs can save data on an inexpensive flash drive (sometimes called a memory stick or thumb drive) that plugs into the USB port on the side or back of their laptop. In addition, PGCMs can utilize Microsoft HealthVault or Google Health to safely store an individual client’s health information which can then be accessed by the PGCM, other professionals, or the client family with appropriate permission granted. 

Home Safety and Monitoring
A top priority for PGCMs is to help a senior be as safe in and about their home as is possible.  So PGCMs should be familiar with:

• Personal Emergency Response Systems (PERS).  The PERS pendant (or watch) is traditionally a first step monitoring a person, typically an older woman living alone.  The pendant transmits to the base unit in the home from a distance of approximately 300 feet, depending on building structure – and is active, that is it requires the user to press the button in the event of an emergency.  Devices like Philips Lifeline and ADT Companion Services (discounted through AARP) all notify wearers to do monthly battery checks which have the added value of requiring a conversation with a call center rep.  Today, some companies are advertising that call centers are staffed with EMTs (ResponseLink, for example, which uses the Visonic product). It should be noted that Medicaid waivers in some states cover PERS systems.
• Passive fall detection devices. Recently a new wearable category of product has emerged that can detect that a fall has occurred without the requirement of pressing a button. Halo Monitoring is an early pioneer in this market and offers a wearable chest strap that can alert about vital sign changes as well as falls – this can be worn against the skin or inside a sports bra. Recently they introduced a belt clip version of the fall detection device.  One major advantage of a wearable technology like this is the ability to detect ‘precursor’ falls that may signal a serious life-threatening fall may happen in the future.
• Passive sensor-based activity monitors.  Because they must be worn and activated, PERS devices are not the most reliable way to detect a problem of a frail, home-bound individual. Nor are they in any way useful for preventing falls or other problems. Beyond PERS, sensor-based home monitors (GE QuietCare, Grandcare Systems, WellAWARE and Healthsense), are more costly but unlike PERS devices, they collect information and therefore can make a determination, based on how they are configured, as to whether to signal for help.  This could include motion sensors that detect absence of movement through a doorway, bed sensors (similar), sensors placed near a refrigerator or outside doorways, all to help monitor and reassure seniors and caregivers. These technologies require custom installation and are primarily found in independent and assisted living facilities – PGCMs should be familiar with their purpose, recommend them to facility management if appropriate, and consider them for residential use with support from the vendor.  
• Web cameras, telecare, and other security devices. The ability to remain in one’s home depends on whether the home is free from obstacles and dangers, and on whether risks are addressed.  First is the home environment safe? Security systems from Alarm.com or ADT, both of which have web camera options, should help ensure notification and reduce risk from a stove being left on, water left running, windows left open, or air conditioning failures.  Web cameras are of special interest to family members who live some distance away and want to see, perhaps, that a frail relative has been in the kitchen today.  Telecare, which integrates and monitors with two-way audio-visual systems can help with preventing incidents.  Examples are Rest AssuredR and Grand Care. 

Medication Monitoring and Management
It is well known that the number of medications prescribed proliferates in relationship to age and chronic disease. Studies indicate $290 billion per year is spent on health care due to medication non-adherence.  Furthermore, it is estimated that 1 in 10 visits to the hospital result from medication mismanagement. PGCMs should consider use of:

• Automated reminder systems.  Telephone-based reminder systems are easiest to set up for ensuring that medication regimens are met (or at least acknowledged). These include phone-based reminders through cell phones and PDAs like OntimeRx and Zume Life.  HealthAnywhere adds mobile telehealth capability by enabling the user to attach a blood pressure cuff and transmit readings, while MedeMonitor offers a pill reminder and a portable pillbox. 
• Medication dispensing units.  Beyond simple reminders, some vendors offer wireless compliance transmission and various forms of dosage management.  PGCMs should consider websites like ePill.com to learn about current offerings, some of which can be purchased and others leased. These include removable canisters (MedSignals), dispensing devices (Philips) and even remote pharmacy re-reconfiguration of dosages (InRange Systems’ EMMA). Like Philips, MedMinder offers a multi-dose, multi-day wireless container that supports 4 dosage periods and 28 compartments.  Transmitted information (including non-compliance warnings) can then be viewed on the web by a PGCM or nurse.  The PGCM might find that medication dispensing units are sometimes offered along with PERS systems as a package to support the elder aging in place (for example, Philips).  

Internet-based and Other Services 
A Deloitte 2008 study of consumers and healthcare found that 80% of consumers want more Internet-based information about their medical records, test results, and information about treatments, but most do not have this access.  This has created an opportunity for Google Health, and Microsoft HealthVault PHR software and their partnerships with health technology products.  Jitterbug phone users can add a service (LiveNurse) in which family members can obtain answers to non-emergency questions 24 hours per day .
Other services include:

• The virtual doctor visit. Depending on the circumstance, it may be of interest and benefit to augment a client’s regular medical care provider with services that can respond and assist electronically 24x7 through e-mail and telephone like AmericanWell (which uses HealthVault), ConsultADoctor, or TelaDoc. For a small monthly or per visit transaction cost, a caregiver can also gain reassurance that a family member’s condition needs emergency treatment or a prescription.
• Internet sites with information or community.  Clients with computers but little mobility can benefit from sharing experiences through condition-specific sites like Diabetesmine.com or experience-sharing on a site like PatientsLikeMe.com.  These internet-aware clients can also access for-profit sites (like WebMD), non-profit or chronic disease management sites like Alz.org for those with Alzheimer’s disease.  For those with internet access, the significance of this can’t be underestimated: according to Alexa.com, there are more than 62,000 health sites which received 55.3 million visits per month, 31% of the US online views of 178 million. 

Prerequisites for Successful Use of Technology.
The technology market is changing rapidly and new devices and entrants continually emerge. Geriatric care managers in group practices should have access to a technology expert who stays current on the products and services that are of benefit to frail elderly clients.  Those who are self-employed should add technology consults to top of the list of their referral networks.  In either case, PGCMs should add:

• Assessments -- that survey tech access and capability. When visiting a client for the first time, look around the home and make a baseline determination about technology access. Is there a computer, cell phone, internet connection available? Used by the client? If so, can they be enhanced with capabilities described in this document? If not, can they be added by the technology expert in the PGCM’s network?
• Systems – structured responder network required. Monitoring systems are useless without a tailored network of responders that may include a family member or members, the PGCM, a facility nurse, or 911. Review the list and make sure that it is regularly reviewed by a family member or a facility.
• Vendors – make them work for you – bring you training and trial use.  Just as PGCMs, however, may be unfamiliar with technologies in the market, so too, technology vendors are unfamiliar with PGCMs. PGCMs should seek out vendors for guidance, suggestions, and sample products that could enhance their practices and improve the lives of their clients.  Technology vendors want to work with PGCMs for the future referrals and business they bring. When you identify a technology software, hardware, or service provider, make them work hard for that referral by providing test equipment, setup, and regular technology checkups.
• Get buy-in from the seniors involved. The PGCM can work with the senior and the family to get the senior’s buy-in before introducing technology. This is particularly crucial when considering any form of monitoring tools. To raise the topic of technology with the senior, the following strategies are recommended: 1) Explain how the technology will help; 2) Involve them in decision-making; 3) Give them a chance to get used to the idea; and 4) Present it as an aid to remaining independent.