This article considers the importance of telecare services in supporting the reengineering of healthcare provision to deal with the needs of an older and ageing population. It supports the importance of the assessment process and offers advice on how to ensure that sufficient information is collected on hazards associated with independent living, and the possible consequences of accidents. From these, the risks and unmet needs may be identified and measured so that appropriate management strategies may be implemented and reviewed to overcome the risks such as falls faced by people living alone in the community. Case studies are presented to demonstrate the benefits of this approach and the benefits that are possible for all stakeholders.
The population of the developed world is ageing. This is, in part, the result of improved healthcare services which have increased life expectancy significantly for over a century, but also because of a reduced birth rate. This means that the ratio of retired people who need to be supported by those of working age is going to increase rapidly over the next 50 years, exacerbating the strain on government finances.
It may be observed (Figure 1) that the situation is most acute in Europe where the number of older people supported by each worker has already fallen to 3.3 and will drop below 2 within 25 years. In the Far East, the Chinese policy of allowing couples to have only one child will increase the dependency ratio by almost a factor of 5 within 2 generations, to approach European levels. The Americas will also see significant ageing though they will be protected to a certain degree by their high level of younger immigrants.
This background is one of the drivers that requires a reorganisation of healthcare provision, including the centralisation of hospitals in large treatment centres while rapidly increasing resources to primary care and to the community where most health and support services can be provided. Digital healthcare technologies will play an increasingly important role in all care settings, but may be particularly relevant to supporting individuals in their own homes.
Problems Dealing with an Ageing Population
The healthcare needs of older people are associated with:
- Increasing numbers of chronic diseases and long term conditions – especially diabetes, and heart , Alzheimer’s, Parkinson’s, and airways diseases;
- A longer recovery time from acute illness or surgery – including viral infections and planned operations; and
- A higher incidence of accidents in the home – especially falls, often due in part to the individual having long term conditions and/or having recently been discharged from hospital.
A major focus must therefore be on introducing prevention measures and strategies for self-care (including a role for family support), as these can promote health and well-being and will therefore have the potential both to reduce future demand for formal services and to encourage the development of community approaches to support better lifestyles. Telecare services are becoming increasingly popular as they provide an electronic safety blanket around vulnerable people which can be an important factor in helping to support their independence. Services are particularly well suited to managing the risks associated with living independently and performing tasks associated with the performing of Activities of Daily Living and Instrumental Activities of Daily Living (see Table 1).
It follows that an individual who is unable to performing more than a few ADL and IADL tasks is more likely to require long term care either in a care home or through personal homecare services. In recent years, there has been a significant movement away from the former and towards the latter in order to avoid premature institutionalisation, but also to enable people to exercise more choice and to be able to “stay put” if that is their wish. However, the cost of providing high quality home care is also increasing rapidly, so the current emphasis is to delay or reduce the need for such support. Reablement services are seen as an effective way of helping people to relearn the domestic skills that they might have lost following accident or injury and to regain the confidence needed for them to continue to provide self-care.
It is widely accepted that assistive technologies will play a key role in enabling people to remain independent. Assistive technologies range from expensive adaptations to the home (such as the building of ramps or the building of a level access wet room) through to low cost portable aids to daily living (such as walking sticks or kettle tippers). Increasingly, they will also include electronic devices some of which are connected to telecare systems. It may be apparent that if an individual is due to be discharged from hospital because they are medically fit but need an item of assistive technology to enable a safe discharge, this is more likely to be achieved using a low cost off-the-shelf item than a complex system that has to be designed, ordered, funded and professionally installed.
It follows that an effective approach to dealing with unmet needs should follow the mantra:
Thus, if the need is to climb the stairs in order to go to bed at night, the options could be:
- No tech – move the bed downstairs or ask for a Physiotherapist intervention
- Low tech – install a second handrail, use a device such as a QuadStep or a StairSteady (see Figure 2)
- High tech – install a stairlift or use an exoskeleton Walk Assist device (see Figure 3)
In each case, enabling an individual to become more independent inevitably means that there will be risks that were not relevant if the tasks were performed by or with someone else. The challenge is therefore to support self-care by providing an effective means of risk assessment and management process.
Steps in Risk Assessment and Management
Risk is all around us but the ways that it is managed remains a complex policy and practice issue. Consequently, positive risk taking, whilst potentially beneficial in giving people the freedom to live their lives to the full, may be regarded as reckless or dangerous in hindsight after an accident has occurred. Telecare, and other assistive technology devices, can play a major role in helping to avoid many of these accidents, thus reducing the threat to the independence and well-being of an individual. The taking of risk is often replaced by defensible decision-making which may be based on the same principles as risk assessment. Essentially, risk assessment and the subsequent elimination or, more appropriately, management of risk relies on a number of key processes.
- Appropriate levels of knowledge collected about the individual, their lifestyle and where they live
- Actuarial evidence associated with past experiences of similar groups of people
- The skills and experience of the assessor
- Communication with family, friends and neighbours, as well as the individual, medical staff and other care providers; and
- Clear recording of all information and actions taken.
In practice, the level of knowledge about a person and their circumstances is unlikely to be complete, so the following 7 step process may be taken in order that a coherent and professional approach has been taken to risk. The steps are shown diagrammatically in Figure 4.
Step 1 – Consider the tasks that an individual needs to perform when living independently
Table 1 shows an example of 16 items for assessment in 5 domains. Some versions of Table 1 include the potential for using assistive technologies and telecare within the Environmental Domain. Whilst assessors should be encouraged to be proactive in looking for opportunities for using technologies as a preventive measure, there seems little logic in having a separate assessment for telecare. Indeed, most care managers and assessors should look first at the potential of telecare and equipment to overcome unmet needs and risk in ALL the domains of Table 1.
An experienced assessor will need to distinguish which tasks the individual needs to perform and wants to perform, as opposed to those tasks which they are happy to accept as no longer part of their lives. This is not a trivial matter as it involves understanding the motivations of an individual and their chosen lifestyle, values and priorities. It sometimes requires conversations with the individual and with their family members in order to clarify these matters. Ultimately, the views of the individual being assessed must take priority over those of family members assuming that they are capable of understanding the process of assessment. It must always be assumed that an individual has mental capacity unless a formal assessment has shown that they are not capable of making informed decisions for themselves.
Step 2 – Identify all the factors involving these tasks that have the potential to contribute to risk
There are five types of risk factor:
- Hazards – environmental issues such as poor lighting, steep steps, dangerous appliances, old wiring;
- Individual deficits/problems – sensory issues and those due to recent illness or long term condition
- Lifestyle habits/behaviour – smoking or alcohol abuse can impact safety and well-being
- Past history of adverse incidents – these are predictors for future events; and
- Statistical factors – these relate to individual physiological parameters including age, speed of walking, upper body strength, living alone, financial resources, education, and serious illnesses.
There are a number of different methods and tools to help identify the risk factors that are relevant to an individual and their living environment. These include home safety checks, checklists of factors relevant to particular health conditions, assessment forms, conversations with carer, both informal and formal, automated collection of activity data, and images relating to visitors to the home. These tools will be described in more detail below. A full list of risk factors would be too great to include. The challenge is therefore to consider only those that may be relevant to a particular individual and their circumstances. It will subsequently be necessary to focus on those risks that can be managed in some way by assistive technology and telecare.
Step 3 – Define the risks presented by these hazards and by the individual’s characteristics.
The risk factors identified in Step 1 are usually relevant to a number of independent risks. Table 2 shows examples of risk factors and their type, together with examples of some of the risks that may be relevant. The second step involves collecting all the relevant risk factors associated with a particular risk and determining the likelihood of a fall occurring as a result of these factors.
In general, it is possible to express the likelihood of an accident or mishap occurring on a scale ranging from Very Unlikely through to Certain, irrespective of whether the primary concern is for the well-being of an individual or the integrity of a building. These can be scored from 1 to 5 as shown in Table 4.
Step 4 – Estimate the Impact of Adverse Incidents
Due to the different concerns of stakeholders, the scoring of the severity of harmful consequences is rather more difficult and must be measured with respect to the current circumstances and a defined time-scale. In practice, different assessors may measure the level of risk differently because of their respective approaches to the concept of risk. This is not only an issue concerning their attitude to risk-taking but also their priorities, and also their respective duties of care, with respect to the type of harm that might result as a result of a defined risk. These are shown as examples in Table 5 and illustrate how assessors must be clear in their own mind how they define harm.
Step 5 – Measure the level of risk
Objective methods of measuring risk are required so that priorities can be applied in managing the risk using interventions such as Assistive Technologies and Telecare.
Risk is defined as the likelihood that harm will occur under particular circumstances.
It is the product of the likelihood (or probability ) of an adverse incident, accident or event occurring multiplied by the likely severity of the consequences i.e. the degree of harm or damage caused.
The results for each risk can be presented in the form of a risk matrix as shown in Table 6.
Risk scores of up to and including 4 (shaded in green in Table 5) are usually seen as acceptable. Those between 5 and 9 (shaded in amber) are a source of concern and should be assessed to determine if the risks are temporary or permanent in nature (or whether they are likely to increase over time). A score of 10 or more (shown shaded in red) indicates an unacceptable level of risk that needs to be reported and an action plan produce to reduce the risk.
Step 6 – Risk management plan
We all live with risk. Indeed, life might appear very boring if all risks were removed. It is better, therefore, to try to manage risks rather than try to eliminate them. This is consistent with allowing people to remain in their own homes rather than moving them into the assumed “risk-free” environment of a care home.
Risk reduction or management may be achieved by either reducing
- The likelihood of an accident or adverse incident from occurring, and/or
- The potential for harm or damage of such an incident.
Assistive Technologies can often help to prevent an accident. For example, a walking stick or automatic light will reduce the risk of falling. Telecare sensors can give a very early warning of an incident, both to an individual and to a monitoring centre. This enables measures to be taken to reduce the impact of the accident. In the case of a fall from which the individual cannot recover without help, lack of assistance could lead to a long lie. Numerous examples have shown that an individual who is left on the ground for longer than 4 hours is likely to become cold and wet, and may develop pressures sores and other forms of ill-health. They will also suffer psychologically so that they are unable to recover their confidence. Telecare solutions will enable them to be helped within a matter of minutes. The knowledge that support is at hand 24 hours a day relieves anxiety and enables vulnerable people to maintain their independence.
In terms of reducing the risk of environmental damage due to flood or fire for example, it is clear that an early warning will enable rapid and appropriate action to be taken which will both save lives and minimise the damage to property. It would be fair to suggest that environmental risks to everyone can be managed through telecare sensor and alarm technology. However, many risks may be low for most people, so it may be difficult to justify an intervention other than a basic dispersed alarm unit, but where a risk is substantial, it should not be ignored.
Step 7 – Recording Details of Risks and Steps Taken to Manage Them
It follows that an official and robust risk assessment must conclude with a clear statement of the level of risks identified and the actions taken to reduce them. This is the document that should be left on file and used by the professional employed to set up and tailor the telecare service. It also forms an important component of the review process used on a regular basis to confirm that the solutions are working appropriately, and to identify is there have been many incidents detected. Such an increase in incidents would imply that the likelihood of problems has increased and, hence, the level of risk. This might justify reassessment and further interventions.
Risks in the Context of Reablement
If telecare and assistive technology was offered only to people in the highest risk bands then opportunities to improve confidence and quality of life may be limited, and they might require a service for rather less than 12 months before they need long term care. It is more cost-effective (and has a greater impact on their lives) if the technology is offered at a much earlier stage as it might then delay or remove the need for community services such as homecare altogether, producing a much bigger impact. In many respects, reablement (or enablement) services aim to do exactly this – so it follows that telecare should be an essential part of the service that people receive for 6 weeks, free of charge, and which helps them to recover their ADL skills after a period of illness or hospitalisation. This may be seen as “digital reablement”.
Risk Management Case Studies
Gillian Brown has mild cognitive disorder but lives alone and has made it clear that she wants to live independently for as long as possible. Her problem is that she loses track of time and place. She goes out in the night and forgets to perform a number of activities of daily living, preparing and eating her meals, going to bed at night, and taking medication for her heart condition. Table 7 shows the risks that have been identified for her, their scores and the effects of some telecare devices on them.
By providing Miss Brown with a linked telecare system, some smart sensor and 3 other items of assistive technology, all the identified risks can be reduced to an acceptable level enabling her to continue to live independently.
2. Falls Management
Mary Smith is aged 93 and has had osteoporosis for a number of years. She lives alone in a small terraced house and is finding it increasingly difficult to get out of a chair, and to go upstairs to the bathroom. The authorities want her to move into a nursing home, but Mary will have none of it and insists that she will be fine with a little bit of help. She has been assessed by an Occupational Therapist who identified the risks shown in Table 8. These can be addressed with telecare and assistive devices.
Mary would be unable to get off the floor if she fell; she might also break a hip. The focus must therefore be on avoiding a fall and ensuring that a fall is detected as quickly as possible in order to minimise the psychological damage.
3. Chronic disease management
John Owen is a 78 year old ex-soldier who has been significantly overweight for the past 20 years. He developed Type 2 diabetes 6 years ago but struggles to adopt an appropriately lifestyle. Consequently, he doesn’t exercise enough, he forgets to take his medication, and he raids the fridge in the middle of the night. His blood sugar levels are poorly controlled leading to both hyper- and hypo-glycaemic incidents. His primary care team have assessed the risks that he faces and have come up with solutions shown in Table 9. He is very keen on gadgets and has bought himself an Android smartphone which he hopes will help him to take charge of his own condition.
A process for identifying, measuring and prioritising risk in community-dwelling people has been developed and employed in 3 case studies. These demonstrate how telecare and other assistive devices can be chosen to produce significant reductions in risk levels in diverse situations. This approach may form the basis for supporting independence using technology in a manner which is consistent, robust and popular.