American Soceity On Aging 031809

Emerging Technologies for Independent Living Aging in America: ASA-NCOA Conference March 18, 2009 Molly Coye, MD, MPH Barbara Harvath, RN, BA David Lindeman, PhD

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© 2008 Health Technology Center

Introduction and Objectives Beneficial Technologies ¾ Emerging technologies are having an ever greater impact on the field of aging, and no more so than in the area of community-based independent living HealthTech ¾ HealthTech is a non-profit research center that has been engaged in forecasting the future of beneficial technologies for over 8 years ¾This presentation includes work done in collaboration with United Cerebral Palsy and through support of The SCAN Health Plan

In this session we will: 1.

Provide an Overview of promising technologies for maintaining the independence of older adults in community-based settings

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Present forecasts of specific technologies and their relationship to the workforce

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Discuss challenges and opportunities for using beneficial technologies to support the independence of older adults 2

© 2009 Health Technology Center

HealthTech’s Research Methodology

Literature Review

Webinars Technology Profiles

Stakeholder Analysis

Expert ExpertInterviews Interviews

Expert ExpertPanel Panel

Forecast & Trend Reports Demonstration Projects

Developer and Product Review

Analysis

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Education

Forecasting

Validation

Diffusion

Persons With Disabilities

46.1 million people (20.8%) over the age of 15 have a disability 30.5 million people (13.7%) have a severe disability 15.6 million people (7.0%) have a non-severe disability 17.6 million people (52.3%) over the age of 65 have a disability

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Challenges of the Aging and Persons with Disabilities

Everyday ChangingLiving Demographics Activities •ADLs: bathing, dressing, grooming, transferring, feeding, toileting •IADLs: using phone, taking meds, light housekeeping, preparing meals, managing finances, going outside alone •Home and personal safety (fall prevention, wandering)

Changing Health Management Demographics •Disease self-management

•Personal engagement •Vision, hearing, sensory, motor

•Lifelong learning

•Nutrition

•Social interaction

•Vital signs

•Being supported by caregivers

•Exercise •Leisure activities •Fatigue/sleep •Cognitive function

•Mobility •Care coordination •Transportation

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Staying Connected and Supported

•Emotional and spiritual wellbeing

Understanding Disability: Types of Impairment There are 3 categories of impairments that can cause functional limitations:

Sensory – long-lasting blindness, deafness, or a severe vision or heading impairment • Examples: Blindness, deafness

Physical – a long-lasting condition that substantially limits one or more basic physical activity such as walking, climbing stairs, reaching, lifting or carrying • Examples: Muscular dystrophy

Cognitive – difficulty learning, remembering, or concentrating due to a physical, mental or emotional condition lasting six months or more • Examples: Dyslexia, Dementia

* These are definitions for disabilities from the American Community Survey (Census). They need to be reworked. 6

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Depression: The Leading Cause of Disability Worldwide By 2030 By 2020, Depression will be the second leading cause of disability worldwide

Source: World Health Organization 7

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Needs of the Aging and Persons with Disabilities:

Shared Needs: Needs of the Aging

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Health management, help with ADL, IADL, staying connected and supported, care coordination

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Needs of Persons With Disabilities

Stakeholder Analysis Aging & Persons With Disabilities Needs & Challenges

Caregiver’s Needs & Challenges

Identifying technologies that maintain or improve quality of life and level of independence for the aging and PWD

Technology Developers Needs & Challenges

Care Providers & Insurers Needs & Challenges

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(Formal & Informal)

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Human Service Orgs Needs & Challenges

Builders & Developers Needs & Challenges

Stakeholder Research Needs

Builders and Technology Developers

Human Services Organizations

Care Providers and Insurers

• Design

• Quality of Life

• Reimbursement

• Outcomes Data

• Prevention

• Outcomes Data

• Business Model

• Safety

• Policy changes

• Policy changes

• Well-being

• Workforce

• Policy changes

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Framework For Forecasts Consumer Experience

Service

Settings and Facilities

Business Models Technology Development, Adoption, and Dissemination

Regulations and Standards

Workforce

ICT

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Key Trends for Technologies of Independent Living Consumer Experience

Service

Many More People With Less Severe Functional Impairment

Consumers Become the Primary Drivers of Technology Adoption Care Models Prevention and Self-Care SettingsIncorporate and

Business Models

Facilities Older Adult Bulge has Windfall Benefits for Persons With Disabilities Technology Development, Adoption, Mainstream Products Repurposed, Intuitive, Customized and Dissemination

The Rise of the Algorithm

Cell Phones are the Primary Platform Workforce

Social Support and Connectedness Gain Importance Downshifting Labor ICT

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Regulations and Standards

Example Trend: Consumers Become Primary Driver of Technology TREND Consumers become the primary driver of technology and service adoption. Boomers, as family caregivers, begin to purchase lifestyle needs technologies and services for their parents, and then continue to demand and purchase technologies and services that enable independent living as they age. Providers and payers will expand their adoption of medical needs technologies and services due to persistent demand of consumers and supporting translational research. Important Technologies and Characteristics: Discreet technologies Personal safety Monitoring and sensors Safe designed housing Telehealth/Remote Care 13

© 2009 Health Technology Center

Consumer Driven Technology Trend: Supporting Forecasts Consumer Experience •The desire to appear independent drives development of discreet technologies and services related to lifestyle needs. 0-2 years: Technologies with simple interfaces and minimal features appeal to older adults. • Example: GreatCall’s Jitterbug

2-5 years: Discreet and affordable wearable sensors are the major modality for collecting physiologic and personal data in remote monitoring applications. 5-10 years: Developers produce aesthetic and functional technologies to meet large Boomer market.

Consumer Experience

Service

Settings and Facilities

Technology Development, Adoption, and Dissemination

Regulations and Standards

Workforce

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© 2009 Health Technology Center

Business Models

ICT

Consumer Driven Technology Trend: Supporting Forecasts Service •Technology develops to help older adults safely transport themselves, whether on foot, driving or public transportation. 2-5 years: GPS-enabled cell phones are customized to help older adults navigate on foot and on public transportation. • Example: iPhone, Blackberry

Geographical Information System (GIS) on cell phones enable older adults to map where they live relative to local services, to reroute public transportation to suit their needs, etc. 5-10 years: Virtual reality driving simulators gain use in clinical practice to assess executive functions and make specific driving recommendations. • Example: Drexel University Applied NeuroTechnologies Lab’s Virtual Reality Driving Simulator, University of Florida’s Independence Drive Program

Service Consumer Experience

Settings and Facilities

Technology Development, Adoption, and Dissemination

Regulations and Standards

Workforce

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Business Models

ICT

Consumer Driven Technology Trend: Supporting Forecasts Settings and Facilities •Consumer demand for independent living drives senior living facility design. 0-2 years: Senior living facilities adopt cognitive fitness, sensor and monitoring technologies initially in more high-end housing. • Example: Eskaton’s National Demonstration Home

2-5 years: Senior living facilities partner with universities to create learning communities • Example: Hebrew SeniorLife’s NewBridge on the Charles

5-10 years: Design elements that promote physical and psychological well being become wide spread Consumer Experience

Service

Settings and Facilities

Technology Development, Adoption, and Dissemination

Regulations and Standards

Workforce

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Business Models

ICT

Consumer Driven Technology Trend: Supporting Forecasts Workforce •New roles emerge to navigate complex systems. 0-2 years: Roles of care coach/manager, ombudsmen, mentors, super-users expand and proliferate. 2-5 years: Increased importance of and demand for web managers in complex service organizations. 5-10 years: Systems integrators needed to manage increasingly interdependent operations: reimbursement, PHR/personal health info, supply chain and Durable Medical Equipment (DME)/equipment, social/gaming, and services.

Consumer Experience

Service

Settings and Facilities

Technology Development, Adoption, and Dissemination

Business Models

Regulations and Standards

Workforce 17

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ICT

The Growing Need for Direct-Care Workers

Between 2000 and 2030, the number of US elders will increase by 104% while women aged 25 to 44 (the traditional source for direct care workers) will increase by only 7%.

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The Growing Need for Direct-Care Workers

•The majority of direct-care workers are now employed in home- and community-based settings, and not in facility-based long-term care settings. •By 2016, home- and community-based direct-care workers are expected to outnumber facility workers by nearly two to one.

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Consumer Driven Technology Trend: Supporting Forecasts Information & Communication Technology •Sensors and monitoring technology evolve to be less intrusive, easier to use, and more flexible. 0-2 years: Due to the early stage of the development, the use of monitoring and sensing technologies is limited to a few simple and basic applications. • Example: Tunstall’s Falls Management System, QuietCare

0-2 years: Monitoring of physiological data and personal data is done discreetly through wearable sensors. 2-5 years: Environmental monitoring appliances are designed with plug-and-play capability to meet the evolving monitoring and support needs of consumers. 5-10 years: Personal and environmental monitoring converge. Cell phones become the main data collection device. Consumer Experience

Service

Settings and Facilities

Technology Development, Adoption, and Dissemination

Regulations and Standards

Workforce

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Business Models

ICT

Aging and Technology Use Internet Penetration •A third of seniors (age 65 and older) have the Internet at home. •More than two-thirds (70%) of the next generation of seniors (50-64 year-olds) have gone online. Internet Usage 51% of adults age 60-69 go online • 88% use email • 72% get health info • 75% get hobby info • 67% get news online

26% of adults age 70+ go online • 86% use email • 65% get health info • 56% get hobby info • 53% get news online

Broadband Use •Those age 50 and over experienced a 26% growth rate in home broadband adoption from 2007 to 2008. •Half of Americans between the ages of 50 and 64 have broadband at home. Some 19% of those 65 and older had home broadband access as of April 2008.

Cell Phone Use • 50% of Americans age 65 and older have a cell phone. What are they doing on line?

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Consumer Driven Technology Trend: Supporting Forecasts Regulations and Standards •Regulation changes lag despite pressure from older adults and persons with disabilities to adapt environments for accessibility. 0-5 years: Higher visibility of environmental challenges for persons with disabilities brought by aging populations. 5-10 years: Better access in public and commercial areas, but low-income housing remains a challenge because of the lack of market power. 5-10 years: Housing developers begin going beyond code standards toward individualization for residents’ needs, but face challenges with local regulators. 10+ years: ADA criteria expands to reflect the changing population.

Consumer Experience

Service

Settings and Facilities

Technology Development, Adoption, and Dissemination

Workforce

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© 2009 Health Technology Center

ICT

Business Models

Regulations and Standards

Consumer Driven Technology Trend: Supporting Forecasts Business Models •Willingness to pay for services out-of-pocket and lack of reimbursement cause technology developers to shift focus away from institutions to individual consumers. 0-2 years: Care-in-place and remote monitoring technologies continue to be paid for out-ofpocket. •Example: Centura Health at Home’s Home Care

2-5 years: Community living facilities pay for inclusion of beneficial technologies in new construction, but pass the costs on to the consumer. 5-10 years: Fee-for-service bundled packages of technology and in-home technical support become available.

Consumer Experience

Service

5-10 years: commercially available technologies such as assistive devices and home health monitoring become widely available in retail stores. 23

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Settings and Facilities

Technology Development, Adoption, and Dissemination

Business Models

Regulations and Standards

Workforce

ICT

Baby Boomers as Caregivers for their Aging Parents

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More than 15 million take care of their aging parents, a responsibility that often includes paying for all or part of their housing, medical supplies and incidental expenses. Many costs are out of pocket and largely unnoticed: clothing, home repair, a cellular telephone.

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Adult children with the largest out-of-pocket expenses are those supervising care long distance, those who hire inhome help and those whose parents have too much money to qualify for government-subsidized Medicaid but not enough to pay for what could be a decade of frailty and dependence.

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The burden is compounded by ignorance, according to a study by AARP, released in mid-December, which found that most Americans have no idea how much long-term care costs and believe that Medicare pays for it, when it does not.

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Families have always looked after their elderly loved ones. But never has old age lasted so long or been so costly, compromising the retirement of baby boomers who were expecting inheritances rather than the shock of depleted savings.

The Perfect Storm Stakeholders, whether they are developers, policy makers, providers, or the consumers themselves, are all interested in the different ways of keeping this population healthy at home.

Changing Demographics - Increased longevity - Age wave - Increased disability incidence - Increased chronic disease among older adults - Increased desire to lead independent lives at home

Scarce Resources

Technologies for Independent Living

Technological Innovation

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- Uncertainty of government safety net programs - Uncertainty over individual financial security - Overstretched healthcare $ - Workforce shortages

The Challenge: Chronic Diseases and the U.S. Care Experience Several themes predominate in the care management of U.S. residents with chronic diseases compared with residents of other nations with such conditions: High cost of care with an emphasis on high personal cost •

54% did not receive recommended medical care, fill prescriptions or visit a physician at some point because of high costs, compared with 7% of participants in the Netherlands

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41% spent more than $1,000 on out-of-pocket medical costs last year, compared with 4% of participants in Britain and 5% of participants in France

Medical errors •

One-third experienced a medical or medication error, received incorrect laboratory test results or experienced delays in test results, the highest rate among participants

Lack of access and continuity across sources of care •

Almost half wasted time because of disorganized care or had received care of limited or no value during the past two years, the study found

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Remote Patient Management Technologies: A Disruptive and Transformative Solution To A National Health Care Challenge The health care system is illequipped to manage the growing disease burden challenge New business models are emerging in response to policies designed to improve outcomes and reduce spending Remote patient management technologies are an opportunity to advance national health care goals Remote patient management technologies are a disruptive and transformative technology Adoption and diffusion paths reflect a balance between technology, policy and market interests

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The Telehealth Process

Person interacts with telehealth device Data collected includes: •Vital signs (blood pressure, glucose meters, pulse oximeters, weight) •Physical and emotional well-being assessment

Personal information is collected & transmitted

Caregiver or clinician receives data & uses

Data transmitted over:

Results include:

•Video over lowbandwidth POTS •Video over IP •LAN/WAN •Broadband

•Enhanced communication between caregivers, providers, and patients leads to improvements in: - care coordination - caregiver support •Reduce unnecessary visits •Improve medication compliance

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The Opportunity: RPM of patients with congestive heart failure The New England Healthcare Institute’s Research Update: Remote Physiological Monitoring reports the following cost savings for all Class III and Class IV heart failure patients, assuming that 80% of the 1.59 million patients in these two classes, or 1.27 million patients, will be hospitalized in a year, at an annual cost of $2,052 per patient for the monitoring technology ($2,802 with DM software): 60% reduction in hospital readmissions compared to standard care and a 50 percent reduction in hospital readmissions compared to disease management programs without remote monitoring. Based on the potential to prevent between 460,000 and 627,000 heart failure-related hospital readmissions each year, NEHI estimates an annual national cost savings of up to $6.4 billion dollars.

The annual cost of a heart-failure related hospitalization per patient ranged from $5,632 for RPM patients to $11,387 for disease management without RPM patients to $13,468 for standard care patients. The net savings of RPM technology (i.e. savings after the costs associated with interventions) were $3,703 per patient per year for those with disease management programs and $5,034 for those with standard care.

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© 2009 Health Technology Center

The Early Adopter Experience: Veterans Health Administration The cost of the program is $1,600 per patient per annum. This compares with direct cost of VHA’s home-based primary care services of $13,121 per patient per annum, and market nursing home care rates that average $77,745 per patient per annum. Since VHA implemented CCHT, a total of 43,430 patients have been enrolled in the program. CCHT patients increased from 2,000 to 31,570 from 2003 to 2007. VHA plans to increase its NIC services 100% above 2007 levels to provide care for 110,000 patients by 2011, or 50% of its projected NIC needs. VHA attributes the rapidity and robustness of its CCHT implementation to the “systems approach” taken to integrate the elements of the program. Wherever possible, CCHT incorporated existing business processes to reduce the program’s overhead costs and increase efficiency.

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Age Distribution of all CCHT Patients

Significant Barriers Remain to RPM Adoption and Diffusion Principal barriers include the limited experience of most providers with this technology, poor preparation for adopting such technologies, and lack of financial models that document return on investment. NEHI updated its 2004 findings on barriers to RPM adoption in Remote Physiological Monitoring to include: Inadequate reimbursement: Medicare does not widely support remote health services, nor do about half of the state Medicaid programs, but approximately 130 insurance companies now provide coverage for telemedicine in some capacity. Provider concerns: Providers remain concerned that telemedicine will generate large volumes of additional work, increase legal liability, and lead to the loss of traditional provider control. Limited patient awareness: Patient awareness of RPM remains low because there is a limited amount of public information available and that which is available is not reaching the target audience – seniors, the chronically ill and their caretakers. Information technology barriers: The lack of interoperable connectivity standards among providers, the spotty adoption of electronic medical records, and the lack of infrastructure in rural areas must all be addressed before RPM technology can diffuse widely in the marketplace

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Policy Change To Support Broad RPM Diffusion Will Drive Cost Savings Analyzing data from the remote monitoring program at the VA, as well as other smaller programs, Better Health Care Together finds the US health care system could reduce costs by nearly $200 billion during the next 25 years if remote monitoring tools were utilized much more widely and supported by specific policy adjustments that include reimbursing health care organizations for remote care and encouraging continued investment in broadband infrastructure. Estimated Savings and Gain from Policy Implementation, by Condition Net Present Value of Savings – Baseline Case

Net Present Value of Savings – Policy Case

Gain From Policy Change

CHF Patients

$79.7 Billion

$102.5 Billion

$22.8 Billion

Diabetes Patients

$42.3 Billion

$54.4 Billion

$12.1 Billion

COPD Patients

$18.7 Billion

$24.1 Billion

$5.4 Billion

Chronic Skin Ulcer Patients

$12.5 Billion

$16.0 Billion

$3.5 Billion

Total

$153.2 Billion

$197 Billion

$43.8 Billion

Source: Vital Signs via Broadband: Remote Health Monitoring Transmits Savings, Enhances Lives 32

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Ideal Technology Deployment: Stakeholder Alignment Government & Payer Partial or Full Reimbursement

Healthcare Provider Disease management & prevention focus

Supportive Policy

Efficient & effective care coordination

Successful Technology Deployment

Vendors Business model is affordable & scalable

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Community Services Provider Underlying infrastructure in place

© 2009 Health Technology Center

Consumer education & trust

Caregiver buy-in

Center for Technology and Aging

Initiative of The SCAN Foundation and HealthTech 3-year grant of $5 million to establish the nation’s first center devoted exclusively to advancing the use of technologies that enhance home and community-based care for seniors. Address the continuing challenge of adoption, expansion and sustainability of creative technologies that benefit the health and healthcare of older adults and the long-term care work force. Goals Identify and evaluate best practices in the diffusion of emerging technologies. Serve as a state and national resource base for providers and policymakers who are engaged in the expansion of technology that improves the quality and efficiency of long-term care services. Develop supportive tools to accelerate adoption of technologies that improve the care and well being of older adults.

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© 2009 Health Technology Center

Center for Technology and Aging Center for Technology and Aging Activities Grant program to test diffusion strategies starting in 2010 Research and evaluation on adoption and diffusion strategies Technical assistance tools Policy and position papers that support the adoption and diffusion of beneficial technologies National dissemination of information concerning successful strategies and programs through web page, e-newsletter, fact sheets, white papers, and publications The Center will focus on an array of technologies, including among others: Remote patient management Medication management Cognitive assessment Assistive technologies Caregiver communication

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© 2009 Health Technology Center

Translating Expert Research and Partner Networks Into Results Molly Coye CEO 415-537-6966 assistant’s phone 415-537-6949 fax [email protected] David Lindeman Director-Center for Technology and Aging Senior Advisor - HealthTech 415-537-6598 phone 415-537-6949 [email protected] Barbara Harvath Senior Advisor 415.537.6969 phone 415.537.6949 fax [email protected]

www.healthtech.org

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© 2008 Health Technology Center

Center for Technology and Aging 524 Second Street, 2nd floor Health Technology Center San Francisco, CA 94107 nd 524 Second Street, 2 floor San Francisco, CA 94107