Insights Draft Paper
Insights into the Adoption of Assisted Living Technology from COBALT Research – Working Draft Paper 3.2
The COBALT research project started in September 2011 as part of the Technology Strategy Board’s ALIP3 programme. Its brief was to investigate the social and behavioural factors affecting the adoption of Assistive Living Technology (ALT) among older people. The COBALT team consist of researchers from St Andrews, Sheffield and Reading Universities and Age UK with engineering support from Bath Institute for medical Engineering (BIME)
The researchers reviewed findings from previous research and gathered new data from older people, health and social care professionals, commissioners, designers and the ALT industry. They have some new insights about the adoption of ALT and are looking for suitable opportunities to share them with the statutory and private health and social care sector. The project will end in August 2013.
A literature review found that many previous researchers had described the problem of older adults resisting the use of technology. However, by asking older people about technology they used and liked COBALT found data suggesting that viewing older people as the problem was misleading. In addition to using standard qualitative methods such as interviews and group discussion, COBALT added the ‘Technology Tours’ approach and created ‘Show and Tell’ and ‘Pioneer Groups’ methods.
These found that there are social, psychological and physical aspects to the adoption of technology by older people. However, much previous research has concentrated on the physical usability of products. Our evidence is that older people will adapt and use even poorly designed technology provided they perceive it can help them achieve what they want from life. This is illustrated in the following case study taken from a Technology Tour a member of the research team undertook with Amy, aged 79:
Case Study 1: Amy, aged 79
Amy lives on the ground floor in Extra Care housing in what she called a ‘disabled person’s flat’ Amy loves to paint and has a wide selection of colourful artwork on the walls of her flat. She is unable to walk and uses a wheelchair to get around. Her wheelchair is a standard NHS model but Amy has adapted it by putting marker pens in the arms so it can hold shopping. She said it is difficult to use on carpets so she purchased an indoor scooter online with the help of her daughter and said this is a luxury.
Amy uses mainly day to day technologies such as the television with exceptions including her electric scooter and electric wheelchair which she has bought herself. Her flat has an oven, cupboards, sockets and light switches at a low level so as to be accessible for her to live independently.
She also has a wet room bathroom and pull cords for the warden alarm system throughout the flat which were all installed when the flat was designed. However some of the work surfaces were too high so Amy’s daughter got her a separate unit which was not ideal but which solved the problem somewhat. Amy feels designers should spend a week in a wheelchair to experience what it is like before designing products.
Amy uses the alarm on her mobile phone three times a day to remind her to take her medication. When asked about it referred to this as ‘vital’.
Amy purchased her outdoor electric scooter online which she had been reticent about as she wants to support local business but as the cost was vastly different this was a deciding factor. She said this was a key purchase for keeping her independence as when out with others she does not want to rely on them and wanted to be able to go off on own. For example Amy likes going to festivals but likes to go to the stalls there on her own without being a burden on others.
Amy’s daughter made her an ‘idiot’s guide’ as she called it, to using her digital camera and she wants one for the DVD player. Her daughter also increased the font size on her Kindle so it was bigger and easier to read.
Amy has a positive attitude to helping herself and said “we just get by” and said it is impossible to design something which suits everyone as people’s needs are different.
When asked why some people do not use technology Amy said they want to be seen as independent and not objects of charity and that cost could be an issue.
This case study shows how Amy’s focus is on getting about and remaining independent and key to this is the help of her daughter in overcoming physical limitations and providing instructions.
Appropriate design methods such as inclusive design have been available for many years to ensure products are usable by a wide range of people. However when COBALT conducted a group exercise offering current ALT products to people from the ALT industry they found their products could not be used effectively as the following illustrates:
“We were interested in the body fat monitor… to see how fat we were…and how it would work…still not totally clear on that…writing was OK…it’s metric…there is a conversion chart…but it’s tiny…I actually know how to convert to feet and inches still I don’t measure myself in centimetres…I don’t know how much I am in kilos still work in pounds …I just started pressing buttons…although I could put in some things I also hadn’t done it quite right when you read the instructions…I came out as underweight which I’m clearly not…” Female delegate at Age UK Engage Event
Through running similar product testing exercises with older adults, COBALT has established that many older people make decisions about a new product within seconds of seeing it for the first time. Having good packaging should be a key aspect of the product but it appears to have a low priority for ALT product managers.
Also older people use a variety of ways of learning to use technology. Those who rely on trial and error need devices to be intuitive and similar to other mainstream devices. Many expect instructions but COBALT has found many which are poorly written and printed in characters too small for older readers. However, one of the most natural and effective methods was learning in pairs or small groups. Older people rely on the advice of health and social care professionals, friends and family, particularly younger people such as children and grandchildren and also digital awareness initiatives that cover not just email, internet shopping but prepare the way for healthy living applications.
COBALT has found that although most people find learning new skills takes longer as they age, there is no upper limit to learning new skills provided the approach is appropriate. However, memory can be a problem but a COBALT researcher with expertise in dementia taught a person with Alzheimer’s to use an iPhone as this extract from his blog shows:
“some very positive things have happened to me. I was successfully relearning my pre- diagnosis ability to use the computer. Thanks to M., I was also learning to use my new iPhone. Other things have happened recently as a result of meeting M. such as delivering presentations and public speaking with a new found confidence” Brian’s blog available at http://cobaltproject.org/category/brians-blog/
COBALT has discussed this topic with managers and professionals in the ALT industry to understand why they were producing products that didn’t quite meet older people’s requirements. Most suggested that inclusive design was the answer but it was too expensive. To investigate this further, COBALT conducted a segmentation of industry. This showed there are a large number of specialised ALT firms producing bespoke engineering devices, a few global companies with aiming to diversify from sectors such as communications or energy into Health Division and a few suppliers of health products. Firms were aware of user centred design but it was expensive and not seen as improving sales.
COBALT suspected that while inclusive design brought an older person’s perspective to physical products it was missing many important aspects of the creation of products and services – market strategy, business model, promotion, partnership, technology champions and coaching. COBALT devised a technique for product development called ‘Pioneer Groups’ which involved meeting with researchers for 10 weekly two hour sessions. The following case study from one of the two groups undertaken by COBALT demonstrates that older people’s groups can be an invaluable source of ideas for tackling these aspects:
Case Study 2: Pioneer group methodology
During two sessions of the ten week COBALT ‘Pioneer Group’ interactive workshops based in Sheffield known as ‘Pioneer Group’, two designers from a London based company asked six older adults aged 68 to 84 from the local area compromising of three men and three women what they want from an item of technology. The ‘Pioneer Group’s task was to re-design an item of technology which would be used to assess their nutritional intake, physical activity, cognitive ability, level of frailty and mood. The participants said that they wanted the technology to appear as an ‘app’ on a tablet like the iPad which according to Clive, aged 70, would provide “a mobile, portable system that is easy to use”. The group really liked the idea that after inputting information on food and drink consumed that day the system could give the user feedback and advice on how to change their behaviour. Ideas from the group ranged from having the device use local language, be a touch screen device, have an audio function for people with impaired vision, and have the ability to add data about foods eaten that day and the next day the system would recommend what to eat based on that. They also had ideas for a reward mechanism such as Tesco Clubcard points, and a connection to the doctor or pharmacy so that if the users’ mood was low there would be an ‘intervention point’ where they would be helped.
The group also emphasised the need for technology to decrease social isolation amongst older adults and suggested an online network for users where they could exchange ‘tips of the day’, best buys and reviews and maybe keep an eye on each other. Thelma, aged 84, proposed that the app could recommend “things to do to prevent feelings of isolation, depression or loneliness”. In terms of creating revenue the group suggested linking in with Tesco or another supermarket who could offer discounts on healthy foods. It was really important to the group that older adults benefited from this technology and that it was well designed and well thought out.
From the Pioneer Group session the designers created a brand concept complete with sketches of the product. As the group recommended this was given the name ‘Life’ with the tagline as suggested by Betty, aged 77 of ‘Get a life’. The designers refined the concepts the group had discussed and the concept includes ‘Tip of the day’ from other users and something called ‘My Stats’ which is a progress tracker -giving feedback to the user with a list of the user’s agreed goals.
Ideas for advertising the’ Life’ brand put forward by the Pioneer Group included an advert with Bradley Wiggins to target those interested in health and fitness and build upon excitement from the Olympics and Nigella Lawson to capturing the foodie market and provide an attractive face for the brand. The group were keen for the product to be in Boots stores as a standalone concession stand with a trainer on hand to explain how to use it and for technical support as they believed having a person there was invaluable. They thought this could be advertised on television, in doctor’s surgeries and in the local press. “
In summary the group had plenty of ideas around a new, holistic item of technology and worked collaboratively with designers to convey their thoughts. The group were knowledgeable about technology such as the iPad and had a wealth of experience and skills to bring to the process. They were also reliable attendees and very engaged and enthusiastic about the process.
COBALT concluded that the ALT industry could improve adoption and the profitability of their products and services by taking on board the social, psychological and physical perspectives of older people.
Health and Social Care Professionals
Health and Social Care professionals prescribe ALT devices as part of carefully defined processes or clinical pathways. Within these processes they use their professional judgement about whether to prescribe an ALT device. Our literature review has found that very few researchers have investigated the impact of health and social care professionals on the adoption of ALT by older people.
However, even when the design is not ideal, COBALT has found older people are more likely to adopt and continue to use ALT when encouraged to do so by people with whom they have a rapport and respect. So the views of health and social care professionals and their relationship with their clients are all important as the following case study from a one-to-one interview conducted by COBALT shows:
Case Study 3: Theresa, Head Occupational Therapist
Theresa is responsible for the professional practice of Occupational Therapists (OTs) across the hospital. She is also responsible for the professional practice of OTs working in the community and line manages an Operational Manager. Her day to day work includes supervision of staff, training staff, speaking at forums and attending meetings.
Theresa has a positive view of ALT and sees it at the core of OT work but also believes the person is at the centre of care and it is key to find the appropriate solution for them. Theresa finds staff to be enthusiastic about ALT but she and the Telecare Leads who run the ALT demonstration sites across the hospital find it frustrating that the equipment is there but does not get used enough on the ground. Theresa feels this is due to the short amount of time staff have with patient as at times their work is very acute.
Theresa spoke about the barriers to staff promoting ALT which included easily accessing equipment, limited time with patients and that sometimes the correct time has passed for the person to use ALT as often that person may no longer be able to stay at home. She said it can take a long time to order equipment, especially if the supplier is out of area. She told a story of how one OT spent an hour ordering equipment because the supplier would not let her use her work email address as they deemed it not secure enough; this impacted on the OT’s busy working day.
Theresa said she is unclear about how an older person on the ground would see some of the ranges of ALT equipment easily and that ‘community hubs’ to demonstrate this may be the way forward. She spoke about the barriers to ALT for older people as cost, cognition problems, and access to equipment and said ALT needs to be what the client wants and not imposed on them. She said there is a ‘disconnect’ between being in a hospital bed and the reality of home. She relayed that if part of going home is buying a piece of equipment people accept it but the reality of use within the home is different. She said OTs try to solve this problem by attending the person’s home and liaising with their family.
Theresa said it is very important for OTs to establish with patients what their role is at first to manage expectations and that a good relationship with the patient is key. Enablers to older adults using ALT Theresa described included patients trying things first (with an OT or as part of a trialling service), having satellite stores of equipment so OTs can give equipment directly to patients and OTs knowing about equipment and having good relationships with suppliers. She said that engaging and informing patients properly is vital as is the engagement of family and carers and that “it does take professionals sometimes to highlight that these things are available”. Theresa said that a range of equipment is also key and spoke about the need to have equipment ready to hand and the importance of impartial advice from staff as opposed to someone from the ALT industry.
COBALT has found that Theresa is typical of health and social care professionals whose focus is the needs of their patients. Occupational Therapists appear to be the most pro-active champions of ALT as they see equipment at the centre of their role. They keep up-to-date through exhibitions like Naidex (NEC 30th April to 2nd May 2013) and are very willing to share their knowledge and act as ambassadors for ALT. However, COBALT has found many professionals feel frustrated by their lack of choice:
“The equipment service in the city seems to be stuck in, and I’m not saying bath boards and the like aren’t important, but they’re stuck doing bath board type equipment for years and you know that’s what” Occupational Therapist
And inability to obtain equipment at the right time:
“The main barrier for us I think is not that the therapists aren’t on board with it but … that person may be on the cusp of not being able to stay at home and what they needed it for was when they were starting to fall or starting to have memory problems and you know by the time people get to us sometimes they’re a lot further down the line than that” Head of Occupational Therapy
Knock-backs from the financial approval process were also barriers:
“Mainly involved in walking aid equipment … no falls sensors on ward despite falls occurring. Put business case in asking for £6000 (£3000 for each ward which she felt was not a lot) but was rejected. Had asked for bed sensors, chair sensors and six pendant alarms to wear on wrist as no nurse call system so can buzz and ask for nurse to accompany. Only emergency system for nurses to call for help.” Paraphrase of comments by Physiotherapist
And excessive time required for ordering ALT:
“it took one OT an hour to order a piece of equipment as she had to do it online to the supplier” Head OT
In England although there is a strong lead from the Department of Health via initiatives such as ‘Three Million Lives’ the decisions on adoption of telehealth are being made at local level. The key local bodies are the Clinical Commissioning Groups (CCGs) where clinicians and professionals work with their local commissioners to develop and implement strategies for improving health outcomes. The role of commissioners is therefore pivotal in adoption of ALT.
Most health and social care in the UK is provided either by the NHS or local authorities. Within each authority, a small number of commissioners assess the needs of their area, develop strategies to meet those needs, obtain approval for their business cases from their Board and Director of Finance before placing contracts with provider organisations for services to achieve specific outcomes. Nine were interviewed during 2012 and because their work is so sensitive they were assured of confidentiality. They were typically professionals who brought years of commitment to health and social care into developing and contracting for services: “the commissioners role is not just about purchasing, but taking a strategic view on how best to achieve the best outcome for the area” COM#1
In most areas the population is ageing so commissioners predict rising demand for services. They typically take a long term view and know that investment in preventative and community services is likely to minimise the need for costly institutional care in hospital or residential care and improve the quality of life of their population.
“The focus for most local authorities is managing demand by investing in prevention” COM#1
Telecare is widely credited with reducing admissions to costly residential accommodation:
“You don’t need to have a home care visit. You can have the technology in to reduce the number of visits. The second thing is in terms of prevention, just going back to what I said, in terms of fall prevention all those other things. We aren’t seeing the numbers of people going into care so there’s got to be a correlation there”. COM#7
With the growth of internet enabled devices in the home, there appears to be an opportunity for the telecare industry to expand its services from simply community alarms to home well-being offerings around personal location, health and fitness, home and personal security, fire and flood, heating, energy, cooking and nutrition. These community based activities do not require clinical professionals and so could be offered as an extension to existing voluntary sector activities such as handyperson services which carry out low cost home maintenance work for older people. However, commissioners have been disappointed that domiciliary care, extra-care or sheltered housing developers, the voluntary sector and ALT industry have not developed innovative, cost effective services even when clients have been given some choice about how they spend their personal budget
In general NHS commissioners are cautious about telehealth. This is despite receiving guidance and funding for pilot schemes and quality improvement projects from Department of Health. COBALT has found the reason is commissioners are faced with budget constraints and conflicting priorities from the public, their Boards and health and social care professionals.
Commissioners expect telehealth will develop so as to enable people to live in community and minimise emergency admissions. However many professionals, particularly clinicians, have opposed telehealth on the grounds that there is insufficient evidence so far for its benefits. The delay in publishing conclusive results from the Whole Systems Demonstrator (WSD) project has left some clinicians concerns unanswered:
“We’ve just commissioned a new heart failure pathway … I was really hoping that the Whole System Demonstrator would say COPD would be the next big area that we need. So we’re doing what we should around heart failure and helping with that – diabetes is still quite unclear. But I was hoping that COPD would be the next area/patient group but very mixed evidence around that and the respiratory physicians say on balance we think the harms outweigh the risk.” COM#9
COBALT has found that although qualitative case studies from pilot schemes remain valuable, commissioners are increasingly basing their investment decisions on risk stratification. They need to be able to quantify the benefits of ALT within individual business cases such as falls prevention or self-care:
“If we’re going to try and shift this much more to becoming a less hospital dependent system and a much more joined up integrated community model – the John Oldham “Holy Trinity” of Risk Stratification, Integration and Self Care. Then we need to give it to the whole population for all their needs not just their unscheduled or urgent care needs.” COM9
Commissioners are concerned at the lack of interoperability of systems. They need ALT to integrate individual devices with each other and standard patient information systems.
“In terms of joint commissioning we need to be joined up with our telecare, telemedicine and telehealth systems … one of the exciting things is the fact that we’re going to have GPs involved because if anything they recognise all the advantages around the preventative end of things “ COM#7
Commissioners have been able to move forward with telehealth but only in certain clinical pathways and as part of an overall improvement to the service which is negotiated with the staff. Several commissioners have experience of ALT initiatives that failed. They typically attribute this to focussing on technology rather than on the overall system for the provision of care. One recounted how their inability to walk in his shoes had forced him to ask a major UK company to leave the programme:
“Thanks, we’re really interested in you as a key player in the assistive technology market to work with us and advise; but we’re not interested in buying your products unless we know those products are what we think we need. It was like, ‘But we know what you need ‘ – ‘No you don’t! “. COM#8
Commissioners need providers to offer ALT as an enabler which is integrated with the processes and systems of the clinical pathway or service. In terms of technical architecture this requires the ALT industry to adopt data standards. In terms of marketing it means building a pre-sales relationship with clinical or care providers rather than simply offering technology in boxes.
COBALT research has identified insights for ALT which are appropriate to (i) the consumers market (ii) health and social care organisations and (iii) home services.
ALT products for consumers should be marketed as a way of enabling people to live the way they want to. They should use mainstream interfaces like smartphones or tables where possible and be marketed through mainstream channels. Initial acceptance should be facilitated by attractive and intuitive design and clear instructions. Resistance to technology should be tackled by digital awareness initiatives well before people require ALT. The risk of abandonment should be minimised by support groups for peers and families. Consumer ALT devices should be checked for social, psychological and physical aspects that affect older people; perhaps by involving older people’s organisations throughout the product lifecycle.
Encouraging ALT adoption in health and social care organisations is quite different. Individual clients and health and social care professionals have limited influence on purchasing decisions. The focus should be on ALT’s role within health and social care processes or pathways. The people to convince are the leaders of local NHS and local authority Boards and their commissioners. The initial decision to invest in ALT devices depends on commissioners and providers to produce a business case for a change to processes or clinical pathways – technology is secondary. The business case must have clear evidence that the change will improve outcomes and save budget. Although all professionals have a voice, GPs will clearly have a leading role within CCGs. Telecare and telehealth fit naturally with the shift in resources from hospital and residential care to community services. So initiatives such as re-ablement, self-care and falls prevention are good starting points and Occupational Therapists are the natural technology champions.
The home is where consumer and organisational technology starts to come together. The ALT industry needs to recognise that many of the Health and Wellbeing functions offered by ALT devices are starting to be found in mainstream technology such as smart TV, smart homes and smart phones. What mainstream devices lack is an interface with health and social care information systems. This is an opportunity for convergence of Health and Social Care Systems and Home monitoring of security, energy and nutrition.
29th January 2013