The Telecare Blog

Taking Telecare to a new level

2012-01-01T13:47:00.001Z

With the beginning of a new year, after considerable thought I have decided to take telecare activities to the next level. Having spent three years as a Telecare Coordinator for a London Borough and obtained excellent CQC reports for the service whilst in charge, and having worked as an academic for over ten years working in the field of telecare, assistive technology, smart homes, telehealth, ambient technologies, ubiquitous technologies, eHealth, mHealth, mobile technologies in addittion to my other interests in architecture and building design, health in general and of course people with long term conditions and disabled people, I now feel that the time is right for something new.

The Whole Systems Demonstrators (WSD) by the UK’s Dpeartment of Health (DH) has recently reported on its headline findings which clearly indicate a positive use of technology can save lives and save resources. There is little doubt that these findings will be scrutinised fully once the full reports are available, and at this point the headlines might not reveal the whole picture, but they are very encouraging.

We can now be confident that technology can save lives and resources, but we also need to ensure that the technology meets the needs and expectations of the people requiring it. It is important that as a result of using technology the person is not expected to become a machine, operating in unreasonable and predictive manners.

If you have a long term condition, your life is punctuated by regular events, such as taking medication, medical appointments, all the way through to the more chronic who might require assistance in all activities of daily living. What I consider unacceptable, is that technology designed to assist becomes the problem. This could be through making assumptions about people’s lifestyles and expecting unreasonable interactions such as checking-in every hour, or pressing a button regularly to stop an alert. This could also be through false alerts or just the technology not meeting operational expectations.

We are in a era which is really exciting. Technology is evolving faster than ever before and we should be able to harness this technology to enhance people’s live by removing barriers of distance, by producing virtual communities, and bringing virtual services through the cloud to people anywhere in the world.

My current concern is that although some electronic devices benefit from the advances in modern technologies, (eg mobile phones, tablets etc) other more mundane technologies, such as pendant alarm based systems or wandering sensors are failing to think beyond the standard.

We are entering a new year, 2012, and we have the chance to begin to create the world we want. A world where distance is not an issue, where access to products and services is far easier through modern technology. My hope for this new year is that we can get together and design products that will last, which have relevance and meaning to those we design for. This year could and should be the year of personalisation and innovation.

We need to stop waiting for tomorrow to create what is needed to today. We need to act now!

We need to change the way we think about products.

We need to change the way we think about services and service provision.

We need to change the way we think about technology and we need to change the way we think about people.

We need to step away from the tick box solution.

Let’s make Person-Centred Design truly person-centred!

It is with these messages in mind that I have started a new business called gdewsbury which is a Freelance Specialist Technology Writing Service and Consultancy (gdewsbury.com) with which I wish to work with the cutting edge businesses to assist in the build and design or truly exeptional products and help small or new businesses become great through expert input.

This is the year to take telecare to a new level.

Wondering about wandering

2011-12-15T10:34:00.001Z

Wondering about wandering

It is a while ago (2008) that I proposed the enablement/containment models as part of the Dependability Telecare Assessment tool (DTA) (http://www.smartthinking.ukideas.com/telecare.html and http://thetelecareblog.blogspot.com/2008/09/enablement-and-containment-models.html) in which I proposed that technology should enable people not contain them. So, 4 years on, I now turn my attention to those who have supposedly been enabled.

In the UK, there are a range of safeguarding structures in place to enable and ensure that a person has basic human rights and the ability to live an unfettered life. Locking the door on a demented family member was the option of a bygone age whereas today people are faced with the difficulty of ensuring the safety of a person who does not have capacity.

From a telecare perspective, there is a range of devices that are on the market that provide one or more of these four features:
1) to alert someone in the house of a person wandering
2) to alert a call centre when someone wanders
3) GPS based bespoke devices that can map where a wandering person is (as long as it is charged and with the person)
4) mobile phone based GPS/GSM systems that provide mapping and voice communication.

So, I am wondering, which is used today and which actually work effectively?

I recall, when I was working in a London Borough, that alerts to a family member in a house were the most effective, followed closely by the alerts to a call centre. But what is being used now and are they really effective?

I recall the problem with GPS tracking devices was that they required regular or daily charging and from what I can see this is still the case. Is their use limited to people who have family close by who are prepared to charge the devices? Additionally, you have to have the foresight to put it into a coat pocket or handbag so the person has it with them when they decide to wander. However, most people highlighted in assessment I did in London, were wandering at night partially clothed.

This means that through the safeguarding and enabling initiatives that have happened people who wander, be they older, younger or middle aged are left with few realistic alternatives. So how does this play out in the real world?

Enabling Who? - The real questions
Are friends and families put under more stress and strain to covertly contain their loved ones by locking them in and not telling anyone about it?

Are friends and families put under more stress and strain by providing their own 24-hour watch of the loved one?

Are families reliant on the telecare alert directly to them so they can drop everything and go looking for the missing person.

Has the responsibility for locating missing people been delegated to emergency organisations such as the ambulance or police services?

Has the responsibility fallen on social services to provide more care and assistance to the people who wander without friends or families?

I wonder, are the wanderers left to wander, and only after they have wandered several times with potentially dangerous consequences, are they then forced into a more contained environment where they cannot wander?

In the news, there is talk of tagging people with GPS type devices or ensuring that it is difficult for people to leave a property without actually stopping them. Both have drawbacks, the former being that this might not be consensual or hard to get agreement from families, and the latter might appear the best solution until the house is on fire and the occupant cannot get out.

I wonder is there another solution?

I wonder what is happening in the real world?

Is enablement the new containment?

Is telecare colluding in this containment in any way?

Choosing a telecare mobile phone

2011-11-27T14:17:00.002Z

The telephone is a simple device that has been with us for many years in various forms. In recent years it has undergone some considerable revolutions allowing hands-free communication, number identification and a range of other features to enhance the experience. For older people, big button phones appeared which were ideal for the visually impaired and phones with loop settings aided the hearing impaired.

The mobile phone is a new development for many. Although most people have a mobile phone, their potential is often not realised. Just as Microsoft Office can do amazing things most people use it for typing things and generally use only a fraction of what it can do.

It seemed to be a good idea to think about phones. Phones make and an ideal gift for parents who are less than tech savvy. The mobile phone has changed so much and continues to evolve with new models three to four times a year. As Steve Jobs understood, the traditional computer is less likely to be developed as handheld mobile devices are likely to proliferate the market. This could happen if the experience of the person using the mobile is equal to their expectations.

I have a confession, I love mobile phones and am passionate about the variety available and which is the best. When it came to my upgrade, I spent months working through exactly the specifications that I needed from my new phone before making the decision.

The mobile market is interesting as it currently has four main operating systems: Windows mobile, Apple IOS, Android (from Google) and Blackberry which are available on the mass market.There are other operating systems out there but these are the big four.

Each operating system has its own usability issues and positive and negative features. The phone manufacturer can also add the the features as can your phone operator by limiting some functions and expanding others, so already you can see that the choice of phone is very difficult.

The mobile phone makes a potentially excellent telecare device. The difficulty is matching the phone to the person. There are a range of simple display phones available. There are also phones with clear well defined keys to enable dialling. There are large displays phones which enable people with visual difficulties to see what they are dialling or writing and loop phones for the hearing impaired, but are these telecare phones? There are a number of mobiles that provide dedicated digits or an extra button which can be dedicated to sending a call through to a pre-specified recipient. These can be useful as long as the person using the phone has the capacity to operate it when required and will operate it.

Mobile phones have a range of other things that might be worth considering. Applications, or apps that can be downloaded from the operating system provider and can be very useful for making a phone into a medical device or reminder system, ideal for people with medical conditions or memory problems. Each operating system has its own apps and it is worth considering the apps available before buying a phone, similarly the ease of downloading them and the reliability are key things to think about. Viruses and malware are problems with smart phones where you can download apps to and the operating systems way that they deal with malware and viruses is also something to consider prior to purchase.

Location, location, location... Many phones have simple location devices built in and most smart phones have a range of locating software built in to the phone which can be used to locate a lost older person and provide a map home (if maps are built in and preprogrammed). Having maps and location properties on a mobile is only the beginning as the actual software that comes with the maps might be too difficult for the user to use so actually playing with the location software is very important in the decision process.

Gyroscopes and accelerometers can be built into phones which can be set to alert a friend or family when someone falls. These are a great idea and well worth exploring but always test the functionality of them before purchase. Do they trigger false alerts? Do they not work when someone actually falls? These conditions can easily be replicated in a shop. It is also important to consider the alert call that could be produced and who is to respond. There is no point in living a long way away and being the first call number, ideally a neighbour or a call centre would be be better, as speed of getting to the person who has fallen is most important, but read the blog entry on fall detectors before considering purchasing this on a phone.

The downside to location services and fall detection is the additional battery usage. As phones have become smarter, more applications run undetected, in the background, constantly working things out, such as where the phone is and at what angle is. All this background data analysis consumes battery life and timely changing of a mobile phone is a critical feature for modern smartphones. Although the battery life that the manufacturers provides are accurate, they are before any applications are downloaded and location and other services are activated. If you want a phone with ‘bells and whistles’ you pay with battery life, so expect to charge the phone daily. This can be a difficulty for some people so the capacity to do this is essential.

Sound quality, network coverage and ability to use the phone are actually the most important aspects to consider in a phone when purchasing it for someone else. A good phone should enable a the person to make calls easily, be able to hear the person they call and have a call go through from where they live without needing to go outside.

Finally, don't forget about the cost of calls and network coverage, the smarter the phone and the more things it does the more likely it will use more bandwidth even if no calls are made as there will be a lot of things sending and receiving data on the phone so ensure the package is one that enables the person to use the phone as they would like.

In sum, a mobile phone is potentially a very good telecare device providing the ability to alert others when a difficulty arises, but just because a phone sounds good does not mean it will be the correct phone for the person. Hopefully, issues already addressed in this blog will help in the decision process and this entry has highlighted the main things to think about.

Telecare Efficiencies

2011-11-06T17:08:00.002Z

One of the main reasons for the use and uptake of telecare is the potential efficiencies it brings. Efficiencies is a euphemism for cuts or savings not the alternative meaning of improving something. This does not mean that by making cuts something could not be improved, simply, this is not the main agenda.

This blog is testament to how efficiencies can be made whilst ensuring the quality of service and care are not reduced.

Telecare can save money, there is considerable evidence to back this up, but it can also waste money. Wastage is most clear when a predetermined set of telecare devices are used as a standard response to a specific condition. This can often mean redundant and disabling devices. Person specific telecare should ensure mean no redundant devices, thereby saving unwanted devices and their potential running costs.

The personalisation of telecare should enable efficiencies through enabling people and promoting healthier behaviours. For example, a woman who had fallen badly several times and been lying on her floor for many hours before being discovered by her daughter. As a result of this fall she sat in a chair all day too scared to move in case she fell again. The provision of a simple telecare pendant meant she no longer felt she had to remain seated. Moving around was now permitted as she could call for assistance in the event of a fall. This is constitutes efficiency and true enablement. Efficiency as all that was required was a pendant alarm. Enablement was through the woman not spending her remaining years sat in a chair. For this woman telecare meant independence. Clearly the hidden savings are in other health related spending as a result of sitting all day and not moving. Over the forthcoming years that could be a seriously large amount of money for this one person.

The most effective efficiencies are derived through assessing people correctly for telecare and ensuring that team that provides the telecare works well. This means the processes and protocols are in a coherent workable form. It also follows that they need to be easy to implement and follow just as audit trails are required to be evidenceable at any time.

The telecare service provision is most likely to be riddled with policies and procedures that either do not exist or outdated and this directly causes inefficiencies. Inefficiencies equate to throwing away money and poor customer service. These inefficiencies can be riddled throughout the whole service including response services and the sales teams.

The increase in telecare

2010-07-13T12:01:00.002+01:00

With the release of the UK government’s “Equity and excellence: Liberating the NHS” document the emphasis for health promotion falls on GPs as they will be getting the vast amount of money from the dissolution of the PCTs (Primary Care Trusts). This really interests me. When I worked for social services in North London, I found that GPs were by and large a very difficult group of people to interest in telecare. Actually finding access to their forum was hard and harder still to get any enthusiasm for the potentials of this new technology.

It seems that with the release of this document and the fact that the commissioning of services will be undertaken predominantly by GPs in the future that they are going to need a crash course in telecare, telehealth, mHealth and eHealth.

So how is this going to happen?

Who is going to do this?

The only way that this can be done is for telecare to be included in the documentation that the government produce but it is nowhere to be seen.

If we are to follow the preventative agenda, then surely telecare must be the spearhead of changing the way we consider health and care. Ideally as a result of the proposed changes and the distinct lack of money in the UK it behoves all GPs to get tele-trained pretty quickly.

I can see that this should also not be something that comes from the manufacturers as this could bread suspicion in GPs rather I can see a role in this for the TSA (Telecare Services Association) as well as the government to bring this information to the desktops of the General Practitioner of tomorrow. But before this can happen, how are can the profile of telecare be raised to such an extent that GPs will actually begin to take a message on board that they have resisted for the last five years?

Any answers gratefully received!

The Recipe for Assessments – More on falls

2010-03-21T18:36:00.002Z

I was watching Masterchef the other night. This is a TV food competition where people who think they can cook are put through their paces. In the first round competitors are given a set of ingredients and told to make something to impress the judges. Low and behold, everyone makes a stab at producing some culinary fare suitable for royalty. The only difference is that some participants actually succeed in making truly great food whilst others produce what can only be fit for farm animal fodder.

So what does this have to do with assessing for telecare?

Well there is a straight analogy, which relates to standardisation processes.

When an assessor undertakes a visit to a person who could benefit from telecare, they are like the competitors in the Masterchef competition. No matter who visits or how the assessment is conducted they all start with the same ingredients: the person, their family, friends; the house structure etc...

What they make of these ingredients will depend on their skills as an assessor as well as their ability to understand the ingredients and put them together in new and innovative ways. In the UK Masterchef programme the judges coo over the people who use ingredients in new ways to make exciting new tastes and put things together to make innovative new combinations that work. Telecare assessments are the same. The Dependability Telecare Assessment (DTA) tool helps develop this element of diversity and innovation in design whilst ensuring a level of dependability.

So let us illustrate this somewhat. Let us take a person who has had a number of falls. We could give them a fall detector, I hear a number of people thinking, and yes, we could, but I would suggest that there are a number of steps we need to go through before we reach our outcome.

Where does the person fall? Is during a transfer from bed to chair or commode? Has the person fallen on the stairs?

When does the person fall? Is it predominantly day or night? Is it whilst doing a particular task? Is the person unsteady getting in or out of the bath?

Are the falls because of something else, such as the need to go to the toilet? Medication?

What does the person do when they have a fall? How did they summon help?

If a person is falling, can they press a pendant button? If they are no cognitive or dexterity issues then a standard pendant is all that might be required. This rules out the use of a fall detector.

If a person is falling at night, perhaps a bed occupancy sensor might be useful. Also a simple sensor light (a light that is switched on by movement in the dark) could be used for illuminating the way and showing up any objects that they might fall over.

Does the person live with someone else? Does the person have a carer at night? If they do then simple standalone alternatives are a possibility.

I could carry on putting questions up and answering each with a suggestion, but the point should be made, that there are a number of possible solutions for any issue. There is no set answer, no set recipe.

In the assessment, I would not expect the assessor to directly ask “have you fallen at night?” rather to determine the answer through a series of detailed questions within a conversational style. This is the mark of a good assessment and anything less would mean the person would not go through to the next round in Masterchef.

We need to encourage diversity and innovation in telecare assessment as well as embrace new service providers if they can demonstrate their equipment is more appropriate. The difficulty is that telecare is growing at such a rate and new technologies are being developed so fast that it can be hard to keep up to date. It is also the case that to actually determine whether a piece of telecare equipment is actually robust and useful is a very skilled process. I certainly agree with and support the idea of trialling anything new, but there is no point in doing this when the product does not meet the DTA criteria in the first place. Here again I refer you back to the DTA as a means of helping you decide whether something is worth investing time and money into.

Most importantly, The Masterchef lesson is that sometimes too many ingredients can ruin a perfectly good dish; similarly not being adventurous enough can also make a potentially great dish mediocre.

When we assess, we must go beyond the tick box approaches to really understand what the needs of a person truly are as well as their aspirations, which might be simply being independent again following a hospital admission. We need to embrace the idea that technology is not always the answer but sometimes, a little technology can make the difference between a person being dependent on help from others and actually helping themselves.

... Now I am hungry....

The Language of Telecare

2010-01-29T11:19:00.009Z

"When I use a word," Humpty Dumpty said in a rather a scornful tone, “it means just what I choose it to mean --- neither more nor less."
"The question is," said Alice,"whether you can make words mean so many different things."
"The question is," said Humpty Dumpty, "which is to be master--- that's all."
Lewis Carroll – Through the Looking Glass.

I am not sure about you, but I think it is time to resurrect the debate about terminology. I have recently been to a number of conferences and at these events people use the words Telecare, Telehealth, Telemedicine and Assistive Technology interchangeably. The speakers seem to appear confused because they are using the words Telemedicine when they are talking about Telehealth and Assistive Technology to mean anything and everything. The term assistive technology (AT) seems to have become an umbrella term for Telecare, Telehealth and Telemedicine which is a little strange as AT is so much more than these small bits. It denigrates the words Assistive Technology. AT after all comprises of environmental control systems, speech helpers any form of technology that can enable an impaired person (http://en.wikipedia.org/wiki/Assistive_technology).

I am not sure that Telehealth enables people in the same way that Telecare does or even qualifies to fit under the banner of Assistive Technology. If you look to the right hand bar I have the definitions of Telecare and AT as: Telecare is the continuous, automatic and remote monitoring of real time emergencies and lifestyle changes over time in order to manage the risks associated with independent living (http://www.telecareaware.com/index.php/what-is-telecare.html).

I would argue that Telehealth monitors patients' health and alerts professionals of possible emergency situations but in a very different mode from Telecare. Telecare produces alarms; it sends real time alerts through to a call centre 24 hours a day; 7 days a week. Telehealth produces less frequent monitoring intervals and the information is sent to staff who are only working when they are at work (often 37½ hours a week). I would also argue that Telehealth does not manage risks associated with independent living, rather it manages peoples' health conditions and possible health deterioration. Therefore, Telecare and Telehealth are significantly different.

On the other hand Assistive Technology (AT) is any product or service designed to enable independence for disabled and older people. (King's Fund, 2001). So Telecare is a small subset of assistive technology. It is not the whole spectrum of assistive technology. Hence, when referring to Telecare, one should use the words Telecare not assistive technology. "the smoke detector is a vital part of assistive technology" is more accurate as "the smoke detector is a vital part of the Telecare repertoire". "Johnathan was helped through the use of assistive technology, the use of augmentative and alternative communication software enables him to communicate for the first time in class". If, for example, I worked with Assistive Technology, I would expect to have some medically training, to have a qualification in engineering and have undertaken the training associated with all people who work in this field. These are very highly skilled people who have years of experience and expertise to offer.

Keren Down from FAST (www.fastuk.org) puts the explanation beautifully “The confusion seems to arise due to the fact that assistive technology is not a term fitted for day-to-day use and that it has been used in very specific (service defined) contexts. It is a term well fitted for strategic planning. An analogy is the term ‘transport’. On the whole people don’t say ‘I’m going to go and take a transport up to the Elephant and Castle’” (http://www.telecareaware.com/index.php/telecare-telehealth-terminology.html).

I would also argue that Telehealth does not fit with the AT definition. Telehealth does not per se actually “enable independence for disabled and older people”. Telehealth supports older and disabled people’s health conditions. I would agree that by these conditions being stabilised the person might be more likely to be independent but this is a by-product of Telehealth not a given. There will be many very sick people who will have their conditions monitored by Telehealth devices in the future but who will not be enabled to be independent as they are too ill.

To me, Telehealth is like a heart monitor people wear at the gym, it is there to monitor fitness where as AT is the machines that people use to get fit. No matter how much you wear a heart monitor it will not make you fit but using the exercise machine will. The gym on the other hand could be considered to be assistive Technology comprising of lots of different component parts.

I think that it is really important that we all understand the basics, and all speak in the same language. If we assume people understand the terms we use then we are making an Ass out of U and Me!

You may not feel that terminology is something we should get het up about, we all 'sort of' know what the person is meaning, but I would argue it is critical! If I am talking to someone about Telecare and they think I am talking about patients in hospitals not people at home, then we start from completely different places. Anything we say after that is interpreted in terms of the initial impression. When I go abroad or talk to people from other countries it often takes a long time to ensure we are both talking about the same thing and understand the words in the same way. If we fail to do this then a conversation can be futile or even dangerous depending on what the other party takes away with them.

So instead of being Humpty Dumpty who states “When I use a word…it means just what I choose it to mean --- neither more nor less” let us use a word to mean what it means, nothing more, nothing less. Moreover, let us ensure that we put pressure on the powers that be to reach clear definitions of the words we need to use… Assistive Technology, Smart Home, Telecare, Telehealth, Telemedicine, e-Health, e-Medicine, mHealth etc. If we don’t decide what they mean soon it will be too late. It is time we master our language within this field.

The TSA Conference 2009 report of exhibitors

2009-11-19T09:38:00.008Z

The Telecare Services Association Conference 2009, Hilton London Metropole Hotel - Report of Exhibitors

Although there were loads of excellent people presenting their wares at the Conference certain ones were found by the author to warrant considerable attention.

The NEAT dispersed alarm supplied by Possum

First up is the NEAT dispersed alarm that Possum had on their stall. Apart from the size and design quality/looks there are a number of excellent features that make this something to watch. Firstly the dispersed alarm unit is small and thin with three buttons which are clear. The unit has a voice unit which can pick up on someone calling for help and trigger an alert to the call centre (the round item in the middle of the picture with the red button on it). The other thing that I really like is the fact that the unit and each device provide a handshake. The handshake means that each device can communicate with the other devices in a smarter fashion as information can go bi-directionally. This opens many possibilities. The main possibility demonstrated to me was the fact that if a device fails by using a simple pendant you can easily find the failing device as the handshake will not occur, as demonstrated by a light on a pendant.

Another thing that I really liked was the fact that each device works in its own state. In this way the system can be a standalone system that can send an alert to the pager in the bottom right of the picture alerting the carer that the person is in difficulties. Any device can be set to do this without the need for the dispersed alarm. Furthermore the pager can be set to have a range of functions such as pass the alert to another pager or accept the alert. The most obvious benefit I can see for this is in supported living services where care staff might require extra help or the person themselves can start to use technology to enable a more independent lifestyle.

The other most important thing the NEAT system can do is to act as a wayfinding device to assist the user in maintaining independence. This can split the house into various zones and these zones can be defined by the practitioner or family or person. If you go out of zone then it is up to the practitioners or family to determine the best course of action. This is just the beginning of what this system can do so keep your eyes open for news on the NEAT system.

The Halliday James Stand

The Halliday James Ltd stall where Bernard Wignall demonstrated the excellent range of technologies that they have developed to support wayfinding. These include mobile phones, simple pendants with GPS and GSM capabilities as well as handheld units that have maps and so forth on them. What impressed me with this is the way in which the person using the technology was always at the forefront of all the design ideas and decisions. The two best products demonstrated were the HTC smartphone in the top of the table that can provide a decision support system for people with memory problems. This is very similar to the things I saw in the USA a few years ago but done better and clearer allowing user pictures to be integrated in to the demonstration and decision support software. Best of all for the first time I have seen a tool that meets my criteria for assisting someone to make a cup of tea. This is excellent!!!

The other standout item from Halliday James Ltd was the standard looking watch below the mapping device in the picture. This is a normal watch and could be the person’s own watch but the strap has a GPS/GSM unit built into the base – out of sight. Therefore the unit looks like normal watch but is actually as wayfinding device. Simple good design shining through again.

The Chubb Fall detector

The third company stall that had something standout to show was Chubb Community Care who finally produced two things I have been looking forward to, and they have been promising, for some time. The first is the new fall detector which as the picture shows is a wrist worn device. It looks like many other wrist worn devices and has a black emergency call button on it. In actual fact it looks just like a standard pendant on a wrist strap but actually is a fall detector that will detect ‘out of ordinary bumps’. “When a fall alarm is raised, the technology will vibrate immediately, during this period if the user does not want to send out the signal of the alarm, they just have to move their arm which will cancel the alarm. If this is not done then a call will be sent through the IntelliLink carephone or to the Carer Alert so the appropriate response can be sent”. Its not rocket science to see that this is fraught with potential possibilities for falls to be canceled as the person is crawling along the floor or some such activity that mimics the cancellation mode. But to their credit it is a well designed and well thought out piece of kit. If the person does decide to wave their arms in the air after a true fall and cancel the signal it can still be reactivated by pressing the black button. So a fail-safe is in place. I am looking forward to testing these out.

The Chubb Flexible Bed Occupancy sensor

Another thing by Chubb that I have been waiting for is the blue flexible mat that acts as a bed occupancy sensor (BOS). This is currently not to be found by me on their website. This is the mat shown above the standard BOS mat. The reason for this mat being exciting is that it can be used on pressure relieving mattresses which inflate and deflate. I am also pleased to see it connected to the new Chubb Bed Occupancy Monitor which enables personalised timing features so that these devices can finally be timed to meet the needs of the person.

This proves to be a valuable conference for many reasons. Not only is it the place to meet and touch base with the Telecare Gurus, but it is also the place to find out what the future direction for Telecare is to be. But for me, the best thing is to see how some manufacturers are still churning out the same things whilst others are beginning to see the true potential of listening to the people who use their devices.

Using Dependability Telecare Assessment to assess a piece of Telecare equipment

2009-10-01T16:19:00.007+01:00

The Dependability Telecare Assessment tool (DTA) can also be used to assess a piece of Telecare equipment or service, either for a specific individual or to determine the dependability case for a device. In order to illustrate this a generic pill dispenser will be used. The pill dispenser has great interest to the author as it was one of the first dependability products he worked on many years ago whilst designing smart homes for older and disabled people.

A generic pill dispenser is a great idea, allowing a person to get timed alerts when medication is required. The pill dispenser provides an auditory and vibratory alert when medication time arrives.

Pill dispensers come in all shapes and sizes from simple Dosset boxes through to Telecare enabled pill dispensers that can alert the call centre if the alert is raised.

So let us consider whether a Telecare pill dispenser meets the DTA criteria (http://1.bp.blogspot.com/_ZFehjKEfwWc/Snv2JHtbU1I/AAAAAAAAADY/tBKUkgz4McA/s400/DTAbigger.jpg) :

Lets' start with the Fitness for purpose column:

Does the pill dispenser meet the broad needs of the person? Possibly it would in some cases. Many people require medication reminders so in many cases it meets this criterion. - Pass

Portability: The pill dispenser might fail on this as the alarm is cancelled by the movement from horizontal to vertical planes. - Fail

Comfort: This is really not applicable as it is not a worn device. – N/A

Timeliness: The pill dispenser should pass this as the alert is generated if the tablets are not taken at the appropriate time. This alert should continue for about one hour which is excellent. The call centre should also be alerted at the prescribed time after the alarm is activated. - Pass

Utility: Again, possibly another pass as the pill dispenser could well be useful to the person - Pass

Responsiveness: This is potentially where things can go wrong. Does the device produce the correct response? It alerts the call centre yes, but what then? What do the response centre do? Do they call the person or send someone out to check that the pills have been taken? Does the call centre need to be part of the equation or should the family or carers be responsible for the person taking the tablets? - Fail

And now lets consider the Trustworthiness column:

Can the person trust the technology to do what is required? Again another potential failure here. There are a number of issues that pertain to trust. The pill dispenser will act in a trustworthy manner by producing alerts at the correct time etc yet the system could fail the trustworthiness tests as pills could get stuck in the chambers; the chambers are too small for people on lots of tablets; who is going to fill the carousel up? What happens when a person takes the tablets out? – this last point is a critical point and leads on to the next Dependability criterion - Fail

Reliability: From experience of my nursing days and my years of working with older people what is clear is that people are distracted and this distraction factor can increase with age. The pill dispenser, does what it says on the packet: dispenses pills but there is no guarantee that the tablets are actually taken. Therefore the pill dispenser fails this criterion. - Fail

Safety: following on from the theme in reliability once the tablets are taken out of the dispenser there is no way to know the person has taken them. I have witnessed on many occasions that a person takes medication out of the dispenser, puts it in their pocket and goes to get a drink to swallow them. Now at this point people can get distracted. The glass of water needed to take the tablets might change to a cup of tea, a biscuit and settling down to watch the telly with the tablets still in the pocket. When the person goes to bed and is emptying their pockets they come across this stash of medication and could decide to take the days dosage in one go with the obvious consequences. So the pill dispenser fails this criterion. - Fail

Maintainability and Serviceability: Here the pass or fail is dependant on the provider’s perspective. The only maintainable parts the carousel trays, time-day discs and keys all of which could be lost and require replacing. The unit itself requires a service when the battery low level light indicates charging is required. This might require external intervention and an attached cost in some cases. – Pass and Fail

Let’s now turn to the Acceptability column:

Does the person find the Telecare an acceptable addition to their lifestyle? I think a definite pass here for most people. - Pass

Usability: - The carousel can be fiddly to fill for some people and requires a certain dexterity to tilt in order to obtain the medication, although a tilt helper can be purchased. The dispenser is also not light. Therefore I could consider this to be a Debateable Pass - Debateable Pass

Learnability: There is little for the recipient to learn but for the person filling the device, they have a lot to learn. The locking –unlocking; filling each tray with the appropriate dosage at the appropriate time etc. Depending on the skills of the filler this would be either a pass or fail; but some chemists might also fill the carousel for the person. Therefore I would consider this to be a pass. - Pass

Compatibility: The pill dispenser should be compatible with any lifeline equipment, requiring a simple protocol and frequency . - Pass

Finally lets address the last column

Adaptability and Aesthetics: Adaptability is not really an issue as the device is unlikely to change but aesthetically the design is in many cases excellent with clean lines. Pill dispensers also come in a range of one colour – white so that does not provide the person with a great choice. – Pass and Fail

So on reflection how does the pill dispenser fare? It received ninepasses and six fails and one indeterminate score; so on balance it could be argued that it passes overall. However, bear in mind these are dependability criteria and as such there should never be a failure. Moreover, the pill dispenser potentially fails all of the Trustworthiness criteria.

Using DTA as a methodology to assess equipment and devices is a simple process. It does not take many minute to think through whether something passes or fails if you follow the DTA tool (http://1.bp.blogspot.com/_ZFehjKEfwWc/Snv2JHtbU1I/AAAAAAAAADY/tBKUkgz4McA/s400/DTAbigger.jpg).

Conclusion

This example demonstrates the use of DTA in determining dependability of devices but what it also demonstrates is that the decision lies in the prescriber’s hands. The pill dispenser for example is a great piece of engineering and something that meets a definite need. Therefore the judgement call is whether the need is such that it out ways the lack of Trustworthiness highlighted through using DTA. I have no doubts that in there are many cases when it will be a very useful device, but perhaps its use will require a number of protocols and procedures to be written before installation. Furthermore the DTA tool highlights a number of areas of concern such as filling and responding to alerts and these will need to be resolved prior to use.

Supporting Carers through Standalone Telecare

2009-08-13T16:41:00.002+01:00

The Problem
Mrs N is carer for her husband who has an acquired brain injury. As a result Mr N has reduced judgement and inability to understand that he is unable to support his own weight. He is unsafe getting out of bed and also unsafe getting out of his chair.

The Solution
A Voice Alert VA6000s (http://www.voicealert.com/) provided by Supra (www.keysafe.co.uk) was provided with the movement sensor beam narrowed. This was placed on the floor under the bed and wirelessly sends an alert to the receiver unit which is located in Mrs N’s bedroom. This movement sensor alerts Mrs N when her husband is getting out of bed. A chair sensor mat was also provided for the chair which works with the same unit and alerts Mrs N when her husband is trying to get out of the chair.

Rationale behind the solution based on DTA tool
The Voice Alert was ‘Fit for Purpose’ as it provides audible alerts to Mrs N which she can record in her own language. The Voice alert also allows different messages for each device connected to it so Mrs N can differentiate between her husband getting out of bed and getting out of the chair. The Receiver unit is portable and Mrs N can plug it in no matter what room she is in. The Chair mat can be sweaty so Mrs N had it placed under the cushion of the armchair. The alerts from the unit are instant with a minimal delay. Without the Technological intervention Mrs N would not be able to support her husband at home.

The Voice alert is ‘Trustworthy’ as it works every time as long as it is plugged in. It is safe and the only maintenance required is the change of battery for the peripheral sensors. Mrs N has a store of the Batteries just for this purpose.

The Voice Alert is ‘Acceptable’ as the unit allows Mr and Mrs N to maintain their lifestyle and independence. The receiver is usable as there are a number of voice alerts that can be recorded and the recording procedure is simple for Mrs N to do. There is little for Mrs N to learn apart from to turn the unit on and off and change the voice message and batteries. All components are compatible with each other as all provided by the same manufacturer.

Finally the Voice Alert is ‘Adaptable’ as it can be used on the chair and in the bed room. The sensor in the bedroom can be moved to the living room during the day so as Mr N improves he can walk around within certain areas but if he goes to somewhere he shouldn’t the alert will be triggered. In fact as Mr N improves the sensors can be used in whatever way Mrs N decides is best for her and her husband. Aesthetically the motion sensor looks a little unsightly as does the lead from the chair sensor mat that goes to the transmitter unit (placed under the chair) but Mrs N ensures that neither of these are in the direct line of sight for visitors or her husband who might get distressed if they were on full view.

DTA a working example - falls

2009-08-07T09:27:00.006+01:00

DTA - an illustration of how it can be used

The problem
Mrs J has recently had a stroke which has left her with a weakness on one side. She has limited capacity to comprehend the consequences of this weakness and falls a lot whilst trying to do normal activities. She recently fell getting out of bed on the way to the toilet at night and also in the bathroom whilst getting off the toilet. Mrs J wants to be independent and feel safer whilst undertaking her daily routines.

The solution
Mrs J was given a bed occupancy sensor, pendant, pull cord in the toilet and a smoke alarm.

Rationale behind solution
This is a simple case in many ways, the main presenting issue is that of falls as a result of weakness resulting from the stroke. If we consider DTA we can see that we are meeting the dependability criteria by offering this solution.

(Click on Picture to make bigger)

The solutions provided are fit for purpose; they are portable, when necessary, comfortable, will work as expected in the appropriate manner and in the correct time. They are trustworthy as they are reliable, will promote safety and not cause danger and are simple to service and maintain. The solutions were acceptable to Mrs J who does not want to be bothered with technology but is happy to wear a pendant. The solutions are practical, require no learning apart from the pressing of the button on the pendant or pulling of the cord in the toilet; and the solutions are compatible as they are all provided from one manufacturer. Mrs J was concerned about the aesthetics of the pull cord but considered that her safety was of more importance than the look of the cord in the toilet and was happy that the placement of the cord was exactly right for her to use if she had difficulties in the toilet in the future.

This example ticks all the boxes for each product. The smoke detector was added as Mrs J could be compromised in the event of a fire in her home. She might fall whilst trying to vacate her house in an emergency situation. The replacement smoke detector replaces her current smoke detector but is positioned in the correct place in her hallway and provides an audible alert as well as alerting the response centre that there is a potential fire in Mrs J’s property.

ALIP

2009-06-18T13:38:00.003+01:00

The Digital Access Project which is part of the Assisted Living Innovation platform ALIP have produced released the first of the demonstrations from a venture I worked on. It is available here. Currently only two videos are available but the scenarios are hopefully useful.

Some web publicity

2009-06-10T15:49:00.005+01:00

I have recently featured in two ventures I am pleased to be part of one working with the UK consumer affairs magazine Which? and the other an interview with Hometoys Emagazine which is the smart home site. Versions of these are available on line:

The Which? article can be found at http://tinyurl.com/nqmhbv
The Hometoys piece can be found at http://tinyurl.com/l5aqs8 - Amended link sorry for the previous error.

More on DTA

2009-05-06T09:22:00.003+01:00

I have finally done a small page on DTA the Dependability Telecare Assessment tool on my website http://tiny.cc/xe2bk. This expands on some of the material in this blog.

The Dependability Telecare Assessment Tool

2009-04-22T16:46:00.003+01:00

The DTA has had a few minor alterations that I presented to the TSA meeting in Hinkly on the 21-04-2009.
They are only slight but also important so the tool now looks like this:
DTA

Fitness for purpose – Does/will Telecare meet the broad needs of the person?
Portability - Can the Telecare be carried by the person?
Comfort – How comfortable is the Telecare for the person to wear for long periods?
Dexterity – Can the person interact with device appropriately and press the correct buttons easily?
Timeliness – Does the Telecare work in appropriate time frames?
Utility – How useful is the Telecare solution to the person?
Responsive – Does the Telecare device produce the correct response?

Trustworthiness – Can the person trust the Telecare to do what is expected?
Reliability - How reliable is the Telecare for the person?
Safety – How safe the Telecare is for the person - does it mitigate risk or potentially cause more?
Maintainability and serviceability – How easy is the Telecare Equipment to get serviced or maintained? Does the Person need to get involved in this process? Are they able to get involved?

Acceptability – Does the Person find the technology an acceptable addition to their lifestyle?
Usability – How practical is the Telecare solution to the person?
Learnability – Is the person able to learn how to use the Telecare solution?
Compatibility – Does the Telecare solution work well with existing technologies? (Interoperability)

Adaptability – Is the Telecare flexible enough to cope with the person’s changing needs?
Aesthetics – Does the Telecare look good and blend in with the person’s surroundings?

Defining Telecare

2009-02-27T11:49:00.001Z

Tele (at a distance) Care.

Any attempt to define Telecare is fraught with contradictions. Here I try to demonstrate the wealth and diversity of the various definitions of Telecare. Let's start with a definition on TelecareAware which comes from an unknown source but is a good lead in:

“Telecare is the continuous, automatic and remote monitoring of real time emergencies and lifestyle changes over time in order to manage the risks associated with independent living.”
Steve Hards (http://www.telecareaware.com/index.php/what-is-telecare.html (accessed Dec 2008).

Defining Telecare is not simple. The definition above contrasts with the following definition by NHS Purchasing and Supply (PASA):

"Telecare describes any service that brings health and social care directly to a user, generally in their homes, supported by information and communication technology. It covers social alarms, lifestyle monitoring and telehealth (remote monitoring of vital signs for diagnosis, assessment and prevention).

“Telecare covers a wide range of equipment (detectors, monitors, alarms, pendants etc) and services (monitoring, call centres and response).

“Telecare equipment is provided to support an individual in their home and tailored to meet their needs. Telecare services range from a basic community alarm service that is able to respond to an emergency and provide regular contact by telephone to an integrated system that includes detectors or monitors (i.e. motion, falls, fire and gas) that trigger a warning to a response centre. More complex systems include telemedicine, which is designed to complement healthcare via monitoring vital signs such as blood pressure. Data is transmitted to a response centre or clinician’s computer where it is monitored against parameters set by the individual’s clinician."
http://www.pasa.nhs.uk/PASAWeb/Productsandservices/Telecare/LandingPage.htm (accessed Dec 2008)

Telecare utilises information and communication technologies to transfer medical information for the diagnosis and therapy of patients in their place of domicile.
(Norris A C, 2002, 4)

A distinct problem with Telecare is its lack of a clear definition. Moreover, the definition of Telecare is constantly modifying depending on who is writing or what the current “in word” is. The first definition above situates Telecare within the social framework whereas the second situates it clearly as medically allied, whilst the third definition sees Telecare as solely a medical intervention transferring medical information. To add to the discussion the Department of Health’s Care Service Improvement Partnership (CSIP) emphasises the remote monitoring aspects of it as well as its use in reducing admissions in their definition:

"Telecare is a broad term which encompasses a wide range of technologies with remote monitoring that can support people to remain independent and potentially reduce the frequency of hospital and care home admissions as well as give peace of mind and reassurance to users, carers and their families."
http://networks.csip.org.uk/IndependentLivingChoices/Telecare/AboutTelecare/ (accessed Dec 2008)

Whereas for David Bradley et al (2002) Telecare is a purely medical allied intervention, when the define Telecare as:

“An holistic approach to the remote provision of healthcare, assistance and monitoring in a community setting, via the use of appropriate technologies, in order to assure client well being.” (Bradley, Williams, Brownsell and Levy (2002) 'Community alarms to telecare – The need for
a systems strategy for integrated telehealth provision' Technology and Disability 14, 64.)

This can be contrasted with Kevin Doughty's recent definition of Telecare as an umbrella term for Domestic AT systems.

"Telecare has become the umbrella term for all assistive and medical technologies that depend on modular, relatively inexpensive and quickly deployed, electronic devices and/or telecommunication systems that help people to maximise their independence within the home environment." (Doughty K, 2007, “Telecare Practice and Potential”).

What is clear is Telecare means different things to different people. Moreover the term Telecare is a euphemism for whatever the new policy of the day is.

The author describes Telecare as the ability to harness simple technology to enable and empower people such that they can live independently in the community. Telehealth and Telemedicine are technological applications which centre on the health aspects of the person and supporting them in the home or hospital. This though is very close to the first definition offered by Steve Hards.

Without a clear strong fixed and universally accepted definition of Telecare, how can Telecare services develop plans and ensure that the people who require Telecare receive the correct information and services?

Telecare User Reviews

2008-12-16T16:34:00.001Z

Telecare User Reviews

Telecare is a type of equipment that is unlike standard equipment provided by an Occupational Therapist (OT). It is unique. A bath board or bath lift might not function correctly but at least it is clear whether or not it works.

Most equipment, especially manual handling equipment has a standard by which it is reviewed. The review is as much as anything to ensure the working of the device as well as its suitability to meet the needs of the person.

So what about telecare?

In the UK there are no official standards for reviewing the telecare service or provision of equipment apart from the standard CSCI (Commission for Social Care Inspectorate) guidelines that apply to equipment. These mean that equipment should get an annual review.

Annual!

Yearly!

Every 365 or 366 days!

Surely something is not right here. As telecare is similar to many other forms of assistive technology we need to look for guidance in this arena. Sadly here we fail to find anything to assist us.

Telecare is new. By this I do not mean telecare devices are new, on the contrary most have their roots in devices decades in age. Rather the use of telecare to support people in their homes is new. This means that if you are to introduce something new, perhaps it is a good idea to review the current services that it will effect and draw up new ways of working to reflect this dramatic change.

Good practice suggests that a review of telecare should be taken initially within the first three months. This gives the user enough time to use the telecare and to determined if it works as expected as well as in the way they wanted it to.

Moreover, when we consider what telecare is designed to do, namely assist older, disabled or impaired people to maintain a quality of life and independence in their own homes, we can see that it is the most vulnerable of people that it is being used with. As telecare is used with vulnerable people it is likely that their needs will change, possibly quite considerably, within a year, sometimes within the month.

Consequently, if a person is initially reviewed after say three months then further reviews need to be scheduled, but these should not be annually. My own suggestion is that telecare should be reviewed every six months after the initial three month review.

Towards Good Practice?

What is even better practice, is to be person-centred putting the person first. If a client is vulnerable or disabled and there is a likelihood that their needs will be likely to change within three months, then the review schedule should be flexible to accommodate a two monthly or even monthly review. Of course 'Fair access to Care services' will have come into play here.

Furthermore, we need to consider what a review entails. Clearly, just asking a person whether they have telecare and whether it is still working are important, assuming the person has the capacity to understand what telecare is, but we need more information. We need to know that the person is actually wearing the fall detector and it is not just sitting on the bedside table. We need to know if any of their needs have changed or if they are likely to change (do they have an operation looming, which will make them more or less dependent on the technology).

We need to know their views on the technology whether it’s working for them and why they think so. We also need to go beyond the polite rhetoric of normal parlance into a qualitative world when the user can trust us to really say what the issues are. This is not easy and is ideally done in the field rather than remotely over a telephone.

So this brings us to 'capacity', the buzzword which is a useful one to know. Clearly if a review is to take place over and above the standard annual one, and is potentially going to involve a visit to someone's house then the company undertaking the review must have the capacity in terms of physical bodies and hours to undertake this venture. There is also a financial implication which puts the company into a position of spending considerable money on these reviews... to what end and return?

The best return is a proactive one, By ensuring telecare meets a person's need, we can enable them to remain independent for longer. It might mitigate hospital admissions. But there is never going to be any proof that telecare has made a direct saving, only conjecture. We can hypothesize that had we not put telecare in it is likely that the person would have ended up in residential care or hospital before a predetermined time but, as we all know, this is clearly just a guesstimate and a very crude one at that. People might end up in hospital even with telecare or without it, just as they might avoid it. We cannot predict humans’ behaviour and activities. When we try, we constantly fail.

Telecare User Review Guidelines

By reviewing someone we can also ensure that the person-fit to technology is still there. We can ensure that what is given to a person is still the best for them and they are happy to use it. The review might also trigger further reassessments if a person's needs have actually changed. This in the short term might cause a problem for service providers but in the long term, if we catch people before they become in need of extra services we win every time and we are ensuring our 'duty of care'. Moreover, it is also in the interest of the user.

I am still amazed that there are no guidelines on telecare reviews.

There should be.

More to the point, as we venture towards best practice in our work we need to be mindful of what we would want if we were on the receiving end of the service provision. Would you want a review annually? I am sure for some people annual reviews are fine, but I suspect for others every three months might not be ideal as they might require monthly ones.

We have to balance need with resources at all times. Evidently resources are the limiting factor here, but I suspect that if resources were made available for reviewing telecare in a person centred fashion in which we put people first then the rewards across the board will be enormous.

My major concern is that as we know, technology can enable and disable the user. The wrong telecare can certainly disable a person or potentially kill them.

If we are to undertake a review process then we need the resources. We need capacity and we need guidance.

I hope when the official guidance does come it is not at someone's expense.

Telecare and Dependability

2008-11-30T22:00:00.000Z

Telecare and Dependability, two concepts that seem very far apart in some senses and inextricably close in others. Dependability is a nebulous concept to many and tends to be something appropriated by software engineers related to a software system. Can the word have use outside the software environment in the social world? The short answer is yes but in order to explain this lets get back to basics.

Dependability is defined as “the trustworthiness of a computer system such that reliance can justifiably be placed on the service it delivers” (Laprie et al 1992, p4). Ignoring the word “computer” is a good starting point to see the definition in social terms but really we need to have technology and people involved hence it could be considered a sociotechnical system. Hence dependability could be seen as the trustworthiness of a sociotechnical system such that reliance can justifiably be placed on the service it delivers. Telecare is a typical sociotechnical system which needs to be trustworthy so people can justifiably be called reliable…. But is it? Is it trustworthy? Is it justifiable? Is it reliable?

Telecare is more than the technology as previous posts have eluded, it is the synthesis of technology with the people who rely on or use it. Evidently, there are a number of ethical questions here which have been dealt with in many seminal papers and I do not want to get bogged down in the simplicity of ethics, rather lets accept that ethics are important in Telecare but so are a number of other factors.

For a Telecare system to be dependable the technology must work correctly, i.e. not produce false alerts and respond every time in a true alert situation. The technology must not make assumptions or to lead others to make assumptions as this could be the difference between life and death for a person.

This leads to a distinction about Telecare that differs from all other home support and that is its safety critical nature. Telecare is safety critical, it is the technology that will often be the difference between someone living or dying. For example, If a fall is detected the person stands a better chance of surviving, if left unattended the fall my have a more serious, even deadly result. Telecare is the intermediary between the person in difficulty and the support network designed to keep and maintain the person.

So the technology is critical, it must work, in the expected manner every time for it to be dependable. But technology alone is not the answer to a dependable Telecare service, the Response service is also critical. If an alert occurs and nothing happens then the dependability of the system fails. Similarly if the Telecare device is not suitable for a person, i.e. they cannot press a button or pull a cord etc., then the dependability criteria are not met.

If we consider Telecare as a dependable system then there are a number of factors that come to play namely:

Fitness for purpose – Does it meet broad user needs?
1. Portability - able to be carried by user
2. Dexterity - user can interact with device appropriately
3. Utility – usefulness of the product to the user
4. Responsive – Does the device produce the correct response?

Trustworthiness – can the user trust the technology to do what is expected?
5. Reliability - How reliable the technology for the user
6. Safety – How safe the technology is for the user
7. Maintainability and serviceability – how easy is the equipment to get serviced or maintained? Does the user need to get involved?

Acceptability – does the user find the technology an acceptable addition to their life?
8. Usability – How practical to the user is the technology?
9. Learnability – Does the user need to learn how to use the technology?
10. Compatibility – Is the system compatible with existing technologies?

Adaptability – is the technology flexible enough to cope with the users changing needs?
11. Aesthetics – Does the technology look good and blend in with the persons surroundings?

So if we see Telecare as a system which includes the technology, the person, the equipment provider, the call centre, the Response service and carers it is useful to look at the above issues that are dependability derived to see if the Telecare service is meets the dependability criteria. The criteria above can also be used to look at specific parts of a Telecare service such as the response service. Simply ensuring it is fit for purpose, trustworthy, acceptable and adaptable will mean that the service should be meeting the end user’s needs.

Dependability is not something that is an academic adventure. It is a practical exercise that has considerable ramifications for things such as cost efficiency. It saves money by ensuring the service meets the Dependability criteria. It possibly also saves law suits as the service can be audited against any of the criteria and if it passes then the service is less likely to cause any major legal issues.

The Criteria above are not all the criteria possible and each Telecare service can add their own parts but research dictates that the eleven elements above are the most common aspects of a dependable system as applied to Telecare. So if we hark back to Laprie’s original definition of dependability we can see that a good Telecare service is something in which each component should comply with the trustworthiness of a sociotechnical system such that reliance can justifiably be placed on the service it delivers.

Over time with new an emerging technology using the dependability criteria above should prove to be a useful method determining if the new technology weakens or strengthens. More information on this is available at http://www.smartthinking.ukideas.com/MDDS.html

The enablement and containment models

2008-09-25T09:48:00.000+01:00

In telecare there are two main models: Enablement versus Containment

It is important to distinguish between the containment model and enablement model of telecare. The Containment Model contains older and disabled people by appearing to care about the person, but actually providing little support. This leads people to not challenge the status quo and accept substandard equipment and not challenge poor interventions. Technology is foisted on people using a spurious medical model which can be used to suggest that technology has pseudo-medical properties which it unlikely to have.

The Enablement Model strives to ensure people are personally enabled. Technological interventions are bespoke and tuned to the person’s actual needs and wishes. Technology rejection should decline and a person’s quality of life should increase as a result of these interventions. When developing a system it is important to consider that the telecare system must enable. From a strategic perspective this means that the telecare provider must be able to source from the best locations and not be confined or tied to specific providers. This, of course, means that things becomes a nightmare for standard purchasing agreements and official channels. It also means that the people who are undertaking the assessment for telecare are required to be trained to a higher specification than if they were limited to just one or two manufacturers.

Enablement extends beyond the user of telecare to also enabling the carers, allowing them to have breaks in care whilst still knowing the person they care for is safe. A person using telecare might be enabled to actually fully engage and challenge their environment through having the confidence derived from appropriate technology designed to assist them.

To exemplify this difference - Let's look at telecare self assessments, these produce a snapshot fast approach to assessing people for telecare. A self assessment will produce a more accurate picture of a person than simply providing a package of telecare based on a person having a certain condition or illness, but the self assessment cannot be more than a quick fix approach.

If we compare self-assessment with person-centred assessments then the enabling qualities of the latter become very clear. If we take the person-centred approach then we can provide telecare that meets the precise need of a person. By providing enabling telecare we are also having a cost-benefit to the person as well as the service providers.

If a person has the wrong telecare provision then there are a number of inefficiencies that have been documented and are apparent. Excessive calls to call centers mean people are tied up answering false alerts or being sent on visits to peoples homes that do not require assistance. Suppliers of telecare spend more money and time as they are required to supply the original poor telecare and then send people out to replace the poor telecare with good telecare. This also means that a second or duplicate assessment is required to be undertaken before the new telecare is provided, so extra resources there.

Good telecare provision should enable a person to undertake activities and have an enhanced quality of life. It should delay a person from accessing more drastic and severe services and allow them to choose to stay at home if that is what they want. Telecare following an enablement model saves all around. Short cuts can be containing and expensive. So which is the best method of providing telecare?

Telecare a risky business

2008-09-24T17:45:00.000+01:00

So lets look at the telecare assessment in more detail. There seems two strands of thought here, 1) of containment and 2) enablement. More explicitly, the notion of measuring and basing judgments upon risk or measuring and judging need. What is clear is that risk and need are not the same. Often they are put together as if they are mutually compatible, but in reality they are quite different.

Risk assessments are useful as they are about the causation of harm and the mitigation of this harm to an individual. Telecare is apt for this as flood, gas and fall sensors are all about ensuring the person does not experience harm or harm reduction. The problem of concentrating on harm reduction and risk analysis is that it is often at the expense of looking beyond the immediate risk. The person is falling.. lets give them a fall detector, rather than stepping back to inquire why are they falling, can we prevent or assist in minimising the falls? Risk analysis of telecare can be achieved in a number of ways such as self assessments or checklists (have you ever had a flood?) without the background detail many people will answer yes to this type of question, as they did have a flood but it was three years ago, or they had one last week as the flat upstairs flooded and the water came in to their place. If this approach is followed to its logical conclusion then it performs a simple containment mechanism where people are given telecare to mitigate risk without ever trying to address the real issues of why the risks are there. Analysing risks is not wrong, it is just not enough by a long chalk.

So what is the option? Person-centred planning of telecare which is truly needs based and holistic is the only possible solution. If the assessment addresses the needs of the whole person and their lifestyle and activities then if telecare is required it will mitigate risk whilst having the correct 'person-fit'. This is a double winner, the person is happy with the intervention and any intervention will last for longer and be more effective.

So mitigating risk is too tunnel visioned to be the main reason for interventions. The other issue with risk mitigation is that it tends to centre on technology to the expense of really seeing what and how the person being assessed ticks. It forces the assessor to concentrate on how technology can be used with the person instead of seeing how the needs of the person can be met, which means telecare is one possible option.

So needs based interventions are person-centred and enabling whereas risk based interventions are potentially disabling and containing.

More on telecare assessments

2008-09-19T08:51:00.000+01:00

What is a telecare assessment?
Is it a method, a process or a determination?
If it is a method then it is something people can learn and be taught, it is measurable and quantifiable.
If it is a process then it is a set of procedures and protocols, but the user is not necessary to the outcome.
If it is a determination then the user is central and it is qualitative and quantitative. Measuring the determination of an assessment is difficult.

So how could one determine if an assessment is good?
1) measure lots of processes and procedures to ensure that all the paperwork leading to and from the assessment are taken care of, so all bases are covered.
2) Send an "expert" to shadow an assessor and see if their is a congruence of opinion between them on specific cases.
3) lay down strict guidance and procedures saying that an assessment must contain x, y and z in it.

If we take option 3 - then we can easily make a self assessment or a computer programme that prompts assessors for the next question or area to investigate. This of course will be limited by the narrowness of the available options and will not be able to take the whole person's needs into account or crucial aspects of their specific domestic environment. So it is likely to be useful only in simple interventions and even then have limited efficacy.

If we take option 1 we have a clear audit trail and are covered legally as ticking all the boxes. But the problem might be that ticking the boxes is often to the exclusion of providing a real assessment or a bespoke service to meet the needs of the person.

If we take option 2 we should get good quality of assessments with the person at the centre of the assessment and their needs being met by technological interventions if appropriate.

So which is best, which option should we go with?

This is the $64,000 question.

To me, we need something that covers all of the aspects. To omit one is to make judgment of an assessment useless or invalid.

If we always start with the person and build our assessment criteria around meeting their real needs, we should find that we naturally develop an auditable trail with clear signposts to good practice and person-centred planning. We would be able to help some people who need no interventions to meet one off needs through bespoke telecare solutions, whilst other people would require more complex interventions and assessments.

So what is the problem with using this interactionist approach?
Simplicity and cost-efficiency, I suspect will be the response. To undertake alll these methods would be prohibitively expensive.
I suspect this is anathema and a white- elephant.
Good practice save money in the long term. Short term high costs for long term gain.
Similarly with telecare if we use it in a preventative manner to meet needs before they escalate we are often stopping the need from being unmanageable by the person.

So if we are to make assessments overly good practice they must contain all three parts. The next big question is how can we accredit the qualitative aspects effectievely and who is qualified to do this?

Person-centred telecare assessments

2008-09-10T09:50:00.001+01:00

What is meant by person-centred? In the UK this term is bandied around as an excuse or a rationale for many things including telecare. Telecare is person-centred! I am amazed at the number of people who talk about their person centred telecare approach and then immediately focus on the telecare technology.

So how should a person centred assessment be conducted? It is funny as there are no current guidelines from the health or social care authorities. The new TSA guidelines concern themselves with assessment but it is a very generic model that is used and the notion of person-centredness is often lost in the translation.

Person-centredness in assessment is about finding out about the whole person, and what their needs are. It is about discussing and allowing a forum for the person's concerns to be aired and for the assessor to best meet those needs by the available options - referrals to other services, adaptions or telecare. So telecare is only one of a range of options.

Telecare assessments should be face to face, as often when people talk about what telecare a person might need, they are not in possession of the full facts. For example, on a home visit, whilst looking around the house with the person it might become clear that the initial options would be unsuitable due to the layout or activity patterns of the person.

Often during an assessment a problem that had previously been highlighted might actually become downgraded as other issues come to light and require more urgent addressing.

This means that assessments over the phone, computer based or via some assessment form will have a limited effect, it might capture some parts of an issue but other more pressing ones will be lost in the process.

Often telecare might sound like a really good option when you speak to a person but when you visit the person's needs are so great that other options need to be explored first.

A possible guideline for an assessment to be person-centred is to not think about telecare. Listen to the needs and consider how best to meet them. If telecare is the best method, then use it, but if other methods are better use them.

What is clear is that person-centred assessments are not conducted by asking a person "are you worried about falls?" "do you ever forget to turn the taps off?" All these questions attempt to pigeon hole the person into predefined telecare categories based on the limited equipment available. A good assessor will always think out of the box and not be telecare-centric. They will be person-centred.