The enablement and containment models

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

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

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

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.