Aging

Archive for Aging

Simple Patient-Centered Design

At Wellpepper, we work hard to make sure our software is intuitive, including working with external academic researchers on randomized control trials for people who may have cognitive or other disabilities. This is both to make sure our software is easy-to-use for all abilities, and to overcome a frequent bias we hear about older people not being able to use applications, and also to provide valuable feedback. We’ve found from these studies, the results of which will be published shortly in peer-reviewed journals, that software can be designed for long-term adherence, and this adherence to programs can lead to clinically-meaningful patient outcome improvements.

User-centered design relies on three principles, all of which can be practiced easily, but require continual discipline to practice. It’s easy to assume you know how your users or patients will react either based on your own experiences, or based on prior knowledge. There’s really no substitute for direct experience though. When we practice user-centered design, we think about things from three aspects:

Immersion

Place ourselves in the full experience through the eyes of the user. This is possibly the most powerful way to impact user-centered design, but sometimes the most difficult. Virtual reality is proving to be a great way to experience immersion. At the Kaiser Permanente Center For Total Health in Washington, DC, participants experience a virtual reality tour by a homeless man showing where he sleeps and spends his days. It’s very powerful to be right there with him. While this is definitely a deep-dive immersion experience, there are other ways like these physical therapy students who learned what it was like to age through simple simulations like braces, and crutches. Changing the font size on your screens can be a really easy way to see whether your solution is useable by those with less than 20/20 vision. With many technology solutions being built by young teams, immersion can be a very powerful tool for usable and accessible software.

Observation

Carefully watch and examine what people are actually doing. It can be really difficult to do this without jumping in and explaining how to use your solution. An interesting way to get started with observation is to start before you start building a solution: go and visit your end-user’s environment and take notes, video, and pictures.

Understanding what is around them when they are using your solution may give you much greater insight. When possible we try to visit the clinic before a deployment of Wellpepper. Simple things like whether wifi is available, how busy the waiting room is, and who is initiating conversations with patients can help us understand how to better build administrative tools that fit into the clinician’s workflow. Once you’ve started with observing your users where they will use your solution, the next step is to have them test what you’ve built. Again, it doesn’t have to be complicated. Starting with asking them how they think they would use paper wireframes or voice interface testing with Wizard of Oz scenarios can get you early feedback before you become too attached to your creations.

Conversation

Accurately capture conversations and personal stories. The personal stories will give you insight into what’s important to your users, and also uncover things that you can’t possibly know just by looking at usage data. Conversations can help you with this. The great thing about conversations is that they are an easy way to share feedback with team members who can’t be there, and personal stories help your team converge around personas. We’ve found personal stories to be really helpful in thinking about software design, in particular understanding how to capture those personal stories from patients right in the software by letting them set and track progress against their own personal goals.

Doctor’s often talk about how becoming a patient or becoming a care-giver for a loved one changes their experiences of healthcare and makes them better doctors. This is truly user-centered design, but deeply personal experience is not the only way to learn.

To learn more:

Check out the work Bon Ku, MD is doing at Jefferson University Hospital teaching design to physicians.

Visit the Kaiser Permanente Innovation Center.

Learn about our research with Boston University and Harvard to show patient adherence and outcome improvements.

Read these books from physicians who became patients.
In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope, Rana Adwish, MD
When Breath Becomes Air Paul Kalanithi, MD

Posted in: Adherence, Aging, Behavior Change, Clinical Research, Healthcare Technology, Healthcare transformation, patient engagement, Patient Satisfaction, Research

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Falls Challenge

How might we enable older adults to live their best possible life by preventing falls? We have entered a challenge with AARP and IDEO to bring our proven falls solutions to the masses. Along side our partners at Harvard and Boston University, we believe that using mobile technology to enhance and scale a proven falls prevention program will lead to better life by increasing access to care and decreasing costs.

The challenge started with over 220 submissions and recently weeded down to the top 40. We’re thrilled to have made the first cut. Our method is proven and we invite you to participate in the next round to refine our idea and help achieve greater impact.

Click here to check out our entry!

 

 

Posted in: Aging, Clinical Research, Healthcare Technology, Outcomes, Physical Therapy, Research, Uncategorized

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Justin Sledge Transforms Senior Care at Aegis Living

When it comes to delivering quality care, Chef Justin Sledge rebels against the idea of senior homes being “retirement homes” by providing great nutrition and interactive design.

Justin aims to combine compassion and creativity to provide the best care for senior residents at Aegis Living. The chef has tremendous influence in the senior home’s decision-making process in nutrition and design due to his wide range of experience and passion to help senior residents. While it is often believed for senior care homes to be quiet and slow, Aegis Living – under Justin’s guidance – blossomed into lively space for the community.

“I believe the best treatment and care is through spending time with loved ones,” says Justin, chef of Aegis Living for five years. “We want to make this a place where everyone wants to visit.”

1028161200bAegis Living has several locations throughout the west coast – each with a different decorative theme, but same core values.  Justin is currently at the helm of the Victorian themed Aegis Living’s kitchen. Every detail that goes into the many floors such intricate dining room, archaic-style movie theater, and hand-painted pizza kitchen spoke volumes about the staff’s care and compassion towards the residents.

The chef of twenty-three years has made the decision to switch from restaurants to senior care and has been there ever since. Justin was also known for baking treats for Seattle’s charitable Queen Bee Café where profits are donated to the city’s selected charities.

I had the privilege to be Justin’s guest as he gave me a tour of what appeared to be a magnificent manor located in Seattle’s Queen Anne area. The windows are wide with a perfect view of the soccer field next door where children often come to play – and visit Aegis Living for tours and activities with the senior residents. A lavish private dining room seats sixteen guests and serves lobster for family holiday dinners. One floor hosts a game room with a handmade painted golf course for residents to play with visiting grandchildren. It seems the entire home was brimming with delightful activities for the senior residents and their guests to enjoy.1028161225b

At the large kitchen, the chef presented the menu of the day – Alaskan salmon, classic Caesar salad, and grilled beef tenderloin – all made with fresh local ingredients. Justin oversees the menus throughout all the Aegis Living homes.

Justin lead me through the Memory Care floor with a multitude of family paintings such as a grandfather laughing with his grandson on a fishing trip and an elderly couple smiling and walking together. He explained that photos like these help trigger good memories for seniors and improves their mood. All the décor and structure are carefully chosen to elicit positive emotions and memories in senior residents. There were also multiple studios for crafts and leatherwork, lavish salons and a beautiful pool. There were even rooms decked out to look like a jungle with screens that play hiking and wildlife documentaries for seniors to calm themselves from anxiety.

The tremendous amount of compassion in each care is what makes Aegis Living stand out most. There is a large social aspect that heavily influenced the design of Aegis Living homes and encourages frequent interactions with friends and family.

Lastly, I was able ask Justin a few questions about his work with Aegis.

 

Q: Why all the focus on design and aesthetics?

JS: Art helps to bring out positive emotions in our residents. It is not a place to put away some of the most important people in our lives who have helped shaped our future. We want to make it as nice an experience as we can for the residents.

 

Q: Why did you decide to choose Aegis Living over your previous career as a restaurant chef?

JS: This was the best decision of my life. I was a chef for twenty-three years and it was like Hell’s Kitchen. The job was demanding and the hours even more so – I hardly had time to see my kids. There would be countless weekends where I had to skip out on ballet recitals and family picnics because of work. This is much more fulfilling and I’ve never been happier. Here, I get the best of both worlds where I have more time to see my kids and I still get to do what I love – being a chef.

 

Q: How do you deal with competitors?

JS: We hope to inspire competitors to do what we do. We hope they try to recreate the same level of care towards their senior residents as well. This might mean switching to more local fresh ingredients or quality of life programs and activities.

 

Q: What are the next steps for you and for Aegis Living?

JS: We are expanding and building six more senior care homes throughout the west coast these next few years. I will be there to help train new staff and help plan everything from what the place should look like to what’s on today’s menu for our senior residents.

Posted in: Aging, patient engagement, Patient Satisfaction, Seattle

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Different System, Same Challenges: Long-Term Care Perspective From Canada

Kristin Helps, our Director of Client Operations, and I had the opportunity to speak about delivering Empathetic Care for Seniors Through Technology at the annual BC Caregiver’s Association Conference in Whistler, BC. The BCCPA is the representative body for long-term care, skilled nursing, homecare and retirement facilities in the province of British Columbia in Canada. These types of facilities are mostly privately run, by both for-profit, and charity organizations, as opposed to acute care which is run by provincial and regional authorities. While this was a BC organization and conference, delegates came from across the country, and ranged from individual home care works, to facility owners, to university professors and researchers.

For the most part we heard similar challenges to those encountered in the health system in the US:

  • Communication between care settings
  • The struggle to deliver patient-centered care
  • Decreasing reimbursement for homecare
  • Enabling staff to operate at the top of their license

At the same time, people expressed a desire to age in place, and the health system wanted to be able to support this. While 80% of Canadians cited wanting to die at home, only 40% actually do.

One of the big differences we noted at this conference was that speakers and participants were calling on the Federal government to step in and fix many of the problems in a way that we don’t often see in the US. Another difference was that participants were looking globally for solutions to challenges, particularly in dementia care.

Looking Globally for Dementia Care

This was our first time at this conference and veterans told us that the previous year was quite focused on analytics, while this year the focus was on dementia care. While not primarily our area of expertise at Wellpepper, we heard about a number of innovative initiatives to improve care, including a novel approach by the government of Japan. Japan decided to characterize dementia as a social problem rather than a medical problem and trained bank tellers and grocery store clerks to recognize the signs of dementia. It was thought that these people were most likely to see problems, for example if someone was unable to understand how to pay bills or buy groceries. Considering that many with early onset dementia are quite successful at hiding changes from their loved ones, this idea is quite interesting. It also puts the responsibility for care back into society rather than relying on medical facilities that often distance the rest of us from the challenges of aging.

Basketball courts at Aegis Living Seattle

Basketball courts at Aegis Living Seattle

The Butterfly Household Model of Care, which was initiated in the UK, but has been implemented in Alberta with some success, is another novel idea. People with dementia often don’t know what day it is or what they had for lunch, but they do have vivid internal experiences, often remembering happier times of their lives. Butterfly Households are designed to stimulate people with dementia with bright colors, and also to stimulate memories with areas designed to invoke feelings of the past, for example an ice cream shop or an area with old photographs. The idea in a Butterfly home is to meet patients where they are, and caregivers report much joy in delivering care and significantly fewer of the violent behaviors often associated with dementia.

While not a designated Butterfly Home, you can see some of these techniques in action at Aegis Living in Capitol Hill, Seattle. Here are a couple of pictures from when I visited last fall. In an outdoor area they have a car and a garden shed designed to stimulate conversation and fond memories, and an old-gym styled basketball court, where you can shoot hoops sitting down.

Invoking memories at Aegis Living Seattle

Invoking memories at Aegis Living Seattle

To find out more about the topics in this post:

Bank Tellers Act Serve as Caregivers in Aging Japan

BC Caregivers Association

Butterfly Household Model of Care

Aegis Living Capitol Hill Seattle

If you’re interested in learning more about our talk on delivering empathy through technology, contact us.

Posted in: Aging, Behavior Change, chronic disease, Healthcare Disruption, Healthcare motivation, Healthcare transformation, Managing Chronic Disease, Seattle, Uncategorized

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Flexible Care for Independent Aging: Don’t Dumb It Down!

I had the pleasure of participating on a panel on technology for aging, along with Honor founder Seth Sternberg and CareTicker founder Chiara Bell during the HX360 event at HIMSS 2016. (HX360 is a “conference within a conference” focused on innovation and C-suite leadership.) The panel was hosted by Jeff Makowka, Director of Market Innovation for AARP, and ranged from topics on entrepreneurship and whether there is a venture rush to technology for aging now to approaches for delivering care for aging in place.

Interestingly, all three panelists were inspired by personal experiences to found our companies. For me, it was poor discharge instructions and lack of continuity of care when my mom was released from 6 months in a long-term care facility. For Seth and Chiara, it was trying to figure out how to enable their parents to age at home. It’s a classic entrepreneurial model to experience a problem and try to find a solution to it, provided the market is big enough, and this market certainly is based only on demographics of the aging baby boomers. Seth and I both made the leap from technology, Seth from Google, and me from Microsoft, and Chiara from a long history in healthcare and homecare.

We were much sharper in real life.

We were much sharper in real life.

Honor’s $20M in funding lead by Andressen Horowitz is proof that Silicon Valley is paying attention to homecare, which can be viewed as important from two aspects: first we need innovative and new thinking to approach these challenges, and second these solutions could require a lot of money. (Although I would posit that we need patient capital in this space, something that Silicon Valley is not always known for. Interestingly, the same week as the panel Dave Chase and Andrey Ostrovsky posted a piece on why Silicon Valley does not belong in homecare. Maybe they should be on next year’s panel.)

The three panelist companies took similar approaches in using technology to scale and empower the people in the process, both patients and caregivers. For Wellpepper it’s about empowering the patient to follow their care plans and get remote support from the healthcare team. Honor and Careticker are more focused on the patient and their homecare team, whether that is professionals or family members. What was similar in the approach was providing information in real-time to the people who need it, and treating everyone in the process with respect. Honor does this by ensuring homecare workers are paid a living wage. Careticker does this by recognizing for people to age in place, the family caregivers need the right information and supports and Wellpepper does this with patient-centered and highly-usable software that is not dumbed down for the aging.

We were perhaps the outlier on this panel as our solution is not aimed specifically at the elderly. However, you could say we are the most representative of the way we need to approach the challenge: we need solutions that are designed with empathy, putting the patient first, and are not categorizing people into “young” and “old.” Well designed solutions and products should can address a broad spectrum of users, and we need to treat those aging in our population as another audience in this spectrum.

Posted in: Aging, Behavior Change, Healthcare Disruption, Healthcare motivation, Healthcare Technology, Healthcare transformation, M-health, Managing Chronic Disease, Patient Satisfaction

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Falls Prevention Awareness Day September 23rd

Last year my 80 year old grandmother fell walking back from my cousins wedding reception, luckily she grabbed onto my sister and broke her fall. Nevertheless as we studied the sidewalk for several minutes only to discover its perfectly flat surface and our tremendous worry… my dear grandmother could think of nothing other than her embarrassment. We later learned from my grandfather that she has fallen several times over the last few months; she shook it off with laughing commentary in the background saying he was exaggerating. Whereas I appreciate her humor, it is no laughing matter. 2.5 million elderly adults are treated in the ER for fall injuries, with one out of five falls result in broken bones. With those statistics I continue to worry about the next time she falls and my sister isn’t there.

Pick up your cars, grandma is coming over!

With that said, today being Falls Prevention Awareness day I cannot help but think of everyone in my life that is prone to falling… which I am sure you are now pondering yourself. So we should all take a minute (or longer depending on how caught up you are on house chores!) and look around our environment for fall hazards and think about prevention. I have a two year old son that contributes a lot to fall hazards with his hotwheels toys strewn all over the house, which makes my house a high risk zone no doubt! I have to ask what’s on my grandmothers floor?! We need to encourage our elderly loved ones to remove fall risk factors in their homes too; broken steps, faulty handrails, uneven pavement, clutter, throw rugs, poor lighting… grandchildren toys! However most of all we need to make sure they are still getting out of the house and do NOT let the fear of falling limit their mobility. Lower mobility is a major fall risk factor due to deteriorating body strength, which in return also influences balance. It is argued strengthening your balance is the single most important factor in avoiding falls. Senior centers across the country teach classes to elderly adults called “Matter of Balance” (I have taught a few in the past!), they are a great way to teach folks about balance strengthening through exercise and awareness of ‘fall-ty’ habits.

Working for Wellpepper and learning more each day about how it is helping patients, I cannot help but think about how mHealth technology could also help with fall prevention. There are several balance strengthening exercises that we do in our ‘Matter of Balance’ classes at the senior center that could be very easily translated onto the mHealth platform. Honestly now that I think about it the whole class could be taught this way, and might even have better results since a lot of elderly adults express interest in the class, but don’t show up because they are too embarrassed about admitting to of fallen, just like my poor grandmother.

Such thoughts of mine have been expressed officially (to say the least!) by Harvard researchers, because today it was announced on Falls Prevention Awareness Day no less, in a press release, that they are utilizing Wellpepper as an patient engagement solution to lower the costs of care and to improve patient mobility skills as well as muscle strength, endurance and power and to decrease the risk for fall-related injuries such as hip fracture. I cannot wait to see how this study plays out, because it could mean a whole world of good for our lovely elderly family members. I cannot help but visualize how cute my grandmother would be practicing her muscle strengthening exercises on an iPad and the great peace of mind my family would have.

Congratulations team Wellpepper for your involvement in making this Falls Prevention Awareness Day a big notch in your ongoing achievement index!

Posted in: Aging, Behavior Change, Healthcare Research, M-health

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Reducing Readmissions and Costs for Total Joint Replacement

Last week CMS announced a major new initiative for Total Joint Replacement, aimed at both reducing and reconciling costs. Total joint replacements are predicted to increase at a rate of 30% to 2020. Demographics are the major driver: people are getting joint replacements at a younger age, and may have more than one in their lifetime. On the one hand, more active baby boomers have put greater strain on their joints by running marathons, and on the other an overweight population is putting more strain on their joints just by walking around.

Since the demand is increasing, and the costs fluctuate wildly, up to 100% by Medicare’s estimates, the opportunities to look for costs savings and to reward based on outcomes is key. Like other bundled payment recommendations, Medicare is looking at the 90-day readmission rates and also using a carrot and stick reimbursement approach.

“Depending on the hospital’s quality and cost performance during the episode, the hospital may receive an additional payment or be required to repay Medicare for a portion of the episode costs.”

While private payers often follow Medicare, this is one area where Medicare cites that it is following a trend that has already been piloted in private scenarios, most notably with self-insured employers contracting directly with healthcare systems on fixed-price knee and hip replacements, like the deals Walmart and Lowe’s have struck directly with hospitals.

Screen Shot 2015-07-12 at 4.00.51 PMThe American Hospital Association is also ahead of the curve on this trend, and they published some recommendations in a 2013 report entitled “Moving Towards Bundled Payment.” In it, they also noted the wide fluctuations in pricing between health systems for total joint replacement, and also that 33% of the costs of a total-joint replacement come from post-acute care.

Screen Shot 2015-07-12 at 4.01.13 PM
Our research has shown that a large driver of these costs is discharge setting related. While the majority of patients do better when discharged to home, they were being discharged to skilled nursing instead as a “belt and suspenders” type of back up. Discharging to the right setting, can improve patient experience and lower costs. However discharge to home requires the right type of patient tools. Patients need to have great educational materials, the ability to track their progress, and the ability to get remote help if they need it. This is something we’re passionate about at Wellpepper, and we are working with a number of leading health systems that are moving to bundled payments to help them digitize the pre and post surgical instructions and collect patient reported outcomes. We’d like to be part of the solution for both patients and providers as we move to these new models of care and reimbursement.

The Medicare proposal is open for public comment for the next 60 days. It’s over 400 pages long, so you may want to print a copy and take it for a little light beach reading.

 

Posted in: Adherence, Aging, Behavior Change, Health Regulations, Healthcare Policy, Healthcare transformation, Outcomes

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Reducing Avoidable Readmissions: Transfer to Home

While studies show that discharge to home can be best for patient recovery from surgery, this is an area where communications and continuity of care often break-down, risking readmissions. The idea of a patient-centered medical home where the patient is at the center receiving consistent care from a group that can bring in specialists is intended to solve some of this problem, but better communications between healthcare organization, primary care physician, and patient and the patient’s care team can go a long way to improve discharge to home without requiring an entirely new model.

This post is part of a series recapping a recent training from the Institute for Healthcare Improvement’s course on Reducing Avoidable Readmissions.

Primary care physicians while often the most trusted person in the care team, and besides the patient the person with the best insight into the patient’s overall wellbeing are often out of the loop when it comes to hospitalization. Once a patient is referred to a specialist for surgery the hospital team takes over, and the primary care physician has little insight into what happens, even though when the patient is discharged they are back in the care of the primary care physician. Often the primary care physician has no idea when the patient has been hospitalized or re-hospitalized.

Primary care physicians who were participating in the course expressed both their desire to participate in this post-acute care follow up and frustration at both the lack of insight they had and felt powerless to influence the hospitals.

While the evidence on post-hospitalization follow up visits is mixed, common sense does point to following up with patients as being a good thing to prevent readmissions. However, depending on the model of care, this is either with a primary care physician or a hospitalist. Considering the PCP is responsible for the general health of the patient, moving to reimbursement models where this is possible also seems to make more sense.

 

Source: IHI.org

Source: IHI.org

One example cited was from Capitol District Physicians Health Plan, where physicians were paid to do post acute care follow-ups. The program plus a phone call from a case manager decreased readmissions from 14% to 6%. (Although it would be interesting to know whether the in-person visit or the phone call had the biggest impact.)

As with other sessions in this course, the keys to improving discharge to home were in communication with the patient and patient caregivers around expectations and communication back to the hospitalist or family physician about medication usage at home, and any concerning symptoms. Too often patients understand “You’re discharged” as “You’re better” and miss their responsibilities for doing follow-up care whether that is physical therapy, wound care, or just easing back into activities they participated in prior to surgery. Ensuring patients and their care givers understand that discharge to home still requires follow-up is a key to decreasing readmissions from this setting.

New models of transitional care and intensive care where patients receive personalized follow-up care and regular check-ins with a healthcare professional after hospital discharge were shown to improve overall function in patients, decrease readmissions, and decrease costs. These types of new models become more practical with the carrot of value-based payments coupled the stick of penalties for readmissions. While the overarching goal of decreasing readmissions is about improving patient care, having financial incentives aligned will provide an extra boost.

Continuing with the theme of the course, there is no one silver bullet. There is no one reason that patients readmit. That’s the bad news. The good news is that some basic common sense improvements, like better communication with patients and their care teams can decrease readmissions. We’ll go into more detail on how to improve communications in the next post on this topic.

Posted in: Adherence, Aging, Health Regulations, Healthcare Policy, Healthcare transformation

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Stroke Rehabilitation is the Poster Child for the Need for Collaborative Care

APTA CSM 2015 Recap: Anne Shumway-Cook Lecture: Transforming Physical Therapy Practice for Healthcare Reform

Speaker: Pamela Duncan, PhD

Interdisciplinary teams and patient-centered care are key to the future of healthcare, and physical therapists attending this keynote of the Neurology track at APTA CSM 2015 in Indianapolis were encouraged to embrace this change. Bemoaning the lag time from research to clinical practice, Pam Duncan suggested that researchers find ways to work with interdisciplinary teams of biomechantical engineers and even private companies to bring innovation to patients faster. She started with the inspiring example of Carol Richards who received the Order of Canada for her work with the interdisciplinary team on the Stroke Network Canada, aimed at decreasing the impact of stroke across Canada.

Source @mdaware on Twitter

Source @mdaware on Twitter

Duncan then told a story to explain her passion for changing post-acute stroke care, involving a personal experience that changed the course of her career. Duncan’s mother suffered a stroke and while Duncan was trying to provide comfort in her mother’s last days, a traveling physical therapist arrived in the hospital room with a goal of getting her mother to get her mother to stand, which was apparently the clinical protocol she was assigned to do. Duncan protested and later spoke to the owner of the physical therapy company that had contracted to the hospital. He shrugged and asked her why she cared since Medicare would pay for the visit. Incensed at the waste of time and money but more furious at the way this care completely disregarded the patient’s best interests, Duncan put aside her plans for opening a private practice and focused research to improve post-acute care for stroke patients.

Translating Research to Evidence and the Humble Researcher

With the same vehemence, Duncan described how she believed that over 180 publications she’d made on the topic had done little to advance stroke care, largely due to the difficulty of translating clinical research into practice, and asked the researchers in the audience to change this by developing interdisciplinary teams, questioning all their assumptions, and thinking about the patient holistically, not just from their own discipline.

She asked researchers to be “humble researchers” referencing a column by the New York Times columnist David Brooks and not just set out to prove what they want to be true. Duncan used an example in her own research which disputed a popular belief on stroke recovery and showed that home-based exercise was more effective than treadmill-based. Duncan described herself as still having arrows in her back from that publication.

Best Practices for Stroke Recovery

After lighting a fire for the audience to think about things differently  by saying

“Take off your neuro-plasticity hat and think about patients holistically.”

Duncan continued with specific examples on how to change care. First was to understand the overall situation. 10-30% of stroke patients face permanent disability, something that is not always clear when they are released from hospital within 3-5 days of the incident. She gave an example of a patient who was discharged with care instructions and prescriptions yet when she got home she couldn’t follow them: she discovered the stroke had affected her ability to do basic calculations.

“If you asked if I had discharge instructions I would have said yes, I heard what the nurse said and I showed her I could inject my drugs, and my math deficit wasn’t diagnosed until I got home. I did the things I needed do to get discharged but wasn’t really able to cope.”

This is a clear example of how our current system fails us. It does not support the patient outside the clinic, and yet it’s so much less expensive and more comfortable for the patient to be released to home. Looking at the costs it’s clear that we need to improve home health options.

Post stroke care costs:

  • Acute inpatient care: $8,000
  • Skilled Nursing Facility: $41,000
  • Inpatient Rehab: $14,000
  • Home health: $6,000
  • Long-term care: $62,000

As Duncan put it, “Home health is a dirty word in Washington” yet this where the patient should be. She called stroke the poster child for the discontinuity of care in healthcare as 73% of post stroke readmissions are for other issues not related specifically to the heart. Duncan sees hope though, and called bundled payments the best thing to happen to stroke recovery as providers will have to collaborate across the care continuum.

She sees the benefits as:

  • Coordinated high quality care with seamless transitions
  • One primary metric for integrated care
  • Excellence based on outcomes

The message to physical therapists is that they are uniquely suited to these multi-disciplinary teams focused on patient outcomes. For patients, outcomes are measured by function. For CMS, value is measured by those functional outcomes divided by the cost and physical therapists can deliver on both.

This session was a great kick-off to the conference, which had an overall tone of embracing the changes coming in healthcare and the role of physical therapists in it. As a company providing continuity of care through digital treatment plans and connections with healthcare providers outside the clinic we were inspired to see so many people embracing this change.

Posted in: Aging, Health Regulations, Healthcare Disruption, Healthcare transformation, Physical Therapy

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Translating Evidence-Based Interventions to Practice: Falls Prevention and Otago

APTA CSM 2015 Session Recap: Falls Prevention: Otago Program and Behavior Change

Presenters:

Mary Altpeter, PhD

Tiffany Shubert, PhD

Clinical Support for Otago

Clinical Support for Otago

The fact that a session entitled “Falls Prevention: Otago Program and Behavior Change “ ended up in the Health Administration /Policy track at APTA CSM 2015 reinforces that we have a long way to go on translating outcomes-based research into care plans. Otago is a proven and effective set of preventative exercises and care for community-dwelling yet frail adults which improves balance and prevents falls risk. It was developed in New Zealand, at the University of Otago over 14 years ago, and prescribes a set of balance and strength exercises that the patient completes independently over 12 months.

Recommended physical therapy visits to access, teach, monitor, and kick-start patient adherence are to occur over 6-8 weeks and after that patients are encouraged to self-manage, and herein lies the reason that this session is in health policy and administration: this is longer than most insurance covers, and there are not currently enough incentives for remote patient monitoring. However, according to presenter Tiffany Schubert, Otago shows an ROI of $1.25 of every dollar invested as it prevents patients from falling which results deterioration to the patient and further burden on the health system.

Barriers to implementing Otago in the US stem largely from reimbursement and the current incident-based payment model that does not facilitate managing patients over a long period of time. As a result, Otago expert and presenter Tiffany Schubert presented an abridged version that might be easier to fit into current payment models.

Delivering Otago: Calendar view

Delivering Otago: Calendar view

However she is also on a crusade to collect outcomes data for Otago in the US so that these barriers can be overcome as the barriers are not just reimbursement. Clinicians have preconceived notions that patients won’t adhere to plans. Tiffany challenges these misconceptions by asking “are you sure or is it your patients just don’t understand.” We’ve definitely seen this with patients we’ve interviewed: they do want to be adherent to their plans but they find out when they get home that they forgot or are confused. Otago and systems like it work well when there is remote support for the patient.

Clinical Barriers to Implementation

Clinical Barriers to Implementing Otago

Given that Otago requires a high-level of patient self-efficacy, understanding factors that impact behavior change is key in driving long-term outcomes and adherence. Hence, the second half of this presentation, from Mary Altpeter focused on strategies to help patients develop self-management skills to complete the independent part of the program. One of the big misconceptions, that we hear frequently from healthcare providers (and definitely from many of the sensor and tracker vendors), is that knowledge is sufficient to effect change. It’s not, many other factors weigh in including readiness to change and social influences. Understanding more about the patient’s own journey and the patient’s barriers and readiness to change can make a big difference in this area. Also understanding the patient’s goals is crucial and personalizing their risk of not changing their behavior.

Breaking behavior change down into stages can really help move the patient along a path. In this session, Altpeter outlined a 5 stage model to affect patient behavior.

6-Stage Behavior Change Model

6-Stage Behavior Change Model

Understanding that while your assessment may show that the patient is at risk for falls, the patient may not have internalized this. First step is to plant the seed of doubt while the patient is in what is called the “Pre-Contemplation” stage. You can do this by personalizing the risk.

In a falls scenario, patients are not actually worried about falls risk. This sounds counter intuitive, but patient goals are usually not functional goals they are life goals. (We can attest to this from the goals patients set in Wellpepper.) So, the patient may be worried about losing their driver’s license which might happen if they had limited mobility. This is moving to patient-centered goals from clinical goals which personalizes the risk. Find out what the patient might be afraid of losing and this can start to plant the seed of doubt that they might be at risk for falls.

During the Contemplation phase the healthcare professional can help the patient break down what it might look like to be able to embark on a program. What might be their barriers or sticking points to do so? When might they do it? This isn’t about making a plan it’s about facilitating the patient in thinking that a plan might be possible.

The next phase Preparation, occurs when the patient has demonstrated that he or she is ready to change, and this is where we can examine the nuts and bolts, breaking down what may seem like a daunting task (adhering to a program for 12 years), into something manageable. Here is where you help the come up with plans to overcome the barriers you identified. One key barrier is often fear of relapse: that is that when a patient stops doing the plan, they can’t get back on the wagon, so to speak. Making it okay to “start over” is a great way to encourage patients.

During the preparation phase you may also want to help the patient break down the program into smaller goals and manageable chunks so they can see progress during the program. Also help the patient identify rewards that will help drive their adherence. These are both important steps when helping with a large and often intangible goal.

Action is putting the plan into place. Here your main role is to support the patient, help them continue to overcome barriers, and be a cheerleader to keep them going in the case of a relapse.

The final stage is Maintenance (which includes dealing with Relapse). Pointing out the patient progress, possibly by completing another falls assessment and showing the difference is a great way to reinforce that the program worked and it’s worth continuing. Also ask the patient to remember what fears they had before the program and whether they feel that now. Simply shining a light on their own experience can help a lot here.

With an aging population, and rising health costs, translating valuable and proven research like the information in this session into clinical practice is key. Given that the average time from research to implementation is 17 years, and that Otago was invented 14 years ago, we can only hope to see widespread adoption by 2018. That’s also in-line with CMS’s new requirements for 50% of Medicare spend being for new value and outcome-based models. It’s time right?

Posted in: Adherence, Aging, Behavior Change, Exercise Physiology, Healthcare Disruption, Healthcare transformation, Physical Therapy, Rehabilitation Business

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Get Your Engines Ready for CSM 2015 Indianapolis

CSM2015Marquee_960x222I’m not a physical therapist, healthcare professional, nor do I play one on TV, but I can’t wait for my third American Physical Therapy Association conference. While I’ll be spending most of my time at our booth (2114 if you’re looking) on the exhibition floor, I’ve managed to find a shortlist of 46 sessions I’d like to attend, and this is from someone who is not looking for clinical practice sessions.

Screen Shot 2015-01-27 at 11.10.50 AMNext week over 10,000 physical therapists, doctors of physical therapy, PhD researchers, and students will converge on Indianapolis (yes, in winter) for the annual American Physical Therapy Association Combined Sections Meeting. The Combined Sections Meeting or CSM as it’s often referred to (we do love our acronyms in healthcare) combines all the interest groups and professional associations within the association including private practice, oncology, neurology, homecare, acute care, orthopedics, sports medicine, and students and academic researchers. The result is a diversity of topics that represent the major trends in healthcare today including: concussions in youth sports; the impact of the Affordable Care Act on practice; high-intensity interval training; caring for an aging population; managing chronic disease; preventative medicine, health and wellness; healthcare technology; and the psychology of pain.

See for yourself in a selection of some of the 46 sessions we’ve flagged:

Sports Concussions in Youth: The Role of PT for a Surging Population

Transforming Physical Therapy Practice for Healthcare Reform

Exercise Prescription for the Older Adult With Multiple Chronic Conditions

Getting Patients Into Cardiac Rehab and Other Wellness Programs and Keeping Them Exercising After Rehab

Google Glass in Physical Therapy Education and Clinical Practice

High-Intensity Interval Training: Rehab Considerations for Health and Cardiovascular Risk

Practice Issues Forum: Does Medicare Really Cover Maintenance Therapy?

I Have Arthritis. Is My Running Career Over? Evidence-Based Management of the Runner With Osteoarthritis

Called to Care: Integration of Positive Psychology

Integrating Physical Therapy in Emerging Health Care Models

Virtual Reality and Serious Game-Based Rehabilitation for Injured Service Members

Of course, our most anticipated session will be “Use of Mobile Health Technology to Facilitate Long-Term Engagement in Exercise in Persons with Chronic Neurological Conditions” where Dr. Terry Ellis Director of the Center for Neurorehabilitation and a Associate Professor at Boston University will be presenting the results of a study where they used Wellpepper and Fitbit to improve adherence to home exercise programs for people with Parkinson’s disease. For a sneak preview of what she will present, see this article from Inside Sargent Magazine.

As in 2013 and 2014, we will do our best to blog about as many sessions as we can so that if you can’t make it to the conference this year, you can still experience some of the flavor.

If you’re going to CSM, what sessions are you looking forward to most?

Posted in: Adherence, Aging, Exercise Physiology, Health Regulations, Physical Therapy, Prehabilitation, Rehabilitation Business, Sports Medicine

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Using Homecare For Positive Change in Healthcare

The week before last, I was fortunate to be invited to attend the Collaborative for Integrated Home Care Aid Innovation Symposium: a group of committed individuals and organizations that passionate about improving healthcare through home care. The goal of the summit, organized by the SEIU union for healthcare workers was to apply the “Triple Aim” principles to home care. With the realization that our current systems cannot support the increase in chronic disease and the aging population, the group was looking for innovative solutions through people, process, and technology, that could provide preventative care and follow-up care in a community setting.

The State of Washington

Washington State CareBill Moss, Assistant Secretary for Aging and Long-Term Support, kicked off the day with a sobering look at the statistics for Washington State. While the number of people in nursing homes has declined by 7,000 since 1993, and more people are cared for in their homes, which provides a better quality of life, the complexity of health issues affecting the population has dramatically increased. In addition to being the preference of patients, at-home care is less expensive. If today we had as many people in long-term care facilities as 1993, it would cost the state an extra $200 M annually, so that’s good news.

Recognizing this benefit, but also understanding the increasing complexity of patients, provides a starting point for improving and supporting the role of home care workers to support more people aging at home. While return-on-investment studies are few and far between, the general understanding of participants is that keeping people out of long-term care facilities can provide financial subsidies to people in long-term care. For example, for the annual cost of one person in a nursing home, $17,500, three patients can be cared for in their homes.Medications Taken By Clients in Washington State

Clinical Care Needs for Washington StateTo support these home care workers and their patients, new training needs to be developed to address some of the top health risks and preventative medicine including nutritional needs, fall risk, and mobility support. By helping people improve their health, we can save money and also improve quality of life.

Continuing on the data wallow, Lili Hay a researcher with Milliman, an independent consulting and actuarial firm, shared a deep dive into the situation in Washington and the complexity of patients that require home care, for example 40% of Medicare patients take 5 or more medications and most have more than one issue.

The Penn Center for Community Health Workers

Next up, Casey Chanton, a social worker and project manager at the Penn Center for Community Health Workers in Philadelphia talked about a unique program for training community leaders as health workers. In dealing with patients from low-income, high-health risk neighborhoods, physicians and patients had both expressed frustration with the gap between what physicians prescribed and the reality of patient’s lives. Physicians might tell a patient to eat a low sodium diet while the patient would be getting most of their meals from a food bank and have little or no control over what they ate. Both felt helpless to bridge the gap. Enter the community health worker. The program trained natural leaders from within these high-risk communities. These leaders visit patients in their homes and help them get the support they needed within the constraints of their own lives.

Not surprisingly, most of the issues were not medical but related to their living situations, income, and access to services. The best recruits to be community health workers were people who listened more than they talked and were non-judgmental. They helped patients set goals that were attainable by using patient-centered goal setting coupled with achievable steps.

Results of the program are impressive and really speak for themselves:

You can learn more about the center and the program here: http://chw.upenn.edu/

Panels on Technology Innovation and Practice Solutions

The next two sessions were panels, one on technology innovation and the second on practice options. There was too much good information for me to summarize everything, so I’ll stick to the major themes.

  • Post-acute care costs are the fastest rising and most variable care costs, so finding a way to manage them is key.
  • Technology is not the solution, people and process are the solution, but technology can help.
  • People of all ages and socio-economic backgrounds can be use technology (although possibly not EMR interfaces—this isn’t a reflection on the people 😉 )
  • If we could start from scratch designing a health system, we would never have designed the siloed-system we have today.
  • Issues of care coordination are causing post-acute care to be the fastest rising cost in healthcare today, even though readmissions are falling
  • Homecare needs to be structured around outcomes not having homecare workers check off task lists
  • Even if the payment models aren’t there yet, we need to take best practices and move forward.
  • Even if all the research isn’t in, we need to take best practices and move forward.
  • Even if healthcare administration isn’t ready for it, we need to take best practices and move forward.

During the panels and Q&A we heard from a few of the homecare workers in the audience about the impact they’ve had on people’s lives because they do what’s right and not what’s required. Particularly striking was the story from a woman who talked about caring for one of her patients who needed to go into a nursing home temporarily after surgery. The nursing home was understaffed so the homecare worker visited her patient there multiple times a day to make sure he was being turned in his bed. She did this because she cared about her patient and she wanted to make sure when he was released back into her care he wasn’t in worse condition than when he entered the nursing home. Rather than consider the negative aspects of this anecdote, let’s look at the amazing resource that exists in home care workers who spend more time with patients than their medical professionals and sometimes their families. That was the point of the day: what can we do to help scale this valuable resource and empower them to help patients even more.

Posted in: Aging, Behavior Change, Healthcare Disruption, Healthcare motivation, Healthcare Technology, Healthcare transformation, M-health, Managing Chronic Disease

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The Healthcare System Is Family

Lynda Bennet and Carey

Lynda Bennet and Carey

The Canadian healthcare system has been my extended family since I was born.  I was born with Spina Bifida in the early 1950’s and it has been there to support me through years even to this day. So asking how healthcare affected decisions in my life is like asking me how my parents affected my life… it’s a long, involved, and murky story.

I can’t really remember my toddler years, but even then I had numerous encounters with doctors, nurses, and other medical practitioners. The first real glimmers memory are of learning how to walk on braces and crutches at Sick Children’s Hospital in Toronto. During my hospital stays, I rarely saw my family, as our home was a great distance away.  Even at that early age, I quickly learned that my ‘adoptive caregivers’ were potential ‘friends’… it was this understanding that launched my awareness of the health care system’s influence.

The hospital is where I learned that it didn’t really matter a caregiver’ s age, nationality, or position, as long as you gave them a quick grin and understood they were often busy, they would always be back with time for you. That was also when I learned that if I ate all of my broccoli, there was a picture of Peter Rabbit at the bottom of the dish; that the Italian person who cleaned my room had children my age and when asked would regale me with stories of the mischief they got into; and that that x-ray technician with the dark skin was from a fascinating far away island called Jamaica.

During my elementary school years, I underwent various corrective surgeries. The issue at that time was whether or not to undergo the procedures necessary to walk without braces and crutches. At that time, abandoning boots for shoes similar to my sister’s held a definite appeal and swayed my agreement much more than what might have been best for me in the longer term. Was the result totally my decision or was it collective judgment of the system, my parents, and me? I’m not sure I’ll ever know.

But again, my hospital visits resulted with life experiences and influences beyond the surgeries. That is when I learned how to make a bed with hospital corners (perhaps a ploy to get me to make my own bed or more likely to keep me ‘busy’). It is where I got to play and help feed the babies in the nursery, and when a bout with septicemia meant I was placed in a single room with a television set. (Remember that TV sets on wards were a rarity in those days even on children’s wards.)  One of my most vivid memories was that room crowded with nurses and interns on duty the night that the Beatles were on Ed Sullivan… and yes, I did get to stay up late!

Corrective surgery went on into my teenage years. Severe scoliosis and fear of pressure sores meant that I was on a Stryker frame for six months. The consequence of this hiatus and my changing body structure was relinquishing my braces and crutches for a manual wheelchair. Preference of the wheelchair over the hard work and potential failure to walk again was mostly my decision… the chair so much easier and faster for getting from point A to point B and with four siblings speed was an unwritten necessity. I am fairly certain that if I had insisted on continuing the use of braces and crutches, I would have had the support of my parents and the health care system to do so. Again though, that and subsequent hospitals stays resulted in life experiences and influences I would have never encountered at home. There was the lady in the bed next to me in an oxygen tent who urged me to promise her that I would never smoke (I kept that promise), the Toronto Maple Leaf player down the hall who told me I was the most beautiful person he had ever met (that one definitely left an impression), and that other patient’s visitors who told me that the reason I was born this way was because my parents had sinned.

Over my working career, my encounters with the healthcare system were few other than plastic surgeries for pressure sores. Although, even during this time health care still exerted its influence on my decision-making. Do I work fewer hours to avoid pressure sores or do I invest big money in a revolutionary new seating system? Do I purchase that new titanium wheelchair or face deterioration of my arm muscles? Do I accept a relocation to the United States with my employer and my workmates? (The healthcare system certainly influenced that decision. Although my employer would have provided private healthcare support, they wouldn’t guarantee my job for any length of time. With my medical history, I just couldn’t take the chance of losing the support of the health care system!)

Approaching my senior years has resulted in renewed encounters with the healthcare system: surgeries for a malformation, cancer, and an encounter with Hashimoto’s encephalitis. The health care system continues to exert its influence in my life decisions. At one point, I was living in a lovely sea-side community in British Columbia, when my primary care physician suggested that I needed to move within the coverage area of an emergency hospital. Who would have thought that access to ambulances, the location of my home, and the structure of the Provincial Health Authorities could make such a big difference? But there it was… either move my home into the coverage area of emergency hospital coverage or face the communication and jurisdictional delays between health care authorities, doctors, and hospitals. Needless to say the decision to move was a no-brainer!

What’s ahead? Who knows! Looking back down the path of past years, I think you’d have to agree that the health care system not only directly affected key decisions in my life but also exposed me to experiences influencing life choices well beyond its designated sphere. It is comforting to know that it is still here for me and with any luck we will continue our relationship into the future.

Posted in: Aging, Health Regulations, Healthcare motivation, Managing Chronic Disease

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APTA Session Recap: What We Say Feeds White and Grey

“Brain‐Enhancing  Strategies for Effective Therapeutic Communication”

Speaker: Karen Mueller, PT,DPT PhD

Therapeutic outcomes are as affected by the therapist’s ability to effect behavior change in their patients as by their clinical skills. However, many healthcare professionals don’t understand the basics. This session by Karen Mueller, PT, DPT, PhD focused on strategies to help improve patient care by examining principles from positive psychology and mindfulness to develop empathy for patients.

We know from research that feeling empathy from the healthcare provider is one of the key factors in patient satisfaction. We also know that a positive relationship between patient and provider is a key factor in improving patient adherence to treatment plans. How much do we think about the impact of the provider on the patient in daily care? Does a more positive and mindful healthcare provider get better results with patients?

The session started with some background research on positive psychology and mindfulness, with reference to renowned happiness researcher Martin Seligman, Director of the Positive Psychology Department at the University of Pennsylvania, in particular the impact of positive psychology in healthcare outcomes.  Unfortunately, our brains are naturally wired towards negativity, which may have been a primitive self-protection mechanism, and it takes a 3:1 ratio of positive thoughts to overcome negative thoughts so we need to actively cultivate positive thoughts to overcome this bias.

Why is this important? Positive emotions appear to create enduring personal resources including creativity, resilience, social relationships, and overall health and well-being.

“The way we choose our words can improve the neural functioning of the brain, in fact a single word has the power to influence the expression of genes that regulate physical and emotional stress” Andrew Newberg, MD

Next the session explored mindfulness, defined clinically as the “cognitive process of directing and redirecting focused attention on an internal physiologic process” and in layman’s terms of focusing and noticing the current experience without attachment, often by using the breath as a tool. Mindfulness has been studied for its impact in healthcare, particularly for managing chronic pain but patients using mindfulness techniques have also seen improvements in fatigue and depression.

Mindfulness has also been proven to be effective in therapeutic practice when used by healthcare providers. A study by Beach et all in 2013, showed that clinicians who practiced mindfulness had an easier time building patient rapport, more patient centered communication, and ultimately more satisfied patients.

Finally the session provided practical advice for people wanting to practice mindfulness when caring for patients:

  • Understand how you are feeling before you meet with a patient. Your negative emotions can have a big impact on them. If you are stressed or burned out, help yourself so you can better help your patients.
  • Speak wisely: express appreciation, speak slowly (slower speech enhances trust and reduces anxiety), speak briefly, check for understanding
  • Listen wisely: paraphrase, don’t interrupt, look at the patient, ask questions

The session provided a comprehensive high-level survey of the topic, and pointed to a wealth of information and research studies for those wishing to explore the topic further to improve their patient care.

Posted in: Aging, Behavior Change, Healthcare motivation, Occupational Therapy

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Health 2.0 Europe “Tools for the Elderly”

Filming a patientPrior to the Health 2.0 Europe Conference there was a deep-dive 3 hour session called “Tools for the Elderly.” I was particularly interested in this session for two reasons, first we are doing some work with Boston University on a study using Wellpepper to manage the health of Parkinson’s patients the eldest of whom is 75 and second, a common criticism we hear from healthcare providers and investors is “old people can’t use technology.” We disagree wholeheartedly, but acknowledge that those who may have less than 20/20 vision or arthritic hands may require different types of interfaces and engagement than the stereotypical 20 year old developer is building for. Based on this, I was very interested to see what types of innovations and challenges this session presented.

Two of the most interesting were Many Happy Returns and Intelesant. Many Happy Returns is a memory, engagement, and conversation aid for people with dementia. It was developed originally as a not-for-profit by Sarah Reed who was introduced to the world of dementia when her mother was diagnosed over 10 years ago. Originally a card game, and now being developed into a mobile application, Many Happy Returns presents pictures from different decades to jog the memory of dementia sufferers and encourage inter-generational communication. People who have dementia have increasingly clear long-term memory with deteriorating short term memory and the cards provide the ability to have meaningful conversations with those with dementia and also learn family stories before they are lost. The app interface was simple and highly usable, and the benefit of using an iPad app over printed cards is huge: sound can be added, and sounds have proven to be very evocative for memory jogging, new card sets can be created by scanning and adding the person’s own photos, and finally, tracking can be done related to which photos, or sounds are most interesting to people.

Tools for the Elderly

Intelesant could have also been in the “unmentionables” session in the full conference. They provided an advance “end-of-life” care plan that was accessible by patients, their care givers, and could be shared with healthcare providers, especially in a care home setting. Too often this information is lost or not communicated clearly until it’s too late, and Intellesant aims to change this. What was compelling about the Intellesant presentation is that the interface, while capable of reporting clinical results, was designed for the patient and the caregiver who are really the most important constituents in this scenario.

There were also three startups that were focusing on building interfaces for the elderly, one to make it extremely simple to use a phone,  one to make it extremely simple to use a tablet, and one to make it extremely simple to have a conference call or telehealth chat through your TV. The first two were solving the problem that Android interfaces are generally a lot less usable than other interfaces, which really seems like 1. A short term problem and 2 something that should be addressed by Android OS developers. (Are you listening Samsung?). The third, SpeakSet was solving a problem that of course affects the elderly, but also everyone else. According to some former colleagues of mine at Microsoft (Skype), it takes 10 minutes on average for any conference call to get started. While there are definitely tools that can help the elderly manage their health and wellbeing, good usable design should be available to everyone. I’d love to use a big button that says “start conference call” and have it work immediately.

The AARP has gone on record asking Silicon Valley to start building tools for the aging population. Based on this session at Health 2.0 Europe, they may want to look further afield.

Posted in: Aging, Healthcare Disruption, Healthcare Technology, M-health

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