U.S. Department of Health and Human Services

Barriers to Implementing Technology in Residential Long-Term Care Settings

Executive Summary

Vicki A. Freedman, Ph.D., Maggie Calkins, Ph.D., Robert DeRosiers, MS, OTR/L, ATP, and Kimberly Van Haitsma, Ph.D.

Polisher Research Institute

December 10, 2005

This report was prepared under contract #HHS-100-02-0017 between HHS's ASPE/DALTCP and the Polisher Research Institute. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officers, William Marton and Hakan Aykan, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Their e-mail addresses are: William.Marton@hhs.gov and Hakan.Aykan@hhs.gov.

The authors thank Karen Kohn, MLS,and Anda Constantine, MBA, for their excellent assistance in preparing this report and Anne Bower for guidance on the qualitative analysis.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

Technology plays a vital role in the lives of older individuals. Indeed, for those in need of long-term care, it can potentially improve the efficiency of care delivery while enhancing the quality of that care and improving individuals' quality of life.

Although the approximately 2 million older Americans living in nursing homes and other residential care settings¹ represent a minority of older persons, they constitute a group of interest for the development of technological applications for several reasons. First, nearly all persons in residential long-term care settings have physical or cognitive limitations that result in disability; thus, technologies targeted at residential long-term care can potentially reach large numbers of older people with the greatest needs. Second, the financial and societal costs associated with caring for this group are substantial and are projected to increase dramatically. In the year 2000, for example, nearly $100 billion was spent on nursing home care. Third, the number of older people in need of long-term care is expected to increase dramatically in the coming decades due to the aging of the baby boom generation. In particular, the number of older people with Alzheimer's disease, about half of whom are cared for in residential care settings, is projected to increase dramatically from about 4.5 million today to over 13 million by 2050. If designed and implemented appropriately, technology can potentially be an important instrument in attaining high quality cost-effective care for this population.

The residential long-term care industry is facing several inter-related challenges that heighten the need for attention to technological innovation. First, there is continued interest, by both providers and federal and state regulators to improve quality of care and quality of life for residents, particularly in the nursing home segment. Second, there is a nationwide shortage of nurses that is especially severe in long-term care. Third, there are financial constraints in the industry due in part to continued pressures on states to limit growth in Medicaid and also to the rising costs associated with risk management.

The purpose of this report is threefold: (1) to describe a range of existing and emerging technological solutions in residential care settings; (2) to identify, based on a review of the literature and discussions with experts in the field, barriers to the successful implementation of technology in residential care settings; and (3) to propose next steps to address the barriers.

To identify technologies we conducted extensive literature and Internet searches, consulted long-term care buyer's guides, and spoke with technology manufacturers and vendors at various conferences. To identify potential barriers we conducted an extensive literature review and also spoke with 16 experts representing four distinct perspectives in long-term care: regulators, providers, technology manufacturers, and other experts about their experience with barriers to implementing technology in long-term care settings.

Existing and Emerging Technologies in Residential Long-Term Care

Assistive technologies are being developed to assist older adults in remaining more independent, safer, and connected to the rest of the world. Although these technologies are generally geared to helping individuals maintain or regain as much independence as possible in their homes, they also may be used in residential care settings. Examples of these kinds of products include architectural elements such as door opening/closing devices, lifts and elevators, ramps, safety equipment and accessible showers; communication devices (such as assistive listening device) sensory aids (such as hearing aids, assistive listening devices); computers and adaptive computing devices; environmental controls (including remotely controlled door openers, telephones, lights and televisions); aids to daily living and mobility; orthotics and prosthetics; and modified furniture and furnishings (such as seat-lifting chairs).

In addition, there are a small but growing number of technologies designed mainly to assist caregivers in residential care settings. These include:

• wander management systems and products;
• fall prevention and management products;
• incontinence products;
• assistance call systems;
• assisted cognition products for individuals with dementia (sometimes called "cognitive orthotics");
• technologies to enhance interactions with families and friends;
• medication management systems; and
• software to manage information to support regulatory and business needs (e.g., MDS software; electronic medical records and recording devices).

For the purposes of this report, five aspects of care in residential settings--wander management, fall prevention, incontinence care, assistance call, and bathing--were identified as key areas in which to investigate technological developments.² These areas were selected with input from the project's Technical Advisory Group based on the prevalence and relative importance (in terms of quality of care and monetary and other societal costs) of the underlying clinical issue being addressed by the technology. In the area of wander management, both low and high-tech options are available. Low-technology options include visual deterrents that are placed on or across doorways and simple battery-operated door alarms that monitor a single door. Higher-tech options include complex alarm systems that monitor multiple doors and elevators; Infrared and radio frequency based elopement management systems that can monitor many doors, elevators, and outdoor areas; and tracking systems that enable caregivers and local authorities to locate residents who have left the facility.

Three distinct approaches to fall management include technologies aimed at reducing the risk of a fall, those that reduce the risk of injury given a fall, and those that notify caregivers when a resident has fallen. Technologies aimed at reducing the risk of a fall include products such as anti-slip footwear and matting that provide a non-slip surface, grab bars that provide support and stability in bathrooms and other areas, and wheelchair anti-rollback devices that prevent a wheelchair from rolling away when residents stand or lower themselves into the chair. Other technologies include chair, bed, and toilet alarms that signal a caregiver when a resident who is at risk for falling attempts to leave a bed, chair, wheelchair, or toilet unattended. In addition, rehabilitation equipment geared toward the restoration and maintenance of strength, endurance, range of motion, bone density, balance, and gait can help reduce the occurrence of falls and fall-related injuries in older adults. Technologies aimed at reducing the risk of injury when falls occur include hip protectors, bedside cushions, and technologies that notify caregivers when a resident has fallen (e.g., using accelerometer technologies, which sense a change in body position, body altitude, and the force of impact to determine when a fall has occurred, or mercury switches that present an audible alarm when the device is tilted from a vertical (upright) position to horizontal (fallen) position).

Incontinence technologies have been developed that prevent the leakage of urine; assist with restorative incontinence programs such as habit training and bladder retraining; and alert caregivers to an incontinent episode. Products that prevent leakage include urethral inserts for women that block the flow of urine at the bladder neck and penile clamps for men that put pressure on the urethra in order to prevent urine loss. Products that assist with restorative training include voiding reminders that encourage residents to void in intervals or predetermined times throughout the day; biofeedback devices that provide visual and auditory reinforcement while performing exercises to strengthen pelvic floor muscles; enuresis alarms that wake the wearer with a vibrating alert at the first sign of moisture in an effort to retrain the bladder; and bladder scanners, which are used to obtain precise readings of bladder volume. Products that alert caregivers to an incontinent episode include enuresis alarms, which can be used to alert caregivers at the first sign of moisture with an audible alert or flashing light.

There are three major categories of assistance call systems: wired, wireless, and telephone based. Newly developed assistance call systems provide two-way voice communications allowing staff to determine need before going to the room. Some of these systems go to a central nursing station, while others tie into a cell phone/pager carried by each staff. The latest development is the passive call system that incorporates strategically placed motion sensors and software with individually defined parameters. These passive call systems automatically alert caregivers when a resident is engaged in a behavior defined as outside their acceptable range (degree of movement, time spent in a bathroom without exiting, etc.).

Many high and low technology products are available to assist both the resident and the caregiver with accessing bathing facilities, as well as performing the actual task of bathing. Examples of products that enable residents to access showers and tubs more independently and safely include barrier free showers, bathtub and shower chairs, transfer benches, portable in-tub bath lifts, commode/shower chairs, grab bars, and anti-slip matting and materials. There are also products that enable residents to perform the actual tasks of washing more independently. For example, wash mitts offer a washing solution for those with decreased fine motor skills and an inability to handle a washcloth. Long handled brushes and sponges enable residents with limited reach to wash areas such as their back and feet. In addition, rinse-free bathing products enable residents to wash their body and hair without the need for water or transferring into a tub or shower. Other products are geared toward making bathing and shower tasks safer and more efficient for caregivers. For example, products that assist caregivers with the transfer of residents to showers and tubs include height adjustable bathtubs, easy entry bathtubs, showering cabinets, bath lifts, shower trolleys, and commode/shower chairs.

A number of emerging technologies may be of interest in residential long-term care. For the purposes of this report an emerging technology refers to new technologies currently in use in the community or acute care settings that have potential applications in residential care settings. We focus in this report on the areas of pervasive and proactive computing, cognitive orthotics, and navigation technologies to enhance mobility, which appear to be especially relevant.

Barriers to Implementing Technology in Residential Long-Term Care

Through our review of the literature and conversations with providers, regulators, manufacturers and other experts, the following five themes emerged as potential barriers to implementing technologies in long-term care settings.

Lack of information about technologies and the residential long-term care market. A pervasive theme was key groups'--manufacturers, providers, and regulators alike--lack of knowledge about the application of technologies in the residential care sector. Providers we spoke with said that they lack information about: (a) where to find technologies, (b) how to evaluate their applicability to their setting, (c) how to evaluate the stability of the technology manufacturer, and (d) how to assess cost-effectiveness of technology. Manufacturers we spoke with said they lack knowledge about how the long-term care market views the importance of technology. Regulators we spoke with said they lack information about the benefits of technology and the process by which to evaluate them.

Perceived lack of financial resources to develop and purchase residential long-term care technologies. A second major theme is the perceived lack of financial resources for manufacturers and researchers to develop useful products and to allow for providers to purchase them. Manufacturers expressed concerns about liability exposure in both the health care and the long-term care industry. Almost all of the experts identified cost of technology, limited provider resources particularly for technologies that require a large initial investment, and limited reimbursement from private and public insurance as substantial barriers to purchasing new technologies. There was also a notable lack of discussion about the potential cost-savings or improvements in quality of care or quality life life.

Failure of regulatory process to keep pace with technological advances. A third major theme is that outdated regulations and the regulatory process hamper the implementation of new technologies and limit manufacturers' creativity in conceptualizing new products. Although newer standards and codes may be more inclusive of the latest technologies, many states do not update their regulations on a regular basis, and thus are enforcing codes that do not account for the latest technologies. The regulatory environment places great emphasis on documentation requirements as the primary means of assessing compliance with codes, as opposed to considering how technology can improve quality of care and quality of life.

Industry's lack of standards for technologies central to residential long-term care. We found a pervasive frustration among providers, manufacturers, and regulators alike with the lack of standards to facilitate the integration of new technologies into residential care settings. Several providers emphasized that the technologies would be far more effective if they were integrated with one another and that standards may facilitate this integration. Several manufacturers explained that standards would help in their development of new products, which often face different codes from state to state. Regulators expressed the desire for standards to help facilitate their evaluation of new technologies and whether they meet the intent of codes.

Providers' lack of knowledge and experience with implementing and managing technological change. A majority of informants pointed to a lack of clarity about the most effective way to go about the process of incorporating technologies into residential care facilities. Providers cited "motivational" problems ranging from a lack of time, to the absence of a local champion, to simply ceasing to use of the technology after external supports are removed. The pattern of responses suggested that resistance was greater for technologies whose purpose was seen by staff to replace or reduce staff members to decrease the "human touch", or to monitor the staff. Providers with more successful experiences viewed the purpose of the technology to address a need expressed by the staff. Moreover, the pattern of responses suggested that technology introduced from the top-down met with resistance whereas providers who utilized a more participatory approach were more likely to describe their technology implementation experience as successful.

Next Steps

Our review of the literature and conversations with experts revealed a complex set of circumstances contributing to the current situation. The methodology we employed uncovered five general themes, but in many cases further research will be needed to confirm the relative importance of each of these themes to the overall challenge. In light of these findings, we provide a series of educational and exploratory strategies to be considered.

1. Remedy existing gaps in knowledge about technologies in residential long-term care settings. Gaps could be addressed with a study to determine the size of the long-term care market, and what their needs are for technology, a study to develop and test a framework for assessing the costs and benefits of different types of technology in residential long-term care settings, further development of easily accessible resources designed to provide information to providers about available technologies, and the development of a forum to train regulators on new technologies for residential care settings.

2. Explore ways to encourage implementation of cost-effective technological innovations in residential long-term care settings. The implementation of cost-effective technologies could be encouraged by development and testing of a framework to assess the costs and benefits of technologies in residential long-term care settings. Such analyses would help providers make informed decisions about investments and may also provide guidance to private and public insurers interested in covering such technologies. In addition, better understanding of nursing home and health care liability issues is needed. Finally, the existing state assistive technology alternative financing programs might serve as a useful vehicle for making low cost loans available to residential care facilities who serve low-income residents.

3. Explore how best to provide guidance to regulatory agencies. Guidance could be enhanced by encouraging states to adopt updated codes on a regular basis, by encouraging the appropriate private associations to provide for interim interpretations of their codes, by developing partnerships with industry representatives to guide regulators around new technologies, by identifying states that are at the forefront of modifying regulations to enhance technological innovation, and by encouraging more information on the benefits of technology in residential long-term care settings.

4. Encourage development of industry standards for residential care technologies. Explore the best way to encourage and support voluntary standard development efforts by industry.

5. Educate providers about implementation issues. Study and educate providers about the relationship between the purpose of and process by which technology is introduced and the successful adoption and sustainability of the technology over time.

NOTES

1. In this report, we define residential long-term care settings as a continuum of care that includes nursing homes, assisted living facilities, board and care facilities, continuing care retirement communities, and adult day care facilities.

2. Detailed product information for these five areas is currently available on http://www.TechforLTC.org, Two additional product areas, medication management and transferring, will be added by September 2005. The web site was initially funded by the Office of the Assistant Secretary of Planning and Evaluation (ASPE) for the purposes of educating professionals about technologies available in long-term care.