Technologies for long term care & innovation 4 the...Technologies for long term care & innovation...

Technologies for

long term care &

innovation

Alex Ross, Director

UNESCAP Regional Expert Consultation on Long Term Care of Older Persons

Bangkok, 9 December 2014

Building societies for older ages Building societies for all ages

Equity Autonomy Dignity

long-term care (LTC) / long-term aged care A range of

health care, personal care and social services provided to

individuals who, due to frailty or level of physical or

intellectual disability, are no longer able to live

independently. Services may be for varying periods of

time and may be provided in a person’s home, in the

community or in residential facilities (e.g. nursing homes or

assisted living facilities). These people have relatively

stable medical conditions and are unlikely to greatly

improve their level of functioning through medical

intervention.

--- WHO Kobe Centre, A GLOSSARY OF TERMS FOR

COMMUNITY HEALTH CARE AND SERVICES FOR

OLDER PERSONS, 2004

Courtesy of Prof Takemi, Councilor, Japanese Diet

What are our goals?

What do we hope to change?

• Keep older persons at home/in community for as long as possible

• Increase quality of life, health status, wellbeing, Dignity (reduce gap in HLFe and Lfe)

• Keep costs down

• Improve care services (referral)

• Prevent/manage functional and cognitive decline - prevent further frailty

• Promote social inclusion and connectivity

• Productivity, contribution : economics

• Empower and include older persons. Inclusiveness

allows for greater connection to disabled

What are our goals?

What do we hope to change?

• Balance social and technological innovation:

• early diagnosis and care; treatment; managing multiple

chronic conditions; enhancing mobility, revising the built

environment

– Blend social, technological, medical innovation :

appropriateness, affordable; safe and effective

– Reduce institutionalization: which technologies and

approaches?

• Work across multiple domains: diagnostics, medicines/vaccines,

care systems, mHealth and ICT, redesigning housing,

• Promote social inclusion and connectivity

• Support health and social service providers

• Support family caregivers

..and examples, more specifically

• Medical and nutrition adherence

• mHealth and eHealth

• Diagnostics

• Managing ADLs

• Link to disability, rehabilitation communities

• Mobility

• Risk factors for LTC and decline into frailty: vision, hearing, eating and drinking, falls prevention, etc

FACTORS DRIVING NEEDS FOR

TECHNOLOGY SUPPORT FOR LTC

• Health status by age; compressing morbidity (DALY profile)

• Diseases, conditions, and impairments, NCD risk factors

(Hypertension, obesity, tobacco use; stroke, dementia,

depression, etc)

• Functional and cognitive decline: mobility, sensory

e.g.walking, hearing, vision

• Limitations in ADLs and ICF; Disability, e.g. ability to perform personal activities, independent living, work

• Pain, sleep duration, living arrangements of elderly

• Life satisfaction

• Family caring, respite care

• Social isolation

4 BIGGEST CAUSES OF DISABILITY

MAINTAINING FUNCTIONAL CAPACITY

OVER THE LIFE-COURSE

THE ROLE OF TECHNOLOGY

OECD

WHAT ARE HEALTH TECHNOLOGIES?

For

• Diagnosis, Prevention, Treatment, Rehabilitation,

Palliation

• Supporting the client

• Supporting the health worker

• Supporting the family caregiver

• Creating an accessible environment

• Diagnostics, Medicines and vaccines

• Medical and assistive devices

• Information technology

• Environmental technologies

HEATH TECHNOLOGIES FOR AGEING

POPULATION

Should be: Considerations:

• Safe

• Effective

• Quality

• Affordable

• Available

• Appropriate

• Accessible

• Acceptable

Principles

• Respond to the needs of people (observed and surveyed) (acceptability)

• Priorities epidemiologically guided

• Health and governance system variations

• Durability and meeting environmental conditions

• Health technology assessment/resource allocation

• Focus on monitoring and evaluation to track effectiveness and efficacy

• Adaptable

• Durable

• Replicable

• Scalable

• Simple

• Sustainable

• Equitable

• Responsive

• Increase

compliance

• Literate

Attempts to solve challenges: Technology

• Communication

• Tele…

– Medicine

– Physiotherapy

– Nutritional guidance etc

• Smart houses

• Safety-technology

• Robots

• Aids

FOR WHOM

• Care recipient?

• Informal carer?

• Professional carer?

• Students?

• Immigrant workers?

14

Despite promising examples, dementia

care technology is not widely used

Promoting social interaction

•e.g. Paro robot in Japan

•Randomised clinical trial planned in the Netherlands

Managing medical needs

•Automated dispensers to reduce medication error (e.g. Germany)

•Telehomecare nurses in Canada provide remote support

Mechanical lifting devices

•Reduce manual lifting and the risk of injury

•British Columbia (Canada) aims to eliminate manual lifting

Monitoring systems

•ComfortZone in the United States provides tracking devices

•The Independent Project in Europe is piloting alarms, fall detectors and gas detectors.

OECD

We must address three key barriers to

the development of care technologies

User-focused development

Robust, independent evaluation

Clear reimbursement criteria 1 2 3

• Some technologies do not currently address the priorities of people with dementia

• Developers need to work closely with users

• Too few robust trials of current technologies

• Essential to give care systems the confidence to implement new technologies

• Most care systems have not set out criteria.

• Would give manufacturers the confidence to invest in development

Care technology assessment processes, mirroring the the health technology

assessments that already exist in many countries, could address points 2 and 3

OECD

KEY WHO REPORTS

http://www.who.int/en

http://www.who.int/kobe_c

entre/en/

and

http://www.who.int/en

http://www.who.int/kobe_centre/en/

http://www.who.int/kobe_centre/en/

EMERGING

EVIDENCE BASE

1. Innovations in assistive

and medical technologies

– Understanding needs,

setting priorities

2. Social innovations –

Assessing the usefulness of

new models of care for older

populations

Class of assistive

device Examples of assistive devices

Orthoses and

Prostheses Upper limb orthoses, lower limb orthoses, upper limb prostheses, lower limb

prostheses, orthopaedic footwear Assistive products for

personal care and

protection

Assistive products for dressing and undressing; toileting; incontinence

management; bathing, showering and washing;

Assistive products for

personal mobility

Assistive products for walking (e.g. walking sticks, crutches, walking frames);

manual wheelchairs; powered wheelchairs; assistive products for orientation

(e.g. white canes); assistive products for lifting people (e.g. hoists)


house keeping Assistive products for dishwashing; housecleaning; chopping and measuring

food; preparing and cooking food. Assistive products for

communication and

information

Assistive products for seeing (e.g. spectacles, magnifiers); hearing (e.g. hearing

aids, amplifiers, headphones); adapted alarms; telephones; writing boards;

Braille typewriters; computers, computer software and technology (e.g. Braille

printers, audible computer displays, screen magnifiers); calculation products


handling objects and

devices

Assistive products for carrying and transporting objects; reaching and grasping

objects;

Examples of Assistive Devices

SOME EXAMPLES OF FRUGAL INNOVATIONS FOR AGEING POPULATIONS

• Low cost smart phones – easy to see and use • A solar powered hearing aid • Low cost vision solutions (including cataract) • Assistive solutions: streamlined availability and

maintenance • Appropriate wheelchair • The cane, with sensors • GIS and sensors: cognitive decline • Utility companies – homes – early warning • Social innovation (e.g. housing, social media, etc)

– Older persons associations • Senior centers = social participation, meals, self care • Many others

ECOSYSTEM OF PATIENT-CENTERED

TECHNOLOGIES

Provider and

Caregiver

Communications

Patient Education

and Support Apps and Gaming

Personal Health Records Remote Patient Monitoring

Medication

Management

Social Networks

Assistive Technologies

mHealth

Sensors

Mood and

Depression Scanners

© I2R, NTT

Portable Clinic

One Community One Clinic

5 Tertiary Care

Centers

5 Secondary Care

Centers

6 Community Eye

Clinics

Primary Care

Centers +

+

Specialty Care

Research

Training

Cataract Services

Specialty Diagnosis

Comprehensive Eye

Examination Minor

procedures

Comprehensive Eye

Examination

1000 - 2000 patients

150 – 400 patients

100 -150 patients

20 -25 patients

A Day

10,000 Patient Examinations

1,500 Surgeries

5-6 Outreach camps

•300 transported to base

for surgery

Classes for 100 Residents &

300 techs & administrators

43

From hospital

to residence

Hospital Community

24/7 system of home nursing

and long-term care

Variety of housing

options responsive to

elderly needs

Transportation and mobility

options for people with

various needs

Primary

physician

Productive social

participation of

healthy elderly

Distance

medicine

Information

network

Health

information

Pharmacy

Financial

cost

QOL of

their family

QOL of

the elderly

Evaluation

Primary care

system

Patient

studies

Source: The University of Tokyo Institute of Gerontology: http://www.iog.u-tokyo.ac.jp/research/research_activity-

e.html

Example of research: for Aging in Place：A community-based social experiment (University

of Tokyo Institute of Gerontology)

http://www.iog.u-tokyo.ac.jp/research/research_activity-e.html





IN THE CONTEXT OF UNIVERSAL HEALTH

COVERAGE

• Current increased attention

on universal coverage has

created momentum and

platform for developing

national health financing

systems

• Services = promotion,

prevention, treatment,

rehabilitative, palliation

• Who? Everyone!

27

Understanding the needs

and preferences of older

people for assistive and

medical technologies

Cost benefit

+

HTA

Measure impact

THE ENABLERS I

• Ethnography

– Usability testing; health literacy

• Regulation: harmonization, framework, definition, conformity

• “Seed to scale”

– Originality vs adaptation

– Leverage existing programmes

• Health system: UHC

– Human resources

– Financing

– Organization

– Quality

• Multi-stakeholder

– Government, academia, industry, NGOs, health workers, foundations,…

THE ENABLERS II

• Understanding longevity and epidemiology – Alter the curve: understanding and influencing trajectories of ageing

– Life span vs. health span: Live longer, but health?

– Wellbeing and happiness

• Economics: social investment; returns on investment; scenarios predicting productivity, tax

contributions, pension, health and social cost tradeoffs with gains; rethinking the workplace; pricing;

incentives; government-individual share of responsibilities?

• Coherent policy – Ageing + eligibility + HTA and regulation + financing + integration with health and social services

– Hubs and partnerships

– Reorienting health and social service systems; decentralization; HRH and coimmunity organizations

– Inclusiveness, social cohesiveness, strengthening the community

– Managing competition – resource limits

– Social capital

• Prioritization -- HTA

• Evaluation

AN ECOSYSTEM FOR

INNOVATION

Research

and

developmen

t based on

needs

Health

Technology

Assessment

Regulations :

Medical devices

Registration and

premarket

approval

Needs

Assessments

Selection

Installation,

Inventories;

User training

Maintenance

Post market

surveillance and

Adverse event

reporting

Approved list

of devices for

interventions

Decommissioning

AD is commonly referred to as Assistive Technology (AT), and also known as ‘aids and equipment’

The World Health Organisation (2004):

‘any device or system that allows individuals to perform tasks they would otherwise be unable to do or increases the ease and safety with which tasks can be performed’

Survey used term Assistive Devices (AD)

Assistive Devices (AD)

33 © 2014 WHO, Motivation Australia & RACS

Definition Medical device (MD) = “any instrument, apparatus,

implement, machine, appliance,

implant, reagent for in vitro use,

software, material or other

similar or related article,

intended by the manufacturer to

be used alone or in combination,

for human beings for one or

more of the specific purpose(s) of

diagnosis, prevention,

monitoring, treatment or

alleviation of disease…” (WHO,

2003).

Medical devices are diverse and widely regulated

Global Harmonization Task Force (GHTF) definition

This survey focused on MD for:

cardiovascular diseases, malignant neoplasms, sense organ diseases and respiratory diseases &

general/broad clinical application

Medical devices (MD)


AD – Functional activities Eat and drink as independently as possible 4.3

Transfer to or from bed or chair 4.2

Able to be clean and hygienic 4.2

Able to hear and communicate 4.1

Able to dress 3.9

Able to see and understand writing 3.9

Move about and use transport 3.9

Grip or pickup items and do housework 3.7

Manage health care & fatigue including following health

advice

3.7

Participate in community activities (can include

employment) & visiting others

3.4

Take care of a family member 3.2

Experience intimate/sexual relations 2.7


AD for seeing 4.2

AD for transfer and turning 3.9

AD for cognitive assistance 3.9

Non AD: Personal assistance 3.7

AD for personal care 4

Supporting handrails and grab bars 4.1

Adapted furniture and accessories 3.7

AD for preparing food and drink 3.9

Adapted beds 3.8

AD for hearing 4.3

Modification or AD for building access 3.7

Safety equipment for home & other places 4.2

AD for managing continence 3.9

Top 13 draft AD priorities


Reasons for AD success (HIC) Functionally very effective 80%

There is a well-functioning and accessible service in place

to assess individual user's needs and prescribe the device

80%

There is Government commitment and action to ensure

access to assistive devices

60%

The device is available for an affordable cost to older

person and/or their family

80%

The device is adjustable; or there is a choice of type to

properly suit the individual

60%

The device is routinely provided for those with identified need 40%

The device is a part of other supports/therapy 70%

There is good community education & awareness of such devices 50%

The device looks good 20%

Culturally appropriate and acceptable 20%

There is research evidence of the benefits the device offers 30%

The device was created and/or is readily available locally 10%


Reasons for AD success (MIC) The device is available for an affordable cost to older person

and/or their family

89%

The device is a part of other supports/therapy 58%

Functionally very effective 61%

There is Government commitment and action to ensure access

to assistive devices

69%

There is a well-functioning and accessible service in place to assess

individual user's needs and prescribe the device

53%

There is good community education & awareness of such devices 47%

The device is adjustable; or there is a choice of type to properly suit the

individual

47%

The device was created and/or is readily available locally 36%

Culturally appropriate and acceptable 28%

The device is routinely provided for those with identified need 36%

There is research evidence of the benefits the device offers 22%

The device looks good 19% 40 © 2014 WHO, Motivation Australia & RACS

Why AD was NOT successful…

Cost unaffordable

Poor community education & awareness

MIC – no service to assess/assist, and local unavailability, unusable

HIC – no adjustment, and stigma


Strategies to improve AD access

1. Government/agency help to get AD

2. Community awareness & education

3. (HIC) Better quality checks

4. (MIC) Suitable devices for local need

5. Locally available services to assist

Health professional training

AD development $

Lowest rank: less regulation!


Medical Devices

Four specialised diseases:

Cardiovascular

Malignant neoplasms (cancers)

Sense organ diseases

Respiratory diseases

General use MD

Basic diagnostic

Laboratory diagnostics

Point of care in vitro

Diagnostic imaging

MD for surgery & intensive care 43

© 2014 WHO, Motivation Australia & RACS

MD for specific diseases

Cardiac

Only cardiography & external defibrillators recommended for health centres. Private hospitals better equipped than public hospitals

Advanced devices currently only in HIC

Malignant neoplasms

Strong support for public hospitals to have MD

Higher availability in MIC private hospitals than in HIC


MD for specific diseases (2)

Sense Organ

Most MD rated important (but not present) in health centres (not surgical or laser related),

Greater coverage needed in hospitals

Respiratory

Peak flow meters & nebulizers priority for clinics, but hospitals higher for all MD in HIC

Availability seems good in most hospitals, but also extra demand for MD


MD for general use

Basic diagnostic – generally good coverage across

the board. Some items ‘not necessary’ in HIC.

Laboratory diagnostic – consistent, and generally

good availability in hospitals. Some items ‘not necessary’ in HIC.

Point of Care in vitro diag.- good availability and

in the right places.

Diagnostic imaging – Availability in hospitals good.

Push for access in health centres for HIC.

Surgery & intensive care – HIC had and expected

more MD in health centres. Public hospitals had highest levels of demand & availability


Ranked influences on MD availability Appropriateness of the device or service in terms of current

practice

Acceptability to health care personnel*

Affordability of the device or service (if it is reimbursable)

Availability of the device in the national medical device market

Affordability of the device or service (if it is not reimbursable and

the person has to pay as out-of-pocket expenditure)

Acceptability to patients

Quality of the devices

Other factors

* Interestingly lack of acceptance by health

personnel did not ‘lead’ to unavailability! 47 © 2014 WHO, Motivation Australia & RACS

Unavailability of MD – other factors

MIC noted

Small hospitals struggled to get/replace MD due to impact on profit

Limited trained personnel to operate

Lack of capital to purchase

Government ‘red tape’ hinders acquisition

Return on investment low if patient funded


Strategies to improve MD access 1 Decrease cost of available devices / services

2 Improve governance and policy

3 Improve levels of training for health care personnel by

manufacturers

4 Improve quality of available devices

5 Improve infrastructure and health service provision.

6 Increase funds for maintenance of medical equipment to avoid

down time that makes them unavailable.

7 Improve distribution of products or services

8 Have a regulatory process for medical devices( if not available)

9 Increase regulatory efficiency ( if available but long response

time)

10 Increase local production of devices in your country, to increase

availability

11 Increase availability of donated devices 49

© 2014 WHO, Motivation Australia & RACS

AD & MD - Conclusions

Need to validate AD focus with older people themselves & extend survey

Cost remains an important driver

AD & MD most effective when part of other services

Governments play vital role in getting affordable AD & MD to those who need it

Education/training – of professionals AND community


Global Forum on innovations for ageing populations

Build the case for innovations Review innovation trends Delineate WHO & WKC research

Double burden of infectious and parasitic disease as well as non-communicable diseases

Widening gap between life expectancy and healthy life expectancy

Increasing prevalence of functional and cognitive decline


The case for innovations


Community and home-based care

Fall prevention and mobility

Sensory Impairment

Mitigating cognitive decline

e-Health and robotics

m-Health

Elder-friendly

medicines

Trends in innovations

Social innovations for ageing and

health

Tools for decision-making

Key recommendations


• Develop an inventory on existing innovations to be assessed for broad

application (to give an idea as to what can be immediately used for

interventions in different country)

• Learn from life in the south for practice in north: ”ageing in place" is the

necessary reality in developing world

• Provide technical support to establish system of home- and community-based

integrated long-term care & mechanisms to support families and communities

in providing care for frail elderly

• Build a stronger evidence base on implementing integrated community care

systems that could be shared among countries.

Delineating the research agenda


Facilitate access to up-to-date

demographic, health and economic

evidence for innovators,

implementers and policy-makers.

Fill-in the evidence gaps and build

tools necessary to catalyse

innovations.

Encourage partnerships between key

stakeholders.

SUMMARY OF PRIORITIES

1. Mobility

2. Vision

3. Hearing

4. Speech

5. NCD related diagnostics, medical and assistive devices

6. Psycho-social (cognitive decline)

7. Environment: home, community, work

8. Policy coherence: technology plan (including innovation hubs)

1. HTA, Regulation, Finance, Integration into system

9. Simpler value chain: development, distribution, maintenance,

scale up + attention to health literacy

STRATEGIES OF LTC DEVELOPMENT PLAN

1. Screening, assessment of LTC needs among elderly and development of management information systems in the community

2. Development of community-based service system for delivery LTC services and preventive LTC

3. Development of sustainable LTC financing model and LTC benefit package

4. Human resources development for LTC

5. Knowledge generation and management and monitoring and evaluation of the system

6. Development of standards, rules, and regulations on LTC

Thank you

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