A sea change is underway in long term care. To tackle this important subject, we bring you a three-part series of articles on the future of home health care. Part Three asks whether robots and other high-tech solutions will make it possible for most boomers to age in place. Journalist Barbara Peters Smith wrote this series as a John A. Hartford Foundation Journalist in Aging Fellow, participating in a broader fellowship program supported by New America Media and the Gerontological Society of America. This article first appeared in the Herald-Tribune (Sarasota, FL) in May 2013 and is also posted at the New American Media website. It’s reprinted here with permission.
Third of Three Parts
If you are 55 years old, you could wake up 30 years from now to the warm, affectionate voice of your personal care robot, asking what you would like for breakfast and why you slept for only 5.8 hours last night instead of your usual 7.3.
After your mattress takes your morning temperature, pulse and blood pressure readings, you might want to reach for the tablet on your bedside table and tap the touch screen to turn up your home’s heat by a few notches before you throw back the covers. The robot can fetch your slippers.
As you rise and walk into your day, floor sensors might trigger an infrared scan of your gait and balance, relaying the information to a nearby nursing center. If anything seems amiss, a car could be on its way to your home.
If not, your environment will continue to gather data for a morning summary sent—with your permission—to the smartphones of your sons or daughters, relaying what you had for your morning meal and whether you took all your medications.
The Home Care Revolution, a three-part series:
Part 1: The Home Care Revolution: Is Family Care on the Way Out?
Such barely visible technology, many aging specialists believe, is what will allow members of the baby boom generation to navigate old age independently in the privacy of their homes. This will be important, they say, in an era of stretched health care resources and at a time when more older Americans are single than ever before.
“My mother is 89 and and my father is 91,” says Marjorie Skubic, director of the Center for Eldercare and Rehabilitation Technology at the University of Missouri. “They’ve been married so long that they know each other very well, and it’s relatively easy for them to pick up on subtle changes with each other. But there are a lot of people that live alone and they don’t have a partner of 65 years. The sensors can pick up on these changes.”
The sensors are what Skubic, an engineering professor, has been working on for more than eight years. An in-home network developed in a collaboration of engineers and health care professionals is being tested in elder communities in Columbia, MO, and Cedar Falls, IA. Changes in the sensor data patterns, Skubic says, have been successful in early detection of health states that can lead to hospitalization—including urinary tract infections, congestive heart failure, pneumonia and post-hospital pain.
The network—which includes an array of devices underneath the mattress and infrared motion detectors on the walls—can tell more about an individual’s health than he or she may know.
“We’ve spent a lot of years looking at this data,” Skubic says. “We can identify changes in patterns about 10 days to two weeks before critical health events—often before the elderly resident even notices that there has been a change. And the sensors do a nice job of pulling out the changes associated with depression.”
The home care revolution—a national move toward letting frail elders remain in their homes without resorting to residential facilities—is already under way, with more than half of America’s direct care workers engaged in a new form of the old-fashioned house call. But as the very old generation expands over the next three decades, far outnumbering those in the health care work force, technology that pinpoints when and where help is needed could be key.
Skubic’s team is also involved in a study of personal care robots, to determine the potential for communication between them and older adults.
“We’re looking at an assistive robot that could be used in a home setting. It can accomplish fetch tasks and has an ability to communicate with a user using very natural facial language,” she says. “We’re finding that it’s not easy for robots to understand imprecise, approximate, ambiguous language. We wanted to explore that, and the fact that older adults use language differently than younger adults. It’s brought out some interesting issues.”
In one study, older people were fine with the idea of robots performing household chores but less comfortable with the notion of a robot helping them dress or bathe.
For instance, Skubic says, a robot may have trouble with the command, “Go get my glasses. I left them on the bedside table.” But it can respond to directions, like, “My eyeglasses are on the table, behind the lamp, next to the bed.”
At least for now, personal care robots may be less than welcome as stand-ins for human health aides. A study by the Georgia Institute of Technology last year asked older adults if they were willing to use robots in the home for daily tasks. Subjects between the ages of 65 and 93 said they were fine with the idea of robots performing household chores but were less comfortable with their performing personal care, like bathing or dressing.
And Debra Parker Oliver, a social work professor at the University of Missouri who studies long term care and end-of-life issues, takes a critical view of the rush to find a technological solution for so many aspects of elder care. She would like to see more research before in-home sensors and robots are considered ready for prime time.
“Businesses have been so focused on developing the gadgets, and not on whether the gadgets are needed,” she says. “The question should not even be, ‘Does it work?’ but ‘Do we want it or can we afford it?'”
Oliver believes home care technology should be subjected to more rigorous studies, with emphasis on long-term outcomes and affordability. Instead, she says, grant funders seem dazzled by the potential for supplanting human beings with hardware.
“You may have a motion sensor that detects restlessness in bed, but what does that mean clinically?” she asks. “If it doesn’t reduce cost, we’ve got to question it.”
The Delivery System
Equally important, say aging specialists, is that this new approach to elder care embodies quality standards along with cost efficiencies. The worst outcome would be some huge, new, health care bureaucracy that imposes tools and services people don’t need or want.
“As a doctor, I believe the value of this transformation we’re going through is that it will actually shed light and raise awareness” of the challenge, says Bruce Chernof, president of the SCAN Foundation, a California nonprofit that promotes aging with dignity and independence.
“I’m not suggesting for a moment that we would medicalize people’s homes,” he adds. “Is the care accessible, is it affordable and can we judge the quality of it: that, to me, should be the metric. It should be really about what the person is experiencing. And these quality measures need to make sense for those paying for services out of pocket.”
How this delivery system is constructed is still a matter for debate. Meanwhile, the federal government and many states are experimenting with approaches that range from a coordinated patchwork of nonprofit community programs, to a single state agency running the system, to a privatized but state-funded operation managed by for-profit companies.
Florida will embark this summer on the third option, contracting with health maintenance organizations to provide care for some 36,000 elderly Medicaid recipients statewide.
Larry Polivka, executive director of the Claude Pepper Center at Florida State University, which studies aging issues, predicts that nursing home use will remain flat—“as we learn more about how to provide services to impaired people at home. But you’re always going to need something like that to care for the most impaired, particularly people with dementia.”
Some warn against creating a situation where people’s basic physical needs are met, but their deeper human and spiritual needs are ignored.
In 2008 Polivka coauthored a paper in The Gerontologist, arguing for an approach that uses the nation’s existing 665 Area Agencies on Aging to coordinate local nonprofits into a coherent home care system.
“The aging network represents an extraordinary, though still underutilized, resource for creating more balanced long term care systems through the expansion of home- and community-based programs,” the authors wrote. Instead of using for-profit agencies that would pull money from the system, they suggested, the network could “identify and maintain roles for informal caregivers and draw on community resources through donations and the use of volunteers” to keep costs down.
The paper echoed a concern among aging specialists that the home care revolution could give rise to a new industry that professionalizes aspects of home care that have been traditionally covered by family members or volunteers. The authors quoted a paper by the 2005 President’s Council on Bioethics, warning of a “danger of the complete transformation of caregiving into labor, creating a situation where people’s basic physical needs are efficiently provided for by ‘workers,’ but their deeper human and spiritual needs are largely ignored.”
But that doesn’t mean Polivka is worried about the dehumanizing potential of personal care robots.
“A lot of people get kind of silly about robots,” he says. “They can, in fact, be of considerable assistance in providing physical aid and might not be that bad as an emotional companion. People, with their imaginations, can create all kinds of characteristics that we might not believe possible.”
Barbara Peters Smith writes about aging for the Sarasota Herald-Tribune and edits its weekly Health+Fitness section. A graduate of Northwestern University’s school of journalism, she was an editor at newspapers in California and Florida until she decided at 55 to return to reporting to challenge herself professionally. She has two adult children, a poet and an artist.