Seniors Aging in Place
Telehealth Programs Allow More Rural Seniors to Live at Home
by Candi Helseth
Revolutionary telehealth approaches across the United States are helping senior citizens continue to live independently in their own homes. In five Midwest states, a research project underway uses advanced telehealth capabilities and motion sensors to track and electronically report residents' daily vitals and changes in trends. In Kansas, integrating telehealth with home nursing care and social service supports has decreased hospital and nursing home admissions. In New York State, short-term home telehealth intervention is helping seniors with chronic diseases manage flare-ups that jeopardize their ability to remain at home.
"Throughout the nation, telehealth technology is transforming health care and bringing advanced technologies into homes," says Dr. Ron Poropatich, University of Pittsburgh School of Health Sciences executive director of the Center for Military Medicine Research and associate editor of Telemedicine and e-Health Journal. "Telehealth is key to the delivery and growth of services in the future, particularly in rural areas."
Phyllis Consoer, 88, and Warren Consoer, 91, are able to maintain a "fierce independence" through the LivingWell@Home program. (Here they are celebrating her 88th birthday.)
Technology transforms homes
When chronic medical conditions threatened Warren and Phyllis Consoer's resolve to remain in their farm home of 55 years near the Iowa-Minnesota border, they found their solution in the LivingWell@Home program. The Consoers are among 1,200 seniors enrolled in the five-year telehealth research project that the Good Samaritan Society (GSS) is conducting throughout 40 communities in South Dakota, Minnesota, Iowa, North Dakota and Nebraska.
The Consoers are still fiercely independent. Warren, 91, operates the tractor and loader to remove snow in the winter. Phyllis, 88, enjoys cooking and baking. "But now we always have someone right here if we need help and that lets us stay in our home," Phyllis adds.
That "someone" is LivingWell@Home's advanced technology. Phyllis and Warren both wear a personal emergency response system (PERS) that will automatically summon help if they are unable to do so. Their daily morning ritual includes a reminder from their telehealth unit to take their vital signs. The unit visually directs them through checks of blood pressure, heartbeat, oxygen, pulse rate and weight. Nearly invisible motion sensors installed in the home monitor their movement and sleep quality 24 hours a day. Data is transmitted via a secure Internet site to GSS's corporate location in Sioux Falls, S.D., where nurses analyze the reports and alert the designated care provider of changes in trends.
"By integrating all this health information, we know what is normal and what is changing for these individuals," explained LivingWell@Home Director Sherrie Petersen. "For instance, if they begin going to the bathroom many times during the night and haven't previously, that change in pattern will initiate looking into whether or not this person has a change in health, such as a possible urinary tract infection."
The Consoers have given their son, Jim, permission to access their care plan from his personal computer at his home 70 miles away. It gives him peace of mind and opportunity to assist with needs that arise.
"The timing for the Good Sam technology was a godsend," Jim said. "The daily monitoring has saved my parents more than once from having to make an emergency trip to their doctor's office."
Coordination of services improves outcomes
Aimee Roberts, a client enrolled in the Windsor Place At-Home Care telehealth program, monitors her own blood pressure.
Since it opened in 1997, Windsor Place At-Home Care (WPAHC) in Coffeyville, Kan., has provided both long-term nursing care and human service supports in the home. In 2007, WPAHC added home telehealth. Executive Director Monte Coffman says the integrated program improves continuity of care and reduces hospitalizations. Because keeping seniors healthy longer at home is less labor intensive, Coffman added, the service stretches limited human resources.
WPAHC is the only reason Para Lea and Ray Bilyeau are able to remain in their country home near Neodesha, Kan., according to Para Lea. Ray, 82, can move only with the aid of a walker and suffers from congestive heart failure and sleep apnea. Para Lea, 75, has limited mobility due to back problems and her need for a third joint replacement. She says she is on "a lot of medication for all the different things wrong with me."
Using a telehealth monitor in their home that electronically reports results to a nurse at WPAHC's office, the couple takes their daily blood pressures, oxygen levels and weight. WPAHC caregivers also go into the Bilyeaus' home to provide personal care assistance, and do cleaning and laundry five days a week, for two to three hours (a schedule that can change, depending on the needs of the patient—each patient is evaluated by a nurse and an individual plan is set up). Caregivers also do the couple's grocery shopping and run errands for them.
"When I had my hip replacement, I couldn't even get in and out of bed so they gave me baths and helped with everything we needed," Para Lea said. "We're pretty thankful. We couldn't do it without them."
The addition of telehealth, which began as a one-year grant approved by the Kansas Department of Aging (KDOA), evolved into a three-year pilot project that confirmed its value. The University of Kansas Medical Center (KUMC) collected data on pilot patients, who averaged 3.2 chronic disease states. Final data demonstrated reductions of 38 percent in hospitalizations, 67 percent in emergency room visits and 20 percent in nursing home admissions. Participants admitted to a nursing home had stays that were 58 percent shorter than the Medicaid average.
"When we serve the needs of the whole person, our chance of success becomes much greater," Coffman said.
Intervention fills the gap
Sometimes, all an individual needs to remain at home is short-term help. The Geriatric Assessment Program (GAP) in New York's Wayne County combines home and telehealth services under the direction of a geriatric team to treat patients whose chronic conditions are out of control. Denise Washburn, a longtime Wayne County resident who is a Certified Geriatric Care Manager, goes to the home to assess the patient and environment. She reports her findings to the geriatrician, who then sees the patient via a telehealth appointment at the local hospital. The geriatrician develops a care plan to manage the patient's syndrome, and Washburn continues to monitor the patient. Once the patient's condition is again under control, the geriatrician refers the patient back to his or her primary physician.
Wayne County has no geriatric specialist so telehealth fills a critical need, Washburn said. Home visits strengthen the service, she added, because they build patient-provider trust and often reveal problems not apparent during a telehealth consultation.
A patient with a history of frequent falls was labeled non-compliant after failing to keep appointments for referrals to outpatient physical therapy. Outside the patient's home, Washburn observed 20 steps the nearly immobile patient couldn't maneuver to go in and out of her home. When GAP arranged PT in the home, the patient began improving. Symptoms related to medication mismanagement account for approximately one-half of patient referrals, Washburn said. She examines all prescription bottles, confirms that they contain the prescribed drug and ensures that the dosage being consumed conforms to the prescribed dates. Then she helps the patient establish a plan to take medications properly.
"Most of my patients are very frail elders," said Washburn, whose patients have included her mother. "The people I work with are generally not part of any other program and they have no one to help them at home. I don't think we should be measuring success solely by how we avoid hospital readmissions and nursing home placements. Success is helping these people live better and healthier."
GAP is funded by a HRSA Rural Health Care Services Outreach Grant, which was awarded to the Wayne County Rural Health Network (WCRHN).
Successes expand services
A patient enrolled in the LivingWell@Home program wears a PERS (personal emergency response system) that will summon help if needed.
"We know that chronic condition management, medication compliance and social interaction improve and that the family caregiver burden, and health care related travel decrease when seniors receive care in the home," Petersen said. "Most importantly, these services support seniors' desire for independence and allow them to live as they wish."
GSS's LivingWell@Home, which began in 2010, is funded with an $8.1 million grant from the Leona M. and Harry B. Helmsley Charitable Trust. Currently, University of Minnesota researchers are evaluating its effectiveness. Petersen said the next step will be developing a sustainable business model that demonstrates the program’s efficacy. Ultimately, the intent is to convince lawmakers that supporting home telehealth technologies is a cost effective means of improving health care nationwide. Telehealth technologies in GSS facilities are being expanded into 24 states throughout 2014.
WPAHC is further proving the value of its integrated model by collaborating with PACE (Program of All-inclusive Care for the Elderly) and three hospitals on two separate projects. WPAHC served 17 PACE patients with advanced chronic conditions for 13 months. Coffman said PACE was very pleased with outcomes: patients had a total of 13 hospital days and no nursing home placements. Six months into a pilot project with three hospitals trying to reduce their 30-day readmissions, the WPAHC patient base has had no readmissions. (As of Oct. 1, hospitals are financially penalized if too many of their patients with certain conditions are readmitted within 30 days of a prior hospitalization.)
WPAHC's service area has grown from about 400 patients in Montgomery County where Coffeyville is located to 1,500 patients throughout Kansas. Coffman said WPAHC is partnering with several managed care organizations to expand telehealth services in 2013.
Lack of broadband or fast Internet access still limits telehealth expansion into some rural areas. According to the 2012 CRS report, Broadband Internet Access and the Digital Divide, 23.7 percent of the 61 million people living in rural areas had no fast Internet service offered for their homes. Yet, rapid growth of cellular communications and the 4G network is going to help propel services into even the most rural areas, Poropatich predicted. The most recent telehealth leap is termed m-Health (mobile) where providers and patients can instantly access information wherever they are using mobile devices such as cell phones and tablet computers.
"As telehealth technology becomes more and more pervasive across rural America, I believe we'll see improved care with frequent proactive health care treatment for patients via mobile devices as opposed to treatment of episodic events," Poropatich said. "Telehealth's possibilities for rural America are endless!"
Seniors Aging in Place
Integrated Social Services is Key Component in Senior Independence
by Candi Helseth
Without the Lighthouse Program, 93-year-old Nannie Edwards wouldn’t be able to stay in her home. The West Virginia Bureau of Senior Services program offers home-based daily living assistance that makes it possible for Edwards to remain independent. Edwards is among 57.8 million American seniors 60 and older who need home-based, long-term support.
"Survey after survey has shown that nine out of 10 older adults want to live out their lives in their homes," says Lenard W. Kaye, Director of the University of Maine Center on Aging. "Home-based social services programs provide the support seniors need to do that. Research has proven that older adults with chronic conditions and disabilities maintain a more stable state when they receive assistance at home."
Demand for community-based programs that help elderly age in place is increasing as the nation's aging population continues to swell. By 2030, the number of Americans aged 65 and older is projected to be more than twice the over-65 population in 2000, increasing from 35 million to 72 million. According to the Administration on Aging (AoA), 27 percent of Americans over 60 have difficulty performing at least one activity of daily living. By age 85, 50 percent need assistance with two or more activities of daily living.
Forty percent of Lighthouse clients are over 85, said Jenni Sutherland, West Virginia Bureau of Senior Services state director. Like Edwards, they are able to manage without 24-hour assistance but they couldn't remain in their home without some assistance. Edwards, who suffers from spinal stenosis and advanced arthritis, is almost totally immobile.
"I can scoot my chair to get from the table to the microwave to make myself stuff and I have a walker or cane if I really have to move," she said. "But this is where I want to be. I've been here 21 years, just been me and Jesus since my husband died 14 years ago. I just hope and pray to God I get to stay here."
She looks forward to her daily visits from caregiver Ann Rogers. Lighthouse caregivers provide up to 60 hours per month in personal care, mobility, nutrition, and housekeeping services. In addition to the physical assistance caregivers provide, they also play a large role in reducing seniors' social isolation, Sutherland said.
"Every day that wonderful woman combs and braids my hair and we visit," Edwards said. "She prepares my evening meal, bathes me, makes my bed, everything she should do plus more!"
To receive Lighthouse services, patients must be over 60, have two or more areas of functional need and not qualify for Medicaid in-home services. Another West Virginia program, FAIR (Family Alzheimer's in Home Respite), helps individuals with dementia and Alzheimer’s stay in the home longer by providing supervision and social interaction as well as respite relief for family caregivers.
Throughout the nation, many seniors benefit from Medicaid’s Home and Community Based Services (HCBS) Waiver Program, which currently offers four program options (two of which were created by the Affordable Care Act). States receive grants, based on their share of the national population age 60 and over, to fund their HCBS programs. (Medicare can pay for home health services for senior citizens who need skilled nursing care. It does not pay for 24-hour care or homemaker services.) In Mississippi, for instance, HCBS offers case management, personal care services, adult day care, expanded home health, home-delivered meals and respite services to nearly 16,000 residents throughout the state (services to the elderly and disabled comprise 12,000 of the 16,000 residents). Mississippi's HCBS services are provided by a variety of organizations, such as home health, case management and personal care service agencies, said Sandra D. Bracey-Mack, a Deputy Bureau Director at the Mississippi Division of Medicaid.
Finding funding for in-home senior care
Funding—or, rather, the lack of it—seems to be one of the biggest barriers for aging in place programs. Viability depends on adequate state and federal funding, Kaye said.
"Over the last 20 years, the funding level from OAA (Older Americans Act) has not kept pace with the needs of the aging population," he said. "To some extent, those in human services need to build compelling arguments to convince state and federal funding sources that human and social services have equal impact and importance with healthcare services in serving older adults."
Mississippi's HCBS services got a boost last year when legislators approved allocating $16 million from a Medicaid surplus after AARP Mississippi convinced lawmakers that the state would save money ultimately. More than 3,000 residents on a waiting list began getting services.
"What we looked at and showed legislators in Mississippi is that it saves taxpayer dollars to provide that funding for people who really don't need 24-hour care," said AARP Mississippi State Director Sherri Davis-Garner. “Three people can be cared for at home for about the same cost of caring for one person in a nursing home. AARP Mississippi has made home and community-based services a key issue for years because our members have told us they want to age at home with dignity."
Sutherland said about 80 percent of West Virginia is rural, and seniors whose income or assets disqualified them for Medicaid services were unable to afford the level of assistance they needed or there were no programs available where they lived. In 2007, the West Virginia Legislature approved state funding that fully covers the costs of Lighthouse and FAIR. Each of the state's 55 counties has a registered nurse who develops care plans for patients. Counties are responsible for caregiver training and supervision. Lighthouse recipients pay for services on a sliding fee schedule, and their contributions go back into the program.
Integration is key
The RUPRI report, Rethinking Rural Human Service Delivery in Challenging Times: The Case for Service Integration, found that there is "an unprecedented need" for increased human service and safety net programs. "For decades, rural communities have found themselves at an unfair competitive disadvantage, as population-based, formula-driven funding allocations and urban-oriented program delivery designs became the norm in federal and state programs," the report authors state. "Federal funding formulas that allocate money based on county population formulas are more likely to exclude less-densely populated rural counties from a limited pot of funding."
The RUPRI report also notes that rural areas must contend with higher costs of service delivery and scarcity of service providers that are quite different from cities with high population concentrations. The report authors recommend moving toward place-based approaches to integrate human services programs that cross geo-political jurisdictions, share resources and staff, and create new entities to provide fiscal and operational program management.
"I think we all agree that it makes sense but we continue to struggle throughout the nation with ways to effectively and efficiently integrate professionals in a genuine system of collaborative team-based care," Kaye said. "We are seeing progress. A number of health care entities are presenting encouraging evidence about the importance of services delivered in the home. And the federal government and several forward thinking foundations are promoting creative projects that test out different structures and mechanisms that may enable an integrated system."