Keiko Nakamura
INTRODUCTION
The use of advanced technology in urban society benefits residents by increasing their quality of life. Examples of the use of technology in Healthy Cities pro- grammes are:
● health-promoting equipment and information services;
● improved care support systems for senior citizens and people with disabilities;
● high-quality and accessible medical services;
● enhanced management of living environments;
● improved systems for monitoring the city’s health and environmental condi- tions;
● a city health and environment information system accessible by the public;
● an information system, such as a geographic information system (GIS), for monitoring and evaluation of health;
● user-friendly devices to support citizens’ health-promotion practices at home;
● a health-information network system, such as e-health;
● an information exchange system among people involved in Healthy Cities programmes at various levels (city, country and worldwide).
The recent development of information and telecommunications technology is now causing rapid changes to people’s everyday lives. Our daily lifestyle will be very different in several years; the changes over the next few years could be greater than those in the past several decades. Health is closely related to people’s everyday activities, such as working, eating, commuting, shopping, leisure-time activities, and sleeping. The conditions for these everyday activities will be radi- cally changed by advanced technology.
To create cities that provide supportive environments for the health of its citizenry, it would be effective to make use of information technology. This chapter illustrates the effectiveness of using information technology in home healthcare and discusses IT’s potential values in promoting health.
TELECARE AND TELEHEALTH
The term ‘telecare’ refers to the provision of home medical treatment, home nurs- ing, nursing care guidance, and nutritional and other types of care and guidance as directly accessed by patients who live at home and their families. The provision of health-promotion information, patient education, consumer education, and related items is sometimes also referred to as ‘telehealth’, but there are frequently no clear divisions between telecare and telehealth. Moreover, within telehealth, access to easily understandable medical information and to information regarding medical institutions by general consumers and patients using the Internet and other information technology is also referred to as ‘e-health’, and this field is exploding into a large market.
HOME HEALTHCARE AND TELECARE NEEDS
In home healthcare, communication and coordination between clients and care providers and among care providers themselves facilitate clients’ indepen- dence and the provision of appropriate care. Therefore, a large percentage of the healthcare needs of senior citizens involves consultations and management of chronic illness and disability. The measurement of mobility, sleep patterns, and domiciliary behaviour, such as cooking, washing, and toileting, can prop- erly identify changes in the functional health status of the client at home.
These everyday activities reflect clients’ independence in living and are essen- tial for them to regain their social life skills. Obtaining emotional and social support is identified as a major home-care problem. Consultations, assess- ments pertaining to the performance of daily living tasks, practical advice to facilitate independent living, and emotional support are all needed in home healthcare.
Home healthcare often requires frequent visits by healthcare professionals, which necessitate the participation of a wider range of professionals. There are great time demands made on the professionals involved. Coordination of services provided to a client by different professionals has helped eliminate duplication and mismatch of services. However, the senior citizen population is growing rapidly, and existing services do not meet growing client demands for more fre- quent communications with professionals and detailed supervision of their health and their acquisition of everyday life skills. It is becoming crucial to improve the quality of home healthcare by using resources wisely.
Thanks to recent advances in telecommunications, interactive audiovisual transmission – videophone technology – between households and healthcare providers has become available. The application of this technology to healthcare services or telecare, particularly in the home-healthcare field, seems likely to widen the choices of better care for those senior citizens who need long-term con- sultation with healthcare professionals.
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The use of videophone technology helps match information with an individual’s needs in a timely manner. This technology has been applied in different clinical settings and is changing access issues in medical care. In the field of home health- care for senior citizens, home telecare employing videophone technology has the potential better to match the knowledge and skills of health professionals with the growing needs of senior citizens seeking care at home.
ASSESSMENT OF EFFECTIVENESS OF HOME TELECARE An intervention study was conducted to evaluate add-on benefits to home health- care from a videophone system (Nakamura et al. 1999). We compared improvement in the functional independence of clients and the time spent by pro- fessionals in providing home-healthcare services with and without videophones.
The intervention group cases were provided home-healthcare services with videophone in addition to conventional services, and they were compared with the reference group cases which were provided regular home-healthcare services only. The former cases were defined as telecare cases and the latter as usual- homecare cases. Telecare cases and usual-homecare cases were selected from communities where home healthcare usually includes physician home visits, vis- iting nurse services, meals on wheels, and household services.
Clients of home telecare were requested to participate in a three-month study of videophone use for their services and an evaluation study of home healthcare.
Individual services were provided by a physician, a public health nurse, a visiting nurse, a physical therapist, an occupational therapist, a speech therapist, a social worker, and one to three home helpers according to individual needs.
The usual-homecare cases were selected as reference cases from ordinary home- healthcare cases provided with ordinary home-healthcare services. Among newly enrolled clients in home healthcare in any month except February, June, and October, those matching the telecare cases on the criteria of sex, age (three-year range), and level of independence as assessed by the Katz index of ADL (Katz 1963) were requested to participate in an evaluation study of home healthcare.
Individual home-healthcare services were provided by a physician, a public health nurse, a visiting nurse, a physical therapist, an occupational therapist, a speech ther- apist, a social worker, and one to three home helpers according to individual needs.
The following services are usually planned and provided based on the regula- tions of a municipality: physician home visits, public health nurse visits, visiting nurse services, visits by physical therapists, visits by occupational therapists, home-visiting services by home helpers, daycare service for frail senior citizens, meals on wheels, mobile shower and bathing service, in-house bathing service for bed-ridden senior citizens, a group rehabilitation programme for senior citizens with disabilities, and others.
We used videophone sets transmitting colour images using 128 Kbps ISDN (Fujitsu VS-700) – video camera, codec, and monitor – for the services for the Applicability of information technologies 133
telecare cases. Videophone sets were installed in the homes of the individual telecare clients and the offices of home-healthcare professionals, namely, the physicians, public health nurses, physical therapists, occupational therapists, and social workers.
The following were offered as services using videophone: medical consulta- tion about clients’ health problems; instructions regarding physical exercise;
communication exercises; assessment and instructions regarding ADL; assess- ment and instructions regarding communication; assessment and instructions regarding daily activities; assessment and instructions regarding clients’ social activities; assessment and instructions regarding nutrition; assessment and instructions regarding caregiving techniques; advice and instructions for visiting healthcare staff; advice and instructions for volunteers; advice on the effective use of health and welfare resources; and emotional support for clients and their fami- lies. Those clients having difficulties in handling the videophone by themselves were supported by their family members in the use of the videophone.
The following assessments were performed both at the first and second assess- ment visits and in both the intervention telecare cases and the reference usual-homecare cases: ADL independence measured by the 13 motor items in the Functional Independence Measure (FIM), including self-care, sphincter control, transfer and locomotion; communication independence measured by the two com- munication items in the FIM; and social cognition independence measured by the three social-cognition items in the FIM (Keith et al.1987). We compared differ- ences in the before-and-after improvements between matched pairs of intervention telecare cases and reference usual-homecare cases using paired t-test, controlling for sex, age, and the baseline Katz index of ADL.
Records of home visits, outpatient care, and consultation via videophone were filed and used for this analysis. According to the dates and hours that clients received services by physicians, public health nurses, physical therapists, occupa- tional therapists, social workers, visiting nurses, and home helpers at home, and services via videophone, person-minutes spent by physicians, public health nurses, physical therapists, occupational therapists, social workers, visiting nurses, and home helpers were calculated for each case, including time spent at clients’ homes; time spent for examinations, treatment, and instructions for a sin- gle client at outpatient settings, such as physician’s clinics, hospitals, or day-rehabilitation centres (in the case of a group session of t1minutes cared for by n1professionals and attended by n2clients, time spent for a single client (t) was calculated as follows: t = (t1 × n1)/n2); and time spent for communication via videophone. Weekly average person-minutes per case were calculated for the tele- care and usual-homecare groups.
RESULTS OF THE ASSESSMENT
A total of 39 clients used videophones. The selection of telecare cases from the 39 telecare cases according to the baseline ADL and case matching defined 16 134Keiko Nakamura
matched pairs for the analysis. They were five pairs of male clients and 11 pairs of female clients. The average age of the telecare clients was 72.1 years and that of the usual-homecare clients was 73.0. Although two cases of home-telecare cases were categorised as G level in the Katz index of ADL, case matching was not suc- cessful with ordinary home-healthcare cases.
The ADL independence scores of the telecare group improved from 61.4 to 62.9 (91 points as maximum score) on average, while those of the usual-homecare group declined from 60.8 to 60.4; the improvement in the telecare group was sta- tistically significant (p<0.05). The communication and social cognition independence of the telecare group during the three-month trial period measured by the FIM improved from 10.4 to 11.4 points (14 points as maximum score) and from 14.2 to 16.1 points (21 points as maximum score) on average, respectively;
these were significantly greater than those of the usual-homecare group (p<0.05).
Communication via videophone facilitated the following assessments and responses: assessment of weight loss and prompt provision of advice; evaluation of nutritional balance and everyday meals at home; assessment of everyday life sched- ule and change of physical condition during the day; supervision of physical exercise suited to clients’ everyday physical condition; advice on health of family caregivers;
provision of everyday face-to-face speech exercise; advice on everyday homemaking activities; encouragement of regular physical exercise at home; and others.
Average weekly total person-minutes required for face-to-face intervention and intervention via videophone by professionals working with the telecare group was 229 minutes per case, while that by professionals working with the usual- homecare group was 219 minutes per case (p>0.05). Time spent for communicating via videophone was 66 minutes per week. Time spent providing visiting services and travelling in the telecare cases was 186 min/week/case and that in the usual-homecare cases was 255 min/week/case (p>0.05). When time for travelling to and from clients’ homes and for pick-up service to provide trans- portation from clients’ homes to care centres was included in the calculation, the average weekly total person-minutes required was 303 minutes per case with the telecare group and 316 minutes per case with the usual-homecare group. Average weekly person-minutes required by professionals were as follows.
● Physicians: 15 minutes (3 minutes via videophone) in the telecare group and 18 minutes in the usual-homecare group.
● Public health nurses, visiting nurses, physical therapists, occupational thera- pists: 151 minutes (63 minutes via videophone) in the telecare group and 109 minutes in the usual-homecare group.
● Home helper: 120 minutes in the telecare group and 170 minutes in the usual-homecare group.
As regards the number of consultations, the telecare group received 7.0 consulta- tions per week (3.8 consultations via videophone and 3.2 consultations as home visiting and ambulatory services) while the usual-homecare group received 3.6 Applicability of information technologies 135
consultations as home visiting and ambulatory services. The frequency of received consultations was significantly greater in telecare cases than in usual- homecare cases (p<0.01).
EFFECTIVENESS OF HOME TELECARE
Home healthcare using videophone, in addition to home visiting and ambulatory services, was more successful in improving the independence of clients than care under conventional support programmes provided through home visiting and ambulatory services. Improvements in clients’ functional independence were realised without requiring extra time by the professionals involved. This evidence shows the potential for telecommunications technologies to improve the quality of home healthcare.
Our experience in this study suggests that services via videophone cannot replace all in-person visits. The net time professionals contributed in services via videophone was 29 per cent of the total time spent with clients (face-to-face in- person services and services via videophone). The frequency of consultations, regardless of the time spent for the consultation, was significantly increased with the application of telecare. This might have increased opportunities to respond to clients’ needs in a timely fashion.
Results of the time study showed that the total person-time required per case for the telecare cases was not greater than that for the usual-homecare cases.
Although the total cost of home healthcare requires inclusion of other direct and indirect costs, it is significant that telecare cases did not require additional per- son-time compared with usual-homecare cases. This is because videophone communication replaced some of the visiting services. If telecare were widely provided as one of the regular styles of home healthcare, more efficient use of time and personnel could be realised.
POTENTIAL ADDED VALUE IN HEALTH PROMOTION
The development of personal skills through the provision of information, educa- tion for health, and other enhancement of life skills helps people exercise more control over their own health and over their environment and make choices con- ducive to health. In rehabilitation at home, task-specific activities based on the client’s personal interests are important. Home-based therapy values purposeful activities that promote adaptation and competence in older adults with chronic disabilities. Communication independence, particularly independence in expres- sion, was improved. Videophones enable communication via body language, physical expression, and appearance. Therefore, repeated opportunities to speak with others via a medium that includes a visual component contributed to the improvement of clients’ personal skills in communication. The use of such an 136 Keiko Nakamura
audiovisual medium was thought to increase compliance, encourage clients, and facilitate health professionals’ decision making.
A senior citizen’s ability to communicate is closely related to his or her physi- cal and interpersonal environment. Support from friends and neighbours is associated with mental and physical health outcomes. Communication via video- phone focuses one’s concentration on one’s interlocutor. Videophone communication widens clients’ social network, and so they can regain their inde- pendence in society. Videophone communication requires greater independence than direct personal communication by visiting or ambulatory services because the client must organise the call. In addition, it is easier to develop better human relationships and greater self-esteem by use of videophone.
In terms of controlling the quality of home healthcare, telecare would facilitate timely assessment by supervisors and/or outside reviewers. As most home- healthcare services are provided at individual households without constant moni- toring by outside reviewers, review of services via videophone is a possible option to protect clients’ rights and guarantee quality services.
Differences in level of home healthcare by geographical area are thought to lead to unequal access to care. Telecare can alleviate regional differences by mak- ing high-quality assessment and supervision of home healthcare available regardless of the distance a client lives from a well-staffed home-healthcare cen- tre and by providing on-the-job training and case supervision and advice to visiting staff by well-trained supervisors.
The add-on effectiveness of videophones in home-healthcare services was found to be significant. Evidence showed that the use of information technology in home healthcare increased the ability of the senior citizen and their families to control and improve their health. The further potential of information technology fundamentally to increase the control of the general public on their health was inferred (Brennan 1999). Appropriate use of information technology is likely to increase opportunities for multiple sectors to participate in decision making in individual as well as population health. Innovative thinking regarding the best use of emerging technology will create new opportunities for health promotion.
References
Brennan, P. F. (1999) Telehealth: bringing healthcare to the point of living. Medical Care, 37: 115–16.
Katz, S. (1963) Studies of illness in the aged: the index of ADL, a standardized measure of biological and psychosocial function. JAMA,185: 914.
Keith, R. A., Granger, C. V., Hamilton, B. B. and Shervin, F. S. (1987) The functional inde- pendence measure: a new tool for rehabilitation. In Eisenberg, M. G. and Grzesiak, R. C.
(eds) Advances in Clinical Rehabilitation. Vol 1. New York: Springer-Verlag.
Nakamura, K., Takano, T., Akao, C. (1999) The effectiveness of videophones in home healthcare for the elderly.Medical Care,37: 117–25.
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