The Use of Technologies in Care Homes

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Introduction

In our work on the Vanguard projects in reducing hospital admissions to care homes we have been considering the role of technology within the care homes setting. Areas that we have been looking at include but are not limited to telehealth, I Pad, and more modern, possibly contentious technologies, such as virtual reality headsets.

When planning this programme we considered:

How might technology increase social engagement in the care homes, without replacing human contact?

How might technology be used to proactively monitor health, to prevent/detect delirium and / or reduce unnecessary hospital admission?

How might technology be used to promote physical exercise in care homes?

The picture in other areas may well be different, but for here, and for now, at least we seem to be lagging as we found a fairly limited take up. This is also representative of the many care homes that we train. However, the potential use of technology in dementia care has been gathering pace, as new technologies emerge onto the market. A recent coping review that was carried out by GIbson et al (2016) identified 171 product types and 331 services. However, many of these are unregulated, and have not been rigorously tested in research conditions. Despite this there is a significant pull for these technologies. One of the driving factors (although not the only factor) is how these technologies increase efficiencies.

Some definitions:

Assistive Technologies: ‘any device or system that allows an individual to perform a task that they would otherwise be unable to do, or increases the ease and safety with which the task can be performed’ (Royal Commission on Long Term Care, 1999)

Telecare: remote social care monitoring

Telehealth: Telehealth is the remote exchange of data between a person at home and their clinician(s) to assist in diagnosis and monitoring typically used to support people with Long Term Conditions. It comprises of fixed or mobile home units to measure and monitor temperatures, blood pressure, glucose levels and other vital signs parameters

The reasons to use technology are vast, and extend far beyond safety but might also include:

Increase engagement, support independence through multiple mechanisms (prompting memory, orientation, supporting motor skills etc), facilitate proactive and preventative health monitoring, improve wellbeing through multiple domains (including encouraging exercise) and relieve carers stress. Then there are the organisational benefits which might include better targeting of human resource, support communication across teams, support compliance and safeguarding through effective monitoring and reporting.

AT are used by different people in different ways. GIbson et al (2016) usefully categorised the AT into 3 camps: ones that are used by people with dementia, ones that are used on people with dementia and ones that are used with people with dementia. For each of these there is a different set of ethical questions, and differing drivers in design. Who is making the decisions about the purchase and use of these technologies? For informal carer’s the quest may be driven by questions like, how can this technology reduce the caring stress levels? Where these technologies are being used to unobtrusively reduce risks, such as monitoring technologies. How much of this is creating a false sense of security? (Nygard et al 2005).

The context

There has been significant investment in the community to respond to demographic challenges. Policy has stimulated investment in the Assistive Technologies (AT), with the Technology Strategy Board investing £25 million of matched funding between 2008 and 2011. However, whilst these technologies are more widely available in the community, at a practice level, there continues to be real challenges in the uptake, both in the community as well as in care homes. Yet the conversations continue about the evolving possibilities of technology. The Dementia Congress in Brighton this year, as well as the Alzheimer Europe conference in Denmark, featured presentations on ‘robots’. The conversations that ensued included ethics, as well as how these could be used in cashed strapped times.

Greenhalgh et al (2012) suggest that there are several conversations going on around the use of AT, of which ethics is only one. The ‘ethics’ conversation is mainly driven by the professionals working in the sector. Developers and ‘modernists’ are concerned with the benefits and use of AT in saving time, and creating efficiencies. There is also the ‘political’ conversation stating the economic benefits of the telehealth, and telecare markets and the role of industry in influencing, or managing vested interests. Then finally there is the ‘change management’ conversation which argues that there is a mismatch between the system, and actual work practices, and work needed to be completed to address this. These conversations create tensions in the development and uptake of AT, and there is boundless interconnectedness between these.

Nauha et al (2016) looked at the use of AT for people at home with a memory disorder. In this study they also explored how the use of these technologies can facilitate, and support the work of the care staff, together with how the technology is effective in supporting the person with dementia. An important consideration, if we are to address the concerns of the ‘change management’ conversations we need to be thinking unilaterally about the benefits of AT. This means looking at the benefits not only to the individual but also for the service.

Barriers

So as stakeholders continue to battle it out in different forum, on a practice level there is more concern about where and how do I source these technologies? Are they affordable? Will they work? How can they enable? How do they support carers both formal and informal? And finally, and possibly most importantly, how can they be used ethically?

Assistive technologies (AT) might include low tech, to high tech. These might include clocks and signage to support orientation. Devices which prompt and remind, such as medication dispenses, recorded devices or iPad technologies. Alerts and alarms, communication aids or technologies that support recreation and engagement.

Local authority social care support has traditionally been the largest supplier of AT, most of which are tele care, services like just checking can monitor movements / or lack of movements, and successfully identify issues, hopefully before they develop. In addition to telecare, telehealth is having an increasing role. In Croyden a pilot project was undertaken, which successful reduced the admissions to hospitals

Therefore, on a strategic level technologies are being introduced to enable us to work more effectively, to reduce impact on an overburdened NHS. However, many of these technologies are being introduced much later on post diagnosis, often where there are already significant challenges to an individual’s health and wellbeing. As local authority eligibility increases, often individuals are at crisis point before accessing these services, and along with that accessing information about suitable AT. To compensate for this many individuals are now looking in other places for up to date information on the range, and suitability of technologies. Sometimes unsuccessfully sourcing the right technology at the right price. Whilst there are some great websites, like www.atdementia.org which was set up some years ago, brilliant and comprehensive these ‘of the shelf’ products are being purchased without any proper assessment. As the major risk factor for dementia is age, many individuals are living with co-morbidity, including, but not limited to sensory problems, impact significantly on the application, and use of these technologies. In addition, individuals are often have cognitive challenges: memory problems, impaired judgement and visual perceptual challenges.

Cahill et al (2007) found for the AT to be utilised effectively, informal and care staff need to be available to support, show and encourage individuals to use the products. Therefore, what training is being provided to front line staff, and informal carer, on how to maximise the use of these technologies, and how many staff are reluctant because of unanswered ethical concerns?

Potential barriers to the use of technology:

Accessing timely and suitable information
Sourcing technology that works with comorbidity
Accessing suitable assessment
connection problems
stigma associated to use
costs and relative funding for technology
as much of the technology needs to be supported by others, training is needed

Another major factor, which is often overlooked and not evident in the research papers I have read is the impact of the cuts on the uptake and use of technologies. On the one hand, you might consider that having technologies in place will create efficiencies, however introducing new technology requires change. As we have seen with the introduction of the Home Spirit Tool home care services are simply too stretched to even entertain the idea of piloting new ways of working.

Ethical barriers

In addition to the potential barriers we have the ethical considerations to make. One of the principle concerns is how can technology be used to address loneliness, but without replacing human contact? How might we manage effectively the tensions between surveillance for safety and privacy. As technology evolves it pushes the boundaries around ethical concerns. For example, we have seen the introduction of Virtual Reality, augmented reality for the individual to simulate experiences. Supporters believe that this can support the recall of memories and positive emotion. However, is this a form of treachery (Malignant Social Psychology – Tom Kitwood)?

Conclusion

Despite these ethical challenges, we will continue to explore the benefits and application of AT in our work both in the development of the Home Spirit Tool www.homespirit.org, and in the development of our training. We aim to give our learners the confidence to explore the ethical dilemmas openly as well as engage the people that they support in these conversations. Particularly, how might AT enable us to positively risk take.

References

Gibson, G., Newton, L., Pritchard, G., Finch, T., Brittain, K. and Robinson, L. (2014) ‘The provision of assistive technology products and services for people with dementia in the United Kingdom’, Dementia, .

Gibson, G., Dickinson, C., Brittain, K. and Robinson, L. (2015) ‘The everyday use of assistive technology by people with dementia and their family carers: A qualitative study’, BMC Geriatrics, 15(1).

Greenhalgh, T., Procter, R., Wherton, J., Sugarhood, P. and Shaw, S. (2012) ‘The organising vision for telehealth and telecare: Discourse analysis’, BMJ Open, 2(4), pp. e001574–e001574.

Hagen I; Cahill S; Begley E; Faulkner JP (2007) ‘It gives me a sense of independence’ – findings from Ireland on the use and usefulness of assistive technology for people with dementia. Technology and Disability 19 (2007) 133–142

Nauha, L., Kera nen, N.S., Kangas, M., Ja msa , T. and Reponen, J. (2016) ‘Assistive technologies at home for people with a memory disorder’, Dementia,

Nygård, L. and Starkhammar, S. (2007) ‘The use of everyday technology by people with dementia living alone: Mapping out the difficulties’, Aging & Mental Health, 11(2), pp. 144–155

Rosenberg, L. and Nygard, L. (2013) ‘Learning and using technology in intertwined processes: A study of people with mild cognitive impairment or Alzheimer’s disease’, Dementia, 13(5), pp. 662–677.

Sugihara, T., Fujinami, T., Phaal, R. and Ikawa, Y. (2013) ‘A technology roadmap of assistive technologies for dementia care in Japan’, Dementia, 14(1), pp. 80–103.

State of Care Report – The Training Imperative

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The CQC Report

Issued in 2014/15 identified a number of safety concerns in the Adult & Social Care sector i.e.

“A range of factors affect the safety of services, including a failure to investigate incidents properly and learn from them so they do not
happen again, ineffective safety and risk management systems and, in hospitals and adult social care, concerns with the adequacy of
staffing numbers and mix, alongside skills, training and support.”

In Adult Care Services specifically contributory factors were staffing levels, understanding and reporting safeguarding concerns, and poor medicines management. It was noted that “adult social care providers struggle to recruit the staff they need. Vacancies and turnover in the sector are high. For nurses, vacancy rates can be as high as 20% in domiciliary care and 11% in residential care.”

Additionally based upon an analysis of the inspections carried out 1 in 10 of adult social care services were rated as inadequate!
The CQC’s comments in relation to those inadequate ratings were “there were a range of governance issues that undermined the organisation’s quality and safety – from poor data quality (such as inaccurate care plans and medication records) or a lack of staff meetings, to little or no responsibility for complaints or mistakes.”

In relation to these concerns, of the inspections undertaken, there has been an increase in CQC enforcement actions to 7% in 2014/15 from 4% in 2013/14.

In contrast the observed outstanding services have management that ensure their staff receive continuous development and training. One inspector commented that

” It was how the people were supported. There were high levels of staff training; the training was just immense really, with staff doing refresher training throughout the year.”

These observations and data, particularly regarding vacancies and turnover, suggest that more effective risk management and quality training would be a substantial contribution to ensuring that care is always safe.

The HSE, following a review, have now recognised that there are aspects of health & safety training that can be covered by online training. Their guidelines are to be updated and will include advice to employers to ensure that the online training is fit for purpose. There are elements of Health & Safety training which must be classroom based i.e. first aid

My experience of training managers in the residential and domiciliary care sectors identifies, quite clearly, the challenge of developing effective risk assessments. Overcoming this challenge by using quality training companies not only assists these organisations in meeting their legal requirements but also minimises the risk of HSE sanctions and penalties that have been substantially increased in terms of fines and custodial sentences.

Neil Bitting (3 Spirit Trainer)

What Makes an Effective Dementia Care Trainer?

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Since the first Dementia UK report in 2007 on the economic impact of dementia there has been a slow, but more recently accelerated, awakening on the potential impact of dementia on our communities, with some liking it to the threat of global warning. As a result, there has been increasing investment in research. With this has come a growing evidence base for the application of non-pharmacological treatments, accelerating opportunities to improve practice and individual outcomes. However, bringing this new research, ideas and practices to front line staff has been a slow burning process. Although I am pleased to say that many of our clients have moved beyond the realms of ‘dementia awareness’ as the only training staff get.

Very early in my career as a social worker I was thrust into the depths of dementia diagnosis. Newly qualified, I was eager, motivated and interested to learn, to forge my sense of professional identity. I quickly got a job in Islington with a team known at the time as ‘Mental Health Care of Older People’. Based in the hospital, and led by a confident and dynamic psychiatrist, I sat amongst a very diverse (multi-disciplinary) group of professionals. What I learnt very quickly is that dementia is a fascinating and complex condition that requires a multiple perspective in order to truly get it’s measure. I couldn’t help feeling, though, that in this group I struggled to find an identity, to understand my professional worth; and truly the worth of the social model. I felt at the time (about 20 years ago!) there was a strong leaning towards medical interventions, some effective, and some fraught with difficulty and undesirable side effects. At this time there was a limited evidence base for non-pharmacological treatments, so many looked to medical treatments.

My occupational training in Islington compelled me to learn more, so I began personally to pursue the possibilities for good dementia support. For the first few years I read widely; I’m ashamed to say in the last 20 years I have never once picked up a novel. I am fascinated instead by the challenges and opportunities available in good dementia support; things like, the way the condition and the battle against it humanise us, connect us, and teach us the importance of meaningful connection. It also reminds us of the dangers of disconnection, demonstrates to us that there are strong correlations between our mental wellbeing and our physical health. The interplay between neurological challenges and the social world has always fascinated me, and the creative ways we can communicate and connect. After grappling with the topic for a number of years I soon started training in dementia care, and was soon asked to author a training manual for the first ever dementia care knowledge sets. By this time, I had a much firmer idea of my professional identity, and the role and power of the bio-psycho-social model of support that had challenged me in my earlier years.

For a while my learning went down a rather formal route; I studied at Bradford, which was a great way to benchmark my ideas and my work. However, I learn most from ordinary experiences, feedback from my training groups, and what I see in my own limited direct practice experience. There is a growing collective consciousness of the experience of dementia, led by many people living with dementia like the brilliant Tommy Dunne @TommyTommytee18, and Chris Roberts @mason4233. This has added another dimension to what we believe the possibilities are. This is tacking stigma and showcasing HOPE. Whilst learning about the lived experience of dementia is critical, dementia does not happen in a vacuum, it touches lives and services in so many ways. Therefore, to be a good dementia care educator we must widen our radar. It’s important to learn from all of those people, not just the academics or people living with dementia, but also family carers, front line support staff and other trainers who are often the catalyst for change. Teaching and training in dementia care and support opens you to all that and good trainers will use those opportunities to refine and enhance their message.

Having a good grounding in your subject, the practical underpinned with the theoretical, is a good start but you now have to convey the message in an effective manner and target the training appropriately. All organisations differ and individual group skills levels differ. A good dementia care trainer will ask not ‘these are the courses I can offer’, but will instead say ‘let’s have a look at what is happening in your organisation and see how we can work together to fill the gaps’. It’s about working together, combining skills, and celebrating successes.

Regulation is important in our society, and organisations like CQC work hard to ensure that staff are appropriately trained. However, their legacy has left a box-ticking approach to mandatory training. CQC make clear in their standards now that prescriptive mandatory training is no longer a requirement but rather staff should receive the training appropriate to their role. Despite this, many organisations lack the ability to audit skills and plan training based on need. Done incorrectly it can become a very expensive business. Troubled with poor staff retention, and persistent cuts, our sector needs targeted and fit-for-purpose training.

So the challenge is developing a course that will have an impact. In my years doing this I feel I have developed a recipe.

Knowing the sector and wider policy drivers is important, and understanding relevant occupational standards to scoping a course that is properly benchmarked.
Ensuring that your content is evidence-based ensures that the course is credible.
Knowing how to share human experience in a powerful way that people relate to; often this means bringing in experts by experience.
Understanding how to weave the key underpinning factors in social care: human rights, communication and recording, safeguarding, dignity, positive risk taking and safety. Person centred planning is critical in getting transition from classroom to practice.
Developing good accessible learning resources. Despite the commercial sensitivity I think it’s always good to share.
Develop content that encourages collaborative, integrative work with health. Giving people the opportunity to contrast medical and social interventions in scenarios helps us to identify which is appropriate, and to value each intervention. Sometimes medical interventions are required so that social interventions are made possible and vice versa.
Providing practical tools that help to bridge the gap between research and practice.
Using case studies that reflect the diverse society in which we live and ask the right questions to push boundaries.
Using the right language. Inappropriate language gives poor messages. For example, ‘wandering’, ‘challenging behaviour’, ‘suffering with dementia’.