Technology is bringing major changes to healthcare. And fortunately, fast, since the cost of healthcare threatens many economies. The recognition of the power of apps to deliver Digital therapeutic impacts is changing views regarding both the care and financial value of person centred care.
It’s a cold reality of life that a financial calculation is necessarily made for every care practice and intervention, and it’s no different in the appraisal of the merits of improving person centred care delivery using technology. So, for a care business looking to introduce technology, whether a residential care facility, domiciliary care provider, memory clinic or hospital ward, there are three things they will need to evaluate and ideally quantify, before they will invest. Firstly, the degree of care benefit to be gained by each party involved in the process, from the person cared for to the family and the care business. Secondly, the practicality of adoption, in other words whether the carers can easily learn and deploy the technology, whether they have the time within their current routines and whether it easily integrates into their existing care practices. Thirdly, whether there is an adequate financial gain both in the short and medium term, to be had despite the pain of adoption whether the key issues are infrastructure, staff training and/or family participation.
We will seek to explore each of the above with reference to the technology that we have developed over the last four years, for use in multiple care settings and in the light of recent developments in the UK regarding the gradual recognition of the NHS of the power of apps to be digi therapeutics and either compliment or replace the prescription of medication, as per our current evidence based trials currently underway in Kingston Hospital, London.
RemindMeCare is an innovative and interactive dementia and elderly care software system, termed Activity Based software, it supports a person from diagnosis and care in the community through to the acute ward and end of life, using digital activities that are based on research validated person centred care interventions. Advanced stages of dementia come with a combination of symptoms and conditions that lead to distress and isolation for the patient mainly due to the impairment of communication skills. Meaningful communication between the patient, the carer and family members are important in maintaining the patient’s quality of life. RemindMeCare (aka ReMe) helps to achieve this by providing a framework for engagement between the patient and their care circle that relies on understanding of the individual, their life history in terms of childhood memories, life achievements, experiences, likes and dislikes and so on. This cutting-edge technology also translates the data into visual search results from the vast resources of global online content. This process enables the carer/nurse to deliver engaging activities, which has the added benefit of improving their care skills, enhancing self-worth and job satisfaction. ReMe is portable across the dementia care journey and can be used by any invited individual, their family members, in care homes, domiciliary care, live-in care, hospitals and at other government local authorities. The result of using ReMe is better person-centred care and improved business processes at a reasonably low cost.
The basis and benefits of digitally enhanced person-centred care: Its policy to deliver person centred care in most care organisations, indeed its common sense to seek to engage with a person being cared for in a manner that reflects a knowledge of the person. Whether using a formulated toolkit such ‘Care fit for VIPs’, (1) or whether using one of the many care training packages available today. The problem is that knowledge of the person is so rarely available. And if it has been recorded at the point of the creation of a care plan, or with the participation of the family, it soon becomes out of date. The likes and dislikes of a person diagnosed with dementia, can change daily and knowledge and material that is results in engagement one week can change in the next. Digital recording of such changes is truly the only way to enable tracking the world that the person wishes to engage with, that they are inhabiting. Without that knowledge the carer must resort to defining the world as they see it, whereas knowledge of the person’s focus allows empathy and understanding. Care can become truly person centred.
The key person-centred care processes; that are generally perceived as being integral within any person-centred care strategy and that are at the heart of the proposition of the efficacy of ReMe’s Activity Based software, are reminiscence, cognitive stimulation and music therapy, plus self-care management and social interactive entertainment. Let’s look at each in turn.
Reminiscence is defined by the American Psychological Association (APA) as “the use of life histories – written, oral, or both – to improve psychological well-being. The therapy is often used with older people.” This form of therapeutic intervention respects the life and experiences of the individual with the aim to help the patient maintain good mental health. The majority of research on reminiscence therapy has been done with the elderly community, especially those suffering from depression, although a few studies have looked at other elderly samples. Whilst reminiscence has often been dismissed as being of little clinical value (2) albeit still a beneficial engagement, however the studies undertaken to date have not involved interventions in which technology has been deployed to optimise the content used and digital recording of outcomes. Recent work by Prof Dawn Brooker of Worcester University and the Association of Dementia studies (3) has shown that the use of tablets can be highly beneficial in the process of carer engagement. When coupled with ReMe’s means to engage the family remotely in the care process, this can achieve improved wellbeing.
The outcome of reminiscence and family engagement is knowledge of the person that can be used in numerous care settings. RemindMeCare is being used to connect hospitals with care homes and domiciliary care business and those cared for at home, such that easily accessible knowledge of the person built up in these care environments is easily available to the hospital at admission, making it possible to use engagement with the patient on topics currently engaging the person can be used to reduce agitation and as an alternative to premature resort to medication to calm agitation, which prevents the early ward onset of wellbeing decline. The use of familiar ReMe hosted activities in the ward, can improve nurse engagement and generate reassurance through familiarity in the patient, ultimately with the aim of an earlier discharge and a return to the original care location, thereby reducing bed blocking. It has also been shown that the use of group activities in the ward setting using content that is familiar to a group of patients can achieve group engagement and reduced staffing needs for the period of the activity. AN evidence base for these care improving and cost saving metrics is currently being undertaken by Kingston Hospital in London.
Cognitive Stimulation Therapy; has long been deployed to engage patients with mild to moderate dementia and whilst its ability to improve cognition is limited (4). However, with the addition of digitally recorded outcomes and the recording of notes during delivery, ReMe is exploring the potential for such therapies, digitally provided, to offer a means for the carer to better engage with the patient and to gain a means to record response and outcomes. With the availability of unlimited content and means to explore instantly unexpected content that is engaging, CST becomes more than a fixed content and static tool being also a search and discovery tool capable of generating cognitive response through discovery, that can be built on consistently in subsequent sessions
Music therapy: whether as part of a multisensory intervention in the case of dementia or as cognitive enhancement therapy for the elderly pre-diagnosis, there is little doubt that music has a beneficial effect in a variety of manners and for a breadth of conditions (5). Technology can be employed simply as a delivery mechanism or it can be used to explore outcomes, combine and record story telling for use in developing acute care management strategies using discovered content for engagement purposes and for enabling a care circle to participate in the content creation and discovery process. ReMe enables during its Music Conversation functionality, the means for those engaged with the person cared for to manage musical content, to record responses to music and to take musical journey to optimise engagement. This use of technology to further the process of music therapy offers not only an easier, structured and more flexible means to delivery music therapy but also the potential to record outcomes and to use them to further bespoke the therapy.
Socially interactive entertainment therapy: The results of trials, funded by the National Institute of Health Research, in which socially driven person centred activity based care was used in nursing home, have been recently published in the journal Plos Medicine (6)The research, led by the University of Exeter, King’s College London and Oxford Health NHS foundation trust, is believed to be the largest non-pharmacological randomised control trial in people with dementia living in care homes. At the end of the period they were assessed for quality of life, agitation and other symptoms. Dr Jane Fossey of Oxford Health NHS foundation trust said: “Taking a person-centred approach is about getting to know each resident as an individual – their interests and preferences – and reflecting these in all aspects of care. It can improve the lives of the person themselves and it can be rewarding for carers too. ReMe enables the delivery of such activities in a digital manner, which further facilitates the outcomes of activities being automatically fed back into the profile of the person thereby incrementally bespoking the content being used in the care activities being delivered to the person. Validation of the outcomes can be achieved through visual, voice and data recordings, and quantification can be used for family, regulatory and research purposes. ReMe has been built to address isolation, loneliness and to achieve social group engagement and digitally quantify delivery and responsiveness.
Self-care management: A vital component of any care at home strategy involves providing tools that enable a person to better self-manage their care. For any care planning strategy that is intended to ensure optimal wellbeing, medication and hydration adherence and achieve community and care circle engagement, it is vital that the plan is person centred and built around knowledge of the person, their habits, likes and dislikes, entertainment and preferred means of engagement. Work undertaken by Prof Clare of Exeter has shown that designing personalised daily activities that can be a reminder of such vital necessities as drinking water, can provide reassurance and a framework for the day (7). ReMe provides an easily accessible format for those involved in the care process, from families to carers, to define the profile of the person and to design daily procedures that enable the bespoke management of daily needs, including not only care but the day to day activities that can prove complicated with ageing. With voice activation using Alexa available to simplify engagement and with ReMe’s knowledge of the person ensuring a sense of personalised familiarity, the potential for achieving user loyalty is increased. Studies are now being undertaken in a variety of care settings, including assisted living and housing, and further information is available upon request.
New trends: Technology is causing treatment paradigms to be reconsidered. For when behaviour change is at the forefront of a conditions presentation, then there’s a need for both treatment and outcomes monitoring to be flexible. Before digital recording existed, it was almost impossible to match treatment with the changing behaviour caused by the condition. Now, with the new emerging fields of Digital Therapeutics and Digiceuticals, it’s possible to match care delivery with behaviour. And with ReMe’s Activity Based software, it’s possible to discover content through response to activities, that can positively impact on behaviour.
So, one of the big questions being asked is whether digitally driven person-centred care that enables the reduction of agitation through positive engagement with the person, can truly reduce the need for medication. If this can be shown to be the case then any system that can achieve that can progress from what is being defined as a digiceutical to a digital therapeutic then warrants being prescribed, either as a supplement to or as an alternative to traditional medication. As a result, the impact that digital prescribing could have on cost savings could be substantial and as a result business payment models will be developed that fit the new treatments. Answers will come when the evidence is there. ReMe offers an insight into what into the new treatment configuration of the future could look like.
Conclusion: Whilst there remains a shortage of evidence-based work regarding the power of technology to impact on the care process, whether for dementia or elderly care, however anecdotally, it does seem that tech’s impact where it has been deployed using optimal systems, can advance the to date academically defined outcomes of person centred care delivery.
What is not clear is whether care businesses are prepared to adopt Activity Based software, such as ReMe, when its adoption has an immediate up-front hardware, training and adoption cost. For, to prove the necessary return on investment that will ensure adoption, it will require more than just improving patient wellbeing and cognitive engagement, with gains being seen instead in such as client acquisition, enhanced family engagement, staff training benefits and general time and cost saving with such as automated reporting. But however long it takes for tech to truly penetrate the last bastions of paper and pills in healthcare, it already takes a brave person to argue against the inevitability of the coming era where technology is at the heart of person centred care.
Information about the author: A co-founder of RemindMeCare, Simon Hooper has a tech background that is non-medical but which he has brought to bear on the care process, courtesy of his experience with the care needs of his family. The company has worked closely with care facilities, day care centres and hospitals to create systems that are directed at improving care delivery.
Further information regarding RemindMeCare can be found online at www.remindmecare.com and a copy of the trial outcomes report can be provided by direct contact at firstname.lastname@example.org.
(1) What is a Digital therapeutic? https://en.wikipedia.org/wiki/Digital_therapeutics
(2) Kingston Hospital and RemindMeCare https://www.kingstonhospital.nhs.uk/news-events/news/remindmecare-at-kingston-hospital.aspx
(3) Care fit for VIPS. Prof D. Brooker: https://www.worcester.ac.uk/discover/care-fit-for-vips-online-dementia-care-toolkit.html
(4) Reminiscence therapy for dementia: Woods B1, Spector A, Jones C, Orrell M, Davies S; https://www.ncbi.nlm.nih.gov/pubmed/15846613
(5) How iPads can support people with dementia living in care homes: Prof. Dawn Brooker; http://www.anchor.org.uk/sites/default/files/news_articles/documents/How-iPads-can-support-people-with-dementia-living-in-care-homes-FULL-report-2015.pdf v
(6) Cognitive stimulation to improve cognitive functioning in people with dementia: Woods B1, Aguirre E, Spector AE, Orrell M; https://www.ncbi.nlm.nih.gov/pubmed/22336813
(7) Music therapy is a potential intervention for cognition of Alzheimer’s Disease: a mini-review: Rong Fang,#1 Shengxuan Ye,#2 Jiangtao Huangfu,3 and David P. Calimag; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5267457/
(8) Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: Clive Ballard ,Anne Corbett, Martin Orrell, Gareth Williams, Esme Moniz-Cook, Renee Romeo, Bob Woods, Lucy Garrod, Ingelin Testad, Barbara Woodward-Carlton, Jennifer Wenborn, Martin Knapp, Jane Fossey: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002500
(9) A Review of Self-Management Interventions for People With Dementia and Mild Cognitive Impairment: Catherine Quinn, Gill Toms, Daniel Anderson, Linda Clare: https://www.ncbi.nlm.nih.gov/pubmed/25608870