CHAPTER NINE

E-HOME CARE

REJUVENATING HOME HEALTH CARE AND TELE–HOME CARE

George Demiris, Joseph Tan

I. Learning Objectives

II. Introduction

III. E-Home Care Concepts

A. Significance of Home Health Care

B. Rationale and Trends for E-Home Care

IV. E-Home Care Applications

A. E-Disease Management

B. E-Medicine in Hospice Care

C. Other E-Home Care Technologies

V. E-Home Care Issues and Challenges

A. Privacy and Confidentiality

B. Accessible Design

C. Reimbursement

VI. E-Home Care Evaluation

A. Clinical Outcomes and Processes

B. Costs of Care and Access to Care

C. Acceptance by Providers, Patients, and Family Members

VII. Conclusion

VIII. Chapter Questions

IX. References

X. The OliverHome Case

Learning Objectives

1. Identify the scope and boundaries of e-home care services in the context of the evolving e-health care system and environment
2. Define e-home care and discuss the significance of home health care in the context of the mainstream health care delivery system
3. Understand the trends and benefits of e-home care that arise from emerging technologies and applications
4. Identify the issues and challenges in e-home care applications
5. Understand the future possibilities for e-home care applications

Introduction

The home health care (HHC) industry has a century-long history. Beginning with wealthy families hiring live-in maids and nurses, as well as caregivers for family members who were either immobilized or homebound due to physical or mental disabilities, the cottage home health care industry soon grew to cater not just to the rich but to anyone who needed home-based services such as rehabilitation, massage, or physiotherapy; food preparation or meal delivery service; help with personal hygiene or moving around the house; arrangements for doctors' and nurses' visits; urgent and emergency responses; and even regular administration of medications. Over the years, the industry has diversified to provide a wide variety of services that are similar to those provided in long-term care facilities such as chronic care units, group homes, or residences for the elderly. Even hospitals are often involved in the delivery of some home care services.

E-home care services may include patient assessment; supervision of patient care; routine nursing care and health monitoring; medication administration and scheduled injections; or management of dietary needs, daily exercise, and lifestyle changes (for example, smoking cessation). Historically, family members performed most of these chores for homebound patients, but nowadays arrangements are often made to have caregivers, nurse's aides, or even professional nurses provide day care services several times a week.

In addition, with rapid advances in science and technology, many who need HHC services can now perform a number of these services independently, using assistive devices and equipment programmed with intelligent software and sensors. E-home care was built on this foundation, incorporating information and telecommunication technologies to support HHC services and community health care. Advancing technological applications that have contributed to the emergence of e-home care include the Internet and associated technologies such as intranets and extranets, videoconferencing devices, personal data assistants (PDAs), and special remote patient monitoring equipment, including spirometers and electronic stethoscopes, that can send readings from the patient's home to nurses, doctors or specialists.

E-medicine has been defined as the use of advanced information and communication technology (ICT) to bridge geographic gaps and improve care delivery and education (see Chapter Eight). Advances in ICT, such as portable monitoring devices and wireless sensor applications like a “robotic dog” that can be easily installed and operated at a patient's home, introduced a new era for home care. Such applications reduce the cost of care and can enrich provider-patient communication and improve patients' quality of life. New applications of ICT and telehealth care have also led to consumer-friendly, Web-based e-health services; applications that promote selfcare directly to consumers; e-clinical care via satellites or wireless technologies to support independent living; use of PDAs by home caregivers or by consumers directly for teleconsultation (or e-consultation) with expert physicians; and use of automated intelligence, decision support technologies, and assistive devices for e-health monitoring (Tan with Sheps, 1998). E-care technologies that support independent living include telephone support, personal response systems, alarm monitoring systems, and assistive devices such as hand-held prescription reminders. Other e-technology systems that can be incorporated into e-home care include e-nursing, e-learning, and remote patient monitoring systems. Several of these concepts have already been discussed and illustrated in previous chapters. Here, we simply note that these e-technologies require the use of e-networking applications to enable nurses and other caregivers to monitor patients in their homes.

In this chapter, we will discuss the role and significance of e-home care in terms of cost savings. In addition, we outline the trends driving e-home care in the context of the evolving e-health care system and environment, review the range of e-home care services, and highlight the benefits and challenges in e-home care. We close the chapter with a look at the evaluation of e-home care technologies and their future prospects.

E-Home Care Concepts

The goal of making e-health care systems sustainable in this era of health care reform and fiscal constraints focuses on improving quality and health outcomes while delivering health care services using cost-effective methods. Providing responsive and dynamic health care requires the effective and coordinated use of new information and communications technologies. E-home care is an innovative approach that has the potential to improve our health care delivery system by meeting the growing need of aging and homebound patients for improved access to health care while maintaining patient autonomy Given the demographic trend toward an older population in most developed countries, e-home care may become one of the fastest-growing domains in the e-health care marketplace.

Over the last few years, a growing number of health professionals and consumers have been using terms such as tele–home care and telecare, which were barely in use before the end of the twentieth century. E-home care, which encompasses those terms, is a relatively young concept, but with the increasing availability of e-technologies and the proliferation of assistive and remote home monitoring devices, it is being gradually incorporated into the mainstream. Home health care products and services are marketed via the Internet, e-health provider and community networks, and other wireless and handheld devices such as mobile telephones. More broadly, the underlying challenges for e-home care include the need to connect e-providers, home health caregivers, and e-patients; to educate and inform e-health care professionals, e-home health caregivers, and e-consumers who are homebound or simply prefer to have health care delivered to their home; and to stimulate innovations in e-home care delivery.

Patient empowerment, a concept that has emerged in the health care literature in the last few years, is based on the principle that patients are entitled to have access to health information and to make their own care choices (see also Chapter Three). Feste and Anderson (1995) argue that the empowerment model introduces “self-awareness, personal responsibility, informed choices and quality of life.” Empowerment can be perceived as an enabling process through which individuals or groups take control over their lives and manage any diseases they may have. Thus, a key element for home care patients is taking responsibility for managing their own illnesses; this can be supported by e-health applications that allow them to stay at home while accessing specialized care and becoming active participants in their own health care management process.

E-home care uses clinical, administrative, and consumer health informatics to enable effective HHC delivery. E-home care is not, in itself, a product; rather, it is a means of accomplishing high quality, patient-centered community, and home-based care with the aid of emerging e-technologies. Its development is therefore a reflection of advances in e-marketing, e-health care, e-medicine, and increasing demand for affordable HHC services.

Significance of Home Health Care

Home health care is one of the fastest-growing areas in the health care industry. More than twenty thousand providers deliver home care services to approximately 8 million individuals diagnosed with acute illness, long-term health conditions, permanent disability, or terminal illness (National Association for Homecare, 2000). Annual expenditures for home health care in the United States alone were estimated to be $41.3 billion in 2001. According to a document produced by the Office of Health and the Information Highway of Health Canada, annual public home care expenses in Canada reached just over $2 billion in 1997–98, representing a substantial increase of $1.1 billion (104 percent) from 1990–91 (Office of Health and the Information Highway, 1999). We can say with some confidence that unless more efficient and effective approaches are applied, the incremental costs of delivering HHC will continue to escalate because of an aging population, rising wages and antiquated technologies. Nevertheless, HHC is already saving the mainstream Canadian and the U.S. health care systems hundreds of millions of dollars annually if one considers what comparable care in a medical office or hospital would cost.

The first U.S. HHC agencies were established in the 1880s. Their number grew to 1,100 by 1963 and to more than 20,000 in 2001 (National Association for Homecare, 2000). Although HHC agencies have been providing services to Americans for more than a century, Medicare's decision in 1965 to make home care services widely available to the elderly fueled the industry's rapid growth (National Institute of Nursing Research, 1994). The goal of HHC is to optimize functional capability (National Center for Health Statistics, 1996), which requires the identification and management of not only medical but also environmental, behavioral, and psychosocial problems. Determining the proper diagnosis and developing a treatment plan often requires information about the patient's home environment and social resources (Ramsdell, Swart, Jackson, and Renvall, 1989). Home care nurses are likely to develop therapeutic relationships with their patients because they see them over extended periods of time and can provide a range of support services through continuity of care (Pesznecker, Patsdaughter, Moddy, and Albert, 1990). This continuity and the extended supervision enhance compliant behavior (McCord, 1986).

Studies suggest that home visits can lead to improved medical care through the discovery of unmet health care needs (Ramsdell, Swart, Jackson, and Renvall, 1989; Arcand and Williamson, 1981; Fabacher and others, 1994). One study found that home assessment of elderly patients with relatively good health status and function resulted in the detection of an average of four new medical problems and up to eight new intervention recommendations per patient (Ramsdell, Swart, Jackson, and Renvall, 1989). Kane and Kane (1987) reviewed several studies on the effects of HHC and found in many cases that home care patients had fewer hospital and nursing home admissions, shorter lengths of stay, fewer outpatient visits, and lower estimated total health care costs.

Home care enables providers to interact with their patients on an ongoing basis in the patients' homes and not a clinical setting. The importance of this interaction is documented in published literature: communicative features of medical consultations have been linked to various outcomes such as patients' satisfaction with care, understanding of medical information, adherence to prescribed regimens, and health improvement (Hall and Roter, 1988; Kaplan and Greenfield, 1989). Kane and Kane (1987) gathered studies that found positive attitudes in terms of satisfaction and perceived health in patient groups receiving home care services. Kaplan and Greenfield (1989) found that “better health,” whether measured physiologically (through blood pressure, blood sugar, and other measures), behaviorally (functional status), or more subjectively (evaluation of overall health status), was consistently related to specific aspects of provider-patient communication.

Nonetheless, especially in the United States, HHC faces several potential threats to its viability, given the combined effect of increased life expectancy, population growth, and funding limitations on the Social Security/Medicare situation. These new, challenging realities will lead to changes in the definition and focus of home care in this new millennium. People aged sixty-five years and older are projected to represent 20 percent of the population in the year 2030 (Economics and Statistics Administration, 1994). Social Security and Medicare programs could experience financial difficulties in the near future because the ratio of workers paying taxes to retirees drawing benefits has long been decreasing. The number of workers paying into Social Security per beneficiary is expected to decrease to 2.1 by 2020 (Social Security Administration, 2000).

Rationale and Trends for E-Home Care

E-home care can address the issues of cost of health care delivery and problematic access to traditional home care for both rural and urban underserved patients. The use of technology has the potential to decrease travel time and costs for nurses and increase the number of patients that an HHC nurse visits in a given day. E-home care, also known as tele–home care, uses telecommunication and videoconferencing technologies to enable a health care provider at a clinical site to make virtual visits to patients. In this context, the term actual visit is used to describe a traditional visit of a health care provider to a patient's home (face-to-face interaction).

A study conducted in 1997 by the Insight Research Corporation estimated that approximately 20 percent of home visits would use e-home care applications by 2001. The following observable trends in the U.S. and Canadian health care systems have contributed to the rapid development of e-home care:

• Integration of health care services, particularly e-health care services, to meet increasing community and primary care needs among underserved patient populations such as seniors, those living in rural areas, and those who have impaired mobility or who are homebound
• Increasing outpatient procedures, decreasing institutionalization, and shortened inpatient stays as a result of discharging patients from hospitals and clinics earlier, even when they require continuing care and regular clinical monitoring
• Demographic changes resulting from an increasingly elderly population, more advanced medical technology and procedures, health-promoting lifestyle and alternative medicine movements, and longer life spans
• Rising prevalence of chronic illnesses—such as diabetes, joint and lower back pain, heart problems, and mental health problems—that require regular therapy, long-term care, and regular monitoring of health status
• Increasing partnerships between the government, granting agencies, universities, health provider organizations, investors, venture capitalists, and private companies to develop e-technologies and innovative products that can be applied to HHC—for example, smart cards, smart cars, automated massage chairs, robot dogs, intelligent refrigerators, and smart homes
• Growth in home care across the continuum of care as a substitute for acute care and long-term care and as a preventive service
• Advances in decision support technologies, diffusion of Internet-related technologies, developments of smart interface technologies, and diffusion of e-health information on community and e-home care services, leading to better-informed patients and caregivers who want more flexible health care delivery

E-home care complements community health infrastructure and enables the system to address the issues raised by these trends.

E-home care can also lighten the burden of unnecessary expenditures and cut waste. First, it reduces unnecessary emergency room visits and decreases the burden on long-term care facilities and minimizes unscheduled visits to physicians. Many patients, especially in countries such as Canada where the government pays the bulk of health care costs, will simply go to an emergency room even though a non-emergency clinic would be more appropriate. Non-emergency patients going to an ER represents the use of inappropriate services that imposes an unnecessary, additional cost to the system. The same is true if a patient needing only non-specialist services insists on consulting with a specialist. Patients may miss prescheduled visits because of work responsibilities or transportation problems. A few simply forget their prescheduled visits.

Looking at statistics for the small Okanagan-Similkameen Health Region of British Columbia, we can see how e-home care services could result in significant cost savings. A spring 1999 report stated, “There is an immediate requirement in this small geographic area for over 900 long term care beds and escalating at a daily cost of between $90,000.00 and $110,000.00 [Canadian dollars] per bed depending on the level of care required.” If we factor in the cost of day-to-day operations and extrapolate these numbers over a larger population, the figures for the province of British Columbia are overwhelming. The provincial government is not able or prepared to absorb all of the costs generated by the mainstream health care system. E-home care could substantially reduce use of traditional health care modalities; provide early intervention and prevention services, resulting in further savings; teach patients self-care and management of early symptoms, thus helping them to avoid health complications; provide round-the-clock information on vital sign fluctuations; and encourage the use of e-administrative and support services—for example, automatic recording of patient-submitted data, on-line payment and service reimbursements, and other critical administrative functions.

E-Home Care Applications

With the development of portable monitoring devices and the diffusion of the Internet, the number of e-home care applications started to increase in the 1990s. Sparks and others (1993) investigated the use of exercise monitoring via telephone as an alternative for cardiac rehabilitation patients who were unable to participate in a hospital-based program. The study was conducted as a randomized, controlled trial and provided indications that this kind of monitoring was an effective supplement to hospital-based monitoring. Turnin, Bolzonella-Pene, and Dumoulin (1995) developed and evaluated a telemedicine system for self-monitoring and dietary education of diabetic patients that had a positive impact on patients' nutritional knowledge and on some clinical outcomes (total cholesterol, cholesterol of low-density lipids). Evaluating the clinical usefulness of cardiac arrhythmia monitoring via telephone, Wu, Kessler, Chakko, and Kessler (1995) found it more effective than ambulatory electrocardiography in detecting arrhythmias. A randomized, controlled trial by Friedman, Kazis, and Jette (1996) demonstrated that automated patient monitoring and counseling via telephone had a positive effect on patient adherence to antihypertensive medications and on blood pressure control. Mehra, Uber, Chomsky, & Oren (2000) studied the efficacy of e-home monitoring for patients with chronic heart failure and identified a need to further investigate this approach. Comparing the use and costs of home care through remote video technology with those of traditional home care, Johnston, Wheeler, Deuser, and Sousa (2000) determined that the remote approach achieved cost savings and improved access to home care support while producing no differences in clinical outcomes.

It has been argued that the application of telehealth technology to home health care services will eventually prove both clinically and technologically sensible. However, the full impact and effectiveness of e-home care in the context of our traditional health care delivery system is far from being realized. The full potential of this technology will be accessible only when e-home care applications are integrated with the data analysis, business intelligence (the application of data mining methodologies to discover hidden trends or patterns for improving business performance), and decision support aspects of e-health, empowering home-based populations to live independently and receive quality care, as needed, in their own homes. One example of an effort to tap the potential of integrated e-home care is the work being done to integrate “smart home” technology with e-home care services, which will be discussed later in this chapter.

E-Disease Management

Disease management includes “a set of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant” (Disease Management Association of America, 2002). These interventions aim to enhance care plans and provider-patient relationships, emphasizing the prevention or delay of deterioration and complications through the use of evidence-based practice guidelines. Additional goals of disease management include improvement of outcomes, cost reduction, patient education, and patient monitoring.

The concept of e-disease management is defined by the utilization of ICT such as the Internet to allow patients with chronic conditions to stay at home and be involved in the care delivery process. Such e-technologies can help co-ordinate e-home care with hospital and ambulatory care and facilitate information exchange and communications between and among patients, family members, and care providers. If an e-patient has to be attended by specialists, for example, in the case of a cardiac arrest, linking e-home care with hospital and ambulatory care would prove more efficient and beneficial in the treatment of the e-patient. E-patient education is an essential component of e-disease management and can be easily supported by the transmission of tailored health information or automated reminders to patients or their caregivers. The integration of commercially available household items such as television sets, mobile phones, videophones, medication dispensing machines, and handheld computers introduces new communication modes and new tools for patient empowerment into e-disease management programs.

The Internet is being used for e-disease management applications in different clinical areas. In e-disease management for asthma patients, for example, the home asthma telemonitoring (HAT) system assists in early detection of allergies and timely intervention to prevent asthma attacks (Finkelstein, O'Connor, G., and Friedmann, 2001). HAT assists patients with the daily routine of asthma care through personalized interventions and alerts health care providers when patients require immediate attention. Web-based management of diabetes can also enhance care delivery because of the disease's requirements for long-term prevention and intervention of other associated illnesses. The Center for Health Services Research of the Henry Ford Health System in Detroit, Michigan, developed a Web-based system to support care delivery to diabetic patients (Baker and others, 2001). The system was evaluated within a nonrandomized, longitudinal study, and findings suggested that Web-based systems integrating clinical practice guidelines, patient registries, and performance feedback can improve the rate of routine insulin testing. A distributed computer-based system for the management of insulin-dependent diabetes was developed and evaluated within the Telematic Management of Insulin-Dependent Diabetes Mellitus project, which was funded by the European Union. The objective was to use Internet technology and monitoring devices to support the normal activities of physicians and diabetic patients by providing a set of automated services enabling data collection, transmission, analysis, and decision support (Riva, Bellazzi, and Stefanelli, 1997).

E-disease management applications can also be developed for post-transplant care. Regular spirometric monitoring of lung transplant recipients, for example, is essential in early detection of acute infection or rejection of an allograft. A Web-based e-monitoring system that provided direct transmission of home spirometry to a hospital was developed and evaluated, demonstrating that home monitoring of pulmonary function in lung transplant recipients via the Internet is feasible and accurate (Morlion, Knoop, Paiva, and Estenne, 2002).

Another application using low-cost, commercially available monitoring devices and the Internet was developed for the TeleHomeCare Project at the University of Minnesota, aiming to enable patients with congestive heart failure, with chronic obstructive pulmonary disease, or requiring wound care to interact from their homes with health care providers at the agency. Personalized Web pages encouraged patients to fill out daily questionnaires, answering questions about vital signs (such as weight, blood pressure, or temperature), symptoms, and overall well-being and nutrition. Alerts were triggered and care providers were instantly notified when a patient's entry required immediate medical attention, which was determined by predefined, personalized rules (Demiris, Finkelstein, and Speedie, 2001).

E-Medicine in Hospice Care

Hospice care is a concept based on the provision of comfort and support to patients and their families when a life-limiting illness no longer responds to cure-oriented treatments. Thus, hospice care neither prolongs life nor hastens death but rather aims to improve the quality of dying patients' last days by offering comfort and dignity, focusing on palliation, individual control, and relief of suffering. Hospice care deals with the emotional, social, and spiritual impact of the disease on the patient and the patient's family and friends through interdisciplinary teams composed of physicians, nurses, social workers, chaplains, aides, and volunteers.

While the number of hospice agencies has increased greatly in the last ten years, less than 25 percent of dying patients in the United States currently use hospice services. Many elderly patients approach the end of life in isolation. Several barriers to the provision of hospice services, especially in rural communities, have been identified—for example, inadequate reimbursement, restrictive regulatory definitions of service areas based on mileage and driving time rather than care outcomes, and shortages of nurses, aides, and social workers interested or willing to work in this area. The same issues are found in other developed countries such as Canada and the United Kingdom.

In the United States, the Institute of Medicine has identified systemic deficiencies in end-of-life care (Field and Christine, 1997) including legal, organizational, and economic obstacles to palliative care and the systemic lack of appropriate education of and effective communication between health care providers. Telemedicine can eliminate some barriers to quality end-of-life care. Hospice services via telemedicine (e-hospice) can be delivered directly into a patient's home through videoconferencing. This is of particular significance for underserved patients in rural and urban sites and for patients with limited caregiver support.

The director of the Hospice Association of America has urged the House Committee on Small Business of the U.S. House of Representatives to further develop initiatives in e-hospice care and services. Interestingly, the incorporation of telemedicine into palliative care has been successfully implemented in many different countries, including Spain (Riano, Prado, Pascual, and Martin, 2002), the United Kingdom (Regnard, 2000), Australia (Elsey and McIntyre, 1996), and Japan (Oyama, Wakao, and Okamura, 1997), as well as in the American states of New York (Oyama, Wakao, and Okamura, 1997), Kansas, and Michigan, (Coyle, Khojainova, Francavilla, and Gonzales, 2002). An e-hospice application can support an agency's commitment to be accessible to patients and caregivers twenty-four hours a day, providing outpatients with one of the advantages of inpatient care.

Other E-Home Care Technologies

Other e-technologies that can be used within an e-home care context include the following:

• Portable monitoring devices
• Videophones
• Wearable sensors
• PDAs
• Smart shirts
• Smart home technologies

Several commercially available portable monitoring devices, such as pulse oximeters, blood pressure monitors, spirometers, weight scales, and glucose monitors can be used for e-home care applications. These devices are tested for accuracy and are approved by the Federal Drug Agency before they become available on the market. In some cases, data are stored in the device and retrieved later; in other cases, they are displayed on a monitor at the completion of the test session. Devices that allow the automatic transmission of data over regular phone lines or in accordance with the system's transmission architecture are preferred over devices in which the patient has to read the results and announce them to a nurse during a virtual visit, which can impose a burden on elderly or visually impaired patients and affect accuracy.

Videoconferencing at patients' homes without any cost for upgrading the existing infrastructure has been enabled by International Telecommunication Union—Telecommunication Sector (ITU-T) standard H324 for multimedia conferencing on plain old telephone service. H324 defines standards for transmitting video, audio, and other data over one analog telephone line. Because local and wide area networks use the same interoperable substandards as H324, significant interoperability among videophones with different features and by different manufacturers can be achieved. Videophones can be installed in patients' homes and operated over regular phone lines. Training required for patients is often minimal because videophones operate like regular phones with the addition of a screen. Some of these devices can also be connected with television sets or other monitors (for example, on a personal computer) to achieve a higher-resolution display. Depending on the application, the camera embedded in the videophone can be sufficient. In cases where providers wish to assess the home environment, a portable camera can be easily integrated into the system. The H324 standards allow low-cost e-home care solutions. However, if low cost is not a priority, there is always the option of using an advanced infrastructure, if one exists, or upgrading the existing one to achieve maximum video and audio quality (for example, by installing ISDN, DSL, or T-1 lines) (see Chapters Six and Seven). As ICT and e-technologies advance, e-networks can be expanded, and the level of achievable audio and video quality of videoconferencing sessions will increase, leading to more creative and appealing interfaces.

Physical, chemical, and biological sensors can also be used to enhance e-home care applications. A physical sensor will measure physical parameters such as temperature or pressure, whereas a biological or chemical sensor involves a receptor (for example, an enzyme or antibody), which binds with an analyte (that is, a target molecule). The signal produced by the sensor is transferred to a circuit and digitized. The resulting digital data can be stored or displayed. Sensors can be incorporated into watches, items of clothing, and eyeglasses. One could argue that wearable sensors function as non-invasive in vitro diagnostic tools, because they are capable of analyzing human sweat, tears, stress, strain, pH increases, and more.

An example of a wearable sensor is the “intelligent knee sleeve” that monitors knee strain or injury (University of Wollongong, 2001). Originally designed for football players, this device is strapped to the knee and provides feedback to the user by emitting an audio tone. It can be a useful application for e-home care patients with mobility impairments or during rehabilitation. Another wearable sensor is a small portable detector in the form of a wristwatch, which provides cystic fibrosis test results in minutes rather than the twenty-four hours that is the typical response time for a laboratory test (Lynch, 2000). The wristwatch device uses an electric field to push pilocarpine nitrate into the skin, thereby dilating the pores. Sweat is then absorbed and stored in a duct in the watch. A sensor analyzes the sample and records the levels of sodium, chloride, and potassium ions. Other wristwatch devices include meters that measure glucose in the interstitial fluid as a low electric current pulls glucose through the skin (Tamada, Lesho, and Tierney, 2002) and a blood oxygen monitor (Wahr and Tremper, 1995).

PDAs are now being used in dietetics and nutritional screening. Two studies at California State University, Los Angeles, have found PDA use in nutritional screenings to be readily adaptable to ongoing efforts by dietitians. The PDAs were found to be useful in identifying potential indicators of poor nutritional status in institutionalized elderly patients as people can check the nutrient content of their food by accessing their PDAs. Food service supervisors can learn to use them in a relatively short time, allowing an increase in the number of nutritionally relevant variables to be assessed and improving the quality of documentation in the medical record.

As new technological innovations continue to arise, the possibilities for sensor use in e-home care become seemingly endless. In the last few years, the smart shirt has been introduced. The smart shirt incorporates technology into the design of clothing to monitor the wearer's heart rate, electrocardiogram (ECG), respiration, temperature, or vital functions, alerting the wearer or physician if there is a problem (Georgia Institute of Technology, 2004). Smart shirts also can be used to monitor the vital signs of military personnel, chronically ill patients, firemen, or frail elderly persons living alone. The U.S. Navy initially funded the smart shirt project in October 1996; in 2000, the Georgia Tech Research Corporation licensed the technology to a private company in order to manufacture and market the product (Georgia Institute of Technology, 2004).

A smart home is a residence equipped with a set of advanced electronics and automated devices that are specifically designed for care delivery, remote monitoring, early detection of problems or emergencies, and maximization of patient safety. A smart home is usually linked with a local processor that analyzes sensor data and detects critical situations; the smart home is also connected to a remote control center that notifies the appropriate emergency service such as the health agencies, police, and the fire station in the case of a fire. Smart home features usually include motion-sensing devices for automatic lighting control; motorized locks; door and window openers; and motorized blinds and curtains; smoke and gas detectors; and temperature control devices (Elger and Furugren, 1998). Such an infrastructure aims to address problems associated with neurological and cognitive disorders in the elderly and to enhance patients' ability to function independently within their own residence.

The Swedish Handicap Institute operates a demonstration apartment as part of the so-called SmartBo project (Elger and Furugren, 1998). This project focuses on solutions for visually impaired, hearing-impaired, and mobility-impaired residents and residents with cognitive disabilities. It is based on the integration of visual and tactile signaling devices, a text-enlargement program, a speech synthesizer, and a Braille display for visually impaired residents. Another smart home project is PROSAFE, which uses a set of infrared motion sensors connected to either a wireless or wired network to support automatic recognition of resident activity and possible falls and, when appropriate, triggers alarms, aiming to accommodate patients with Alzheimer's disease (Chan and others, 1999; Chan, Bocquet, and Steenkeste, 1999). Finally, the Aware Home Research Initiative is an interdisciplinary research initiative at Georgia Tech that addresses the fundamental technical, design, and social challenges associated with smart home technologies (Kidd, Orr, Abowd, and Atkeson, 1999).

E-Home Care Issues and Challenges

The success and diffusion of e-disease management systems in particular and e-home care applications in general depends on the following critical factors:

• Privacy and confidentiality
• Accessible design
• Reimbursement

Privacy and Confidentiality

As a result of recent technological advances, the health care sector faces many challenges in guarding the privacy and confidentiality of individuals' health information. Information privacy refers to patients' right to control the use and dissemination of their personal information. Confidentiality is a tool for protecting privacy. In 1998, the “Notice of the Proposed Rule from the Department of Health and Human Services Concerning Security and Electronic Signature Standards” was introduced in the United States as part of the Health Insurance Portability and Accountability Act (HIPAA) that was passed in 1996 (U.S. Department of Health and Human Services, 1999). This proposed rule became law in the United States in 2000 and proposes standards for the security of individuals' health information and electronic signature use for health care providers, systems, and agencies. These standards refer to the security of all e-health information and have a great impact on the design and operation of e-home care applications such as ensuring that home-based electronic prescription services are not misused.

Privacy issues related to video and audio recording, maintenance of tapes, storage and transmission of still images, and other types of patient records have yet to be codified, and efforts must be undertaken to address these challenges fully. The transmission of information over communication lines such as phone lines and satellite or other channels raises concerns about possible privacy violations. An additional concern in some cases is the presence of technical staff assisting with transmission procedures at the clinical site (or at both ends of the transmission), which could create a perceived or actual loss of patient privacy. In addition, patients' unfamiliarity with the technical infrastructure and operation of the equipment can lead to misperceptions of the possibilities of privacy violation during a videoconferencing session.

In the context of Web-based e-disease management, issues of access to and ownership of the data have to be addressed. In many e-home care applications, patients record monitoring data and transmit these daily to a Web server, which is owned and maintained by a private third party, that allows providers to log in and access their patients' data. Such an application calls for discussion and definition of the issue of data ownership and patients' rights to access parts or all of their records. Implications include not only possible threats to data privacy but also ethical debates about the restructuring of the care delivery process and introduction of new key players.

Accessible Design

Many patients requiring e-home care services or e-disease management interventions are elderly and in some cases have functional limitations due to aging, illness, or injury. A functional limitation is a “reduced sensory, cognitive or motor capability associated with human aging, temporary injury, or permanent disability that prevents a person from communicating, working, playing or simply functioning in an environment where other people in the population can function” (Telecommunications Industry Association, 2004).

While many argue that the Internet and advanced e-technologies have the potential to empower patients and even revolutionize the process of health care delivery, the fastest-growing segment of the U.S. population (people over the age of fifty) are at a disadvantage because software and hardware designers often fail to consider them as potential users, although usability and accessibility are important quality criteria for Web-based interventions (Bellazzi, Montani, Riva, and Stefanelli, 2001). Designing an intelligent Web-based interface that targets users who are inexperienced with the technology and who may have functional limitations can be a real challenge. Systems targeting e-home care patients should provide a high level of functional accessibility (Demiris, Finkelstein, and Speedie, 2001) and should have undergone rigorous usability tests. Several design considerations should be taken into account when developing systems for patients with functional limitations (Demiris, Finkelstein, and Speedie, 2001). For example, an interface that could be activated via a person's eye movements would be suited to assist someone who may be deaf and mute.

Reimbursement

The Health Care Financing Administration has initially denied Medicare reimbursement of e-home care, emphasizing that it has not been proven cost-effective. Some evidence demonstrates the cost-effectiveness of traditional disease management (for example, a retrospective analysis of 7,000 patients found a savings of $50 per member per month in diabetes treatment costs over twelve months and an 18 percent decrease in hospital admissions) (Georgia Institute of Technology, 2004). As yet, there is little evidence on cost-effectiveness or even possible reduction of long-term costs through the use of the Internet or other advanced ICT and e-technologies in e-disease management and e-home care applications.

The U.S. Balanced Budget Act (BBA) of 1997 allows reimbursement for telemedicine services in specific cases, especially for rural locations, which the BBA has defined to mean health professional shortage areas (HPSAs). In these cases, reimbursement is provided for Medicare patients who stay at home and receive HHC services via telemedicine. In 2000, a new means of paying for home care, the Prospective Payment System (PPS), went into effect. This system apportions payment per episode of care (using sixty-day periods) instead of per “physical” visit, allowing e-home care agencies to integrate “virtual” visits to be counted as part of the total treatment episode within the care plan.

Cost analyses and cost-effectiveness studies will contribute to discussions of reimbursement issues in regard to Web-based monitoring services and will further address the question of which party or parties should bear the costs of implementing and maintaining the requisite systems.

E-Home Care Evaluation

In evaluating the merit of e-home care applications, a number of criteria should be examined, including clinical outcomes, clinical processes, costs of care, and access to care, as well as acceptance by providers, patients, and family members.

Clinical Outcomes and Processes

The measured outcomes of e-home care should be the same or better than those of traditional care. This question has been investigated to some extent, but there is a need for large randomized clinical trials. Johnston, Wheeler, Deuser, and Sousa (2000), for example, studied the effect of e-home care on medication compliance and ability to provide self-care in a quasi-experimental study with a control group that received traditional home care and an intervention group that received access to a remote video system in addition to traditional care; they found no statistically significant difference between the two groups. Jerant, Azari, and Nesbitt (2001) conducted a one-year randomized trial to assess the effectiveness of e-home care delivered via a two-way videoconferencing device with an integrated e-stethoscope and found that this technology could reduce hospital readmissions and emergency visits for patients with congestive heart failure.

The premise of most e-home care applications is that the enabling e-technologies can yield more intensive and frequent physiological monitoring, which can lead to early detection of health problems and appropriate intervention. In addition, these technologies can be used as tools to monitor medication compliance and promote patient education. As mentioned earlier, the time has come to move from small-scale feasibility studies to large clinical trials.

It could be argued that video-mediated communication alters the relationship between nurse and patient and decreases the quality of care due to the lack of personal contact. Face-to-face interactions are considered “more spontaneous” and “free-flowing” than videoconference interactions (O'Conaill, 1997). Therefore, it might be expected that the range of issues addressed during a virtual visit and the communication between the participants in general differ from those of an actual visit. One could also argue that the use of e-home care technology might intimidate patients and result in limited participation during the virtual visit. The lack of patient participation is potentially significant because patients tend to value the opportunity to express their concerns, questions, and opinions when seeking care (Street, 1992; Ende, Kazis, Ash, and Moskowitz, 1989). Furthermore, patient participation in medical care often contributes to improved postconsultation outcomes such as greater satisfaction with care (Lerman and others, 1990), greater adherence to treatment recommendations (Rost, Carter, and Inui, 1989), a stronger sense of control (Street and Voigt, 1997), and more successful disease management overall (Kaplan and Greenfield, 1989).

Moreover, addressing technical issues, such as focusing the camera or adjusting the audio, constitutes an additional theme of communication that does not take place in an actual visit and that could dominate the virtual visit. Thus, the study of the e-home care delivery process versus traditional care delivery is important. The nature of communications in virtual home care visits has been examined to some extent. In a study conducted by Demiris, Finkelstein, and Speedie (2001), 122 virtual visits were reviewed, and a content analysis was performed. Time was apportioned among the following categories of communication: assessing the patient's clinical status, promoting compliance, addressing psychosocial issues, general informal talk, education, administrative issues, technical issues, assessing patient satisfaction, and ensuring accessibility. While some activities clearly cannot be conducted during a virtual visit, these findings indicate that e-home care has the potential to enrich the care process. Further studies and direct comparisons between actual and virtual visits will provide clearer insight into the process of virtual visits. It has yet to be determined whether telemedicine enhances or inhibits patients' communication about their discomfort, symptoms, and emotional state or whether it encourages or inhibits doctors' communication of instructions or expressions of empathy (Bashshur, 1995).

Costs of Care and Access to Care

Virtual visits should provide a cost-effective alternative to traditional home care. The economic analysis of an e-home care system is a comparison of specified sets of inputs and outputs in the provision of health care. Inputs involve the level of medical expertise, facilities, technology, service personnel, and client characteristics. The focus is on assessing the effects of known quantities of health care, such as episodes of care and hospital stays or the length and quality of the care process. If e-home care increases costs but produces only the same clinical outcomes as traditional home care, it will fail to address the challenges of home care services.

Cost savings from the use of e-home care systems can be realized if the following outcomes can be demonstrated:

• Reduction of unnecessary visits to the emergency room
• Reduction of unnecessary or unscheduled visits to the physician's office
• Early detection of health problems, allowing early intervention
• Prevention of repeat hospitalizations or overall reduction of rehospitalization rates
• Patient education that leads to improvement of lifestyle choices and medication compliance

Many argue that substituting virtual visits for actual visits, which would reduce travel time and its associated costs, could in some cases reduce the number of actual visits. Using portable devices and ICT applications, vital signs data can be collected and interpreted several times a day rather than only during scheduled weekly visits. This may result in earlier detection of health problems and earlier intervention in some cases, while signs of deterioration or problems may be missed or identified later if patients are monitored less frequently.

HHC agencies and patient advocate groups need to determine whether e-home care increases access to care for rural and urban underserved home care patients. The question of whether e-home care provides the means for more frequent monitoring of patients or whether it could be claimed as a cost-saving method and used as an excuse to deprive patients of actual home care visits also needs to be addressed. Specifically, such an investigation should aim to study how e-home care services address issues associated with the decreased use of traditional services, particularly at the entry to care, and the associated structural, financial, or personal barriers.

Acceptance by Providers, Patients, and Family Members

The success of e-home care depends largely on the acceptance of care providers, because they are often the ones who determine how the care process is to be conducted. An e-home care intervention alters the practice patterns of providers and has an impact on their work flow. Nurses, for example, who will be conducting virtual visits, have to accept this mode of care delivery and be comfortable using the required equipment and interacting with their patients by using videoconferencing technology. As with all technological innovations, stakeholders' commitment is essential to the optimum system use.

One unique aspect of e-home care is the fact that the required technology is installed and used in homes and will be operated by the patients or their surrogates. In this sense, the success of e-home care depends not only on its acceptance by the care providers but also on acceptance and technological competence on the part of patients and their family members. The way in which patients understand e-home care will influence its level of acceptability and, consequently, its rate of diffusion. Therefore, patients' perceptions should be investigated before and after they have participated in an e-home care system, and the features they perceive differently after experiencing it should be identified. The acceptance of the technology by patients and their family members will also be contingent on the satisfaction with the e-home care system.

There is a lack of consistent effort among researchers to develop valid and reliable instruments to measure patient perceptions of or satisfaction with e-home care. One such instrument is the Telemedicine Perception Questionnaire (TMPQ) (Demiris, Speedie, and Finkelstein, 2000). This instrument has been extensively tested and shows a high level of internal consistency and very high test-retest reliability. The TMPQ covers domains such as perceived effect on quality of and access to health care; time and money, including time expenditure for the patient and nurse and costs for the patient and the health care agencies; factors related to the conduct of a virtual visit, including ease of equipment use, equal acceptability of virtual and real visits, protection of privacy and confidentiality, lack of physical contact, reduced sense of intimacy, and the patient's ability to explain medical problems during a virtual visit; and general impression of the concept of e-home care and its role in the future (Demiris, Speedie, and Finkelstein, 2000).

Conclusion

The Center for Medicare and Medicaid Services estimates that total U.S. spending for health care will rise to $2.1 trillion by 2007, which represents almost 17 percent of the gross domestic product (Centers for Medicare and Medicaid Services, 2003). As the health care sector aims to curtail expenditures, emphasis is being placed on outpatient services; as a result, especially given the increase in life expectancy and in the aging population, the number of patients being cared for at home is increasing. As HHC services become more costly and the shortage of home health providers continues, e-home care technology has the potential to provide a cost-effective alternative modality, thereby increasing the likelihood of quality care for rural and urban underserved populations as well as the general population.

Modern ICT and e-networking technologies are believed to have the potential to contribute to the “ability of patients to actively understand, participate in and influence their health status” (Bruegel, 1998). Patients are viewed as consumers of health care who can participate in their own disease prevention and treatment. The success of e-medicine, e-health, e-disease management, e-clinical care, e-learning, and other e-technological applications in the area of e-home care will be determined by the extent to which the necessary technologies are integrated into the process of care delivery, meet the needs of the users, and achieve acceptance among the general public.

Several factors must be considered in determining whether the use of technology is ethical and appropriate for a particular patient. These include the following:

• Stability of the patient's disease processes
• Level of the patient's functional limitations
• Infrastructure at the patient's home (depending on the type of application, a phone line, a phone, or a television might be required)
• Patient's mental state
• Patient's attitude toward the system and willingness to provide informed consent

The American Telemedicine Association (ATA) (2004) has produced a set of clinical guidelines for the development and deployment of e-home care applications. These guidelines include patient, provider, and technological criteria. The patient criteria involve the need for informed written consent, selection of patients able to handle the equipment, and training. The health provider criteria cover the need for plans of action, training issues, and after-hours technical support. The technological criteria encompass the operation and maintenance of equipment, establishment of clear procedures and safety codes, and protection of patient privacy and record security. The ATA initiative indicates one important factor to take into consideration when implementing e-home care applications: determining the appropriateness of the innovation.

Based on the patient's primary diagnosis, stability, and ability to use the system, the health care provider should determine the type of virtual visit and the visit pattern. Patients challenged by medication compliance or at risk of adverse drug reactions, for example, might benefit from an application that provides frequent monitoring and different types of medication reminders, as well as assistance in the retrieval of relevant education materials on the patient's diagnosis and nutritional needs.

Chapter Questions

1. How will the familiarity of the younger generation with technological innovations affect the diffusion of e-home care as they grow older?
2. What are some possible ethical concerns associated with the installation and maintenance of medical sensors and assistive devices in a patient's home and the “medicalization” of their residence?
3. Consider an e-home care network in which e-health care providers from the acute care institution from which the patient was discharged, the home care agency, out-of-state family members, and social workers are linked and able to interact with the patient via videoconferencing and transmit data from one site to another. What considerations need to be addressed, given that each institution has its own computerized patient record? What implications does this application have for security and confidentiality of patient data? Suggest guidelines for protection of the patient's privacy rights and auditing methods that will ensure confidentiality of patient data.

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The OliverHome Case

Joseph Tan, George Demiris, Joshia Tan

Steven, a seventy-two-year-old home care patient, was discharged from the hospital only a few months ago. Since his home care agency suggested that Steven be enrolled in an experimental project to adapt his home into a smart house named “OliverHome,” he has dramatically transformed his daily routines. The main concept of OliverHome is to provide Steven, who is heavily disabled and also becoming hard of hearing, with access to special functions installed as additions to the existing basic infrastructure of his house. Indeed, Steven had already spent much of his hard-earned savings to convert his house to facilitate his movement around the bedrooms and kitchen. Such costly but necessary renovations included special handles and locks for easy accessibility to closets and toilets, resizing of the bathtub and shower stand so that all of the switches and vital controls can be reached effortlessly, and installing easy-to-use remote-controlled doors, lighting, and other accessories. Now the OliverHome Project promises to help Steven take the next step in independent living.

The OliverHome Project

The OliverHome Project evaluates e-home care equipment and provides a model for consultancy in the area of smart housing. Steven's home (OliverHome) is now equipped with an electronic central bus system for control of particular functions. Because Steven must use a wheelchair, some of the controls of these functions have been integrated and placed conveniently on Steven's wheelchair. In essence, there is a separate bus for mobile environment control. Because Steven is a successful fiction writer who writes about future worlds, abduction of human earthlings, and visits from extraterrestrials, it is hoped that further development of OliverHome will apply laboratory-tested e-work technologies to support Steven in working at home; for example, integrating his television and his computer would allow Steven to complete his novels and transfer his final drafts directly to his publishers for further editing, production, and printing. The monitor for the computer would not have to be a television; instead, it could be a common display that would integrate work and entertainment interfaces. Other types of display units can address visual limitations of impaired individuals that common computer monitors or television sets cannot.

The OliverHome Project supports individuals such as Steven who are disabled or chronically ill who want to continue to e-work meaningfully in their own homes. The idea is to equip the house with a number of stand-alone e-home care applications, such as an e-paging system and optical signaling (good for Steven and others who are hard of hearing). It is important to note that a person like Steven, who suffers from cognitive impairments, may be physically capable of bathing, showering, doing housework, and even preparing meals, but impaired memory will limit his ability to perform these activities. Other home management functions enabled by the OliverHome Project include a security system and a temperature maintenance system that also includes humidity controls, which not only improve comfort levels but also protect Steven's grand piano. Ongoing plans for OliverHome include continued development of ways to integrate home management functions with external services such the police, the fire station and ambulance services.

Nowadays, as soon as he wakes up, Steven transfers into the wheelchair at his desk and near the television. He measures his blood pressure, his lung capacity, and his weight using networked devices. He controls these devices from an OliverHome centralized remote control system that he can take with him around the house; many of the more critical functions are also available from the operating system installed directly on Steven's wheelchair so he can complete these without having to access the centralized remote in order to do them. More important, Steven knows that Oliver-Home will automatically transmit all these measurements to his agency for monitoring and analysis, and thus his medical record is always updated. Steven uses a medication-dispensing machine attached to the OliverHome network system to take his morning pills. He knows that he will be notified if he forgets to do so. Then he fills out an on-line questionnaire, reporting symptoms, problems, and nutrition. Twice a week, he has a virtual visit with his home care nurse; during these visits, he can see her on his television screen while talking to her on the phone. Although Steven e-mails questions and general observations that he wants to share with his nurse on a regular basis, much more information is shared during these visits.

Development of Steven's OliverHome

Steven's home was completely rewired to convert it into OliverHome so that he can live in his own home despite his diagnosis, his daily needs, and his changing health status. When he first became homebound, Steven was concerned about his location in a rural area, miles away from the town. Since he has no family members and he was in a frail state, he was concerned about isolation. Thanks to smart home technology and the OliverHome Project, his home care agency does not seem so distant anymore, which helps Steven manage his concerns about isolation.

With the help of a central data highway (network) acting as the control bus, the old house that Steven lives in is now wired to allow intelligent remote transmission of health monitoring data. Within the area of Steven's control, each device or system to be controlled in OliverHome, such as Steven's television, his computer, and other health-monitoring gadgets, is interfaced or networked to the central bus. Although the controls are not difficult to use, Steven did get on-line training from his home care agency. The agency will be automatically notified of any malfunction of the control systems and will then check out what is going on in OliverHome. Because of the system's complex interface, Steven also needs access to the controls in other environments, such as when he is moving around, in public places, or during an emergency by accessing his PDA linked to his wheelchair, his pager and other sensors installed in his vehicle.

Theoretically, Steven can manage three different levels of OliverHome control systems: his direct mobile environment; the fixed environment (that is, OliverHome); and the distant environment. When Steven is in his wheelchair away from the OliverHome centralized control system, a local bus permits him to interact with local, directly coupled input devices such as the keyboard on his laptop, the joystick attached to the game system linked to his wheelchair, and various switches and output devices such as a telephone handset, personal communication systems such as a pager, a PDA, and other mobility controllers. When Steven is at home, OliverHome's centralized bus systems permit varying levels of control of the home environment. The features that would allow interaction with the distant environment are still in development, because this set of controls involves local authorities, mobile and telecommunication equipment providers, and large corporations such as banks.

OliverHome Applications

The OliverHome Project aims to cover three major areas of e-home care applications. The first is safety—for example, reducing the risk of Steven falling when he tries to get out of bed at night. Cueing is the second application, which provides Steven with assistance for daily living tasks such as moving around the house, personal hygiene, basic housekeeping, meal preparation, and remembering to eat his meals. Finally, supervision, which enables remote monitoring by e-caregivers and e-health care professionals, is the application that is most significant to e-home care. The remote monitoring activities of Steven and his agency have already been discussed, so we will now focus on how OliverHome handles safety and cueing.

When Steven gets out of his bed during the night, lights in his bedroom and the adjoining hall come on at a low level of illumination, increasing to a full level after a few minutes. Steven's bathroom light is automatically switched on when his footsteps or the movements of his wheelchair trigger the sensors.

After Steven leaves the bathroom, the bathroom light automatically switches off. After he gets back into bed, his bedroom light gradually dims from a full to a half level after one minute or so and then switches off automatically. If Steven does not leave his bathroom after 20 minutes or so, OliverHome alerts the HHC agency, which then beeps the bracelet sensor that he always wears on his left wrist. If Steven does not respond by pressing a sequence of buttons on this wired bracelet, an alarm is activated and a home care nurse is dispatched to OliverHome. If Steven responds correctly, the HHC will expect a report from Steven via e-mail in the next twenty-four hours, explaining why his bathroom trip took so long. Steven can choose to delay the alerting system while in the bathroom by temporarily bypassing the “set alert system” timing. The system, however, will default to the original timing two hours after each temporary bypass is initiated. Of course, all data sent back to the agency are kept for further analysis.

If Steven forgets to do his stretching as scheduled, he may be prompted with a familiar voice, or music may play in the family room. Following the music, a tape used for his regular stretching routine will be played, and illumination will be automatically increased to get Steven started with his routine. The exercise equipment machines, once selected, will automatically move to Steven's timing. Sensors in the machine record how long it took Steven to complete his movements. This information is eventually transmitted to his HHC agency. Because OliverHome's control system learns from Steven's previous actions and commands and behaves intelligently according to past patterns of Steven's actions and stored commands, if Steven were out of the house, this action sequence would not be initiated. At the end of the routine, Steven may move on to the computer in his office to get on with his work. The illumination in the family room will be dimmed, and the tape will stop playing.

Conclusion

E-home care systems have the potential to revolutionize the field of home health care. In fact, e-home care providers can provide better-quality care through frequent monitoring, increase patients' access to care services, increase visit frequency, and ensure quick response to early detection of any health problems. The success of any e-home care system depends to a large extent on providers' ability to communicate with patients and to effectively monitor them in spite of geographic distance. E-home care applications can empower patients and provide them with increased knowledge, autonomy, control, involvement in their care, and satisfaction with delivered care services. The challenge for researchers, designers, and users of such systems will be to acknowledge the system's limitations and to address the need for extensive formative and summative evaluation of its operation.

Case Questions

1. What benefits does this e-home care program provide to Steven, as opposed to staying in a long-term care facility?
2. Why is OliverHome considered a smart home?
3. Do you see any ways to improve the services provided by OliverHome?
4. Imagine that Steven's home health care agency wants you to assist in evaluating OliverHome. How would you go about this, and what questions would you ask Steven? Discuss the impact of OliverHome on traditional long-term care facilities.