Katrien Luijkx

What it Takes to Successfully Implement Technology for Aging in Place: Focus Groups With Stakeholders

Background There is a growing interest in empowering older adults to age in place by deploying various types of technology (ie, eHealth, ambient assisted living technology, smart home technology, and gerontechnology). However, initiatives aimed at implementing these technologies are complicated by the fact that multiple stakeholder groups are involved. Goals and motives of stakeholders may not always be transparent or aligned, yet research on convergent and divergent positions of stakeholders is scarce. Objective To provide insight into the positions of stakeholder groups involved in the implementation of technology for aging in place by answering the following questions: What kind of technology do stakeholders see as relevant? What do stakeholders aim to achieve by implementing technology? What is needed to achieve successful implementations? Methods Mono-disciplinary focus groups were conducted with participants (n=29) representing five groups of stakeholders: older adults (6/29, 21%), care professionals (7/29, 24%), managers within home care or social work organizations (5/29, 17%), technology designers and suppliers (6/29, 21%), and policy makers (5/29, 17%). Transcripts were analyzed using thematic analysis. Results Stakeholders considered 26 different types of technologies to be relevant for enabling independent living. Only 6 out of 26 (23%) types of technology were mentioned by all stakeholder groups. Care professionals mentioned fewer different types of technology than other groups. All stakeholder groups felt that the implementation of technology for aging in place can be considered a success when (1) older adults’ needs and wishes are prioritized during development and deployment of the technology, (2) the technology is accepted by older adults, (3) the technology provides benefits to older adults, and (4) favorable prerequisites for the use of technology by older adults exist. While stakeholders seemed to have identical aims, several underlying differences emerged, for example, with regard to who should pay for the technology. Additionally, each stakeholder group mentioned specific steps that need to be taken to achieve successful implementation. Collectively, stakeholders felt that they need to take the leap (ie, change attitudes, change policies, and collaborate with other organizations); bridge the gap (ie, match technology with individuals and stimulate interdisciplinary education); facilitate technology for the masses (ie, work on products and research that support large-scale rollouts and train target groups on how to use technology); and take time to reflect (ie, evaluate use and outcomes). Conclusions Stakeholders largely agree on the direction in which they should be heading; however, they have different perspectives with regard to the technologies that can be employed and the work that is needed to implement them. Central to these issues seems to be the tailoring of technology or technologies to the specific needs of each community-dwelling older adult and the work that is needed by stakeholders to support this type of service delivery on a large scale.

“Grandma, You Should Do It—It’s Cool” Older Adults and the Role of Family Members in Their Acceptance of Technology

Despite its potential, the acceptance of technology to support the ability to live independently in one’s own home, also called aging in place, is not optimal. Family members may play a key role in technology acceptance by older adults; however, it is not well understood why and how they exert influence. Based on open interviews with 53 community-dwelling older adults, this paper describes the influence of family members, including spouses, on the use of various types of consumer electronics by older adults as was reported by themselves. Such a broad focus enables understanding the use of technology as was reported by older adults, instead of its intended use. Our study reveals that the influence of each family member has its own characteristics. The influence of technology acceptance is a natural and coincidental part of the interaction with spouses and grandchildren in which entertainment and pleasure are prominent. This is also partly true for the influence of children, but their influence also is intentional and driven by concerns. Our study indicates the importance of including all family members when implementing technology in the lives of older adults. Besides information for children about the use(fullness) of devices, it is worthwhile to give grandchildren an important role, because older adults easily adopt their enthusiasm and it might eventually lighten the burden on children.

Implementation of integrated care for diabetes mellitus type 2 by two Dutch care groups: a case study

BackgroundEven though previous research has demonstrated improved outcomes of integrated care initiatives, it is not clear why and when integrated care works. This study aims to contribute to filling this knowledge gap by examining the implementation of integrated care for type 2 diabetes by two Dutch care groups.MethodsAn embedded single case study was conducted including 26 interviews with management staff, care purchasers and health professionals. The Context + Mechanism = Outcome Model was used to study the relationship between context factors, mechanisms and outcomes. Dutch integrated care involves care groups, bundled payments, patient involvement, health professional cooperation and task substitution, evidence-based care protocols and a shared clinical information system. Community involvement is not (yet) part of Dutch integrated care.ResultsBarriers to the implementation of integrated care included insufficient integration between the patient databases, decreased earnings for some health professionals, patients’ insufficient medical and policy-making expertise, resistance by general practitioner assistants due to perceived competition, too much care provided by practice nurses instead of general practitioners and the funding system incentivising the provision of care exactly as described in the care protocols. Facilitators included performance monitoring via the care chain information system, increased earnings for some health professionals, increased focus on self-management, innovators in primary and secondary care, diabetes nurses acting as integrators and financial incentives for guideline adherence. Economic and political context and health IT-related barriers were discussed as the most problematic areas of integrated care implementation. The implementation of integrated care led to improved communication and cooperation but also to insufficient and unnecessary care provision and deteriorated preconditions for person-centred care.ConclusionsDutch integrated diabetes care is still a work in progress, in the academic and the practice setting. This makes it difficult to establish whether overall quality of care has improved. Future efforts should focus on areas that this study found to be problematic or to not have received enough attention yet. Increased efforts are needed to improve the interoperability of the patient databases and to keep the negative consequences of the bundled payment system in check. Moreover, patient and community involvement should be incorporated.

Context, mechanisms and outcomes of integrated care for diabetes mellitus type 2: a systematic review

BackgroundIntegrated care interventions for chronic conditions can lead to improved outcomes, but it is not clear when and why this is the case. This study aims to answer the following two research questions: First, what are the context, mechanisms and outcomes of integrated care for people with type 2 diabetes? Second, what are the relationships between context, mechanisms and outcomes of integrated care for people with type 2 diabetes?MethodsA systematic literature search was conducted for the period 2003–2013 in Cochrane and PubMed. Articles were included when they focussed on integrated care and type 2 diabetes, and concerned empirical research analysing the implementation of an intervention. Data extraction was performed using a common data extraction table. The quality of the studies was assessed with the Mixed Methods Appraisal Tool. The CMO model (context + mechanism = outcome) was used to study the relationship between context factors (described by the barriers and facilitators encountered in the implementation process and categorised at the six levels of the Implementation Model), mechanisms (defined as intervention types and described by their number of Chronic Care Model (sub-)components) and outcomes (the intentional and unintentional effects triggered by mechanism and context).ResultsThirty-two studies met the inclusion criteria. Most reported barriers to the implementation process were found at the organisational context level and most facilitators at the social context level. Due to the low number of articles reporting comparable quantitative outcome measures or in-depth qualitative information, it was not possible to make statements about the relationship between context, mechanisms and outcomes.ConclusionsEfficient resource allocation should entail increased investments at the organisational context level where most barriers are expected to occur. It is likely that investments at the social context level will also help to decrease the development of barriers at the organisational context level, especially by increasing staff involvement and satisfaction. If future research is to adequately inform practice and policy regarding the impact of these efforts on health outcomes, focus on the actual relationships between context, mechanisms and outcomes should be actively incorporated into study designs.

Implementation of integrated geriatric care at a German hospital: a case study to understand when and why beneficial outcomes can be achieved

BackgroundMany health systems have implemented integrated care as an alternative approach to health care delivery that is more appropriate for patients with complex, long-term needs. The objective of this article was to analyse the implementation of integrated care at a German geriatric hospital and explore whether the use of a “context-mechanisms-outcomes”-based model provides insights into when and why beneficial outcomes can be achieved.MethodsWe conducted 15 semi-structured interviews with health professionals employed at the hospital. The data were qualitatively analysed using a “context-mechanisms-outcomes”-based model. Specifically, mechanisms were defined as the different components of the integrated care intervention and categorised according to Wagner’s Chronic Care Model (CCM). Context was understood as the setting in which the mechanisms are brought into practice and described by the barriers and facilitators encountered in the implementation process. These were categorised according to the six levels of Grol and Wensing’s Implementation Model (IM): innovation, individual professional, patient, social context, organisational context and economic and political context. Outcomes were defined as the effects triggered by mechanisms and context, and categorised according to the six dimensions of quality of care as defined by the World Health Organization, namely effectiveness, efficiency, accessibility, patient-centeredness, equity and safety.ResultsThe integrated care intervention consisted of three main components: a specific reimbursement system (“early complex geriatric rehabilitation”), multidisciplinary cooperation, and comprehensive geriatric assessments. The inflexibility of the reimbursement system regarding the obligatory number of treatment sessions contributed to over-, under- and misuse of services. Multidisciplinary cooperation was impeded by a high workload, which contributed to waste in workflows. The comprehensive geriatric assessments were complemented with information provided by family members, which contributed to decreased likelihood of adverse events.ConclusionsWe recommend an increased focus on trying to understand how intervention components interact with context factors and, combined, lead to positive and/or negative outcomes.

The Development, Description and Appraisal of an Emergent Multimethod Research Design to Study Workforce Changes in Integrated Care Interventions

Introduction: In this paper, we provide a detailed and explicit description of the processes and decisions underlying and shaping the emergent multimethod research design of our study on workforce changes in integrated chronic care. Theory and methods: The study was originally planned as mixed method research consisting of a preliminary literature review and quantitative check of these findings via a Delphi panel. However, when the findings of the literature review were not appropriate for quantitative confirmation, we chose to continue our qualitative exploration of the topic via qualitative questionnaires and secondary analysis of two best practice case reports. Results: The resulting research design is schematically described as an emergent and interactive multimethod design with multiphase combination timing. In doing so, we provide other researchers with a set of theory- and experience-based options to develop their own multimethod research and provide an example for more detailed and structured reporting of emergent designs. Conclusion and discussion: We argue that the terminology developed for the description of mixed methods designs should also be used for multimethod designs such as the one presented here.

Advancing integrated care and its evaluation by means of a universal typology

Health systems around the globe implement integrated care interventions to address the Triple Aim of simultaneously improving population health, patient experiences and cost-efficiency. However, the underlying definitions and conceptualisations of integrated care often differ considerably, which makes uniform measurement and comparison difficult. Rather than agreeing on one definition of integrated care, we argue that a universal typology of integrated care interventions should be developed to enable the comparison of interventions that are based on different understandings of integrated care. This universal typology should combine rankable and intangible components with unrankable and tangible sub-components, and be conceptually sound and flexible. The content of the typology should be developed by an international consortium of relevant stakeholders.

Origins and consequences of technology acquirement by independent-living seniors: towards an integrative model

BackgroundLiving independently can be challenging for seniors. Technologies are expected to help older adults age in place, yet little empirical research is available on how seniors develop a need for technologies, how they acquire these technologies, and how these subsequently affect their lives. Aging is complex, dynamic and personal. But how does this translate to seniors’ adoption and acceptance of technology? To better understand origins and consequences of technology acquirement by independent-living seniors, an explorative longitudinal qualitative field study was set up.MethodsHome visits were made to 33 community-dwelling seniors living in the Netherlands, on three occasions (2012–2014). Semi-structured interviews were conducted on the timeline of acquirements, and people and factors involved in acquirements. Additionally, participants were interviewed on experiences in using technologies since acquirement. Thematic analysis was employed to analyze interview transcripts, using a realist approach to better understand the contexts, mechanisms and outcomes of technology acquirements.ResultsFindings were accumulated in a new conceptual model: The Cycle of Technology Acquirement by Independent-Living Seniors (C-TAILS), which provides an integrative perspective on why and how technologies are acquired, and why these may or may not prove to be appropriate and effective, considering an independent-living senior’s needs and circumstances at a given point in time. We found that externally driven and purely desire-driven acquirements led to a higher risk of suboptimal use and low levels of need satisfaction.ConclusionsTechnology acquirement by independent-living seniors may be best characterized as a heterogeneous process with many different origins, pathways and consequences. Furthermore, technologies that are acquired in ways that are not congruent with seniors’ personal needs and circumstances run a higher risk of proving to be ineffective or inappropriate. Yet, these needs and circumstances are subject to change, and the C-TAILS model can be employed to better understand contexts and mechanisms that come into play.

The 3 A's of the access process to long-term care for elderly: Providers experiences in a multiple case study in the Netherlands

The access process is an important step in the care provision to independently living elderly. Still, little attention has been given to the process of access to long-term care for older clients. Access can be described by three dimensions: availability, affordability and acceptability (three As). In this paper we address the following question: How do care providers take the three dimensions of access into account for the access process to their care and related service provision to independently living elderly? To answer this question we performed a qualitative study. We used data gathered in a multiple case study in the Netherlands. This study provides insight in the way long-term care organizations organize their access process. Not all dimensions were equally present or acknowledged by the case organizations. The dimension acceptability seems an important dimension in the access process, as shown by the efforts done in building a relationship with their clients, mainly through a strong personal relationship between client and care advisor. In that respect it is remarkable that the case organizations do not structurally evaluate their access process. Availability is compromised by practical issues and organizational choices. Affordability hardly seems an issue. Further research can reveal the underlying factors that influence the three A dimensions.

Love, intimacy and sexuality in residential dementia care: A spousal perspective:

The experiences and needs of spouses of residential care facility residents with dementia, regarding friendship, love, intimacy, and sexuality were explored. Understanding of how spouses make sense of their experiences was pursued. Semi-structured interviews were held with nine spouses of people with dementia, living in high intensive 24-hour care units within residential care facilities. The results show that friendship, love, intimacy, and sexuality were still embedded in the couples’ marital lives, but all in their own way. Changing roles and a shift in purpose of the relationship recurred. Although intimacy was found to be still important in the lives of spouses, emotional, and practical residential care facility barriers were experienced by the spouses, of which the absence of communication were most important. Our findings on the experiences of spouses with regard to intimacy and sexuality can help residential care facility staff and policymakers to recognize the needs of couples and take these into account.