Human factors challenges in home health care
Research Activities, December 2011, No. 376
We've been caring for each other in our homes since the dawn of time. It's what humans do. But home health care in the 21st century is different.
Here are four reasons:
- One, we're living longer and more of us want to "age in place with dignity."
- Two, we have more chronic, complex conditions.
- Three, we're leaving the hospital earlier and thus need more intensive care.
- And four, sophisticated medical technology has moved into our homes. Devices that were used only in medical offices are now in our living rooms and bedrooms.
From babies leaving the hospital with heart monitors to war veterans returning with life-altering injuries to seniors struggling with chronic conditions, home health care—a cradle-to-grave issue—demands more attention. The Agency for Healthcare Research and Quality (AHRQ) is leading the way by highlighting home health care with a focus in human factors research.
"By employing the field of human factors research—the discipline of applying what we know about human capabilities and limitations to designing products, processes, systems, and environments—we're learning how to achieve better, more effective and safer health outcomes in the home," says Kerm Henriksen, Ph.D., human factors advisor for patient safety at AHRQ. Much of human factors research in the home involves information technology (IT). "Our homes aren't designed for health care activities. We're interested in learning what people really do in the home to take care of themselves and others and why, and applying that knowledge to health IT design," says Teresa Zayas-Cabán, Ph.D., senior manager of health IT at AHRQ. "At the end of the day, our goal is to help ensure a good quality of life."
Committee tackles the issues
AHRQ awarded a contract to the National Research Council of the National Academies, which established the Committee on the Role of Human Factors in Home Health Care. The Committee examined the major trends and challenges influencing the growing home health sector. "A number of interacting factors directly affect home health care—the capabilities of patients and caregivers, the tasks and medical therapies undertaken, the devices and technologies used, and the physical as well as community environment in which all this occurs," explains Henriksen. "The Committee was given the task of understanding the complexities of the home health care environment so that high quality and safe care can occur."
Caregivers and patients range in literacy and health, as well as cultural traits. Tasks range from simple feeding and bathing to managing home dialysis and complex intravenous drips. Environments range from those with low lighting or stairs that block wheelchair users, to homes with no Internet access for data transfer or remote monitoring. Finally, the home includes structural relationships with families and friends as well as the community.
As part of the Committee's work, Zayas-Cabán asked the National Research Council to develop a guide for designers and developers of health IT systems used in the home, which shows how to incorporate human factors design into products to facilitate use by home caregivers. Future systems may include everything from mobile devices that track nutrition to "aware" refrigerators that can suggest menus or warn about food allergies.
The Committee recommended ways to improve the usability and effectiveness of technology systems and devices that include guidance on the structure and usability of health IT and standards for medical device labeling, among other recommendations. Common health IT applications range from in-home monitoring and self-management systems to telemedicine and mobile phone applications. Research Activities spoke to Committee members and AHRQ grantees involved in applying human factors research to the home.
Looking at home care through a broad lens
"Home health care is a burgeoning issue that will continue to grow," says Committee member Sara J. Czaja, Ph.D., of the University of Miami. "We can't look at it from a narrow lens. We need a broad, multi-disciplinary approach." Yet, home health care involves many factors, as Czaja points out, from the use of technology, including telemedicine, robotic aids, virtual coaches, respiratory equipment, and other approaches, to the people involved. "We have to think about the diversity of the people we deal with—their language, literacy, and support—both technical and social. The benefits to understanding the characteristics of home health populations' care receivers and providers are essential for developing equipment and technology," says Czaja.
Putting home health care into practice
Eric De Jonge, M.D., director of geriatrics at the Washington Hospital Center and Committee member, is part of a House Call team in Washington, DC, caring for 600 patients, most of whom are ill, frail, and elderly and have multiple chronic conditions. His practice is similar to those of other geriatricians, but De Jonge and his team care for all patients in the patients' homes. "Mobile technology allows so much to be done in the home. We have portable blood testing, EKGs, vital signs, and home X-rays," says De Jonge. "We can communicate wirelessly to the medical record."
De Jonge is convinced that home-based medical care works better for the elderly who can't get to medical appointments. "Our care is more convenient, costs less than office-based health care, and helps prevent hospitalization," he says. A national study backs up the savings that De Jonge sees in his practice. He says, "The national VA (Veterans Administration) program of home-base primary care has shown annual cost savings of 24 percent using this mobile model of care for ill elders."
The cost savings of home care to society are also substantial—and rising. A recent report, Valuing the Invaluable: 2011 Update, The Growing Contributions and Costs of Family Caregiving, by AARP estimates that the economic value of family caregivers' unpaid contributions was approximately $450 billion in 2009, up from $375 billion in 2007.
A checklist for the home
"The home is the fastest growing health care setting in America," says Robyn Gershon, M.H.S., Dr.P.H., professor, University of California, San Francisco and AHRQ grantee, "but it's tremendously overlooked. We really need to focus on safety in the home health care sector."
Gershon, formerly at the Mailman School of Public Health at Columbia University, focused her research on health and safety hazards faced by home health care workers and 100 patients in public housing units in New York City. She didn't have to look hard. "We often realized there were potential harms the minute we walked in," she says.
Gershon developed a household safety checklist for households of patients enrolled in home health care, most of whom are elderly. The checklist included photos of potential hazards or safety risks, ranging from pictures of excessive clutter and rotten food to bedbugs and cockroaches.
"We wanted a tool that was easy to use and respectful of the fact that for many home health care aides, English is a second language" says Gershon. "Using the tool was an eye opener for many of the aides. In fact, many were flabbergasted. They said, 'Oh my goodness, I never saw the mold, the mouse droppings, or realized the apartment was so dark.'"
Even the patients were supportive. "We were surprised at how engaged they were," says Gershon. "We often fail to see hazards we see every day. The checklist helps identify hazards in the household that can harm us. By identifying them, we can address them and potentially save money by preventing accidents that may result in more medical care, including costly hospitalizations."
Although Gershon's checklist was low-tech paper, she says, "This would easily work on an iPhone or computer." After completing her study, Gershon put together safety kits for the homes using materials donated by local agencies and businesses, including such items as smoke detectors. She urges us all to check on the safety of the household—not only for ourselves and our families but for others. "It's more than a nice thing to do; it's the right thing to do."