the two biggest slices of the pie.” Home health care has the potential to reduce both of those costs.

Assessing Efficacy

The efficacy of much of the current health care that takes place in homes is unknown. For example, some assistive devices have high abandonment rates. “Something like 30 to 50 percent of people who adopt or are fitted for a hearing aid will put it in a drawer and not use it at some point,” said Charness. Yet many people also express a preference to be treated in their homes. As one measure of this preference, in Canada from 1994 to 2004 the percentage of total deaths that occurred in hospitals declined from 78 to 61 percent.

In analyzing home health care technologies and practices, Charness and his colleagues often assess the fit of capabilities and demand. Health care devices, technologies, and practices can make many demands on a person’s capabilities. A videoconferencing system, for example, might have a software interface that a care recipient has to understand in order to use the technology. But users differ greatly along many dimensions, including their age, their education, their health literacy, their technical experience, and their perceptual, cognitive, and psychomotor capabilities. These factors affect outcomes like efficiency, efficacy, and safety. Thus, the outcomes of home health care depend on the fit between a device, technology, or practice and a person’s capabilities.

Charness used as an example an older person who has just been diagnosed with adult-onset diabetes. Such a person might be told to monitor blood sugar levels, inject insulin, and modify diet and exercise. All of these tasks can be difficult for many people. They may not like to use a glucose meter or inject insulin. They may also have unrealistic expectations, thinking that changes in diet or exercise will immediately improve their condition. “If you don’t have appropriate expectations, that can lead to inappropriate adherence to the routine that you have been asked to engage in,” Charness said.

The Diversity of Home Health Care Users

Home health care is an extremely diverse enterprise. It encompasses people with very different illnesses and capabilities, from children with diabetes to young adults with mental illnesses to middle-aged adults who might be taking medication for hypertension to older adults with dementia or renal failure. The home environment also exhibits tremendous diversity. About 27 percent of all the households in the United States have single members, rising from a low of 17 percent for adults under age 20 to as



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