5
Concluding Discussion

In the final session of the workshop, David Wegman led a general discussion of the core concepts and concerns raised by the speakers and invited participants to comment on issues not yet discussed.

Paula Milone-Nuzzo raised the issue of violence associated with home health care and the problems it creates for providers to get to people’s homes. It may not be possible to go into certain communities at particular times or without a police escort.

Mary Weick-Brady observed that coordination of regulations is needed in addition to coordination of care. Medical devices, reimbursement issues, transportation, housing, and even the bandwidths used for medical monitoring are all important factors in home health care, and in an ideal world the regulations governing these domains would work together rather than at cross purposes. George Demiris added that software platforms for disease management or telemonitoring need to be coordinated to avoid problems with interoperability, vocabulary, and communications. Christopher Gibbons made the same point for medical information that directly targets consumers. Jon Sanford observed that a similar situation exists with regard to building regulations. Although a national standard exists, it is model code that is not enforceable, and many thousands of municipalities adopt their own codes. The original intent of the codes was for public health, safety, and welfare, but that is not necessarily the principal concern today.

Molly Story observed that the principal message she took away from the workshop was that “it’s a mistake to … take the medical care of health care and try to cram it into the house.” Health care needs to understand the home much better and make changes based on that understanding.



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5 Concluding Discussion In the final session of the workshop, David Wegman led a general dis- cussion of the core concepts and concerns raised by the speakers and invited participants to comment on issues not yet discussed. Paula Milone-Nuzzo raised the issue of violence associated with home health care and the problems it creates for providers to get to people’s homes. It may not be possible to go into certain communities at particular times or without a police escort. Mary Weick-Brady observed that coordination of regulations is needed in addition to coordination of care. Medical devices, reimbursement issues, transportation, housing, and even the bandwidths used for medical moni- toring are all important factors in home health care, and in an ideal world the regulations governing these domains would work together rather than at cross purposes. George Demiris added that software platforms for dis- ease management or telemonitoring need to be coordinated to avoid prob- lems with interoperability, vocabulary, and communications. Christopher Gibbons made the same point for medical information that directly targets consumers. Jon Sanford observed that a similar situation exists with regard to building regulations. Although a national standard exists, it is model code that is not enforceable, and many thousands of municipalities adopt their own codes. The original intent of the codes was for public health, safety, and welfare, but that is not necessarily the principal concern today. Molly Story observed that the principal message she took away from the workshop was that “it’s a mistake to . . . take the medical care of health care and try to cram it into the house.” Health care needs to understand the home much better and make changes based on that understanding. 

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8 HUMAN FACTORS IN HOME HEALTH CARE Changes in the education of health care professionals can help establish this new emphasis, said Judith Matthews. The focus of education in the past has been acute care, but that does not equip people to practice in a community setting. Neil Charness called attention to the challenge very low population densities pose to home health care. Technology may provide a way to do virtual visits in such settings, but technology does not necessarily offer full access to a person’s home. More than half of the older population lives alone, which highlights the need for supportive technologies that can help these individuals remain independent in their communities. In many cases, family members do not live nearby, exacerbating the problem of providing effective health care. For caregivers who visit homes, these homes are their workplace, said Margaret Quinn. In addition, for many paraprofessionals, who are pre- dominantly female and members of minority groups, their work and social positions are largely invisible in the larger society. Effective models of care recognize that home care is patient- and home-centered while simultane- ously acknowledging the home as a workplace. Committee member Daryle Jean Gardner-Bonneau observed that care recipients and care providers are part of a single system. Both groups will have a major effect on the way the system is designed and structured. The system needs to be flexible enough to enable a wide variety of choices by both care recipients and providers, and, she said, “I am not sure we always do that.” COMMITTEE PERSPECTIVE Wegman summarized some of the messages he heard at the workshop. • Better definitions can inform interdisciplinary analyses of home health care. • Funding practitioners and knowledge in separate silos restricts the construction of more comprehensive and coherent systems for the delivery of home health care. • Thinking longitudinally over the life course can help to meet the needs of care recipients in a home or community. • New approaches can improve education and training, ranging from specific training in the use of a device to general interdisciplinary professional education. • Care providers and care recipients always operate together as a dyad, and productive policy discussions will consider this dyad as a unit.

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 CONCLUDING DISCUSSION • Models from abroad can inform future discussions and work in home health care. • Devices can be designed for the full range of the population, not just for the median of the population. • Formal and informal markets for home health care devices can be a powerful influence on how these devices are used. • Implementation of new programs and approaches ideally will be accompanied by studies of their efficacy and effectiveness. • The principles of universal design can provide a foundation for thinking comprehensively about home health care. • Reimbursement is “a glorious mess” in need of concerted attention. • Good care management emphasizes teams of care providers. • Existing models of effective home care can be implemented else- where and studied. SPONSOR PERSPECTIVE Kerm Henriksen commented on some of the main messages he absorbed from the discussion. • The knowledge in people’s heads can be translated into knowledge in the world to address such issues as the personnel shortage in home health care. • Examples of very effective home health care can be studied to draw lessons from experience and existing expertise. • Assessment methods used in inpatient care could have beneficial applications in home health care. • Human factors techniques, such as root cause analyses or failure modes and effects analyses, could provide useful insights in the home health care setting. • Quasi-experimental designs and evaluation techniques could be used to spur interest in research and applications. • Aesthetics in design can play an important role with respect to home assistive technologies. • Home health care has a dark side, as evidenced by violence in the community, abuse in the home, and frustration because of dementia. • The problems of transitional care are ripe for human factors research. • Training in silos is antithetical to working in teams, yet teamwork is essential in home health care.

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0 HUMAN FACTORS IN HOME HEALTH CARE • Health care may not be a unified system, but systems analysis can be applied to the role that health care plays in people’s lives. • Health care needs change over time, and human factors research can consider the ways in which these changes affect the delivery of health care.