Transcript Maintaining Independence with Assistive Technology

ADDRESSING THE CHALLENGE:
EMERGING POLICY AND ETHICS
AND ASSISTIVE TECHNOLOGY
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Moira Fordyce MD, MB ChB, FRCPE, AGSF
[email protected]
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Geriatrician
California Coalition for Caregivers
Vice-chair AGS Public Education Committee
Member CA AT Coalition
Teaching
Writing
Public Speaking
Educational TV Program
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1. Policy
and AT
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1. Policy and AT
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b)
c)
d)
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f)
g)
h)
i)
Lip service paid
Health Care Reform Bill
CLASS Act
Older Americans Act
Americans with Disabilities Act
Funding for AT
DME benefit
IOM recommends
A model program
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a) Lip Service Paid to AT
• 2009 President Obama - value of homebased care
• DHHS Healthy People 2020 included:
• Increase the proportion of adults with disabilities
who participate in social, recreational, community,
and civic activities to the degree that they wish
• Reduce the number of people with disabilities who
report unmet need for assistive devices, service
animals, technology services, and accessible
technologies they need
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b) Health Care Reform Bill and AT
(HR 3590)
Patient Protection and Affordable
Care Act
Signed into law March 23, 2010
www.healthcareandyou.org
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Health Care Reform Bill and AT
1. Certified EHR Grant Program for LTC
Facilities - $67.5 million
2. Demonstration Project for Use of HIT
in Nursing Homes to Improve Resident
Care
3. Development of Medicare Part D
Prescription Dispensing Techniques in
LTC Facilities
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HCRB and AT
4.
New Models of Care Utilizing
Technology
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II.
The “Community Living Assistance
Services and Supports Act” - CLASS Act
Use of technology in new cost efficient
payment models - Center for Medicare
and Medicaid Innovation - CMI November 2010
<innovations.cms.gov>
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HCRB and AT
III. Use of HIT in Health Homes for
Enrollees with Chronic Conditions
IV. Use of technology in new state
options for LT Services and
Supports
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Sad but True
• Expansion of health care coverage does
not necessarily mean access to care
• So, Medicaid and Chip Payment and
Access Commission (MACPAC) set up
under the Affordable Care Act (ACA) to
review access and payment policies
• Dual eligibles and disabled children
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c) Community Living Assistance
Services and Supports Act
• CLASS Act will enable a new model of
funding for long-term services and
supports, including the use of aging
services technologies to meet care
needs
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CLASS Act
www.advanceclass.org
• Cash benefits paid into a Life
Independence Account of an eligible
beneficiary shall be used to purchase
non-medical services and supports that
the beneficiary needs to maintain his or
her independence at home or in another
residential setting of their choice in the
community
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CLASS Act Services and Supports
Including (but not limited to)
• Home modifications
• Assistive technology
• Accessible transportation
• Homemaker services
• Respite care
• Personal assistance services
• Home care aides
• Nursing support
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CLASS Act
• January 5, 2011 - Kathleen
Sebelius, the DHHS Secretary
announced her intent to open the
doors of the Office of CLASS within
the Administration on Aging (AoA).
This decision is the first step in
helping millions of Americans
overcome barriers to independence
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CLASS Act
• Kathy Greenlee (Assistant Secretary of
Aging) made administrator of this
program
• February 7, 2011 Secretary Kathleen
Sebelius reinforced the Administration's
commitment to moving forward with the
implementation of the CLASS Act.
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d) Older Americans Act
Funds programs and services to keep
older adults independent including:
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Meals On Wheels
Home and community-based care
Senior centers
Family caregiver support
Prevention of elder abuse
Older worker training and employment
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Older Americans Act
• Transportation
• Long-term care ombudsman program
• Legal services
• Services for Native Americans and Native
Hawaiians
• Research and training
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e) Americans with Disabilities Act
• Defines a disability as a condition which
limits a person’s ability to function in
major life activities – including
communication, walking, and self-care
(such as feeding and dressing oneself)
– and which is likely to continue
indefinitely, resulting in the need for
supportive services.
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Need for AT
As population ages, need for AT
increases, but • Economy in a mess
• Major cuts in all areas - feds and state
• Number in poverty increasing
• Much talk, little action so far
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f) Funding for AT
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Medicare - under DME benefit
Medicaid - under DME benefit
Department of Veteran’s Affairs
Not-for-profit organizations
Private organizations
Community resources
Grants
Self-funding
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Funding for AT
• Unpredictable
• Effect on developers?
• Could uncertainty about payment
inhibit new developments?
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g) Durable Medical Equipment
Benefit
• Definition of DME obsolete
• Needs to change
• Narrow focus on restorative care only
• Focus needs to shift to:
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Preventing loss of function
Preventing illness and injury
Maintaining independence
Staying in community
Working at gainful employment
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DME
www.durablemedicalequipment.org
• Review and redefine “medical
necessity”, perhaps re-name?
• Educate health professionals
• Educate lay people
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h) Institute of Medicine
Recommends:
• A comprehensive disability monitoring system
should be created to help monitor disability
and inform policymakers. There should be
more public funding for disability research
programs.
• The Department of Justice should increase
efforts to enhance the Americans with
Disabilities Act, which will require health
insurers to cover assistive technologies and
devices.
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IOM Recommends:
www.iom.edu
• Congress and administrative agencies
should eliminate long waiting periods for
disability insurance.
• Consumers and professionals alike
should be better educated about the
proper care for people with disabilities
and about they challenges they face.
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Low Tech in Action!
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i) A Model Program
The Department of Veterans’ Affairs
(DVA):
• Purchases more assistive devices
for individuals with disabilities than
most other agencies
• It has a systematized structure to
pay for its large volume of
equipment
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DVA
• It provides widespread education
for consumers and clinical
personnel
• It also invests in R and D,
evaluation, development of
standards, and development of
procurement guidelines for
assistive devices.
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DVA
• The DVA program covers traditional
medical equipment such as artificial
limbs and wheelchairs, as well as
products that don’t fall under the
heading of medical necessity, such as
automobile and home modifications.
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Bottom Line - Policy
• Much talk
• Little action
• Keep pressure on legislators to, for
example, implement the CLASS
Act, build on the DVA program
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2. Ethics and AT
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ETHICS AND AT
a)
b)
c)
d)
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f)
g)
Four principles
Monitoring
Tested and True?
Needs and Resources
Possible Problems
New Hammer
Effects on Whole Society?
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a) Four Principles
• Non-maleficence simply means Do no harm. Are we in danger of doing
more harm than good?
• Beneficence means striving
consciously to be of benefit to the
person
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Four Principles
• Autonomy refers to respecting the
person’s rights to things like self
determination, privacy, freedom, and
choice
• Justice means treating everyone
fairly. For example providing equal
access to technology, or taking into
account diversity and individual
differences.
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1984 - Big Brother!
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b) Monitoring in Different Settings
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At home
On computer
Place of work
Other buildings
In automobile
In nursing home
In hospital
ANYWHERE!
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Monitoring in Different Settings
• What data will be collected?
• Medical?
• For safety?
• Financial?
• Other? For marketing?
• Why is it being collected?
• Are there “more protected” data?
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Monitoring in Different Settings
• Where is data stored?
• If data archived, how long will it stay
there?
• Does it follow you around?
• Can any information be deleted?
• Can any information be changed?
• If so by whom?
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Monitoring in Different Settings
• Who has access to it?
• How is access controlled?
• How easy is it to hack in?
• What scams could arise from covert
monitoring?
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Monitoring in Different Settings
• Can an individual’s data be combined
with others for prediction models?
• Can you be monitored against your will,
without your consent?
• What happens to privacy and freedom?
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c) Tested and True?
• Is it ethical to market and use technology that
has not yet been proven to be of benefit?
• Who will evaluate it?
• How to evaluate it?
• How reliable and safe is the AT?
• Can it be easily fixed/serviced?
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d) Needs and Resources
• Resources are scarce and getting
scarcer:
• Who gets help/funding to have AT?
• Who decides this?
• How is the decision made?
• More need than resources
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Ethical AT Use
e) Possible Problems
• Learned helplessness?
• Loss of function?
• Loss of human contact/interaction?
• AT used to cut back on this?
• Does AT help or hinder
relationships?
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Possible Problems
• Does AT improve quality of life?
• Does AT focus on person’s problems
instead of strengths?
• Are there other options that would be as
good as or even better than AT?
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Possible Problems
• Some older adults do not want to
advertise the fact that they need
help, so avoid AT
• What scams could arise from AT
marketing claims?
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f) New Hammer
Nails Everywhere?
• What are the attitudes of health
professionals to AT?
• What are the attitudes of engineers and
other researchers to AT?
• Risk/benefit analysis essential:
• To do or not to do?
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New Hammer - Nails Everywhere?
• AT can be good and bad at same time:
• Monitoring for safety invading privacy
• Should take a long term view rather than
quick fix
• Love small gains!
• Is need episodic or progressive?
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g) Effects of AT on our whole
society?
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AT and Society
• Aging boomers and AT
• All of us affected, if we’re lucky!
• Depersonalization?
• Isaac Azimov
• Three Laws of Robotics
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Three Laws of Robotics
1. A robot may not injure a human being or,
through inaction, allow a human being to
come to harm. (Humanity - fourth law)
2. A robot must obey any orders given to it by
human beings, except where such orders
would conflict with the First Law.
3. A robot must protect its own existence as
long as such protection does not conflict with
the First or Second Law.
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Web Sites
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www.aahsa.org/cast.aspx
www.aoa.gov
www.eskaton.org
www.advanceclass.org
www.house.gov
www.senate.gov
www.whitehouse.gov
www.toolsforindependence.org
www.goldviolin.com
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