[Senate Hearing 114-868]
[From the U.S. Government Publishing Office]
S. Hrg. 114-868
AGING IN PLACE:
CAN ADVANCES IN TECHNOLOGY HELP
SENIORS LIVE INDEPENDENTLY?
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HEARING
BEFORE THE
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
WASHINGTON, DC
__________
MAY 6, 2015
__________
Serial No. 114-05
Printed for the use of the Special Committee on Aging
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
49-523 PDF WASHINGTON : 2022
SPECIAL COMMITTEE ON AGING
SUSAN M. COLLINS, Maine, Chairman
ORRIN G. HATCH, Utah CLAIRE McCASKILL, Missouri
MARK KIRK, Illinois BILL NELSON, Florida
JEFF FLAKE, Arizona ROBERT P. CASEY, JR., Pennsylvania
TIM SCOTT, South Carolina SHELDON WHITEHOUSE, Rhode Island
BOB CORKER, Tennessee KIRSTEN E. GILLIBRAND, New York
DEAN HELLER, Nevada RICHARD BLUMENTHAL, Connecticut
TOM COTTON, Arkansas JOE DONNELLY, Indiana
DAVID PERDUE, Georgia ELIZABETH WARREN, Massachusetts
THOM TILLIS, North Carolina TIM KAINE, Virginia
BEN SASSE, Nebraska
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Priscilla Hanley, Majority Staff Director
Derron Parks, Minority Staff Director
C O N T E N T S
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Page
Opening Statement of Senator Susan M. Collins, Chairman.......... 1
Opening Statement of Senator Claire McCaskill, Ranking Member.... 3
PANEL OF WITNESSES
Laurie M. Orlov, Founder, Aging in Place Technology Watch........ 5
Carol Kim, Ph.D., Vice President for Research, University of
Maine.......................................................... 7
Maureen McCarthy, M.D., Deputy Chief Patient Care Services
Officer, Veterans Health Administration, and Acting Chief
Consultant for Telehealth Services, U.S. Department of Veterans
Affairs........................................................ 8
Marjorie Skubic, Ph.D., Professor of Electrical and Computer
Engineering, and Director, Center for Eldercare and
Rehabilitation Technology, University of Missouri.............. 10
Charles S. Strickler, Caregiver.................................. 12
APPENDIX
Prepared Witness Statements
Laurie M. Orlov, Founder, Aging in Place Technology Watch........ 31
Carol Kim, Ph.D., Vice President for Research, University of
Maine.......................................................... 34
Maureen McCarthy, M.D., Deputy Chief Patient Care Services
Officer, Veterans Health Administration, and Acting Chief
Consultant for Telehealth Services, U.S. Department of Veterans
Affairs........................................................ 37
Marjorie Skubic, Ph.D., Professor of Electrical and Computer
Engineering, and Director, Center for Eldercare and
Rehabilitation Technology, University of Missouri.............. 41
Charles S. Strickler, Caregiver.................................. 43
Questions for the Record
Laurie M. Orlov, Founder, Aging in Place Technology Watch........ 51
Marjorie Skubic, Ph.D., Professor of Electrical and Computer
Engineering, and Director, Center for Eldercare and
Rehabilitation Technology, University of Missouri.............. 53
Statements for the Record
Laurie M. Orlov - Technology for Aging in Place.................. 59
Marjorie Skubic, Ph.D. - Aging in Place and Eldertech Research at
the University of Missouri..................................... 100
AGING IN PLACE:
CAN ADVANCES IN TECHNOLOGY
HELP SENIORS LIVE INDEPENDENTLY?
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WEDNESDAY, MAY 6, 2015
U.S. Senate,
Special Committee on Aging,
Washington, DC.
The Committee met, pursuant to notice, at 2:07 p.m., Room
216, Hart Senate Office Building, Hon. Susan M. Collins,
Chairman of the Committee, presiding.
Present: Senators Collins, Cotton, Perdue, Sasse,
McCaskill, Casey, Blumenthal, Donnelly, and Kaine.
OPENING STATEMENT OF SENATOR
SUSAN M. COLLINS, CHAIRMAN
The Chairman. This hearing will come to order. Good
afternoon. This afternoon's hearing will explore the potential
of new technologies to help seniors age in place safely and to
retain their independence.
The U.S. population is aging. According to Census Bureau
projections, 21 percent of our population will be age 65 and
older by the year 2040. That is up from just under 14 percent
in 2012. Every day, 10,000 Baby Boomers turn 65. As many as 90
percent of them have one or more chronic health conditions.
Americans aged 85 and older, our oldest old, are the
fastest-growing segment of our population, and this is the very
population that is most at risk of multiple and interacting
health problems that can lead to disability and the need for
long-term care.
At the very time that our population is growing older, the
need for care and support is increasing. The population of
professional and informal caregivers is, however, declining.
Today there are seven potential caregivers for each person over
age 80 and at the highest risk of requiring long-term care. By
the year 2030, there will be four, and by 2050, the number
drops to fewer than three. As a consequence, in the future more
and more people will have to rely on fewer and fewer
caregivers.
As people age, they naturally want to remain active and
independent for as long as possible. Aging in place is the
ability to live in one's own home and community safely,
independently, and comfortably, regardless of age or ability
level.
Surveys taken by AARP consistently reflect the fact that
aging in place is the preferred option for seniors who want to
continue living independently and avoiding nursing homes and
other institutionalize care for as long as possible.
Today's hearing will examine some of the recent advances in
technology that are providing new options to allow seniors to
remain in their homes longer by monitoring their health status,
detecting emergency situations such as debilitating falls, and
notifying families and health care providers of potential
changes in health status or emergencies.
While it is not a replacement for professional care or
personal attention from family members, technology can help to
bridge the care gap and extend the amount and length of time a
person is able to live independently. Technology can also help
to reduce isolation and enrich the lives of seniors by keeping
them engaged and connected to their families and their
communities.
We will also hear this afternoon about technologies that
can make the lives of family caregivers easier by giving them
the tools they need to support their loved ones as they age in
place.
Finally, we will hear from the Veterans Administration, a
real pioneer in telehealth, which has used technologies such as
videoconferencing and smart monitors to reduce hospital
admissions and to shorten hospital stays. This has resulted in
lower costs and has also allowed some of our older veterans
with chronic health conditions to live independently at home
right where they want to be.
Many of us are familiar with the decades-old and well-known
phrase, ``I've fallen and I can't get up.'' That phrase, of
course, was an advertisement for a medical alert system. While
many seniors still rely on this device, breakthroughs in modern
technology have brought us a long, long way, providing many new
options for seniors and for their families.
Technological solutions can be cost-effective and tailored
to meet the specific needs of a senior and his or her living
situation. Companies that develop these technologies are
starting to realize that not only is there a growing need to
design products that meet seniors' needs, but also that there
are many seniors who want technology and devices that look just
like those used by younger generations.
For example, this phone is an older-generation device that
is specifically designed for seniors to be easy to use. It has
large numbers, for example. This new-generation version of the
phone is a smartphone that still has the same ease of use as
this old version of the Jitterbug phone, but looks like the
smartphones that people's children and grandchildren use.
Much more important than its appearance, however, this new
generation device also includes technologies that help seniors
maintain their independence. For example, it has features to
help with medication adherence, provide 24/7 access to medical
emergency operators, as well as an app that the family
caregiver can download to keep them up-to-date on their loved
one's well-being.
We will also explore the challenges posed by these
technological advances such as privacy concerns and the unequal
access to the Internet that exists across our country.
Before I turn to Senator McCaskill for her opening
statement, I want to give a special welcome today to Dr. Carol
Kim, the vice president for research at the University of
Maine. Dr. Kim oversees the university's Successful Aging
Initiative for Living, or SAIL, program. She has traveled to
Washington today to tell us about Maine's aging and thriving in
place movement that will benefit significantly from the
development of new technologies, products, and devices. I look
forward to hearing not only from her but from all of our
witnesses this afternoon.
Senator McCaskill.
OPENING STATEMENT OF SENATOR
CLAIRE McCASKILL, RANKING MEMBER
Senator McCaskill. Thank you, Chairman Collins. Helping our
seniors remain in their communities and age with dignity is an
important issue and a top priority of this Committee. You have
assembled a great panel today, and I am looking forward to
hearing about the exciting innovations that can help seniors
and their families.
There is a real disconnect between the number of seniors
who say they want to stay in their homes and communities and
the number of seniors who end up having to move to nursing
homes. In fact, a recent AARP study found that 87 percent of
older adults would prefer to remain in their own communities as
they age. While it may not be possible for every person,
depending on a number of factors, to remain in their homes, for
many of us, with the right supports, it is possible, and it is
preferable both in terms of quality of life and certainly for
financial implications.
Recent advances in technology are providing these new
options for seniors and their families that can allow them to
remain at home for longer by monitoring health status,
detecting emergency situations, and notifying health care
providers about changes in health status. These technologies
can also make family members' and caregivers' lives easier by
providing them with tools to support their loved ones and
giving them peace of mind. This really is a win-win situation.
Seniors are much happier continuing their normal routines and
social activities where they feel comfortable, family members
can make sure their loved ones are safe, and society as a whole
benefits from significantly reduced health care and long-term-
care costs.
There are many assistive technologies that are already on
the market. Home improvement stores, other big-box retailers,
and even telecommunications companies all sell versions of
connected home systems that can keep seniors secure in their
homes. Developers are creating senior-specific monitoring
devices such as bed, toilet, and pillbox sensors that can
monitor activity within the home. Pillbox sensors are so simple
in nature, but can prevent tragic accidents by making sure that
seniors are not mixing medications or taking too many pills.
Wearable devices are also popular for tracking physical
activity and helping to prevent falls. Falls are the leading
cause of injuries in older adults, with one out of every three
seniors falling each year. Some of the newer fall-monitoring
devices do not even require the push of a button; they can
detect when a person has fallen using an accelerometer.
Technology has also been critical to the growth of telehealth
and particularly helpful for seniors who, by using telehealth
services, can have their most of their health monitored from
the comfort of their home rather than the doctor's office.
These innovative technologies are being developed by
researchers all across the country, one of whom is with us here
today. I am so pleased and proud to introduce Dr. Marjorie
Skubic. Dr. Skubic is the director of the Center for Eldercare
and Rehabilitation Technology at my university, the University
of Missouri. The Center at Mizzou, in partnership with
Americare, has created TigerPlace, a specifically designed
continuing-care living environment that utilizes a number of
advanced technologies in the senior apartments. Dr. Skubic and
her team have even found a way to use radar and 3-D sensors to
monitor seniors' risk level for falls. I look forward to
learning more about this and other emerging technologies from
Dr. Skubic's testimony.
I know there are some concerns about preserving the privacy
of seniors and that using webcams and video-monitoring might
present some challenges. We definitely want to ensure the
privacy of seniors and their dignity using this technology, but
we also want to make sure that we are looking out for their
safety. I know that Mizzou has utilized privacy-preserving
techniques, such as using only silhouettes on video monitors
that can help ease some of the privacy concerns of older
adults. The challenge for those who develop these technologies
is to find ways to maximize safety with a minimal invasion of
privacy.
Thank you to Chairman Collins and to our witnesses for
taking the time to be here today, and I look forward to
listening and learning from your testimony.
The Chairman. Thank you very much for that excellent
statement.
I want to note that we have been joined by Senator Perdue,
Senator Kaine, Senator Sasse, and Senator Casey, and I am very
pleased that you could join us this afternoon.
We are now going to turn to our panel. We will first hear
from Laurie Orlov, who is a tech industry veteran and the
founder of Aging in Place Technology Watch. I understand that
she also has the wisdom to have a summer home in the State of
Maine on Frye Island. That cinched it for me as far as inviting
you to testify today.
I have already introduced Dr. Carol Kim, who is the vice
president for research at the University of Maine.
Our next witness will be Dr. Maureen McCarthy from the
Department of Veterans Affairs. She is the Acting Chief
Consultant for Telehealth Services and will discuss the VA's
telehealth program, which by many measures has been a success
and has helped to reduce costs.
Professor Marjorie Skubic from the University of Missouri
has already been introduced by the Committee's Ranking Member.
Finally, I would like to welcome Charles Strickler to
today's hearing. Mr. Strickler, who is from Virginia, knows all
too well the challenges of caring for seniors who have a desire
to age in place, and he will share his personal story with us
and how he has used technology to assist in the care of his
mother and mother-in-law.
First we will start with Ms. Orlov.
STATEMENT OF LAURIE M. ORLOV, FOUNDER,
AGING IN PLACE TECHNOLOGY WATCH
Ms. Orlov. Thank you. Chairman Collins, Ranking Member
McCaskill, and members of the Committee, I want to thank you
for the opportunity to testify today about the potential and
requirement for technology innovation to help older adults age
in place.
As you have noted, demographics make this technology market
essential. These categories of enabling technology will help
make it feasible for older adults to meet their needs as they
age, and as we have already noted, nearly 90 percent of adults
age 65 want to remain in their own homes and, in fact, today
actually are remaining in their own homes.
Successful aging has been described as ``the ability to do
things for myself; feel safe; and have good health.'' Aging in
place, therefore, is the ability to successfully age in your
home of choice, and aging-in-place products and services,
including technology, provide a useful underpinning and
enhancement of the quality of life for seniors as they age in
place.
We have talked a bit about demographics. I just want to add
a couple of refinements of what we have already heard.
We know there are 46 million adults who are 65 or older
today, and of those, 20 million are 75 or older; 46 percent of
women aged 75-plus today are living alone. The Society of
Actuaries recently updated life expectancy at age 65 to reflect
a new reality that women age 65 can now expect to live on
average to be 88.8, with 25 percent of them living to 90 or
more. Men at 65 are going to live on average to 86.6. The
average 1-year cost of assisted living in the United States
will be $51,000 a year by 2020, and in the Northeast, San
Francisco, Chicago, and most memory-care units, that number has
already been reached and exceeded. Seniors know this, and they
are deferring move-in to assisted living communities until they
reach their mid-80's, but most of them still remain at home.
Let us talk about the categories of technology for aging in
place. If you could bring up that slide? Thank you.
They are best represented by what I describe as
``interlocking pieces of a puzzle'', and the puzzle paradigm is
specifically used here to show that if you leave out any one of
these pieces of the puzzle, people are at risk of depression,
of isolation, and undetected illnesses, and all kinds of
complications in their lives. Older adults benefit from
innovations, and particularly related training and how to
benefit from them, that address their ability to connect with
other people and opportunities, stay engaged in their
communities, be safe, and manage their health and well-being,
so looking at each category, starting with the upper-left
puzzle piece, let us examine them one at a time.
In the category of communication and engagement
technologies, while the devices may change over time--and have
changed significantly as you showed by your examples of
phones--their purpose remains the same: They help older adults
stay connected to others, through e-mail, online text, and
video chat, searching the Internet, participating in forums,
playing games, finding people with shared interests, and just
as important, finding services and resources that meet their
changing needs, and in particular, with video it can be used to
monitor but can also be used to engage people in some social
connections with their families and friends. Today, while 59
percent of the 65-plus population has access to the Internet
and 27 percent have smartphones, both percentages drop off
noticeably at age 75.
The second category on the right upper corner is the safety
and security category. The most important aspect in this
category is a home alarm system that can monitor and alert
about fire, temperature, and excessive moisture in the home.
Without it, the other technologies are just nice-to-haves.
Other useful technologies listed here include personal
emergency response system pendants, which we have already
talked about, and safety watches; fall detectors in the home;
home-based motion sensors; and activity monitors that can now
monitor absence of activity and decline over time.
Increasingly, information from various devices will be combined
to detect changes in patterns over time and we are hoping
detect gait changes or other signs that indicate a risk of
falling.
Health and wellness technologies is the category at the
bottom right that includes telehealth, as we have heard, but
also wearables, smartphone apps--as people acquire smartphones,
that may be useful--and online health information, and there
are new tools being developed all the time to help with
dementia care, support care coordination, and help find home
care workers, and a variety of these new devices can also
assist with people of low vision and people with hearing
impairment.
The bottom left-hand corner is about learning and
contribution and how we stay engaged in our society, continue
to learn new things, which is how we remain content with our
lives and interested, and it helps keep our minds sharp. Tools
that help people tell and record their life stories, for
example, online sites that enable them to volunteer, enable
them to find work, 20 percent of people after the age of 65
these days are actually working, many of them full-time.
People can learn new skills. They can learn new skills that
are leisure-related and work-related, and all of this online
training is free. This is the times we live in now. It is free.
Forums are available to find expertise and ask questions. The
biggest problem we have is that mobile device data plans today
average between $60 and 80 a month, and WiFi access is
typically being used by people in coffee shops and libraries
because having a high-speed Internet connection into the home
can be quite costly, $50 a month or more. That is a limitation
on access for lots of folks.
As people age, all the four categories are enhanced by
inclusion of the role of the formal and informal caregiver,
which you can see in the middle, and that could include the
professional caregiver. There are newer technologies that not
only track time and attendance of caregivers but also
communicate care status--that is, what is going on with
activities of daily living, communications with family members,
mobility, eating, and cognitive function.
One last point. The future market potential of this market
is greater availability of smartphone features, in-car
technologies, and will move even into robotics. It has been
sized at the low end at $20 billion by 2020, but in the future,
you will see fewer special-purpose offerings for seniors. There
will be more examples of standard hardware and device platforms
with customizable software that will meet the specific needs of
the user, so we will not have to invent special-purposes
technologies for everything. That concept is called ``Design
for All'' and can be seen today in the customizable features in
your car, in tablets, in smartphones, in television, and
consumer electronics. Design once, customize for the
individual.
I hope this overview has been helpful to you, and I want to
thank you very much for your time.
The Chairman. Thank you for your testimony.
Dr. Kim.
STATEMENT OF CAROL KIM, PH.D.,
VICE PRESIDENT FOR RESEARCH, UNIVERSITY OF MAINE
Dr. Kim. Good afternoon, Chairman Collins, Ranking Member
McCaskill, and distinguished members of the Senate
Special Committee on Aging. My name is Dr. Carol Kim, and I
am appreciative of the opportunity to share with you the
technologies that the University of Maine is developing to
allow older individuals to age and thrive in place.
It could not be timelier. We are convinced that the aging
and thriving in place movement is destined to benefit greatly
from the rapid deployment of technologies, products, and
devices that maximize human performance; improve mobility,
navigation, home environments, and intelligent living; improve
emergency detection; and contribute to older adult falls
prevention, mitigation, and response.
The University of Maine has launched a major cross-campus
aging research initiative in partnership with community
agencies and organizations and has established an
interdisciplinary research incubator from social work to
engineering to disability studies that is responding to major
public health issues that affect aging Americans.
In the area of home safety optimization and falls
prevention, we are developing technologies to promote mobility,
avert falling, increase contrast sensitivity, promote outdoor
exercise, and improve balance.
One of the most common challenges that occurs with age is
loss of visual contrast sensitivity. This can be extremely
dangerous for older adults as it turns commonplace low-contrast
features--show here in this slide--such as cement stairs,
curbs, or benches into falling hazards. Our goal is to improve
safety and reduce falling via a cost-efficient solution that
can be implemented without any infrastructure build-out. To do
this, we are exploring the use of computer vision as a means to
detect low-contrast edges in the environment and improve their
visibility. This technology is likely to reduce the falling
problem because it is optimized to address known perceptual and
cognitive changes that occur with age.
Although walkers, crutches, and canes have long been
available, these are minimally functional for outdoor exercise
and are perceived as stigmatizing and inconvenient, so in this
movie, the assistive jogger was created to fill an unmet need
for populations who, without adequate mobility support, would
be less likely, unable, or unwilling to participate in
ambulatory exercise. The assistive jogger is an aesthetically
designed, convenient, foldable, actively steered, three-wheeled
standing support device that improves balance and weight-
bearing assistance during walking, jogging or running. It is
fitted with biofeedback and innovative load-sensing technology
and is currently in the early phase of commercialization.
In the area of falls mitigation and impact minimization, we
are developing advanced energy-absorbing clothing technology. A
team at the University of Maine is currently working to develop
non-stigmatizing protective gear to mitigate injury for
individuals at risk for falls. The Maine company, Alba-Technic,
a UMaine corporate partner, has developed a highly effective,
impact-resisting material system and offers a head gear option
for older adults that can be integrated into fashionable
headwear while providing protection against head injury, as
shown in this slide. This technology is lightweight and can be
incorporated into caps, scarves, and hats. Performance tests
demonstrated a significant potential for reducing head injury.
In 2013, 258,000 people over the age of 65 were admitted
for treatment of hip fracture. The Hip Project expands our
current work with head gear to innovative, wearable hip
protection for elders. UMaine researchers are collaborating
with Alba-Technic to design aesthetically pleasing hip
protection consisting of undergarments in a changeable shell
that will be regularly worn by elders at risk for falling, and
I have samples of this material here if anyone is interested in
taking a look at that.
In the areas of fall response, we are developing wireless
networking technologies with wireless detection and vital sign
sensors to assist first responders.
Loss of sensory, cognitive, and motor function that occurs
as people age can lead to many safety risks for older adults
living independently. Current responses to this concern involve
installation of expensive and obtrusive video monitoring. We
have re-created a typical apartment setting for testing a new
extensible system that makes use of minute and low-cost
technology such as RFID tags and micro controllers. RFID tags
can easily be embedded into the physical structure of an
apartment--under carpets, behind the paint on walls and
ceilings. Our RFID reading device is small and designed to be
worn comfortably by an individual. The system tracks the user's
location as they move about their home and sends an alert if
there is a problem. The system will help to reduce in-home
falls and improve safety, efficiency, and independence.
Finally, I would like to thank the Committee for the
opportunity to describe some of the exciting and necessary
technologies that researchers at the University of Maine are
pursuing to improve the quality of life for our older
population.
The Chairman. Thank you very much, Dr. Kim.
Dr. McCarthy.
STATEMENT OF MAUREEN MCCARTHY, M.D., DEPUTY CHIEF
PATIENT CARE SERVICES OFFICER, VETERANS
HEALTH ADMINISTRATION, AND ACTING CHIEF
CONSULTANT FOR TELEHEALTH SERVICES,
U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. McCarthy. Thank you. Chairwoman Collins, Ranking Member
McCaskill, and distinguished members of the Senate Committee on
Aging, thank you for the opportunity to discuss the high-
quality care and support that the Department of Veterans
Affairs, Veterans Health Administration, Telehealth Services
programs are privileged to provide to our Nation's veterans.
Joining me today are Dr. Richard Allman, Chief Consultant for
Geriatrics and Long-Term Services, and Ms Catherine Buck,
National Home Telehealth Lead and Clinical Nurse Analyst for
Telehealth Services. Senator Kaine, she is from Richmond.
VA is recognized as a world leader in the development and
use of telehealth. Telehealth Services are mission-critical to
the future direction of VA care to veterans, and they are one
of the VA's major transformational initiatives aimed at
ensuring care is convenient, accessible, and patient-centered.
Telehealth increases access to high-quality-care services
by utilizing secure information and telecommunication
technologies to provide health services when the patient and
practitioner are separated by geographical distance. In Fiscal
Year 2014, VA telehealth occurred in over 900 sites of care,
allowing more than 717,000 patients--that would be 12.6 percent
of our enrolled veterans--to receive care through telehealth.
This amounted to over two million telehealth episodes of care.
Currently, telehealth is available in over 45 specialty care
areas.
At VA, we use three telehealth modalities to ensure
excellence in care delivery.
Clinical Video Telehealth is the use of real-time
interactive videoconferencing, sometimes with supportive
peripheral technologies, to assess, treat, and provide care to
a patient remotely.
Home Telehealth is a program for veterans that applies care
and case management principles to coordinate care using health
informatics, disease management protocols, and technologies
such as in-home and mobile monitoring, messaging, and video
technologies.
Last, Store and Forward Telehealth is the use of
technologies to asynchronously acquire and store clinical
information that is then forwarded to or retrieved by a
provider at another location for clinical evaluation.
Home-Based Primary Care began in 1970 and provides long-
term primary medical care to chronically ill veterans in their
homes under the coordination of an interdisciplinary treatment
team. Telehealth support for chronically ill veterans can
include recording the weight of the patient, sending regular
reminders about medication, taking medication, asking key
symptoms that indicate the need for a particular intervention.
Telehealth support also allows the patient to send pictures
of healing wounds to a nurse or doctor who can then advise on
what additional care is needed. In addition, telehealth can act
as an educational tool and a support system for a caregiver.
For example, a spouse who might be overwhelmed by the
complexity of caring for a loved one is provided with the
needed knowledge and skills as well as access to emotional
support.
VA Telehealth Services have delivered many positive
outcomes. We have increased to primary care and specialist
consultations leading to reduced wait times. Telehealth has
improved patient outcomes resulting in reduced utilization of
inpatient care. For example, in Fiscal Year 2014, when we
studied veterans receiving Home Telehealth services for non-
institutional care needs and chronic care management, those
enrolled veterans had a 54-percent decrease in VA bed days of
care and a 32-percent decrease in VA hospital admissions
compared when those veterans were compared to themselves in the
year prior to their enrollment in Home Telehealth.
Veterans receiving mental health services via Clinical
Video Telehealth, what we call ``TeleMental Health,'' had a 35-
percent reduction in acute psychiatric bed days of care.
In addition, VA Telehealth Services programs reduce the
necessity for veterans to travel to VA facilities for care.
Clinic Video Telehealth and Store and Forward Telehealth have
been shown to result in an average cost savings of $35 to $40
per patient per consultation. Home Telehealth has also
decreased costs for VA and non-VA care and has been shown to
reduce VA net patient costs by $2,000 per veteran per year that
were Home Telehealth that year.
Most importantly, veteran satisfaction scores have rated
high with between 88 and 94 percent approval for these kinds of
telehealth modalities.
In conclusion, VA is transforming health services from
being provider-centric to being veteran-centric. For many
veterans and their loved ones, travel to the VA medical centers
can be a complicated and sometimes arduous task. Not only that,
travel time is time away from the veteran's work or family.
VA's Telehealth Services programs revolutionize this travel
time challenge by changing the location where health care
services are routinely provided, improving access to care for
veterans, and helping veterans take a more active role in the
management of their health and well-being.
Madam Chair, this concludes my testimony, and I am prepared
to answer any questions you or other members of the Committee
may have.
The Chairman. Thank you very much.
Dr. Skubic.
STATEMENT OF MARJORIE SKUBIC, PH.D., PROFESSOR OF
ELECTRICAL AND COMPUTER ENGINEERING, AND DIRECTOR,
CENTER FOR ELDERCARE AND REHABILITATION
TECHNOLOGY, UNIVERSITY OF MISSOURI
Dr. Skubic. Thank you for the opportunity to be here among
this distinguished panel and all the Senators and the visitors.
I want to tell you a story about Eva who lived a
TigerPlace, the facility that Senator McCaskill mentioned, an
aging-in-place senior housing facility in Columbia, Missouri,
with 54 independent apartments. Residents can stay there
through the end of life. If they need extra help, services are
delivered to them.
A private corporation, Americare, build TigerPlace and
operates the housing, housekeeping, and dining. Clinical
operations are handled through the nursing school at the
University of Missouri.
Dr. Marilyn Rantz, a nursing professor at MU, set up
TigerPlace to investigate new ways to help seniors age in
place. We started testing technology there in 2005.
Back to my story, Eva had a history of congestive heart
failure and a cycle of rehospitalization as her condition
worsened, got better, and then worsened again. She volunteered
to be a participant in our sensor study. We installed motion
bed and chair sensors in her apartment. The sensor system
detected changes in Eva's patterns. When Marilyn saw this, she
knew that Eva's health was again worsening. If we did not act
now, she would have to go back to the hospital again.
In this case, it meant changing her medication. Eva's
doctor was resistant to this request because Eva had not gained
enough weight to satisfy his standards protocol. However, his
one-size-fits-all protocol did not work for Eva. She needed the
change now. Marilyn finally convinced the doctor to change
Eva's medications, and she never went back to the hospital for
heart failure again. This broke the cycle of rehospitalization.
The sensors in Eva's apartment picked up subtle changes before
Eva or her doctor noticed it.
Since then, we have developed a clinical decision support
system with automated health alerts sent to nursing staff. The
system now includes a bed sensor that captures pulse,
respiration, and restlessness; a fall detection system; and a
walking gait analysis system. Sensors are discreetly mounted in
the environment and operate without the client required to wear
anything or do anything special.
For example, the bed sensor is installed under the bed
mattress. Two sensors can be installed in the same bed for
couples. To respect the senior's privacy, no surveillance
cameras are used. Instead, we use depth images that produce
shadowy silhouettes.
The sensor system observes the seniors, learns their
typical patterns, and sends alerts to clinical staff when there
are signs of health problems. We have detected early signs of
pneumonia, urinary tract infections, pain, delirium, and
hypoglycemia. In one case, we were able to recognize changes in
walking speed and stride length of the husband in the home that
corresponded to his early dementia, even when his wife was
living there and they had many visitors coming into the home.
In the case of a fall, alerts are sent to staff with a link
to a depth video so they can see what happened leading up to
the fall. Residents get help immediately.
I do not have a presentation, but pictures and links are
included in my written testimony so you can see what these look
like, and I would be happy to show them to anybody. As a
professor, I carry all of my slides with me, and I have lots.
I have another story about my mother-in-law, Yvette, who
did not have this technology. She got up in the middle of the
night, fell down and broke her shoulder. My father-in-law,
Andy, was sleeping soundly without his hearing aids, so he did
not hear her call. She lay on the floor for hours in pain. The
next morning, Andy found her, but by then the damage had been
done. Her shoulder never healed properly, and she was in
constant pain for the rest of her life.
With her damaged shoulder, her mobility was severely
limited. She could not cook or bake anymore or pick up her
great-grandchildren, and the constant pain was a drain. Even
though she survived the fall, her quality of life was
drastically diminished. I can imagine a different outcome if
she had had our sensors in her home and gotten help
immediately.
Research studies have shown that the in-home health alert
system works. Seniors with the sensors have better health
outcomes. Seniors with sensors have a longer stay in
independent apartments at TigerPlace compared to those without
sensors by nearly two years longer. We now have a commercial
partner, Forsyth Healthcare, that is bringing this technology
to seniors. Many of my colleagues at other universities have
also developed exciting technology to help seniors, such as we
have already heard today.
The potential for proactive health care is significant.
Detecting health problems early so that early treatment can be
offered is more effective and less expensive than the current
approach and will help keep seniors healthier so they can stay
in their own homes.
We have seen this work in Missouri. I would like to see it
used throughout our country so that others can benefit,
including my Mom and Dad in South Dakota and your loved ones,
too.
The Chairman. Thank you very much for your testimony.
Mr. Strickler.
STATEMENT OF CHARLES S. STRICKLER, CAREGIVER
Mr. Strickler. Good afternoon, Chairman Collins, Ranking
Member McCaskill, and members of the Committee. On behalf of
caregivers of aging parents, thank you all for the opportunity
to testify before you today.
It has been a difficult process to find the right assistive
technologies to help our parents achieve their goal to age in
place in a home environment. My wife and I have widowed mothers
who are ages 85 and 76, respectively. Both have always desired
to live at home as long as possible. Needless to say, it has
been a challenge to stay in tune with their state of mind,
safety, and well-being while respecting their spirit of
independence and privacy. Living several hours apart makes it
even more challenging.
My mother is very independent and lives alone. She is
active in her community and continues to enjoy gardening.
Consequently, she uses a cellular pendant so she can remain
independent and yet have the security of an alert system that
enables her to summon help with the touch of a button or
automatically if she is incapacitated. It works wherever she
goes. Unlike most PERS customers, she is diligent about wearing
her pendant. However, we know PERS solutions have been
ineffective for the vast majority of users for many reasons.
My mother-in-law's aging experience is one such case. My
mother-in-law has experienced a much different aging scenario
than my mother. She has dementia. After arriving at her home
and finding a toaster oven had been left on for more than 24
hours, it was apparent she needed more assistance and we needed
to have her closer to us. We modified a cottage next to our
home by incorporating a walk-in tub and handicap accessibility
features. She moved in full-time in September 2012.
Our existing home security system would alert us to doors
opening and detect motion in each of the four rooms of the
cottage, so we were able to know when she was active.
As the dementia progressed, we became concerned about
falls. We tried several different PERS products, but she
refused to wear the pendants and would not respond to the
unfamiliar ``voice in the box.'' In short, these products were
ineffective and failed to solve our concerns.
We worked with our home security company to find and
install some alternative technologies, including a bed sensor,
chair sensors, a toilet sensor, a refrigerator sensor, and
three big easy buttons to summon help. Incorporated with the
existing door and motion sensors, this system enabled Lib to
continue to have some independence and privacy while we were
able to monitor her normal schedule and get alerts when
patterns changed or when issues arose that required immediate
assistance. We were able to set parameters that allowed us to
be alerted via cell phones to potential falls or wandering
alerts, so we could immediately check on her.
For example, bed sensors facilitated tracking normal and
changing sleep patterns. The refrigerator sensor helped
recognize when she would forget to eat.
Before she had full-time caregiving, pressing the help
button summoned help. While the system provides many of the
alerts based on individual sensors, it provides a comprehensive
wellness overview, including data summary tools that make it
much easier to see trends and patterns. User-friendly graphics
make it easy to understand what is gradually changing in Lib's
lifestyle. Thus, the system has enabled to us to know when to
layer in additional care and assistance, matching it to her
state of health as her capabilities changed.
My wife and her twin sister, who are the two primary
caregivers, will tell you the three most valued benefits of the
system are encompassed by the breadth and totality of the
solution.
First and foremost, the system provides a tremendous
``peace of mind, assuring us Mom is safe, even allowing us to
check on her even when we are not in her cottage.''
The second major benefit is that the technology is a
``priceless gift enabling us to honor Mom's request to stay at
home and live as independently as her capabilities allow.'' My
wife also said, ``Financially, it has been a relief to be able
to preserve her resources allowing us to provide the best
possible one-on-one care now that she needs it.'' Had we moved
her into assisted living, the costs would have been
significant. To date, the cumulative cost for 2091/2 years,
moving into an average Virginia nursing home, would have been
$223,000 plus an additional $104,000 for homemaker and health
aide services. In contrast, the cost of our system was about
$2,200, plus a $59 monthly fee.
While we still need to supplement our own caregiving
efforts with contracted home care support, the nominal
investment in technology has clearly provided a huge cost
savings and a higher standard of care in a more comfortable
environment.
The company we are working with has continued to innovate,
and now our system has even more capabilities that would have
been very useful for our family when Lib was more mobile: a
stove sensor alerting caregivers when the stove is left on for
prolonged periods; remote control over thermostats, lights, and
locks; motion sensors activating lights; alert pendants which
can unlock the doors; PERS functionality in their app for quick
emergency notifications away from home.
Aging-in-place technologies are not a magic solution that
will solve all of our problems of cost-effectively caring for
our aging population, but from our experience, they can be a
very integral part of the solution. These technologies can be
objective tools that can help with the difficult conversations,
prolong independence, and help guide assistance intervention,
all in a very cost effective and non-intrusive manner,
affording both caregivers and their aging loved ones excellent
lifestyle choices.
Thank you.
The Chairman. Thank you very much for your firsthand
experience and sharing it with the Committee.
Dr. Kim, as I watched the technology that you illustrated
for us today, I could not help but think that I could have
thought for years and never come up with the assistive jogger.
I realize that there is a certain stigma that is associated
with walkers, for example, and that seniors are very eager to
avoid those, but how do you come up with the technologies and
the products that you are developing at the University of
Maine?
Dr. Kim. In terms of that assistive jogger, for instance,
that started with two faculty members in disability studies.
One of the faculty members, she herself has walking and balance
issues and wanted to develop some kind of system so that she
could exercise outside and remain active in part of the
community. Her goal was to participate in a 5K.
She partnered with a professor in mechanical engineering,
and students as well, and developed this assistive jogger, and
she was able to complete the 5K, so even though the technology
was originally designed for someone with walking issues and who
had disabilities, easily you could see that this assistive
jogger would be a great piece of equipment for someone who is
aging or someone who has had a knee or hip replacement and is
going through rehabilitation.
As I mentioned in my testimony, there are also sensors that
are included in the assistive jogger so that you can make sure
that you are not putting too much weight on a joint, especially
if you are, again, rehabbing, so there are lots of technologies
that can come from this original technology that can be
transferred to the aging people.
The Chairman. That is an example of where some professors
came up with it. Do you survey seniors to see what their
biggest problems are? Do you reach out to health care
providers, home health agencies?
Dr. Kim. All the above, so as an example, you know, even
with a small group of students going to the local assisted
living facility in Orono--that is right there--the students in
engineering met with residents at this facility, and in a 1-
hour period of time, you know, they were asked--the residents
were asked, ``Well, what could we design that would help you in
your daily lives?'' In a 1-hour period, they came up with 50
different items that they would like to have designed.
The Chairman. That is incredible. That just shows that
there really is such a need for this kind of innovative
devices.
Ms. Orlov, let us look at the other side of this issue. I
read an article in which you were quoted as observing that,
``Aging in place does not imply watching us age.'' I do
understand the concerns about privacy that some of these
technologies may raise, particularly web cams, implanted
devices even. How can we make sure that we are striking the
right balance between maximizing safety so that people can stay
in their own homes and yet not making them feel that Big
Brother--or maybe actually not Big Brother but the adult child
who is watching them?
Ms. Orlov. Well, the first thing I would like to say about
the use of any monitoring technologies, there is a concept
opting in and giving permission basically that you are willing,
and I know a lot of implementations of monitoring technology
have been done under sort of the--I would not call it the
``guise,'' but on a basis of threats basically: ``If you do not
let me put this technology in your home, I am going to have to
have you move to assisted living because I am too nervous about
your well-being to leave you living alone.'' I would call that
sort of the ``loving threat.'' The loving threat has worked in
many cases, but it is very important that people understand
what they are opting into. They are not opting in necessarily
to having their every move watched, and people who design
technology properly design for alerts that show, for example,
the absence of activity in a particular window of time or the
absence of going near the refrigerator, the presence of a cat
or a dog that may jump by the sensors, the idea that you may go
on vacation and, you know, there are your sensors saying you
are not moving but you are really away for several weeks, I
mean, a lot of thought has to go into how these things are set
up and configured, but when configured properly, they can work
well.
The Chairman. Thank you.
Senator McCaskill?
Senator McCaskill. Thank you.
I would like to talk a little bit about cost savings and
the financial implications of all this and taking things to
scale. Professor Skubic, what are the cost savings that you all
can attribute to some of these advancements as it relates--one
of the things we have tried to stress in this Committee that I
think many people out there who are not directly involved, they
do not understand that a huge proportion of the Medicaid
dollars that are spent in this country are not spent on
struggling families who are not working but, rather, are spent
on our seniors who are in nursing homes, and that the high
proportion of nursing home beds that are Medicaid beds makes
this a really important hearing for our debt and our deficit,
because if we can figure this out, the cost savings and the
implications of those cost savings are dramatic to the long-
term problem we have with the demographic bubble that is
represented with my generation going into Medicare and
ultimately, if not having sufficient money saved, into a
Medicaid nursing home bed.
What kind of savings can you actually quantify at this
point that we might be able to realize if we started embracing
these monitors in people's homes, these sensors?
Dr. Skubic. Well, first I want to clarify something. You
know, I am talking about a relatively narrow aspect of this
technology rather than the very broad array that Laurie had
mentioned, but in the context of what we are doing, we are
specifically looking for early signs of health changes, early
signs of illness and functional decline, and when we first
started working with the nurses, they talked about the typical
trajectory of aging and functional decline in a stairstep
fashion where you will go on a trajectory--you will go on a
plateau for a while until something dramatic happens, and you
get dropped down to the next level very quickly until the next,
you know, dramatic thing happens.
Our premise was always if we can recognize the beginning of
that decline so that an intervention could be offered, we can
keep people up at the top of that level, and some people call
this ``squaring the life curve,'' where you go along for some
period of time and then there is a sharp dropoff when you die.
I mean, I am hoping this is what happens to my parents
actually.
Senator McCaskill. And to me.
Dr. Skubic. To all of us, right. Yes, to all of us, that we
would end up being very functionally active until the end.
Senator McCaskill. Right.
Dr. Skubic. Now, trying to quantify that in terms of cost
savings is really hard. We have not yet done the study that
really quantifies the effectiveness in those terms, in economic
terms, of the technology alone. We are involved in an NIH-
funded randomized controlled study right now that has scaled up
this work beyond TigerPlace, and we are hoping to have some
economic cost-savings figures associated with this.
I can tell you that my collaborate, Marilyn Rantz, has
looked at the economic impact of--or the cost savings of using
nursing care coordination in this context, which is what they
are doing at TigerPlace as well. It is how they do the nursing
care as well as how you add the technology part on top of that,
and they have shown quite a dramatic potential cost savings
associated with what they have been able to do with just the
organized and coordinated care, and we have seen, as we have
compared the standard level of care at TigerPlace with those--
between those who have sensors and those who do not, we see
much improved health outcomes and a longer stay in independent
living, so I am extrapolating and saying--I do not have the
actual quantitative numbers for you, but I suspect that they
are quite significant.
If you look in my written testimony, I did include some
numbers that are based on just the nursing care coordination,
part of it, and those are pretty dramatic by themselves, too.
This one statement that is in here--and this comes from
Marilyn's work--that ``About 10 million people need long-term
care in the U.S.'' Of these, 4.6 million are older than 65 and
live in the community. These 4.5 million represent a potential
$89 billion in cost savings if everyone had access and
participated in the RN nurse care coordinator intervention that
has been tested at the University of Missouri. That is huge.
Senator McCaskill. Yes, we would love to get the details of
that survey, and just as soon as the academic community can
begin to put some numbers on some of these advancements.
I know that TigerPlace is more expensive than some of the
other facilities that are in the area in terms of care, but I
understand it is small, and you guys are doing a lot of
research, and I understand all that, but I think we have got to
start monetizing these savings as quickly as possible, because
the more quickly we can monetize them, the more quickly we can
begin adopting them as part of public policy preferences, which
would have a huge impact on their availability to most people.
Dr. Skubic. Actually, TigerPlace is not that much more
expensive than a lot of other facilities.
Senator McCaskill. Just slightly more.
Dr. Skubic. Yes, it is not too much more.
Senator McCaskill. Yes, that is right. Listen, I am a big
fan of what you are doing there. I am not trying to--I am just
saying I want to try to deliver this to as many people as
possible. I think in the long run not only does it help their
lives, but it helps us struggle with how we are going to make
sure our grandchildren are not inheriting a debt that they
cannot swallow.
Thank you very much.
Dr. Skubic. Yes, and I am all in support of that.
The Chairman. Thank you.
Senator Perdue?
Senator Perdue. Well, I want to echo the Ranking Member for
her comments. There is an ulterior motive. First of all, we
want the best care we can for our parents and that generation.
They have earned it, and second is this is--I am hearing an
opportunity here, a tremendous opportunity to deal with one of
the largest cost items we have coming at us in the next 20 to
30 years to affect this debt.
Like several of you, Mr. Strickler and others, I have a
personal experience with this. Contrary to some of my political
opponents, I do have a mother, and she is 89, and she is very
tech savvy. She is independent, but this ``aging in place'' is
a new phrase for me. It is a new phrase for her, but she is
living that out.
Contrary to that, my wife's mother is a bit younger and has
just been diagnose with Alzheimer's disease, and so we have a
different trajectory there to deal with.
Dr. McCarthy, I am very excited about what you are doing
with the VA. I think you have got a perfect laboratory to
answer some of these questions that you are hearing today,
particularly about cost, about accessibility, acceptability.
You have got a perfect laboratory. You have independent
patients who are sometimes in denial about need. Second, you
have got a medical staff that might be less than receptive
potentially to some of these sort of new technologies, or not.
Maybe it is a perfect lab to develop these.
I would like to get your experience about cost, just give
us a general sense of that, acceptability with the patients,
and also with the medical staffs that you deal with.
Dr. McCarthy. I would like to start by answering about home
telehealth in particular. We have an example of a little device
that would be placed, for instance, in the veteran's home. I am
not going to turn it on, but this is a device that would
monitor, for instance, the blood pressure or the weight or the
temperature or something of the veteran, and we provide those
devices. A device like that costs about $350 and can be
repurposed when one veteran is finished with it, cleaned and
used for someone else. The costs of using a device like that
are about $1,600 a year.
When I talked about the cost savings, I did not translate
the bed days of care or the hospital admissions into savings,
but if you think a veteran before the use of a device like this
and after the use of a device like this, for last year, for the
patients we started last year, they had a 54-percent decrease
in bed days of care, numbers of days in a facility, and then a
32-percent decrease in actual numbers of admissions, so that
translates into a significant cost savings.
I think it is important, though, to know that the devices
do not exist alone. The devices are part of a system, and for
us, we have home telehealth coordinators, so for about every
100 veterans who are enrolled in our program--and patients need
to be selected. It needs to be the right population of
patients. For about every 100, we have one care coordinator.
We--people smart than me--have published about this data, and
we have had inquiries--I have been in the role of Acting Chief
Consultant for Telehealth since September. I have inquiries
from all over the world where people want to reproduce our
results, and some of the problems that people in other
countries have experienced, for instance, not having the care
coordinator available or perhaps selecting the wrong group of
patients. There are four disease conditions for which these are
extremely helpful.
One is congestive heart failure that people have mentioned
before. Congestive heart failure basically means that the heart
is not functioning as strongly, as effectively as it used to,
and ``congestive'' because it backs up, the fluids back up.
When the fluids back up, you see things like weight gain, and
so weight is an incredibly important sensor for when someone
with congestive heart failure is starting to deteriorate
because of their diet or because of some other condition, and
so when the data about weight is conveyed to, for instance, the
home telehealth coordinator, that is a very important piece of
information to notice the trend.
Another one is COPD, lung disease, chronic obstructive
pulmonary disease, what people sometimes call ``emphysema.''
Pulse oximetry devices are attached which can measure, for
instance, oxygen saturation and give us a hint when someone
needs to intervene.
The beauty of the devices is that for us, the veteran and
the caregiver do not have to get in the car and travel, but the
intervention can be made based on the result that is available.
I also wanted to mention PTSD, which is a very important
condition for us, where people are able to track their moods or
their symptoms and so forth.
The fourth one I wanted to mention was diabetes, where
blood sugars can be monitored and with that other conditions as
well.
The care coordinator serves such a crucial role in trending
the data, in communicating with the patient, communicating with
the health care team, to make sure the interventions happen
appropriately.
Senator Perdue. Well, thank you for that very thorough
answer, and thank you all for your contributions today. Thank
you.
Thank you, Ms. Chairman.
The Chairman. Thank you.
Senator Blumenthal?
Senator Blumenthal. Thank you, Madam Chair, and thank you
very much for holding this very important hearing.
I want to focus on an aspect of security, which perhaps has
not been mentioned so far, and that is the security of the data
and the information that is collected, and perhaps begin with
you, Ms. Orlov, if you could tell us what specific steps have
been taken and what more has to be done to make sure that the
personal information, confidential medical and other
information, can be kept secure.
Ms. Orlov. Well, we are in the midst of a data crisis right
now in the United States. You all know about the Anthem 80
million records that were stolen and the identity theft that is
associated with that. I would say this has created a heightened
awareness of all of the players that are in the continuum of
care for not just older adults but for everyone, and that
includes insurance companies, for which this data was, in fact,
stolen, but also includes health care providers and their
management of electronic medical records, so the good news is
that awareness has been dramatically heightened in the past
four to six months.
Senator Blumenthal. Well, awareness has been increased, but
should have been heightened years ago.
Ms. Orlov. Years ago, yes.
Senator Blumenthal. And Anthem's data, for example, was not
encrypted. Is yours?
Ms. Orlov. Are you talking to me? I do not have any data,
thank God. The VA maybe you could ask.
Dr. McCarthy. Ours is encrypted, yes, sir.
Senator Blumenthal. Would you recommend that data be
encrypted as part of this program to provide that kind of
insurance?
Dr. McCarthy. We certainly would recommend the protection
of privacy. It is interesting for us because our journey
started in the early 2000's decade, and the technology that was
available to ensure privacy and security has changed, and so
some of our rules and requirements reflect what was available
then. Some of our care into the veteran's home, for instance,
is using devices or technology that was required at that point.
There are newer means to conduct those kinds of visits, the
telehealth visits, and we are migrating our technology that
way, but without compromising security and safety.
Senator Blumenthal. I want to ask what may seem to be a
complicated question. I am going to try to make it simple. As
you know--and I am the Ranking Member of the Veteran' Affairs
Committee--we have an ongoing controversy about the 40-mile
rule, whether the 40-mile rule should apply to clinics or to
the clinics that can provide the care that the veteran needs. A
veteran may be within 40 miles of a clinic, but the clinic may
not be able to provide the care that is needed, so then a
veteran is able to go to a private health provider.
What I am wondering is whether the telehealth program from
hospitals, the 100-plus hospitals that there are, to the
hundreds of clinics would fill a gap that would enable more
veterans to go to the clinics and get the care that they need.
How much of that potential have we explored and actually
fulfilled? I hope my question is comprehensible to you.
Dr. McCarthy. It is, sir, and thanks for your service on
the Veterans' Affairs Committee. We appreciate it.
What you are talking about is the part of telehealth that
we call ``clinical video telehealth,'' in particular, in which
a provider sees a patient, and a lot of folks are familiar with
Skype or Facebook--not Facebook. FaceTime, I am sorry, but that
is the technology that people are most familiar with, which
replicates what goes on with clinical video telehealth. In VA
Central Office, I provide care, continue to provide care now as
a psychiatrist to patients I had seen in the Salem, Virginia,
VA Medical Center from time to time, so those clinical visits
can happen from one of our parent hospitals to the community-
based outpatient clinics. They can happen from one community-
based outpatient clinic to another. They are also happening
into the patient's home, and with us, space is a challenge. We
are also looking at exploring ways for the provider to not have
to take up the space of a medical center to be able to provide
this kind of care.
We have probably about 12.7 percent of our patients are
engaged in clinical video telehealth or other kinds of
telehealth. There is a large opportunity for expansion. It is
music to my ears that you ask, and we are working down the
barriers that we see and expanding this as an option. I can
tell you that someone who wrote in the mid-1990's wrote that
the biggest barriers to the expansion of telehealth are not the
technologies; they are the administrative burdens, and what we
often refer to as the fact that our Nation has a health care
system that is excellent, but it is a bricks-and-mortar kind of
base health care system based on hospitals.
In Third World countries where there is not a system of
hospitals but there are many smartphones, telehealth has taken
off in an incredible way to provide access to patients who have
the smartphones. It is our goal that we will get to the point
where the care can be provided timely, in a veteran-centered
way, not clunky, so that it is easy for the provider, easy for
the veteran and the family member to be able to have that care.
Senator Blumenthal. And you used percentage, I think, 12 to
20 percent, is that----
Dr. McCarthy. I said 12.7 percent.
Senator Blumenthal. 12.7.
Dr. McCarthy. Yes.
Senator Blumenthal. Okay, now use the telehealth.
Dr. McCarthy. Yes.
Senator Blumenthal. Thank you. Thank you all for your
excellent work.
Dr. McCarthy. Thank you
The Chairman. Thank you.
Senator Cotton, welcome.
Senator Cotton. Thank you, and thank you all, as Senator
Blumenthal said, for your excellent work on a very critical
topic that we will all face one day in our life sooner or
later.
Dr. McCarthy, I would like to continue along the lines that
Senator Blumenthal was discussing. At the VA, you have focused
a lot on various telehealth approaches. I want to expand that a
little bit and talk more about home telehealth. In a rural
State like Arkansas, we face a couple challenges that are
relevant here. One is the small number of health care providers
in rural areas. Second is also the sometimes slow nature of
broadband services in rural areas, in particular areas like
eastern Arkansas, where we have very low population density or
the Ozarks or the Ouachita Mountains, given the line-of-sight
issues.
In what you have experienced at the VA, how much of the
telehealth challenges do you think are going to revolve around
that kind of infrastructure limitation? How much is going to
revolve around the novelty of it or the resistance to change
that we all have a natural human instinct?
Dr. McCarthy. That is a good question. I think there is a
requirement for buy-in on multiple parts, administratively from
the provider's perspective and from the patient's perspective.
We can tell you stories of elderly patients that have kind of
coached our younger providers through their first telehealth
visit in a way that has been very positive for everybody
engaged.
Technology is an issue. We have for home telehealth three
kinds of technology that we use: we use device connections; we
use the interactive voice responses; and then we use the Web
browsers.
The interactive voice responses is how a lot of people used
to do their banking. They would put in their number in the
phone and what they want to do with what account and so forth,
and you can do that either by pushing buttons or by voice
recognition.
The device connections can be through the telephone system,
just a regular telephone system--it is sometimes called the
``P-O-T-S'' for ``plain old telephone system''--the cellular
system or with an Internet type protocol, and then through the
Web browser.
We have some devices that we are rolling out that have
built-in cellular antennae that allow for that kind of
connection, but sometimes the technology is a barrier, and
adoption of the technology, but it has been my experience that
so many of our aging veterans who have grandchildren at a
distance are becoming more and more familiar with the FaceTime
and the Skype and so forth, so they are very engaged in this.
The incredible convenience of not having to travel, to
park, to kind of figure out what is going on, to move around
the medical centers and so forth, to kind of have an
appointment at two and see your provider at two and be done and
not have to engage in all that whole process has been very well
received by them. The home telehealth they are very positive
about as well.
Senator Cotton. Ms. Orlov, in your work have you developed
a perspective on this question about infrastructure challenges
on the one hand and consumer taste preferences and habits on
the other hand?
Ms. Orlov. Well, I have looked into it. One of the things
we have not talked about is the role of carriers,
telecommunications carriers, in boosting connectivity for older
adults. There have been pilot programs in the United States to
provide discounts for Internet connectivity for seniors, but at
this point there is not a standard program across all the
carriers in the United States that would make Internet access
affordable for many people of lower income, so that is an
opportunity, it seems to me, that can be--we can do a lot more
with. The same thing with cell plans, so I think the average
cellular plan in the United States now is around $50 to $60 a
month, and an Internet service plan at $60 a month now means
you are out $120 a month, which is beyond the means of many
people of lower income, so I believe there is an opportunity to
work with the carriers and come up with a better idea.
Senator Cotton. I would say for the record it is just
another example of the importance of rural broadband.
Ms. Orlov. Absolutely.
Senator Cotton. It may provide some cost on the up-front,
but the savings that we can achieve through the Government in
Medicare or in our society as a whole through private insurance
are no doubt substantial.
Ms. Orlov, building on some of the work you have done, I
have no doubt that there are very strong incentives in the
market to provide this kind of technology given that seniors
are a rapidly growing population as the Baby-Boom generation
retires. They are generally some of the most affluent citizens
in our country as well, so there are strong market incentives.
Are there strong legal barriers for markets for aging in place
to develop, things that we could address as a Congress?
Ms. Orlov. Legal barriers? Well, I mean, just looking at
the physical environment for aging in place, which is the
home--right?--and looking at building code and looking at the
way even new housing for older adults is being designed, there
is no nationwide building code that would make homes even
modestly accessible. There is nothing that requires smooth
thresholds, nothing that requires wide doorways and bathrooms,
nothing that requires sink heights that could potentially
enable faucets to be accessed if you are, in fact, in a
wheelchair, so if you want to think about something that could
be done to enable people to age longer in their home from a
policy standpoint, it would be to talk to organizations that
lobby on behalf of builders, like the National Association of
Home Builders, and look at what are the barriers, and there are
probably barriers at the State level in 50 States one way or
the other to enabling use of standards. Even if, in fact, you
move into the home and you are completely able-bodied and have
no issues at all, is your home able to age with you? That is
the question.
Senator Cotton. Great. Thank you all again.
The Chairman. Thank you very much, Senator Cotton. I am
very glad you brought up the issue of rural broadband because
that is a real issue in my State as well, and I was thinking
about some of these sensors and other devices would simply not
work in some parts of the State of Maine. It is something that
nationwide we really need to do more work on.
I am just going to ask a couple of other questions. Mr.
Strickler, I noticed that you did do the cost comparison that
all of us are interested in, and you have talked about the cost
of the setup was $2,000 and then a monthly fee of $59, and if
my math is right, when you look over the 2091/2 years, if you
had had nursing home plus home health, it is more than
$300,000, and so I think this does have very important cost
implications for us, and one of the issues I think we as
Congress need to work with the administration on is what is
reimbursable to health care providers under the Medicare and
Medicaid program, because a lot of times we will pay for the
consequences of unchecked diabetes, but we will not pay for the
ongoing consultation that prevents the person from having the
complications, and I can see many of you nodding on this, so
that is something we need to look at as well.
Mr. Strickler, one final question that I want to ask you,
and that is, in your testimony, you mentioned that I think it
was your mother-in-law did not want to wear that emergency
alert pendant. How did you find out about the alternative ways
of keeping her safe by the use of sensors, by putting them all
over--it sounds like all over the house. To make sure she is
eating, you put on in the refrigerator door. I do not think
most people would even know where to begin. How did you get the
advice you needed on what you should purchase for her and what
was available?
Mr. Strickler. I think the approach that we tried to take
was to find a trusted adviser that could help us. Honestly, we
started grappling in the dark, groping in the dark a little
bit, if you would, and explored a couple things that were not
successful, and we really reached out and visited with other
people that had found solutions that did work, and then said,
okay, let us find somebody that really knows and understands
technologies and can help sort of guide us through this
process, so my advice to anybody also trying to do that would
be find a trusted adviser, and then they can help you identify
which technologies are appropriate, because different
technologies are appropriate in different circumstances, and so
I think in our case we reached out to our home security folks,
and they were able to sort of help us zero in on things that
really spoke to the needs that my mother-in-law had, and when
we couldn't get her to wear a pendant, we needed to be alerted
if she fell, so having those sensors, being able to identify if
she was up and about and did not reach Point A or Point B in a
timely fashion, it would send us cellular alerts to let us
know, hey, you need to go check on her and make sure if
something is amiss, and so that was very helpful to be able to
reach out and have that resource.
The Chairman. Thank you, and my final question is for Dr.
McCarthy, and that is, you mentioned that you were doing
telemedicine I believe from 900 sites. Is that correct on that?
Dr. McCarthy. Let me just check. I believe that is the
correct figure, yes.
The Chairman. I guess my real question about that is: Is
this happening from your community-based clinics and your VA
hospitals?
Dr. McCarthy. Yes.
The Chairman. Or it is not individual outside providers
that you are contracting with?
Dr. McCarthy. It could include that, but that is primarily
VA driven from our community-based outpatients and our clinics,
and some of the sites where the care is provided to would be
other clinics or other parts across the country; you know, as a
network we are supporting one another, but also the veteran's
home as much as possible, too.
The Chairman. I think the cost savings that you have quoted
of $2,000 per veteran per year, when you start multiplying
that, you get into real numbers very quickly.
This has been a very interesting hearing. I want to call on
Senator McCaskill for any final questions she might have.
Senator McCaskill. I really do not have any final
questions, but I do think we need to go back and look and see
how we began distributing scooters with reckless abandon. At
one point in time in the Medicare program, I know when I began
talking about scooters, we actually found a couple of--one
woman who worked in my office whose grandmother had three, and
the lift chairs and all of those things where we are--in many
cases they are needed, but how do we get approval for all those
to be paid for by the Medicare program? And what do we need to,
instead of paying for those, pay for sensors that can monitor
things that will allow us to intervene in a way that is cost-
effective and healthy and allow seniors to age in place? And
the more quickly the entrepreneurial free market in this
country comes with products that can be brought to scale that
they can present to the Medicare system for possible
reimbursement that would result in these savings, I think the
more quickly we could really turn this thing.
I certainly urge all of you that are in academia to
continue to reach out in the public-private partnerships that I
know many of you are engaged in with your companies at the
University of Maine and with your partners at the University of
Missouri, and I know the VA has a lot of commercial partners,
the more quickly we can get this technology to the point that
you do not have to have--I mean, most of us do not have a
trusted tech adviser. Therein lies the problem. Most Americans
do not even know where to find a trusted tech adviser, because
if you look up online for a trusted tech adviser, you are
liable to get somebody who is not a trusted tech adviser.
I think the more quickly we can do that, the more quickly
we can really make some progress in this area, and I really
appreciate this hearing. I learned a lot. I think all of us are
motivated at this point to see if we cannot push this envelope,
and I thank all of you for your work, and thank you once again,
Chairman, for a really good hearing.
The Chairman. Thank you very much. I think your comments
are very well taken. This Committee has held a number of
hearings on scams, and we want to make sure that as we start
promoting this kind of new technology that can give peace of
mind to caregivers and help our seniors age in place and be in
the comfort, security, and privacy of their own homes, that we
are not opening a whole new avenue for con artists out there
who will exploit any possible opening as we have found in our
various investigations.
I want to thank all of our witnesses for being here today.
Dr. Kim, I love the fact that you are involving the students at
the University of Maine and taking them, I suspect, to Dirigo
Pines to talk with seniors there, and it is incredible that
that 1-hour visit came up with 50 different ideas. That should
keep them busy for quite some time.
Each of our witnesses has contributed to our understanding
of this issue, and I thank you for taking the time to testify
before us today.
Committee members will have until Friday, May 22nd, to
submit questions to any of our witnesses or additional
materials for the record.
I want to thank Senator McCaskill and all the members of
our Committee who participated, as well as the Committee staff
who put together an excellent hearing for us today. Most of
all, thank you to our witnesses.
This hearing is now adjourned.
[Whereupon, at 3:31 p.m., the Committee was adjourned.
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APPENDIX
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Prepared Witness Statements
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Questions for the Record
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Statements for the Record
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