2. Agenda
• LeadingAge and the Center for Aging
Services Technology (CAST)
• State of Technology in Aging Services
• Aging Technology Ethical Issues
• TeleHealth Overview
• Case Study: The VA and TeleHealth
• Continua Health Alliance
• Reflections
3. LeadingAge Imperatives
• Strengthen not-for-profit leadership
• Engage consumers
• Create the new financing paradigm
• Lead innovation
• Cultivate talented people
• Pioneer technology
– Technology is potentially the single most
important phenomenon that can synergize the
other driving forces to assure value for all
concerned
4. CAST FUTURECASTS
• Holistic Approach
• Simplified Coordination
• Person-Centered Service
• Hands On Case-Management
5. CAST FUTURECASTS
• Transparency
• Person-Centered Follow Through
and Feedback
• Connectivity
• Technology Enabled Services
and Supports
6. 10 Aging Services Technologies
• Intuitive computer interfaces
• Wireless data communication
networks
• Electronic health record (EHR)
systems
• Electronic records sharing
• Telemedicine/Telehealth
7. 10 Aging Services Technologies
• Behavioral/activity monitoring
systems
• Fall prevention/detection systems
• Tracking/wander management
systems
• Medication adherence systems
• Brain and physical fitness
technologies
8. State of Technology
in Aging Services
• Potential of Aging Services Technology
– Help older adults maximize their
independence
– Support the needs of professional and family
caregivers
– Improve quality of care and quality of life
– Reduce our nation’s health care costs
– Increase aging services provider efficiency
9. Open Letter from Andy Grove
• The average American spends $440,000
on health care in his lifetime, and
$280,000 will be spent after age 65.
• 50% of that post-65 outlay goes to
assisted-living facilities and nursing
homes.
• Keep elderly patients in their own homes
longer, without degrading quality of care
a cheaper and better system.
10. Open Letter from Andy Grove
• Using everyday, low-cost technology - the
sensors, microchips, small radios you'd
find in today's PCs, in cell phones, and in
Bluetooth earpieces.
• Endorsement and reimbursement by
Medicare is critical
• The savings achieved by keeping just 10%
of the aging population in their homes can
amount to $30 billion a year.
11. State of Technology
in Aging Services
• Barriers to Implementation
– Negative Experience and Misconceptions
– Privacy and Security
– Usability
– Provider Workflow and Interoperability
– Liability
– Lack of Consensus on Value
– Lack of Financial Incentives
12. AARP Healthy@Home 2.0
• Home Safety Devices
– Roughly 80% believe the devices would make
them feel safe, and be a comfort to
family/friends
– Roughly 80% are concerned about the costs
to install and maintain the devices
– 54% would be willing to pay $1 to $50 per
month for the devices and 41% would not be
willing to pay anything
13. AARP Healthy@Home 2.0
• Personal Health and Wellness Devices
– 70% believe that devices would make them
feel safer, and benefit family but, 80% are
concerned about costs to install and maintain
– 50% or more are concerned about stigma and
privacy
– 51% would be willing to pay $1 to $50 per
month for the devices and 42% would not be
willing to pay anything
14. State of Technology
in Aging Services
• Recommendations
– Raise Awareness of Benefits
– Support Research on Value Equation
– Provide Investment Incentives
– Develop Technology Infrastructure
– Incorporate Older Adults in Design
– Promote Collaboration Among Technology
Firms
15. Three Types of Technologies
• Health and Wellness
• Safety
• Social Connectedness
16. Health and Wellness
Technologies
• Health Management Programs
• Robots
• Medication Adherence Devices
• HD Audio and Video
17. Polycom Healthcare Delivery
Technology
• Lockable Drawer
• Available over Ultimate HD architecture
• Two monitor functionality with one monitor
– Send images while simultaneously showing
participants
• Easy connectivity to Medical Peripheral Devices
– Otoscopes, Handheld camera, Stethoscopes,
Dermascope, etc
• End to end encryption
• Based on AES (the strongest possible encryption
algorithm)
• Stereo sound provides high quality audio for medical
interactions HDX / VSX
Practitioner Cart
18. Safety Technologies
• Remote Monitoring
• Bio-Sensor Systems
• Smart Homes
http://www.harris.cise.ufl.edu/gt.htm
19.
20. High Technology for Low Vision
• Customizing a computer LowBrowse
• Cellphone with camera and feedback
KnfbReader Mobile
• GPS system Trekker Breeze
• Mini magnifiers
• Prosthetic contacts
21. Social Connectedness
Technologies
• Wii http://us.wii.com/
– Best Wii Games for Seniors
• Brain Fitness
http://www.positscience.com/
• Jitterbug Cell Phone
http://www.greatcall.com/
22. Aging Technology Ethical Issues
• Privacy of Information
• Privacy of Person/Place
• Informed Consent
• Equity of Access
23. Aging Technology Ethical Issues
• Autonomy Versus
Dependence
• Paternalism
• Patient and Provider
Relationship
• “Medicalization” of Home
24. Telehealth Leadership Initiative
• What are the Different Types of
Telehealth?
– Tele-Dermatology
– Tele-Radiology
– Tele-Nursing or Ask-a-Nurse
– Tele-Psychiatry
– Tele-Dental
– Tele-Ophthalmology
– Tele-education / Continuing Education
25. Telehealth Leadership Initiative
• Telehealth can:
– Reduce unnecessary delays in receiving Rx
– Reduce or eliminate travel expenses
– Reduce or eliminate the separation of families
during difficult or emotional times
– Provide MD services in underserved areas
– Allow patients to spend less time in waiting
rooms
26. Value of Remote Monitoring
• There is increasing evidence to support the
value of remote monitoring for individuals with
chronic conditions, including:
– 35-56% reduction in mortality
– 47% reduction in risk of hospitalization
– 6 days reduction in length of hospital admission
– 65% reduction in office visits
– 40-64% reduction in physician time for checks
– 63% reduction in transport costs
27. Agency for Healthcare Research
and Quality: Telehealth
• Telehealth can improve patient safety and
quality of care.
• Guidelines for reimbursement of telehealth
are necessary for sustainability.
• Telehealth systems should be integrated
with electronic health record (EHR)
systems to promote continuity of care
across clinical settings.
28. Medicare Payment for
Telehealth
• Medicare reimbursement for telemedicine
or telehealth services is divided into three
areas:
– Remote patient face-to-face services seen via
live video conferencing
– Non face-to-face services that can be
conducted either through live video
conferencing or via store and forward
telecommunication services
– Home telehealth services
29. The VA and Telehealth
• Telehealth/Telemedicine:
“The use of electronic information and
communications technologies to provide and
support health care when distance separates the
participants.”
• Types of Telehealth
– Synchronous: Real-time
– Asynchronous: Store-and-forward
34. VA Telehealth Outcomes:
Patient Census Growth
Year Census Change
FY03 2,000 Base Year
FY04 4,430 121%
FY05 8,922 101%
FY06 21,572 142%
FY07 31,570 46%
35. Use Reductions
Condition # of Patients % Decrease in
Utilization
Diabetes 8,954 20
Hypertension 7,447 30
CHF 4,089 25
COLD 1,963 21
Depression 337 56
36. Continua Health
• Continua Health Alliance was established June
6, 2006 with 22 member companies. More than
240 companies are members today.
• Mission: to establish an eco-system of
interoperable personal connected health
systems that empower individuals and
organizations to better manage their health and
wellness.
• Market segmentation: Living independently
longer, wellness, and managing chronic
conditions
37. Continua Health
• Continua member companies will select connectivity
standards and publish Guidelines for strict
interoperability.
• Continua is establishing a test and certification program
with a recognizable logo signifying the promise of
interoperability with other certified products.
• Interfaces and standards set for:
– personal devices (weight scale, glucose meter, pulse
oximeter)
– health records (E H R, PHR, NwHIN, HIE)
38. AST Research Opportunities
• How aging services technologies can be
incorporated into the structure of ACOs and
patient centered medical homes
• Translational research that examines the
efficacy and cost-effectiveness of technology
• Demonstrate that in-home technologies
preserve health, independence and dignity
• Produce practical implementation guides that
providers could use to replicate tested
strategies and create sustainable business
models
Notas do Editor
Michael O. Bice
Revised 12.4.2012
Interest in AST on several different levels: First, primary focus area in health services research; second, as a teacher and consultant, discovery of CSF’s and business models for AST companies; and finally, an attempt to be an informed consumer (And, trusted advisor) of AST products and services.
The LeadingAge community (www.LeadingAge.org) includes 6,000 not-for-profit organizations in the United States, 39 state partners, hundreds of businesses, research partners, consumer organizations, foundations and a broad global network of aging services organizations that reach over 30 countries. Source: http://www.leadingage.org/About_LeadingAge.aspx
Larry Minnix, President and Chief Executive Officer, LeadingAge, Washington, DC. “LeadingAge organizes our agenda around what we call the Six Leadership Imperatives. These are major driving forces that we believe will shape the future of long-term services and supports (LTSS) over the next decade.”
Source: CAST The Future is Now April 2012.pdf, p.4
Formerly known as American Association of Homes and Services for the Aging (AAHSA). Changed name after 2008 study.
The LeadingAge Center for Aging Services Technologies (CAST) is focused on development, evaluation and adoption of emerging technologies that will transform the aging experience. As an international coalition of more than 400 technology companies, aging-services organizations, businesses, research universities and government representatives
Source: CAST Scenario Planning 2011.pdf CAST’s vision of the future for long-term services and supports: that future will encompass eight primary components
Holistic We envision a future in which all older consumers receive the services and supports that enable them to age in the place of their choice. This collection of services will include primary, acute and traditional long-term services and supports, but it will also emphasize wellness promotion and disease-prevention.
Simplified The consumer of the future and his or her family caregivers will call one telephone number, or log onto one website, to gain access to a community-wide network of services and supports.
Person-Centered The future consumer will be familiar with, and familiar to, the “onestop- shop” that receives his or her request for assistance. A “concierge”—who could be a trained case manager, service coordinator or health coach—will know the consumer by name and will have immediate access to that person’s medical and service history through an interoperable electronic health records (EHR) made available with the consumer’s permission.
Hands On Some older customers and their families will be able to arrange their own services, while others will need the concierge to take ownership of their case and negotiate the community’s health and service system on their behalf.
5. Transparency No one connected to the older consumer will be left “in the dark” about that consumer’s health and well-being or his/her need for services and supports.
6. Person-Centered The concierge will follow up after the intervention to make sure that the requested services and supports were actually provided, to gauge the consumer’s impression of the quality of those services and supports, and to ascertain whether additional services and supports might be needed.
7. Connectivity The community service network would not have to operate in a vacuum and could be connected to umbrella organizations that achieved regional or even national scale. Despite these broad connections, however, the network would emphasize its local roots and would help older consumers remain connected to local service and social networks.
8. Technology Consumers of the future will view technology as a resource that supports human interaction but does not replace it. Following this philosophy, the community-based health team will employ a variety of technologies that help improve the quality and efficiency of its services
Touchscreens and graphic user-interfaces “have made computing devices accessible not only to frontline staff that might not have the same computer competencies and skills as administrators and RNs, but to older adults who are even less familiar with computer technologies,” says Alwan.
These networks have spurred the development of mobile computing and point-of-care systems that have “severed the tether, allowing (you) to carry the devices, roam around and have access to data … not only within the facility but anywhere you have similar wireless coverage,” says Alwan.
EHRs provide complete information about residents, as well as their needs and preferences. These electronic records can reduce medication errors when they are coupled with e-prescribing, physician electronic order entry, clinical decision support, and electronic medication administration systems.
Interoperability standards enable providers of long-term services and supports to electronically share residents’ health records with hospitals and physicians. “This is extremely important for the elderly, particularly around transitions of care,” says Alwan.
Telemedicine and telehealth facilitate consultations via videoconferencing, transmission of still images, remote monitoring of vital signs, continuing medical education, consumer-focused wireless applications and nurse call centers. “Telehealth can be exciting, particularly if health care professionals are properly incentivized or reimbursed for the time required to review the data and recommend an appropriate course of action,” says Alwan.
Source: Wondering which managerial, operational and resident care technology solutions belong in your organization? CAST Executive Director Majd Alwan recently shared these suggestions with readers of Long-Term Living magazine
6. These systems allow caregivers to monitor resident behavior and activities and note a decline in health well before a resident becomes symptomatic.
7. Bed and chair alarms, and user-worn automatic fall detectors, have the potential to “reduce rescue time, reduce the severity of the ensuing injury and improve the outcome of a fall.”
8. A number of technologies address wandering management through use of radio-frequency transmitters, RFID (radio-frequency identification) devices or GPS (global positioning system) and cellular signal-based tracking systems. “You need to balance the safety of the individual and the concern of the caregiver with the privacy of the individual,” says Alwan.
9. Electronic Medication Administration Records (eMAR) are usually software systems that staff uses to ensure and document medication compliance among residents. Automated medication dispensers are designed for older adults who can take medications on their own with some assistance.
10. “Thanks to intuitive user interfaces, touchscreens, graphical user interfaces, accelerometer controllers and the like, these technologies provide hours of entertainment and fun activities that have or may have a therapeutic benefit for residents,” says Alwan.
Center for Aging Services Technology (CAST): Mission is to unleash the potential of technology for innovative development across the continuum of health care, housing and services for the aging
Source: http://www.leadingage.org/CAST_Mission_and_Vision.aspx (Accessed 10.23.2012)
"The cost of caring for the elderly is huge and will only grow as our population ages. Of the $440,000 the average American spends on health care in his lifetime, $280,000 will be spent after age 65.Probably 50% of that post-65 outlay goes to assisted-living facilities and nursing homes.
So it stands to reason that if there were a way to keep elderly patients in their own homes longer - without degrading quality of care - we'd have a cheaper and better system.
And we can do just that using technology. I'm talking everyday, low-cost technology - the sensors, microchips, small radios you'd find in today's PCs, in cellphones, and in Bluetooth earpieces. It's not too difficult to use this stuff as monitoring tools. Not to spy, but to detect trouble. For example, did the patient go outside to get the newspaper or did she wander away? Has the patient taken his meds? The same technology that brings us HBO can watch over the patient and trigger human intervention when needed.A critical step to make this happen is to have it blessed - and reimbursed - by the dominant health-care supplier to the aged, Medicare. Candidates, I hope to see a phrase in your inauguration speech that starts like this: "I will have Medicare define specifications for electronic equipment that allows the average aging citizen to stay home two years longer than today."As for affordability, Grove claims "As for the elder-care plan, the savings achieved by keeping just 10% of the aging population in their homes can amount to $30 billion a year."
Source: Fortune June 11.2007 Open Letter from Andy Grove
Sources: CAST State of Technology in Aging Services: Summary (March 2008), HHS Report to Congress Aging Services Technology Study (June 2012), and Wikipedia (http://en.wikipedia.org/wiki/VeriChip)
“Negative” VeriChip was the only Food and Drug Administration (FDA)-approved human-implantable microchip. It was marketed by PositiveID, a subsidiary of Applied Digital Solutions, and it received United States FDA approval in 2004. Its manufacture and marketing were discontinued in 2010.
Privacy Concerns: Certain privacy advocates have raised concerns regarding potential abuse of the VeriChip, with some warning that adoption by governments as a compulsory identification program could lead to erosion of civil liberties. In addition, it has been shown that the VeriChip's lack of security features made it susceptible to cloning, which could present a risk of identity theft.
Religious Concerns: Some activists, including Mark Dice, the author of a book titled "The Resistance Manifesto", make a link between the VeriChip and the Biblical Mark of the Beast. Gary Wohlscheid, president of These Last Days Ministries, has argued that "Out of all the technologies with potential to be the mark of the beast, the VeriChip has got the best possibility right now".
Usability issues are particularly relevant for older adults who have limited familiarity with technology and for people with disabilities whose physical limitations may create challenges to routine technology use (e.g., when paralysis of the arms impedes use of a hand-operated computer keyboard, mouse, touch-pad or touch-screen).
Source: AARP Healthy@Home 2.0 pdf. April 2011 (Follow up to 2007 study 1.0) pp.24-29
Home Safety-sensors (Less than 20% of respondents), smart appliances (About 10%), etc
Source: AARP Healthy@Home 2.0 pdf. April 2011 (Follow up to 2007 study 1.0) pp.30-34
Personal Health and Wellness = personal emergency response system (PERS), electronic pillbox
9% of respondents use PERS and fewer use electronic pillboxes
Stigma = unable to care for self, looks like I need help
CAST State of Technology in Aging Services: Summary (March 2008)
CAST State of Technology in Aging Services: Summary (November 2007)
Health Management Programs: Health Buddy
Robots: Gecko Systems CareBot
Medication Adherence Devices: The SIMpill® Medication Adherence System is a medication adherence solution that assists patients and/or caregivers in making sure that medication is taken as prescribed.
HD Audio and Video: Polycom HDX Practitioner Cart
Polycom provides full integration of video, voice, multimedia content, bridging, recording/archiving/streaming, and support.
Signature Healthcare Benefits
Key Message: PLCM is the only company who provides true unified collaborative communication (voice, video, and content over a single infrastructure).
Care Innovations™ QuietCare® uses advanced motion sensor technology that learns the daily activity patterns of residents and sends alerts to help caregivers respond to potentially urgent situations. Caregivers can simply check in as part of their daily routine or quickly intervene if necessary.
Positive ID Corp: Easy Check breath glucose test , a non-invasive glucose detection system that measures acetone levels in a patient’s exhaled breath; and the iGlucose system, which uses wireless SMS messaging to automatically communicate a diabetic’s glucose readings to the iGlucose online database.
Welcome to the University of Florida Gator-Tech Smart House: moving technology from the drawing board into the home. In this laboratory-house, our research and development is designed to assist older persons in maximizing independence and maintaining a high quality of life.. A virtual tour is provided to introduce you to the smart house's current and future smart features (or as we call them hot spots).
WSJ 9.9.08 by Melinda Beck More than 16 million Americans report some form of visual impairment even when wearing glasses or contacts. That number is expected to double by 2030 as the aging population brings rising rates of macular degeneration, glaucoma, diabetic retinopathy and other eye diseases. An ever-growing array of devices can help people maximize their remaining vision and in many cases, compensate for what they've lost.
Free Software from Lighthouse-The software lets you select the type size, style, color and spacing of the text that appears in the banner.
a cellphone with a camera. Take a photo of any text, and the phone reads it back to you aloud or via headphone.
a global-positioning system that announces the names of streets and intersections as you are walking or riding.
Desktop devices that magnify reading material, photographs -- even your hands as you sew or write checks
Custom contact lenses -- fit to thousands of reference points on the eye -- can sometimes correct problems that off-the-shelf contacts can't, including corneas damaged by trauma.
Source: http://online.wsj.com/article/SB122091525305212313.html
Most people think of children when they think of the prime audience for video games, but thanks to Nintendo's Wii system, that is changing. Many Wii games are popular with older adults, and the physical and psychological aspects of Wii games make the games good for their health as well.
Source: The Best Wii Games for Older Adults | eHow.com http://www.ehow.com/list_7221368_wii-games-older-adults.html
LeadingAge Hosts National Senior League 2012 National Senior Wii Bowling Championship by Emily Wilson 10/10/2012
Two teams will compete for the title of champion of the National Senior League (NSL) 2012 National Senior Wii Bowling Championship, which will be held at the LeadingAge Annual Meeting...
Source: http://www.leadingage.org/LeadingAge_Hosts_National_Senior_League_2012_National_Senior_Wii_Bowling_Championship.aspx
Source: Janice M. Blanchard, Ethical Considerations of Telehealth in an Aging Society, Telehealth Symposium 2003
(1) Privacy of information. Who has access to data and how it will be used? Can it be bought and sold? How will privacy, confidentiality, and security of user information be assured?(2) Privacy of person/place. Can user control monitoring system (e.g., turn it off and on, or establish a monitor-free zone)? How is the privacy of others in the home maintained?(3) Informed consent. What constitutes informed consent, particularly with a technologically naïve or cognitively impaired person?(4) Equity of access. How do we develop equal access when technology use presupposes some technological sophistication, skills, and basic comfort level? Who will pay for services? Will it develop into a two-tier system of medical service delivery?
(5) Autonomy versus dependence. Does home monitoring foster autonomy or dependence? What will be the consequences of perceived non-compliance?(6) Paternalism. Does the desire to “keep a better watch" over aging parents actually reveal or underscore a paternalistic attitude on the part of service providers, adult children, and/or the medical establishment towards elders?(7) Patient and provider relationship. What is the overall effect on quality of care? How are empathy, compassion and trust maintained via telecommunication?(8) Medicalization of home. Will long term monitoring change the character of home? How do we maintain the separation of public and private sphere?
(Cleland et al 2005; Lee R, Goldberg et al, 2003; Scalvini S et al., 2001; Elsner et al, 2006; Van Ginneken et al 2006)
Source: http://www.continuaalliance.org/static/cms_workspace/Continua_Overview_Presentation_092812.pdf
AHRQ Decision Maker Brief on Telehealth (AHRQ Publication No: 08-0045 August 2008)
Integration of systems allowed these projects to capture patient data using telehealth equipment and transmit that information to clinicians at the point of care.
Outcomes from these projects have the potential to change the U.S. health care system, and they offer valuable insight for others who look to use telehealth applications in their own organizations to produce similar results.
Source: http://www.americantelemed.org/files/public/policy/medicaretelemedicine2012.pdf January 2012
Patricia Ryan MS RN Associate Chief Consultant, Director VISN 8 Community Care Coordination Service (ASPEC Conference 10.4.08)
Source: http://www.visn8.va.gov/VISN8/index.asp
VISN 8 has the largest VA Home Telehealth program in the nation—using technology to provide quality health care in the comfort of a patient’s home. Besides avoiding long trips and offering easier access to specialists, this kind of care reduces emergency care visits, hospitalization, and long-term institutional care for Veterans—especially important to an aging population. And the costs are much lower.
• In 2010, more than 6,800 Veterans were enrolled in the Home Telehealth program in our facilities. This enables patients with chronic diseases like diabetes, heart failure and chronic pulmonary disease to be monitored at home. Mental health conditions like Post Traumatic Stress Disorder and depression can also be closely watched.
• 100,504: That’s the number of Home Telehealth encounters between our healthcare providers and their patients in 2010.
Source: http://www.visn8.va.gov/VISN8/news/annualreports/Expanding_VAHealthCare.asp
Source: http://www.americantelemed.org/files/public/abouttelemedicine/Terminology.pdf
Synchronous: This term is sometimes used to describe interactive video connections because the transmission of information in both directions is occurring at exactly the same period.
Source: http://www.cadth.ca/publication/788
Real-time (Synchronous) telehealth involves the use of information and communication technologies (e.g., a minimum set of video cameras, computer displays, and a secure high-speed Internet connection) to enable individuals to communicate live (or synchronously) over long and short distances. Real-time telehealth could be an effective way to improve communication between patients and providers, monitor chronic conditions such as congestive heart failure, and support patients with psychiatric and neurological conditions in remote and under-served communities. However, uncertainty remains. Information about cost-effectiveness, access to services, resource utilization, process of care, and user satisfaction is lacking.
Source: http://www.cadth.ca/en/products/health-technology-assessment/publication/789
Asynchronous telehealth refers to the storage of clinically important digital samples and relevant data (e.g., pictures of moles or surgical wounds and radiological images) from any location and forwarding them to a health care professional at a distant site for assessment at a convenient time.
Source: http://www.americantelemed.org/files/public/abouttelemedicine/Terminology.pdf
Store & Forward is a type of telehealth encounter or consult that uses still digital images of a patient for the purpose of rendering a medical opinion or diagnosis. Common types of S&F services include radiology, pathology, dermatology and wound care. Store and forward also includes the asynchronous transmission of clinical data, such as blood glucose levels and electrocardiogram (ECG) measurements, from one site (e.g., patient’s home) to another site (e.g, home health agency, hospital, clinic).
Source: http://www.continuaalliance.org/static/cms_workspace/Continua_Overview_Presentation_092812.pdf
Board Members include: Intel, Panasonic, Oracle, UnitedHealth Group, Cisco, Samsung, and Qualcomm
Source: http://www.continuaalliance.org/static/cms_workspace/Continua_Overview_Presentation_092812.pdf (Slides 12 and 13)
One reason that health-care professionals are unaware of ASTs is that the professional, peer-reviewed literature to which they often refer for information and guidance does not contain a great deal of published research on ASTs or their interplay with health IT. Indeed, because professional societies often base continuing education and practice recommendations on accumulated evidence from peer-reviewed sources, it is not surprising that health-care professionals have had limited exposure to AST-related information. This gap in the scientific literature creates challenges for AST adoption among providers because many of these technologies have not been adequately evaluated in the field, and therefore often lack recognition from professional organizations (Wasson et al., 2008). Further, professionals may be reluctant to recommend AST use in the home for their patients because of the perceived and real lack of scientific evidence supporting their effectiveness.
Source: HHS Report to Congress Aging Services Technology Study (June 2012), p.171
