THE ESSENCE PROJECT

Alarms and key holding

Case studies

Read the full case study for 'Telecare for older people' here (PDF)
Michela Tinelli, Catherine Henderson, Danielle Guy, Martin Knapp 2019

KEY POINTS

Telecare is a form of assistive technology that is available in different packages according to the wide range of products featured.

  • There is great policy interest in the potential of telecare to improve outcomes,including functional independence, psychological and quality of life, as well ascarer outcomes.
  • There is also policy interest in whether wider use of telecare could reduce or contain use of other services and costs.
  • The evidence suggests that telecare, as deployed in England at the present time,does not deliver the outcomes of effectiveness and cost-effectiveness thateveryone might have wanted.
  • More research is needed to evaluate technologies in use, strengthen workforce training and share learning across settings.

Evidence

Connecting with Health and Care
Foundations and Housing Learning and Improvement Network, London. 2009

In Autumn 2007 Foundations, the National Body for home improvement agencies, was commissioned by Communities and Local Government to carry out research and produce a report examining the options for the future delivery of home improvement agency (HIA) services. The report draws on examples from within and outside the HIA sector to highlight possible areas for development. It does not present a ‘one-size-fits-all’ model, but a series of options that may be appropriate depending on the identified needs of the local population, taking account of other services already in place.

Cost-effectiveness of telecare for people with social care needs: the Whole Systems Demonstrator cluster randomised trial
Henderson C, Knapp M, Fernandez JL, et al Age and Ageing, 43, 794-800. 2014

Purpose of the study: to examine the costs and cost-effectiveness of ‘second-generation’ telecare, in addition to standard support and care that could include ‘first-generation’ forms of telecare, compared with standard support and care that could include ‘first-generation’ forms of telecare.

Design and methods: a pragmatic cluster-randomised controlled trial with nested economic evaluation. A total of 2,600 people with social care needs participated in a trial of community-based telecare in three English local authority areas. In the Whole Systems Demonstrator Telecare Questionnaire Study, 550 participants were randomised to intervention and 639 to control. Participants who were offered the telecare intervention received a package of equipment and monitoring services for 12 months, additional to their standard health and social care services. The control group received usual health and social care.

Primary outcome measure: incremental cost per quality-adjusted life year (QALY) gained. The analyses took a health and social care perspective.

Results: cost per additional QALY was £297,000. Cost-effectiveness acceptability curves indicated that the probability of cost-effectiveness at a willingness-to-pay of £30,000 per QALY gained was only 16%. Sensitivity analyses combining variations in equipment price and support cost parameters yielded a cost-effectiveness ratio of £161,000 per QALY.

Implications: while QALY gain in the intervention group was similar to that for controls, social and health services costs were higher. Second-generation telecare did not appear to be a cost-effective addition to usual care, assuming a commonly accepted willingness to pay for QALYs.

Cost-effectiveness of telehealth for patients with long term conditions (Whole Systems Demonstrator telehealth questionnaire study): nested economic evaluation in a pragmatic, cluster randomised controlled trial
Henderson C, Knapp M, Fernandez JL, et al British Medical Journal, 346, f1035. 2014

OBJECTIVE:

To examine the costs and cost effectiveness of telehealth in addition to standard support and treatment, compared with standard support and treatment.
DESIGN:

Economic evaluation nested in a pragmatic, cluster randomised controlled trial.
SETTING:

Community based telehealth intervention in three local authority areas in England.
PARTICIPANTS:

3230 people with a long term condition (heart failure, chronic obstructive pulmonary disease, or diabetes) were recruited into the Whole Systems Demonstrator telehealth trial between May 2008 and December 2009. Of participants taking part in the Whole Systems Demonstrator telehealth questionnaire study examining acceptability, effectiveness, and cost effectiveness, 845 were randomised to telehealth and 728 to usual care.
INTERVENTIONS:

Intervention participants received a package of telehealth equipment and monitoring services for 12 months, in addition to the standard health and social care services available in their area. Controls received usual health and social care.
MAIN OUTCOME MEASURE:

Primary outcome for the cost effectiveness analysis was incremental cost per quality adjusted life year (QALY) gained.
RESULTS:

We undertook net benefit analyses of costs and outcomes for 965 patients (534 receiving telehealth; 431 usual care). The adjusted mean difference in QALY gain between groups at 12 months was 0.012. Total health and social care costs (including direct costs of the intervention) for the three months before 12 month interview were £1390 (€1610; $2150) and £1596 for the usual care and telehealth groups, respectively. Cost effectiveness acceptability curves were generated to examine decision uncertainty in the analysis surrounding the value of the cost effectiveness threshold. The incremental cost per QALY of telehealth when added to usual care was £92 000. With this amount, the probability of cost effectiveness was low (11% at willingness to pay threshold of £30 000; >50% only if the threshold exceeded about £90 000). In sensitivity analyses, telehealth costs remained slightly (non-significantly) higher than usual care costs, even after assuming that equipment prices fell by 80% or telehealth services operated at maximum capacity. However, the most optimistic scenario (combining reduced equipment prices with maximum operating capacity) eliminated this group difference (cost effectiveness ratio £12 000 per QALY).
CONCLUSIONS:

The QALY gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only, and total costs associated with the telehealth intervention were higher. Telehealth does not seem to be a cost effective addition to standard support and treatment.

Effect of telecare on use of health and social care services: findings from the Whole Systems Demonstrator cluster randomised trial.
Steventon A, Bardsley M, Billings J, et al Age and Ageing, 42, 501-508. 2013

Objective: to assess the impact of telecare on the use of social and health care. Part of the evaluation of the Whole Systems Demonstrator trial.

Participants and setting: a total of 2,600 people with social care needs were recruited from 217 general practices in three areas in England.

Design: a cluster randomised trial comparing telecare with usual care, general practice being the unit of randomisation. Participants were followed up for 12 months and analyses were conducted as intention-to-treat.

Data sources: trial data were linked at the person level to administrative data sets on care funded at least in part by local authorities or the National Health Service.

Main outcome measures: the proportion of people admitted to hospital within 12 months. Secondary endpoints included mortality, rates of secondary care use (seven different metrics), contacts with general practitioners and practice nurses, proportion of people admitted to permanent residential or nursing care, weeks in domiciliary social care and notional costs.

Results: 46.8% of intervention participants were admitted to hospital, compared with 49.2% of controls. Unadjusted differences were not statistically significant (odds ratio: 0.90, 95% CI: 0.75–1.07, P = 0.211). They reached statistical significance after adjusting for baseline covariates, but this was not replicated when adjusting for the predictive risk score. Secondary metrics including impacts on social care use were not statistically significant.

Conclusions: telecare as implemented in the Whole Systems Demonstrator trial did not lead to significant reductions in service use, at least in terms of results assessed over 12 months.

Extending the Housing Options for Older People: Focus on Extra Care
Petch A Institute for Research and Innovation in Social Services, Glasgow. 2014

This Insight summarises the evidence on policy and practice issues for housing with care and support for older people, focusing on extra care provision, and the extent to which different models provide an effective alternative to residential and nursing care. The review begins by providing a short overview to the policy context in Scotland. It then looks at the evidence in the following areas: location, support arrangements, quality of life, provision for dementia, building design, end of life and cost. The Insight covers ‘extra care’ that offers self-contained accommodation units, support accessible 24 hours, some collective meal provision and a range of leisure and other facilities on site.

Framing the evidence for health smart homes and home-based consumer health technologies as a public health intervention for independent aging: A systematic review
Reeder B, Meyer E, Lazar A, et al International Journal of Medical Informatics, 82, 565–579. 2013

Introduction
There is a critical need for public health interventions to support the independence of older adults as the world’s population ages. Health smart homes (HSH) and home-based consumer health (HCH) technologies may play a role in these interventions.

Methods
We conducted a systematic review of HSH and HCH literature from indexed repositories for health care and technology disciplines (e.g., MEDLINE, CINAHL, and IEEE Xplore) and classified included studies according to an evidence-based public health (EBPH) typology.

Results
One thousand, six hundred and thirty nine candidate articles were identified. Thirty-one studies from the years 1998–2011 were included. Twenty-one included studies were classified as emerging, 10 as promising and 3 as effective (first tier).

Conclusion
The majority of included studies were published in the period beginning in the year 2005. All 3 effective (first tier) studies and 9 of 10 of promising studies were published during this period. Almost all studies included an activity sensing component and most of these used passive infrared motion sensors. The three effective (first tier) studies all used a multicomponent technology approach that included activity sensing, reminders and other technologies tailored to individual preferences. Future research should explore the use of technology for self-management of health by older adults, social support and self-reported health measures incorporated into personal health records, electronic medical records, and community health registries.

How can Local Authorities with Less Money Support Better Outcomes for Older People?
Centre for Policy on Ageing Joseph Rowntree Foundation, York. 2011

Research shows that older people want and value low-level support – ‘that bit of help’ – but the benefits of investing in this are realised over many years, making it harder to prove impact and protect funding in the face of severe pressure on spending.

This ‘Solutions’ published by Joseph Rowntree Foundation provides examples of imaginative, affordable and effective ways of supporting older people’s health, well-being, social engagement and independence. It highlights projects with some local authority involvement whether as lead commissioner, subsidiary partner, or through small grants or seed-funding.

The projects demonstrate the importance of:

involving people who use support and services in shaping them;
investing in collective solutions, small grants or seed-funding for self-help groups, and developing local markets to provide the support people want and value;
greater emphasis on the assistance that older people need and choose, and their experiences rather than on conventional social care and/or services;
developing place-based approaches that reflect the whole of people’s lives, and delivering value for money, for example by including transport

Impact and economic assessment of assistive technology in care homes in Norfolk, UK
Al-Oraibi S, Fordham Ric, Lambert R Journal of Assistive Technologies, 6, 192-201. 2012

This study looked at whether new assistive technology (AT) systems in care homes for elderly residents, reduced the number of falls and demands for formal health services. The project collected retrospective data about the incidence of falls before and after AT systems were installed in two care homes in Norfolk, UK. These homes were selected purposefully because a recent assessment identified the need for upgrading their call system. They had different resident profiles regarding the prevalence of dementia. Standard incident report forms were examined for a period starting ten months before the upgrades to ten months after in Care Home 1 and from six months before to six months afterwards in Care Home 2. Overall there were 314 falls reported during the course of the study; the number reduced from 202 to 112 after the introduction of AT. The mean health care costs associated with falls in Care Home 1 were significantly reduced (more than 50%). In Care Home 2 there was no significant difference in the mean cost. The results suggest that installing an AT system in residential care homes can reduce the number of falls and health care cost in homes with a lower proportion of residents with advanced dementia compared to those with more residents with advanced dementia

Investing to Save: Assessing the Cost-effectiveness of Telecare. Summary Report
Clifford P, et al Face Recording and Measurement Systems, Nottingham. 2012

This summary report describes the findings of a project evaluating the potential cost savings arising from the use of telecare. Another aim was to develop a methodology that will support routine evaluation and comparison of the cost-effectiveness of local telecare implementations. Evaluation was made of the suitability of telecare for 50 clients for whom Overview Assessments had been completed by FACE Recording & Measuring Systems Ltd. Where telecare appeared suitable, the social care costs of meeting the client’s needs before and after provision of telecare were estimated. Estimates were also made of the total savings achievable by the deployment of telecare. Out of the 50 cases, 33 were identified as potentially benefitting from telecare. The average weekly cost of telecare was £6.25, compared to £167 for the average weekly care package for the sample pre-telecare. The results confirmed previous studies showing that very substantial savings are achievable through the widespread targeted use of telecare. Potential savings lie in the range of £3m to £7.8m for a typical council, or 7.4-19.4% of total older people’s social care budget.

Money Matters: Reviews of Cost-effective Initiatives
Institute of Public Care The Institute for Research and Innovation in Social Services, Glasgow. 2011

This set of eight case studies, produced by the Institute of Public Care on behalf of IRISS (the Institute for Research and Innovation in Social Services), provides detailed analysis of the cost-effectiveness of a series of recent social care initiatives, ranging from nationwide and relatively high-profile schemes such as individual budgets to those thus far unique to one country, city or local authority area in the UK.

In each case, the report provides an overview of the initiative – its origins, including previous variants of the scheme, who it is intended to help, and how it works in practice – before justifying claims of cost-effectiveness by reference to detailed comparative costings, using one illustrative implementation of the scheme where the initiative is nationwide. Based on the analysis, the report sets out the initiative’s applicability to other settings as well as potential impediments to broader implementation.

The eight initiatives scrutinised are:

A study of Shared Lives schemes in south east England for providing care in the carer’s own home for individuals placed there by the local authority.
An extra-care housing scheme completed in Bradford.
Health in mind – social inclusion support for people with mental health needs in Bradford based round a series of mental health “well-being cafes”.
LinkAge Plus – analysis of nationwide DWP-funded pilot schemes for an holistic approach to provision of services for older people.
The Rapid Response Adaptations Programme – a Welsh initiative for providing adaptations such as ramps to let people return to their own homes.
A project in north west England to guide older people with low-level needs through a self-assessment process.
Analysis of various pilot sites taking different approaches to individual budgets, based on a broader evaluation conducted in 2008.
A project in two acute trusts in London to reconfigure hospital discharge procedures to emphasise rehabilitation.

Releasing Somerset's Capacity to Care: Community Micro-providers in Somerset
Community Catalysts Community Catalysts, Harrogate. 2017

An evaluation of the Community Catalysts project in Somerset. Community Catalysts is a social enterprise working across the UK to make sure that people who need care and support to live their lives can get help in ways, times and places that suit them, with real choice of attractive local options. In Somerset, the project aimed to increase the number of flexible, responsive, high quality local services and supports that can give people real choice and control over their care. As part of the project Community Catalysts has worked with partners to develop the Community Somerset Community Micro-enterprise Directory. The directory features 275 community-enterprises all of whom offer services linked to health, care or wellbeing. 223 offer help to older people to enable them to stay at home. 58% of these providers offer personal care services, including for people with more complex care needs. This care is often provided alongside home help, domestic and social support. 42% offer home help type services including support, companionship, domestic help, gardening, cleaning, trips out, transport. 3,500 hours of care a week are delivered by Community micro-enterprises in Somerset. Community Catalysts also undertook a survey of 45 families who have used both a micro-provider and a traditional domiciliary agency. The results showed that community micro-providers are able to deliver strong and valued outcomes for the people they support, and significantly outperform traditional domiciliary care delivery. The evaluation indicates that 32 community micro-enterprises in rural West Somerset are delivering £134,712 in annual savings. Projected across the 223 micro-enterprises supported by Community Catalysts in Somerset, the project delivers: £938,607 in annual savings; 56% of people supported use direct payments, showing £525,619 of direct and ongoing annual savings to the council.

Room to Improve: The Role of Home Adaptations in Improving Later Life
Centre for Ageing Better Centre for Ageing Better, London. 2017

This report summarises the findings from an evidence review on how home adaptations can improve later lives and provides recommendations to improve access to, and delivery of, home adaptation and repair services. It shows that both minor and major home adaptations are an effective intervention to improve outcomes for people in later life, including improved performance of everyday activities, improved mental health and preventing falls and injuries. It also identifies good evidence that greatest outcomes are achieved when individuals and families are involved in the decision-making process, and when adaptations focus on individual goals. Based on the findings, the report makes recommendations for commissioners and service provides. These include for Local Sustainability and Transformation partnerships to put in place preventative strategies to support people at risk in their home environment; for local authorities to make use of the Disabled Facilities Grant to fund both major and minor adaptations; and for local authorities to ensure people have access to information and advice on how home adaptations could benefit them, in line with the Care Act 2014.

Telemedicine and telecare for older patients - a systematic review
van den Berg N, Schumann M, Kraft K, et al Maturitas, 3, 94–114. 2012

Telemedicine is increasingly becoming a reality in medical care for the elderly. We performed a systematic literature review on telemedicine healthcare concepts for older patients. We included controlled studies in an ambulant setting that analyzed telemedicine interventions involving patients aged ≥60 years. 1585 articles matched the specified search criteria, thereof, 68 could be included in the review. Applications address an array of mostly frequent diseases, e.g. cardiovascular disease (N=37) or diabetes (N=18). The majority of patients is still living at home and is able to handle the telemedicine devices by themselves. In 59 of 68 articles (87%), the intervention can be categorized as monitoring. The largest proportion of telemedicine interventions consisted of measurements of vital signs combined with personal interaction between healthcare provider and patient (N=24), and concepts with only personal interaction (telephone or videoconferencing, N=14). The studies show predominantly positive results with a clear trend towards better results for “behavioral” endpoints, e.g. adherence to medication or diet, and self-efficacy compared to results for medical outcomes (e.g. blood pressure, or mortality), quality of life, and economic outcomes (e.g. costs or hospitalization). However, in 26 of 68 included studies, patients with characteristic limitations for older patients (e.g. cognitive and visual impairment, communication barriers, hearing problems) were excluded. A considerable number of projects use rather sophisticated technology (e.g. videoconferencing), limiting ready translation into routine care. Future research should focus on how to adapt systems to the individual needs and resources of elderly patients within the specific frameworks of the respective national healthcare systems.

The Costs and Benefits of Preventative Support Services for Older People
Pleace N Centre of Housing Policy, York. 2011

This paper is a brief overviewc ommissioned by Scottish Government Communities Analytical Services. This paper reviews the evidence on the cost effectiveness of preventative support services that assist older people with care and support needs to remain in their own homes. The costs of these preventative support services are contrasted with the costs of specialisthousing options, such as sheltered and extra care housing and also with the costs of health services, as part of reviewing the value for money of preventative support services

The effect of telecare on the quality of life and psychological well-being of elderly recipients of social care over a 12-month period: the Whole Systems Demonstrator cluster randomised trial
Hirani SP, Beynon M, Cartwright M Age and Ageing, 43, 334-341. 2013

Abstract
BACKGROUND:
home-based telecare (TC) is utilised to manage risks of independent living and provide prompt emergency responses. This study examined the effect of TC on health-related quality of life (HRQoL), anxiety and depressive symptoms over 12 months in patients receiving social care.

DESIGN:
a study of participant-reported outcomes [the Whole Systems Demonstrator (WSD) Telecare Questionnaire Study; baseline n = 1,189] was nested in a pragmatic cluster-randomised trial of TC (the WSD Telecare trial), held across three English Local Authorities. General practice (GP) was the unit of randomisation and TC was compared with usual care (UC).

METHODS:
participant-reported outcome measures were collected at baseline, short-term (4 months) and long-term (12 months) follow-up, assessing generic HRQoL, anxiety and depressive symptoms. Primary intention-to-treat analyses tested treatment effectiveness and were conducted using multilevel models to control for GP clustering and covariates for participants who completed questionnaire measures at baseline assessment plus at least one other assessment (n = 873).

RESULTS:
analyses found significant differences between TC and UC on Short Form-12 mental component scores (P < 0.05), with parameter estimates indicating being a member of the TC trial-arm increases mental component scores (UC-adjusted mean = 40.52; TC-adjusted mean = 43.69). Additional significant analyses revealed, time effects on EQ5D (decreasing over time) and depressive symptoms (increasing over time). CONCLUSIONS: TC potentially contributes to the amelioration in the decline in users' mental HRQoL over a 12-month period. TC may not transform the lives of its users, but it may afford small relative benefits on some psychological and HRQOL outcomes relative to users who only receive UC. International Standard Randomised Controlled Trial Number Register: ISRCTN 43002091.

The Role of Home Adaptations in Improving Later Life
Powell J, et al Centre for Ageing Better, London. 2017

A systematic review of evidence on the effectiveness and cost effectiveness on how home adaptations can contribute in helping older people to maintain their independence for as long as possible and what works best to improve the health and wellbeing. Conducted by a team from the University of the West of England, the review covered peer-reviewed literature and professional and practitioner-led grey literature published between 2000 and 2016. It found evidence that both minor and major home adaptations can improve outcomes for people in later life, including improved performance of everyday activities, improved mental health and preventing falls and injuries. It also identified good evidence that greatest outcomes are achieved when individuals and families are involved in the decision-making process, and when adaptations focus on individual goals. It also found strong evidence that minor home adaptations are an effective and cost-effective intervention. The report also includes analysis from the Building Research Establishment which shows that home interventions to prevent falls on stairs, can lead to savings of £1.62p for every £1 spent. Based on the findings, the report makes recommendations for commissioners and service provides. These include for Local Sustainability and Transformation partnerships to put in place preventative strategies to support people at risk in their home environment; for local authorities to make use of the Disabled Facilities Grant to fund both major and minor adaptations; and for local authorities to ensure people have access to information and advice on how home adaptations could benefit them, in line with the Care Act 2014

The UTOPIA Project: Using Telecare for Older People in Adult Social Care. The Findings of a 2016-17 National Survey of Local Authority Telecare Provision for Older People in England
Woolham J, Steils N, Fisk M, et al Social Care Workforce Research Unit, King's College London, London. 2018

This report describes how electronic assistive technology and telecare are used by local authorities in England to support older people. It is based on an online survey of local authority telecare managers to identify local authority’s aims when offering telecare to older people, the methods they use to assess whether their objectives are achieved, and how telecare is operationalised and delivered. It also aimed to explore why the findings of the earlier the Whole System Demonstrator project – which found no evidence that telecare improved outcomes – have been overlooked by local authorities and policy makers, and whether there is other evidence that could account for WSD findings. The survey results found a third of local authorities used research evidence to inform telecare services and half were also aware of the Whole System Demonstrator. It also found that telecare is used in most local authorities to save money. Although there was some evidence of monitoring, there was no evidence of local authorities adopting agreed standards. The final section of the report provides suggestions for improving telecare service practice. They include the areas of using telecare as a substitute for social care; expanding the focus on telecare beyond risk management, safety and cost reduction; the impact of telecare on family members, carrying out effective assessments, and training

Total Transformation of Care and Support: Creating the Five Year Forward View for Social Care
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2017

Adult social care has repeatedly demonstrated its capacity for transformation: pioneering de-institutionalisation, personal budgets and more recently, asset-based approaches.Health and care systems will not provide good services that meet rising demand without realigning around people and communities.There are five areas where transformation needs to take place: 1Helping all people and families to stay well, connected to others and resilient when facing health or care needs.2Supporting people and families who need help to carry on living well at home.3Enabling people with support needs to do enjoyable and meaningful things during the day, or look for work.4Developing new models of care for adults and older people who need support and a home in their community.5Equipping people to regain independence following hospital or other forms of health care. If the sector scales up promising practice, economic modelling shows that outcomes can be improved and costs reduced.The sector needs to have difficult, challenging and creative local conversations involving people who use services and others, which create space to move forward together. Further research and economic modelling is needed on the promising practices to build a business case for proper and effective investment in truly integrated care and health.

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