Older people’s needs and technology: how can we match them?

In the future that awaits us, we will need solutions that can cope with the expected increase in demand for care and protection as countries struggle to sustain their national welfare systems. Population projections show that by 2100, the old-age dependency ratio¹ will almost double (57 per cent) that of 2019 (31 per cent), meaning that for each older person aged 65 and over, there will be fewer than two people of working age (Eurostat, 2020). The growth in the projected population of older people implies the need to analyse and consider main lines of action that can be pursued now to adapt the world of social and health services to the expected rise in demand. These should include ensuring that care providers can implement initiatives to educate citizens to approach their own ageing differently and, increasingly, to adopt behaviours and lifestyles that generate health over time.

Many European Commission initiatives and projects² that tackle this phenomenon focus on the role of public authorities, both as being responsible for organising social and health services, and as promoters of service innovations and new technological solutions capable of transforming older people’s use of services. Within this perspective, a central feature of service innovations is the opportunity, in collaboration with care provider organisations, to improve the parameters and timely use of health data, avoiding unnecessary transitions between services and making information immediately and simultaneously accessible to health professionals and family members. Also important is the potential role of information technologies in building forecasting models, based on early signs of changes in the person, that can predict how these will develop and trigger rapid clinical decision-making that can prevent risks or adverse events likely to lead to deterioration in older people’s health.

The recent crisis generated by the COVID-19 pandemic is accelerating changes in care processes. Now, more than ever before, the need for technology-mediated contact with, and supervision of, older users is understood and seen not just as a way of replacing moments of in-person contact, but, above all, as having benefit due to its predictive value. To achieve this, however, a change in perspective in service systems is required towards the effective adoption of the opportunities that eHealth technologies offer for the organisational models of care provider organisations. First, there needs to be an increase in older people’s digital literacy, which is still at a low level despite the potential use of eHealth devices, applications and wearable smart sensors for the self-management of care. Second, the organisational models in place in health and social care since the last century need to change. Innovation in care is not just about adopting information and communication technology (ICT) into existing processes. Rather, digital transformation in care requires a redesign of the care model, based on the whole triangle of the patient/older person, their carers and providers, in which ICT tools are used for real-time communication and data provide the glue that connects the parts, also in real time. Existing, almost linear, processes of care that align with care delivery timelines (evaluation of needs, care plan design, care delivery and follow-up evaluation) should switch to a continuous, circular and rapid-response socio-technical system, in which patients/older people are understood as active agents who co-produce their own health. This requires an outcome-driven dynamic, driven and supported by real-time data. Third, both organisational models and eHealth applications should be co-designed with users. If we want to meet older persons’ needs, it will be essential to envisage their engagement, as things develop, in the new value proposition for care. In so doing, it will be possible both to meet user expectations and to optimise organisational efforts.

Finally, we need to move from a pay-per-volume reimbursement system to one based on value creation for the patient. For this, care delivery should be the result of a shared decision-making process involving the older person (care recipient) and social and healthcare practitioners. The logic of this value-based healthcare model needs to be combined with a value-driven patient-centred care approach that considers the outcomes that matter for the older person, as well as how far they are achievable (according to the patient’s situation in relation to a worldwide benchmark of standard indicators). Last but not least, there needs to be an equitable resource allocation for each citizen that takes into consideration health outcomes, related costs and the potential impact on the person’s need for community care, including when there are co-morbidities.

Beyond the barriers of the digital divide

Implementing interventions that, through use of technologies, can both help reduce operating costs and change the strategies for empowering a large number of citizens requires appropriate training and support actions focused on digital tools that can facilitate such interventions. This has been shown in various experiments within international projects and initiatives concerned with the use of technology in care services (see, for example, the 2014 CarerSupport Project, funded under the Active Assisted Living programme [AAL, 2014]). With this approach, the big step forward will be not only lower costs in providing care, but also positive effects on health improvement. Better health will result from the preventive actions implemented spontaneously by the user, supported by the care team. The key concept in this type of intervention is proactive care, in which proactivity is reinforced by older people’s greater awareness of their own health condition(s). The focus needs to shift from ‘fixing’ (which often results in expensive, uncomfortable and unnecessary procedures) to keeping people healthy in the first place and spotting issues before they arise. As such, a new model of proactive care is emerging that is: customer-centric, connected, continuous and coordinated (Longobucco et al, 2019).

Some experiments at the European level have shown that the promotion of self-care management, with the help of assisted living solutions that involve informal carers in caring activities, can lead to savings of up to 10 per cent on hospital readmission costs and cost reductions (up to 30 per cent) due to fewer admissions to institutional care (D’Angelantonio and Oates, 2013). Several aspects of the technological supports that can create value through independent living interventions should be considered (Tunstall Healthcare Group UK, 2020). One lever is the adoption of dedicated apps for social networking. These can be effective tools that connect users with their care nodes, break down communication barriers and share information. However, these types of app must take current regulations on privacy and ethics into account, and consider users’ wishes (see ‘Privacy by design’, GDPR 679/2016 EU Regulation). As such eTools are introduced, it is also important to consider their usability as the main factor for real everyday adoption by users. In the UK and Spain, for example, it has been shown that for many users, technological innovations in telemedicine and care delivery, as well as the use of apps, can lead to improvements in citizens’ independence, satisfaction and exposure to risk, and overall cost savings for providers (Tunstall Healthcare Group UK, 2018). All innovations in care have shown that the social and health domains should be considered together and adapted to users’ wishes, hence the importance of co-design as a key factor to be addressed.

Creating solutions with users

When providing a digital service, such as management of an electronic health record or a device for remote pressure monitoring, it is recommended that the habits and preferences of future users are taken into account by promoting (in addition to participatory design) a bring-your-own-device (BYOD) approach. This allows designers to exploit the links users already have with their own devices and the familiarity derived from prolonged use of these.

It is also important that people perceive technological objects as an extension of their own self and feel involved in (and can participate in) achieving objectives. If this type of feeling is not established, users may perceive the device as ‘an outsider’. This will create more difficulty in developing a form of attachment to it, and the device may be considered too complex to use, or too unreliable, and therefore less useful.

The user as ‘ambassador’ of innovation

To encourage a change in older people’s attitudes to using technological tools that can help them connect with loved ones, with social and health services, and with those who can support them, we can draw on some concrete experiences that have proved effective (Vincent, 2006). In the UK, the charity AGE UK ran a One Digital project (2015–20) that offered citizens, in an ecological and simple way, the opportunity to meet in community venues made available by local stakeholders (bookshops, libraries and senior citizens’ clubs), where a person expert in information technology acted as a ‘digital champion’ (see AGE UK, 2020). By enhancing volunteers’ passion and ability to transmit simple computer knowledge in order to facilitate older people’s access to the digital world, this approach engendered social motivation, based on being together, learning and having fun. The initiative embraced a ‘gamification’ perspective, in which the binomial fun-game offered a humane and effective way to deliver knowledge and skills. In this way, we can understand and enhance some older people’s roles in their communities of reference, as digital ambassadors are able to involve, motivate and articulate the benefits of using specific technologies or software and to facilitate their adoption into daily routines. Evidently, such communication tools imply having someone to communicate with, or someone to stay in relationship with.

The co-production of health as an approach to the introduction of technological innovation into home care

Looking at the future, it seems that new, post-baby boom generations are assuming a new attitude linked to the world of ageing, with American technology entrepreneur Gina Pell defining them as ‘perennials’. She observes that the new online world groups people not on the basis of their age, but on the basis of their tastes and purchases. Amazon or Netflix, for example, do not suggest products based on how old customers are; rather, they suggest products based on what customers prefer. This implies a change in perspective towards the traditional division of the moments of life into the phases of ‘training’, ‘work’ and ‘retirement’, towards a ‘becoming’, constantly linked to one’s own potential and in which learning, work/production and free time coexist. In all this, the person is at the centre and is increasingly the protagonist of their own destiny.

Within this evolving cultural framework, the idea of active ageing is also moving towards the concept of being active and co-participating as agents/co-producers of one’s own well-being (Chountalas and Karagiorgos, 2015). This health co-production approach is based on theoretical models with significant operational spin-offs that are useful for practitioners and managers of personal services, and to support the empowerment of citizens regarding their lifestyle management skills. These include the selection, optimisation and compensation (SOC) model, which identifies these three fundamental processes of development regulation as essential for successful development and ageing (Baltes and Carstensen, 2003). Selection, optimisation and compensation are designed to maximise the gains and minimise the losses associated with ageing, thereby promoting successful development and ageing.

Selection promotes the success of ageing in several ways. Feeling committed to goals contributes to making one feel that one’s life has purpose. In addition, goals help to organise behaviour over time and in all situations, and guide attention and behaviour. One of the central functions of selection is to concentrate the limited resources available. In older and very old age, when resources become more limited, selection becomes even more important. Empirical evidence shows that the selection of certain areas of life to focus on is particularly adaptable for older people whose resources are severely limited. The SOC model distinguishes between two types of selection – elective selection and loss-based selection – which differ in their functions. Elective selection refers to the delimitation of objectives in order to match the needs and motivations of a person with available or attainable resources. Elective selection aims to achieve higher levels of functioning. Conversely, selection based on loss is a response to the loss of previously available resources that are necessary to maintain functioning. Loss-based selection refers to changes in goals or the goal system, such as rebuilding one’s own goal hierarchy by focusing on the most important goals, adapting standards or replacing goals that are no longer achievable. This allows the individual to focus or redirect their efforts when resources used to maintain positive functioning, or as a substitute for a functional loss (compensation), are not available or would be invested at the expense of other, more promising objectives.

Optimisation means that to achieve the desired results in the selected domains, it is necessary to acquire, apply and refine the means relevant to the objective. The most suitable means to achieve one’s goals vary according to the specific sector (for example, family and sport), personal characteristics (for example, age and gender) and sociocultural context (for example, institutional support systems). Prototypical cases of optimisation are the investment of time and energy in the acquisition of target-relevant means, the modelling of other successful people, and the practice of target-relevant skills. In old age, optimisation continues to be of great importance for successful development because engaging in growth-related objectives has positive regulatory functions. The attempt to achieve growth-oriented goals is associated with a higher degree of self-efficacy and leads to positive emotions and greater well-being. In old age, when losses are prevalent, it may be particularly important to support growth-oriented goals to promote well-being, rather than focus primarily on losses. The positive function of optimisation in old age has also been empirically supported in the Berlin Aging Study (Freund and Baltes, 1999). In this study, older people who reported engaging in optimisation processes reported more positive emotions and greater satisfaction with ageing.

Compensation concerns the question: how do older people manage to maintain positive functioning in the face of health-related constraints and losses? Maintaining positive functioning in the face of loss could be as important for successful ageing as sustained growth. A relevant strategy for the regulation of loss-based selection has already been discussed. Loss-based selection denotes the restructuring of one’s system of goals, for example, by giving up unattainable goals and developing new ones. Developing new targets and investing in their optimisation, however, can also exhaust resources. In addition, important personal goals can be crucial to a person’s well-being and not easily abandoned in the face of loss. In this case, it may be more adaptable to maintain one’s objective by acquiring new resources or by activating unused internal or external resources for alternative means of pursuing objectives. This process is defined as compensation.

In order to build a social response to these challenges, it is first necessary to look at the users of services in a different way, considering them as able to influence their own care path and letting services stand in the background as facilitators of the process. The new dynamic should be oriented towards consultancy in order to bring out the objectives and potential of the users, and to connect them with the answers needed. The question to ask ourselves now is: who are the subjects, present in different localities and close to where older people live, with the potential and will to initiate processes of networking professional knowledge about social and health domains, and capable of building new service propositions to which citizens will attribute value? The value we are talking about here is what each person determines in response to the question ‘What matters to me?’

Recent statements, mainly from the US, and now also from Europe (Sweden and the Netherlands), on value-based healthcare models go in the direction of redefining the integration of services. Value-based healthcare models place the person at the centre, and by focusing on measurable health outcomes based on international standards sets (International Consortium for Health Outcome Measurements, 2012), they have the capacity to achieve comparable therapeutic actions, costs and outcomes at a global level, irrespective of individual states’ health systems and regulatory mechanisms (Porter and Teisberg, 2006). Within value-based healthcare models, technologies play a crucial role. Indeed, they represent the source of information that can provide feedback in real time to the individual, and to their caregivers, on trends in their own health conditions based on behaviour, therapeutic compliance and decisions taken jointly by the person being cared for and the team taking care of them.

Conclusion

Looking to the future in the medium to long term, the data indicate a substantial increase in the number of older people and, among them, a significant rise in the dependency rate. If not addressed in time, this will jeopardise the stability of the social and economic structure of our countries. In addition, there is a progressive flourishing of technological solutions capable of detecting illness, making suggestions and supporting the person in the event of the first signs of the main chronic pathologies that significantly impact the adult and older population. This possibility, offered by technology, represents an opportunity to combine progress with the adoption of a proactive intervention perspective to support people before the appearance of a pathological picture already marked by chronicity.

What is proposed involves changing the paradigm of services to the person in their ageing process, in which they can co-produce their own health, mobilising resources still available in their cognitive, physical and social reserve in favour of what counts and has value for them. In this value-based perspective, the potential of services can be realised within a framework of integrating social and health components, supported by a robust information system fed by data.

In the background, two critical elements remain to be addressed if the digitisation of care is to be achieved: the need to enhance older people’s digital skills; and the need to adapt service delivery models by improving the usability of devices. This requires co-design tools and methodologies capable of co-generating the most sustainable adaptation between people and the artefacts they need.

Conflict of interest

The author declares that there is no conflict of interest.