Research in Gerontological Nursing

Research Brief 

Older Adults’ and Case Managers’ Initial Impressions of Community-Based Telehealth Kiosks

Karen L. Courtney, PhD, RN; Jennifer H. Lingler, PhD, FNP; Laurel Person Mecca, MA; Laurie A. Garlock, BBA; Richard Schulz, PhD; Andrew W. Dick, PhD; Ellen Olshansky, DNSc, RNC, FAAN

Abstract

Community-based (multi-user) telehealth interventions may be beneficial for older adults, but there is little research regarding such interventions. As a first step in feasibility assessment, we used a qualitative descriptive approach to examine the acceptability and perceived value of community-based telehealth kiosks with regard to current health self-management practices of community-dwelling older adults. Participants included residents (n = 6) and community agency case managers (n = 3) of a U.S. Department of Housing and Urban Development-subsidized senior apartment building. Both positive impressions from and concerns of each group are presented. Findings helped guide plans for future telehealth kiosk implementation and training.

Abstract

Community-based (multi-user) telehealth interventions may be beneficial for older adults, but there is little research regarding such interventions. As a first step in feasibility assessment, we used a qualitative descriptive approach to examine the acceptability and perceived value of community-based telehealth kiosks with regard to current health self-management practices of community-dwelling older adults. Participants included residents (n = 6) and community agency case managers (n = 3) of a U.S. Department of Housing and Urban Development-subsidized senior apartment building. Both positive impressions from and concerns of each group are presented. Findings helped guide plans for future telehealth kiosk implementation and training.

Telehealth refers to a range of technologies that bridge geographical distances in health care delivery (Demiris, 2004) by enabling patients to virtually visit providers, conduct remote monitoring of health status (Finkelstein, Speedie, & Potthoff, 2006), or receive disease-specific information (Kleinpell & Avitall, 2005; Vincent, Reinharz, Deaudelin, Garceau, & Talbot, 2006). Mounting evidence suggests that telemonitoring technologies are user friendly and beneficial when used in private homes among individual patients (Finkelstein et al., 2006; Kleinpell & Avitall, 2005; Louis, Turner, Gretton, Baksh, & Cleland, 2003; Mahoney & Tarlow, 2006); however, little is known about the acceptability and effectiveness of such interventions in community or multi-user settings. Exploring the feasibility of these interventions is important because community-based telehealth applications that can be shared among a group of users may be economically preferable to individually based applications, especially among older adults who have financial or mobility-related limitations regarding their access to health care services. This brief report describes older adults’ and community case workers’ perspectives gathered as a first step for a feasibility assessment of a Viterion 500® (Viterion TeleHealthcare, Tarrytown, NY) telehealth kiosk device with blood pressure and weight monitoring capabilities to be placed in a common area of a U.S. Department of Housing and Urban Development (HUD)-subsidized senior apartment building in Pittsburgh, Pennsylvania.

Method

Setting and Sample

With approval from the Institutional Review Board, we recruited residents of a HUD-subsidized senior low-rise apartment building who receive free care management through a community program that connects older adults with the support services they need to age in place (Cheek, Nikpour, & Nowlin, 2005; Marek et al., 2005; Rantz et al., 2005). As part of usual care, program participants receive monthly blood pressure checks and health education. Through the planned telehealth kiosk implementation project, program staff would have remote access to blood pressure and weight measurements taken by residents via the telehealth kiosk. Both residents and staff had a brief opportunity to view and handle the kiosk at information sessions that took place prior to data collection. These information sessions were not designed to be comprehensive training sessions; rather, information derived from pre-implementation focus groups and interviews was used to develop formal training sessions.

Six residents participated in two separate focus groups. Eligible residents had to be older than 70 and have at least one self-reported chronic health condition. Residents who did not speak English, had a clinical diagnosis of dementia, or scored less than 22 on the Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975) were not eligible to participate. Focus group participants included a convenience sample of 5 women and 1 man; their ages ranged from 73 to 89, and all were Caucasian. During recruitment, it was emphasized that individuals who were both planning or not planning to use the kiosk were invited to participate.

Participants had between 8 and 14 years of education, and their MMSE scores ranged from 22 to 30. On a 5-point Likert scale ranging from poor to excellent, 2 participants rated their overall physical health as good, and 4 rated their overall physical health as fair. All participants estimated their annual income to be less than $20,000 and reported that it is either somewhat or very difficult to pay for basics like food, housing, and medical care.

All 3 community service agency staff (1 nurse and 2 social workers) who worked with the residents of this apartment building participated in individual interviews.

Data Collection

All interviews and focus group sessions were audio recorded for verbatim transcription. Interview guides with semi-structured questions were used in both interviews and focus groups.

Two pre-implementation focus groups (n = 6) and individual interviews with program staff (n = 3) were conducted addressing the acceptability and perceived value of the telehealth kiosks with regard to residents’ current health self-management practices. The Table includes the primary questions from the focus groups. The focus group and staff interviews had parallel sets of questions, although in some instances the phrasing was slightly modified for the audience or administration format (group versus individual interview). Focus group sessions lasted 60 to 90 minutes, and interviews lasted an average of 20 minutes.

Focus Group Sample Questions

Table: Focus Group Sample Questions

Data Analysis

Transcribed data from focus group and interview sessions were analyzed separately to generate a qualitative description (Sandelowski, 2000) of both older adults’ and case managers’ perceptions of benefits and concerns regarding the technology. Credibility was established by using within-group member checks in which participants were asked to review the findings and to validate whether these interpretations reflected their own experiences.

Findings

Case Managers

In response to questions about their global impressions of kiosk implementation, case managers consistently reported deriving a sense of pride from the selection of their particular site for device pilot testing. Although they acknowledged that certain health conditions are more conducive to kiosk use than others, overall they felt the advantages of the kiosk were substantial. They also felt certain that the kiosk would not interfere with their relationships with the residents; in fact, they believed the kiosk would enhance their relationships and provide “another set of eyes” for them in caring for the residents. Case managers’ reservations regarding the kiosk focused primarily on potential resident reactions to the kiosks. Case manager concerns can be classified as relating to:

  • The device (kiosk).
  • Residents’ reactions to kiosk-generated data.
  • The physical environment in which the kiosk is located.

Concerns About the Kiosk. Regarding the kiosk itself, case managers expressed concerns that various factors could influence residents’ ability to use the kiosk independently. As one case manager stated, “It depends on how good their vision is, their motor control, their patience to go down and sit in front of it [kiosk].” Case managers were concerned that the kiosk may be viewed as a computer, triggering anxiety. “I think…some residents…are fearful of using a computer item,” one case manager reported. “Even though this isn’t a computer, they look at it that way, and this generation isn’t used to computers.”

Concerns About Residents’ Reactions to Kiosk-Generated Data. Case managers discussed potential resident reactions to seeing their health care data. They were worried that residents might inappropriately focus on their measurements (“You know some people may become obsessed with going down and checking”) or overreact to mild abnormalities in their data (“Maybe when the numbers are a little bit higher they will start to panic”). Another issue was the potential for residents to use the kiosk for replacement of regular or urgent health care.

Concerns About the Physical Environment in Which the Kiosk is Located. The physical placement of the kiosk was also identified as a potential issue. It was believed that having other residents nearby in the community room might deter some residents from using the kiosk: “There’s a couple of residents there who are very private and probably wouldn’t want to go down and use it when other people are around.”

Residents’ Health Management Practices

Residents’ descriptions of their health management activities and interactions with the health care system were punctuated by expressions of dissatisfaction with care delivery. Expressions of dissatisfaction with health care were pervasive and focused on problems noted within two key domains: communication and quality of care.

Concerns about health-related communication spanned multiple levels, including patient-physician, patient-nurse, and provider-provider. In one instance, such concerns were tied to technology, as exemplified by the following statement made by a woman describing repeated unsuccessful attempts to contact her primary care provider: “They put a machine on, and it seems like they don’t want to answer the phone anymore.” Her peers strongly supported her observation, with one individual describing a “hatred” of complicated voicemail systems. The residents’ narratives revealed how communication problems have the potential to fracture provider-patient relationships.

Like poor communication, concerns about care quality were also reported to negatively affect provider-patient relationships, yield interruptions in care-seeking behaviors, or cause excessive use of health care resources. Overall, the residents’ powerful portrayals of their recent and current experiences with the health care system provided a backdrop against which to evaluate their perceptions regarding the telehealth kiosk.

Residents’ First Impressions

Resident attitudes toward the kiosk were generally positive, as described by statements such as “I think it’ll be great for me.” Residents placed a particularly high value on blood pressure monitoring in managing health. As a result, the kiosk blood pressure monitoring capability was cited as personally valuable: “I think it’s a good idea, yeah.... My…primary care [provider] is always worried about my blood pressure. It tends to go up and down, up and down.” Residents also expressed an understanding that the kiosk could be beneficial in drawing early attention to signs and symptoms of serious medical events. As one resident stated, “It could warn you.” However, participant statements suggest the potential for residents to have false reassurance of blood pressure as a global marker of health status (e.g., “Blood pressure determines a lot of things. It does.”).

Several residents described self-monitoring of blood pressure through the kiosk as a possible means to improve their co-management of health conditions with their health care providers. One resident described how her blood pressure was currently only checked every few months, and she expressed concern that this interval could be too long for making appropriate medication adjustments. The kiosk was seen as a mechanism that could enable more frequent monitoring and therefore ultimately lead to better management of her hypertension: “I go every 4 months and now…maybe the medicine’s not working right, so that way you could find out if your medication isn’t working.”

Several residents indicated they believed their primary care providers would be supportive of their use of kiosk and self-monitoring. As one resident said: “Do you know, I think I saw…my primary care [provider] a couple weeks ago when this was announced; I told her we were having one [kiosk], she said, ‘Oh, that’s a good idea!’” Others were not as confident about the involvement of their primary care providers: “Oh he probably won’t care.”

Residents also saw the use of the kiosk as potentially reducing unnecessary visits to their primary care providers. One resident’s statement—“Save $10, besides the trip itself. You can save the trip itself”—describes the value placed on both time and money savings by avoiding unnecessary medical visits. Given the difficulty the participants expressed in paying for basic items such as food, rent, and medications, avoiding even a modest visit co-payment such as $10 may be a substantial benefit of kiosk use.

Resident Concerns About the Kiosk

Despite an overall favorable impression of the kiosk, resident participants expressed a number of psychosocial and logistical reservations about using the kiosk.

Psychosocial Concerns. Issues regarding communication and sharing data with their health care providers were of concern among participants, stemming perhaps from negative past experiences with the health care system. They questioned how the kiosk data would be shared with their providers: “I’d rather know how, how they’re gonna tell what your pressure is on that machine. Is that gonna to go to the office?” Residents also expressed skepticism about their providers actually using the data: “Are they gonna wanna to do that, you know? They’re pretty busy up there. I can’t get ’em, when I call ’em I can’t get ’em.”

Residents were also concerned about looking foolish or unintelligent when using the kiosk. These concerns were sometimes expressed in resident preferences for individualized training, as exemplified by one resident’s statement: “You know, everybody’s different. That way we don’t have a lot of people that find out how stupid you are. Just be between you and the person who is teaching it.” In contrast to staff concerns regarding privacy and stigmatization, residents’ concerns about these issues were overshadowed by worries related to provider communication and the physical security of the kiosk.

Logistical Concerns. Physical security of the kiosk device was a prominent logistical concern. Participants shared a number of stories of theft and questioned whether they might be asked to oversee the kiosk: “Does somebody have to be there as a, like, guard of it or something? You know?” In addition to their security concerns, participants in one focus group expressed worry that residents may inadvertently damage the kiosk or hurt themselves while using it: “Well, the machine would go off if the electric go off, but the fact is, would it affect us? Would it hurt us?”

Discussion

Older adult and case manager participants expressed a wide range of potential benefits and drawbacks to implementing a multi-user telehealth kiosk device for vital sign monitoring in the common area of a HUD-subsidized building. Although both groups primarily viewed the kiosks in a positive light, their concerns directly influenced the design and content of training sessions to prepare other residents for subsequent kiosk implementation. For example, during training, we were careful to emphasize what the kiosk does and does not measure or identify. To address case managers’ concerns regarding residents’ potential overreliance on blood pressure as a global health status indicator, we provided a user action guide for interpreting blood pressure readings and recognizing serious signs and symptoms (i.e., for heart attacks and strokes) requiring immediate evaluation, regardless of blood pressure readings. The logistical preferences of focus group participants affected the location of the kiosk and the availability schedule (i.e., hours of the day). In response to their concerns about privacy and the potential theft of the kiosk, the kiosk was placed in the community room where it was not immediately visible from the lobby, and then secured in a locked room when not available to residents. One of the residents volunteered to take responsibility for setting up the kiosk and securing it each weekday. This was not part of the original implementation plan, but the adaptation was readily incorporated into it.

Although the details of participants’ perspectives on the implementation of multi-user telehealth devices are likely to be site specific, our findings demonstrate there is clear value in the early engagement of key stakeholders in community-based telehealth projects. Unique issues arise when translating to a community setting interventions that were first tested on individual patients. Attention to these issues will likely be critical for ensuring that those who may benefit most from community-based telehealth applications actually adopt them.

Conclusion

Community-based telehealth may be a useful strategy to address health disparities and the digital divide by bringing telehealth services to underserved individuals who have limited access to care because of cost, experience, and training. Findings from this study suggest that such individuals and those who provide outreach services to them are generally receptive to multi-user telehealth technologies but have specific concerns that should be addressed early in the implementation process.

References

  • Cheek, P., Nikpour, L. & Nowlin, H.D. (2005). Aging well with smart technology. Nursing Administration Quarterly, 29, 329–338.
  • Demiris, G. (2004). Electronic home healthcare: Concepts and challenges. International Journal of Electronic Healthcare, 1, 4–16. doi:10.1504/IJEH.2004.004655 [CrossRef]
  • Finkelstein, S.M., Speedie, S.M. & Potthoff, S. (2006). Home telehealth improves clinical outcomes at lower cost for home healthcare. Telemedicine Journal and e-Health, 12, 128–136. doi:10.1089/tmj.2006.12.128 [CrossRef]
  • Folstein, M.F., Folstein, S.E. & McHugh, P.R. (1975). “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198. doi:10.1016/0022-3956(75)90026-6 [CrossRef]
  • Kleinpell, R.M. & Avitall, B. (2005). Telemanagement in chronic heart failure: A review. Disease Management & Health Outcomes, 13, 43–52. doi:10.2165/00115677-200513010-00005 [CrossRef]
  • Louis, A.A., Turner, T., Gretton, M., Baksh, A. & Cleland, J.G. (2003). A systematic review of telemonitoring for the management of heart failure. European Journal of Heart Failure, 5, 583–590. doi:10.1016/S1388-9842(03)00160-0 [CrossRef]
  • Mahoney, D. & Tarlow, B. (2006). Workplace response to virtual caregiver support and remote home monitoring of elders: The WIN project. Studies in Health Technology and Informatics, 122, 676–680.
  • Marek, K.D., Popejoy, L., Petroski, G., Mehr, D., Rantz, M.J. & Lin, W.C. (2005). Clinical outcomes of aging in place. Nursing Research, 54, 202–211. doi:10.1097/00006199-200505000-00008 [CrossRef]
  • Rantz, M.J., Marek, K.D., Aud, M.A., Tyrer, H.W., Skubic, M. & Demiris, G. et al. (2005). A technology and nursing collaboration to help older adults age in place. Nursing Outlook, 53, 40–45. doi:10.1016/j.outlook.2004.05.004 [CrossRef]
  • Sandelowski, M. (2000). Whatever happened to qualitative description?Research in Nursing & Health, 23, 334–340. doi:10.1002/1098-240X(200008)23:4<334::AID-NUR9>3.0.CO;2-G [CrossRef]
  • Vincent, C., Reinharz, D., Deaudelin, I., Garceau, M. & Talbot, L.R. (2006). Public telesurveillance service for frail elderly living at home, outcomes and cost evolution: A quasi experimental design with two follow-ups. Health and Quality of Life Outcomes, 4, 41. doi:10.1186/1477-7525-4-41 [CrossRef]

Focus Group Sample Questions

Please describe how you manage your health here as a resident.

What are your feelings about using the telehealth kiosk here at [apartment complex]?

What factors might make people want to use the kiosk?

What factors might make people not want to use the kiosk?

How do you think this kiosk could be useful in managing your health or the health of other residents you know?

How do you think this kiosk might not be useful in managing your health or the health of other residents you know?

How do you think using the telehealth kiosk could affect your health?

How do you think using the telehealth kiosk could affect your relationship with [aging in place] program staff?

How would you like to be able to access the kiosk here at [apartment complex]?

How would you like to learn about how to use the kiosk?

We’ve talked a lot today about being a resident here and managing your health with the telehealth kiosk. Is there anything else you want to add that we haven’t covered?

Authors

Dr. Courtney and Dr. Lingler are Assistant Professors, Ms. Garlock is Project Manager, School of Nursing, Ms. Mecca is Senior Research Specialist, Dr. Schulz is Professor, School of Medicine, University Center for Social and Urban Research, University of Pittsburgh, Dr. Dick is Senior Economist, RAND Corporation, Pittsburgh, Pennsylvania; and Dr. Olshansky is Professor and Director of Nursing Science, College of Health Sciences, University of California, Irvine, Irvine, California.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. This project was supported in part by the National Science Foundation (NSF 0540856) and the RAND-University of Pittsburgh Health Institute (RUPHI; http://www.ruphi.pitt.edu), a formal collaboration between the RAND Corporation, RAND Health, and the University of Pittsburgh Schools of the Health Sciences. The project described is supported by grant 5 UL1 RR024153 from the National Center for Research Resources (NCRR; http://www.ncrr.nih.gov), a component of the National Institutes of Health (NIH) and NIH Roadmap for Medical Research, and its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH. Information on Re-engineering the Clinical Research Enterprise can be obtained at http://nihroadmap.nih.gov/clinicalresearch/overview-translational.asp

Address correspondence to Karen L. Courtney, PhD, RN, Assistant Professor, School of Nursing, University of Pittsburgh, 415 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15261; e-mail: courtk@pitt.edu.

Received: February 19, 2009
Accepted: December 09, 2009
Posted Online: May 28, 2010

10.3928/19404921-20100504-03

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