1.   Purpose of White Paper and Executive Summary    
        1.1    Purpose of White Paper    
        1.2    Executive Summary    
        1.3    Disclaimer    
2    Safety Technology    
        2.1    Definition    
        2.2    Areas of Safety Concerns    
                2.2.1    Falls    
                2.2.2    Elopement/Wandering    
                2.2.3    Environmental    
                2.2.4    Crime/Security    
       2.3    Why We Need Safety Technologies    
                2.3.1    How They Have Made Things Better    
                2.3.2    How They Are Being Utilized Today    
3    Types of Safety Equipment    
        3.1    Emergency Notification Systems    
        3.2    Emergency Response Systems    
                 3.2.1    Pendants or Personal Emergency Response Systems (PERS)    
        3.3    Nurse Call Systems    
        3.4    Wireless Nurse Call Systems    
        3.5    Two-Way Staff Communications System    
        3.6    Fall Detection and Prevention Technologies    
                 3.6.1    Fall Detection    
                 3.6.2    Fall Prevention Technologies    
                 3.6.3    Location Tracking Technologies    
       3.7    Access Control Technologies    
       3.8    Access Control Software    
4    Benefits of Safety Technologies    
        4.1    Reduced Response Time    
        4.2    Reduced Incidences    
        4.3    Increased Resident/Staff/Family Safety and Satisfaction    
        4.4    Increased Peace of Mind    
        4.5    Improved Regulatory Compliance    
        4.6    Improved Outcomes    
        4.7    Reduced Costs    
5    Potential LTPAC Provider Business Models    
        5.1    Medicaid Waiver Coverage    
        5.2    Potential Affordable Care Act (ACA) Opportunities    
        5.3    Private Pay    
        5.4    Standard of Care and Other Payment Sources    
        5.5    Return on Investment (ROI) of Safety Technologies    
                5.5.1    ROI to Patients and/or their Families    
                5.5.2    ROI to Payers    
                5.5.3    ROI to Care Providers    
                5.5.4    Online ROI Calculator    
6    Planning for and Selecting Appropriate Safety Technology    
        6.1    Understanding the Population, Issues, Care Settings, Needs, Program Services, and Partners    
        6.2    Planning for Safety Technology Solutions    
                 6.2.1    Visioning and Strategic Planning    
                 6.2.2    Organizational Readiness Assessment    
7    Safety Technology Matrix Components    
8 Acknowledgement of Contributors    
     8.1 Contributing Writers    
     8.2 Workgroup Members    
     8.3 Participating Safety Technology Vendors    
9 References and Resources    

1    Purpose of White Paper and Executive Summary

1.1    Purpose of White Paper

    This white paper will help LeadingAge members and other aging services organizations to understand the uses and benefits of safety technologies. In addition, the white paper and a matrix will help providers plan for, select, and implement the technology solutions that best fit their requirements. 

1.2    Executive Summary

CAST’s Safety Technology Workgroup, consisting of providers, vendors, and consultants, compiled a list of safety products that currently serve the long-term and post-acute care (LTPAC) market, as well as a list of functionalities and capabilities. The Safety Technology Matrix will help providers choose the product that best fits their business line and functional requirements. It has 18 sections to help organizations narrow their choices.

This white paper explains different technologies and systems that can be used to both prevent and/or report incidents in different senior living settings. When these technologies are available and user-friendly, they can help keep residents safe, comfortable, and secure, as well as assist family members and care staff in various senior living settings. 

The paper investigates the prevalence of safety-related issues such as falls, elopement and wandering, environmental, and crime and security. It then provides an introduction to the types of systems available—emergency notification systems, emergency response systems, nurse call systems, wireless nurse call systems, fall detection and prevention technologies, and location tracking and access control technologies and software.

Next are the benefits of safety technologies, including reduced response time; fewer incidences; better resident, staff, and family safety and satisfaction; increased peace of mind; improved outcomes; improved regulatory compliance; and reduced costs.
 
A discussion of potential LTPAC provider business models includes Medicaid waiver coverage, potential Affordable Care Act opportunities, private pay options, as well as standard of care and other payment sources. To help determine the full benefits of safety technologies, the white paper helps readers calculate the return on investment to patients and/or their families, payers, and care providers.

Recommendations on planning for and selecting safety technology lead with how to plan strategically and assess organizational readiness. The white paper walks readers through understanding the population and care setting, staff and resident needs, program services, IT infrastructure, cybersecurity issues, partner capabilities, and more.

Finally, it reviews the components of the Safety Technology Matrix that CAST prepared, for an understanding of how this tool can help providers select the most appropriate safety technologies for their organization’s unique needs. 

1.3    Disclaimer

This information is meant to help you understand safety technologies, but it cannot possibly include all systems that may be available. Products mentioned in this report are only illustrative examples and have not been tested, independently evaluated, or endorsed by LeadingAge or LeadingAge CAST. Please use this as a general guideline in understanding functionalities and examples of current safety technology systems. Where appropriate, we have included provider case studies.

2    Safety Technology

2.1    Definition

In senior living settings, safety technology includes different technologies and systems that can be used to both prevent and/or report incidents. When these technologies are available and user-friendly, they can help keep residents safe, comfortable, and secure, as well as assist family members and care staff in senior living communities. 

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Safety technology can be used to prevent and/or report incidents.

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A “safety device” is a piece of equipment that will help ensure a resident is cared for and monitored. A safety device could be a pressure pad in the resident’s bed or chair, a mobile transmitter that allow the resident to call for help and/or detects if the resident has fallen, a motion detector in the resident’s living space, a wander management system to ensure the resident do not elope from the building, and many others.

This Primer and Provider Selection Guide provides a thorough discussion of safety technology for long-term and post-acute care (LTPAC). It investigates some areas of concern: falls, elopement and wandering, environmental, and crime and security. It also addresses other categories relating to safety technologies, such as the prevalence of safety-related issues, financial impact, and why we need safety technologies in senior living today. In later sections, it covers the types of systems available, benefits of using these safety technologies, and how to plan for and select appropriate technologies.

2.2    Areas of Safety Concerns

2.2.1    Falls

In senior living, resident falls continue be one of the most prevalent allegations in all different types of care, according to the 2016 Aging Services Claim Report published by CNA. Falls also can cause some of the most detrimental outcomes, including physical injury, financial impact, and reputational costs ¹.  

In the claim report, falls held the highest percentage of closed claims in the five-year period studied (2011-2015), sitting at 42.7% of all claims with an average paid claim of $186,589. Between 2014 and 2015, more than half of the fall claims closed involved a resident who had a prior fall within the previous 12 months. Out of all 1,117 resident fall-related claims closed in this five-year period, 88.5% of the claims involved allegations of failure to monitor and improper care. 

The most common outcome of resident fall claims is death, at 48.4%, followed by permanent partial disability at 27.6%. The Centers for Disease Control and Prevention (CDC) corroborates this growing public health concern in reporting that in 2014 alone, roughly 29 million falls occurred, resulting in 7 million injuries.² 

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In a five-year period, 88.5% of resident fall-related claims alleged failure to monitor and improper care. 

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The CDC has prescribed programs such as Stopping Elderly Accidents, Deaths, and Injuries (STEADI) to train staff and caretakers to create fall prevention routines. The program has shown some success. A before-and-after study showed a decrease in the average hospital stay for fall victims from 7.9 to five days. The average rate of patients discharged to home increased from 46.8% to 63.6% over two years. Before STEADI implementation, 1.5% of fall victims returned with a second fall, but only 0.6% returned after implementation ^3.  

Organizations have successfully worked to reduce the severity of resident falls—and pressure ulcers—by standardizing and promoting consistency in care practices and decreasing variance, as well as other steps. Focusing on policies that engage and help residents, as well as discarding or limiting ones that do not enhance quality resident care, will also assist caregivers by allowing them to focus on providing the best possible care, which can help lower risks and prevent resident falls overall. 

On top of these practices, award-winning communities are setting standards in their care levels with factors such as consistent and purposeful rounds, certified nurse assistant (CNA) hall monitors, investigations at multiple levels of each fall, monthly fall meetings, minimizing the use of psychotropic medications, open communication from CNAs, and a restraint-free environment in almost all cases. Weekly or monthly education and exercise classes with residents can help prevent falls that cause injury.

More information about falls and fall detection, prevention approaches and technologies, and related peer-reviewed studies can be found in the Falls Chapter of the Aging Services Technology Study: Report to Congress. ⁴

2.2.2    Elopement/Wandering

Residents who have cognitive decline or other medical conditions may be deemed “clinically unsafe” to leave a community unattended, as they are at higher risk of physical injury. Elopement and other concerns, while quite infrequent, have the highest average total paid claims. 

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More than half of elopement claims are associated with assisted living care.

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With the highest paid average of $325,561 er claim, elopement sits much higher than the total claims average of $211,709. ⁵  CNA’s 2016 Aging Services Claim Report lists a total of 46 elopement claims between 2011 and 2015, rounding at 1.8% of claims closed. 

The report also shows that more than half of the elopement claims are associated with assisted living care, as opposed to skilled nursing care. These findings show a rising number of cognitive-impaired residents moving into communities, and moving into a lower level of care than residents with a higher likelihood of wandering or eloping actually need. 

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Despite popular belief, residents in care for 12 months or longer make exactly half of elopement claims.

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Cognitively impaired residents make up the majority of elopement claims, 84.8%. Psychiatric issues hold 13% of claims, with anger causing the remaining 2.2% of claims. Although popular belief is that elopement risk lowers or subsides after the first year of residency, residents in care for 12 months or longer make exactly half of the claims. Leading causes of elopement include insufficient staff training on caring for impaired residents, as well as a lack of vigilance in maintaining a secure environment.

Solutions: To help prevent wandering and elopement, consider the following:

• Perform thorough and complete risk assessments. Assess which residents are wanderers and which are exit seeking and communicate this information throughout all staff.
• Inspect environmental safeguards routinely.
• Perform staff rounds.
•  Use wander management systems and distributed alerts when a door is opened, which will allow staff to respond as quickly as possible to attempted elopements or wandering residents. 
• Provide continuing education courses that help protect residents from leaving secure units. 
• Keep staff trained in risk management and proper care for impaired residents. Ensure that staff know what to do when someone elopes; this knowledge can prevent a lost resident or help find a resident before an injury occurs.

2.2.3    Environmental

Passive devices in the environment also can help keep residents safe. For example, fire, smoke and/or carbon monoxide detectors with strobe lights or low frequency sounders can catch the attention of those with hearing loss. Smart thermostats and simple lighting systems can be scheduled or controlled remotely. Stove sensors can shut off a stove burner when it is unattended for a period of time and alert staff or loved ones of activity and/or incidents.  

2.2.4    Crime/Security

Seniors need ways to ensure their safety from physical crime, such as someone breaking into a living space or taking a purse/wallet while in public, and cybercrime attempts to steal passwords and finances. Seniors can secure their homes with smart locks; loved ones can control the lock and even be alerted of attempted break-ins. Many smart locks also include local alarms, which can alert residents of unwarranted access and deter burglars. 

When it comes to cybersecurity, technologies such as anti-virus and anti-malware programs installed on computers can monitor for programs trying to steal data. A password storage service can also be used to securely manage usernames and passwords. These password services allow ease of mind, as seniors do not have to remember or write down passwords; family members also could have access to these services when needed. Please see CAST’s Cybersecurity Resources for more information ^6. 

2.3    Why We Need Safety Technologies    

2.3.1    How They Have Made Things Better

Many technologies have changed the world of caring for older adults—devices to call for help and prevent falls, wander management solutions, check-in systems and practices, and community-wide communication devices. While statistics have not yet been tracked, the invention of systems that monitor residents and enable them to call for help has surely reduced the number of residents who fall and do not get help for long periods. 

For example, a study of the thigh patch showed a 91% overall reduction in falls among nursing home users. The same study indicated that the device was effective in reducing fall risk behavior among dementia residents, a group that has particular difficulty remembering to call for help before attempting to walk or transfer. Importantly, staff members’ and patients’ acceptance of the device was favorable ⁷. 

In addition, automated resident check-in systems help residents and staff perform daily checks better than did old methods, such as manually moving a flag outside of resident rooms. 

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Technologies that reduce nursing home falls may offer a particularly attractive return on investment.

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Given the high rates of falls in nursing homes, technologies that reduce falls in this care setting may offer a particularly attractive return on investment. The downside of alert devices is that they prevent falls only if staff or caregivers are available and respond quickly to the alarms, and if the alarms actually reflect the occurrence of a high-risk behavior or movement. 

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Where caregiver availability and/or staffing levels are sufficient, these devices may provide one useful element of a tailored program to reduce falls.

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A high rate of false alarms may eventually result in lack of response from caregivers, which limits this technology’s utility ⁸. Moreover, staff response time depends largely on staffing levels—and directly affects these technologies’ efficacy whether residents wear the devices or not. As a result, we may not be able to generalize individual studies because staffing levels are different across care settings. 

Nonetheless, in care settings where caregiver availability and/or staffing levels are sufficient, these devices may provide one useful element of a tailored, multi-factorial program to reduce falls and fall-related injuries—as long as the older person is willing to use the device if needed ⁹.

2.3.2    How They Are Being Utilized Today

Nowadays, in most senior living communities, building-wide emergency call systems can be—and are being—used to provide even more benefits for residents than before. Devices with different types of sensors are gathering data and using such data to help staff care for seniors. 

Motion sensors, pressure pads, temperature sensors, light sensors, and more are all being used to alert staff of someone potentially in need and to recognize and prevent problems. Wander management and access control systems help keep residents safe by ensuring those with dementia or wandering tendencies stay in the building and by allowing access to only authorized people. Integrating different systems enables staff to provide even higher levels of care than before.

3    Types of Safety Equipment  

The technologies below are unique solutions to increase safety for residents in senior living communities. As with any approach to safety and security, no one technology can provide 100% protection. Technology along with policies, procedures, resident/client education, and staff training can help provide the safest environment for residents and staff.   

3.1    Emergency Notification Systems

All communities should be prepared for emergency events with a comprehensive disaster recovery plan. That plan should include a mass notification system. Whether a natural disaster like a tornado, hurricane, earthquake, or wildfire, or a man-made one, like an active shooter, it’s important to keep everyone informed about what is happening and what steps they need to take. It is important to send notifications in as many ways as possible to those likely to be affected within the community as well as to emergency responders in a timely and effective way. 

The companies that offer mass notification also provide their expertise in developing a communication plan. Alert profiles can be different depending on the type of emergency. For example, a fire alert, which requires people to evacuate immediately, is different than a tornado warning, which requires people to take shelter.  

Mass notification events can trigger alerts to be sent over several paths and devices. Once a plan is put together with the pre-defined alert profiles, then the mass alert technologies can send the messages to various devices, including the following: 

• Desktops.
• Smartphones.
• Landline telephones.
• Pagers.
• Two-way radios.
• Wearable badges.
• Public address systems.
• Strobe lights.
• Audible alarms.
• Vibrating pillows.
• E-mails.
• Closed Circuit Televisions (CCTVs).
• Wall boards / screens.  

As an example, Onsolve provides a good list of features to look for in a mass communication system, including the following ¹⁰:

• The ability to send real-time alerts via a variety of methods, including by phone, e-mail, SMS, and others depending on the situation.
• The ability to schedule specific types of alerts based on certain events to save time in a crisis.
• The opportunity to send multi-language alerts to a multilingual workforce or community. 
• The ability to select a geographic area on a map to send alerts to people within that area. This solution can reach anyone, anywhere, at any time—whether they’re on site or in the field.
• The opportunity to send attachments within alerts if needed.
• A solution must also offer the opportunity to track who has accessed alerts as things change. 
• The option to combine multiple alerts into a single message if/as needed. 

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To maximize an organization’s investment, bill reminders, menu updates, or updates about local events also can be automated.

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Not all alerts need to be for an emergency. To maximize an organization’s investment, other automated alerts can be sent such as bill reminders, meal menu updates, or updates to family members about local events coming up within the community.  

3.2    Emergency Response Systems

Emergency Response Systems within senior living communities enable residents to reach staff for help when they need it. Systems include in-room pull cords, nurse call systems, and wearable devices for more-mobile residents. Some companies provide wearable badges for staff or pendant devices for home-based support, while others offer full nurse call systems with several device types. The following is a brief description of each type of device and where it is commonly used. 

3.2.1    Pendants or Personal Emergency Response Systems (PERS)

Wearable pendants provide more independence for the more-agile residents. The most basic function of the pendant is to enable a resident who has fallen to send an alert to the care staff with a single button push on a pendant that is worn on a lanyard or clip. When a resident activates a pendant, the signal goes back to a central station to notify the care team. Information is sent along with the alert, including the resident room and name, and location if available. 
PERS can be integrated with a nurse call system within a senior living community or the resident can purchase it directly. PERS, not part of a nurse call system, can provide a lifeline to help for seniors living at home or in independent living communities.

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PERS can provide a lifeline to help for seniors living at home or in independent living communities.

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Home Based PERS
Home-based alert systems come with the wearable pendant that connects wirelessly to a base station. The base station connects to the resident’s phone line. The base station has a very sensitive microphone and high-volume speaker. When a resident presses the alert button, it sends a signal to the base station that automatically calls the service provider’s live agent call center. The call center agent can then communicate with the resident through the base station speaker and microphone. The speaker is very loud so that it can be heard throughout the house. If the resident is able to respond, the agent will determine if emergency medical service (EMS) needs to be sent to the home. If the agent doesn’t hear anything from the resident, then he or she will send EMS to assist and assume the resident has lost consciousness. 

Modern versions of PERS systems incorporate sensors like accelerometers and gyroscopes to detect falls automatically or even help prevent them. Please see section 3.5 for a discussion on these technologies. 

PERS with GPS
For increased mobility, there are options for global positioning system (GPS) and cellular-enabled PERS. With GPS and cellular-enabled pendants, a resident can receive assistance from anywhere there is a signal on the cellular network. When the alert button is pressed, it notifies the service provider that an alert has been triggered, along with the resident’s location. Some pendants have a speaker and microphone built in so the service provider can reach out to the resident to assess the situation and provide assistance. With the GPS location available to the service provider, EMS can be sent to assist the resident. 

Geo-fencing
Geo-fencing is defined as “the use of GPS or radio frequency identification (RFID) technology to create a virtual geographic boundary, enabling software to trigger a response when a wearable or mobile device enters or leaves a particular area.” With PERS that are enabled with GPS, caregivers can not only track the resident’s location, but also set up a Geo-fence. The Geo-fence can be based on a list of the most common places the resident will regularly go, such as the grocery, pharmacy, hair dresser, and the bank. It can also be set up with a maximum distance from home. When the Geo-fence perimeter is broken, an alert can be sent to the service provider and to the family. This is a good option to provide more freedom for seniors that are exhibiting signs of dementia. 
 
Cell Phone PERS
Another option to the pendant is to have the same service provided on a cell phone. There are several providers that offer the same emergency support for seniors using a cell phone as a wearable pendant. Bay Alarm Medical, Orion, and GreatCall are examples.

3.3    Nurse Call Systems

Nurse call systems, also called bell or call light systems, provide the communication link between the residents and the care team. The system can be installed on a wired or wireless network. A nurse call system will have a master station that receives residents’ calls from various types of remote call stations. A system will have call stations mounted in resident rooms using wall-mounted call stations, pull cords, or code switches. For outdoor areas, there are vandal-resistant stations available to withstand outdoor conditions. For the more acute care communities, the use of call cords and pillow speakers are available. Optional equipment can provide other alarms to be sent to the nurse call system, including pressure pads to detect movement and fire alarms.  

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Nurse call systems, also called bell or call light systems, link residents and the care team.

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Corridor lights are also available to provide the visual indication that a resident within a room has initiated an alert to the nurse call system. They can have several color options that can be programed to light up based on the type of alert or request made through the nurse call system. 

The master station receives all the notifications; however, several systems also send alarms to pagers, smartphones, and other mobile communication systems. This reduces the need for a staff person to sit near the monitoring station to receive alarms. Alarms can be sent directly to the caregivers with the pertinent information.

Many of the nurse call systems also provide wander management capabilities that are described later in this paper.  

3.4    Wireless Nurse Call Systems

The most common wireless technology used in nurse call systems is 900MHz spread spectrum. This wireless infrastructure is well suited to simple alarms to be sent from pendants and pull cords because it can be deployed over a large area inexpensively. Because alert devices that operate on this network don’t require a lot of battery power, wearable devices such as pendants can run for up to three years on one battery. Wireless system endpoints are set up to constantly self-test their connection back to the base station, preventing any missed alarms or false positive alarms.

Some providers can leverage the existing Wi-Fi network, but they still require the 900MHz network to be in place for the pendants and other wireless endpoints to operate. The main challenge with using the Wi-Fi network for devices like the pendant is that the battery life of the device would be short, making it difficult to manage.

3.5    Two-Way Staff Communications System

Two-way communication platforms enable staff to initiate calls over wearable communication badges using simple voice commands. These calls can be made by saying the name or role of the individual needed, such as “nurse in charge” or “maintenance.” The technology is ideal for care provision when staff must be hands-free, such as when attending to a resident’s daily needs. 

Two-way communication platforms are an alternative to standard consumer smartphones or two-way radios. The wearable badges are lighter and leverage the building Wi-Fi network to help eliminate communication dead zones. These systems can also integrate into the existing memory care, nurse call system, or PBX. This integration enables multiple functions, including sending text alerts directly to staff to be read on the badge screen, helping to reduce response times, and enabling staff to call outside to get help, such as to 911 or desk phones within the community.  

Communities adopting this type of technology will require a Voice over IP (VoIP) enabled Wi-Fi network to support voice calls. Vendors can evaluate existing systems to make sure integration is possible.  

3.6    Fall Detection and Prevention Technologies

3.6.1    Fall Detection

Properly detecting a fall using wearable technology can be a challenge because it’s difficult to differentiate between an actual fall and someone just sitting down. However, there are technologies that do a good job making this differentiation. The key technologies include accelerometers, barometers, gyroscopes, and software algorithms. 

Accelerometer & Algorithms
An accelerometer is a device that measures changes in gravitational acceleration. Often found in cars, ships, and aircraft, accelerometers are also used to detect if a person has fallen. The challenge with this technology, when used by itself, is that it can’t always differentiate the difference between a fall and someone simply sitting down abruptly, which is considered a false alarm. 

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Accelerometers, barometers, gyroscopes, and software algorithms can distinguish between a fall and someone sitting down.

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Several companies have come up with algorithms to reduce the number of false alarm events. For example, they try to determine if the resident needs assistance right away by checking for more movement after the fall event. If there is movement, they cancel the alarm because they believe the resident is cognizant enough to press the button on the alert tag to ask for help. If no movement is detected, then the alarm is sent to the care team to send assistance. This of course doesn’t eliminate false alarms, but the goal is to reduce them.

Barometer
The Philips Fall Detection System incorporates accelerometer technologies along with a barometer. The barometer can differentiate the change in barometric pressure from a resident in a standing position to one that is lying down. If there is a lack of movement for an extended period and the barometer reading shows the resident in a low position, the system can decide to send an alarm to the caregivers.  

Audio Systems 
Some fall detection systems incorporate two-way voice communication capability that enables staff to reach out to the residents directly to assess their situation. Audio capabilities require a strong network to support the feature. Make sure you know if your community has what it needs for two-way audio solutions. 

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Various fall prevention technologies try to address the multiple root causes of falls.

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3.6.2    Fall Prevention Technologies 

Fall prevention technologies focus on preventing falls of individuals assessed and found to be at high risk of falling. Since there are multiple potential root causes of falls, various fall prevention technologies try to address these causes. For example, darkness increases the risk of falling, especially for residents with visual impairments, so automatic night lights triggered by motion can reduce these falls. Similarly, bed and chair alarms as discussed earlier may reduce falls if staff are available and respond quickly.

Other fall prevention technologies may incorporate accelerometers and other wearable sensors to monitor walking velocity, upper body sway, etc. to determine if the older adult user is at increased risk of falling. They prompt staff to implement the appropriate fall prevention program, including potentially targeted muscle strengthening or balance-enhancing exercise programs.

3.6.3     Location Tracking Technologies

Location tracking technologies are also referred to as Real Time Location Systems (RTLS). RTLS are used to keep track of assets such as wheelchairs, important medical equipment, and/or residents that have a risk of wandering or elopement. 

When GPS track cell phone locations, multiple satellite signals are received by the GPS chip in the phone, which uses algorithms to triangulate the phone’s location. This process is accurate when outside a building, but within many buildings the satellite signal isn’t strong enough to get through and accurately report the position. To address this limitation, several companies have come up with ways to achieve the same capability using local wireless networks and sensing devices.  

Wi-Fi RTLS
Companies like Stanley Healthcare Systems, among others, leverage the existing Wi-Fi network to act as active RFID readers to determine location and status of RFID tags. Location is determined by analyzing the Time-of-Arrival (TOA) data from the network access points. The systems can calculate the precise position of an RFID with TOA data from three access points. It is important to know if an organization’s Wi-Fi network has the TOA or ToF (Time of Flight) data-gathering capability before considering a Wi-Fi RTLS system. 

3.7    Access Control Technologies

Senior living communities often have many doors that staff cannot monitor. There are restricted areas that need to be locked and monitored, including medication dispensary rooms, storage rooms, or management offices. Using the traditional keys is cumbersome and hard to manage with a large mobile staff that needs access to rooms quickly. Replacing keys can be difficult with high staff turnover. Keeping the residents safe while providing them the independence they need requires more sophisticated access control systems. 

Several companies offer various solutions to fit a community’s needs. The list below highlights the components that make up a security system. This is not a complete list of capabilities, but some technologies such as biometric readers and elevator controls are not commonly used in long-term care.  

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IP-based systems can provide significant cost savings, depending on a community’s size and needs. 

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Recently, there has been a shift in the access control industry from hardwired control box deployments to Internet Protocol (IP) based systems that leverage an organization’s existing IP network. There can be significant cost savings depending on a community’s size and needs. 

3.8    Access Control Software

Access control software is the brains of the access control system that gives a dashboard view of what is happening in the building. Combining the access control software with the variety of door controllers, electronic key readers, cards and key fobs can provide more reliable controlled access to a community. According to Stanley, the typical uses of access control in senior living communities can do the following: 

• Restrict access to certain storage rooms, offices, and medication dispensary rooms.
• Allow staff members to use badges/ID cards to unlock and enter exterior doors.  
• Allow perimeter doors to be locked and alarmed after normal business hours, as scheduled.  
• Provide a documented audit trail of who entered a controlled area and when entry occurred.

Key Fob and Card Readers
Key fobs and cards are used to access restricted areas of the building by electronically providing the access credential. With the access control software, each employee can be granted rights to some areas and be restricted from others. For example, nursing staff will have access to the medication dispensary, but maintenance staff will be restricted unless accompanied by an approved escort. The system also can deactivate a card or key fob if an employee leaves the organization. 

The key fob is a convenient option to provide the electronic credentials for some situations and may be a good fit for smaller communities. The alternative is to provide a key card that also has the employee’s picture ID printed on it. This provides another form of verification if needed.  

Readers
Readers are the entry point for credentials to accept or reject a request to enter a restricted area. Readers are connected to the electric door locks of an entry point, and when the correct credentials through either an electronic key fob or card reader are presented, then the door is opened. Some exterior doors where residents also need to gain access can be equipped with a key pad for password entry. It is important to work with a security company to determine the best reader solution for each community. 

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Work with a security company to determine the best reader solution for each community. 

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Wander Management Readers
Wander management readers on the market can recognize a wander-risk patient by the RFID within the patient’s pendant, woven into a piece of garment, or embedded into a wearable device. When a wander-risk resident approaches an entry point, unescorted, the electronic door won’t unlock. If the patient is escorted by a staff member with the right credentials, then the door will open. The readers can also monitor low tag battery, door ajar, and resident loiter. These readers can be integrated with the existing nurse call system if they are compatible.

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Often, residents who don’t have PERS have a longer response time when they request help.

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4    Benefits of Safety Technologies

4.1    Reduced Response Time

Safety technology can significantly speed notifications to the appropriate staff and reduce the response time. For example, if a resident needs assistance in an independent living apartment, having a PERS with or without an auto-fall detection can increase the likelihood of a quick response time if an alert is triggered. Often, residents who don’t have access to PERS have a longer response time when they request help.

Mass communication systems—such as mass e-mails, telephone calls, or texts—can rapidly communicate an emergency to a community through these multiple channels. As a result, communities with a mass communication system typically have residents who respond quickly once a mass emergency notification is sent out.  

4.2        Reduced Incidences  

Safety technology can also reduce the number of incidences. For example, an access control system like automatic door locks and elevator access controls can significantly reduce the number and likelihood of resident elopements. Perimeter-based monitoring systems can also reduce incidences. 

4.3    Increased Resident/Staff/Family Safety and Satisfaction

Safety technologies like surveillance cameras and environmental monitors—such as smoke, fire, and carbon monoxide detectors—provide residents and staff a safe living and working environment. More-advanced smart monitors can communicate with each other to trigger sprinkler systems or shut-off systems, such as to the gas supply. For example, a smart smoke detector that detects a possible fire can communicate with a smart thermostat to turn off any fan-based systems to prevent smoke from spreading further and faster. Similarly, if a smart carbon monoxide detector triggers, it will tell the smart thermostat to stop any heating system that uses fossil fuels.

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More-advanced smart monitors can communicate with each other to trigger sprinkler systems or shut-off systems.

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A community that is open to visitors but restricts uninvited guests provides residents and family members a sense of safety and satisfaction that residents live in a safe environment. Digital visitor management systems can provide an electronic log of who is entering a community, providing enhanced security. For example, a digital visitor management system can not only log who is visiting but also take digital images and provide analytics to management. Access control systems can automatically lock entrances and only allow access to authorized guests and residents with access fobs.   

4.4    Increased Peace of Mind

Residents and family members can have an increased peace of mind knowing that safety technology is available in their home and/or community to facilitate assistance when needed.  For example, a person with a PERS may have an increased peace of mind knowing that if an emergency such as a fall occurs, he or she can request assistance.  Auto-fall detection technology paired with a traditional PERS can enhance that peace of mind since this technology can automatically request assistance without the user pressing the button.  

4.5        Improved Regulatory Compliance 

Different types of residential and care communities have regulatory requirements that vary based on the state where the community is located. Given that call systems are so important, safety and performance standards have been created specifically for the nurse and emergency call systems used in skilled nursing and assisted living communities. 

These standards include the following:

• Underwriters Laboratory (UL) standard UL 2560, for Emergency Call Systems for Assisted Living and Independent Living Facilities: UL 2560 was introduced in 2011 to address the operational requirements of emergency call systems intended for use in non-acute care settings, like the ones typically found in senior living environments. It focuses mainly on wireless systems.
• UL 1069, the standard for Hospital Signaling and Nurse Call Equipment: UL 1069 applies more to the traditional nurse call equipment found in hospitals, though it does allow for portions of that system to be wireless. Since the seventh edition’s introduction in 2007, some states have mandated that any nurse call system used in a skilled nursing environment must meet the UL 1069 standard, but most states do not currently have this requirement ¹¹. 

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Older adults who receive help within one hour of a fall are nearly six times more likely to survive than those who wait longer for aid.

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4.6        Improved Outcomes

Older adults who receive help within one hour of a fall are nearly six times more likely to survive than those who wait longer for aid.¹² Personal emergency response systems assist older adults in receiving prompt medical attention after a fall. Despite the dearth of published evidence on efficacy of PERS, survival statistics suggest that technologies that facilitate early detection of falls and rapid receipt of medical care can result in substantial mortality risk reduction, a key fall-related outcome. ¹³ PERS may be especially helpful for older adults who live alone and are more likely to have to wait for help if a fall occurs.

4.7    Reduced Costs

Early detection of an emergency, such as a fire, can greatly reduce the cost of repairs. Surveillance technology, such as a closed circuit security camera or access controls, reduce the likelihood of theft. An automated access control system, such as a digital front entrance sign-in, can reduce or eliminate the need for staff to manually sign in visitors or guests. Although the main priority is safety and security of residents and staff, safety technology as noted above can reduce the costs. 

5    Potential LTPAC Provider Business Models   

Safety and security technologies in senior living are mostly investments made by the provider community to comply with applicable regulation and/or differentiate and market the community to prospective residents, staff, and families. They are not covered directly under any reimbursement scheme. 

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The impact of safety technologies’ may positively reflect on quality measures, like CMS Five Star Ratings.

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However, the impact of these technologies may positively reflect on quality measures, like the Centers for Medicare & Medicaid Services (CMS) Five Star Ratings. An example is fall prevention’s positive effect on the number of falls and overall quality of care. The CMS rating may indirectly support the organization’s bottom line, as it affects reimbursement rate and being part of a narrow referral network for hospitals, accountable care organizations (ACOs), managed care organizations, etc. 

5.1    Medicaid Waiver Coverage

Medicaid waivers are vehicles states can use to test new or existing ways to deliver and pay for healthcare services in Medicaid and Children’s Health Insurance Program (CHIP). There are four primary types of waivers and demonstration projects: 

• Section 1115 Research & Demonstration Projects: States can apply for program flexibility to test new or existing approaches to financing and delivering Medicaid and CHIP.
• Section 1915(b) Managed Care Waivers: States can apply for waivers to provide services through managed care delivery systems or otherwise limit people’s choice of providers.
• Section 1915(c) Home and Community-Based Services Waivers: States can apply for waivers to provide long-term care services in home and community settings rather than institutional settings.
• Concurrent Section 1915(b) and 1915(c) Waivers: States can apply to simultaneously implement two types of waivers to provide a continuum of services to the elderly and people with disabilities, as long as all federal requirements for both programs are met  ¹⁴. 

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A CAST Analysis of Medicaid Waiver Programs found that 47 states, excluding Alaska, Kentucky, and Mississippi, reimburse for home emergency monitoring or PERS.

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According to a CAST Analysis of Medicaid Waiver Programs ¹⁵,  47 states, excluding Alaska, Kentucky, and Mississippi, reimburse for home emergency monitoring or PERS, under sections 1915(b) and/or 1915(c). 

Rates and requirements vary. For more details about the coverage of medication management and other aging services technology services in these states, please see CAST Analysis of State Payment for Aging Services Technologies (ASTs).  

5.2    Potential Affordable Care Act (ACA) Opportunities

The Affordable Care Act (ACA) is shifting the healthcare system in the United States away from the traditional fee-for-service to a pay-for-performance system. This change is starting to eliminate the misalignment of incentives inherent in traditional Medicare, Medicaid, and private insurance programs. 

There are many provisions and models in the ACA that would benefit from, provide opportunities to cover, and consequently encourage the adoption of medication management technologies and services.

New Models
The act created the Center for Medicare & Medicaid Innovation (CMMI), which is tasked with exploring new care delivery and payment models and initiatives that do the following: 

• Use more holistic, patient-centered, and team-based approaches to chronic disease management and transitional care.
• Improve communication and care coordination between and among care providers.
•  Improve care quality and population health while reducing growth in expenditures. ¹⁶

The act puts explicit emphasis on the use of health information technology (health IT), including safety and remote patient monitoring, in Health Homes for Enrollees with Chronic Conditions, the Independence at Home Demonstration, and the Use of Technology in New State Options for Long-Term Services and Supports. These initiatives include the following:  

• Hospital Readmission Reduction Program (HRRP) ¹⁷.
• ACOs  ¹⁸.
• Bundling of Payments models; the following are relevant to LTPAC providers:
  • Retrospective Acute Hospital Stay plus Post-Acute Services ¹⁹.
  • Retrospective Post-Acute Care Only ²⁰.     

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New care delivery and payment models will enable LTPAC providers using technologies to improve their strategic partnership position and/or to derive revenues from strategic partners.

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LTPAC providers bring a significant value for hospitals, physician groups, payers, and accountable care organization (ACO) partners by providing the following services:  

• Rehabilitation and skilled nursing facilities that provide post-discharge/post-acute patient rehabilitation. 
• Skilled nursing facilities, assisted living facilities, continuing care retirement communities, housing with services, and home health agencies that provide post-acute patient stabilization and sub-acute chronic disease management. 
• Holistic person-centered care, including support services. 
• Lower-cost care settings than hospitals.  

These new care delivery and payment models will give LTPAC providers using technologies—like health IT, safety, and remote patient monitoring technologies—opportunities to derive revenues from strategic partners.

5.3    Private Pay

Other payment sources for safety and security technologies and services may be private payers or out-of-pocket payments by residents or clients.

5.4    Standard of Care and Other Payment Sources

LTPAC and community health providers, special population agencies, self-pay and self-insured organizations, and others, especially not-for-profits, may offer an array of safety monitoring technologies and services. 

Grants may cover these services. Or the organization may absorb the cost, with different revenue sources covering it, including charitable contributions.

5.5    Return on Investment (ROI) of Safety Technologies

Return on investment (ROI) represents the ratio of the net gains relative to the initial investment over a certain period of time. Subsequently, ROI can be expressed in the following equation:

As discussed above, safety and security technologies deliver various benefits, including potential financial savings, to different stakeholders. Stakeholders include patients and/or their families, payers, care providers, etc.

However, the financial savings and ROI depend on a number of factors, including the care/service delivery model, the payment/reimbursement model, the technology, and of course costs. The first and most important step in calculating ROI is to consider the different stakeholders, identify the investors, and calulate the gains and savings netted/accrued to each investing stakeholder under each particular care delivery and payment model. 

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When calculating ROI, one should only include the gains that accrued to that particular stakeholder minus all expenses, relative to that stakeholder’s investment/cost.

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When calculating ROI, one should only include the gains that accrued to that particular stakeholder minus all expenses, relative to that stakeholder’s own investment/cost. Often the reduction of hospital days is erroneously included in the providers’ ROI, which is not true under the traditional fee-for-service reimbursement model and can be misleading; such a reduction usually accrues to the payer.

5.5.1    ROI to Patients and/or their Families

ROI to patients and/or their families can be calculated as follows: 

For private pay patients and their families, for example, the financial gains of safety technologies are in prolonging independence by delaying the transition to a higher and more-costly level of care. These benefits are significant. The gains may also include savings in co-pays for recurring hospital visits, and of course a peace of mind for the individual and their family, which is difficult to quantify. The patient’s and family’s expenses are the monthly out-of-pocket cost of safety technologies, plus any co-pay for the occasional interventions.

5.5.2    ROI to Payers

ROI to payers can be calculated as follows:  

For example, for dual Medicare- and Medicaid-eligible patients who are nursing home eligible, the financial gains of PERS and/or other safety monitoring under a Medicaid Waiver program that accrue to Medicaid lie in remaining in their own home with home health, home care, and other supportive services. Otherwise, Medicaid would be liable for nursing home room and board costs.

Medicaid’s investment is the monthly rate of PERS and additional supportive services aimed at keeping the individual independent.
  
In this particular example there may be additional savings, like reductions in hospitalization and hospital readmission costs that accrue to Medicare, which is liable for and covers healthcare costs. Consequently, such savings or gains should not be included in calculating Medicaid’s ROI, which in this case is investing in the PERS and supportive services.

5.5.3    ROI to Care Providers

ROI to care providers can be calculated as follows:  

The care provider who makes investments in information and communications technology infrastructure, including the safety monitoring technology and the clinical and care services, may gain these benefits:

• Lower costs in delivering the same services, including staff efficiencies and staff travel costs (if the payer covers the safety monitoring and supportive services).
•  Higher reimbursements/payment from the payer or strategic partner as incentives for avoiding more costly care settings, procedures, events, or penalties. 

For example, an LTPAC provider partnering with a physician group accountable care organization (ACO) to manage a chronically ill patient population can potentially get a percentage of the incentives or shared savings payments the ACO receives from the payer for reducing hospitalizations and hospital readmissions. These amounts can be significant for certain populations.

LTPAC Provider
The LTPAC provider’s net gain is the same as above 
+ Plus the sum of all gains accruing to the LTPAC provider in staff efficiencies, increased referrals from the ACO, increased traditional fee-for-service rates, and additional incentive payments received from the ACO 
– Minus the costs of leasing the safety monitoring equipment and actual costs of services delivered.

Physician Group ACO 
The physician group ACO’s ROI is the same as above 
+ Plus the portion of the payer’s incentive payment that it gets to keep plus any additional fee-for-service payments due to more frequent office-based services
– Minus the actual costs of services it delivers (for example in medication reconciliation or care coordination), relative to the portion of incentives it passes through to the LTPAC provider.
  
In contrast, in a partnership between an LTPAC provider and hospital under the traditional fee-for-service model, for example, the LTPAC provider may help its hospital partners reduce falls and consequently all-cause 30-day readmission rates. This scenario helps the hospital avoid Medicare’s payment penalties under the HRRP.  

The hospital may contract with and pay the LTPAC provider a percentage of the penalties saved for delivering safety monitoring and fall prevention programs that lead to reducing 30-day readmissions for patients discharged from the hospital after being admitted for one of these three conditions.  

LTPAC
The LTPAC’s net gain is the same as above 
+ Plus again the sum of all gains accruing to the LTPAC provider in staff efficiencies, increased referrals from the hospital, increase in the rate of traditional fee-for-service payments, and additional payments received from the hospital
– Minus the costs of leasing the safety monitoring equipment and actual costs of services delivered.

Hospital
The hospital’s ROI is the same as above 
+ Plus the portion of avoided penalties it gets to keep, plus any additional fee-for-service payments it gains for more referrals and increased rates due to improved quality ratings
– Minus the actual costs of services it delivers, relative to the portion of avoided penalties it passed through to the LTPAC provider
+ Plus any additional costs incurred for staff time in safety monitoring, falls prevention, and/or supportive services, for example.

5.5.4    Online ROI Calculator

Once individual investors have been clearly identified, an estimate of the ROI to the different stakeholders can be calculated. The SCAN Foundation recently published a white paper on making the business case for person-centered care, with instructions for using an ROI calculator it developed.

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The SCAN Foundation recently published a white paper on making the business case for person-centered care, with an ROI calculator.

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The business case for person-centered care involves weighing the costs against the benefits in dollars.

This ROI calculator is designed to quantitatively assess the business case for person-centered care (PCC) programs that serve older adults with chronic conditions and functional limitations. PCC programs are ones that elicit individuals’ values and preferences, which guide all aspects of their healthcare and support their realistic health and life goals. This type of care requires a collaborative relationship and decision-making process among the person, their chosen supports, and their medical and social service providers. 

As discussed in detail above, the business case for PCC involves weighing the costs of offering this approach to care against the benefits expressed in dollar terms. Benefits accrue principally as avoided medical utilization, but also potentially as higher revenues ²¹.

The ROI calculator has a number of practical features:    

Risk Stratification
The population that is suitable to receive PCC can be segmented into high and moderate risk categories. The ROI will be likely a higher percentage for the segment that is at higher risk for medical utilization. The calculator can show how limited the offering must be to seek a specific return. 

Potential Revenue from PCC
The calculator allows for PCC program offerings to incorporate possible revenue enhancements in addition to the more probable benefits resulting from reducing costs.    

Slider Bars
This feature allows the user to compute instantaneous “what-if” calculations by changing values of inputs and immediately viewing these new inputs’ influence on the ROI.   

Flexibility in Expressing Variables
The user can enter all variables for convenience—per person, per month, or per year. Hospital admissions, for example, are generally reported on an annual basis while encounters with a social worker or nurse practitioner are often expressed on a monthly basis. The calculator automatically converts rates and volumes, no matter how expressed, into a common per-member per-month measure.

Scenarios
This feature allows ROI comparisons across different programs as well as varied constellations of input values. For example, the user can create optimistic and pessimistic scenarios and compare the results. Sometimes even the pessimistic scenario can yield an acceptable result for the ROI.

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One feature lets the user create optimistic and pessimistic scenarios and compare the results. 

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Accounting for Uncertainty
Admittedly, some key determinants of the ROI are uncertain. A “Monte Carlo” simulation that accounts for uncertainty with respect to the magnitudes of key variables is an optional part of the tool. This simulation recognizes this uncertainty and displays a reasonable range of ROI results rather than a single deterministic value. The tool also quantifies the strengths of the separate influences each variable has on the resulting ROI.

Other Metric – Payback Period
In addition to the ROI result, the calculator displays the payback period—defined as the number of months the PCC program would need to operate, assuming a positive operating margin, to recoup any initial investment. This metric may be useful for programs involving substantial up-front launch costs.   
 
Threshold Analysis
The tool provides the ability to conduct threshold analysis, where the user can ask the calculator questions such as the following: What is the maximum amount that can be spent on PCC so that the program does not lose money? Or for a given cost of delivering PCC, how effective must it be in reducing certain events such as hospital readmissions to generate a required (hurdle) level of ROI?  

Access The SCAN Foundation calculator tool.   

6    Planning for and Selecting Appropriate Safety Technology

6.1    Understanding the Population, Issues, Care Settings, Needs, Program Services, and Partners

Safety technologies are necessary, but how effective is an alarm if it just creates or adds noise? Planning and selecting the technology set that best fits each environment’s needs is crucial. Most end users look at safety and security from a reactive position—something happens, someone files a complaint or concern, and then diagnostics are done to track down what happened and who was involved. 

Being proactive in assessing and even anticipating the needs of residents, staff, and family members is critical to planning, selecting, and supporting the most appropriate safety technology for each unique setting. 

The planning and selection process should include understanding the population the organization serves, be it independent, assisted, skilled care, memory care, rehabilitation, hospice, or a combination of all of the above. The organization’s constituencies drive the issues and needs that the level of care and programs must address. Safety technologies are not one size fits all, so thoroughly understanding and assessing the organization is recommended before selecting a partner or partners.

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Assessing and anticipating the needs of residents, staff, and family members is critical to having the most appropriate safety technology for each unique setting.

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6.2    Planning for Safety Technology Solutions 

6.2.1    Visioning and Strategic Planning 

Visioning and strategic planning are necessary to make senior living communities successful and sustainable. The incorporation of technology, once a result of strategic planning, has now become its catalyst. Emerging technologies such as mass notification systems and mobile devices play a critical role in community safety and emergency management, which incoming residents expect. Regulatory requirements or environmental factors may affect the time to incorporate safety technologies. However, to begin planning for safety technology, stakeholders must make a strong commitment to provide a safe living environment. 

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To adopt safety technology, organizations need a global approach to emergency preparedness, and a cultural shift that encourages proactive monitoring of self and community.

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Once the vision is clear, two factors are needed to adopt safety technology: a global approach to emergency preparedness, and a cultural shift that encourages proactive monitoring of self and community.

6.2.2    Organizational Readiness Assessment

Consider several areas when assessing an organization’s readiness for certain safety technology solutions.

6.2.2.1    IT infrastructure

Convergence refers to the confluence of voice, data, wireless, and even body-area networks that provides an unprecedented level of connectivity. The beauty of the World Wide Web is the world-wide part, so there’s Wi-Fi in buildings and cellular outside of buildings for roaming and handoff from office to home and anywhere in between. The meshing of networks and devices has created the Internet of Things, with Cisco’s Internet Business Solutions Group predicting some 25 billion devices were connected in 2015, and 50 billion by 2020.

The power of this persistent connection makes it possible to do all sorts of great things. So organizations can leverage data networks—not just rely on them. By assessing the current infrastructure, organizations can plan to augment it with technology they select. 

6.2.2.2    Available Technology Solutions 

As other sections in this white paper have covered, a number of technology solutions address both general and specific safety needs. Mobility solutions enable caregivers to respond to unfolding situations more quickly, initiate alerts and associated response plans more effectively, and escalate/notify others as necessary. Many of these solutions were developed specifically for use in healthcare environments to improve workflow and collaborative care.  

By assessing a community’s current safety systems like nurse call, wander management, fire, etc. as well as its current communication methods—landlines, smartphones, radios, PA systems, wall boards, CCTVs, tablet-based kiosks, etc.—organizations can determine which solutions complement their existing investment. 

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Using multiple communication end-points ensures redundancy, which is critical for life safety, so this step is important in overall planning.

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Note that using multiple communication end-points ensures redundancy, which is critical for life safety, so this step is important in overall planning. However, keep in mind that one system may not fully address an organization’s needs, and that organizations may need to invest in multiple systems. In those cases, it is important to consider interoperability and integration capabilities between the new and the existing systems the organization plans to keep, and/or consider working with a third-party systems integrator.  

6.2.2.3    Available Data 

Safety technologies assist both staff members and residents, so data related to all stakeholders is important. This data can reside in human resources (HR) systems, point of service (POS) systems, electronic medical records/electronic health records systems, security systems, and a variety of other databases. Assessing this data is important to avoid having redundant systems or competing databases of information when introducing new systems into any environment. 

6.2.2.4    Additional Data Needed and Sources

Consider other sources of data that the residents may be bringing that may help an organization achieve its goals. Personal monitoring and tracking devices, like activity trackers, may be an example of such data sources.

6.2.2.5    Interoperability/ Interfacing Capability

Although isolated technologies are often powerful, they are amplified when combined and harnessed in a technological ecosystem. Interoperability allows the community to have a strategic comprehensive and holistic system of emergency alerting and response management, rather than multiple disjointed systems and response plans. Inefficient, standalone alarms can become detailed alerts with the right integration strategy.
 
Making the right technology decision that works in the existing and future environment will help create operational efficiency and interoperability that will enable cost savings. Maximize the return on technology investments by converging technology silos in the ecosystem where information is streamlined and caregivers can focus on providing care, including the social component of care. Technology integration empowers older adults to live safe, secure, connected, and purposeful lives.

6.2.2.6    Staff Needs

Staff needs often depend on the populations and care settings of those they are serving. Take into account the importance of mobility, on-site versus off-site notification, accountability requirements, proactive versus reactive care, and the organization’s brand promise.

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Ongoing training should always be a part of the overall plan to support any technology, but especially one that impacts life safety and security.

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6.2.2.7    Staff Competencies and Availability 

The staff’s technical aptitude should be a factor in selecting safety technologies for a facility, but not a driving one. Ease of use should be considered regardless of the staff’s skill level. No technology should compete for the time staff should be dedicating to residents. Ongoing training should always be a part of the overall plan to support any technology, but especially one that impacts life safety and security.

6.2.2.8    Cybersecurity

According to a legal expert in the field of cybersecurity threats for long-term and post-acute care, Nelson Mullens, “Many LT/PAC providers face unique resource challenges due in part to budget constraints, such as inadequate information technology (IT) infrastructures, staffing constraints, and various barriers across multiple facilities. Experts have found that these providers ‘are implementing or updating their IT systems in a gradual but haphazard manner,’ according to a 2014 issue of the Journal of Health Organization and Management. This leaves the LT/PAC community particularly vulnerable to cybersecurity threats.” ²² Vendor failure to protect data is a major concern. How protected health information (PHI) and other proprietary data is protected should be considered in the technology selection process.

6.2.2.9    Policies and Procedures

Selecting and implementing various types of safety technologies will affect existing policies and procedures. With the goal of the technology to help create a safer environment for staff and residents, introducing technology will affect the activities to support resident care.  

For example, the organization can measure caregiver response times to residents who need help. Accessing caregivers’ and residents’ locations can give a better picture of where they are spending time and if either are in harm’s way, as can monitoring other contributing environmental factors. Policies and procedures will have to evolve to support whatever type of technology the organization selects, and consultants and vendors who specialize in helping long-term care facilities with business process reengineering can address these challenges and opportunities. 

6.2.2.10    Partner Assessment

Selecting a technology partner dedicated to innovation is the first step. There are a lot of technology “vendors.” Choose a partner instead. Good partnership requires deep resources to create a positive experience for all aspects of an organization. Selecting a partner who is dedicated to innovation and a convergence strategy, who can assist in evaluating workflow and processes, and can deliver both mobility and resident engagement technologies, is important to the overall success.

According to a provider in the technology field addressing the future of senior living, “While investing in new and advanced forms of technology for senior living facilities can be expensive and time consuming, it is critical to staying relevant in the industry and meeting the growing demand of residents. As communities look at new projects or go through re-financing on existing communities, it is important to engage technology experts and include forward-thinking solutions in the budget planning process.”²³ 

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While investing in new and advanced forms of technology for senior living facilities can be expensive and time consuming, it is critical to staying relevant in the industry. 

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6.2.2.10.1  Available Technology Solutions

It is important to learn about the types of safety technologies available, how they function, their uses and benefits, their high-level network requirements, and the connectivity they require.  

With the ideal safety systems in mind, consider the type(s) of safety technology solutions needed. Things to consider include the following:  

• Does the technology need allow for silent alarms? 
• Can it support mass notification, targeted notification? 
• Does it need to support acknowledgement, acceptance, and response tracking? 
• Does the technology integrate, interface, or interoperate with existing technologies?
• Does the solution need to support communications with parties outside the organization? If so, who and how?

6.2.2.10.2    Available Data 

Based on the initial assessment, and the ideal safety and security process, consider the data that would be needed to create and periodically update safety plans. Then the data can be organized into these categories: 

• Data readily available to the organization (patient/resident profiles, risk assessments data, location), etc.
• Additional data essential to have in the safety plans.
• The source of that data.  

A primary data source would be the patient’s electronic health records. These records will provide much of the needed information for compiling the essential data. Other sources may include visitor databases and HR records, as well as access requirements and authorizations.    

Understanding what information is necessary will be essential to successful safety technology planning, selection, and implementation.   

6.2.2.10.3    Additional Data Needed and Sources

It is also important to focus on the types, and sources, of data that are currently not readily available to the provider but that would be essential or extremely beneficial for successful safety planning. Family members and other providers, including people that patients/residents identify as part of their care team or social support network, will be able to provide additional data or information. These people will be a primary source for information and patient care on a day-to-day basis. Consider the format, modality, and frequency of getting this data in a way that does not add to the burdens of the extended care team.

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It is also important to focus on the types, and sources, of data that is now not readily available to the provider but that would be extremely beneficial for successful safety planning.

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6.2.2.10.4    Interoperability/Interfacing Capability

The first step is to identify all needed information and data, their format, and their sources. The next step is to consider all the interfacing, integration, interoperability, and information exchange needs. In this step, consider vendors that have implemented interoperability standards, have application program interfaces (APIs) to other systems, have successfully integrated with other systems, and/or have demonstrated exchanging the types of information needed for the organization’s program. Please keep in mind that sometimes one system may not meet all requirements, and working with integration engines may be necessary.

6.2.2.11    Considerations for Resident/Client

It is also important to consider resident/client needs and preferences when selecting a safety technology. This includes any special needs, like hearing or cognitive impairments, as well as preferences that increase likelihood of acceptance and adherence with use.

6.2.2.11.1    Assessment of Issues/Needs, Including Special Needs

Assessing issues and special needs is usually the first part of the care planning process and in selecting a specific safety technology solution that the resident/client will use. Furthermore, if the resident/client has a special need, like hearing or visual impairment, those needs must be considered when selecting the appropriate safety technology solution and alerting modality.  

6.2.2.11.2    Assessment of Competencies/Abilities

Staff will need to assess resident/client competencies in using the safety technology, understanding how it works, and what the resident/client needs to do. Staff must also develop and maintain effective safety procedures, including a response tree with designated responsible first responders. This step is especially important when caring for patients with cognitive issues or other limitations.  

6.2.2.11.3    Assessment of Personal Preferences

Personal preferences may be important factors in whether the resident/client uses the technology, especially critical safety technologies, like wearable PERS or technologies installed in their living environment. For example, a PERS cannot help a resident/client who is not wearing the pendant because it is perceived to be stigmatizing. However, that resident/client may be happy to wear a wristwatch PERS. 

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Providers will need to evaluate payment streams and residents’ ability to pay and choose affordable solutions that meet the essential requirements.

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6.2.2.11.4    Ability to Pay  

For most Americans, the ability to pay for healthcare is becoming more difficult every day. Cost of care and payment resources have become a critical policy issue. Government and private insurers have examined alternative models of payment that may or may not participate in a care planning and coordination program. Providers will need to evaluate payment streams and residents’ ability to pay and choose affordable solutions that meet the essential requirements.

6.2.2.11.5    Provider Services and Responsibilities

6.2.2.12    Care Providers

Care providers will need to review with the patient and family the common challenges and pitfalls that can hinder the proper development and implementation of safety technologies. In addition, providers will need to identify the appropriate person or persons to maintain the safety plan and communicate the patient’s needs if those needs are not being met.

6.2.2.13    Operating Environment 

The operating environment includes the care setting, the state in which the community is located, and the applicable federal and state regulations. 

6.2.2.14    Operational and Programming Planning 

6.2.2.14.1    Project Team 

Operations team members will play a key role in implementation success, as they are the most connected to the people they serve. Ensure that operational leadership has buy-in early, and work alongside of them to identify the best individuals in the field to become evangelists. The key to engaging field operations in the initiative’s goals—such as nurses, therapists, certified nursing assistants, activity directors, and administrative staff—is that they are not sales people; they are the connection evangelists.

6.2.2.14.2    Goal Setting

Defining the safety technology goals is critical to measuring success. Each organization will have different ideas of what success looks like based on strategic goals and internal operations. Before starting a safety technology program, the organization should set a clear series of goals and metrics. 

Keep in mind that goals should be measurable and routinely reported on within the organization’s operations. Ensure that they are SMART goals: 

• Specific.
• Measurable.  
• Attainable. 
• Realistic.
• Trackable.   

Setting both short-term and long-term goals for the safety technology program is highly recommended. The program will naturally change and progress over time. Organizational goals set at the program’s start will likely be different six to 12 months post implementation. The goals should be evaluated continuously and updated as programs change. It is also important to understand that a new program will have the ability to achieve several major goals during its initial adoption.

6.2.2.14.3    Program Design

Safety technology programs should be designed with the organization’s short- and long-term goals in mind to help ensure success. Each program’s design should always consider how to align objectives, strategies, and technical plans by using safety technology. Be sure to share experiences from other similar organizations to assist in strategies to build a safety technology program within the organization or strengthen an existing one. 

Before starting any program, clearly define the new model of care and prepare staff with training and support plans.

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Before starting any program, clearly define the new model of care and prepare staff with training and support plans.

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6.2.2.14.4    Technology Review and Selection

Once an organization has completed the visioning and strategic planning exercise, assessed organizational readiness, assembled the project team, set the project’s goals, and designed the program, then the team needs to develop a set of detailed technology requirements. These criteria will be used to review and select the appropriate safety technology solution.  

Setting and Focus
The planning process would help identify key requirements that should include the following: 

• The care setting(s) where the organization wants to deploy the safety technology solution; this should be the primary setting for the targeted population (home health, skilled nursing facility, housing with services, etc.). 
• The target population and the types of safety issues the organization wants to manage and coordinate.

The criteria should inform the types of care planning and coordination systems that may help the organization achieve its goals. 

Safety Modality
The planning team should also consider the system modality types, which include one or more of the following: 

• Emergency Notification/Communication Response System
• Fall Detection and Prevention
• Location Tracking
• Access Control
• Elopement Prevention
• Surveillance and Monitoring (Security and Environmental)

System Embodiment
The planning team should consider the desired system embodiment, which may include the following:

•  Pendant    
• Wristwatch/Smartwatch    
•  Badge    
• RFID Tagged Clothing    
• Ankle Bracelet    
• Other (please list wearable)    
• Smartphone/Tablet    
• Key Card/Fob        
• Pull Cord (Wired, Wireless, Both, No)    
• TV/ Set Top Box    
• Fixed Touch Screen     
• Sensors Embedded in the Environment (such as RFID readers, cameras, motion sensors)
• Door Locks    
• Voice Activated Assistant Technology (such as Amazon’s Echo)    

In addition, the team should weigh whether the system embodiment should be for a single user or geared to multiple users.

Front-End User Interface – Types of Prompts/Controls/Accessibility Features Support
When selecting a safety technology for older adults, consider the characteristics and special needs that the system’s front-end user interface should support. These needs may include the following prompts/controls: 

• Push Button
• Touch Screen    
• Voice Control
• Visual Prompts    
• Gesture-Activated Control
• Motion-Activated Control    

Also, the target population may require one or more accessibility features to provide support for the following:

• Hearing
• Vision
• Dexterity

Program Development and Vendor Support
The available resources, capabilities, and expertise in program design and operationalization would inform the type and level of development and support needed from the prospective vendor. These may include the following:  

• Program Development (Planning, Design, Business Model Templates, Workflows, Change Management, etc.)
• Response Protocol Development    
• Staff Training    
• Caregiver Training    
•  User Education     User Training    
•  User Engagement (such as Strategies for Sustained Usage)
• Family Engagement

Program Support Services
The support services that vendors may offer include the following: 

• Equipment Delivery/Pick Up 
• Site/Home Installation 
• IT/Network Troubleshooting and Support 
• Front-End System Set-up/Customization 
• Back-End System Set-up/Customization 
• On-site/Online Staff Training 
• On-site/Online User/Patient Training 
• Equipment Cleaning/Refurbishing

Another important feature is generating immediate urgent alerts and sharing them with interested parties, including the following:  

• Client/Resident/Patient’s Physician 
• Client/Resident/Patient’s Nurse/Other Licensed Clinician
• Care Manager/Professional Caregiver
• Client/Resident/Patient/User/Self
• Family  

Legal and Regulatory Requirements
Of course legal and regulatory requirements are important. Please consider the following requirements:

• UL 2560 (Emergency Call Systems for Assisted Living and Independent Living Facilities)
•  UL 1069 (Hospital Signaling and Nurse Call Equipment)
• TMA (CSAA) Five Diamond Certified Monitoring Center
• HIPAA (if applicable)
•  HITECH (if applicable)

Hardware and Software Requirements
Finally, hardware/software requirements that could guide the selection process include how software is offered: 

• Local Model, which means that it needs to be installed on servers local to the care provider.
• Third-Party Hosted Model/Software as a Service Model (SaaS), where the software is hosted somewhere else and the provider pays licensing and hosting fees or pays for usage, as opposed to maintaining local servers’ infrastructure.   

Other important hardware and software requirements include remote access functionality support, offline functionality support when running third-party hosted or SaaS software, and mobile device support, such as for smartphones and tablets.

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Use the CAST Safety Technology Online Selection Tool to narrow the selection to a few shortlisted candidate systems and vendors that meet the must-have high-level requirements. 

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Use the CAST Safety Technology Online Selection Tool to narrow down the selection to a few shortlisted candidate systems and vendors that meet the must-have high-level requirements.  

In the CAST Safety Selection Matrix, CAST outlines many additional options and detailed features and functionalities. These details will help drill down into these shortlisted products and narrow the selection to a list of two or three vendors who can be invited to submit a response to a request for proposals (RFP).  

During the RFP process, providers are encouraged to interview prospective vendors and engage many staff in the interviews and product evaluation: front staff, nursing and medical directors, care managers/ coordinators, and representatives from management, finance, and IT teams. Please check provider case studies with the vendors, including those collected by CAST, and conduct appropriate due diligence including reference checking. In addition, providers may want to use the LeadingAge CAST/Technology Listserv to ask peers about the shortlisted products and their experience with these vendors.  

6.2.2.14.5    Implementation 

The implementation and planning phase takes the information gained by the assessment phase and begins to answer the “who,” “how,” and “when” questions. During this phase, executive steering committee members are identified and a project charter is created. Enough time should be set aside for this phase, as it is involved and detailed.  

Contingency planning is part of the overall plan; the team must assess and identify potential risks throughout the project and deal with them quickly. Most often, risk is not going to severely impact the project. However, when a risk that could impact the project’s timeline, budget, or goals appears, the steering committee should be made aware to make decisions.

6.2.2.14.6    Post-Implementation Monitoring, Adoption, and Support

It is important to provide continuous monitoring of any program. Monitoring validates the program, tracks improvement, and identifies any new problems that may occur. Measuring the program’s quality will provide an opportunity to establish its positive impact on the organization, consumers, and any partners. If post-monitoring does not show significant differences in care planning and coordination for those individuals served, the organization will need to rethink the program.   

7    Safety Technology Matrix Components 

Summary: CAST’s Safety Technology Workgroup, consisting of providers, vendors, and consultants, compiled a list of safety technology products that serve the LTPAC market, as well as a list of functionalities and capabilities that would help providers choose the product that best fits their business line and functional requirements. 

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The Safety Technology Matrix has 18 sections to help organizations narrow the possible Safety Technology products.

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The Safety Technology Matrix has 18 sections to help organizations narrow the possible products:
1.    Business Line/Care Applicability
2.    Safety Modality
3.    Embodiment
4.    Program Development and Support Offered
5.    Front-End Hardware Unit Patient/Client/Resident/User Interface and Communications
6.    Hardware and Software Requirements – Front End
7.    Front-End Unit Support
8.    Back-End Support/Response Call Center Support
9.    Reports Access
10.    Communications and Alerts
11.    Interfacing, Integration, and Add-Ons
12.    Program Support Services
13.    Interoperability, Interoperability Standards, and Certification
14.    Technical Supportability
15.    Legal/Regulatory/Cyberliability 
16.    Hardware and Software Requirements – Back End
17.    Company’s Experience and Viability 
18.    Strengths

CAST’s Safety Technology Workgroup, consisting of providers, vendors, and consultants, compiled a list of social connectedness and engagement products that serve the LTPAC market, as well as a list of functionalities and capabilities that would help providers choose the product that best fits their business line and functional requirements. 

Each of the safety technology vendors then received the opportunity to complete a self-review of the workgroup’s pre-determined questions. Some of these vendors chose not to participate. Those who participated then could nominate a case study from a provider’s perspective on the use of the vendor’s social connectedness and engagement product. 

The Safety Technology Matrix includes the following sections:

Business Line/Care Applicability
Business line/care applicability illustrates the various business lines to which the safety technology product is applicable, including the following:

• Acute Care Settings (Physicians’ Offices, Emergency Department, Hospitals, Attending LTPAC Physician).
• LTPAC and Other Settings (Home Health/Home Care, Hospice, Housing with Services, Community-Based Programs, Adult Day Care/Senior Centers, Assisted Living Facilities, Acute Rehab Facilities, Long-Term Acute Care Hospitals, Long-Term Care Rehab Facilities, Skilled Nursing Facilities, Intermediate Care Facilities, Intellectual Disabilities/Mental Retardation/Developmental Disabilities (ID/MR/DD) Facilities, Life Plan Community (Formerly CCRC), Program of All-Inclusive Care for the Elderly (PACE), Accountable Care Organizations (ACO)/Integrated Delivery Networks (IDN), Multiple Site Integration).

Safety Modality
Safety Technology Modality illustrates the different product types, including the following:

• Emergency Notification/Communication/Response System
  • Nurse Call System     
  • Emergency Call System    
  • Personal Emergency Response System (PERS)
  • Two-Way Staff Communications System
  • Mass Communication
    • Mass Text Message
    • Mass Voice Message    
    • Mass E-Mail Message
  • Other
• Fall Detection and Prevention
  • Auto Fall Detection (If Yes, Explain How, such as Motion Sensors, Accelerometer)     
  • Fall Prevention (If Yes, Explain How, such as Gait Monitoring, Balance Sensor, Lighting, etc.)
  • Other 
• Location Tracking
  • Indoor and/or Outdoor Location Tracking (Indoor, Outdoor, Both, No)
  • Continuous and/or Point-in-Time Tracking (Continuous, Point-In-Time, Both, No)
  • GPS Tracking     
  • Bluetooth Tracking
  • Beacon Tracking (Yes; Radio Frequency (RF), Yes; Bluetooth Low Energy (BLE), Both, No)
  • RFID Tracking
  • Cell Tower Triangulation
  • Wi-Fi-based Positioning System (WPS)
  • Ultra-wideband Tracking
  • Infrared Tracking
  • Ultrasound Tracking
  • Motion Sensing
  • Other
• Access Control
  • Visitor Sign-In
  • Intercom    
  • Offline Locks
  • Online Locks    
  • Wire Free Virtual Network Locks (Yes; Online; Yes; Offline, Both, No)
  • Other
• Elopement Prevention
  • Perimeter-Based Monitoring 
  • Virtual Mapping/ Geo-fencing Monitoring
• Surveillance and Monitoring (Security and Environmental)
  • CCTV System (Yes; Analog, Yes; IP, Both, No)    
  • IP Camera    
  • Motion Sensing
  • Doorbell Camera    
  • Environmental Detection (such as Fire, Smoke, Water, Carbon Monoxide, Gas Leak, Flooding, and Similar)
  • Other

Lastly, we also asked vendors if their system is for a single user or multiple users.

Embodiment
This category includes the following options:

• Pendant    
• Wristwatch/Smartwatch    
• Badge    
• RFID Tagged Clothing    
• Ankle Bracelet    
• Other (Please List Wearable)    
• Smartphone/Tablet    
• Key Card/Fob        
• Pull Cord (Wired, Wireless, Both, No)    
• TV/ Set Top Box    
• Fixed Touch Screen     
• Sensors Embedded in the Environment (such as RFID Readers, Cameras, Motion Sensors)
• Door Locks    
• Voice-Activated Assistant Technology (such as Amazon’s Echo)    
• Other (Please List)    

Program Development and Support Offered
This category includes options for the following:

• Program Development (Planning, Design, Business Model Templates, Workflows, Change Management, etc.)
• Response Protocol Development    
• Staff Training    
• Caregiver Training    
• User Education     User Training    
•  User Engagement (such as Strategies for Sustained Usage)
• Family Engagement
• Other (Please List)

Front-End Hardware Unit Patient/Client/Resident/User Interface and Communications
This category includes the following options:    

• Types of Prompts
  • Front-End Interface
  • Login Modality, Please List if Applicable (such as Scan Card, PIN)    
  • Push Button
  • Touch Screen    
  • Voice Control
  •  Visual Prompts    
  • Gesture-Activated Control    
  • Motion-Activated Control    
  • Other (Please List)
• Accessibility Features/Support
  • Hearing     
  • Vision    
  • Dexterity
• Communications Modality
  • Plain Old Telephone System (POTS) Line
  • Wired High-Speed Internet Connectivity    
  • Wi-Fi Connectivity    
  • Cellular Connectivity
  • Other (Please List)    
  • Minimum Internet Connectivity Speed Required

Hardware and Software Requirements – Front End
These requirements list the required desktop/laptop specifications for software-only solutions, including requirements for the following: 

• Minimum Processor Speed, Hard Drive Storage, RAM Requirements if Applicable 
• Operating System (OS) – Windows 
• Operating System (OS) – Apple 
• Operating System (OS) – Chrome
• Operating System (OS) – Unix/Linux 

Other features compared include the following:  

Network Specifications Wireless Specifications  Modern Browser Support  Minimum Internet/Bandwidth Specifications  Miscellaneous Software/Applets Needed (such as Citrix)  Miscellaneous Reporting Specifications (such as Crystal Reports)  Support Ability to Store/Handle Attachments (Insurance Card, Historical Notes, etc.) Available for Lease

Available for Purchase Scalability  Local Model  Hosted Model  Software as a Service Model (SaaS)  Remote Access  Offline Functionality

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Lastly, mobile options are listed as the following: 

• Cellular Carriers that Support Solution 
• Mobile OS – Android 
• Mobile OS – Blackberry 
• Mobile OS – iOS 
• Mobile OS – Unix/Linux 
• Mobile OS – Mobile OS – Windows (Win 10 Mobile, Windows Universe, Both, No) or
• Mobile-Optimized Interface (through Dedicated App or Mobile-optimized Webpages) 

Finally, CAST added a tab for additional notes on hardware and software requirements.

Front-End Unit Support
This category includes the following options:

• Educational Materials (On-Screen Educational Material,     Educational Audios    , Educational Videos)
• Front-End Unit Multi-Language Support (English, Spanish, Mandarin, Cantonese, Korean, Russian, French, German, Hindi, Urdu, Portuguese, Arabic, Hebrew, Other (Please Specify))
• Remote Updates
• Remote Configuration Capability

Back-end Support/Response Call Center Support
This category includes the following options:

• Customizable Branded Responses    
• Multiple Language Support
• System Testing
• Training/Education Materials/Learning Management Systems for Staff
• Emergency Medical Dispatch (EMD) Certified

Report Access
This element includes whether reports can be the following:    

• Customizable Alert    
• Customizable Reports    
• Ability to Schedule Automatic Reports 

Report Access Provided to the Following External Parties (Call Center, Security Officer/Safety Officer, User’s Nurse/Other Licensed Clinician, Care Coordinator, Other Professional Caregiver, User, Family, Other (Please Specify))

Communication and Alerts
This category includes the following options:

• Real-Time Voice Communication
• Real-Time Alerts
• Alerts Can Be Sent to the Following External Parties (Emergency Services, Call Center, User’s Nurse/Other Licensed Clinician, Care Coordinator, Other Professional Caregiver, Security Officer/Security Officer, Family, Other (Please Specify))
• Alerts Sending Modality (Audible Alarm , Light Notifications, Pager, Two-Way Digital Voice Communications System (such as Vocera), 2-Way Radio Telephone (Voice Messages), E-Mail, Text Message, Mobile App (Yes, iOS; Yes, Android; Yes, Both; No), Other (Please Specify))

Interfacing, Integration, and Add-Ons
This category includes options for the following:

• Fire Alarm Control Panel
• Facility Communications System    
•  Electronic Health Record (EHR)    
• Personal Health Record (PHR) or Patient Portal    
• Telehealth
• Medication Adherence Monitoring Dispensers
• Other Safety Monitoring Systems (such as Nurse Call Station)
• Functional Assessment and Activity Monitoring    
• Smart Home Technologies (such as Smart Thermostats, Smart Lights)
• Customer Relationship Management (CRM)    
• Printing Supported
• Dashboard Views    
• Analytic Tools; Please List (such as Utilization of PERS)
• Explain Integration Modality, Please List (such as Single Sign-On (SSO), Lightweight Directory Access Protocol (LDAP))
• Other (Please List)

Program Support Services
This section includes options for the following:

• Equipment Delivery/Pick Up    
• Site/Home Installation
• IT/Network Troubleshooting and Support
• Front-End System Set-up    
• Front-End System Customization 
• Back-End System Set-up
• Back-End System Customization
• On-site Staff Training
• Online Staff Training    
• On-site User Training
• Online User Training    
•  Equipment Cleaning
• Equipment Refurbishing
• Other (Please List)

Interoperability, Interoperability Standards, and Certification
This section begins with type of interoperability and exchange capabilities supported, which include the following:

• None, Export Data Only, Import Data Only, or Bi-Directional Data Import and Export

This section also includes options for the following:

• Supported Interoperability Standards (HL7 Personal Health Monitoring Report, Other)
• Back-End EHR/PHR Certification (2014 and 2015 ONC-ATCB Certification (Complete (Please Provide Link); Modular (Please Provide Link); No)    
• Front-End Certification
• API and API Notes
•  Integration through Middleware

Technical Supportability
This category includes options for the following:

• Phone Support—No, Yes (Limited Hours), Yes (24 Hours)    
• Web Support—No, Yes (Limited Hours), Yes (24 Hours)    
• E-Mail Support    
• Listserv and/or Usergroup    
• Online Training    
• On-site Training    
• Knowledge Base
• Other 
• Warranty Information (Length of Product Warranty, Parts, Parts and Labor, Parts, and In-Field/On-Site Labor)    

Legal/Regulatory/Cyberliability
This area touches on the following:                                

• UL 2560 (Emergency Call Systems for Assisted Living and Independent Living Facilities)
• UL 1069 (Hospital Signaling and Nurse Call Equipment)
• TMA (CSAA) Five Diamond Certified Monitoring Center
• Safety of Electrical Medical Equipment IEC 60601 Certification
• FDA Clearance/ Listing – Cleared, Listed (This Category May Include Medical Device Data System (MDDS)), Pending, or None
• FDA Classification (Class I, Class II, etc.)
• HITECH    
• HIPAA    
• Security – List HIPAA & HITECH Act Requirements Met    
• List Applicable Regulatory Requirements Met    
• Provide a Link to Company’s Cyberliability Policy    
•  List Any Other Legal Requirements    
• Provide Link to Sample Contract

Hardware and Software Requirements – Back End
These requirements list the required desktop/laptop specifications for Software-Only Solutions, including requirements for the following: 

• Minimum Processor Speed, Hard Drive Storage, RAM requirements if applicable 
• Operating System (OS) – Windows 
• Operating System (OS) – Apple
• Operating System (OS) – Chrome 
• Operating System (OS) – Unix/Linux 

Other features compared include the following:  

Network Specifications Wireless Specifications  Modern Browser Support  Minimum Internet/Bandwidth Specifications  Miscellaneous Software/Applets Needed (such as Citrix)  Miscellaneous Reporting Specifications (such as Crystal Reports)  Scalability

Local Model  Hosted Model  Software as a Service Model (SaaS)  Remote Access  Offline Functionality Support Ability to Store/Handle Attachments (Insurance Card, Historical Notes, etc.) Available for Lease Available for Purchase

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Lastly, mobile options are listed as the following: 

• Cellular Carriers that Support Solution 
• Mobile OS – Android 
• Mobile OS – Blackberry 
•  Mobile OS – iOS 
• Mobile OS – Unix/Linux 
• Mobile OS – Mobile OS – Windows (Win 10 Mobile, Windows Universe, Both, No) and/or 
• Mobile-Optimized Interface (Through Dedicated App or Mobile-optimized Webpages) 

Finally, we added a tab for Additional Notes on hardware and software requirements.

Company’s Experience and Viability
This area includes the following: 

• Number of Years in Business 
• Release Date of Current Version 
• Number of Patients Served 
• Core Customer Base/Focus of Line of Business 
• Links to Additional Case Studies 

Assessments
The last section of the matrix is dedicated to the following: 

• Strengths 
• Areas for Improvement 
• Ongoing Development 
• References

8 Acknowledgement of Contributors

8.1 Contributing Writers

Alissa J. McGuire, Pilgrim Place
Amy Jeffs, Status Solutions
Anthony Geiger, Silversphere
Damon Lamb, Silversphere
David Bingham, Vocera
Majd Alwan, LeadingAge CAST
Scott Code, LeadingAge CAST

8.2 Workgroup Members

Alissa J. McGuire, Pilgrim Place
Amy Jeffs, Status Solutions
Anthony Geiger, Silversphere
Craig Smith, Vocera
Damon Lamb, Silversphere
Danielle Myers, Status Solutions
David Baker, Asbury Communities
David Bingham, Vocera
Frances A. Ayalasomayajula, HP
James Jansen, Direct Supply
Jerel J. Johnson, Cornell Communications
Jessica Pearson, Cornell Communications
Majd Alwan, LeadingAge CAST
Malcolm Graham, Silversphere
Rick Taylor, Silversphere
Scott Code, LeadingAge CAST

8.3 Participating Safety Technology Vendors

Accushield
ASSA ABLOY
Carepredict
Cornell Communications
Digital Care Systems
HelpWatch
HP
MyNotifi
Notify by Eldermark
One Call Now
Response Care, Inc.
Rauland
RF Technologies
Secure Care Products
Silversphere
Stanley HealthCare 
Status Solutions
Symtech Solutions
Systems Technologies
TekTone
Theora Care
Torrence Sound Equipment Company
UnaliWear
upByte
Vigil Health Solutions
Vocera

9 References and Resources

1. https://www.cna.com/web/wcm/connect/a669c765-f601-4823-b0bc-a53a021a9210/Aging-Services-2016-Claim-Report.pdf?MOD=AJPERES&utm_campaign=AS2016ClaimStudy&utm_source=Media&utm_medium=pressrelease&utm_content=2016November01
2. https://www.cdc.gov/media/releases/2016/p0922-older-adult-falls.html
3. https://www.cdc.gov/steadi/stories/hospital.html
4. https://aspe.hhs.gov/basic-report/report-congress-aging-services-technology-study#fall 
5. https://www.cna.com/web/wcm/connect/a669c765-f601-4823-b0bc-a53a021a9210/Aging-Services-2016-Claim-Report.pdf?MOD=AJPERES&utm_campaign=AS2016ClaimStudy&utm_source=Media&utm_medium=pressrelease&utm_content=2016November01
6. http://leadingage.org/cybersecurity-resources  
7. Kelly, K.E., Phillips, C.L., Cain, K.C., Polissar, N.L., Kelly, P.B. (2002). Evaluation of a nonintrusive monitor to reduce falls in nursing home patients. Journal of the American Medical Directors Association, 3(6), 377-382.
8. Bressler, K., Redfern, R.E., Brown, M. (2011). Elimination of position-change alarms in an Alzheimer’s and dementia long-term care facility. American Journal of Alzheimer’s Disease and Other Dementias, 26(8), 599-605.
9. Cheek, P., Nikpour, L., Nowlin, H.D. (2005). Aging well with smart technology. Nursing Administration Quarterly, 29(4), 329-338.
10. https://www.onsolve.com/blog/mass-notification-system-comparison-vendors-stack/
11. http://rftkentico.cloudapp.net/getattachment/21a696ae-6f6d-4677-a716-64c15ba895da/White-Paper-Understanding-and-Navigating-Industry 
12. Gurley, R.J., Lum, N., Sande, M., Lo, B., Katz, M.H. (1996). Persons found in their homes helpless or dead. New England Journal of Medicine, 334(26), 1710-1716.
13. Otto, C.A., Chen, X. (2009). Automated fall detection: Saving senior lives one fall at a time. Caring, 28(3), 44-46.
14. Medicaid Waivers Information, Medicaid. Available online at: https://www.medicaid.gov/medicaid/section-1115-demo/index.html. 
15. http://www.leadingage.org/sites/default/files/CAST_State_Paymen_%20Analysis.pdf
16. CMMI Innovations Models and Initiatives, CMMI, CMS. Available online at: https://innovation.cms.gov/initiatives/index.html. 
17. Medicare Hospital Readmission Reduction Program, CMS. Available online at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html.
18. CMS ACO Initiatives, CMMI, CMS. Available online at: https://innovation.cms.gov/initiatives/ACO/.
19. Retrospective Acute Hospital Stay plus Post-Acute Services Payment Bundling Demonstration, CMMI, CMS. Available online at: https://innovation.cms.gov/initiatives/BPCI-Model-2/. 
20. Retrospective Post-Acute Care Only Payment Bundling Demonstration, CMMI, CMS. Available online at: https://innovation.cms.gov/initiatives/BPCI-Model-3/.
21. https://www.thescanfoundation.org/business-case-person-centered-care
22. https://www.lexology.com/library/detail.aspx?g=402db636-465f-4d99-8a24-3ec173c3411f
23. https://its-networks.com/technology-and-the-future-of-senior-living/