The Community Assessment of Risk and Treatment Strategies (CARTS): An Integrated Care Pathway to Manage Frailty and Functional Decline in Community Dwelling Older Adults

Developing Game-Based Design for eHealth in Practice: 4-Phase Game Design Process

BACKGROUND

Games are increasingly used in eHealth as a strategy for user engagement. There is an enormous diversity of end users and objectives targeted by eHealth. Hence, identifying game content that drives and sustains engagement is challenging. More openness in the game design process and motivational strategies could aid researchers and designers of future game-based apps.

OBJECTIVE

This study aims to provide insights into our approach to develop game-based eHealth in practice with a case study (Personalised ICT Supported Services for Independent Living and Active Ageing [PERSSILAA]). PERSSILAA is a self-management platform that aims to counter frailty by offering training modules to older adults in the domains of healthy nutrition and physical and cognitive training to maintain a healthy lifestyle. We elaborate on the entire game design process and show the motivational strategies applied.

METHODS

We introduce four game design phases in the process toward game-based eHealth: (1) end-user research, (2) conceptualization, (3) creative design, and (4) refinement (ie, prototyping and evaluations).

RESULTS

First, 168 participants participated in end-user research, resulting in an overview of their preferences for game content and a set of game design recommendations. We found that conventional games popular among older adults do not necessarily translate well into engaging concepts for eHealth. Recommendations include focusing game concepts on thinking, problem-solving, variation, discovery, and achievement and using high-quality aesthetics. Second, stakeholder sessions with development partners resulted in strategies for long-term engagement using indicators of user performance on the platform's training modules. These performance indicators, for example, completed training sessions or exercises, form the basis for game progression. Third, results from prior phases were used in creative design to create the game "Stranded!" The user plays a person who is shipwrecked who must gather parts for a life raft by completing in-game objectives. Finally, iterative prototyping resulted in the final prototype of the game-based app. A total of 35 older adults participated using simulated training modules. End users scored appreciation (74/100), ease of use (73/100), expected effectivity and motivation (62/100), fun and pleasantness of using the app (75/100), and intended future use (66/100), which implies that the app is ready for use by a larger population.

CONCLUSIONS

The study resulted in a game-based app for which the entire game design process within eHealth was transparently documented and where engagement strategies were based on extensive user research. Our user evaluations indicate that the strategies for long-term engagement led to game content that was perceived as engaging by older adults. As a next step, research is needed on the user experience and actual engagement with the game to support the self-management of older adults, followed by clinical studies on its added value.

Predicting Outcomes in Frail Older Community-Dwellers in Western Australia: Results from the Community Assessment of Risk Screening and Treatment Strategies (CARTS) Programme

Understanding risk factors for frailty, functional decline and incidence of adverse healthcare outcomes amongst community-dwelling older adults is important to plan population-level health and social care services. We examined variables associated with one-year risk of institutionalisation, hospitalisation and death among patients assessed in their own home by a community-based Aged Care Assessment Team (ACAT) in Western Australia. Frailty and risk were measured using the Clinical Frailty Scale (CFS) and Risk Instrument for Screening in the Community (RISC), respectively. Predictive accuracy was measured from the area under the curve (AUC). Data from 417 patients, median 82 ± 10 years, were included. At 12-month follow-up, 22.5% (n = 94) were institutionalised, 44.6% (n = 186) were hospitalised at least once and 9.8% (n = 41) had died. Frailty was common, median CFS score 6/9 ± 1, and significantly associated with institutionalisation (p = 0.001), hospitalisation (p = 0.007) and death (p < 0.001). Impaired activities of daily living (ADL) measured on the RISC had moderate correlation with admission to long-term care (r = 0.51) and significantly predicted institutionalisation (p < 0.001) and death (p = 0.01). The RISC had the highest accuracy for institutionalisation (AUC 0.76). The CFS and RISC had fair to good accuracy for mortality (AUC of 0.69 and 0.74, respectively), but neither accurately predicted hospitalisation. Home assessment of community-dwelling older patients by an ACAT in Western Australia revealed high levels of frailty, ADL impairment and incident adverse outcomes, suggesting that anticipatory care planning is imperative for these patients.