Motivation to become responsible ... the best grant applications I have reviewed that focus on home care all include this issue. They have decided to use a form of 'technology assisted coaching' to help motivate patients to comply with certain elements of their care program. Technology augments, but never can replace, the human voice. The industry has already seen care delivery role shift from physicians to PAs. This shift will continue and expand to ‘personal care coaches’ as the first point of contact for chronically ill patients. Motivation to become responsible … will not be driven by patient financial incentives nor by a capitated payment structure, since ultimately the cost of non-compliant will not be born by the patient.

Since the roles of the employees of health care systems were defined a generation ago, the habits of physicians and nurses will be the biggest obstacle for mainstream adoption of new ‘remote care’ role models. I suspect the new role models will be filled by new, younger, less expensive, part-time employees while demographics work to reduce the size of the existing work force. I would be surprised if these phone-coaches were locally based.

I'd like to say that people will participate because they know its good for them. Some will. A group that is currently not engaged in healthy behaviors will 'convert' when they get access to rich educational content and their own physiologic information. We have seen evidence of this already. Another group will need incentives. The best current example of a program that offers incentives is Virgin Life Care's Healthmiles (www.virginlifecare.com). Still others will convert when something is done to make it harder for them to lead an unhealthy life -perhaps steeper premiums for their insurance coverage. All of these are better thann what we have now, but there will still be folks who insist on leading a self-destructive lifestyle for whatever reasons.

Would these phone coaches need a clinical background? It seems that hospitality and being organized are the desired characteristics that a modern health worker can exhibit. This feeds into a concierge model of care, with former travel agents and property managers taking on the role of care coordinator or personal coach.

Pharmaceutical companies have demonstrated some success in patient compliance for their clinical trials using technologies like
 - RFID enabled pill bottles
 - PDAs with daily capture of vitals
 - Automated phone reminders

If planned and incentivized effectively, ensuring patient compliance is not an impossible task. The bigger issues are around freedom of choice and striking an optimum balance of incentives/disincentives and motivation.