Let me tell you a story about elder care.

At the beginning of 2011, my grandparents appeared to be as healthy and energetic as when they got married 58 years earlier. Then my grandfather had a stroke. He was effectively paralyzed and other aspects of his health began to decline. My mother put aside her own affairs to step in and help full time, in addition to hiring caregivers.

On top of taking care of her paralyzed father, she discovered that her mother was developing dementia. Juggling the responsibilities of a second household, a mother with dementia, a declining father, and managing caregivers was a full time job. Her father died, which triggered her mother’s dementia to decline more rapidly. While her mother was physically capable, she couldn’t be left alone - which meant coordinating caregivers for every hour of the day. It’s an understatement to say the caregivers weren’t the most engaged or conscientious people in the world - half of my mother’s anxiety was over whether they would do their job or bail on a shift at the last minute. It was both expensive and shitty. This state of affairs lasted for more than two years. Stuck in grad school, my role in all of this was as support network - hearing the blow-by-blow and wondering “there must be a better way.”

And this story is not uncommon: ask anybody who has had to manage care for an older adult and they will have a similar story. Few people say “oh yeah, we had great caregivers and it was fine.”

Now let’s look at elder care systemically.

  • There are 12 Million Americans who need some form of care. That number is expected to become 23 Million by 2050.
  • At the same time the ratio of working-age adults who can provide care is expected to drop from 5:1 to below 3:1. That’s just in America. Every developed country in the world has the same demographic trends or worse.
  • Americans spend $36.5 billion/year on care alone - at least $2.4 billion/year of it is out of pocket.
  • On top of that, collectively 35 billion hours are spent/year by unpaid caregivers - these are daughters and sons, spouses, and other relatives and friends who sometimes quit their jobs to provide care.

These trends, informally known as the “Silver Tsunami”, exists in basically every wealthy country in the world.1 These data illustrate that elder care is a big deal.

As an outsider who has been delving deep into elder care, I’ve realized that it’s a complicated world. I want to simplify it and share what I’ve learned through the lens of three ideas. I’ve found each of these incredibly useful for thinking about elder care: 1) Story Thought and Systems Thought 2) Design Dyads 3) Wicked Problems.

Story Thought and Systems Thought

The story about my grandparents is an example of story thinking while the statistics about elder care are an example of systems thinking. I’m pulling the excellent definitions from this post from Mills Baker:

  • Story thought emphasizes subjective human experience, the primacy of individual actors, narrative and social ordering, messiness, edge cases, content, and above all meaning.
  • System thought emphasizes 3rd-person descriptions of phenomena from a neutral perspective, the interchangeability of actors and details, categorical or logical ordering, measurements, flow, form, and above all coherence.

Keeping both of these thought styles in mind is especially important in elder care. Systems thinkers and the story thinkers often talk right past each other. Elder care is a world where people tend to skew strongly one way or another and great solutions require both styles.

Dyads

A dyad in person-centered design is a construct that allows a designer to think of two individuals as a single persona or user.

My mother and my grandmother were a parent-child dyad, from the perspective of anybody trying to build something to help them. This dyad model is critical in elder care because both the parent and the child are using the same product. Dyads can be confused with other systems where there are multiple stakeholders - when there are separate people paying for and using the product, for example. In a dyad, both sides are actively using the product in some way.

Wicked Problems

In eldercare, the goals of the older adult and the loved one are not identical. The older adult (like most people) desires independence, while the loved one desires assurance that everything is ok. However, they usually share a common goal of wanting safety and health to be enjoyed by both parties.

This balance between independence and assurance creates a wicked problem. Wicked problems are design problems where there is a tradeoff that cannot be designed around: here it is between independence for one side of the dyad and assurance for the other. Assurance for the loved one requires information to be collected about the older adult, which reduces their independence by definition.

These three concepts help answer the question: “why do we see so few innovations take hold in elder care, even though it is such a big problem with so much lip service to innovation and so much money being thrown around?”

Of course, dyads, wicked problems, and different stories aren’t the only issues. The sheer number of other players in the system and their often contradictory or hidden incentives are another reason for the innovation gap. Insurance companies, doctors, elder care facilities, different parts of the government, care agencies, professional caregivers, social workers, and entrepreneurs create a tangled nest of incentives.

How can you use these tools – story vs systems thinking, dyads, and wicked problems – to look at innovations in care? Here are a set of questions that I always ask:

Does the Product Create a Solution?

Imagine dumping a cup of water on a raging forest fire: yes, you’re directly addressing the problem, but the action is not solving the problem. This analogy applies to many ideas in elder care which address a problem but do not solve it.

As an illustration, take the company building hip airbags for older adults. Falls causing broken hips are a well-known and large problem for older adults. On the surface hip airbags that sense a fall and inflate instantly to pad your hips when you fall seem like a great idea. Even with perfect execution though, they don’t solve the whole problem.

Why? Many falls occur either in the bathroom or when getting dressed. Guess what you won’t be wearing in either of those situations? These subtleties that make all the difference is where systems thinking often fails, unless it’s incredibly granular, and story thinking shines.

Is the solution at least acceptable to both sides of the dyad?

Many proposed solutions solve a problem on only one side of the family-older adult dyad. At the end of the day these will also not be used. Take most monitoring systems for example. If all they do is monitor the older adult without offering any additional benefits, they are catering entirely to the family, regardless of how unobtrusive they are. Nobody wants to live in a panopticon. However, most people are happy to give all their data to google because they get things in return: free email, maps, and search.

Does the Product Appeal to System and Story?

Solutions that don’t fit into both a system and a story will struggle. Either they will be rejected by the dyad or an organization like a nonprofit, hospital, insurance company, or care agency. The dyad’s day-to-day struggles are hard to capture in data which makes stories the only way to get buy in from them. On the flip side, organizations and their representatives are data driven. They demand systems explanation of how a solution will address their metrics and priorities.

Conclusion

Story and System Thinking, dyads, and Wicked Problems don’t pop up exclusively in elder care. The next time you run into a situation where there are many unsolved problems that seem fixable, try looking at it through those lenses.

Shameless Plug

At Fern, we’re working on products that we think can wiggle out of the wicked problem through a combination of design and technology. If you’re interested in learning more, please reach out to ben@carebyfern.com!

1 See the demographic report here for more information