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Evaluation of a Hospital-in-Home Program Implemented Among Veterans
 ABSTRACT

Objectives: To examine the outcomes (ie, costs, hospitalizations, and mortality) associated with a Hospital-in-Home (HIH) program implemented in 2010 by the Veterans Affairs (VA) Pacific Islands Healthcare System in Honolulu, Hawaii.

Study Design: Retrospective cohort study.

Methods: We obtained medical information for veterans who were enrolled in the HIH program in Honolulu, Hawaii, between 2010 and 2013. For purposes of comparison, we also gathered VA data to identify a cohort of hospitalized veterans in Honolulu who were eligible for, but not enrolled in, the HIH program. Using VA administrative data, we extracted a set of individual-level variables at baseline to account for the differences between program enrollees and comparators. In total, 99 HIH program enrollees and 322 unenrolled veterans were included. We identified 3 sets of outcome variables: total costs of care related to the index event (ie, HIH services for enrollees and hospitalizations for comparators), hospitalizations, and mortality after discharge from the index event. We used a propensity score-matching approach to examine the difference in related outcomes between enrollees and comparators.

Results: The average medical cost was $5150 per person for veterans receiving HIH services, and $8339 per person for veterans receiving traditional inpatient services. The difference was statistically significant (P <.01). There was no statistically significant difference in mortality or hospitalization rates after the index event.

Conclusions: This study provides evidence of the potential benefits of a model that delivers acute care in patients’ homes. Considering the emergence of accountable healthcare organizations, interest in broader implementation of such programs may be worthy of investigation.

Am J Manag Care. 2017;23(8):482-487

Takeaway Points

We evaluated a Hospital-in-Home (HIH) program implemented in Honolulu, Hawaii. Using Veterans Affairs administrative data and a propensity score-matching approach, this study provided further confirmation of the potential benefits of this new care delivery model.

The costs of HIH services were 38% less than that of comparable inpatient hospitalizations.

There were no statistically significant differences in postdischarge hospitalization rates or mortality between HIH enrollees compared with veterans who were not enrolled in the program.

With the reform of Medicare payment models and the emergence of accountable care organizations, there may be more interest in implementing HIH programs.

The hospital is the traditional place to provide acute care. However, hospitalizations can be costly and may lead to further deterioration in health status among the elderly.1-4 The Hospital-in-Home (HIH) model offers an alternative approach to traditional hospital services.5-8 At the core of the HIH model is the goal of delivering hospital-level care to patients who have developed an acute episode that typically would require inpatient services, but who are medically stable enough to be treated at home.7-9 The common conditions that have been managed through HIH include congestive heart failure, chronic obstructive pulmonary disease, community-acquired pneumonia, and cellulitis.7,8,10-13 The HIH model has been associated with superior patient outcomes, such as reduced risks of delirium, improved functional status, improved satisfaction among patients and their family members, reduced mortality, reduced readmissions, and significantly lower costs.5,6,12,14-22 These studies vary in research design (eg, randomized trial or observational studies), study populations (eg, patients with different conditions in a variety of healthcare settings), and contrasting study methods and study outcomes.

Despite promising findings, however, the HIH model has not been widely implemented in the United States. One of the barriers to the adoption of this model is the misalignment of financial incentives among patients, payers, and providers under the traditional fee-for-service payment system.7 Such disincentives may not be applicable to integrated healthcare delivery systems that are responsible for discrepancies in the costs and care of defined populations, such as managed care, accountable care, and the Veterans Health Administration (VHA) healthcare systems.7

The Veterans Affairs (VA) health system is America’s largest integrated healthcare system. Its highly integrated medical delivery system aligns both financial incentives and quality care delivery, and thus is motivated to promote an HIH model. In 2010, the VA Office of Geriatrics and Extended Care (GEC) community-based transformational (T-21) programs piloted the HIH model as an alternative to inpatient services. One of the HIH programs was implemented at the VA Pacific Islands Health Care System (VAPIHCS) in Honolulu, Hawaii. This program is unique in that it does not have its own acute care hospital, and instead relies on the Tripler Army Medical Center (TAMC) in Honolulu, to provide inpatient care to its veterans. A steady flow of resources is transferred from the VA to the Department of Defense to reimburse the Army as veterans receive inpatient care from the TAMC, making the financial incentive for the implementation of the HIH program apparent at the VAPIHCS. The aim of our study was to evaluate the costs and related outcomes of this program. It was conducted as an operationally requested quality improvement project that was exempt from Institutional Resource Board review. Approval to publish these results was obtained from the GEC.

METHODS

The Honolulu HIH Program

When the VAPIHCS implemented the HIH program in September of 2010, the main targeted conditions included heart failure, pneumonia, chronic obstructive pulmonary disease, and cellulitis. To recruit patients, the HIH program staff made repeated and frequent visits to the TAMC and the VA Ambulatory Care Center in Honolulu. The HIH staff communicated with hospitalists, medical residents, discharge planners, and social workers at the TAMC, as well as VHA providers, nurses, and other staff at the facility, and maintained a close working relationship with a home-based primary care (HBPC) facility whose staff would refer eligible patients. A pamphlet was developed with basic information regarding the HIH program and outlining the patient referral process.

One of the components of the Honolulu HIH program was the substitutive model (ie, it provided hospital-equivalent care in the veteran’s home for those who would have otherwise been hospitalized). The requirement to enroll in the program was that the veteran was living at home and had 1 of the required admitting diagnoses. Veterans were referred to the HIH program from outpatient clinics and the VA HBPC, and were screened by physicians or registered nurses for appropriate diagnoses to ensure that care could be safely provided in the home. Once admitted to the program, veterans received required intravenous (IV) infusions, respiratory treatments, laboratory tests, x-rays, and wound care in the home. They also received daily nursing and physician visits, as needed, and had 24-hour access to an on-call geriatrician. Although no specific age limit was imposed in this study, the HIH program is listed under geriatrics service, and all of the physicians covering HIH are geriatric-trained physicians.

HIH staff ordered and delivered required supplies and medications, scheduled medical transportation, and coordinated care to meet the medical needs of veterans, their families, and caregivers. The HIH nursing staff took calls during duty hours on weekends and holidays, and worked with an outside pharmacy to provide all needed IV medications. Veterans were discharged from the program once symptoms improved; ultimately, they transitioned to their usual primary care providers (PCPs) or HBPC, if necessary. A discharge summary was placed in the Computerized Patient Record System, the patient’s Patient Aligned Care Team was notified, and follow-up care appointments were made with the PCP.

Data source. To evaluate the program, we (the GEC Data Analyses Center) followed specific steps. First, basic information was requested from the HIH program director to identify veterans who received care through this program. Social security number (SSN), date of birth, and gender were used to obtain the veteran’s identifier number (ie, scrambled SSN) used in the VA data systems. Dates of HIH program enrollment and disenrollment were also used to define the “active” period within the program and to establish both the program pre-enrollment phase prior to the trial, and the follow-up period following the program’s completion.

Data were then obtained from multiple VA administrative sources via the VA’s Corporate Data Warehouse. Specifically, data included vital status file, enrollment file, patient file, patient treatment file, outpatient file, Ward file, pharmacy file, inpatient treating specialty file, and fee-basis file from January 1, 2007, to September 30, 2013. These files contained demographic information (ie, age, gender, and race), VA enrollment status, and information about VA-provided services or VA-paid services, including the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, dates of service, medication use, and the costs of VA-provided and VA-purchased services. These VA data were linked by individually scrambled SSNs and compiled chronologically into a single file to track veterans’ utilization of health services.

Study Populations

The study population included HIH enrollees who were admitted to the Honolulu HIH program from a noninstitutional location (eg, outpatient clinics or home) between September 2010 and June 2013, and they were compared with a group of veterans who were not enrolled in the program, but were comparable to the enrollees. To identity potential comparators for the study, we used administrative data to include veterans who were not enrolled in the HIH program, but who were admitted to the TAMC for inpatient services from a noninstitutional location between January 2008 and September 2012 in Honolulu, Hawaii. We did not include nonenrollee veterans who had hospitalizations in fiscal year 2013 (FY13) as controls due to the concern of potential bias. Because of the expansion of the program, it is likely that the program enrolled most of the eligible veterans in FY13. Thus, those who were not enrolled during the same time period could be quite different from those who were enrolled. We then identified the primary diagnosis associated with hospital admissions and selected patients whose primary diagnosis was among the set of admission conditions stipulated for HIH enrollees. Furthermore, we identified the diagnosis-related group (DRG) and identified select hospital admissions with low-weight medical DRGs, with the assumption that the HIH enrollees did not have complications. This resulted in the 99 program enrollees and 322 nonenrolled veteran comparators who were identified for the study.

Analyses

Three sets of outcome variables were evaluated. The first outcome was the total cost of care, including inpatient, outpatient, or pharmacy costs, incurred during the index event. These services were either provided by the VA (ie, DSS data) or paid for by the VA (ie, TAMC-provided inpatient services were captured on fee-for-service files). The duration of the index event referred to the time between the admission and discharge dates of HIH services for enrollees and hospitalizations for nonenrollees. Costs were adjusted to 2013 dollars by the Consumer Price Index. The second set of outcomes included the incidence of 30- and 90-day hospitalizations after the discharge of the index event. The third set of outcomes entailed 30-, 90-, and 180-day mortality after the veteran had been discharged from the index event.

Based on VA administrative data, we extracted a set of individual-level variables at baseline (ie, the admission of the index event) to account for the potential differences between program enrollees and comparators. These variables included individual sociodemographic characteristics (eg, age, gender, race, and VA priority status that determined eligibility for Priority group 1 [veterans with 50% or more service-connected disabilities that precluded employment]), prior VA healthcare utilization (eg, number of inpatient events and total VA-paid costs in the 3, 6, and 12 months prior to the index event). In addition, we utilized VA claims data to obtain the ICD-9-CM codes recorded within the 1-year period prior to the admission of the index event, and identified a set of chronic conditions for each veteran. We also calculated the number of different drug classes used by the veterans within 1 year prior to the index event. We categorized the number of drug classes into 3 groups, including fewer than 5 drug classes (lower 25th percentile), 5 to 10 drug classes, and more than 10 drug classes (upper 25th percentile), to allow for the potential nonlinear relationship between the number of drug classes and outcomes. These individual-level characteristics could be correlated with the outcomes and, thus, the differences in each factor between enrollees and other subjects were considered.

We used a propensity score-matching approach to examine the difference in related outcomes between enrollees and controls. Specifically, a logistic regression was first estimated to predict the probability of HIH enrollment, based on individual factors we identified at the baseline, as described previously. After obtaining the probabilities, nonenrollees were matched to program enrollees based on the enrollee’s probability of enrollment. (We used a radius-matching approach and required nonenrollees’ probabilities of enrollment to be within the radius of 0.01 of the enrollees’ probabilities). The outcomes were then compared between the 2 groups of veterans with matched probabilities. If there were multiple matched nonenrollees to 1 enrollee, the average difference in outcomes was calculated. The average treatment effect on the treated (ATT) population which represents the average difference in outcomes between the enrollees and matched nonenrollees) was then estimated by averaging over the unit-level treatment effects across matched pairs. The standard errors for the difference in outcomes (ATT) were obtained by a bootstrapping approach with 1000 iterations. The propensity score-matching process was performed by a STATA procedure, PSMATCH2. All the analyses were performed in STATA version 13 (StrataCorp; College Station, Texas) and SAS version 9.3 (SAS Institute Inc; Cary, North Carolina).

RESULTS

The average age of enrollees was 73 years. As expected, the majority of veterans were admitted for pneumonia, congestive heart failure, diabetes, unitary tract infection, or cellulitis. The remaining veterans were admitted for management of other heart conditions (eg, chronic ischemic heart disease), kidney conditions (eg, pyelonephritis), or infections (eg, osteomyelitis). Similarly, approximately 90% of nonenrollees were hospitalized with a primary diagnosis of cellulitis, pneumonia, unitary tract infection, and heart failure. The DRG weights of these hospitalizations varied between 0.6176 and 0.9938 for nonenrollees. On average, the LOS of HIH services was 9.24 days for enrollees and 6.21 days for inpatient events.

Table 1 presents a comparison of individual characteristics between enrollees and nonenrollees before and after propensity score matching. Individual characteristics were reasonably balanced through the propensity score-matching approach, with the average age being 73 years for enrollees and 74 years for comparators. About 95% of enrollees and 97% of the comparators were male. The prevalence of chronic conditions for the 2 groups was similar, with approximately 24% of both enrollees and comparators experiencing an inpatient event within 90 days of the index event. Overall, the comparators were not sicker than enrollees, and the likelihood of overestimating the effect of the HIH program would be small.

Eight enrollees could not be matched with a nonenrollee veteran, and therefore, were not included in the propensity score-matched population. The unmatched enrollees seemed to be sicker than the other enrollees at baseline. For example, on average, they were 7 years older than the other enrollees and had more comorbidities. They also incurred higher healthcare costs prior to the index event than the other enrollees (data were not presented in the table).

The comparison of the outcomes between enrollees and comparable nonenrollees after the propensity score matching (ie, the ATT population) is shown in Table 2. The HIH program was associated with a 38% reduction in costs compared with an inpatient event. The average cost for HIH services per enrollee was $5150, and the average cost of an inpatient stay among the comparators was $8339 per person. The difference, $3189 (38.2%), was statistically significant (P <.01). The differences in the 30-day and 90-day rehospitalization rates after discharge were not statistically significant (ie, the 30-day rehospitalization rate was 14.3% for enrollees and 12.6% for the comparators; P = .75), and the 90-day rehospitalization rate was 16.5% for program enrollees and 21.4% for comparators; P = .38). The 30-, 90- and 180-day mortality rates were 6.6%, 11,0%, and 13.2%, respectively, for enrollees, and 6.2 %, 14.1%, and 19.7%, respectively, for comparators. These differences were not statistically significant.

DISCUSSION

The growing population of aging veterans and the increasing demand for inpatient services present a challenge to the VA healthcare system. This study evaluated an HIH program implemented among veterans in Honolulu, Hawaii. It was an observational study, and the identification of the comparison group and evaluation of the outcomes were based on administrative data. A propensity matching approach was applied to account for the potential differences between the enrollees and the comparison group. Although the study population and the study approach were different from previous studies,11,12,14,23,24 the findings were consistent in that we found that the HIH program provided hospital-equivalent care to eligible patients at a lower cost. Unlike some of the similar programs,13,14 the VAPIHCS did not operate an inpatient hospital, and so, creating the program required diligence in planning the care and the provision of special services to be developed from the beginning, including a comprehensive set-up of medical equipment, supplies, and personnel. Many managed care organizations are in a similar position as the VAPIHCS in that they are based in physician groups rather than health systems that operate hospitals, and it is reassuring that a nonhospital can successfully implement an HIH program.

We followed the HIH enrollees and the veterans chosen as comparators following their discharge from the HIH program or hospital, and did not find any statistically significant differences in mortality or rehospitalizations. On the other hand, it is likely that we underestimated the positive outcomes associated with the HIH program. For older adults, hospitalizations are associated with a high risk of adverse events (AEs), such as delirium, falls, and nosocomial infections.1-3,19,25 These hospital-acquired AEs not only lead to impairment in patients’ health status, but can also be costly.26 Providing acute services at a patient's home, when possible, is a logical way to limit these negative outcomes, and has been found to be associated with better functional status and better quality of life (QOL) compared with those who received hospital inpatient care.15,22

The HIH model is well aligned with the goal to deliver patient-centered care, and the HIH team identifies each veteran’s specific needs and provides high-quality care to accommodate them in a uniquely personal setting: the veteran’s residence. Veterans can benefit from support of family members while receiving hospital-equivalent services, which could potentially improve QOL and general welfare.

The HIH model also has the potential to reduce the extent of care discontinuity occurring during an acute episode. For example, instead of sending a veteran to TAMC, the Honolulu HIH staff collaborates with HBPC staff, geriatric healthcare providers, and primary and specialty care staff to provide necessary services in patients’ homes. Such collaboration and coordination facilitates the exchange of information among healthcare providers and ensures that appropriate medical measures are administered to veterans during and after participation in the program.

Limitations

However, these findings should be interpreted with caution. Unfortunately, we were not able to assess change in veterans’ functional or cognitive status due to a lack of available data. In addition, we were not able to compare an individual’s satisfaction level with their experience with the HIH program versus hospitalizations. We are also likely to have underestimated the positive outcomes of HIH programs as we only selected hospitalizations with low-weight DRGs, and it is likely that the HIH program provided care to patients with more complicated diagnoses.27 Furthermore, the propensity score-matching approach only accounted for observed factors. This was not a randomized trial, and therefore, it is likely that there were some unobserved differences between enrollees and comparators that could have confounded the effect of the HIH program on outcomes. For example, the severity of individual conditions at admission—which can be related to costs, rehospitalizations, and mortality—may not be completely captured by administrative data. If this is the case, our findings may be biased. However, we have accounted for critical individual-level factors. Furthermore, based on the observed characteristics between enrollees and nonenrollees at baseline, nonenrollees did not seem to be sicker than enrollees, making the likelihood of overestimating the benefits of HIH services low. Last, we only investigated the costs incurred within the VA system. It is possible that veterans in both groups differentially used non—VA-paid services, such as Medicare or Medicaid, which were not captured by our study.

CONCLUSIONS

Earlier studies have demonstrated the success and promise of the HIH model. This program demonstrated that it was possible to build a program without a hospital, and provided a useful example to managed care systems wishing to develop such a cost-effective program. With Medicare payment reform (eg, accountable care organizations) and incentives for providers to administer more efficient care, there may be pronounced interest in implementing programs, such as HIH, more broadly.

Acknowledgments

The authors would like to thank the Veterans Health Administration’s Office of Geriatric and Extended Care (GEC) Transformational Initiatives for supporting the Hospital-in-Home program. The authors also thank Dr Kenneth Shay and Karen Massey in the VA Office of GEC for their support in the evaluation of the program and comments on the manuscript.

Author Affiliations: Geriatrics & Extended Care Data Analyses Center (SC, OI, RM, CSP, BK), Canadaigua, NY; Department of Public Health Sciences, University of Rochester (SC,OI), Rochester, NY; Canandaigua VA Medical Center (SC,OI), Canandaigua, NY; VA Pacific Island Health Care Systems (MLM, PL), Honolulu, HI; Center for Gerontology & Healthcare Research, Brown University School of Public Health (RM), Providence, RI; Corporal Michael Crescenz VA Medical Center (BK), Philadelphia, PA; Division of Geriatrics, University of Pennsylvania School of Medicine (BK), Philadelphia, PA; Health Economics Resource Center and Center for Innovation to Implementation, VA Palo Alto Health Care System (CSP), Menlo Park, CA; Department of Pediatrics, Division of Neonatal & Developmental Medicine, Stanford University School of Medicine (CSP), Stanford, CA.

Source of Funding: The Hospital-In-Home program and the evaluation of the program conducted by the National Geriatrics & Extended Care Data & Analyses Center were supported by the Veterans Health Administration’s Office of Geriatric and Extended Care Transformational Initiatives.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (SC, PL, MLM, BK, CSP, OI); acquisition of data (PL, RM, MLM, CSP, OI); analysis and interpretation of data (SC, RM, BK, CSP, OI); drafting of the manuscript (SC, BK); critical revision of the manuscript for important intellectual content (PL, MLM, BK, CSP, OI, RM); statistical analysis (SC, RM, CSP); obtaining funding (OI); administrative, technical, or logistic support (OI); and supervision (OI).

Address Correspondence to: Shubing Cai, PhD, Department of Public Health Sciences, University of Rochester, 265 Crittenden Blvd, Rochester NY 14642. E-mail: shubing_cai@urmc.rochester.edu.

REFERENCES

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4. Pfuntner A, Wier L, Steiner C. Costs for hospital stays in the United States, 2010. Healthcare Cost and Utilization Project website. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb146.pdf. Published January, 2013. Accessed March 8, 2015.

5. Kuehn BM. Hospital at home program cuts costs, improves patient health and satisfaction. JAMA. 2012;308(2):122. doi:10.1001/jama.2012.7420.

6. Caplan GA, Sulaiman NS, Mangin DA, Aimonino Ricauda N, Wilson AD, Barclay L. A meta-analysis of “hospital in the home”. Med J Aust. 2012;197(9):512-519.

7. Leff B. Defining and disseminating the hospital-at-home model. CMAJ. 2009;180(2):156-157. doi: 10.1503/cmaj.081891.

8. Shepperd S, Doll H, Angus RM, et al. Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data. CMAJ. 2009;180(2):175-182. doi: 10.1503/cmaj.081491.

9. Leff B, Burton L, Bynum JW, et al. Prospective evaluation of clinical criteria to select older persons with acute medical illness for care in a hypothetical home hospital. J Am Geriatr Soc. 1997;45(9):1066-1073.

10. Jeppesen E, Brurberg KG, Vist GE, et al. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;(5):CD003573. doi: 10.1002/14651858.CD003573.pub2.

11. Leff B, Burton L, Guido S, Greenough WB, Steinwachs D, Burton JR. Home hospital program: a pilot study. J Am Geriatr Soc.1999;47(6):697-702.

12. Leff B, Burton L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005;143(11):798-808.

13. Mader SL, Medcraft MC, Joseph C, et al. Program at home: a Veterans Affairs healthcare program to deliver hospital care in the home. J Am Geriatr Soc. 2008; 56(12)2317-2322. doi: 10.1111/j.1532-5415.2008.02006.x.

14. Cryer L, Shannon SB, Van Amsterdam M, Leff B. Costs for 'hospital at home' patients were 19 percent lower, with equal or better outcomes compared to similar inpatients. Health Aff (Millwood). 2012;(6):1237-1243. doi: 10.1377/hlthaff.2011.1132.

15. Leff B, Burton L, Mader SL, et al. Comparison of functional outcomes associated with hospital at home care and traditional acute hospital care. J Am Geriatr Soc. 2009;57(2):273-278. doi: 10.1111/j.1532-5415.2008.02103.x.

16. Leff B, Burton L, Mader S, et al. Satisfaction with hospital at home care. J Am Geriatr Soc. 2006;54(9):1355-1363.

17. Leff B, Burton L, Mader SL, et al. Comparison of stress experienced by family members of patients treated in hospital at home with that of those receiving traditional acute hospital care. J Am Geriatr Soc. 2008;56(1):117-123.

18. Ricauda NA, Tibaldi V, Marinello R, et al. Acute ischemic stroke in elderly patients treated in hospital at home: a cost minimization analysis. J Am Geriatr Soc. 2005;53(8):1442-1443.

19. Caplan GA, Coconis J, Board N, Sayers A, Woods J. Does home treatment affect delirium? a randomised controlled trial of rehabilitation of elderly and care at home or usual treatment (The REACH-OUT trial). Age Ageing. 2006;35(1):53-60.

20. Caplan GA, Coconis J, Woods J. Effect of hospital in the home treatment on physical and cognitive function: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2005;60(8):1035-1038.

21. Qaddoura A, Yazdan-Ashoori P, Kabali C, et al. Efficacy of hospital at home in patients with heart failure: a systematic review and meta-analysis. PloS One. 2015;10(6):e0129282. doi: 10.1371/journal.pone.0129282.

22. Aimonino Ricauda N, Tibaldi V, Leff B, et al. Substitutive “hospital at home” versus inpatient care for elderly patients with exacerbations of chronic obstructive pulmonary disease: a prospective randomized, controlled trial. J Am Geriatr Soc. 2008;56(3):493-500. doi: 10.1111/j.1532-5415.2007.01562.x.

23. Frick KD, Burton LC, Clark R, et al. Substitutive hospital at home for older persons: effects on costs. Am J Manag Care. 2009;15(1):49-56.

24. Ram FS, Wedzicha JA, Wright J, Greenstone M. Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence. BMJ. 2004;329(7461):315.

25. Strausbaugh LJ. Emerging health care-associated infections in the geriatric population. Emerg Infect Dis. 2001;7(2):268-271.

26. Scott DR II. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. CDC website. http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf. Published March 2009. Accessed July 13, 2017.

27. Liu J, Schwab E, Buxbaum L, Haggerty M, Jang M, Kinosian B. Comparison of adverse event rate between hospital in home and acute inpatient care. J Am Geriatr Soc. 2016;64(suppl 1):S16.

Output: he hospital is the traditional place to provide acute care. However, hospitalizations can be costly and may lead to further deterioration in health status among the elderly. The Hospital-in-Home (HIH) model offers an alternative approach to traditional hospital services. At the core of the HIH model is the goal of delivering hospital-level care to patients who have developed an acute episode that typically would require inpatient services, but who are medically stable enough to be treated at home.


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Input:
'Granny pods' become a solution for retirees with limited budgets
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Like many boomers, Jane Baldwin faced a difficult question: "Where do I go next?"

The 67-year-old retiree was living alone in Wyoming, and had grown tired of cold winters. She wanted to be closer to her family in Oakland, California.

Not ready to give up her independence entirely by sharing a roof with family — but also unable to purchase another property thanks in part to the Bay Area's notoriously high cost of housing — Baldwin decided to look no further than the backyard. Her answer was to build a 400-square-foot "granny pod."

"I am in love with it," said Baldwin. "I can't foresee leaving here until I'm dead."

The tiny house is built for accessibility and includes a living room, galley kitchen as well as bedroom. Its hallways and doorways are wide enough for a wheel chair should Baldwin ever need one. All the floors are even eliminating tripping hazards and the shower stall is a walk-in.

400-square-foot "Granny Pods" Source: Inspired Independence

Baldwin's story could become more common. The American population is aging rapidly, with the number of older Americans expected to double in the next three decades, reaching 88 million people by 2050, according to the National Institutes of Health. Of that number, a 2016 Genworth study estimated that 70 percent will need some form of long-term care, something Medicare doesn't cover. It's why deciding where these older Americans will age is often a difficult family conversation fraught with financial and emotional issues.

"If people can age in place and age at home it's much healthier, and the family is happier, but it can be very expensive," said Carolyn McClanahan, a financial planner at Life Planning Partners in Jacksonville, Florida. "Granny pods can cost anywhere from $100,000 to $250,000. So you got to weigh longevity in there with it."

With the cost of skilled nursing care reaching nearly $93,000 a year, a granny pod may make more financial sense if you expect the person living there to stay for several years.

However, it's important to also weigh the individual's cognitive health. Someone with dementia or in need of help with daily tasks is not a good granny pod candidate, McClanahan added.

400-square foot ‘Granny Pods’. Source: Inspired Independence

Output: Like many boomers, Jane Baldwin faced a difficult question: "Where do I go next?" The 67-year-old retiree was living alone in Wyoming, and had grown tired of cold winters. She wanted to be closer to her family in Oakland, California.


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Trump Moves to Impede Consumer Lawsuits Against Nursing Homes
 “Individuals are very vulnerable when they sign contracts to enter a nursing home,” said Kimberly A. Valentine, a lawyer in Orange County, Calif., who has represented scores of nursing home residents. “In many cases, they are transferred from a hospital, and they are in a nursing home bed for several days before the contracts are even signed. The arbitration agreement may be just one page in a voluminous contract of 30 to 40 pages. Most of the people who come to me have no idea they’ve even signed an arbitration agreement.”

The Obama administration tried to ban such agreements, saying it was “almost impossible for residents or their decision-makers to give fully informed and voluntary consent to arbitration before a dispute has arisen.” Poor or negligent care at some nursing homes has persisted, even after the facilities have attracted regulatory scrutiny.

But the Trump administration says the ban on arbitration agreements imposes “unnecessary or excessive costs on providers” of nursing home care. It noted that President Trump, in an executive order, had directed agencies to roll back rules and reduce “regulatory costs.” The Centers for Medicare and Medicaid Services cited that guidance from the White House in issuing the new proposal.

“Upon reconsideration,” the Trump administration said of the proposed nursing home rule, “we believe that arbitration agreements are, in fact, advantageous to both providers and beneficiaries because they allow for the expeditious resolution of claims without the costs and expense of litigation.” The money that nursing homes spend on lawsuits could be better used caring for patients, it said.

Nursing homes generally welcomed the proposal, but other reaction has been overwhelmingly negative.

The attorneys general of 16 states, led by Brian E. Frosh of Maryland and Xavier Becerra of California, strongly opposed the Trump administration proposal.

Output: The Trump administration is pushing to scrap a rule that would have made it easier for nursing home residents to sue nursing homes for injuries caused by substandard care, abuse or neglect, bringing its campaign to relax federal regulations to the delicate business of care for older Americans.


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Aging Parents With Lots of Stuff, and Children Who Don’t Want It
 As baby boomers grow older, the volume of unwanted keepsakes and family heirlooms is poised to grow — along with the number of delicate conversations about what to do with them. According to a 2014 United States census report, more than 20 percent of America’s population will be 65 or older by 2030. As these waves of older adults start moving to smaller dwellings, assisted living facilities or retirement homes, they and their kin will have to part with household possessions that the heirs simply don’t want.

“We went from a 3,000-square-foot colonial with three floors to a single-story, 1,400-square-foot living space,” said Tena Bluhm, 76, formerly of Fairfax, Va. She and her 77-year-old husband, Ray Bluhm, moved this month to a retirement community in Lake Ridge, Va.

Before the move, their two adult children took a handful of items, including a new bed and a dining table and chairs. But Mrs. Bluhm could not interest them in “the china and the silver and the crystal,” her own generation’s hallmarks of a properly furnished, middle-class home.

The competitive accumulation of material goods, a cornerstone of the American dream, dates to the post-World War II economy, when returning veterans fled the cities to establish homes and status in the suburbs. Couples married when they were young, and wedding gifts were meant to be used — and treasured — for life.

“Americans spent to keep up with the Joneses, using their possessions to make the statement that they were not failing in their careers,” wrote Juliet B. Schor, the Boston College sociologist, in her 1998 book, “The Overspent American: Why We Want What We Don’t Need.”

Output: Mothers and daughters talk about all kinds of things. But there is one conversation Susan Beauregard, 49, of Hampton, Conn., is reluctant to have with her 89-year-old mother, Anita Shear: What to do — eventually — with Mrs. Shear’s beloved set of Lenox china?


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Aging healthy and happy during your greater years
 Gina Harkins

USA TODAY Best Years magazine

Lucy Rose Fischer spent much of her life studying aging, but not even decades of academic research fully prepared the retired gerontologist for getting older herself.

“Theoretically, I knew that people were living longer,” she says. “But what’s really amazing to me is that there is a whole (new) life that starts.”

Many women are expected to live into their 80s, which means a chance at starting new hobbies or watching their grandchildren — and even great-grandchildren — grow up. That kind of longevity is still a relatively new concept, and the health care and social systems haven’t quite caught up.

“We’re having more years of good health, but also having more years of various chronic conditions,” says Andrew Scharlach, a professor of aging in the University of California-Berkeley’s School of Social Welfare.

“We are changing individually much more quickly than our physical and social environments are.”

Even though Fischer, 72, of St. Louis Park, Minn., says she doesn’t love everything about aging, she’s still finding life after retirement to be creatively rewarding. She’s able to focus on her love of creating painted-glass art, and she wrote and illustrated a book about aging called I’m New at Being Old.

“In a way, it feels like starting over,” she says. “But the difference between being 15 and 60 when you’re starting a new stage in life is that you have all this experience behind you that you’re able to use.”

A changing society

An aging population doesn’t come without challenges. U.S. Census Bureau data shows that by the year 2050, nearly 84 million people will be 65 and older. Many in that population will face the risk of chronic diseases, especially as people live long enough to develop them. One in 10 people over age 65 have Alzheimer’s, for example, according to the Alzheimer’s Association, and while overall cancer rates have declined, cancer rates still rise with age, according to the National Cancer Institute.

Scharlach says this could weigh on the American health care system, which is not equipped to deal with long-term conditions on a large scale. The Baby Boomer population is aging, he said, but many physicians don’t have experience treating older adults. Access to medical professionals is also on the decline, Scharlach adds, since some communities don’t have enough doctors and nurses, or people can’t afford the high cost of treatment.

That’s what people like Grisel Rodríguez-Morales, a health promotion and disease prevention manager at Chicago’s Rush University Medical Center, are trying to change. Her team helps give people the tools they need to “age successfully,” she says, by holding seminars about how to manage their health conditions.

“As providers, this is new to many of us,” she says. “As the aging population continues to grow, we want to make sure that we … are thinking not only about health, but health within the context of aging.”

That requires not only informing doctors, nurses and other health care providers about the needs of aging adults, but family members and friends, too. That way, they understand that something like depression, for example, is not a normal part of aging, she says.

“If you saw an 18- or 20-year-old who didn’t want to do anything, you wouldn’t think twice about immediately taking them to the doctor,” Rodríguez-Morales says. “So if you see an older adult, why not do the same thing instead of just saying, ‘Well, they’re old.’”

As the older population continues to grow, Scharlach says it’s vital that people see beyond age. Americans are slowly starting to value older generations, he says, but there’s still a long way to go.

“Having popular images that reflect aging as it really is and provide a sense that we can age well and age fully will go a long way,” he adds. “It’s about seeing that 80-year-old not simply about what they can’t do, but who they are.”

One of the things Fischer did when she retired was to quit dyeing her hair. Once she accepted her silver hair, she grew to like the look — along with the tiny crinkles around her eyes.

“There is a kind of focus on always trying to look younger,” she says, “but you can be vital at 72 and be beautiful.”

When she was studying aging, Fischer and her colleagues at HealthPartners, a Minnesota-based nonprofit health care organization, developed the ALIVE model.

The acronym stands for five healthy aspects of aging: activity, learning, intimacy, vitality and engagement. Now she tries to apply the model to her own life.

Fischer stays active by hiking with her husband and walking her dog. She considers continuing education an important way to exercise her brain. She maintains close, intimate relationships with friends of all ages. Her artwork and positive attitude give her life vitality, and she remains engaged in her wider community and society.

Healthy and happy aging requires a real investment, Scharlach says. Many people plan carefully for their financial futures, he says, but fail to devote time and effort to other aspects of their lives, like Fischer does with her ALIVE method.

“We have to take care of our body, our mind, our relationships,” Scharlach says. “There’s that old saying, ‘If I had known I was going to live this long, I would’ve taken better care of myself.’ There’s enormous truth to those words.”

Output: Lucy Rose Fischer spent much of her life studying aging, but not even decades of academic research fully prepared the retired gerontologist for getting older herself. “Theoretically, I knew that people were living longer,” she says. “But what’s really amazing to me is that there is a whole (new) life that starts.”


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Cyber crime more lucrative than global drugs trade
 Boss of Dublin-based IT security firm Ward Solutions, Pat Larkin said failure to take cybersecurity breaches seriously was costing some firms hundreds of thousands of euro in the short term following a breach.

He said it was also having an impact in the medium to long term with share prices dropping and not recovering because of investor concerns over security.

Mr Larkin was speaking in the wake of the world’s biggest shipping company admitting it faces a $300m (€255m) bill following an online breach in June.

Danish shipping group Moller Maersk said it expected a $200m to $300m bill from a cyber attack that disrupted its container shipping operations for weeks.

The attack contributed to Moller’s $264m loss in the second quarter, highlighting the toll on corporate earnings of a June 27 malware attack.

Cyence, which helps insurers measure cyber risk, said economic costs from the attack would total $850m.

Mr Larkin said cybercrime was now more lucrative than the global drugs trade.

“Cybercrime is now bigger than the drugs trade and firms have to get serious about it. Information security is a continuous journey.”

Europol, the EU-wide intelligence network, has warned the global impact of cybercrime has risen to $3 trillion, making it “more profitable than the global trade in marijuana, cocaine and heroin combined”.

A recent survey by British IT research firm Juniper said criminal data breaches will cost businesses a total of $8 trillion over the next five years, due to higher levels of Internet connectivity and inadequate enterprise-wide security. It found that SMEs are particularly at risk from cyberattacks .

Juniper forecasts that the number of personal data records stolen by cybercriminals will reach 2.8 billion in 2017, almost doubling to five billion in 2020.

Mr Larkin said boardrooms had to get more informed about the risks of cyber breaches.

“We are starting to see a much more serious approach thankfully. Historically, information security and risk has been seen as merely an IT department problem. It never really surfaced at executive level. However, the amount of time we are spending at executive briefings is up around 500% in the past three years,” he said.

Mr Larkin said the damage that could be done from a perception point of view was damaging enough, but that the long-term effects also had to be considered.

“Whether it is malware or a data breach, the bad PR alone is enough to cause damage. Companies and executives are beginning to understand that. However, it can also have a major impact on a share price post-breach. You see 2-3% being knocked off in the medium term. The ongoing damage is very measurable,” he said.

Mr Larkin said executives and their IT departments had to improve communication in order to get better at dealing with cybercrime.

“There is a communication gap, as in how much is really understood by executives when it comes to technical language by IT professionals. That must get better and companies must work to try and create a common language,” he said.

Additional reporting,

Bloomberg

Output: The worldwide cost of cyber crime has grown to $3tn, and is now “more profitable than the global trade in marijuana, cocaine and heroin combined”, according to the EU-wide intelligence network Europol. British IT research firm Juniper found in its own survey that by 2022, cyber attacks will cost a total of $8tn for companies, thanks to lacking cybersecurity and increasingly widespread internet adoption.


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China's middle class moves from instant noodles to online options
 A man eats noodles served on a high-speed train from Guangzhou to Beijing. China’s demand for instant noodles has dropped 17 per cent over the past four years. Photo: Simon Song

Output: China's booming middle classes are moving away from instant noodles and towards a healthier diet. This coincides with the rise of food deliveries via smartphone apps which provide quick, easy and inexpensive food of a higher quality. Demand for instant noodles fell 17% between 2013 and 2016, according to the World Instant Noodles Association. Uni-President, which provides over a fifth of China's instant noodles, reported a 27% decline in net profit during H1 2017.


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Insurer Sinosure provides finance facility for Sri Lankan LPG hub
 Aug 21, 2017 (LBO) – Sri Lanka’s LAUGFS Gas and Standard Chartered have announced the first private sector financing facility supported by China Export and Credit Insurance Corporation (SINOSURE) for the 30,000MT import and export terminal at Hambantota.

The liquid petroleum gas (LPG) storage terminals by LAUGFS Terminals Ltd., a subsidiary of LAUGFS Gas PLC, is being built with an investment of US 80 million dollars and will be one of the largest LPG import and export terminals in South Asia.

As a principal party to this transaction, Standard Chartered acted as the coordinating bank, sole facility arranger and lender for the financing facility.

“This marks a significant milestone for our LPG Terminal project, which is well on track to be commissioned in the 2nd half of 2018,” W K H Wegapitiya, chairman of LAUGFS Holdings said.

“Once completed, the LAUGFS terminals in Hambantota will garner tremendous economic benefits to our country by helping to position Sri Lanka as a central energy hub in the region.”

The Hambantota Port is located on a strategic sea route in close proximity to some of the largest emerging LPG markets in the region, such as Bangladesh and Myanmar and the new terminal will operate as a central hub for LPG importing, re-exporting as well as the provisioning to retailers.

SINOSURE is a state-funded policy-oriented insurance company, which provides medium and long term export credit insurance, overseas investment (leasing) insurance, bonds and guarantees concerning foreign trade and a range of other related products.

“The strategic location of the terminal in the midst of the world’s largest shipping routes will undoubtedly be an enormous advantage that the company can leverage on,” Guo Yilin, deputy general manager of SINOSURE said.

“We are pleased to be part of this visionary endeavour with the first ever such private sector finance facility in Sri Lanka.”

Constructed by China Huanqiu Contracting and & Engineering Corporation (HQC), the first phase of the LAUGFS LPG Terminal will be of 30,000MT storage capacity, with plans to extend to 45,000MT in phase two.

Once completed, the facility will consist of above-ground spherical LPG storage tanks, each with a 6,000m3 volume. With the proposed cargo heating system at the existing jetty, the Terminal will be well-equipped to accept VLGCs with refrigerated or pressurized cargo.

LAUGFS has been strengthening its energy presence within the region over the recent few years with the expansion of its LPG downstream businesses to Bangladesh, rapid expansion of its LPG vessel fleet under LAUGFS Maritime, and the setting up of its energy trading arm in Dubai.

Jim McCabe, chief executive officer of Standard Chartered Sri Lanka says that they were pleased to arrange and structure a financing facility supported by SINOSURE for the LAUGFS Terminal project.

Output: Sri Lanka's Laugfs Gas and Standard Chartered, with support from China's Export and Credit Insurance Corporation (Sinosure), have announced the first private sector financing facility for the 30,000 MT import and export terminal at Hambantota, which will become one of the largest LPG import and export terminals in south Asia. “Once completed, the Laugfs terminals in Hambantota will garner tremendous economic benefits to our country by helping to position Sri Lanka as a central energy hub in the region," said W K H Wegapitiya, chairman of Laugfs Holdings.


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McDonald’s UK staff to strike over pay
 Workers at two McDonald’s restaurants in the UK will go on strike on 4 September, the US Labor Day holiday, in an attempt to coordinate action against the fast food giant with allies around the world.

The announcement of the symbolic date comes after staff at restaurants in Cambridge and Crayford, in south-east London, voted overwhelmingly on Friday to go on strike. They are demanding wages of at least £10 an hour, secure contracts with guaranteed hours and formal trade union recognition from McDonald’s.

The choice of Labor Day is intended to signify the workers’ solidarity with fast food employees internationally, according to the Bakers, Food and Allied Workers Union (BFAWU).

In previous years, thousands of US fast food employees have participated in Labor Day strikes and demonstrations as part of Fight for 15, a campaign for a $15 (£11.60) hourly wage, coordinated by the Service Employees International Union.

The UK action is taking place with the help of organisers from the Unite union in New Zealand, who are visiting the UK to advise the striking workers. Unite has won significant victories, including a $15 an hour minimum wage and legislation outlawing zero-hours contracts, in New Zealand.

A delegation of workers from Belgium will also be travelling to London to support the UK strike. The BFAWU is calling for international support, and it is hoped that allied unions in other countries will also take part in actions on 4 September. A BFAWU representative said: “In the past we have had action on every continent.”

In April, McDonald’s announced it would offer guaranteed-hours contracts to all employees who wanted them. However, the BFAWU claims that workers at most stores were told nothing about this until workers decided to strike. Organiser Gareth Lane said: “All of a sudden they’ve put it online where workers can see that all workers will have a contract with guaranteed hours by the end of the year. This is a huge victory for these workers who’ve stood up, decided to organise and take this strike action.”

He said the intention of the action on 4 September was to maintain pressure on the chain to deliver on its offer. “We don’t trust McDonald’s to deliver these guaranteed hours to workers,” he said. “We want them to sign, legally, that they’ll give these guaranteed contracts by the end of the year.”

Shen Batmaz, one of the McDonald’s workers going on strike in Crayford who is also a political campaigner, said international support had helped bolster workers’ determination to strike. “For a long time we were told as fast food workers we were really hard to organise because people leave all the time and a lot of us are young people,” she said. “For us to see there were people doing it, not just in the US but all over the world, we knew it was time for us to come together.”

A spokesman for McDonald’s said on Friday: “We can confirm that, following a ballot process, the BFAWU have indicated that a small number of our employees representing less than 0.01% of our workforce are intending to strike in two of our restaurants.”

Output: McDonald’s staff in two UK outlets will strike on 4 September as part of coordinated worldwide action against the fast food company. Staff at the restaurants in Cambridge and Crayford voted strongly in favour of the action. Workers are demanding a minimum wage of £10 ($13) per hour, secure contracts and union recognition. Thousands of US fast food workers have participated in Labor Day strikes in previous years, as part of the Fight for 15 campaign for an hourly wage of $15.


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JPMorgan Chase pledges $2m to anti-hate groups
 JPMorgan Chase CEO Jamie Dimon attends a policy forum with President Donald Trump in the State Dining Room at the White House, Feb. 3, 2017, in Washington.

JPMorgan Chase , whose outspoken chairman and chief executive, Jamie Dimon, joined a chorus of other business leaders condemning President Donald Trump's response to the deadly violence in Charlottesville, Virginia, earlier this month, is pledging up to $2 million to anti-hate groups.

"While there are no simple answers, it is vital that we recommit ourselves to the principles of equality, respect and acceptance," said JPMorgan's Peter Scher, a former Clinton administration official who is now the bank's head of corporate responsibility and runs its foundation. He is also the bank's face in Washington, D.C., as chairman of that region.

It is clear, he said in an internal email Monday, "that the events of the past week reflect deep divisions across our country and compel us to redouble our efforts."

The planned donation follows similar moves by Apple and 21st Century Fox 's James Murdoch. Last week, Apple CEO Tim Cook pledged $1 million each to the Anti-Defamation League and Southern Poverty Law Center and said the company would match employee donations. Murdoch, head of 21st Century Fox, pledged $1 million to the ADL.

JPMorgan is giving $1 million to be split between the ADL and the Southern Poverty Law Center "to further their work in tracking, exposing and fighting hate groups and other extremist organizations," Scher said the email. JPMorgan is also giving $50,000 to the Charlottesville community foundation and will match employee contributions to the anti-hate groups up to another $1 million.

In a statement emailed to CNBC later on Monday, ADL's spokesperson said the organization also has received donations in the last week from Uber, MGM Resorts and Bumble, an online dating service.

ADL's online donations last week increased six-fold versus the average for 2017 and the amount of funds raised increased 1,000 percent, Betsaida Alcantara, the spokesperson, added. "We are proud that the great majority of the individual online donations came from first-time donors."

Richard Cohen, the president of the Southern Poverty Law Center, said in his own statement emailed to CNBC: "Now more than ever, America's leading institutions must speak out against white supremacism. While we appreciate JPMorgan Chase's contribution, we are even more grateful for its strong public position against hate and bigotry."

Business leaders, including Cook, Dimon and Murdoch, have condemned Trump's response to the violence that erupted between white supremacists and counterprotesters during a weekend march earlier this month. Two business councils advising the administration, made up of CEOs and others, disbanded last week as a wave of CEOs quit.

"I strongly disagree with President Trump's reaction to the events that took place in Charlottesville over the past several days," Dimon said in a memo to staff last week. "Racism, intolerance and violence are always wrong."

JPMorgan says its foundation has a tradition of donating money after natural disasters or events that affect communities where it has operations. Last year it donated $300,000 to Orlando, Florida, for recovery efforts after a deadly nightclub shooting, and it matched employee gifts up to another $200,000. The foundation also gave $200,000 for flood relief in Louisiana.

Output: JPMorgan Chase has pledged to donate up to $2m to anti-hate groups, following condemnation of President Trump’s response to violence in Virginia earlier this month by CEO Jamie Dimon. The Anti-Defamation League (ADL) and the Southern Poverty Law Center will receive $1m between them, while the Charlottesville community foundation will receive $50,000. The bank will also match employee donations to the groups up to the sum of $1m. The move follows similar donations from Apple and 21st Century Fox’s James Murdoch. ADL has also announced donations from dating service Bumble as well as from MGM Resorts and Uber.


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UK sees weekly farm pollution breaches
 Lynda and Richard Whittemore bought Quennells farm, in the quiet Sussex countryside, six years ago. They hoped to lead “an idyllic lifestyle”, tending their flock of 400 pedigree, grass-fed Lleyn sheep and 45 Highland cattle on 180 acres of farmland.

“We have an undulating field at the back of the stream, winding to the other corner", said Lynda. "Usually it has lovely clear water, with a gentle slope down to the water supply. It’s picturesque...they don’t need troughs, they can walk down to drink the water.”

Next door to their farm was another: Crouchland. But this farm was not a small-scale, pedigree operation like that of the Whittemores. Crouchland is an intensive dairy farm which also processes large amounts of manure, turning it into biogas.

By 2013 it had installed an industrial-size anaerobic digester - government-subsidised machinery which turns food and agricultural waste into gas which can be sold to the national grid. It began processing waste from 20 local farms and built extra slurry vats in order to store the byproducts.

In March 2015, Lynda explained, there was a “nasty spill of digestate” - a toxic mix of manure, water and chemicals - linked back to Crouchland farm. It polluted 70 acres of Quennells farm land. “Thick, black smelly tarry stuff flowing down our stream," she said. "It was chugging along, killing little frogs, fish and invertebrates. They were wiped out.”

Such an occurrence is far from a one-off case. A Bureau investigation has found pig, poultry and dairy farms are releasing harmful pollution once a week on average in England and Wales.

We have documented dozens of instances of manure pouring into waterways, carcasses being illicitly dumped and noxious fumes being emitted, among other infractions - all of which can seriously damage ecological systems, and are often against the law.

Output: Livestock farms in the UK are causing weekly serious pollution incidents, according to England’s Environment Agency and its devolved partners in Scotland and Wales. Between 2010 and 2016, over 5,300 cases of agricultural pollution occurred in the UK. Even serious incidents may not be prosecuted and the farms responsible may continue to receive subsidies, according to an investigation by The Guardian and the Bureau of Investigative Journalism. Many breaches result from underinvestment in equipment, including slurry stores, and there are fears the situation may worsen if farm incomes decline after Brexit.


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Researchers explore making energy from salt water and fresh water
 The idea of getting energy from salinity variant, where freshwater meets seawater, was first considered in the 1970s to be largely forgotten. But over the last few years interest has been resurrected and now a team from Penn State has developed a new hybrid technology to create power using the electrochemical charge created by the meeting of different salt concentrations.

The team at Penn State aims to harness this charge using a custom built technology made of two cells, one containing saltwater and one containing freshwater. Between the two is an anion-exchange membrane, and there is a nickel hexacyanoferrate electrode in each cell. As the saltwater passes through the cells it creates a charge that can be collected using graphite foil and discharged as electricity.

Researchers predict that the technology could meet up to 40% of the world’s energy needs, if it can be successfully rolled out. But a host of challenges lie ahead before it can be produced on a large scale.

Uniting salinity gradient technologies

This hybrid combines elements of two older methods used in the field: capacitive mixing (CapMix) and reverse electrodialysis (RED). Both have proved inefficient for a number of reasons and this hybrid seeks to adopt the best elements from both.

“One approach is to use what's called reverse electrodialysis, in which potentials develop across ion exchange membranes,” says Penn State assistant professor in environmental engineering Christopher Gorski. “So, as saltwater and freshwater are flying through an electrochemical cell this potential develops and then generates a voltage in the cell which can be used to discharge electricity.”

“The other approach is often referred to as capacitive mixing, in which potentials develop at electrode surfaces,” says Gorski. “An electrode develops a potential based on the amount of salt in the solution and when the two electrodes are exposed to different salt concentrations, they develop a voltage between the two electrodes of a potential difference. Then that can be discharged to generate electricity also.” While this has proven to be a relatively successful technique, as with RED, it simply doesn’t produce enough power to be viable.

However, Gorski and his team believe they may have found a way to yield a far greater amount of energy from salient differences by combining aspects of RED and CapMix. “In the cell we had electrodes that developed potentials based on the salt concentration, as well as the membrane that developed the potential across it,” says Gorski. “By combining those two and reconfiguring the cell a little bit, we were able to generate far more electricity than either of those two technologies could do independently.”

The potential to create more energy

In a recent test, 12.6W/m2 of membrane power was generated. “In principle, the amount of power that we could generate was competitive with the best technologies that are out there [currently] that are mainly based on osmotic pressure,” says Gorski.

"In a recent test, 12.6W/m2 of membrane power was generated."

The team claims that this technology could meet as much as 40% of the world’s energy supply, a bold claim based on the study ‘Membrane-Based Production of Salinity-Gradient Power’ by Guy Z Ramon, Benjamin J Feinberg and Eric M V Hoek, published in the journal Energy & Environmental Science. The study examined points where river water meets seawater, taking into account both geographical and practical constraints, to estimate how much energy each location could generate.

“What goes into that are several assumptions that are probably somewhat impractical, like you'd have 100% efficiency,” expands Gorski. “If you just look at solar energy, for example, and said that you would assume 100% efficiency, you'd easily provide all of the global demand for energy too, so there's that consideration.”

While the previous study gives an indication of the technology’s potential, there are further variables affecting the accuracy of the calculations. “There are other factors that need to be taken into account, like sea level rise,” says Gorski. “As you have tides and high tide and low tide, that influences where freshwater and seawater mix and how much pumping energy you need to put into it, so that will probably also reduce that value.”

“I think in a very practical sense, where this technology would be used would be more where you have large cities on coasts, and you have a discharge of wastewater,” he says.

“We did some back of the envelope calculations and in San Francisco they discharge about 20 billion gallons of wastewater per year to the San Francisco bay,” explains Gorski. “So, if you just mix that treated wastewater with the seawater, you'd generate about 20% of the electricity that San Francisco needs. So there you have a very controlled water stream that you're mixing with, and that seems feasible to me.”

Along with wastewater plants, it’s hoped that the hybrid could be incorporated into the infrastructure at desalination plants. As water is desalinated, a salty substance is left over which is usually dumped straight back into the ocean which could instead be used with wastewater to generate power.

More time for testing

Tests of the hybrid technology were very promising but it’s still got a long way to go before it could be rolled out. “One of the main things is longevity,” says Gorski, explaining that “We did these experiments using pretty pure solutions and relatively short timescales. But if you wanted to implement this on a pilot-scale plant, you'd want to run it for years, ideally.”

The brief time period of testing the hybrid leaves a degree of uncertainty over its durability. Furthermore, the lab conditions raise concerns over the membrane’s ability to perform in real-life applications. “It's not really clear how well the membranes hold up over time, or the electrodes hold up over time when they are exposed to all the random things that are in seawater and freshwater, like small particles, bacteria, strange metals that might get into the water,” says Gorski. “We don’t know how that will affect their performance over a time. So that's something that we're looking at now.”

As tests continue, the team is experimenting with various materials for the membrane to ensure the hybrid is as efficient as possible. “We used nickel and iron, but there's other metals that you can put into it that will change its properties,” says Gorski, and it seems that there is a long way to go from here as, “lots of people have studied how those metals influence it and, sort of, the theory behind that, but haven't explored their use for these sorts of materials, these purposes”.

Output: Researchers at Penn State College of Engineering have developed a technology that uses the meeting of salt water and fresh water to produce electricity. If the technology is successful it could meet up to 40% of the world's energy needs, however, many obstacles would need to be overcome first. Although methods of producing electricity by using a saline gradient have been ineffective so far, a combination of earlier approaches has the potential to generate a far greater amount of energy, said Penn State assistant professor Christopher Gorski.


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'Digital twins' leverage internet of things for energy industry
 This article first appeared on Bloomberg View and the Bloomberg Terminal.

By Nathaniel Bullard

In a prescient 2011 essay, venture capitalist Marc Andreessen declared that “software is eating the world.” Six years on, software is eating more of the world than ever — and it is also creating. One of those creations is digital twins, virtual models of industrial equipment, built up with gigabytes and terabytes of sensor data, that allow companies to remotely monitor the performance of power plants, jet engines and … well, anything worth monitoring, really. These digital twins will create numerous opportunities for companies and their clients, as well as raise challenging questions.

Digital twins aren’t unique to a particular kind of company, though industrial conglomerates General Electric Co. and Siemens AG are their most visible proponents. The technology represents an evolution within industrial firms and the logical outgrowth of a number of factors that my Bloomberg New Energy Finance colleagues have identified: cheaper and better sensing, processing and data transmission.

It’s also early days for the technology. Research firm Gartner puts digital twins in the “innovation trigger” phase of its Internet of Things hype cycle. Still, the potential market for digital twins is already large, even within a select group of energy and transport assets. Consider wind turbines, which have seen 265,000 installed since 2000. Wind turbines alone are a far larger market for digital twinning than the 30,000 jet engines in GE’s digitized fleet.

Many Potential Twins

Selected energy* and transportation assets

Sources: Bloomberg New Energy Finance, GE

*Energy assets commissioned since 2000

The market for digital twins in fossil fuel power plants may seem smaller (BNEF tracks only 477 new coal plants commissioned since 2000), but each one contains dozens, perhaps hundreds, of pieces of equipment that could be digitized. That market will only grow, as the number of devices that can be digitized grows and the cost of digitizing them drops.

So which industries are best situated to own and operate digital twins? Ed Crooks of the Financial Times explored the industrials-versus-software question in an article this week: In Crooks’ words, “what is it exactly that they do?” Is a turbine manufacturer a maker of dumb metal for a software company to optimize? Is software a service and support for industrial operations, or are industrial operations the input to a software-determined set of processes or even businesses?

Another question: How many digital twins is too many? Take those 265,000 wind turbines and GE’s 30,000 jet engines; both have spinning rotors and can and would need to capture much of the same types of data. Then there are the 15,000 solar projects — but those projects are each made up of tens of thousands (even millions) of individual solar panels as well as other pieces of equipment. What is the twin of a solar project? Is it the entire plant? The inverter “string” of hundreds of solar panels? Or will a solar project’s digital twin be a family of twins, so to speak, each a single solar panel? As processing becomes cheaper, as sensors become better, as data transmission becomes both, is there a logical upper limit to how many digital twins the world can have?

A final question: What is the liability paradigm in a world of digital twins? A digital twin could assess an impending failure in a piece of industrial equipment, and a company could fail to act on it. Or a digital twin could fail to predict a failure, and industrial equipment could suffer. Where is the liability in such scenarios?

To put it another way: Are digital twins the black boxes of the world? And if so, how long before a digital twin is called to testify against its physical counterpart and its corporate operators?

Output: "Digital twins" are allowing energy companies to create virtual models of industrial equipment using sensor data, allowing it to be remotely monitored and enabling impending failures to be detected. Wind turbines may provide the largest potential market, with 265,000 having been installed since 2000. Fossil fuel plants also contain hundreds, or even thousands, of potential pieces of equipment that could make use of digital twins. Issues to be considered include how many individual "twins" would be needed for large projects and where liability should fall in the event of equipment failure.


Instruction: create a high quality summary of the given input

Input:
Researchers develop new way to track oil leaks
 Leaks from offshore oil rigs often go undetected for a long time, as even seemingly large quantities of oil are immediately diluted by the surrounding water. Previously developed sensors have lacked the precision to quickly and accurately pick up on oil leaks because of this, often allowing gradual oil releases into the surrounding ecosystem for months at a time.

In a bid to tackle this problem, the Norwegian Geotechnical (NGI) teamed up with Kjeller Innovation to develop a polycyclic aromatic hydrocarbon (PAH) sensor. It is able to collect precise data and make it digitally available in real time to operators monitoring it on the rig.

It is hoped that the increased monitoring capacity provided by the sensor will help tackle oil leaks and help prevent the environmental and economic disasters they can cause. But what makes it different to previous methods?

A more precise sensor

NGI’s new sensor is based on years of research conducted as part of the IMiRO project. Funded by The Norwegian Research Council this project was designed to investigate in-situ monitoring of hydrocarbons within water.

The PAH sensor differs from previous techniques for monitoring oil leaks because it is better able to separate pollutants from background hydrocarbons, and then provide a constant stream of information to the rig.

“The thing that is new with this sensor is that there is a separation of background hydrocarbons and potential leaks before the final measurement is done, which looks at the concentration of the PAH of the sea, to identify those which are toxic compounds that would be dissolved in the water during an oil spill,” says NGI's project manager and technical lead for contaminated sediments Espen Eek. “This is based on similar principles as earlier methods but with an extra step that improves the method significantly.”

Background hydrocarbons

One of the problems sensors have previously faced has been the background levels of hydrocarbons in oceans. Worldwide 40% of oil found in the water comes from natural seeps in the ground, and within North American waters as much as 60% of oil in the water has seeped up from underground.

"Worldwide 40% of oil found in the water comes from natural seeps in the ground."

Alongside naturally occurring oil there is that which comes from human activity unrelated to oil production. Oil from on land vehicles is washed into oceans through rain water, and recreation boats and jet skis often leak oil. These leakages are very hard to quantify as an estimated 80% of spills go unreported, and a still greater amount unnoticed.

Because of these background hydrocarbons, previous sensors have struggled to precisely identify leaks from oil rigs. “One of the problems has been the lack of separation that make sensors very vulnerable to other compounds naturally occurring in the water and that are not coming from the oil spills,” says Eek. “There are various natural organic matters actually in the seawater that are potentially damaging to such measurements. It is why it's necessary to have a more precise method that is at the same time more intricate.”

By taking into account the levels of hydrocarbons present within the water at any time, the PAH sensor identifies changes caused by leaks more accurately.

The information about the background hydrocarbons is also hoped to provide a greater general understanding about the waters surrounding offshore rigs. “More precise environmental monitoring will mean you're able to see which oil producing units cause the least or most environmental impact and you can use information,” explains Eek.

This information could inform the design and implementation of future rigs to ensure they have a minimal impact on the surrounding environment.

Collaboration for commercialisation

The NGI now has a prototype of the sensor ready for testing over the course of the next year. “Our plans are to test the prototype in the near shore environment this year and then begin offshore testing next year,” says Eek. “It's really exciting to see how it's all turned out, and to get it from the lab to the sea is the last, important step.”

"The NGI now has a prototype of the sensor ready for testing over the course of the next year."

Testing will initially begin in the Olsofjord, an inlet in south-eastern Norway, and if it proves successful the sensor will be placed in a fully operational oil field. Its creators are hoping that it will become commercially available within the next few years, helping to minimise oil leaks through early detection and recognition of the most environmentally friendly practises.

It is here that the collaboration between NGI and Kjeller is particularly important. “Collaborating with Kjeller Innovation has been great because we at NGI have a more technical and environmental focus, a chemical technical focus, and they have a greater focus of commercial marketing,” says Eek. “So we can just focus on the technical aspects and they will work more with the marketing and the funding part of the project.”

Putting an end spills and leaks

Globally there are 496 offshore oil and gas rigs in operation today, and operators have made extensive efforts to prevent oil spills. But given the extreme conditions in which they operate, this remains an ever-present challenge.

Oil leaks from rigs tend to have a smaller visual impact than oil spills, the largest of which happened during the Gulf War when Iraqi forces released between 252 and336 million gallons of oil into the Persian Gulf. The environmental effects of such a spill are colossal.

Whilst the result of an oil leak is less dramatic, it is nevertheless damaging to the surrounding environment. Even small amount of hydrocarbons can be poisonous to sea creatures and plants. However, because they have been so difficult to track previously, the true effect of constant low-level hydrocarbon pollution is largely unknown.

In April 2016, an oil rig off the coast of Australia leaked an estimated 10,500 litres over the course of two months. This leak, amounting to 175 litres a day, went unnoticed over the course of the period as works were taking place on the rig. Oil production was therefore halted, as were the hydrocarbon tests within the surrounding waters which would normally have taken place. The leak occurred due to erosion of a well seal, and has drawn criticism from environmental agencies around the world such as Greenpeace Australia. It is events such as this that NGI and Kjeller are particularly hoping the PAH sensor will put an end to, as the leak could have been picked up on much faster with constant monitoring.

Output: The Norwegian Geotechnical Institute (NGI), in cooperation with Kjeller Innovation, has developed a new way to track oil leaks. The polycyclic aromatic hydrocarbon (PAH) sensor measures hydrocarbons in the waters surrounding oil wells, aiming to prevent undetected leaks by gathering accurate data and making it digitally available in real time to operators. NGI has a prototype of the sensor ready for testing over the course of the next year.


Instruction: create a high quality summary of the given input

Input:
Solar thermal and storage are going to dictate the power market

The 150MW solar tower and molten salt storage plant to be built in Port Augusta has been made possible by a ground-breaking pricing and contract structure that could help completely reshape Australian power markets, including the end of “baseload” power as we know it.

The South Australian government announced last week that it had signed a deal with US company SolarReserve to build the 150MW solar tower with molten salt storage project – to be known as Aurora – just a few kilometres from the now closed Northern coal-fired power station.

The output of Aurora will be around 500GWh – roughly the same as the annual consumption of the state government and the various assets it owns.

But it is the unique nature of the contract that explains the difference between what the government will pay SolarReserve ($75-$78/MWh), and what SolarReserve will receive, and will likely serve as a template for more “dispatchable” renewable energy projects in the future.

Essentially, Solar Reserve will provide the S.A. government with some of its needs from other sources in the market when demand and the price is low. Aurora will cover the government for energy and prices when the government’s demand is at its highest, around the middle of the day.

But because the government can and will get some cheap power elsewhere, Aurora will be able store its solar power in its molten salt storage tanks so it can sell into the market at the system peaks, in late afternoon and early evening, when the market prices are highest, boosting its revenue.

For those in the market, it is a little like a power purchase agreement where an off-taker takes part of the output, while the rest of the plant goes “merchant”. But this contract has a lot more flexibility and is more flexible than plants that use traditional cap contracts.

Danny Price, from Frontier Economics, who helped the government design the contract, says it was struck with a mixture of a capacity purchase agreement (CPA) and a hedge, with the CPA designed to break down the fixed costs and the variable costs.

“We had to have a contract for wide range of technologies,” Price tells RenewEconomy, and the contract structure was designed to level the playing field between dispatchable renewables, which may struggle following loads MW for MW.

Although the fine details of the contract are not being released, at least not yet, the significance should not be understated.

South Australian energy minister Tom Koutsantonis boasted last week that it would send “shivers” through the spine of the coal industry – not that there is one left in his state, but there is no reason why this cannot apply in other states.

There has been great debate about how traditional energy markets, which rewarded baseload power with expensive peaking capacity, could evolve to include renewables with zero fuel costs such as wind and solar.

Price says rather than redesigning the whole system, this contract structure plays within the current design – and the ultimate goal is to provide more stability to markets. It also avoids the pitfalls of conventional capacity markets, which have been shown in Western Australia to be disastrous if badly designed.

Aurora will have no incentive to do as wind and solar PV farms do, and bid in negative prices to guarantee dispatch, and the fact that it is competing in peak times means it reduces the ability of the thermal players to game the market up to pricing peaks of $14,000/MWh.

What’s more, it’s a cheaper technology than gas or new coal. “You couldn’t even buy the gas for that price – let alone the capacity,” says Price of the $75/MWh contract price. And new coal, he says, cannot be built for less than $100/MWh.

“Who would build a gas or coal-fired generator if you can get a dispatchable renewable energy technology like solar thermal for $70/MWh? Why would you do it?

“It is a terrific outcome for the market and for renewable energy. It shows how you can construct a contract to encourage dispatchable renewables.

“It means we can get a renewable energy technology up that is cheaper than thermal plant. So while the federal government stuffs around on carbon pricing, technology is just taking them over.”

Price said one of the keys to the project win was the learnings of SolarReserve from its Crescent Dune facility in Nevada, which has been operating for just over a year -– apart from a few months off-line to deal with a leak or leaks in the molten salt storage tank.

Price said the key to the technology was the receiver, and it was “a very good technology.” SolarReserve had learned a lot from its first plant, capital costs had fallen 40 per cent, and costs were continuing to come down.

“The technology is not really a risk. We get the benefit of the learning so far, and we are second cab off the rank.”

Please read this piece by Simon Holmes á Court, which looks at some of the other interesting aspects of this development, particularly his observation that solar thermal technology is already nearing the price predicted by Alan Finkel for 2050, just a few months after the Finkel report was released.

There are a few things that could still go wrong.

The current contract price is dependent on the $110 million equity partnership promised by the federal government both before the election and when it was negotiating a tax package with Senator Nick Xenophon, whose dual-citizenship means his immediate political future is now subject to a High Court ruling.

It is clear, and SolarReserve CEO Kevin Smith said as much in a radio interview on Monday, that the pricing would have to be revisited if that component did not come through.

He did, however, say that financing has been lined up. It is not thought that renewable energy certificates will contribute largely to the deal.

While they are trading round $80/MWh now, they are expected to have fallen dramatically by the time this plant is up and running in 2020, and could have negligible value before they expire in 2030.

Solar towers with molten salt storage, because of their high storage levels, offer the flexibility to offer either continuous power 24/7 (baseload), higher outputs over shorter periods to meet specific demand (such as powering Las Vegas between noon and midnight), or acting as a “peaking” power station.

This new South Australian plant appears to be designed to include the last two components. Its nominal capacity of 150MW will likely be reduced to 135MW during the day, where it uses some of its own power to operate and control the sun-following field or mirrors.

But by being dispatchable in such a way, the solar tower will beat both coal and gas at their own game.

Coal’s big weakness, apart from the fact that it is now dirty and expensive, is that it can’t readily be turned off, which is why loads such as hot water systems are switched on only at night – to give the coal-fired power plants something to do during the night.

The arrival of “base-cost” renewables, however, means that much of the power supply can be delivered by wind and solar at cheap prices.

And the emergence of storage in its various forms – batteries, pumped hydro and now solar towers – means that output can now be dispatchable, or can be balanced, and can mean manufacturers may no longer have to operate only at night when the power cost is low. Cheap power may be a day-time event.

Aurora will not need to operate all the way through the night, although it could. If the government needs power, it will likely buy from other sources at a cheaper price, Aurora will deliver to the government during the day, meet and cover its peak demand, and sell into the afternoon and evening system peaks.

Of course, Aurora is not the only solar thermal project happening in the world right now. SolarReserve is building another plant in South Africa, and other companies are building plant in Morocco, Chile and China.

Keith Lovegrove, director of the Australian Solar Thermal Energy Association, recently returned from a conference in China, where he says the main news is that of 20 announced projects of between 50 and 100MW, three are well under construction and a further five will begin soon.

“The attached pic is a visit to the Shouhang 10MW molten salt tower system there in Dunhuang,” he says.

“It looked good (from the outside at least). Right next door that company is well into building the 100MW salt tower system that is one of the three mentioned above. CSP is alive and well in China and maybe has finally a good chance of life in Australia.”

Please listen to our podcast with Keith Lovegrove and David Leitch, and this article’s author to discuss the solar tower project, its economics, the implications for the market, and what may follow.

(Note: This article has been updated to make it clear that SolarReserve will be buying power on market, and at cheaper prices when demand is low, not the S.A. government. The purchase will be made by SolarReserve as part of its contract to meet the government’s power needs).

Output: Cheap electricity during the daytime could become a reality in South Australia, thanks to a uniquely flexible deal signed with US firm SolarReserve, whose 150MW solar tower with molten salt storage project – known as Aurora - looks set to beat coal and gas at their own game. Aurora's high storage levels make it an ideal dispatchable, base-cost renewable, while the deal inked allows SolarReserve to sell power at peak times to third parties. However, the deal is dependent on a $110m equity partnership, which could be at risk following questions surrounding Senator Nick Xenophon's dual citizenship.