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Use Cases

Ireland

Use case I “Escalation protocols for red flag events”

Maura is a 76 year old lady living alone, her husband passed away three years ago. She has two children, one daughter Bernie who lives nearby, and one son who lives abroad. She has two close friends in the area. She lives in a medium-sized town in the south-west of Ireland. Maura has middle-stage dementia which is deteriorating rapidly despite the use of medication.

Maura’s daughter comes in every day to check on her and spends a few hours providing practical support around the house. Three times a week Patricia, a care assistant employed by the Alzheimer Society (ASI), comes to help Maura take a shower and exercise, as well as cleaning and cooking. Jane the Care-Co-ordinator carried out an initial assessment on Maura and reviews this every three months.

Maura has a full telecare package installed (base unit, pendant alarm, smoke alarm, three movement detectors, heat sensor, property exit sensor, CO detector, flood detector and fall detector). This has been in place for 12 months. The telecare centre is based in Bunclody, County Wexford. It provides a 24-7 service to ASI clients. Sensors installed in a client’s home communicate via RF to the base unit, which then transmits this information back to the secure server. The bespoke software system PNC4 converts the information and presents it in a form of a client record to the telecare operator with all relevant contacts listed as well as presenting the device that created the alert. Prior to INDEPENDENT, activity reports were generated weekly and exported into an excel format which was forwarded to ASI Care Co-ordinators.

Over the last three months, Maura has consistently left the house on Friday nights at midnight. The front door of the house has not always been alarmed due to the family carer forgetting to set the alarm. She has been identified as missing on a number of occasions and found by the local police. She has lost the ability to remember where she lives and has consequently spent nights in the local hospital.

On a Friday night at 12 midnight, Maura leaves the house by the front door. Bernie has remembered to activate the door exit sensor. Maura walks towards the main street of the town. The alert has come in to Monica in the telecare centre. Monica contacts Bernie immediately who advises her to contact the other people on the contact list as well, so that everyone can join the search for Maura. Maura is returned home in a confused and agitated state by Bernie who remains with her for the rest of the night.

The next morning, Monica contacts Jane the care co-ordinator in the ASI, to inform her of the red flag event which took place the previous night. Jane logs into the telecare portal and views the log of the event. She then makes a phone call to Bernie to establish whether any further steps need to be taken to assure Maura’s continuing safety and security, thus supporting her continued independent living. Jane then contacts Patricia to alert her to the event of the previous night, and Patricia is able to adapt her next visit to try and reassure her and calm her into a normal routine.

Jane then checks back over Maura’s record via the telecare database in the portal, to see whether a pattern of such events is evident. She sees that Maura has left the house consistently on Friday nights. Access to the telecare database allows Jane to assess whether she needs to make a change to the care plan. She contacts Bernie, who says that she is happy for Maura to stay at home with the support of the telecare service and some extra hours of home help. Jane agrees and adjusts Maura’s care plan accordingly.

Use case II “Continuous real time information” (Variant I)

Mary is a 67-year-old married woman who has suffered from depression through her life, now further complicated by Alzheimer’s dementia. Her husband has fulfilled the role of carer for the last 10 years, first due to her depression, and for the last two years, due to her dementia. Mary and Tom live in a small rural town of about 2,000 people in the southeast of Ireland. Her deterioration has been rapid and marked and she has had a core telecare package (base box, pendant, two smoke alarms, flood detector and property exit sensor) installed for the last nine months. She has had access to a home care package from the Alzheimer Society, for the last nine months. The home care package consists of the services of a care assistant (Patricia) who visits five days a week for three hours a day. Patricia the care assistant helps with cleaning, and personal care, exercise (taking Mary out for a walk) as well as providing general support to Tom.

Mary has three children, one daughter Anne (aged 40) who lives locally and is married, and a daughter and son who both live in Dublin and work full-time, and are in committed relationships. Neither the daughter nor the son who live in Dublin have the time to visit Mary regularly.

Mary loves to cook, and frequently leaves the electric cooker switched on. She has also flooded both the kitchen and the bathroom on an increasing number of occasions. This nearly always happens at night. Tom and his daughter are extremely stressed and exhausted as they are both sleep-deprived and are providing 24-7 care.

Tom brings Mary to bed at 9pm. Mary has slept for most of the previous day (Tuesday). At 2am, while Tom is sleeping, Mary gets out of bed, goes downstairs and begins to cook a meal. When she has finished cooking, she leaves the kitchen, leaving the frying pan on the hob and forgetting to turn off the cooker. The smoke detector in the hallway picks up the smoke from the frying pan, and creates an audible alert which is simultaneously transmitted to the telecare alert centre.

Tom is raised from his bed, and a call is made from the monitoring centre to his house to make sure everything is alright, to which he responds that he has identified the problem and everything is fine. He says that there is no need to contact anyone else. This is the fourth such event in a three-week period. Tom brings Mary back to bed and they both go back to sleep.

The following day, Jane, the care co-ordinator, receives a report on this event, and subsequently logs on to the telecare portal and enters the telecare database section in her office to map the instances of alerts over a three-month period. She finds a steady increase in the amount of activations over the last three months, specifically from the flood detectors and smoke alarms. She rings Tom to arrange a visit in the next week. When she visits Tom and Mary, she looks at the log book first and then in conversation with Tom she assesses the situation and suggests a review case meeting on Mary’s care, with Tom, his daughter Anne, and Patricia the care assistant present.

In the review meeting, Jane is able to build an alarming pattern of incidents during the night through the reports accessed in the telecare database, and suggests that the support mechanisms for Tom are inadequate and 24/7 care is required. Tom agrees with this conclusion. It is agreed that a case meeting is required with Aoife, the public health nurse, and Anne asks Jane to set this up.

During the case meeting it is agreed to a re-assessment of Mary’s situation, following which it is discovered that her needs have increased beyond the provision of domiciliary care, in addition to which it is discovered that due to Tom’s financial situation and his deteriorating health, he is no longer able to provide care for Mary at home. A decision is made to make an application for admission to a local HSE-run nursing home. A few weeks later Mary has been admitted to the nursing home.

Use case II “Continuous real time information” (Variant II)

In Variant II, Mary is in the same situation as Variant I. However, the review meeting has a different outcome, as follows:

In the review meeting, Jane is able to build an alarming pattern of incidents during the night through the reports accessed in the telecare database, and suggests that the support mechanisms for Tom are inadequate and 24/7 care is required. Tom agrees with this conclusion. It is agreed that a case meeting is required with Aoife the public health nurse, and Anne asks Jane to set this up.

During the case meeting it is agreed to have a re-assessment of Mary’s situation, following which it is discovered that she has had an ongoing urinary tract infection. She is referred to her general practitioner to receive appropriate treatment. In order to provide further support to Tom, he will be introduced to a carers support group in a neighbouring town, and encouraged to attend a carers training programme run by the ASI due to be held the following month in the county. The public health nurse has agreed to provide respite care for Mary in a local respite centre.

Geldrop, the Netherlands

Use case I “Exercise from home”

Peter is 76 years old and a COPD patient. He has smoked almost his entire life and has only recently quitted smoking, when his GP and the pulmonologist urged him to do so. He is widowed and lives alone in the centre of Geldrop in his own house. Peter has become quite depressed since he was diagnosed with COPD. Since his wife died 2 years ago he lost motivation to meet friends and to continue his hobbies. He rarely leaves his house. Shopping is done by a voluntary carer, two times a week.

Simone is a 32 years old physiotherapist from Eindhoven and works at TopSupport. Twice in a year, she comes to the hospital St. Anna for a meeting with the pulmonologist to talk about the exercise programmes and their COPD patients.

Recently, Peter started using the INDEPENDENT system that enables him to exercise from home guided by a physiotherapist through the use of a webcam and a special web service. The web service also enables communication with other patients.

Once a week, Peter trains at the practice of the physiotherapist, and once a week he can stay at home, which is quite a benefit for him. He always looks forward to it. Not so much because of the exercises, which he feels are a necessary evil, but because he will see the people again with whom he attended the rehabilitation programme in the St-Anna hospital.

Margreet, a friend of Peter, is 67 years old and has also COPD. The two met when they were in the same rehabilitation group some time ago. She lives by herself in Veldhoven, a suburb of Eindhoven. Peter always logs in a little earlier to have a chat with Margreet. A bit later, also the physiotherapist Simone logs on and checks whether everybody is present and ready to start the exercise programme. They usually have a session with about 4 patients. Simone starts the session with some basic exercises, after which they continue with some breathing exercises. Simone ends the session, while Peter and Margreet stay online to have another chat.

Use case II “Check patient file and progress”

Peter is 76 years old and has COPD. He has smoked almost his entire life and has only recently quitted smoking, when his GP and the pulmonologist urged him to do so. He is widowed and lives alone in the centre of Geldrop in his own house.

Recently, Peter started using the new INDEPENDENT service, a secure web service that keeps track of his vital sign measurements, medical treatments, important medical documents and the patient history. Another service that is offered through the system keeps track of all measurements of the physical activity monitor Peter is wearing. The physiotherapist can access these measurements on a patient level or on a group level.

Peter checks his health record, just to keep track of his current condition, and to see how his health is progressing. He likes the fact that he can look up his exercises, medication prescriptions, and measurements. Peter can be quite forgetful sometimes. By checking his patient file, Peter can refresh his memory, and see how his condition is. Of all the data Peter can look-up, he likes the graph of his physical activity the most. He uses this to see if he made any progress, and it helps to motivate him to take little walks.

Dr. Hendriks is a pulmonologist working with two other pulmonologists in the pulmonary department of the St. Anna hospital. He is also happy with the new patient file system. It allows him to keep track of the patient history as well as the current medication the patient receives. The patient file system also keeps track of the vital signs measured by the patients, which give Dr. Hendriks a good picture of how the patients are doing. Dr. Hendriks can also see the results of measurements conducted by the physiotherapist. Furthermore, the system allows Dr. Hendriks to communicate with the physiotherapist about a certain treatment.

Simone, the physiotherapist, uses two parts of the system. One part to keep track of the results of the measurements she conducted with Peter and to look into muscle function reports conducted by the hospital in the past. She uses this information to tailor her exercise programme for Peter. The other part of the system is the overview of Peter’s physical activity. She uses this to notice improvements, or when the physical activity changes, to adapt the exercise programme. She likes the fact that she can not only see the physical activity of a patient, but also of a group of patients combined. She uses this information to create new groups of patients that are on the same level.

Hull, United Kingdom

Use case I “Unscheduled Care”

Edna is an 87 year old woman, who lives in a self-contained flat within Housing with Care and Support (HWCS). Edna has COPD, which causes her to become breathless on moderate exertion. She also has type II diabetes, which is well-controlled by oral anti-diabetic medication and diet. Edna is becoming increasingly frail and finding some activities of daily living more difficult to carry out. Specifically, she is struggling to carry out personal care unaided. Edna also wants to stay in the HWCS as she enjoys the social activities for residents living on or near the scheme. Recently, Edna developed a venous leg ulcer that is being dressed twice a week by a community nurse.

Colin is Edna’s son. He lives over 300km away from Edna. Though he feels very remote from his mother, he is unable to move closer to her due to his family and work commitments.

Most recently a so-called Multi-User Device (MUD) is placed within a private room that is available for use by residents of the HWCS for consultations and minor healthcare interventions. The MUD has a number of capabilities. In addition to a touch screen interface and keyboard, the MUD also allows for measurement of blood pressure, pulse and weight. Data from the MUD can link into a range of health and social care systems, and is able to provide a directory of services that can be accessed by users and practitioners.

Mavis, a personal carer, arrived at Edna’s flat to help her get washed and dressed. She noticed while helping Edna that the bandage on her leg ulcer had soaked through with exudates. Edna was not sure when she had last had the leg redressed, or when Steve (the community nurse) would be coming to dress it again. Edna appeared upset about the state of the bandage and was concerned that the wound would smell.

Because of the new technology, Mavis has greater access to healthcare services. Mavis went to the MUD in the residents’ room, where she was able to access Edna’s care records. By being able to access the monitoring team via the MUD, Mavis discovered that Edna was not due a routine appointment for another two days. Using the MUD, Mavis was able to report the soaked bandage to the monitoring nurses who contacted her community nurse who, as a result, was able to rearrange his workload and visit her that afternoon to redress her leg.

Steve visited Edna that afternoon, and redressed her leg ulcer. He was able to record this intervention using the MUD, generating a message that was sent to Colin, Edna’s son, informing him of the care delivered. In this case, Colin is a passive recipient of information – albeit information that reassures him that his mother is being well-cared for. However, the cross-sectoral functionality of the MUD means that in similar circumstances, the third sector carer is able to take on a more active role. For example, if Edna had reported to Colin on the phone that her bandage had soaked through, he could have directly messaged the health and social care teams via remote access to the MUD.

Finally – had Edna wished to – the functionality of the MUD would allow her to directly message the community nursing team to request a dressing change.

Use case II “Directory services”

Edna is an 87 year old woman, whose details are described in Use case I (“Unscheduled Care”). She lives in a self-contained flat within Housing with Care and Support. Colin is Edna’s son. He lives over 300km away from Edna. Though he feels very remote from his mother, he is unable to move closer to her due to his family and work commitments.

Colin had travelled over to visit his Mum one weekend, to see how she was getting on and ask if she needed anything. During his visit, Edna mentioned that she was getting a bit bothered by her toenails, which were getting rather long and uncomfortable. She hadn’t mentioned this to her social carer or community nurse, as she didn’t want to cause any fuss.

In the past, a problem like this would have required Colin to have phoned the chiropody service himself at the start of the working week, and try to arrange for someone to come round to see Edna at a convenient time. However, Colin and Edna are now able to go down to the resident’s room, and use the Multi-user device (MUD) to access a directory of services. The MUD was recently installed and the directory allows Edna to gain information about a range of third sector (including her meals on wheels service), social care (such as benefits) and health care services.

On this particular day, Colin and Edna use the MUD to access information regarding the local chiropody service. The directory allows them to see when community chiropody visits are available, and also provides a ‘choose and book’ function so that an appointment can be made online. This means that Edna is reassured that the chiropodist will come to visit her the following week and Colin is happy that his Mum’s concerns have been dealt with. The Chiropody service also benefits, as appointments are filled without the need for telephone discussion and administration.

Use case III “Long-term care monitoring”

Henry is a 76 year-old man, who lives alone in a terraced house in Hull. Henry has a ‘lifeline’ alarm system, linked to the Housing and Care Telemonitoring Centre. He was diagnosed with heart failure 12 years ago, and recently required a hospital admission due to fluid retention and breathlessness. In addition to his heart failure, Henry is occasionally forgetful when it comes to elements of self-care such as medication administration and food preparation. Henry’s wife – Jean – died 15 years ago.

Sue is Henry’s daughter. She lives in a small village approximately 50km from Henry. Though she is able to visit him every weekend Sue worries that she is too far away from her father. She is particularly worried about the fact that he is reluctant to call for help and sometimes forget things. Her concerns have been exacerbated by the fact that Henry seems more anxious and less mobile since his discharge from hospital.

The system within Henry’s home is a technology hub that links to the telehealth service, hospital information systems and the Electronic Patient Record. The system provides facilities for the measurement of blood pressure, pulse and weight. It also allows for questionnaires related to health and social care issues to be posted for Henry to complete. The system also contains educational and motivational resources linked to living with heart failure. Finally, the system allows for multi-level access to online data and individualised messaging services.

One morning, Henry woke up feeling a little unwell. He didn’t sleep very well, and found that he was a little more breathless than usual. Nonetheless, he got up as normal, ate his breakfast, and switched on his television and PHWS. The system indicated that he had a number of reminders and messages.

The first reminder was to carry out the vital sign check for the day. He recorded his blood pressure, pulse and weight, and these measurements were available for him to see immediately. He noticed that his weight had gone up a little bit, and his pulse was a bit faster than usual. The ability of the system to show him trends in his vital signs was something that Henry found very useful. He now had a much better understanding of the importance of weight, blood pressure and pulse as indicators of health, and understood how behavioural changes could alter findings.

Following the vital sign measurements, Henry was prompted to answer some questions about how he was feeling. These questions had been formulated collaboratively between his health and social care workers. They asked about his symptoms and, when he indicated that he wasn’t feeling too well, Chris, the voluntary sector worker was messaged about this by the monitoring nurses and asked if he wanted to be visited straightaway. Henry felt that he would benefit from a visit and indicated this through the system. Chris visited Henry and was able to get a clearer idea of whether there was any other assistance that Henry needed at this point. As part of the monitoring team, she has a laptop with her that allows her to communicate with the PHWS and to input information for Debbie, the specialist nurse, to view.

Half an hour later Henry received a call from Debbie, the specialist liaison nurse. Debbie had been alerted to the fact that Henry’s vital signs were outside the normal limits, and that he had reported feeling breathless and she has now seen the follow up from Chris’s visit on the system. After talking to Henry for a few minutes, Debbie decided that some input from the community long-term conditions nurse would be useful. She contacted Jackie, explained the situation to her and they decided that Jackie would arrange to visit Henry later that day. After Jackie visited Henry, some changes were made to his medication regime.

These data, responses and interventions were all recorded on the PHWS which therefore reduces duplication of effort in relation to data entry by healthcare staff. At the time of installation, Henry decided that his daughter should also receive information about his condition so she has access to the information on the PHWS via her laptop computer. Sue therefore has been kept up to date with what has been going on with her dad and has used the system to send messages to him to check that he feels looked after.

Milton Keynes, United Kingdomm

Use case “Support of informal carers”

Yvonne is 84 years old and now lives alone. In the past 18 months her husband has passed away and her 3 closest friends have also passed away. Yvonne’s only remaining friend Janice visits her daily to assist with daily tasks in and around the house. Janice has no previous experience in how to approach the issue of achieving reactive, immediate or more formal support for Yvonne when daily living issues arise. Janice also has no previous experience in exploring how she might be supported in her new unexpected role as a much relied upon informal care. Recently, she has made contact with Carers MK, a voluntary organisation supporting informal carers.

Yvonne had no access to the internet or a home computer or other devices at home, until a technology package was provided and implemented by ConnectMK a few months ago. Her only means of communication prior to this was by fixed line telephone, which she used infrequently for fear of incurring significant additional call costs. Since some weeks Yvonne can use the INDEPENDENT service. Kaye, the technology Support and Trainer at ConnectMK installed the necessary equipment and provided the necessary training. After a few days Yvonne really got used to the new portal and appreciates the support she gets.

Yvonne woke early today and didn’t feel well in herself, not ill as no determining factors but not her “usual” self. After getting out of bed and making her breakfast she decided that she wanted to speak with Janice who was not due to visit her until tomorrow. Firstly she logged onto Connecti, the portal developed in INDEPENDENT, and answered the “wellbeing” prompt about how she was feeling adding a brief description about how she was feeling.

When Janice logged in to check for any correspondence from Yvonne she immediately saw her comments and arranged a web conference through Connecti. When the conference call takes place Janice immediately recognises the physical and verbal differences in Yvonne and although the call improves Yvonne’s emotional state the combination of the of the wellbeing assessment and the web conference resulted in Janice altering her schedule and visiting her later that day.

Janice stayed with Yvonne until very late that night and had to do considerably more that night to support Yvonne’s needs. It left Janice very tired and frustrated as she was struggling with the balance of supporting her friend and juggling her own life needs. It brought about the realisation that Yvonne may need more than she can offer at short notice.

After some initial online support Janice booked another web conference with staff at Carers MK to discuss additional support for both Yvonne and for herself. That confidential, remote support enabled Janice to deal with Yvonne’s additional needs.

She does not need to be at home to have confidential communication because she uses the facilities at Yvonne’s home and logs in using her secure details. For Janice this is real time support.

Andalucia, Spain

Use case I “Medical appointments”

Anna is 72 years old and lives with her husband Miguel. Three months ago, she experienced a serious fall and broke her hip. Since then, she has to visit periodically the doctor to check how she is recovering. To arrange the appointments with the doctor, she usually calls ASSDA, because she just has to push the button of her social alarm device to contact an operator, who then arranges everything for her.

One day, Anna needs to ask for an appointment with her family doctor, but she is not feeling well today. Her husband Miguel decides to do it for her. Although he is not a client of ASSDA, he knows that he can make the arrangements using the social alarm device from his wife. Miguel pushes the social alarm button in order to request for an appointment with Anna’s family doctor. Marta at ASSDA answers the call, and after listening to the request, she transfers the call together with the user’s data to Juan, the operator at Salud Responde.

In this way, Miguel is able to speak directly with Juan in the same call, without hanging up the phone and calling another number, as it was necessary before the new INDEPENDENT service was implemented. Juan and Miguel quickly arrange an appointment with the family doctor.

When Juan hangs up the phone, a notification with the date and time of the appointment is sent to ASSDA, so Miguel can ask the Tele Care service for a reminder the day of the appointment or access that information by just one call at any time.

Use case II “Health Advice”

David is 67 years old and lives with his wife. He has diabetes and has therefore to control his weight regularly, adhere to a special diet, do regular exercises, and follow a medical treatment to control his level of sugar. Recently, David sometimes forgets to take his medication on time. Usually his wife is there to remind him to take the medication but since last week he is alone at home because his wife has gone to visit her sister and will stay there for a few weeks.

David is alone at home and is having breakfast when he suddenly remembers that has not taken his medication. He pushes the social alarm button to ask the operator at ASSDA what to do. Laura receives the request. As it is not an emergency she transfers the call directly to Salud Responde, where Monica, the nurse, provides the necessary advice to David, who is very grateful for that.

When Monica hangs up the phone, a notification is sent to Laura at ASSDA who checks that David received well the information.

Additionally, in the event that “an originally classified as medical advice” use case become an emergency situation after being assessed by Salud Responde the call will automatically be transferred to the 061 Emergency Services from EPES which will handle the call as required. Additionally, a notification will be sent straight away to ASSDA so they can transfer the data from the users directly to EPES assigning the ID of the user and the call, so that the emergency services will access to the users information in real time. This will allow for a direct interaction with the CommonWell project which is already being piloted in the region of Andalucia between ASSDA and the emergency health services from EPES.

Trikala, Greece

Use case “Psychological support to the informal carer through Tele-counselling”

Yiannis (85) is a retired farmer suffering from mild cognitive impairment. He lives in a remote village of Trikala prefecture in Greece. His sense of orientation has recently deteriorated in such a level that he moves only in the perimeter of his own garden. He lives together with his 77 years old wife Maria who is his devoted carer. Their children, Dimitra and Spyros, live in Athens and Cologne with their families. Since they are very worried about their parents they have recently convinced them to seek assistance from the municipality’s telecare centre, a non for profit organisation offering specialised services to all inhabitants of the area.

Maria is a housewife who spent her entire life in the village and whose health is very good. She found herself in the unpleasant situation where her spouse is totally dependent on her while his behaviour can be really difficult to cope with. She usually feels tired and disillusioned and quite close to desperation as she feels left out and completely isolated.

Maria woke at 6:30am today and, as every working day, she prepares breakfast for her and her husband Yiannis. She is doing the household and waits until Yiannis wakes up. Yiannis didn’t sleep well last night, he had nightmares and Maria tried to calm him down.

At around 8:00am, Yiannis wakes up and seems very well. He eats his breakfast and then he watches his favourite TV show. Maria goes into the garden to do some work. When she returns into the house she is not able to find her husband. Although she is searching for him in the entire house she cannot find him. She’s getting very worried about him and starts searching also outside the house. Two hours later, Yiannis returns home saying that he was at work. Maria reminds him that he is retired but Yiannis doesn’t agree with her.

Maria is really worried about Yiannis and so she decides to call Kostas, the service operator at the municipality telecare centre, in order to ask for a transfer of Yiannis to a nursing home. She really feels that she can no longer ensure Yiannis safety and wellbeing. Kostas tries to calm Maria down and records the appropriate information to the integrated electronic health record. Eleni, the psychologist working at the telecare centre, looks on her computer and sees the alert message from Kostas. She enters the medical folder and has immediate access to specific fields. She checks on the data already entered and calls Maria to check the situation. Eleni persuades Maria to go into video counselling three times per week for a period of one month before she makes a final decision about her husband. Maria agrees.

Dimos, the technical personnel of the telecare centre, receives an alert in his personal computer that informs him to go to Yannis and Maria’s house to install all appropriate equipment for the video counselling. Dimos visits the house in order to make the adequate equipment installations. George, the physician, accompanies Dimos in order to check the general health status of Yiannis and Maria. After the visit Dimos and George fill in the corresponding fields in the EHR and an automated alert is sent to the psychologist.

The following Thursday Eleni starts a video call with Maria. The two have a very good and encouraging conversation and Eleni boosts Maria’s psychological situation by saying that she can manage the situation and that Eleni is going to help her. When the call is finished Eleni enters the integrated EHR and fills in the corresponding fields with the adequate information. After a few sessions Maria is much more confident about the way that she will cope with the caring for her husband. It soon becomes evident that there are qualitative changes in the everyday life of the couple.