A person-centered framework for technology adoption that works in real life

Monica A. Wallace | Founder & Executive Director, Resources Needed for Independence, Inc.

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Executive Summary

Technology is now central to how people manage their health, safety, and daily lives at home. Telehealth visits, remote monitoring, medication reminders, patient portals, and online accounts are increasingly the expected way to receive care and services. For some people these tools increase independence. For others (particularly adults with IDD, including autism, older adults aging at home, and the family caregivers who support them), they can create a new barrier between the person and a task they previously knew how to accomplish.

Most technology initiatives measure access and adoption: devices delivered, accounts activated, trainings completed. But adoption alone is not the outcome. A person can have the device, the account, and the training and still be unable to use the technology safely, confidently, and consistently in daily life.

More care is moving into homes, with family caregivers increasingly expected to assist. Workforce shortages are accelerating technology-first care models, making one practical skill essential for those who support people at home: deciding when to use, adapt, or step away from technology.

Use. Adapt. Opt Out. begins with the outcome a person needs to achieve (better health, greater safety, and more independence at home) rather than with the technology an organization wants the person to use.

Use. Adapt. Opt Out. is a practical toolset, not a program: a decision process, four fit tests, a self-assessment for service pathways, and outcome measures that any organization serving older adults, adults with IDD, family caregivers, or the workforce that supports them can adopt. Used together, the tools are designed to improve outcomes, and the measures in Section 6 show whether they do.

1. The Problem: Adoption Is Not the Outcome

Health care, aging services, and disability services are rapidly moving to digital-first delivery. Organizations have invested heavily in access: devices, connectivity, and digital literacy training. Those investments matter, but they do not guarantee that a person can use the technology to reach the result it was meant to support. A process is not necessarily accessible simply because it is available online, and a device is not necessarily helpful simply because it was installed.

The gap is well documented. Research on assistive technology has found that nearly one-third of devices are abandoned, with even higher rates reported for some device types, most often when the device does not keep pace with the user's changing needs. ^[1][5] Although 78% of adults 65 and older now own a smartphone, roughly one in five do not, ^[2] and ownership does not mean a person can navigate a portal, authenticate an account, or join a telehealth visit without help. When technology does not fit, the work often shifts to family caregivers, who now number 63 million Americans, about one in four adults. ^[3]

Care is also moving into the home, and onto the people who live there. As early as 2008, telehealth innovators were predicting that the patient’s home would become the hub of health care. ^[11] Today telehealth visits, connected devices, portals, and reminders all assume that someone at home will set them up, operate them, and troubleshoot them, and for people who need support that work often falls to a family caregiver. The value of unpaid family caregiving has been estimated in the hundreds of billions of dollars a year, and caregiving takes a documented toll on caregivers’ work, health, stress level, and finances. ^[12]

Workforce shortages are a major reason technology is becoming the default. In home care, a 2025 industry analysis reports that the sector will need about 4.5 million care workers by 2029, that most agencies expect shortages, and that turnover has climbed to nearly 80%, and it describes providers turning to automation, remote monitoring, and AI to ease the strain. ^[13] The pattern is not new: in rural health care, too few specialists pushed telehealth to the center of care delivery years ago. ^[11] In IDD services the shortage is just as severe. ANCOR’s 2025 survey of 469 providers found that 88% reported moderate or severe staffing shortages and 62% were turning away new referrals, and national data show direct support turnover near 40%. ^[14] The State of the States project that tracks Technology First lists addressing direct care workforce shortages among its reasons for the approach. ^[15] When workforce pressure is the reason technology is adopted, technology becomes the standard whether or not it fits the person. That is the risk this framework is designed to manage.

A QR-code-only flyer, app-only communication system, mandatory portal, or online-only registration form can be efficient for an organization while unintentionally transferring the burden of access to the participant. The key question is not, ‘Did we make this available digitally?’ It is, ‘Can the person successfully accomplish the task?’

This distinction is especially important for older adults. Digital inclusion should not require every older adult to become a confident smartphone user. Knowing when and how to bypass unnecessary technology while still getting something done can itself be a form of digital confidence.

A more useful pathway adds the step most programs skip: Access → Adoption → Adaptation → Outcome. Access asks whether the person can obtain the technology. Adoption asks whether they will try it. Adaptation asks whether it can be made to work for this person, in this home, with these supports. Outcome asks whether the person can reliably achieve the result the technology was meant to support. Use. Adapt. Opt Out. is the decision process for that missing adaptation step, and it always starts by defining the outcome.

Use. Adapt. Opt Out. builds on established research. The Matching Person and Technology model showed that technology often goes unused when it does not fit the person, their environment, and the supports around them. ^[6] The NASSS framework showed that health and care technologies frequently fail after adoption because of complexity across people, organizations, and systems. ^[7] Use. Adapt. Opt Out. translates these findings into a simple decision process that community organizations, caregivers, and direct support workers can apply in real-life home settings.

2. The Use. Adapt. Opt Out. Framework

Use. Adapt. Opt Out. starts with the outcome the person needs to achieve. Each support is matched to the path that best reaches that outcome: use it as designed, adapt it to fit, or use an effective alternative. Use is considered first by default, but any path may be chosen first when the person's needs, preferences, or known barriers call for it. Paths are revisited as needs and circumstances change, and a single task may combine paths, for example an adapted voice reminder with a printed backup.

USE: Technology as an Independence Tool

Use technology as designed when it meets four tests: it is usable (accessible and understandable for this person), fits daily life (works within their routines, environment, and support system), is effective (reduces effort or improves health, safety, or independence), and is sustainable (can be repeated over time without adding burden for the person or caregiver). Examples include voice assistants for reminders, medication prompts, connected health devices such as blood-pressure and glucose monitors, telehealth, automated routines, simplified digital calendars, and environmental or safety alerts that reduce the number of steps a person or caregiver must manage.

ADAPT: Change the Process, Not the Person

When a support does not pass the four Use tests, the first response should not automatically be more training. The interface, environment, or process may need to change. Adaptation can include voice instead of typing, automation instead of multi-step routines, visual prompts, simplified instructions, caregiver-supported or remote setup, larger text, fewer authentication steps where permitted, or a different communication channel. Caregiver-supported setup counts as adaptation when the person still completes the task themselves.

OPT OUT: Another Pathway Is Still Access

Sometimes the most accessible technology solution is not to use the technology. Opting out does not mean abandoning the task. It means identifying the simplest effective non-digital or lower-tech route to the same outcome when technology adds burden, cannot be made to work, or is not wanted by the person: calling instead of using a portal, registering by text or phone instead of scanning a QR code, using a simple pill organizer instead of an app, receiving printed instructions, or having staff or a caregiver complete a digital process on the person's behalf. When someone else completes the task, access is achieved but independence is not built, so that choice is documented and revisited over time.

3. How the Framework Changes Service Design

This framework supports a multiple-pathway, or ‘no wrong door,’ approach to service design. A participant should not have to prove digital competence before receiving a service. Online tools may be available, but they should not automatically become the only door.

• Learn about the service through digital or non-digital outreach.
• Contact the organization by the method that works for the participant.
• Identify communication, sensory, cognitive, physical, and digital access needs.
• Use or adapt technology where it increases independence.
• Provide a workable non-digital or lower-tech route when technology is not the best pathway.

4. Different Populations, Different Digital Barriers

Older Adults Aging at Home

Three in four adults 50 and older want to stay in their homes as they age. ^[4] For many, the barrier is a process that moved online after years of being completed by phone, mail, or in person. Increasingly, that includes managing finances and keeping up with paying bills online, and managing health at home, such as joining a telehealth visit, using a blood-pressure or glucose monitor, or responding to a medication reminder. The goal is not automatically to teach the app; it is to determine the easiest sustainable way for the person to continue accomplishing the task.

Adults with IDD, Including Autism

Technology can be highly enabling when it reduces verbal demands, supports routines, provides visual or voice prompts, or automates complex sequences. Accessibility may therefore depend heavily on adaptation rather than opting out.

Use. Adapt. Opt Out. complements the Technology First initiatives adopted by several state IDD systems, which consider technology as a first option when planning supports. ^[8] Technology First asks whether technology can meet a support need; Use. Adapt. Opt Out. determines how to make it work for the person, and when an alternative is the better choice.

Family Caregivers

Caregivers frequently manage multiple accounts, portals, appointments, reminders, and service systems for themselves and the people they care for. For many caregivers who also work full-time outside the home, it is much easier to complete a task for the person than to help the person complete it independently. The strain increases when the person is an aging parent who feels they are losing independence and resists having tasks done for them. Technology should reduce caregiver burden, not add another application, password, or workflow to maintain. Adapting the task so the person can do it themselves serves both: it protects their independence and gives the caregiver time back.

Rural Communities

When local providers are scarce, telehealth often becomes the default way to reach care. Telehealth first took hold where specialist shortages left rural hospitals and remote regions without local expertise, ^[11] and in IDD services, 59% of providers that offer case management reported struggling to connect people with services because too few providers were available. ^[14] But telehealth assumes a reliable connection, a working device, and someone comfortable using both. Early telehealth programs found that adequate bandwidth could not be assumed everywhere and fell back on simple technology and shared community spaces. ^[11] For rural families, an adapted setup, a phone-based option, or a printed or in-person alternative can be the difference between receiving care and going without.

Public investment in rural health is increasingly directed to telehealth, remote monitoring, and connectivity. The federal Rural Health Transformation Program alone is awarding $50 billion across all 50 states from 2026 to 2030. ^[16] Too often, programs assume that access and training will produce better health outcomes on their own. Use. Adapt. Opt Out. closes the last-mile gap between access and outcomes, and organizations should design it into programs so that investments translate into results for the people they serve.

The Workforce That Supports Them

Direct support professionals, home care aides, community health workers, and family caregivers are increasingly the people who set up, explain, and troubleshoot technology. Two barriers affect them. The first is numbers: turnover and vacancy rates in direct support remain high, ^[14] and approaches that add tasks to a stretched workforce are unlikely to last. The second is skill: most training does not cover judging whether a technology fits a person, adapting it, or choosing an alternative. The same pressure reaches clinicians (see Section 8). Use. Adapt. Opt Out. helps on both fronts. It gives workers a short, repeatable decision process in place of ad hoc troubleshooting, and it directs technology to the tasks where it truly reduces workload while keeping a human route where it does not.

5. A Practical Organizational Self-Assessment

Organizations can apply Use. Adapt. Opt Out. by examining the participant journey rather than reviewing technology in isolation.

• What is the person actually trying to accomplish?
• Are we requiring technology to accomplish it?
• Is the technology usable, does it fit daily life, is it effective, and is it sustainable for this person?
• If not, can we adapt the interface, instructions, or process?
• If adaptation still creates unnecessary burden, can the person opt out?
• Does the alternative pathway achieve the same meaningful outcome?
• Are we measuring whether the person achieved the outcome, not just whether they adopted the tool?
• Are the savings from technology real, or are costs shifting to participants and family caregivers?
• Have we unintentionally made organizational efficiency the participant’s accessibility burden?

6. Measuring What Matters

Use. Adapt. Opt Out. shifts measurement from activity to outcome. Attendance, devices distributed, accounts activated, and trainings completed remain useful implementation measures, but they do not show whether technology is working in a person’s life. The framework recommends pairing them with the outcome measures below, set with the person at planning so there is a baseline to compare against.

Results should be reported by path. A strong completion rate built mostly on staff completing tasks for people is a different finding from one built on independent use, and funders and partners should be able to tell them apart.

Organizations new to measurement can start with three measures: task completion, repeat completion at 30 days, and path with reason. The rest can be added as capacity grows.

7. Piloting the Framework in Practice

Use. Adapt. Opt Out. is being tested and refined in real service settings, not developed in the abstract. It draws on years of direct assistive technology provision through RNI Designs & Associates, and it is currently being piloted through RNFI's Independence by Design program, which serves adults with disabilities, older adults, and family caregivers across rural North Carolina.

Independence by Design operates in part with support from a Community Care Corps grant, a federal program that specifically encourages remote, virtual, and low-tech implementation approaches and looks for practices that can be replicated by other organizations. That alignment is one signal, among others, that the framework addresses a need the field already recognizes, but the framework itself was not built for any single funder or program. It is a general practice model applicable to any organization serving people for whom digital-by-default systems can become a barrier.

8. Preparing the Workforce

The workforce needs skill, not only numbers. Technology only works at home if the people supporting the person know how to make it work. Industry analysts expect the caregiver workforce of the future to need just-in-time training, and AI coaching tools are already being used with home care aides during assessments. ^[13] The same gap appeared in health systems years ago, when telehealth leaders had to ask how to make sure clinicians were trained and comfortable with the technology. ^[11]

That gap persists today, even among skilled clinicians. Health care workers whose primary job is clinical care spend substantial time navigating applications, portals, and digital devices to deliver that care. Tools meant to reduce operational burden or make care delivery more seamless assume that workers can easily find the critical health information they need before a telehealth visit begins. Standards such as Fast Healthcare Interoperability Resources (FHIR) aim to make that information easier to exchange between systems, but the worker still has to know where to look and what to trust. The challenge is greater for direct support professionals and family caregivers, who often have less training and support.

These workers, along with community health workers and students entering health and human services, need practical skills that most training does not cover: setting up and troubleshooting home technology, recognizing when a tool does not fit, adapting it, and knowing when an alternative is the better choice. Use. Adapt. Opt Out. gives them a common method to learn and apply. RNFI uses it as the foundation for hands-on, work-based learning in realistic home environments, preparing the next generation of workers to turn technology into outcomes for the people they serve.

9. From Practice to Partnership Model

This framework has two applications. First, it guides direct technology-enabled health, safety, and independent-living work with participants and caregivers at home. Second, it can help other organizations examine their own service pathways.

A partner-facing assessment can map how a person learns about a service, registers, communicates, receives reminders, completes required steps, and gets help when a digital process fails. Each step can then be evaluated through the Use, Adapt, or Opt Out lens.

Keeping Opt Out Real: Implications for Funders and Policy

Opt Out only works as a real pathway if it is funded and staffed. As more programs adopt technology-first models, often to ease workforce shortages, ^[13][14] the non-digital route tends to erode quietly. No one decides to remove it. It simply stops being staffed because maintaining two pathways costs more than one. When that happens, the alternative becomes an exception that a person or caregiver has to request and justify, which is the very barrier the framework exists to remove. For people with intellectual, developmental, and cognitive disabilities, including those with autism, a standard designed around what most people find easy can quietly become a requirement. Organizations, funders, and policymakers can protect the pathway in practical ways:

• Fund the non-technology route as core service, with its own staffing and budget line, not as an exception handled on request.
• Write the alternative into program and procurement requirements. Any technology-first policy should name the alternative pathway and who provides it.
• Measure outcomes by path, as described in Section 6, so cost savings and throughput are not the only reported results.
• Bring in people with disabilities, older adults, and family caregivers before technology is deployed, not only as testers afterward.
• Review pathway decisions on a schedule. A person’s fit with a technology changes, and a choice made at intake should not become permanent.
• Say plainly when workforce or cost pressure is a reason for adopting technology, so the tradeoff is made on purpose.

None of this opposes technology. It keeps technology a choice that serves the person, instead of a standard that fits only some people.

10. Invitation to Learn Together

RNFI welcomes opportunities to explore this framework with peer organizations, aging and disability networks, health systems and payers, caregiver organizations, and community-based service providers. A facilitated session can help organizations map a real participant journey, identify hidden barriers to technology adoption, and determine where to use technology, adapt it, or preserve an effective opt-out pathway.

To discuss a learning session, consultation, or speaking engagement, contact Monica Wallace at monica.wallace@rnidesignsinc.com.

References

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11. Sarasohn-Kahn, J. (2008). Right here right now: Ten telehealth pioneers make it work. California HealthCare Foundation. https://www.chcf.org/wp-content/uploads/2017/12/PDF-TelehealthTenInnovators.pdf
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13. Orlov, L. M. (2025, June). The future of AI in home care: What’s now and next. Aging and Health Technology Watch. https://www.ageinplacetech.com/files/aip/Future%20of%20AI%20in%20Home%20Care%20-%20Final-2025.pdf
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