A Changing Environment

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March 2003

By Jon Pynoos, PhD, and Julie Overton, MSG, MHA

A wheelchair lift was installed in this home to be useful, while not taking away from the design of the stairway.

With the aging of the Baby Boomers and their parents, the home environment is becoming a crucial element in providing care and improving the quality of life. Adapting the home to make it supportive often requires changes in physical setting (eg, addition of handrails and grab bars) and the way in which the environment is used.

The home environment significantly affects how individuals maintain and maximize their independence. More than 80% of older adults would like to stay in their current dwellings and never move.¹ Unfortunately, their homes, described as “Peter Pan housing” (built for people who never grow old), often lack supportive features and contain barriers. More than one third of individuals 45 years and over are concerned about having to move to a nursing home because they will have trouble getting around in their home in the future.¹

Home modifications (HMs) are often discussed in the context of individuals losing their ability to manage effectively and safely. An alternate perspective is that the environment itself is the problem (eg, the bathtub with no grab bars or supports is “handicapped,” instead of the person). The change of perspective is important so that people think not only of accommodating to the environment but changing elements of the setting itself.

WHY IS HOME MODIFICATION IMPORTANT?

HMs are important for quality of life. A home’s condition and suitability affect the ability of persons to care for themselves and to maintain optimal levels of independence. For example, research demonstrates that HMs such as grab bars can reduce bathing difficulty for persons with high levels of functional impairment especially when combined with an OT assessment and follow-up.²

Safety is also very important. The elimination of hazards and addition of supportive features can help reduce accidents such as falls by reducing environmental demands. Falls are a leading cause of injury deaths among people 65 years and older.³ One of every three Americans 65 years old or older falls each year.⁴

HMs can also be cost-effective. Research indicates that assistive devices and HMs along with an OT’s assessment and home care can substantially reduce case management, nursing, and institutional care expenditures for older persons, even to the extent of delaying institutionalization.⁵

Finally, the home’s condition and supportiveness affect the capacities of formal and informal caregivers to provide assistance. For example, a roll-in shower may ease the process of bathing and wider doorways may support navigation throughout the home.

People who need home modifications include elders who want to age in place. The proportion of individuals who have difficulty with activities of daily living increases with age. Approximately 12% of the population between 65 and 74 years of age, 26.5% between the ages of 75 and 84, and 57.6% 85 years and older experience difficulty performing basic activities of daily living. At the same time, only half of seniors with disabilities have the home modifications they need.⁶

Others include families who have children with disabilities, adults with disabilities, Baby Boomers planning for the future, and families bringing aging parents into their homes, as well as individuals discharged from the hospital.

COMMON PROBLEMS AND SOLUTIONS IN THE HOME

Three main problematic areas exist in the home. The first is access. Most homes have a set of steps leading up to a porch, deck, or landing at the door. These steps can become obstacles for persons who are frail, have problems with balance or vision, or use wheelchairs, walkers, or canes. Solutions include installing a sloping walkway, ramp, outside lift, door openers, and providing handrails on both sides of steps.

Another issue is getting up and down the stairs. Stairs inside the home can be as difficult as stairs outside. According to the US Bureau of the Census (1994), the proportion of the housing stock with stairs has increased 182% since 1970. Solutions here are to add an additional handrail for support on both sides, increase lighting on stairs with switches at both levels, install a color strip on the first and last steps to identify changes of level, and put in elevators or lifts to provide access to all floors.

The third common problem is managing in the bathroom. Wet, slippery surfaces in a small, cramped space can lead to falls, regardless of functional limitations. For persons who use wheelchairs, transferring from the chair to the toilet, bathtub, or shower can also be problematic. Most showers have a bottom base that is raised three or four inches, thereby creating a curb that obstructs easy entry into the shower for people using wheelchairs or individuals with poor balance or vision.

Solutions for bathtubs are to install a vertical grab bar on the wall that supports the faucet and a horizontal grab bar on the rear wall of the tub, use bath chairs and stools to reduce fatigue, obtain a battery-powered bath chair that allows transfers and via remote control lowers a person into the bathtub, adhere a bath mat or nonskid strips to the bottom of the tub to help prevent falls and injuries, and, if necessary, provide increased space to allow for caregiver assistance in bathing. For showers, one should install a roll-in or curbless European-style shower with the drain located at the bottom of a slight slope to prevent water from backing up. If a redesign is not possible, install a small ramp to accommodate wheelchairs. Equip showers with grab bars and shower chairs. Some benches attach to the shower wall and fold up when not in use. Colorful bath benches and grab bars are available. A light located inside the shower can improve poor lighting. Handheld showering equipment can enable people to sit down and spray themselves without getting fatigued.

Solutions for safe toileting are to install grab bars near the toilet and locate the toilet paper in a convenient place. Raise the toilet base using a device or install a raised toilet seat. For using the sink and countertop, remove cupboards to allow for wheelchair access or seating. Insulate pipes to prevent scalding from the heat of hot water.

WHO PROVIDES HOME MODIFICATIONS?

HM providers include remodelers, contractors, tradesmen (eg, plumbers and electricians), handyworkers, medical supply companies, housing organizations, social service agencies, health care professionals, and volunteers. Two major clusters of public and private organizations provide HM services: 1) health, aging, and social services that tend to focus on “the person” and provide different types of support/assistance for households with disabilities and/or low incomes; and 2) housing, economic, and neighborhood/community development that emphasize “the housing stock” and/or “the neighborhood” as opposed to “the person.” A recent home modification/repair (HMR) services study in California identified nearly 300 providers.⁷ The most common services provided were ramps, widened doorways, grab bars, and handrails. Almost half (45%) were limited in the number of clients they serve annually and more than half (57%) indicated that they have a waiting list. The use of assessments by HMR service providers that address both the environment and clients’ functionality is not widespread. The majority of HMR service providers assessed either the environment or functionality, but not both. Thus, most providers do not adequately evaluate clients’ needs and abilities themselves.

WHAT ARE THE BARRIERS TO HMs?

Several barriers impede the availability of HM. One is lack of awareness. Many people simply do not like the idea of changing their home while others fear that their home might end up looking like an institution or a hospital. There is evidence, for example, that consumers under-report environmental problems because of their lack of knowledge or concern.⁸ Home modification might symbolize a loss of independence, rather than a way to maintain and maximize independence.

Another barrier is cost. The expense of home modification often comes unexpectedly. Costs range from less than $100 for the purchase and installation of a simple handrail or grab bar to more than $2,000 for a roll-in shower or a stair lift. To pay for modifications, more than 75% of persons use their own savings, assets, or income. The remaining one quarter of home accessibility features are paid for by third-party sources,⁹ each with its own set of eligibility requirements (eg, Medicaid, Community Development Block Grants, and the Older Americans Act). Most insurance companies do not reimburse for HM.

An additional obstacle is an inadequate and uncoordinated service delivery system. Many professionals who come into contact with older persons (eg, doctors and nurses) may not typically take into account the importance of a supportive home environment. It might be easier to prescribe personal care services than to arrange for environmental modifications. Nearly one third (28%) of individuals over the age of 45 are concerned about finding a HMR service provider should they need to make changes to their home.¹ Unlike defined services such as Meals on Wheels or Adult Day Health Care, HMs are in limbo among housing, social, and health services. Many agencies are responsible for only one aspect of the HM process (eg, information and referral, assessment, or funding) or supply only specific modifications.

In addition, current accessibility laws are limited. The Fair Housing Amendments Act of 1988 requires basic accessibility in entrances, hallways, and individual units but applies only to residential buildings of four or more units, excluding single-family housing and smaller complexes that make up the largest component of new construction. Owners of properties that fall under the Act must allow tenants to make “reasonable modifications” to their own units but are not required to pay for them. The vagueness of the statute and the reluctance of older tenants to use legal means to rectify problems have limited its impact. Additionally, there is both a misconception and misapplication of the Americans with Disabilities Act (ADA) to private spaces. While the ADA created public building accessibility codes for the average user, it does not apply to residential settings. Moreover, many of its standards and specifications are inappropriate to home settings in which changes should be tailored to the needs of individual residents.

DEVELOPMENTS AND TRENDS

Recent developments present opportunities for health care professionals to better meet the HM needs of individuals of all ages. For one, the Olmstead decision, made in 1999 by the Supreme Court, requires states to develop a comprehensive, effective working plan to place individuals in a less restrictive setting than nursing homes. HM may be included as a service that supports living at home.

Another development has been in Medicaid coverage. Except for waivers, Medicaid does not pay for many HMs. However, in Blue v Bonta, a San Francisco appellate court ruling ordered Medicaid to pay for motorized stairway chairlifts in medically necessary circumstances. The court argued that the very purpose of home health care coverage for durable medical equipment is to help individuals live at home rather than in an institution.

Additionally, there has been increasing coordination between HM service providers. Area agencies on aging, centers for independent living, housing and community development departments, and builders and remodelers are starting to play a larger role in delivering HM services.^7,10 Additionally, local HM action coalitions are forming around the country that bring together the various professionals along with consumers involved with HM. There has also been a proliferation of new products developed recently, such as simple swing clear hinges that add two to three inches to doorways without structural modifications, accessible kitchen cabinetry can be found in many building supply stores, and grab bars are now available in many colors and materials.

Finally, there has been a greater awareness by professionals and consumers. Consumer safety booklets and Public Service Announcements are available to raise the awareness of consumers. In addition, a number of in-person and online programs have been developed to train professionals such as the University of Southern California Andrus Gerontology Center’s online program that offers an Executive Certificate in HM.

RECOMMENDATIONS

In order to stimulate new and enhanced HM activity, the following recommendations should be considered:

Increase consumer awareness and acceptance by providing products for people to test, education through videos (eg, on hospital television networks), and proactively using HMs in a preventive manner,¹¹ especially for those who have a history of falls.
Improve use and availability of existing funding mechanisms. While it is a difficult time to obtain new funds to pay for HM, some strategies might include: 1) advocating for Medicare and Medicaid to pay for HM assessments and reimburse a greater range of HMs; 2) alerting HMOs and insurance companies that HMs are cost-effective; and 3) informing older home owners that reverse mortgages can be used to pay for HM.
Improve the HM delivery system by addressing ways to better connect HM service providers with OTs, PTs, and case managers.
Assessments and follow-up. Encourage health care professionals to use more comprehensive assessment instruments that evaluate the environment as well as functioning, such as CASPAR, which also incorporates a team approach with an occupational therapist, contractor, and designer, working directly with the client.

The process should also include follow-up and reassessment to ensure that the modifications are working appropriately, that the individual and any caregivers know how to use them, and that additional HMs are made as needed.

CONCLUSION

The environment has a profound impact on behavior, and a supportive environment can contribute to or hinder an individual’s health. Home modifications present opportunities to maximize independence and are an important part of rehabilitation management.

Jon Pynoos, PhD, is Professor of Gerontology and Policy, Planning, and Development at the University of Southern California Andrus Gerontology Center and director of USC’s National Resource Center on Supportive Housing and Home Modification in Los Angeles. Julie Overton, MSG, MHA, is a program manager at the center.

REFERENCES

Fixing to Stay: A National Survey on Housing and Home Modification Issues. Washington, DC: American Association of Retired Persons; 2000.
Gitlin L, Miller KS, Boyce A. Bathroom modifications for frail elderly renters: outcomes of a community-based program. Technology and Disability. 1999;10:141-149.
Hoyert DL, Kochanek KD, Murphy SL. Deaths: final data for 1997. National Vital Statistics Reports. 1999;47:19.
Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319:1701-7.
Mann W, Ottenbacher KJ, Frass L, Tomito M. Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care costs for the frail elderly. Arch Fam Med. 1999;8:210-217.
Joint Center for Housing Studies. The State of the Nation’s Housing 1999. Boston: Joint Center for Housing Studies of Harvard University; 2000.
Overton J. The Delivery of Home Modification and Repair Services: Status, Issues and Recommendations. Los Angeles: National Resource Center on Supportive Housing and Home Modification; 2002.
Steinfeld E, Shea S. Enabling Home Environments: Strategies for Aging in Place. Buffalo, NY: Center for Inclusive Design and Environmental Access; 1993.
La Plante MP, Hendershot GE, Moss AJ. The prevalence of need for assistive technology devices and home accessibility features. Technology and Disability. 1997;6:17-28.
Liebig PS. Home modification services for aging individuals: the roles of centers for independent living. Presentation given at: Inclusion by Design: Planning the Barrier-Free World; 2001; Montreal.
Mathieson K, Kronenfeld JJ, Keith VM. Maintaining functional independence in elderly adults: the roles of health status and financial resources in predicting home modifications and use of mobility equipment. Gerontologist. 2002;42:24-38.

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March 2003