Q&A with Jon Pynoos, PhD

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April 2004

By Sarah Schmelling

In March 2003, Jon Pynoos, PhD, a 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, wrote an in-depth article for Rehab Management on the state of home modification. Editor Sarah Schmelling recently caught up with him to find out what has changed in the world of home modification over the past year.

Rehab Management: In your March 2003 article, you talked about the need for people to change perspectives—from seeing the person with a disability to seeing the environment as having a disability. Can you elaborate on this idea?

Jon Pynoos: For too long our society has adopted a medical model of disability. Fortunately, a shift is occurring from the medical to a broader social model of disability. In the medical model, disability is seen as a problem within the person that prevents the individual from participating as an active member of society. In contrast, the social model of disability acknowledges the presence of social and physical environmental barriers. The limited participation of persons with disabilities in school, work, and social activities is no longer perceived as simply the result of their impairments, but also as barriers in the social and physical environment.

The social perspective of disability is reflected in the World Health Organization’s international system of disease classification, called the International Classification of Functioning, Disability, and Health (2000). The framework recognizes that forces external to the individual, such as the physical, social, and attitudinal environment, influence a person’s level of disability. These external barriers, including the environment, can and should be changed.

RM: To what extent can home modification affect quality of life?

JP: Modifications that make homes more supportive and accessible can have a large impact on a person’s independence, safety, and ability to carry out tasks. They are key components in efforts to allow persons to live in the community, a basic goal of the Olmstead Decision.

For example, there was a recent article in The New York Times about frail older persons who live in walk-up apartments and can no longer use the stairs. In many ways, they were prisoners in their own units, unable to go outside. Modifications such as chair lifts or elevators could liberate them. On a smaller scale, grab bars and handheld showers can make it possible for people to bathe more easily and safety. Modifications also make it easier for caregivers to provide assistance.

RM: I see that there will be a conference on fall prevention in April. How involved are home modification specialists in fall prevention research? Can you tell us more about what will be discussed at the conference?

JP: Falls are a very serious problem, especially for older persons. For a number of years, we tried single interventions such as modifying the environment to reduce falls. It turns out that the best approaches to fall prevention are multifactorial strategies. In addition to environmental modifications, they include careful medical assessments, exercise, and monitoring medication.

In relation to the environmental, it is important to assess the home, remove hazards, provide supportive features (eg, handrails), and teach people new ways to use the environment, such as slowly getting out of a chair and balancing oneself before walking. These approaches will be highlighted at a 1-day set of sessions on fall prevention sponsored by the Archstone Foundation that will be held on April 15 as part of the American Society on Aging/National Council on Aging conference in San Francisco. One goal of the daylong event is to develop a network of professionals working to develop policies and programs that will help reduce falls.

RM: Please tell me about the report, “California Home Modification and Repair Services: States, Issues and Recommendations.” What is the most important information in the report? What are some of the recommendations?

JP: The report provides an overview of home modification and repair (HMR) services in the state, an analysis of non-profit and for-profit HMR organizations, a list of challenges faced in the service delivery system, and recommendations to meet the demand for and facilitate the supply of HMR services.

The report identified three interrelated challenges faced by providers of HMR services: funding, client awareness, and administrative issues. Cost limitations and public resource budget cuts have significantly reduced funding sources for many HMR service providers, while client awareness—or the lack thereof—has served as a challenge in delivering services. Also, the ability to conduct outreach is made difficult because of the lack of connectivity with other professionals and organizations.
Some of the recommendations put forward to meet the demand for and facilitate the supply of HMR services include: 1) increasing advocacy by the aging, disability, and housing networks; 2) conducting scientifically based evaluation studies that appraise how HMR services affect quality of life and long-term care expenditures; and 3) developing an evaluation of the client’s environment functionality.

RM: What are the major problem areas within an unmodified home? What are some solutions to these areas?

JP: Three areas of homes that are the most troublesome are entrances, stairs, and bathrooms. Many people have trouble climbing stairs. Sometimes simple handrails can make a big difference. In other cases ramps or lifts may be needed, especially for persons who use wheelchairs. Bathrooms are often cramped, slippery, and inaccessible. As in all home environments, solutions should be tailored to the needs of the resident and the spaces in the home. For some people, it may be as simple as a bath bench, while for others a walk-in or roll-in shower may be needed.

RM: What are the most basic ways to modify homes? Can you explain the benefits and purposes of such essentials as ramps, lifts, and widening doors?

JP: Some basic ways to modify homes involve simple adaptations like swing-clear hinges and [gripping devices]. Installing swing-clear (or off-set) hinges can provide that extra clearance to allow easier passage of a wheelchair or walker. [Gripping devices], especially useful for persons who have limited gripping abilities, make it easier to turn a doorknob or water faucet control.

Installing ramps and widening doorways make it easier for a person using a walker or wheelchair to get in and out of the home or to access various parts of the home. Ramps are beneficial for people who experience difficulty negotiating steps, or for those using wheelchairs or walkers. Widened doorways also facilitate the use of adaptive equipment such as wheelchairs and walkers, and provide better access to other parts of the home like the bathroom. These home modifications (HMs) can provide immediate relief and allow caregivers to provide assistance more easily and safely and with less stress.

RM: What improvements are being made in the products used for home modification? How has research helped the modification process evolve?

JP: There is continual improvement in products along several dimensions. Evidence suggests that the number of HMs has increased dramatically over the last decade. Correspondingly, the market for products related to home modification is expanding. Both manufacturers and places where they are sold have been responding.

As a result, many products can now be found not only in medical supply stores but also in hardware stores, building supply outlets, and even pharmacies. Moreover, they are no longer hidden in the back, but now out in view, sometimes in their own separate sections. The expanded demand has also brought about more choices and attractive products. This is very important to consumers who want their places to remain home-like and prefer modifications that fit in. It is therefore helpful that even items such as grab bars come in different configurations, colors, and materials. New products are always being invented such as monitoring devices, lifts, and supportive chairs that hold the promise of better lives for disabled persons. The downside is that reimbursement for such products, which is already limited, faces even more barriers with reductions in Medicare and Medicaid budgets.

RM: Who are the primary people who require home modification? Is this expected to change as the Baby Boomer population ages?

JP: Persons with disabilities of all ages can benefit from HMs. According to a 1997 Disability Statistics Report from the National Institute on Disability and Rehabilitation Research, 7.3 million people aged 15 years and older have some difficulty with one or more activities of daily living (ADLs). Difficulties with ADLs such as transferring, bathing, dressing, and toileting can be addressed using HMs.

The need for HMs will increase with the aging of the Baby Boomer population. Persons aging with a disability, as well as the frail elderly, will benefit from HMs. A report from the US Department of Housing and Urban Development states that 1.14 million elderly households reported unmet needs for HMs in 1995, a need that will only increase in the future.

RM: What are the primary barriers to providing home modification?

JP: Some barriers to providing HMs include: inadequate problem identification; lack of sufficient funding; lack of trained, qualified HM service providers; and lack of coordination.

HMR service providers face competing service priorities. They may have to address code and safety issues prior to implementing HMs. For example, lead paint abatement requirements may overwhelm resources. The majority of service providers that serve low income persons are unable to address needs for major modifications due to modest budgets and long waiting lists. Most insurance companies do not reimburse for environmental assessments by professionals such as occupational therapists, a key part of the home modification service delivery process.

Consumers and payors have been concerned about adequate training and skills of providers, especially to meet the needs of persons with visual impairments and diseases that affect cognitive functioning such as Alzheimer’s disease. Only recently have licensure/certification programs and standards begun to be created for professionals who deliver, install, and assess for HMs.

There is a need for more outcomes research to find out who needs HMs, what HMs are specifically needed, and which ones are most effective.

RM: In what ways can those in the rehabilitation community increase awareness of the importance of home modification?

JP: There are several ways to increase awareness of HMs in the rehabilitation community. One approach is through the media. Articles in disability newspapers and magazines are an effective way to increase awareness. Another valuable strategy is to widely circulate information about HMs to community agencies such as Centers for Independent Living and Senior Centers serving persons with disabilities. Coalition-building among disability and aging groups on the local, state, and national level is also an effective approach. Coalitions can help provide consumer education, train building professionals, promote accessibility guidelines, and raise awareness for public officials and legislators.

Sarah Schmelling is editor of Rehab Management.

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April 2004