June/July 2002

Help for the Home

By Ben Van Houten

Dealing with everyday life tasks that able-bodied people take for granted can be extremely challenging for those with mobility impairments, from travelling a block to the grocery store to accessing public transportation. Now imagine not being able to climb the stairs to use the bathroom-in your own home. Or even struggling to get up the front porch steps. These are just a few of the dilemmas facing people with disabilities who live in outdated homes, often by themselves. And that problem also affects the physical and occupational therapists who deal with the frustration of working with patients who live in such environments.

In fact, these are precisely the types of issues that occupational therapists like Pamela Toto, MS, OTR/L, BCG, and Sharon Glover, OTR/L, have decided to face head on through their volunteer work with Rebuilding Together with Christmas in April®, a Washington, DC-based organization specializing in the modification of homes for the elderly and people with disabilities. Toto and Glover, who both work as OTs in Pittsburgh, have more than enough to work with in that old, hilly city. "Most of the housing stock here dates from the 1930s and 1940s," says Toto. "So you see a lot of two-story houses, and some of them have up to 100 steps leading just to the front door, because of the hills. Also, many of them have very narrow staircases, tiny bathrooms, and no grab bars set up. Not to mention the lighting is terrible-these older houses have no overhead lights at all."

ENVIRONMENTAL ASSESSMENTS

Toto, who has been doing home health care for 13 years and home modification for the past 5 years, works largely with geriatric homeowners, since Allegheny County (where Pittsburgh is located) is home to the second highest population of older adults in the United States. "It is challenging, but it is something I love doing," she says. "We usually do a walk-through of the house, but we don't put hands on the clients. However, we ask them a lot of detailed questions about the everyday things they do, about their abilities and difficulties. Then, we give a visual assessment of the living environment, using our skills as therapists. Finally, we ask them to do something, like demonstrate how they get in and out of the tub. That is when we make the modification recommendations."

Toto notes that it is not a typical occupational therapy evaluation, but rather an "environmental assessment."

Often, the reasons for home modification are simple, says Toto, such as light bulbs that have burned out or bathrooms needing grab bars. But sometimes, the needs are a bit more dramatic. According to Glover, who is director of the rehab and activity departments at Wightman Center for Rehabilitation, Pittsburgh, several recent projects she worked on required slightly more drastic measures. "We were working with a deaf couple," she says. "You walked up to their front door, and there was a sign that said, ‘We are deaf. The doorbell doesn't work, so knock loudly.' Which is basically an open invitation for a burglar! So we attached a doorbell to a light in the house, and then we had to rig up a flashing light to the smoke detector as well. In this case, it was purely about safety."

Glover also worked with a wheelchair-bound woman with multiple sclerosis. "She had not taken a shower in 7 years-she'd been trying to wash up in the sink," she says. "We had to first reconfigure the traffic patterns in the living room and bedroom to get rid of all the clutter, and then set up a hand held shower system for her." Even more surprising, another client had a hip fracture and could not do any lifting or bending, and was using the rickety towel racks in her bathroom as grab bars to get in and out of the tub. "Also, her kitchen cabinets were too high, so she had just put all her pots and pans on the floor," she adds. "All we had to do was lower the cabinets, and as a result of there being less clutter, it was much easier for her to move around."

Glover also recalls going to a house of an 80-year-old woman with cancer, who also happened to be a foster parent of three young children. "Not only was she trying to look after these kids, but she was also going through chemotherapy treatments, which meant she was very weak much of the time," says Glover. "So we put in a bathtub seat for her, as well as steps for her to get into the tub, and a new toilet."

Glover says incidents like that one are particularly acute, since Medicare does not pay for bathroom modifications. "You cannot buy grab bars and have Medicare reimburse them, for example," she says. "It makes the work we do in home modification that much more important to us and our clients."

Most of the modifications are funded through grants from the US Administration on Aging and the Department of Health and Human Services, according to Glover. To qualify, homeowners must be low-income and elderly or living with a disability. They are then selected by referrals, usually from neighborhood associations, churches, or other community groups or local services. Usually, much of the labor and supplies for the modifications are donated by community volunteers.

Not all the work Glover and Toto are involved with is minor. Toto, for example, has worked extensively with people in need of major home overhauls. "We are constantly rearranging kitchens and installing railings, both outside and inside, and even fixing leaking roofs and other structural problems," she says. "It's not just the small things that we are dealing with."

TIPS FOR THERAPISTS

Toto says that, as part of the Pennsylvania Occupational Therapy Association, she has also helped create a training manual for the leaders of Rebuilding Together projects. Both women have a lot of advice for therapists interested in home modification. "Therapists should always see the house before they get involved with making design modification recommendations," says Glover. "Many therapists think, because they are so busy in the hospital or rehab center, that they do not have the time to go see a house. But it is really essential to the process."

Likewise, Toto adds that getting more education is key to successfully getting involved. "Doing this is really an advanced competency skill," she says. "You need to develop a more advanced knowledge, maybe through continuing education, and you have to do research on what type of equipment is out there." She specifically mentions the University of Southern California's home modification certification program, which PTs and OTs can take via the Internet.

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