To report that life is very different following an injury or illness that permanently impairs or entirely ends one’s ability to ambulate is, of course, to state the obvious.
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However, it is precisely because life is so different that most such individuals choose without hesitation to continue residing in the home they occupied at the time of impairment. The reason is that this home, those familiar surroundings (and the security they represent), become more emotionally comforting than ever—no matter that the place has hallways so narrow, bathrooms so compact, and steps so many or high that movement and other activities of daily living prove difficult at best, impossible at worst.
Fortunately, in instances where the individual decides not to relocate to a mobility-friendlier house or apartment, there exists the option of home modification.
Home modification is akin to home remodeling, except that instead of summoning carpenters, electricians, and plumbers to add a room and give things a new look, the goals are to create accessibility and reduce the risk of accidents. Achieving these objectives can entail little more than removing throw rugs, rearranging furniture, installing grab bars, adding assistive devices, or redesignating room usage (for example, turning a ground-floor living room into a bedroom that formerly was upstairs). Or these objectives can require grander solutions involving room enlargement, the installation of an elevator to allow for easy travel between floors, or the extraction of a toilet so that it can be situated in another corner of the bathroom where transferring to it from a wheelchair is less cumbersome and risky.
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| At left: A customized ramp allows access to a recreational deck and the back entrance to the house. At right: A poured earthen ramp provides front door access and enhances the home’s landscape. | |
MONEY TALKS
Homes requiring modification come in all sizes, shapes, and ages. Christopher Lynch, president of Alternatives to Barriers, a Hewitt, NJ, firm specializing in the design of wheelchair-accessible residential environments, contends that there is no such thing as an unmodifiable home.
“The real issue is will the home be worth modifying— because, sometimes, the answer is no,” he says. “Modification is the most expensive way to go—probably 100% more expensive to modify than to build a new dwelling from scratch because modification involves intricate and careful demolition and rebuilding, both of which are time-consuming.”
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| Old kitchen. |
Prices vary, but the average home modification job runs at least $100,000 and can top out at around $250,000. “The price of a project depends on the extensiveness of the modifications, which in turn depend on the functionality and mobility levels of the occupant, and on the setting, original design, original materials, and original construction methods of the house itself.”
Lynch has performed home modifications since at least the mid-1980s. He does not advertise his services; jobs come entirely by word-of-mouth and through established relationships with insurance company case managers. “When someone is injured or has an ongoing disability that requires modifications to the home, we go in and assess the house for what needs to be done,” he says. “We generate a report with photos that detail the accessibility and safety issues, and we produce a preliminary set of blueprints showing the structural changes we propose to make. We also offer a cost estimate.” These items are packaged and delivered to the payor, which could be an insurance company, an attorney, the property owner, or some other involved party. “If they decide to green-light the work, we then develop full construction blueprints. If asked, we’ll also project-manage the job—soliciting bids from local construction contractors and then overseeing the job from beginning to end once a contract is awarded.”
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| Remodeled kitchen incorporates such ADL modifications as lowered work counters and cooking surfaces, as well as wider wheelchair access and turnaround. | |
Lynch himself is a wheelchair user, so he brings to these projects an invaluable perspective. “I know exactly where a chair can go and what’s required to enable it to go there,” he says. Since the homes he modifies are at first lacking in accessibility, he frequently must dismount from his wheelchair and drag himself through tight hallways and up and down stairs to inspect rooms and take measurements. “A lot of the clients are newly disabled. So, when they see me confidently getting around like this, it actually reassures them that life can go on after what’s happened to them. In fact, maybe 50% of my time at the initial visit is spent doing peer counseling.”
DIPLOMATIC MISSION
One of the first considerations addressed by professionals like Lynch when preparing to create an accessible and safe environment is how and where the wheelchair user will enter and exit the home. Lynch says, “There need to be at least two means of ingress and egress, and, ideally, from divergent areas of the house.” Sounds easy enough. But not always. “Trying to achieve accessible ingress and egress for a hillside home—a place built right into the side of a slope—introduces a special set of issues.” For example, outside there may be impossibly slender walkways, porches, and steps. Moreover, being nestled up against the hill usually leaves precious little real estate for expanding or improving those amenities. Same story indoors: hillside homes often feature split-leveling, which can complicate efforts to develop good room-to-room flow.
Among the most challenging spaces to modify in any home—hillside or otherwise—is the bathroom. “This is where a number of the most essential activities of daily living (ADLs) occur, so extra attention must be paid to the bathroom and getting it right,” Lynch says. If indeed it has been set up right, those ADLs can be performed more independently, time-efficiently, and safely. “Just to illustrate, one of the things we want to do is to eliminate the need for multiple transfers in and out of the wheelchair in order for the person to use the various amenities of the bathroom. That’s important not only from the standpoint of time savings but also from the standpoint of reducing encounters with surfaces that have the potential for becoming dangerously slippery when wet.”
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| Above, left and right: A remodeled bath features a raised toilet, a roll-in shower, and a lowered sink and vanity for easy access. | |
Another challenge can be the home’s age. “You’ll have old homes where the interior walls are solid brick—a technique for insulating that was used 100 years ago,” Lynch says. “The fact alone that the wall is made of brick is a problem. But also, it often turns out that the local historical preservation society won’t want you to alter a thing about the wall or the home—or, if they’ll permit it, they’ll put significant limits on what you can do and how you can do it.”
Lynch says he finds himself extensively engaged in customer hand-holding during many a modification project. “We go into a home and tell the occupants that we have to move an heirloom china cabinet a few feet from the place where it’s stood since Grandma was a child, and everyone panics. So a lot of what I do involves diplomacy and giving reassurances that the work won’t turn the house upside down or damage things or be too disruptive of the familiar.”
CODE CRACKING
Seldom are the builders Lynch hires for these jobs specialized in modifications for wheelchair users or the elderly. “My selection criterion is that the contractor have a record of good work at a good price,” Lynch divulges. “Any competent builder can build what’s in the plans I prepare.”
An aim of Lynch’s is to avoid modifying a home in such a way that it ends up looking as if it, in fact, does belong to someone in a wheelchair. “Visitors to the homes I’ve worked on usually have no clue that it’s designed specifically for accessibility,” he says, adding that this is a reason why he eschews the design recommendations contained in the building codes of the Americans With Disabilities Act (ADA). “First of all, the ADA has no application whatsoever in one- and two-family homes,” Lynch clarifies. “And that’s a good thing. Because if the ADA’s codes did apply, you would have modifications that cost more and leave you with a home that looks and feels very institutional.”
In addition to the ADA codes, most states have adopted or in some fashion incorporated the codes developed by the industry-recognized International Code Council (ICC). Lynch thinks those codes are fine, but only when applied to commercial space. “The ICC codes are based on American National Standards Institute 117.1 handicap accessibility codes, as in many ways are the ADA’s codes,” he says. “We want to be able to design the home for the occupant’s specific injury or illness and needs. ADA and other codes are too generalized for that purpose. They’re meant really for offices and other workplaces where you have many different people with many different needs wanting accessibility—these codes are written to cover 99% of the potential needs for those environments. But the needs in an office building are not the same as the needs someone will have in their own private residence.” Most building inspectors are unaware of the ADA codes’ lack of applicability to single-family homes, so Lynch knows going in that he must devote time to educating them about that.
Then there are the products used in home modification projects. “I try as much as possible to stay away from traditional medical items,” Lynch confesses. “These tend to be very overpriced and very hospital-institutional looking. And, to the extent possible, I prefer to specify standard plumbing, standard cabinetry, standard everything. It’s OK to use standard materials—what makes a home accessible is not the type of materials but the way you use them.” Lynch expresses a particular fondness for voice-activated environmental control units (ECUs). “These go a long way toward enhancing quality of life for a seriously injured person such as a high level quadriplegic. Using speech alone, the wheelchair user is able to operate whatever can be electronically latched to the ECU. This would include doors, windows, shutters, drapes, lights, heating-and-cooling systems, telephones, TV, the bed, and kitchen appliances.”
Products galore for home modifications can be found by clicking the Web links (or by cutting and pasting them into your computer’s Internet browser search bar) at www.homemods.org, a service of the Fall Prevention Center of Excellence (originated by the National Resource Center on Supportive Housing and Home Modification, a university-based, nonprofit organization dedicated to promoting aging in place and independent living for persons of all ages and abilities).
Rich Smith is a contributing writer for Rehab Management. For more information, please contact .
