Photography provided by the author and Invacare

Current statistics demonstrate that the need for home modifications is on the rise. A joint report from the First Consulting Group and the American Hospital Association1 illuminates that the number of Americans aged 65 or over will double, while the number of people age 85 and over will quadruple by the year 2050. The report further discusses that “more people will be enjoying their later years, but will be managing more chronic conditions and therefore utilizing more health care services.” The results of the AARP Survey on home and community preferences of the 45+ population suggest “that wanting to remain in one’s home and one’s community as one ages continues to be paramount.”2,3 Ultimately, the aging population is living longer, with an increase in poor health status and chronic conditions consequently limiting their ability to participate in and complete functional activities within their also aging home environment. Home modifications for safety and accessibility can alleviate this growing issue.

In determining the best possible access for a client, multiple factors must be taken into consideration. This is a careful balance of looking at the client’s current functional abilities, current use of any assistive device for mobility, the setup of the home environment including how the home is utilized by all residents, and possible future changes in status due to the typical aging process and/or progression of illness, injury, and/or disability. These factors, combined with potential budget constraints, are all taken into consideration when determining safe and appropriate environmental modifications.

Individual needs vary greatly, and successful environmental modification recommendations are the outcome of a comprehensive assessment of the person and their environment. Comprehensive assessments link a person’s ability to carry out activities of daily living and instrumental activities of daily living independently with an evaluation of the home’s ability to provide support.4 An occupational therapist who specializes in environmental modifications brings to this evaluation a thorough knowledge of illness, injury, and disease process and prognosis, as well as an understanding of how different impairments affect functional performance. As an OT who specializes in environmental modifications, I look holistically at the person, taking into consideration their strengths and limitations and how this will impact the task to be performed. I am also considering the environment in which the task is to be performed and how the environment may also impact the person’s health, wellness, and participation.5 A person’s physical, visual, cognitive, and sensory functioning is all considered.

Bath chairs and stools help reduce fatigue by allowing users to sit during baths and showers.

A home accessibility evaluation will help to determine safe, accessible options for entrance and egress from the home. The focus is how is this particular space (ie, the home entrance) impacting this client’s ability to complete the task (enter/exit)? There may be a barrier if there are three steps to the entrance and the client is a wheelchair user. There also may be a barrier if there is limited lighting, no handrails on the stairway, and the client has a visual and/or a cognitive, but no physical impairment. Establishing the impact of the environment on the client’s current and future level of functioning will help to determine appropriate recommendations.

The optimal situation would be to provide for a stepless entrance—this includes a sill that is 1/2 inch or less if beveled, or ¼ inch or less if square, with a 34-inch minimum clear door opening width and 18-inch minimum maneuvering clearance parallel to the doorway beyond the latch side. The exit of the home would lead to a sloping pathway, ideally no greater than 1:20, created with a stable, firm, and slip-resistant surface. The amount of space there is to work with in front of the entrance along the trajectory of the pathway (ie, to the driveway, to the garage, etc) will help to determine feasible recommendations. The preference would be to berm the land into a gentle sloping path that leads to a flat 5- x 5-foot platform in front of the entrance. Berming integrates a more universally designed approach whereby the creation of the accessible entrance is invisible, as it has been integrated into the landscape. This option maintains the home’s aesthetics and aids potential future resale value. Berming, however, is an expensive option compared to the addition of a ramp to allow for access to the front entrance.

Allowing for a level entryway frequently poses a concern for drainage. Integrating drainage into the design that allows for run-off away from the path of entry provides a safer option by decreasing the chance of ice formation, in colder climates, on the entrance pathway into/out of the home, while also eliminating the concern of having water permeate the no-step entrance. Foundation waterproofing and a drop-down door seal will also provide protection.

Although this is a preferred option, there are many instances where berming or building a sloping path (ramp) is not feasible due to space limitations not allowing for a 1:20 (no more than 1:12 maximum) slope. In this instance, a vertical lift may be needed to allow for safe entry and egress. Consideration must be taken for the location of a vertical lift to ensure the client has enough space to enter and exit. There should also be enough space to allow for an accessible route from the lift, allowing entry into the home as well as exiting the lift out to the driveway, garage, and/or other desired location.

In either scenario, it is important to provide for coverage from the weather and adequate lighting, and integrate safety features to allow for easy access both during the day and at night. Considerations for how the area is going to be used by the client and others within the home are key to meeting lifestyle needs. Some options include: a package shelf just outside the door to hold items for ease while opening the door; motion detection lighting and/or automatically set dusk until dawn lighting with motion detection that can be added for ease when entering the house at night; and the addition of a second peephole, a sidelight, and/or a security camera that are possible options to aid with viewing guests at the door. There is a spectrum of door openers that run from a standard lever, to keypad, to remote-controlled, digital keyless tag deadbolt and even fingerprint access. Determining your client’s current abilities and having an awareness of the aging and/or disease process are a means to make appropriate decisions to allow for safe access in and out of the home for the long-term.

It is optimal to have at least two safe egress points within the home in case one of them is blocked during an emergency. In some situations, this may not be feasible and other strategies must be considered and put into place. While making modifications to your home to allow for safe egress during an emergency is of utmost importance, it is equally important to create and practice an emergency escape plan to stay prepared.5

Once inside the home, we are faced with the next challenge of determining safe and efficient access to the second floor. Once again, this is when you have to weigh the desires of the client and their current and possible future status to provide the safest options. This, at times, can be a spectrum of options ranging from the addition of a handrail on both sides of the stairwell with increased lighting and providing for a firm, stable, and slip-resistant surface to the installation of an elevator to bypass the stairwell altogether.

A frequent question is the use of a stair glide versus an elevator. Multiple factors help contribute to this decision. It is important to determine if the client can safely transfer on and off the stair glide. If there is any concern for the client’s safety while entering, exiting, or riding the stair glide, this may not be the appropriate recommendation. If a client uses a mobility device, they would need that device with them at the top and bottom of the stairs. It would need to be determined if the client is able to safely bring their assistive device with them on the stair glide and/or if they have a second assistive device that will be waiting for them at the next level of the home. The width of the stairway is also important. Minimum stairway width to accommodate a stair glide on a straight stairway is 36 inches. Keeping in mind that it is best to make recommendations that will meet the needs of all residents within the home, adding a stair glide to a narrow stairway will impact traffic and safety on the steps when the stair glide is in use.

A stair glide is considerably less expensive than an elevator, but will this meet the client’s needs for the long-term? Understanding that there is a budget to every home modifications project, and providing recommendations that allow for increased safety and overall decreased falls risk for all family members, are of utmost importance. A third option is an incline wheelchair platform lift. This option is an alternative to an elevator for the client who is a wheelchair user, allowing the client to sit safely during stair mobility. A manual wheelchair (locked in place on the platform) would be needed for use with this system for maximum safety, as standing with bilateral auxiliary crutches, a walker, and/or a cane on this system is not recommended.

In a continued effort to think about the current and future needs of the client as well as the caregivers, the possible need for a lift system should be assessed. The National Institute for Occupational Safety and Health (NIOSH) recommends that no caregiver should manually lift more than 35 pounds of a person’s body weight for a vertical lifting task (Waters, 2007).6 It is further recommended that when the weight to be lifted exceeds this limit, assistive devices should be used. If an assistive device is needed, it is imperative to evaluate both the space needed to safely manage the device as well as the number of caregivers needed to operate and use the device for safe transfer of the client. An overhead lift system provides the benefit of requiring less floor space and easy storage, but is the most expensive option. Collaboration with other members of the home modifications team is necessary in making appropriate recommendations for an overhead lift system.

Modifications in a bathroom can run the spectrum from the addition of hand-held showers, anti-scald devices and a non-skid surface inside the bath/shower to the conversion of a tub to a walk in shower and the addition of a grab bars and/or a roll-under sink. When considering accessibility for a bathroom, one really needs to make sure they are fully meeting the current, and potential future, needs of the client. Other than entrances/exits, the bathroom is a priority area for accessibility and independence. Being that the bathroom is considered to be one of the most dangerous places in the home, special considerations must be taken to increase safety and decrease overall falls risk. To assist with making appropriate recommendations to the physical layout, it is important to consider all persons in the home that will be using the bathroom as well as if the client will require assistance when using the space. Having enough space for the client, as well as a caregiver is important not only for accessibility, but for maintaining the safety and wellbeing of both parties. Designing an environment that is conducive to increasing the ease of completion of ADLs is a win-win for both client and caregiver.

Home modifications are a team approach. A contractor or an engineer would determine structural integrity regarding the installation of an elevator, an incline wheelchair platform lift, or a stair glide. As an occupational therapist who specializes in environmental modifications, I bring a unique perspective to the aging in place and home modifications team. By utilizing a science-driven background, I am able to assess how a person may function in their home and participate in activities of daily living (ADLs). Through additional Americans with Disabilities Act Accessibility Guidelines (ADAAG), Aging in Place, and Universal Design (UD) training, appropriate recommendations are made to improve a person’s accessibility, independence, and safety within their home. We (OTs, contractors, builders, interior designers, product vendors, architects) are all pieces of the puzzle, but together best meet the needs of the client for home accessibility evaluations.5 Our services are complementary. Collaboration provides a marriage of the medical and construction industries for the benefit of home accessibility.

Home modifications are not one-size-fits all. Individual needs vary greatly as do the homes to be modified. ADAAG provide minimum guidelines to be followed. If used strictly, the client’s needs may not be met. One example is the ADAAG technical specification for forward reach (308.2.1 Unobstructed high forward reach: 48 inches maximum). If your client has limited shoulder active range of motion and strength and a closet rod is installed at 48 inches, access may not have been provided. It is imperative to have knowledge of ADAAG to have minimum guidelines to follow; however, simply following minimum guidelines for access may provide only minimal access. It is the combination of a thorough knowledge of illness, injury, and disease process and prognosis, and an understanding of how different impairments affect functional performance, with the additional training in ADAAG and Universal Design principles that will yield a more individualized approach to meet the varying access needs of your clients.

In the early 1980s, architect Ron Mace coined the term “Universal Design.” Mace defined UD as “the design of products and environments to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design.” It is designing to meet the needs of as many users as possible. According to the Center for Universal Design,7,8 there are three levels of UD features. Each level has an increased amount of universally designed elements within a given environment. Integrating universal design principles into home modification recommendations is just good sense, but needs to be tapered with the understanding that the client may need additional accessible design recommendations to allow for safe and independent access.

Funding the budget for a home modifications project requires a healthy knowledge of federal, state, and local resources. However, these resources may have specific restrictions such as age, disability, socioeconomic status, and/or geographic location and fund only about 20% of home modifications and repairs. It is estimated that “approximately 80% of home modifications, renovations, and repairs are paid for by the primary occupants of the residence” with personal savings.9 It is important to educate your clients that any out of pocket expenditures for home modifications may be eligible for a tax deduction under their medical expenses. Second mortgages, as well as reverse mortgages, are also popular methods to fund home modifications.

Use of the Medicare Part B Outpatient benefit is available to those who are enrolled and eligible. With a physician’s script and documentation that there has been a decline in functional status, this benefit will cover the occupation therapist’s evaluation and follow-up training with the modifications. However, the modifications to the home are not covered. There is limited coverage if the modifications meet the requirements for durable medical equipment (DME).

Medicaid is also a possible funding option. Each state has specific programs under Medicaid, consisting mostly of waiver programs, with criteria to determine eligibility for funding assistance. Other programs that make up the 20% are state associations (Division of Vocational Rehabilitation, Veterans Affairs), organizations (MS Society, ALS Association, Rebuilding Together), as well as civic associations (Rotary, Kiwanis, and Lions clubs) to list just a few.

Debra Young, Med, OTR/L, ATP, CAPS, is a RESNA and NAHB-certified clinical occupational therapist. She owns and operates EmpowerAbility™ (www.empowerability.com), a consulting agency specializing in assistive technology, home safety, aging-in-place, and accessibility consultation. She can be reached at .

REFERENCES
  1. When I’m 64: How Boomers Will Change Health Care. Washington, DC: First Consulting Group and the American Hospital Association; May 2007.
  2. Keenan T. Home and Community Preferences of the 45+ Population. AARP Research & Strategic Analysis. Surveys and Statistics. 2010.
  3. Available at: www.aarp.org/home-garden/livable-communities/info-11-2010/home-community-services-10.html. Accessed on February 7, 2011.
  4. Trickey F. Maintaining Seniors’ Independence: A Guide to Home Adaptations. Montreal: Public Affairs Centre CMHC; 1989.
  5. Young D. Home is where you hang your hat, if you can access the closet. Delaware Assistive Technology Inititative (DATI). 2011;
    19:6-7.
  6. Waters T. (2007) When is it safe to manually lift a patient? American Journal of Nursing. 2007;107:53-59
  7. Center for Universal Design. www.design.ncsu.edu/cud/
  8. Gold, Silver and Bronze Universal Design Features in Houses. Raleigh, NC: Center for Universal Design; 2004.
  9. Fagan LA, Cabrera C. Funding for Home Modifications and Programs. Washington, DC: National Association of Home Builders (NAHB); 2007.