Home Modifications across the Lifespan:Creating and Modifying Home Environments for Lifelong Living

Jon A. Sanford, M. Arch. Lisa Ann Fagan, MS, OTR/LGeorgia Institute of Technology Towson UniversityCenter for Assistive Technology & Environmental Access Dept. of Occupational Therapy & Occupational ScienceResearch Scientist, Atlanta VA Medical Center Chair, AOTA Home & Community Health SIS

Co-sponsored by:

Homes for Life Coalition of Howard County

and

Howard County College

Division of Continuing Education & Workforce Development

March 14, 2008

The Need for Home Modifications & Lifespan Homes

• Growing Numbers of Older Adults

• Growing Numbers of People with Disabilities

• Growing Desire to receive care in the home and community

• Growing Regulatory Support

Age is the Largest Predictor of Disability

Social Movements that Promote Participation

• Deinstitutionalization

• Independent Living Movement

• Aging in Place

Services to promote AIP

• Modifications and repairs to the home– Safety– Function

• Assistance with ADL/IADL– Visiting nurse– Home health aid / personal assistant– Housekeeper / lawn service / handyman– Geriatric care manager

• Community supports– Senior center– Transportation service– Meal delivery

Who wants to Age in Place?

• Almost everyone!– According to an AARP survey over 80% of

those over 55 would prefer to age in place in their current homes.

• 55-64 years old 83%• 65-74 years old 92%• 75+ years old 95%

AARP (2003). Beyond 50.03: A Report to the Nation on Independent Living & Disability.Photos: Grandma's First Cub's Game, R. Ramaekers

Dancing with Grandma, M. Eichler

Growing Regulatory Support

• Visitability Regulations– State and local laws– MD SB 792

• Money Follows the Person

Approaches to Home Modifications

• Accessible Design and Assistive Technology

• Universal Design– LifeSpan Design– Inclusive Design– Design for All

Accessible Design and AT

• Specialized designs/add-on components intended to support specific types and levels of abilities

• ExamplesExamples– Ramp (1:12 max)Ramp (1:12 max)– Raised toilet (usu. 17”-19”)Raised toilet (usu. 17”-19”)– Grab barsGrab bars– Tub benchTub bench– Audible alarmsAudible alarms

• Often based on Americans with Disabilities Act Accessibility Guidelines*

The First Rule The First Rule of Home Modificationsof Home Modifications

WARNING: DO NOT USE ADAAG FOR S.F. H

OUSING

Differences between Accessible and Universal Design

Accessible Design/AT Universal DesignSpecialized designs to reduce environmental demands on people with functional limitations.

Reactive, code-compliant approach late in the design process

Accessibility is a band-aid

Typical designs to reduce environmental demands on all individuals.

Proactive, problem solving approach at all stages of the design process

Accessibility is part of the design

How do people

get in the house?

Where do I put the ramp?

Second first rule Second first rule of Home Modificationsof Home Modifications

all universal design is accessible, but

not all accessible design is universal

What Makes Design Universal?

1. Equitable Use2. Flexibility in Use3. Simple and Intuitive Use4. Perceptible Information5. Tolerance for Error6. Low Physical Effort7. Size and Space for Approach and Use8. Functional & aesthetic integration9. Social integration & participation

http://www.design.ncsu.edu/cud/univ_design/princ_overview.htm

How do we find UD modifications?

you don’t, because they are invisible!

Center for Universal Design, NCSU - Next Generation Universal Design Home

How do we get from AD/AT to UD?

1. Incorporating UD Principles in AD/AT

2.2. Incorporating AD/AT Concepts in Everyday DesignIncorporating AD/AT Concepts in Everyday Design

3. Repurposing Everyday Design

The Need for a Team Approach• Typical home remodeling uses a team approach to define

problems and implement the best solution– Architect/Interior Designer – Structural Engineer – Systems Subcontractors (HVAC, Plumbing, Electric) – Other Subcontractors (Roofer, Cabinet Maker, etc.)

• But, problems & goals for home modification differ– The team should reflect those differences– Need to include individuals who have specialized knowledge about

the person and his/her abilities (e.g.,occupational therapists, physical therapists, home health nurses) who may already be working with clients.

Differences between Home Mods and Typical Remodeling

Typ. Home Remodel Home Modification

Personal Abilities

Taken for granted – not a factor in defining goals or solutions

Driving force in defining goals and solutions

P-E fit (goals) Meeting lifestyle needs (e.g., update kitchen, expand home, convert office space)

Meeting performance/ occupational needs (e.g., facilitate transfer, getting in the house)

Environment (situational factors)

Characteristics of home

Range of possible solutions

What works best in the home

Cost – what fits budget

Characteristics of home

Range of possible solutions

What works best in the home

Cost – what fits budget

Likely Team Members

• Client

• Case Manager

• Therapist

• General Contractor

• Designer

• Construction support players

• Handyman/woman

• Payers’ representatives

Who is the Team Leader and what does he/she do?

• Might be any one of the key players

• Should be knowledgeable of all facets of the process, although not necessarily an expert in any

• i.e., Ideal role for therapist (or GC with expertise in home mods)

• Or, could be independent consultant (e.g. “Independent Living Strategist”)

The Home Modification Process

• Assessment

• Implementation

• Training

• Outcomes

Steps in the Assessment Process• Investigation

– Action: Acquisition of usability (PEO) and other factors (e.g., preferences, cost, codes) that influence performance

– Outcomes: Identification of actual and potential usability/performance problems and rehabilitation needs

• Interpretation– Action: Analysis of needs filtered through clinical reasoning

and experience to identify strategies to improve usability/performance

– Outcome: Potential interventions based on usability

• Intervention– Action: Analysis of situational appropriateness of potential

solutions based on mediating factors– Outcome: Best fit solutions

What is the best assessment?

• Not all assessment tools are created equal.

• Should match the user’s level of expertise.

• Client goals provide direction for determining what to assess.

• The content of the assessment (i.e., information needed) should match the type of outcomes desired (i.e., problem identification, strategies or modification recommendations).

Ans. One that meets the needs of the situation.

Implementation

• Selecting a contractor

• Contractor assessment

• Signing a contract

• Getting it done

• Monitoring the work

Training

• Often when the rehabilitation professional is needed again.

• Teaching the client and or caregiver to use the modifications safely and effectively.

• Crucial element to the success of the modifications

Outcomes

• What difference did the modifications make?– safety / risk of falls/injury

– independence / need for assistance

– pain / effort / time to accomplish activities

– tenure in the community

– quality of life / participation

Home Modifications Across the Lifespan

• Access and Egress

• Areas for Personal Care

• Areas for Household Activities

• Areas for Socialization and Leisure

Access and Egress

• Getting in / out / around the home– Walkways– Porches– Garages– Doors– Stairs

Areas for Personal Care

• Bathing and hygiene– Bathrooms

Areas for Household Activities

• Daily activities (cooking, cleaning)– Kitchens– Laundry room– Bedrooms

Areas for Socialization and Leisure

• Spending time with others, hobbies and other activities– Family rooms– Patios/decks– Gardens

Getting the Work Done

• Funding options

• Organizations

Funding Options

• Self-pay• Entitlement Programs

– Medicaid Waivers– CIL / MFP– Voc. Rehab– AAA

• Insurance Programs– Long-term Care Policies– Automobile / Worker’s Compensation

• Reverse Mortgages

Non-governmental Organizations that Provide Free / Low Cost Repairs / Home Mods

• Rebuilding Together

• Faith-based Organizations

• Civic Organizations

• MOW

What are Livable Communities?

• Communities that enable people to remain at home as long as possible

• Communities in which the environment does not obstruct or inhibit functioning, safety, and comfort, but enhances them

Livable Communities and Participation

• Enable participation outside the home– Links home w/ places of work, play, learning, & commerce.– Provides places where activities and interactions occur

outside home, workplace, school and public buildings.

• Participation related to numerous health issues– Physically and mentally healthier (Berkman, 1995; Berkman et al,

2001; Mendes de Leon et al, 2003)

– Diminished cognitive decline (Barnes et al, 2004; Bassuk et al, 1999; Stevens et al, 1993; Yeh et al, 2003)

– Decreased mortality (Glass et al, 1999; Kiely et al, 2000; Zunsunegui et al, 2003)

– Higher quality of life (Yang, 2004)

Participation and Mobility

• Participation in community cannot be achieved without freedom to travel.– Community provides transportation

infrastructure and modalities for walking, using wheelchairs or other mobility aids, biking, riding public transit, and driving personal vehicles.

• Communities that promote participation are sustainable.

Impact of Environmental Barriers on Community Mobility

• At a minimum barriers to travel can be frustrating.• At worst, they are dangerous, and exclusionary.

– < in independence– < in activity/lack of exercise– < in health– < participation in community activities

Universal Design in Community Spaces

• Goal is participation for all individuals

• Does not differentiate between people or ability

• Participation is universal, based on fit between ability and environment

For More Information

• National Center for Supportive Housing and Home Modifications (www.homemods.org)

• Center for Universal Design (www.design.mcsu.edu/cud)

• AOTA (www.aota.org)

• AARP (www.aarp.org)

• NAHB (www.nahb.org)

The End

Go forth and modify!