ronments that promote independence could reduce health care needs and those that promote health could facilitate independence. In fact, the World Health Organization has suggested that an important goal in health promotion is the creation of environments that support healthy living and well-being (World Health Organization, 1991). Nonetheless, the environment is perceived quite differently by the individuals who function in it and the systems that regulate it. On one hand, a home should provide a prosthetic environment in which individuals can live and function safely as long as they choose to remain there. On the other hand, a number of factors, including the cost of health care and advances in communications and medical technologies, have made the home a preferred environment for health care delivery. Thus, the home has become, not by choice and often in spite of its design, a de facto therapeutic environment. Not surprisingly, the independent living and home health goals that should be mutually supportive—that is, independent living should promote health and home health should promote independent living—often are addressed without consideration for each other.

To engender a more holistic approach to activity and health needs and to provide home environments that are more supportive of those needs, a number of policy, public, and personal constraints must be overcome. These include (1) a reimbursement system that provides only limited coverage for the costs of environmental assessments and modifications for activity limitations only, and particularly lacks incentives for the use of solutions that have broader benefits beyond the specific health-related problems or individuals for whom they were intended; (2) a delivery system that is fragmented, so that the array of health care services, including assistive technologies, health care technologies, environmental modifications, home therapy, and home health, are provided by many different and disconnected providers and funding mechanisms; (3) a regulatory system of building and zoning codes that enables housing to continue to be built as if people will never have activity or health care needs (Pynoos and Regnier, 1997); and (4) a reluctance on the part of homeowners to make changes in their homes due to lack of awareness of, and misperceptions about, the importance of the home environment in effecting engagement, comfort, novelty, and stimulation as well as participation in meaningful activities (Gitlin, 2003).

The success of the home as a health care environment is therefore more complicated than simply modifying the physical environment of the home to fit activity and health care needs. For such interventions to occur, there must be fundamental paradigm shift with regard to the importance of the home environment in promoting activity, health, and health care. To compound the problem, changes must occur in a number of different and mutually exclusive systems that are not particularly aware of the role of the environment in supporting activity and health needs or of each other.



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