Not all assessments are the same, said Sanford. Some look at the expected performance of an individual, and others look at actual performance. Assessments of expected performance look at the anticipated performance of activities based on ability and environmental attributes. They do not accurately reflect differences between what individuals can do and what they actually do.

Assessments of actual performance focus on activities rather than abilities or attributes of the environment. These kinds of assessments then require additional assessments of the environment to determine what needs to be modified and how. For example, one assessment asks people if they are satisfied with what they are able to do in terms of dressing, bathing, feeding, and so on. If they are not satisfied, the next question is how the situation can be modified to allow them to do what they want to do.

By linking assessments of abilities, activities, and attributes, designers of the physical environment can develop best-fit solutions. These solutions should be individualized, customized, and personalized, Sanford said, to fit the functional needs of the individual. Still, best-fit solutions are situational. A number of confounding factors can mediate and influence decisions about modifications. Examples of these factors include the personal tastes or preferences of individuals in the home, the social constraints of the living situation, the structure of the home, building and zoning codes, and cost.

The majority of the modifications that are typically made relate to getting into and out of the home, safe movement within the home, and safe transfers and greater independence in self-care activities. For getting into and out of a home, ramps and lifts can obviate the need for stairs. Chair lifts and architectural modifications, such as wider doors, can facilitate movement within the home. And safe transfers and greater independence can involve modified toilets, sinks, and baths; grab bars and other devices in bathrooms and kitchens; and other modifications designed to facilitate daily activities.

A wide variety of organizations and individuals support and provide these modifications, including government agencies, nongovernmental organizations, private contractors, remodelers, builders, occupational therapists, home health nurses, and social service providers, some of whom are trained and certified for their jobs and others of whom are not. Overall, the system is complex and fragmented, said Sanford. “Imagine people trying to get into the system and figure it out.”

Most home modifications are paid for by the recipient of care or someone associated with the recipient. From one perspective, this makes sense, since disability can be seen as a life-cycle event comparable to having a baby or building a home office. But modifications could also be seen as part of the health care system. In some countries, the government subsidizes home modifications throughout the life span. “Whatever you need you get, and



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