ronments as they apply to health care in the home. The family vignettes in Boxes 6-1 and 6-2 serve to illustrate many of the points made.

PHYSICAL ENVIRONMENTS

In contrast to more structured settings, such as hospitals, nursing homes, or doctors’ offices, the physical environments of homes are more uncontrolled, dynamic, personal, and diverse (Gitlin, 2003; Siebert, 2009). These locations therefore pose novel challenges to providing direct health care and using health technology and equipment. Homes vary widely in their location, size, condition, and physical characteristics (see Table 6-1). Each of these factors affects provision of care and how health technologies are used. Home environments can either help or hinder the ability of individuals to perform physical functions, carry out personal care tasks, or use health technologies. Individuals and families also differ in their willingness to change the home environment to facilitate health care, their preferences for where they perform basic activities of daily living, and their willingness to use health technologies (Albert, 2010). As each home is unique, solutions that may be suitable for one individual, family caregiver, and home may not be appropriate or effective for others.

Housing in the United States

The United States is characterized by great diversity of residential locations, housing types and conditions, and cultural, neighborhood, and health policy influences. These variations have important implications for the provision of health care in the home.

According to 2010 U.S. census data, approximately 244 million persons in the United States live in urban and suburban areas, and 65 million live in rural areas (U.S. Census Bureau, 2010). These locations have different capacities to support the health needs of individuals due to the varying availability of public transit, housing options, and health care services. Moreover, the types of housing vary considerably: nearly 79 million are detached single-family homes, 5 million are duplexes, 28 million are multifamily units, and 9 million are mobile homes (American Community Survey, 2008).

In these different settings, older adults make up a large proportion of the 133 million U.S. residents with one or more chronic illnesses (Wu and Green, 2000). Nearly 86 percent of the more than 37 million people over age 65 have chronic illness (Centers for Disease Control and Prevention, 2008), but many older adults reside in older homes that are not well suited to their changing needs (Gill et al., 1999; Commission on Affordable



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