The Role of Human Factors in Home Health Care Workshop Summary (2010) / Chapter Skim
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10 The Physical Environment and Home Health Care--Jonathan Sanford
10 The Physical Environment and Home Health Care--Jonathan Sanford
Pages 201-246
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From page 201... ...
. To compensate for and help manage health conditions, the physical environment of homes can be both prosthetic and therapeutic.
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From page 202... ...
. 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.
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From page 203... ...
Other chapters in this volume address social and policy environments. Physical environmental barriers, such as stairs, lack of toilet and tub grab bars, poor lighting, and poor visual contrast, and lack of space can reduce accessibility; create dangers in the home and community; put communitydwelling individuals with chronic conditions and functional limitations at significant risk for adverse health events (such as falls)
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From page 204... ...
More broadly, home modifications and assistive and communication technologies have been found to prevent functional decline and disability, promote independent activity and safety, increase task self-efficacy, and enhance health outcomes (Connell and Sanford, 1997, 2001; Mann et al., 1999; Gitlin et al., 2001a; Freedman, Martin, and Schoeni, 2002; Tinetti et al., 2002; Gitlin, 2003; Ferrucci et al., 2004; Oswald and Wahl, 2004; Spillman, 2004; Allen, Resnick, and Roy, 2006; Sanford and Hammel, 2006; Sanford et al., 2006; Oswald et al., 2007) by reducing task demand (Verbrugge and Sevak, 2002)
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From page 205... ...
. As a result, activity performance, participation, and health are expressions of the fit or misfit between an individual and his or her environment.
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From page 206... ...
It is up to individuals and care providers to either take advantage of any opportunities presented by prosthetic and therapeutic environmental facilitators or overcome the demands of any barriers that are present. PROSTHETIC INTERVENTIONS: HOME MODIFICATIONS TO IMPROVE ACTIVITY OuTCOMES Reducing environmental demands to improve P-E fit can be accomplished through a variety of home modification strategies (i.e., prosthetic facilitators)
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From page 207... ...
. Although both are common and have their benefits, the results of each are subject to different levels of bias, validity, and reliability that can impact the fit between therapeutic interventions and the individual as well as the home environment.
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From page 208... ...
are two performance-based instruments that can identify actual home modification needs as well as changes in performance after modification interventions. However, these instruments are purely performancebased; they do not assess either environmental attributes or ability.
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From page 209... ...
These guidelines apply neither to private residences nor to individuals who have functional losses that do not "qualify" as a disability. Therefore, whether these interventions are assistive technologies, accessible designs, or universal designs, they should be individualized, customized, and personalized to best fit the functional needs of individuals for independent living and their caregivers for providing assistance.
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From page 210... ...
Not surprisingly, therefore, the majority of home environmental interventions have traditionally focused on modifying entrances, circulation paths and stairs, and the bathroom to facilitate mobility and transfer tasks. Moement into and Out of the Home.
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From page 211... ...
Regardless of purpose, however, the effectiveness of devices is impacted by and has unique implications for the design of the home environment.
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From page 212... ...
These decisions, in turn, affect not only the effectiveness of modifications in meeting functional needs, but also their impact on the home environment. Who Proides Home Modifications?
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From page 213... ...
While the latter does not specifically focus on home modifications, it is the only certification that is eligible for reimbursement as a clinical service, although occupational therapists can be reimbursed for some home assessments under occupational therapy licensure. In addition, several universities, including the University of Southern California and Georgia Institute of Technology, offer certificates for online programs.
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From page 214... ...
Still, modifications for healthy, independent living in the community should be a public health concern for which funding is made available. Such is the case in many countries where home modifications are considered medical interventions.
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From page 215... ...
While the number of potential mediators is large, cost is by far the most common and most influential. In the end, home modifications that are the best fit for the situation may or may not be an "ideal" fit with the functional abilities of the client or caregiver or with the home environment.
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From page 216... ...
. Like home modifications and assistive technologies, medical devices and technologies for self-management can have a large impact on the home environment and on the individuals living there.
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From page 217... ...
, are easy to install and maintain, and are integrated with each other and with other home technology systems. NEW CONCEPTS IN HOuSING: INTEGRATING PROSTHETIC AND THERAPEuTIC INTERVENTIONS IN A HOME ENVIRONMENT The large number of home modifications and assistive technologies and medical equipment and health care technologies, combined with the variety of typical personal technologies, such as wheelchairs and walkers, evokes a picture of a home environment cluttered with devices that take up large amounts of space, can potentially get in the way of each other and others in the home, and can themselves become hazards.
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From page 218... ...
. Clearly, maintaining independence and transplanting medical care to the home in the 21st century will have impacts on the physical environment that go well beyond ramps and grab bars.
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From page 219... ...
. universal Homes Unlike accessible design, which is an add-on component to support specific types and levels of ability, universal design (UD)
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From page 220... ...
Many home modifications would be unnecessary if homes had originally been designed to better meet people's needs. For example, bathrooms in most homes are inaccessible to people with physical limitations and disabilities because the doors are too narrow, the floor space is too limited, the layout of fixtures is ill conceived, the fixtures themselves are often poorly designed, and there are no supporting features.
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From page 221... ...
While the barriers to residentially focused environmental interventions are numerous and varied, they can be traced back to the origins of federally funded health and housing subsidies, which were designed to operate as separate systems, each achieving separate public goods. As a result, the systems through which these services are delivered, as well as the regulations, performance measurements, and implementation guidelines of the two systems, can often conflict and impede coordination.
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From page 222... ...
. As a result, these individuals often underestimate the importance of the physical environment and may not recommend environmental interventions.
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From page 223... ...
Demand Side Barriers On the demand side, the fragmented delivery system also ensures that consumers are uninformed about the benefits and costs of UD and other environmental modifications. Even making small changes can pose large problems for individuals who are unfamiliar with UD and home modifications and have misperceptions of what they are and what benefits they offer.
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From page 224... ...
However, it is not a practice that is used in assessing needs for therapeutic home interventions. Although this is primarily because many home modifications either need to be installed (e.g., grab bars)
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From page 225... ...
. While these perceptions have a firm basis in the many assistive and health care technologies and accessible design solutions that have an institutional or medical appearance, there are many newer UD products that have been designed specifically for homes.
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From page 226... ...
, system inadequacy may render environmental interventions infeasible due to the costs of upgrading (e.g., adding a curbless shower when the plumbing needs to be replaced)
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Not only should public policy encourage health care payers to continue paying for existing equipment and assistive devices, it should also encourage accessible design modifications and, wherever possible, universal design modifications to facilitate safe activity performance and prevent accidents, promote wellness and health management, and ultimately forestall institutionalization. To accomplish this, reimbursement must overcome its "hands-off-the-home" policy, create incentives for universal design, incorporate access into local building codes, make environmental interventions a medical issue, and certify providers of prosthetic and therapeutic interventions.
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From page 228... ...
for such features as handrails, stairs, and ramps, these requirements are based on safety, not access. There are several reasons for this exclusion of environmental interventions to support independent living and home health care.
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From page 229... ...
, as it usually does, UD interventions offer more effective solutions overall than home modifications or assistive technologies that benefit only the individual with a functional limitation. In addition, there is a need for products and equipment that work better for everyone and fit better into the home environment.
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From page 230... ...
Similar policy changes that require or create incentives for UD features, such as curbless showers, bathrooms with a 5-foot turning radius, and wider hallways, through tax breaks or fast-tracked approvals by municipal or state officials, are needed to overcome accessible design mentality. Nonetheless, with the Americans with Disabilities Act and its mandated accessibility guidelines clearly forging the way (although it has no jurisdiction in home environments)
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From page 231... ...
However, it is a rare physician who considers environmental interventions as part of a care plan. Nonetheless, while no one really expects physicians to prescribe home modifications, they should be knowledgeable enough to suggest them, just as they would suggest diet and exercise as an intervention, and recommend a consultation with an expert in the area, such as an occupational therapist, which could be reimbursable.
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From page 232... ...
In addition, certification should be more stringent than that currently offered and should be designed specifically for the home environment (e.g., neither occupational therapist licensure nor assistive technology practitioner certification ensures a knowledge of either the client's housing needs or the home environment)
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From page 233... ...
effectiveness of specific environmental interventions as they relate to home health; and (d) barriers to and facilitators of social participation.
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From page 234... ...
To date, studies have used traditional rehabilitation outcomes, such as improved activity performance, to evaluate the effectiveness of assistive technologies and home modifications (e.g., Mann et al., 1999; Gitlin et al., 2001a; Gitlin, 2003; Sanford and Hammel, 2006; Sanford et al., 2006)
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when the physical environment is the intervention, but most real-world circumstances make it difficult to use these and other experimental intervention designs (e.g., random/
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From page 236... ...
. There are many practical and ethical concerns, such as the high initial costs of many physical environmental interventions, the costs of changing interventions in crossover designs, the disruption of installing or constructing environmen tal interventions, and the ethics of withholding intervention/treatment in the control group if the intervention is the only alternative or of exposing patients to an inferior intervention when an alternative is deemed more appropriate.
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From page 237... ...
Limited information contributes to a lack of consumer demand; limited demand for home modification services results in few experienced providers and remodelers; inexperienced providers and remodelers produce poorly crafted, ill-suited modifications; small, scattered, little-known, and underutilized funding sources produce a patchwork of public service programs and make it hard for low-income households to undertake projects. Consumers are often frustrated by the process of obtaining and making home modifications and are discouraged by the results.
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From page 238... ...
Ultimately, the adoption of the physical environment, and UD in particular, as a broad-based intervention strategy will require fundamental paradigm shifts in both housing and health that recognize the home environment and everything in it as an integral part of the medical milieu. Today, most UD products and homes are generally more expensive than other consumer products.
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Occupational Therapy Journal of Research, 1(3)
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From page 240... ...
. Adherence to occupational therapist recommendations for home modifications for falls prevention.
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From page 241... ...
. Factors predicting the imple mentation of home modifications among elderly people with loss of independence, Physi cal and Occupational Therapy in Geriatircs, 12(1)
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From page 242... ...
. Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care costs for frail elderly: A randomized controlled trial.
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From page 243... ...
. Assessing universal design in the physical environment.
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From page 244... ...
. Development of a comprehen sive assessment for delivery of home modifications.
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From page 245... ...
. What is important to continuity in home care?
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