The Physical Environment and Home Health Care
There is a direct relationship between health and housing. When an individual is in poor health, is impaired, or has functional declines due to aging, health concerns are virtually indistinguishable from housing concerns, particularly in an aging housing stock (Lawler, 2001). To compensate for and help manage health conditions, the physical environment of homes can be both prosthetic and therapeutic. As a prosthetic environment, the home can compensate for limitations in functional abilities to enable individuals to carry out basic activities associated with daily living safely and independently, participate in social roles, and receive personal assistance from caregivers as needed. Therapeutically, the environment can facilitate health maintenance and management by supporting health-promoting behaviors and provision of health care services.
Many homes are not designed to support either prosthetic or therapeutic needs. They contain potential hazards that can lead to accidents, are deficient in design features that permit safe and independent functioning in daily activities, and lack sufficient space and layout for assistive technologies and personal assistance. Neither is housing designed to accommodate health care equipment, health care providers, or the communications infrastructure necessary to share health information with remote care providers. As a result, there is often a lack of fit between the independent living and health needs of community-dwelling individuals and the places in which they live.
Exacerbating the lack of fit between needs and the design of homes, activity performance and health promotion are typically treated autonomously and with different environmental implications, even though envi-
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.
This chapter examines the prosthetic and therapeutic roles of the environment in promoting positive activity and health outcomes, identifies barriers to supportive home environments, and proposes that universal design—the design of products and environments to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design (Mace, Hardie, and Place, 1991)—be adopted as the conceptual basis for the paradigm shift that is needed to promote independent living and health management. Specifically, the chapter presents (1) a theoretical background to support the role of the environment in independent living and home health care; (2) a discussion of the relationship between prosthetic environmental interventions and improved activity outcomes through facilitating both independence and caregiver assistance; (3) a use of the home as a therapeutic environment in which communication and monitoring technologies can improve health management and treatment through facilitating access to health care; (4) new housing concepts, including smart homes and universal design, that can minimize the impact of prosthetic and therapeutic interventions on the home environment; (5) the barriers to adoption of new housing innovation; (6) the policy changes necessary to improve adoption of housing innovation; and (7) a research agenda that can provide the evidence needed to justify changes in home health policy.
THE ROLE OF THE ENVIRONMENT IN INDEPENDENT LIVING AND HOME HEALTH CARE
Home and community settings are complex environments comprised of physical as well as social, cultural, personal, and temporal environmental factors. For example, social factors might include the impact of other individuals in a home, who may or may not be providing care, as well as the impact of modifications on those individuals (Gitlin, 2003). While a number of environmental factors exist across a variety of contexts (e.g., community, work, school), this chapter specifically focuses on the physical barriers and facilitators (both prosthetic and therapeutic) of positive activity and health outcomes in the home. 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 community-dwelling individuals with chronic conditions and functional limitations at significant risk for adverse health events (such as falls) and injuries, loss of independence, or difficulty in performing activities of daily living (ADLs); minimize the effectiveness of caregivers, assistive technologies, and health care devices; and even lead to relocation or early institutionalization (Carter
et al., 1997; Clemson, Roland, and Cumming, 1997; Cumming et al., 1999, 2001; Oswald et al., 2002; Fange and Iwarsson, 2003; Stark, 2004; Iwarsson, 2005; Lau et al., 2007). Barriers, particularly environmental hazards, are common and pervasive (Gill et al., 1999). For example, one study of factors associated with home environmental problems among older adults reported an average of 13 problems with the environment that posed barriers to safe and independent performance (Gitlin et al., 2001b).
In contrast, environmental facilitators reduce barriers and have positive impacts on functioning of individuals and their caregivers. In fact, one study (Freedman, Martin, and Schoeni, 2002) suggests that gains in functioning of older adults over the past few decades may be the result, in part, of the introduction of facilitators and the reduction of environmental barriers. A second study reviewed 64 studies of environmental interventions for the management of Alzheimer’s disease (Gitlin, Liebman, and Winter, 2003) and reported that environmental interventions had some level of success in 90 percent of the studies, resulting in significant improvement in experimental group participants in 10 of 11 randomized clinical trials. More broadly, in a review article of studies on the home environment and disability, Wahl and colleagues (2009) reported that the majority of studies provided supportive evidence that improving the home environment reduces disability-related outcomes.
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). In addition, home modifications have been shown to increase caregivers’ effectiveness, well-being, and self-efficacy, as well as to decrease caregiver stress and upset (Gitlin et al., 2001a, 2003). Similarly, research has shown that physical environment facilitators can reduce sedentary behaviors, promote community mobility, and enhance health (e.g., Andersen et al., 2000; Frank, Engelke, and Schmid, 2003; Frumpkin, 2003; Saelens, Sallis, and Frank, 2003).
However, linking specific environmental barriers and facilitators in the home directly to activities is a formidable task (Connell et al., 1993; Connell and Sanford, 1997). Traditional medical models (World Health Organization, 1980) attribute activity performance and health outcomes primarily to an individual’s functional abilities. More specifically, these models predict that impairment causes functional limitations, which in turn result in negative performance and health outcomes.
Although the physical environment has long been associated with individual functioning and disability (Rubenstein, 1999; Wahl, 2001; Iwarsson, 2004; Scheidt and Windley, 2006), social models of health have only recently become more accepted. These models suggest that, whereas physiological factors set the threshold on functional ability and health, environmental factors set the threshold on the point at which limitations in ability become a disability (Stineman et al., 2007). Outcomes are therefore situational, the result of the interaction between an individual’s abilities (as opposed to limitations) and the demands of the environment, according to the environmental press model (Lawton and Nahemow, 1973). As a result, activity performance, participation, and health are expressions of the fit or misfit between an individual and his or her environment. Optimal person-environment (P-E) fit occurs when an individual’s abilities and the demands of the environment are compatible. Conversely, P-E misfit occurs when the environment is either too challenging (i.e., demands exceed abilities) or not challenging enough (i.e., abilities exceed demands). An environment that fits an individual will facilitate positive performance and health outcomes that are manifest in his or her ability to participate in activities when, where, and with whom he or she desires. In contrast, an environment that does not fit an individual will result in negative performance outcomes or performance deficits that may prevent him or her from participating in an activity altogether.
Whereas Lawton’s environmental press model suggests the role of the environment in activity and health, the enabling-disabling process model of the Institute of Medicine specifically identifies the environment as a pathway for intervention (Institute of Medicine, 1997). The model suggests that the disabling process is the dislocation of an individual from his or her prior integration in an environment due to increasing needs relative to the environment. In contrast, the enabling process is either the restoration of the individual’s function or environmental modification to remove barriers that limit performance.
Two decades after proposing its medical model, the World Health Organization developed the International Classification of Functioning, Disability and Health (ICF), a new classification system based on a more robust social model (World Health Organization, 2001). The ICF attributes differences between what individuals can do (capacity to engage in activities and participation based on body function and structure) and what they actually do (performance of activities) to the influence of personal and environmental (both social and physical) factors. The classification system not only associates specific environmental factors with positive or negative outcomes but also provides a mechanism for measuring the level of P-E fit or misfit by rating the strength of a particular factor as a facilitator (from 0 to +4) or barrier (from 0 to −4).
Differences between medical and social models have important implications for health and independent living in the home and community. Medical models suggest that achieving positive outcomes involves changing the person (i.e., eliminating or minimizing impairment) or compensating for a functional limitation (i.e., providing assistive technology). In contrast, social models suggest that positive outcomes involve changing either the person or the environmental circumstances or both. Importantly, although the physical environment plays an important role in activity performance and health, it neither dictates nor determines activity performance or health behavior. Rather, the environment simply creates opportunities for activity or behaviors to occur. 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), including assistive technologies and accessible design features (i.e., specialized equipment and environmental features intended to support people with specific disabilities) and universally designed products and spaces (i.e., environmental features intended to support people regardless of ability), that meet the activity and health needs of individuals and their care providers. Furthermore, the process of environmental intervention is a confluence of activities and delivery of services that begins with assessing needs and includes identification and implementation of solutions, training in the use of solutions, and evaluating outcomes (Sanford, 2004). Of particular relevance here are the following: (1) assessing the demands and needs for eliminating barriers, (2) prosthetic interventions that meet the functional needs of both individual and caregiver, (3) delivery and reimbursement systems to supply and fund best-fit interventions, and (4) choice and impacts of best-fit interventions that must ultimately meet the real-world needs of the situation.
Assessment: Determining Fit, Demands, and Modification Needs
Research suggests that residents’ perceptions of their own abilities and environments differ from those of experts and significantly underreport the presence of environmental barriers (Steinfeld and Shea, 1993; Iwarsson and Isacsson, 1996). As a result, a systematic process, performed by skilled specialists, is needed to acquire information about the fit between a person’s
abilities, activities performed, and environmental attributes; analyze the information; and use clinical reasoning to translate the information into appropriate interventions that will best fit the situation (Steinfeld and Shea, 1993; Pynoos et al., 1997; Anemaet and Moffa-Trotter, 1999; Gitlin and Corcoran, 2000; Niva and Skar, 2006).
To be effective, assessments must produce unbiased, objective information that is both valid and reliable. Yet assessments are conducted by an array of home health service providers—occupational therapists, rehabilitation engineers and technologists, home health nurses, and social workers—and, to a lesser extent, building professionals—remodelers, architects, and interior designers. In addition, some assessments are based on expected abilities and activity performance, and others assess actual activity performance (Sanford and Bruce, 2010). 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. Of equal importance, few assessments have proven psychometric properties. In fact, in a review article, Wahl and colleagues (2009) questioned the validity and reliability of assessment procedures of more than half the studies they examined.
Expected Performance: Predicting Needs from Attributes
Assessments that measure a specified set of environmental attributes based on expected rather than actual measures of ability and activity performance result in a prediction of potential, rather than actual, environmental demands. As a result, interventions based on such information are determined irrespective of the actual abilities of the individuals for whom the interventions are intended. This type of assessment is illustrated by a number of instruments, such as the Housing Enabler (Iwarsson, 1999) and the Cougar Home Safety Assessment (Fisher, Coolbaugh, and Rhodes, 2006; Fisher et al., 2008). Both instruments assess the severity of environmental barriers in the absence of an assessment of a client’s actual ability or performance. For example, the Housing Enabler, one of the few tools with known psychometric properties, uses a set of typical impairments and functional limitations as a surrogate for individual disability/incapacity. Various environmental attributes are then systematically rated in relation to their expected impact on performance.
Clearly, the measurement of potential demands is helpful when there is no single client whose abilities can be determined (such as for the accessibility of public buildings) or when actual performance of specific activities cannot be determined, such as assessing the home environment for a patient prior to his or her discharge from a clinic. However, measuring potential demands has its limitations. Going back to the discussion of the ICF, con-
textual factors (including environmental demands and personal factors) account for the difference between an individual’s hypothetical capacity to function (i.e., what people can do) and actual performance (i.e., what they actually do) or enacted function (Glass, 1998). If actual ability and activity performance are not assessed, how can one be sure that performance based on expectations of what individuals can do accurately reflects what they actually do and, consequently, the effectiveness of the environmental modifications for a particular client?
Actual Performance: Assessing Needs from Activity
Requiring individuals to demonstrate how they perform routine activities would provide an accurate sense of how the individual interacts with the environment (Pynoos et al., 1997). Thus, when performance outcomes can be determined, as is the case when an individual is living at home, then measurement of actual demands will provide a more accurate picture of environmental demands than will prediction of demand potential. The Canadian Occupational Performance Measure (COPM) (Law et al., 1991) and the Safety Assessment of Function and the Environment for Rehabilitation-Health Outcome Measurement and Evaluation (SAFER-HOME v. 3) (Letts et al., 1998) 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 performance-based; they do not assess either environmental attributes or ability. Without a measure of ability, one cannot determine if there is a difference between what an individual can do and what an individual actually does. Moreover, without a measure of environmental attributes, it is not possible to determine what specific changes should actually be made.
Linking the Three A’s: Ability, Activity, and Attributes
While assessments of expected demand link environmental attributes to expected levels of ability and activity performance, few assessments examine all three: (1) ability, (2) activity, and (3) attributes. Without all three, it is not possible to determine best-fit interventions for a particular individual. The Comprehensive Assessment and Solutions Process for Aging Residents (CASPAR) is one of the few instruments that measure all three factors (Sanford et al., 2001; Sanford, 2002; Sanford and Butterfield, 2005). It includes a measure of ability under standardized conditions (e.g., turn on a light switch, open a drawer, and turn a doorknob); activity-related problems (e.g., going up steps and stepping over the side of a tub); and detailed measures of activity-relevant environmental attributes, such as the number of steps and the height of the tub. However, CASPAR, like
other home assessments, requires a specialist onsite to collect the required information.
Remote Assessment: Overcoming Limitations of Time and Distance
To overcome travel time and distance that increase costs and limit the ability of experts to access clients’ homes, a number of studies have demonstrated that real-time, interactive videoconferencing can be used by specialists to successfully identify needs and provide sufficient information to recommend interventions (Sanford et al., 2004, 2007; Sanford and Butterfield, 2005; Hoenig, Sanford, and Griffiths, 2006), thus potentially eliminating the need for a specialist to travel long distances to perform an assessment. These studies suggest that relatively inexpensive videoconferencing technology (e.g., as little as $1,200 for two videophones and a video camera) that uses the telephone system enables specialists to conduct remote assessment in a manner similar to in-home assessments, thus maintaining the integrity of the therapist-patient interaction, and provides a practical alternative to traditional home visits by a therapist for improving task self-efficacy. Nonetheless, to date, teleconferencing technology has been limited to research studies and has not been translated into practice in any ongoing home assessment programs.
Home Modifications: From Needs to Prosthetic Interventions
Providing a facilitating environment in the home is different from providing an accessible environment in community settings. In public places, the Americans with Disabilities Act accessibility guidelines (U.S. Access Board, 2002) are intended to ensure at least basic levels of usability and access for people with acknowledged disabilities. 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.
Improving Independent Activity: Prosthetic Modifications for Mobility and Self-Care
Although problems can and do occur throughout the home, research and experience suggest that environmental barriers to the safety and health of individuals in the home are linked to three primary activities: (1) getting into and out of the house, (2) moving around the house, and (3) performing
self-care (toileting, bathing, and grooming). Clearly, mobility and transfer tasks are integral to each of these activities. 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.
Movement into and Out of the Home. Many houses are built above ground level and have a set of steps leading up to a porch, deck, or landing at the door. Not only are stairs a barrier to wheelchair users, they also can become a safety hazard and an obstacle to independence for individuals with gait and balance problems and those who use walking aids. In addition, walkways and stairs frequently are in poor condition and lack handrails for support and adequate lighting at night. To increase safety and mobility, walkways should have smooth, slip-resistant surfaces; steps should be in good repair, with handrails on both sides and with contrasting nosings (the rounded edges of stair treads), or should be replaced with a ramp, sloping walkway, or mechanical lift. In addition, the threshold should be reduced to minimize tripping, doorways should be widened, sufficient space should be provided to maneuver, and an automatic opening system should be installed to eliminate twisting and turning of doorknobs. There should also be adequate lighting operated by motion detectors or timers at all walkways and doors to help maintain independence and ensure the safety of individuals with mobility issues as well as those with vision loss.
Mobility in the Home. Inside the home, people who use mobility aids, such as wheelchairs, frequently lose access to rooms, particularly bathrooms, because hallways or doors are too narrow, furniture obstructs the path of travel, or stairs prevent travel to other floors in the home. Stairs, slippery floors, and obstacles are also potential safety hazards. Stairs, in particular, account for a greater number of falls than any other single location in the home (Kochera, 2002). And the number of multistory homes being constructed has increased precipitously since 1970 (U.S. Bureau of the Census, 1994). For individuals with mobility issues, typical modification strategies to ensure activity, increase safety, and improve health are similar to those for outdoor environments, although stair lifts are commonly used instead of ramps between levels of a home. In addition, for people with vision loss, it is important to control glare by using sheer curtains or translucent shades (as opposed to metal miniblinds that reflect light) to buffer bright sunlight and reduce dark-light transitions between rooms.
Transfer Safety and Self-Care Activities. The bathroom, with its wet, slippery surfaces, small, cramped spaces, and hard surfaces can easily lead to falls and serious injury, even for people without functional limitations.
Bathroom floors are extremely dangerous when wet. For many individuals who have difficulty raising and lowering themselves, including those who use wheeled or ambulatory mobility aids, health, safety, and fall risks are associated with difficulty transferring to the toilet, bathtub, or shower. While individuals who use wheelchairs often lack space to maneuver or get close enough to a fixture, ambulatory individuals with gait and balance problems often lack support (i.e., something to hold onto) to safely lower themselves down onto a toilet or the bottom of a tub or, conversely, to pull themselves back up from these positions. To increase safety and mobility, sufficient space should be available at the toilet, bathtub, shower, and sink for mobility aids and caregiver assistance. In addition, safety can be enhanced by reducing the distance an individual must raise and lower himself or herself (e.g., raising the height of the toilet) or the need to lift one’s legs over the side of the tub (e.g., walk-in tub) or the shower curb (e.g., a curbless shower). In addition, safety can be increased and transfers facilitated by adding supports (such as grab bars, safety frame, or floor-to-ceiling pole) or using a fixture with integral supports and increasing the visibility (e.g., contrasting color of the toilet or toilet seat from walls) of all fixtures.
Improving Caregiver Assistance: Prosthetic Devices for Mobility and Transfer
Although mobility and transfer tasks are the most strenuous and difficult activities for caregivers, they are also the most frequent tasks with which both formal and informal caregivers provide assistance (Gershon et al., 2008). Given the strenuous nature of these tasks and the clutter, lack of space, and other safety risks in the home (Gershon et al., 2008), it is not surprising that caregivers experience considerable difficulty and have an increased incidence of injury compared with other health care and human services workers (Myers et al., 1993; Ono et al., 1995; Galinsky, Waters, and Malit, 2001).
To reduce injury and facilitate caregiver assistance, a number of products and devices have been developed to make moving around the home and transferring easier, safer, more efficient, and more dignified, both for the care recipient and the caregiver (see Chapter 8). These include lift systems for moving individuals through the home as well as products that assist with, or eliminate the need for, transfers in bathing and toileting. Regardless of purpose, however, the effectiveness of devices is impacted by and has unique implications for the design of the home environment.
Service Delivery: From Intervention to Implementation
Implementation is somewhat more complex than merely finding someone to install or supply the necessary modifications. Like assessors, there are many providers, who come from different programs and disciplinary backgrounds that can impact what they are able to provide and how they provide it. In addition, the costs of some modifications are reimbursable, while others are not. As a result, providers and payers typically impact decisions about what modifications are actually made. These decisions, in turn, affect not only the effectiveness of modifications in meeting functional needs, but also their impact on the home environment.
Who Provides Home Modifications?
In the United States there is no single model for home modification service delivery. Rather, there is a fragmented system of social service, health service, and construction providers that varies not only by state, municipality, and organization but also by the client’s point of entry. Similarly, there is no single profession that provides home modification services; although there are some certification programs, none is recognized beyond its own professional organization.
Home Modification Programs. Many rehabilitation providers include a home modification program as part of the rehabilitation service. However, while individuals who suffer from trauma or chronic illness are placed into the rehabilitation system, others, such as seniors with declining abilities, are typically on their own to find out how and where to enter a complex system of services that could be provided by any number of programs. These include the local area agency on aging (AAA), natural occurring retirement community (NORC) initiative, or center for independent living (CIL); municipal agencies, such as a mayor’s office for people with disabilities (MOPD) and department of housing; and state assistive technology programs, departments of veterans affairs, and volunteer organizations like Rebuilding Together. Even more daunting is that the same type of organization may offer different types of services in different locales. For example, in Philadelphia, the local AAA, the Philadelphia Corporation for Aging, provides an extensive in-home modification and repair service from assessment to implementation. In Atlanta, the Georgia NORC initiative provides assessment by an occupational therapist and links homeowners with local nonprofits to provide the modifications. In Chicago, the MOPD offers a complete range of home modification services for people with disabilities up to age 59, and the Department of Housing provides services for people ages 60 and older.
Home Modification Professionals. Like assessments and service programs, home modifications are delivered by a variety of professions. As discussed above, assessments are undertaken primarily by health and other providers of social services and, to a lesser extent, by professionals in the construction industry. However, the scope of modifications differs along professional boundaries. Health professionals typically limit their scope of services to small-scale, off-the-shelf assistive technologies and adaptive products, as well as environmental strategies, such as moving furniture, adding task lighting, and changing the location of activities. In contrast, building professionals focus primarily on changes to the physical environment, ranging from installing grab bars to moving fixtures to adding lifts to full-scale remodeling. However, they may also supply assistive devices and equipment.
A variety of certifications are associated with home modifications, although none is legally binding or affiliated with any professional licensure. For example, the National Association of Home Builders (NAHB) offers a Certified Aging in Place Specialist (CAPS), the American Occupational Therapy Association (AOTA) offers a Specialty Certification in Environmental Modifications, and the Rehabilitation Engineering Society of North America (RESNA) offers an assistive technology practitioner (ATP) certification. 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.
It is important to recognize that there are no national standards for provision of home modification services. Anyone can provide the service, regardless of certification or licensure, although the scope of services that an individual can provide may be restricted by their professional licensure. For example, occupational therapists can perform home assessments, modify products (i.e., use duct tape and Velcro), and provide off-the-shelf products in states in which they are licensed, but they are not permitted to engage in home remodeling as occupational therapists. In contrast, home remodelers are not restricted from providing any of those services, including assessments, regardless of whether they are CAPS certified or not. As a case in point, I am not a licensed therapist, contractor, or architect, yet I not only provide all of these services but also have trained professionals in all three disciplines to do so as well.
Who Pays for Home Modifications?
The majority of home modifications are paid for out of pocket by the homeowner. In fact, less than one-fourth of home modifications are paid for
by third-party payers (LaPlante, Hendershot, and Moss, 1992). Of course, most individuals pay for a typical home remodeling, so why shouldn’t they pay for home modifications? After all, one could argue that aging or disability is a life event that requires changing one’s home just the same as other life changes, such as having children. No one would expect a private or public third-party payer to help modify one’s home, such as by adding a nursery, to accommodate such a lifestyle change.
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. As part of the Swedish public health program, for example, each municipality provides needed services to individuals with functional limitations, including the modifications necessary (regardless of cost and income level) to continue living in their own homes for as long as possible.
In the United States there is a patchwork of potential funders, ranging from government agencies, to private insurers and workers compensation to social service organizations, such as AAAs and NORCs, to nonprofit volunteer organizations, such as Rebuilding Together. State agencies often have their own programs using tax or bond revenues, often through a housing finance agency. Municipalities often offer tax credits, particularly to developers who build accessible homes. In the federal government, there are at least seven departments that have programs in which funds can be used for home modifications, including Agriculture, Energy, Education, Health and Human Services (HHS), Housing and Urban Development (HUD), Treasury, and Veterans Affairs. Some programs are loans directly to households (e.g., the HOME program of HUD), others are loan guarantees to lenders, and still others are grants, usually to social service organizations. However, regardless of the program, eligibility for services depends on one’s situation, unlike Sweden. Some of programs have age restrictions or dollar limits. For example, social services block grants from HHS and home and community care block grants from the Administration on Aging (AOA) are available to social service organizations, but recipients must meet age and income criteria. In addition, many home modification programs in the United States have capped costs from $5,000 to $10,000, which will generally cover only a ramp and some bathroom modifications.
Securing a traditional loan is always an option. For seniors, reverse mortgages, which are based on home equity, are also available, although up-front costs are fairly steep, sometimes amounting to almost 25 percent of the loan. With the fragmentation and restrictions, it is not surprising that in 2000, only half of the 2.1 million older U.S. households that needed home modifications to facilitate aging in place had them (Joint Center for Housing Studies, 2000).
Best-Fit Solutions: From Prosthetic to Practical Interventions
Whereas prosthetic interventions may best fit an individual’s or caregiver’s functional needs, as the previous discussion suggests, overall best fit is not based simply on functional ability. In addition to provider and payer issues, a large number of other confounding contextual factors impact decisions. These include personal tastes and preferences of a particular individual and others living in the home, social constraints of the living situation, structural limitations of the home, and building and zoning codes. These factors have nothing to do with improving activity outcomes, but they mediate and influence decisions about which interventions should be implemented. 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. For example, assistive devices, such as lifts, tub benches, and toilet seats, are typically more intrusive than structural changes to the home that might provide more space and better performance. Nonetheless, because these devices are less expensive, more often reimbursable, more familiar to health care providers, and more readily obtained, they are much more likely to be installed. Not coincidentally, they also have a much larger impact on the use of space in the home environment.
THERAPEUTIC INTERVENTIONS: TECHNOLOGIES TO IMPROVE HEALTH MANAGEMENT AND TREATMENT
The number of people with chronic conditions is growing rapidly. In fact, 45 percent of the community-dwelling U.S. population have at least one chronic medical condition, and about half of these, 60 million people, have multiple chronic conditions (Wu and Green, 2000). Approximately 83 percent of Medicare beneficiaries have one or more chronic conditions, and 23 percent have five or more chronic conditions (Anderson, 2005). By 2015, an estimated 150 million people in the United States will have at least one chronic condition (Wu and Green, 2000). With the variety of chronic health conditions comes a dramatic increase in the level of care requirements, higher costs (e.g., chronic diseases account for 75 percent of all U.S. health care costs), and the need to integrate multiple physicians, specialists, and formal and informal caregivers (Scheschareg, 2006).
Technology has long been an integral part of health care delivery, primarily in clinical settings to permit diagnosis, intervening treatment, and care of acute or chronic health conditions. New technologies enable active self-management and passive monitoring of safety and activity. Home-based
technologies are changing the way health care is provided by “freeing” patients from health care institutions (Sinding, 2003), as well as how the home environment is utilized and conceptualized.
Active Technologies for Self-Management
A variety of standalone and integrated devices are available that enable patients to actively manage their own health and reduce acute episodes. Treatment technologies commonly found in the home are often large pieces of equipment that are used to provide a variety of therapies and to assist bodily functions, including assistance in breathing, medicine delivery, body function, and suction (see Chapter 8).
In contrast to treatment technologies, preventive technologies tend to be smaller portable or mounted electronic monitoring devices that allow individuals or family members to measure and obtain feedback about specific health conditions or physiological status or to facilitate communication with friends, family, and care providers. In addition, several different types of integrated monitoring devices exist. These devices are used by the patient to collect information from multiple peripheral devices (e.g., blood pressure cuff, scale, pulse oximeter) and transmit it to caregivers and care providers. Other systems combine patient monitoring and video that enables patients and providers to interact in real time.
Communication technology to foster social connectedness and prevent deterioration in psychological health, particularly among individuals who have transportation difficulties, is an important, although sometimes overlooked, component of the home-based care system (see Chapter 9). 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. Large pieces of equipment have obvious space requirements, but smaller items, such as a pulse oximeter or a blood pressure cuff, need to be stored somewhere, as do medical supplies. Disposal of medical supplies, particularly used needles, and a backup generator in case of a power outage are also major considerations. In general, smaller monitoring and communications technologies have little impact on the structure of the home. However, they require space for both the communications hardware as well as any biometric tools (e.g., glucose meters, blood pressure cuff, digital scale) that are needed. Clearly, the larger the number of different systems and biometric tools that are introduced into the home, the more space is required.
Passive Technologies That Monitor Safety and Activity
In contrast to active technologies, there are passive home-based systems that do not depend on active engagement of individuals in the home. These technologies use networks of sensors, transmitters, and receivers embedded in the home environment to (1) monitor activity and location, (2) identify and reduce potential safety hazards, and (3) communicate physiological status to health care providers.
Despite the unobtrusive nature of embedded passive monitoring systems, the installation and potentially the appearance of these technologies will clearly be somewhat intrusive in the home environment. However, simply getting this technology into homes is only part of the problem. Like other technologies, there will be issues with the design of sensor networks that fit unobtrusively in the home environment (e.g., visibility of packaging and antennas), 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. When these conditions are introduced into homes of older adults or individuals with other chronic conditions, they frequently exacerbate conditions in which many health and safety hazards already exist, including lack of space, clutter, poor lighting, and loose rugs (Gershon et al., 2008).
Unsafe conditions put both home care patients and home health care workers at risk. Among care providers, these conditions contribute to awkward postures lifting and shifting patients that are linked to increased incidence of musculoskeletal injury (Myers et al., 1993; Ono et al., 1995; Galinsky, Waters, and Malit, 2001). Among care recipients, these conditions can increase the risk of falls and other injuries, although the latter issues have not been assessed (Gershon et al., 2008).
To further complicate provision of home health, studies have identified a number of additional concerns about the safety of home environments that can negatively impact care providers and thus the provision of care. These include the location of housing in unsafe neighborhoods, overheated room temperatures, poor indoor air quality, and unsanitary conditions,
such as the presence of insects and rodents, mismanagement of medical waste, and lack of standard disinfection practices (Kendra et al., 1996; Fazzone et al., 2000; Manangan et al., 2002; Markkanen et al., 2007; Gerson et al., 2008).
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. Space is limited, and there are ever-increasing technologies and devices vying for it. Nonetheless, housing is not being designed, and often is not being remodeled, with these needs in mind. In addition, individuals with functional limitations on dexterity, vision, hearing, or cognition may have difficulty manipulating, seeing, hearing, or understanding technology interfaces. To ensure that these technologies can be used by consumers, particularly older adults who make up the majority of home health recipients and who are less familiar with technology, the design of these devices will need to be based on more user-centric principles.
The challenge, however, is to design and incorporate modifications, health care products, technologies, and devices into the home environment without violating two basic principles. First, while space might be the great equalizer, the builder’s prime directive is that the home cannot increase in size (i.e., cost). Second, the consumer’s prime directive is that products, technologies, and modifications that go into the home must be residential in scale and appearance (i.e., look like they belong). Adherence to these principles will require new approaches to product and housing design that integrate technological systems with each other and in the home environment so that the home remains a home and does not become a hospital.
Woodward and colleagues (2004) argued that home care is dependent on three types of knowledge and skills: (1) those that are appropriate to the client, (2) the care required, and (3) the home. All three have implications for the design of the physical environment, from the standpoint of the design of the home as well as the technologies themselves. As a result, the success of home health care will depend on fundamental changes in the way both homes and technologies are conceived and designed.
To achieve these aims, housing and technology must be appealing to consumers as well as supportive of people with a wide range of functional abilities and health conditions, their caregivers, families, and health care providers. To do this, housing and technology must first work together as a seamless, integrated system. Second, housing should be universally designed, as should the products and technologies themselves. While such solutions are yet to be fully embraced by today’s housing market, innovations that embrace smart home technologies and universal design principles offer promise for the future.
Whereas smart home technologies enable compatible products (e.g., appliances and devices that act as receivers and remote controls or keypads that are transmitters) to talk to each other over a network, the technologies are being developed independently of each other. As a result, there are complex and redundant networks of sensors and hardware that connect care recipients with caregivers and care providers both inside and outside the home. The major difference between a smart home and a smart technology that resides in the home is the integration of systems in the smart home into a controlled network that connects systems and appliances to each other and to the outside world. Not only will such system integration bring together all of the health related information, it will also enable remote care providers to be informed when problems occur, regardless of the nature of the problem.
In the late 1990s and early 2000s, a large number of model smart homes were constructed on many university campuses (e.g., Drexel University, Georgia Institute of Technology, Iowa State University, Massachusetts Institute of Technology, University of Florida) as demonstration homes and laboratories to develop and test new technologies. These homes were designed to monitor daily activities, particularly of older adults, to enable them to have a greater degree of independence and remain at home longer. While many of the technologies had isolated functions, some were integrated systems that worked as a smart home. For example, at Iowa State University, everyday kitchen appliances, including the microwave and the refrigerator, were equipped with sensors. Each appliance had its own capability—the microwave scanned bar codes to calculate cooking times, and the refrigerator calculated the weights of food items to determine when items were running low—and they were also connected to the main computer system that sent a shopping list to the resident’s cell phone, which is also integral to the smart home.
As the first decade of the 21st century nears an end, the focus of smart homes is expanding from monitoring activity-based technologies to facilitate aging in place to include home health technologies for a range of care recipients. For example, Matsushita has been developing a variety of health-enabled bathroom products, such as a toilet seat with embedded passive monitoring sensors to monitor and send weight and body fat ratio, heartbeat, blood pressure, and glucose levels to the patient’s doctor via the Internet (Brooke, 2009).
Unlike accessible design, which is an add-on component to support specific types and levels of ability, universal design (UD) is everyday design that
supports all types and levels of ability. As a result, the seven principles of universal design (see Table 8-2) define a basic level of usability for everyone.
In contrast to accessible design, which is prescriptive (e.g., a threshold may be no greater than 1/4 inch to allow wheelchair access), UD is performance-based; it describes how and why a design can minimize demands on all users (e.g., a level entrance will enable everyone to safely enter) rather than what the design specification should be. As a result, UD is compatible with the ICF, which suggests that disability is not a single point requiring specialized intervention, but a continuum of ability that would benefit from less demanding design. In so doing, UD, unlike accessible design, makes access the norm, rather than the exception.
An underlying principle in making access and usability the norm is that a home should look like a home, not like an institutional setting. It is therefore important to remember that any products and technologies that are brought into home, regardless of their purpose, should be residential in appearance and tailored to meet the personal needs and tastes of the users. If they are not, users simply will not accept them.
The same rationale applies to traditional medical devices, new assistive products for caregivers, and any new telehealth technologies. These products need to be usable by both health care recipients and providers, and they need to fit into the home environment. Moreover, any home-based technologies will require common interface designs so that users do not need to learn and manage different systems. The technology products need to be easy to use and to learn, and they should take into account declining skills of older adults, such as vision, dexterity, and memory.
While it is unlikely that every design will be usable by everyone, UD can eliminate the need for many adaptive, add-on, specialized accessibility products that are commonly used today. 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. Better initial design would greatly improve usability for everyone and reduce the need for modifications later on. Ultimately, the universal home sets a baseline from which assistive technologies and accessible design can be introduced when and if they are needed.
A Smart Universal Home: Eskaton’s National Demonstration Home
Eskaton is a nonprofit organization headquartered in Carmichael, California, that provides a full spectrum of residential living, health care, and services for more than 14,000 older adults throughout northern
California. The National Demonstration Home, completed in 2008 on the Eskaton Village campus in Roseville, California, provides an innovative approach to healthy, independent living by combining UD, smart home health care technologies, and green living features.
The home combines universal design features, such as wider hallways, stepless entry, curbless showers, and motion sensor lights that minimize hazards, enhance safety, and promote independent activity with a number of technological systems (e.g., monitoring of ADLs, smart appliances, two-way video communication) seamlessly integrated into the design. As a result, technology complements, integrates, and reinforces the physical elements of UD to promote health and wellness, social and health provider connectivity, and safety.
BARRIERS TO ADOPTION OF HOUSING INNOVATION
Even as the home has become a centerpiece of health care in the United States, the lack of supportive housing to promote activity, health, and health care needs is exacerbated by the striking disconnect between these needs and the U.S. health care system (Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century, 2002). It comes as little surprise, therefore, that most prosthetic and therapeutic home interventions continue to be designed as medical devices and that UD and smart homes have not yet been adopted on a broad basis.
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. Not surprisingly therefore, there is a general lack of a coordinated and comprehensive system of services that would permit expanded health care and housing options, promote self-sufficiency and independence, and offset social isolation (Lawler, 2001). In its stead, there is a fragmented system of services provided by various public and private health care and social service organizations (Pynoos et al., 1997; Lau et al., 2007) that are hampered by a lack of information, experience, funding, and resources. Similarly, consumers are often uninformed or harbor misperceptions about environmental innovations. Together, these factors have resulted in both a poor supply of and limited demand for environmental innovations. Finally, to compound the problem, the home environment itself is often the source of impediment, inadequately designed or poorly maintained and unable to support the
environmental innovations due to disrepair, inadequate systems, and lack of space.
Supply Side Barriers
On the supply side, service providers are typically constrained by resources, the scope and geographical area of support services, their general lack of knowledge of UD and home modifications in general, and a dearth of educational opportunities to learn more about them. As a result there are too few professionals with expertise in environmental interventions to provide services as well as too few of those professionals who have formal training in the area and have a good understanding of universal design. Policy disincentives for UD and a maze of funding resources are also major barriers to acquiring appropriate interventions.
Lack of Providers with Expertise in Environmental Interventions
There is a lack of specialists who can assess both functional abilities and the relevant environmental characteristics (Pynoos, 1993; Pynoos et al., 1996). No single discipline or systematic program provides training that encompasses a comprehensive understanding of the person and the environment sides of the equation, resulting in disciplinary bias that separates the health professions from the building professions (Pynoos et al., 1987). Although some disciplines, such as occupational therapy and architecture, include college-level courses on environmental interventions, these are typically isolated efforts of individual faculty members, not promoted by the program or the profession. Only recently have professional organizations created certification programs, although none is sufficiently comprehensive to ensure a broad knowledge of home environmental interventions.
Even among specialists, intervention decisions often vary by discipline and level of expertise of the individual delivering services. Each profession tends to have its own disciplinary perspective that influences its understanding of needs and intervention solutions. By virtue of their training and driven by reimbursement systems, health care professionals are understandably more familiar and concerned with impairment and activity performance of the client than with environmental factors, residential construction, or even the range of potential environmental modifications (Pynoos, 1992; Pynoos et al., 1997). As a result, these individuals often underestimate the importance of the physical environment and may not recommend environmental interventions. Yet construction professionals
know less about activity and ability than about environmental attributes. As a result, assessments undertaken by construction professionals may overestimate the need for environmental interventions. Similarly, agencies that pay for modifications often introduce system bias by requiring assessments that adhere to their guidelines and result in recommending only interventions that will be reimbursed.
Provider Misperceptions of Universal Design
Despite the widespread acknowledgment and acceptance of the UD principles across many professions and among many manufacturers, application of the principles to the design of housing, as well as to consumer products and technologies, has been slow to take place. Many professionals rely on what they already know rather than try something new (Belser and Weber, 1995). Since many are familiar with accessible design, they often misuse the term “universal design” as a synonym for the former. In addition, misperceptions about the additional cost of UD are manifest in a reluctance to use it as a design strategy. However, if introduced at the beginning of a project, additional costs might be negligible. For example, the cost of a wider doorway is offset by the diminished costs of the wall around it.
Policy Disincentives for Universal Design
UD can have economic advantages for both consumers and providers, particularly if it is part of housing and product design from the beginning. In such cases, everyday housing and products can be used to support health and activity needs without the need for expensive modifications. However, because the reimbursement system is client-centric, it is concerned with meeting the needs of individual clients. In fact, it provides economic disincentives for UD by supporting specialized assistive technology and (to some extent) accessible design solutions, which may have lower initial costs, but greater long-term costs and far less benefit to multiple individuals or society.
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. As a result, studies indicate that the majority of people fail to plan for future needs in their home environment (Filion, Wister, and Coblentz,
1992), and also that people in need often adapt to their current environment, rather than change their home to meet their needs, particularly when the alterations are related to aging or disability (Filion, Wister, and Coblentz, 1992; Gilderbloom and Markham, 1996; Pynoos et al., 1997). This reluctance may explain, in part, why older individuals with disabilities are no less likely to be exposed to environmental hazards in their homes than those without disabilities (Gill et al., 1999). Despite a reluctance to make changes, the strongest predictor of adapting one’s home is recognizing the need for environmental interventions (Pynoos et al., 1987). In fact, one study found that when people perceived that environmental interventions would improve performance, they were four times more likely to modify their homes (Gosselin et al., 1992).
Lack of Consumer Awareness of Environmental Interventions
A major reason for the large numbers of individuals with unmet needs for environmental interventions is the lack of awareness of either the interventions themselves or their benefits for activity performance (Pynoos, 1993). Moreover, because UD and other environmental intervention strategies are the exceptions to home design rather than the norm, there are few traditional marketing strategies (e.g., TV advertisements) to inform consumers about their benefits. Even advertisements that feature modifications are often promoting the contractors who specialize in modifications, rather than the modifications themselves, and few include UD features. As a result, consumers may only be familiar with ADA accessibility features that they have seen in public settings or “handicapped” features (e.g., ramps and stainless steel grab bars) in their friends’ homes.
One mechanism for creating awareness of the advantages of UD is to try out alternatives to see what works best. This is common practice with most consumer items, as well as in the assessment of individuals with disabilities for modifications needed for the workplace. 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) or are too big to transport (e.g., chair lift), many smaller items, such as tub benches or thermostats, could be included in an assessment. Another option for consumer education is the use of demonstration homes (such as Eskaton), in which people can actually try out different design features (e.g., Mills, Holm, and Christenson, 2001). However, demonstration homes provide only one example of each UD feature, thus restricting comparison across alternatives; they are geographically restricted, which limits their exposure to a broad audience; and, unlike Eskaton, most have been built by local builders and ultimately sold to
private individuals, limiting their availability as demonstration homes on a long-term basis.
Consumer Misperceptions of Environmental Modifications
Consumers often associate prosthetic and therapeutic interventions with the stigma of disability and institutional care (Pynoos et al., 1997; Wolford, 2000), which are not perceived to be compatible with the residential appearance and are seen to reduce the market value of their homes (Gilderbloom and Markham, 1996). 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.
Consumers also may believe that the costs of environmental modifications are prohibitive, even when they know the benefits. For example, one study (Sohn, 1997) found that older consumers’ perceptions of the usefulness and attractiveness of UD features increased after trying them out, although they still believed that the products were too expensive.
The separation of housing and health care in different governmental agencies has created various systems of public subsidies that make it difficult for individuals to find or receive adequate funding. Housing dollars are distributed as a limited subsidy by HUD, which sets income restrictions on who qualifies for housing assistance. In contrast, health dollars are distributed as an entitlement by Medicare at the federal level and by Medicaid at the state level (Lawler, 2001). As a result, funding can come from a number of sources that are hard to categorize and locate. Difficulty finding funds is compounded by eligibility restrictions (e.g., income, age, location, and health status). There is especially limited funding to provide assistance to low-income households, which have a disproportionately high level of need for modifications.
The design or the physical condition of the home itself can be a barrier to environmental innovation. Data from the American Housing Survey 1997 suggest that this may well be the case for older adults with functional limitations. Survey data further suggest that homes built after 1980 and multifamily structures are significantly more likely to meet some of the prosthetic needs of older adults than units built in any earlier time period (Louie, 1999). In fact, the data are quite remarkable. For example,
elderly households in need of access to the home are about twice as likely to have a ramp (80 versus 41 percent) and a bathroom designed for easier accessibility (77 versus 37 percent) in units built after 1980 than such households in units built before 1940 (Louie, 1999).
In single-family housing, these findings may be attributed in part to changes in home design that occurred around 1980. These included construction of more one-story, slab-on-grade and one- to two-step ranch homes that are more conducive to ramps than older homes, which are often 36 inches or more above grade level; increased size of spaces, such as larger master bedrooms and baths and larger kitchens that facilitate easier wheelchair access; and changes in spatial layout, such as the master bedroom on the main floor and more open floor plans that provide opportunities for easier and safer mobility. In multifamily housing, these improved conditions may be due to governmental regulations for accessibility that went into effect in the 1980s and 1990s (e.g., the Fair Housing Act Amendments and the Americans with Disabilities Act) to prevent discrimination against people with disabilities in housing and public environments.
However, the vast majority of disabled elderly households do not live in newer housing or multifamily units. Instead, most live in older single-family homes built before 1940, of which slightly more than one-third need structural repairs (e.g., new roof) or updated systems (e.g., electric) compared with slightly less than one-quarter of housing units in general (Louie, 1999).
This need for repairs and systems updating is not surprising. Regular maintenance and upkeep of a home, particularly for individuals who are in poor health or have functional declines, may become unmanageable or unaffordable (Lawler, 2001). As a result, these individuals are more likely to shoulder a housing cost burden and live in units with moderately to severely inadequate overall structure and physical systems (Louie, 1999). Whereas structural inadequacy might divert funds for needed environmental interventions (e.g., widening doorways when the roof leaks), 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). Electrical systems that are outdated and do not meet current building codes are particularly problematic; most local codes require the entire system to be brought up to code when any electrical work is done. Thus, installing a lift could potentially result in having to bring in a new power line from the street, replace the panel box, and rewire the entire house.
POLICY CHANGES TO INCREASE ADOPTION OF HOUSING INNOVATION
On one hand, policy (at the reimbursement level) or lack of it (at the legislative level) bears considerable responsibility for spawning the current system of fragmented services. On the other hand, policy responses to support independent living and home health care, like the system itself, have been piecemeal and fragmented, leaving many people in homes that are unsupportive and in communities that offer them few housing options. This concern is particularly relevant in the current health policy context (Coyte and Young, 1997), in which high-tech home care is increasingly seen as a quick solution to budgetary constraints and a growing elderly population. 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.
Overcoming the Hands-off-the-Home Imperative
The greatest obstacle to the success of home-centered health care is ensuring that the government, private insurers, and the public wholly embrace environmental intervention as a necessary component of the health care system, regardless of the real or perceived value it adds to an individual’s home. Unlike Sweden and other countries that include home environmental interventions as an option to support independent and healthy living, the U.S. reimbursement system does not. Medicare, for example, will pay for personal assistance, assistive devices, and medical technologies but not home modifications (i.e., accessible design). Medicaid may cover some home modifications, depending on the state. Thus, while willing to spend dollars on medical model interventions, such as caregiving and assistive devices, the system does not generally support the environmental interventions that are necessary to reduce the cost of caregiving and technology or even ensure that they are effective.
Clearly, the reluctance of both public and private agencies to invest in permanent changes that might enhance the value of a private residence is a major barrier to more supportive, universal homes. At the public level, paying for changes to private residences can give the appearance of spend-
ing taxpayer dollars on unnecessary remodeling that increases the comfort and wealth of individuals, even if homeowners themselves do not perceive that these changes will increase value. At the private level, third-party payers are reluctant to spend money on environmental interventions that may increase the value of property that they do not own and that could be sold at any time.
Incorporating Access into Local Building Codes
Building codes, which are intended to protect the health, safety, and welfare of the public, should include requirements for accessible or universal housing—but they do not. Even though the building codes use the same requirements as accessibility standards (i.e., ADA accessibility guidelines) 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.
First, promoting independence has generally fallen under the purview of civil rights legislation to provide access to public settings, not to improve public health in private housing. As a result, there are few accessibility-focused regulations that cover residential facilities and even fewer that comprehensively regulate the design and modification of private housing specifically for people who have functional or health limitations (Hyde, Talbert, and Grayson, 1997). Nonetheless, there is a growing movement in some countries to extend accessibility regulations to private housing. Moreover, in the absence of specific legislation, accessibility design standards for public buildings are often used as a guide when modifying private homes. In the United States there is a growing movement toward visitable housing, which, while still based on access rather than health, is a step toward broader regulation of private housing.
Second, and perhaps more influential, is that environmental modifications are not considered to be medical interventions under the old medical model. Yet the earliest example of a building law—the New York City Tenement House Act of 1867—was precisely a means to social policy (Davis, 1997). This law was intended to protect society from squalid living conditions that were associated with smallpox and tuberculosis epidemics. The legislation included not only policies to protect the health of the New York’s citizens but also enforceable building regulations that mandated design features for cleaner, safer, and better built housing and designated public agencies to carry out those regulations. Similarly, the ICF and the social model of medicine on which it is based reinforce the link between the home environment and health. As a consequence, the ICF provides the impetus and rationale for incorporating environmental interventions for supportive housing into the building codes.
Zoning ordinances must also recognize and support the role of the home as a health care environment. The home may need to support round-the-clock care, which frequently requires live-in caregivers. However, many local zoning ordinances restrict cohabitation by unrelated adults or control multifamily housing (i.e., more than one kitchen) in many communities. Although originally intended to prevent overcrowding and squalid health conditions that were prevalent in late 19th-century cities, such restrictions effectively preclude care providers from living with care recipients. They also restrict the construction of such housing as accessory dwelling units for caregivers or care recipients (e.g., in-law suites) on traditional single-family lots, even though such units can delay the need for institutional care.
Both zoning regulations and building codes restrict the size of dwelling units based on the ratio of unit floor space to lot size. For zoning, this is to maintain the character of a neighborhood, while building codes are designed minimize the amount of impervious (impenetrable) surfaces (e.g., concrete or a roofed structure) to limit water runoff onto adjacent properties. Zoning also restricts where one can locate a structure on a lot, with requirements for front, side, and rear setbacks. The result limits the size of dwelling units and hence the ability to add accessory dwelling units or other housing options that increase the footprint or even size of the original home. Clearly, for the home to succeed as a health care environment, zoning ordinances and building codes must be changed to recognize cohabitation or multifamily units for health reasons.
Creating Incentives for Universal Design
UD is not just a solution for new housing stock. When retrofitting existing housing that must accommodate others in the household (e.g., family members, friends, caregivers, care providers), 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. Simply put, better design solutions are needed, and UD provides them. The principles guide both better activity performance (i.e., works better) and better integration (i.e., fits better) in the social and physical context. However, accessible design is perhaps the largest impediment to adoption of universal design. As promulgated and reinforced by codes and standards, accessible design is based on a 20th-century if-you-build-it-they-will-come mentality that is predicated on the belief that enabling independence in activities will beget participation in social roles. UD, in contrast, is a 21st-century model, which, like the ICF, is predicated on the notion that activity and participa-
tion, while interconnected, are separate constructs that require their own environmental responses.
In new construction and remodeling, a number of municipalities have changed local building codes to require or offer tax breaks for basic access for wheelchair users. However, these visitability ordinances are by no means “universal design lite.” Visitability enables wheelchair users to visit. While it may enable an inhabitant to access the home and live on the first floor, it does not necessarily ensure that the environment will meet the health and activity needs of individuals who occupy the home. 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), accessible design is inextricably tied to U.S. civil rights legislation. At the same time, assistive technologies in particular, and to a lesser extent accessible design, are reinforced by medical model–based reimbursement policies. These policies focus primarily on improving independence in activity performance rather than participation in social roles. While the former are specific to the individual client, the latter would include environmental interventions that might have additional benefits to the client or others.
In a recent article in the New York Times, Ashlee Vance (2009) paints a grim portrait of the reimbursement system as a process so invested in the medical model that specialized medical devices and equipment are preferred over universally designed everyday designs, even when the latter are less expensive, work better, and are preferred by the user. Although the article is based on reimbursement for an assistive device, the same policies hold true for environmental modifications. Regardless of the type of intervention, policies that support specialized technologies over everyday designs may result in increased costs, decreased effectiveness, and poor outcomes. Vance writes:
Kara Lynn has amyotrophic lateral sclerosis, or A.L.S.… A couple of years ago, she spent more than $8,000 to buy a computer … that turns typed words into speech…. Under government insurance requirements, the maker of the PC, which ran ordinary Microsoft Windows software, had to block any nonspeech functions, like sending e-mail or browsing the Web…. Dismayed by the PC’s limitations and clunky design, Ms. Lynn turned to a $300 iPhone 3G from Apple running $150 text-to-speech software.
Medicare and private health insurers decline to cover cheap devices like iPhones and netbook PCs … despite their usefulness and lower cost. Instead … if Ms. Lynn and others like her want insurance to pay, they must spend 10 to 20 times as much for dedicated, proprietary devices that can do far less. The logic: Insurance is supposed to cover medical devices….
“We would not cover the iPhones and netbooks with speech-generating software capabilities because they are useful in the absence of an illness or injury,” said Peter Ashkenaz, a spokesman for the federal Centers for Medicare & Medicaid Services.
Medicalizing Environmental Interventions
The American Medical Association should support and promote environmental interventions as a health care issue. If, as the ICF suggests, the environment is an intervention in both health treatment and prevention, then one should expect that the professionals responsible for people’s health and well-being (i.e., physicians) would be aware of, if not somewhat knowledgeable about, these types of health interventions. After all, preventive medicine and clinical intervention are dependent on environmental modification. 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.
Primary care clinicians, including physicians, physician assistants, and nurse practitioners, should be instrumental in recommending home interventions of any kind, including those in the physical environment. Not only are these clinicians most likely to be seen by the majority of people, but because they are expected to be knowledgeable about medical interventions and they are generally well respected, it is also likely that their advice will be followed. However, to be the first line of defense in educating the American public, primary care clinicians need to recognize how the home environment might affect their treatment plans. This will require policy changes in the American Medical Association, medical and nursing schools, and training hospitals to adopt a social model of medicine and seek out experts in environmental intervention to train the clinicians of the future.
Certifying Service Providers
Professional organizations should focus on developing practitioner expertise by designing certification programs that promote uniform and accurate assessments, ensure appropriate intervention recommendations, and result in successful and efficacious interventions. However, educating the range of professionals involved in home health interventions, including health care professionals, social service personnel, and workers in the building industry will require policy change not only at the level of the professional organizations but also at the regulatory level. At the organizational level, it will require a change in the laissez-faire policy that acknowledges the need for training but does not proactively apply a comprehensive program to ensure that professionals are adequately trained. At the regulatory level, it will require change in the way the Centers for Medicare & Medicaid Services (CMS) reimburses. Although CMS already requires licensure/certification for some services (e.g., licensed occupational therapists can perform functional assessments, certified assistive technology practitioners can perform assistive technology assessments), certification for all of the various types of home intervention services (e.g., assessment, medical remodeling, training) should be included. 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). Where CMS leads, private insurers will follow.
TOWARD AN AGENDA FOR RESEARCH ON THE PHYSICAL ENVIRONMENT AND HOME HEALTH CARE
Everyone who has an impact on the quantity and quality of housing—from consumers to builders to clinicians to regulators and legislators—needs evidence that environmental modifications can improve functioning and health outcomes, are cost-effective, and reduce the need for future modifications. However, the gaps in the knowledge base related to state of the physical environment and home health are wide enough to drive a truck through. Most of what people think they know is based on practice rather than evidence. After three decades of debate, there are few empirical data and a general lack of psychometrically sound measures (Gitlin, 2003). Research is still needed to identify the best methods of service delivery; adequacy of training; types of interventions that work for whom, where, and when; environmental impacts of various interventions; value added by UD; and effectiveness and cost benefits of interventions for care recipients, care providers, and society.
If the goal of research is to inform and affect practice both directly and through legislation and regulatory policy, then it is imperative that research create an evidence base that demonstrates not only the efficacy and effectiveness of interventions (i.e., what works and for whom) but, more importantly, their cost-effectiveness and benefits. In fact, the evidence base for UD is extremely weak, although this is not surprising given the current regulatory environment that denies reimbursement for everyday design. As a result, there are few published cohort studies that have described and compared the types of UD interventions used by people within and across user groups or have evaluated the effectiveness of specific ones in meeting needs across individuals.
At the heart of the problem is a lack of understanding and consensus about both independent and dependent variables. On one hand, there is a need to understand the environment as an independent variable: What are the salient environmental factors that affect activity and health? On the other hand, there is a need to identify key performance measures and appropriate outcome (dependent) measures—such as the physical and mental health of individuals and their caregivers as well as their acceptance of health technologies in the home. In addition, there is a need to continue to pull together the research that has been done (e.g., Wahl et al., 2009) and to identify the types of research designs that can be appropriately undertaken to answer relevant human factors questions, including: (a) benchmarking of environmental effects on ADLs, health, and injury; (b) environmental impacts based on individual and subgroup differences; (c) effectiveness of specific environmental interventions as they relate to home health; and (d) barriers to and facilitators of social participation.
Environment as an Independent Variable
Environmental research has suffered from studies, many firmly entrenched in epidemiological models, that lacked a basic understanding of the key environmental factors that impact activity and health outcomes. Such studies have focused on associating outcomes with the presence or absence of specific environmental barriers or facilitators (e.g., presence or absence of a grab bar or handrail) rather than the measurable attributes (e.g., height and diameter) of those features, the demands they exert, and valid measures of those demands (Stark and Sanford, 2005; Sanford and Bruce, 2010). As a result, many studies have used inappropriate and invalid environmental measures that have underestimated the contribution of environmental factors to health outcomes.
This underestimation is particularly evident in many studies of falls, which may account, in part, for findings reported by Wahl and colleagues (2009) that support for environmental influences on fall-related outcomes
was less favorable than for functional ability-related outcomes. For example, in a prospective cohort study to determine whether the prevalence of environmental hazards increased the rate of nonsyncopal (i.e., not from fainting) falls among older adults, Gill, Williams, and Tinetti (2000) had a trained research nurse assess home hazards using a standard instrument that included 13 potential slip and trip hazards. Based on falls reported over a 3-year period, the risk of a nonsyncopal fall was only significantly elevated for 1 of the 13 hazards. Although the investigators concluded that there was no support for an association between environmental hazards and nonsyncopal falls, an alternative would be to question whether the 13-item assessment instrument, which, despite its widespread use, has never been actually validated, accurately measured fall risk. In addition, the list of hazards, such as throw rugs, lack clear definition of the attributes that actually are associated with falls. Clearly, throw rugs can be differentiated from each other by such a wide range of attributes—e.g., thickness, size, contrast, location—each of which could potentially induce a fall (or not). There is nothing inherent in rugs themselves that would make them a potential hazard. As a consequence, the researchers were perhaps misled to an overgeneralized conclusion at the expense of understanding perhaps the more salient environmental factors that impact falls.
Defining Appropriate Outcome Measures
Environmental research has also suffered from a lack of a set of mutually agreed-upon health outcomes. 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). While these measures may be appropriate to evaluate individualized interventions for people with specific functional limitations, without assessing activity outcomes of others they say little about the UD implications of these interventions. However, defining activity performance is not as simple as it seems. Difficulty and dependence are common outcomes that can measure performance either directly, through observations or self-report (e.g., Connell et al., 1993; Connell and Sanford, 2001), or indirectly, through self-efficacy (Tinetti, Richman, and Powell, 1990; Sanford et al., 2006). Although these two outcomes measure different constructs (e.g., problems encountered with or without assistance versus level of assistance required, respectively), they often are used interchangeably. Time (e.g., time to transfer on/off a toilet) is also frequently used as an outcome measure (see Sanford and Megrew, 1995; Sanford, Story, and Jones, 1997; Sanford, Echt, and Malassigne, 1999). Generally the assumption is that the faster one can perform a task, the better. However, it is not
always clear that increased speed of performance is a positive outcome. For example, enabling an individual to perform a controlled versus an uncontrolled transfer to a toilet will not only decrease speed of transfer but also increase safety.
The inability to measure critical outcomes has too often resulted in studies in which the effectiveness of environmental interventions lacks statistical significance. However, the most critical consideration in defining positive health outcomes is identifying ones that are important to the target group of individuals for whom the only issue is simple: Does it make a difference in my life? In fact, small changes in measurable health outcomes, even if they are not statistically significant, may equate to big gains in the quality of people’s lives. This suggests that clinical significance may be important regardless of whether statistical significance can be demonstrated.
Defining measures of cost-effectiveness is equally complicated and is determined by the cost of the benefits of an intervention. However, it is not clear who benefits. If, like health benefits, cost benefits are consumer driven, they can involve a number of factors, such as added value, aesthetic value, functional value, and emotional value. If, instead, benefits are defined by society, then societal value is clearly important. Finally, when defined by the reimbursement system, initial and life-cycle costs would also be important.
Although environmental studies are easy to identify, they are not easy to undertake in real-world environments in which contextual factors are impossible to control. As a result, there are critical methodological challenges for studies in this field (Wahl et al., 2009). Of particular relevance and importance is the applicability, or lack thereof, of randomized controlled trials and longitudinal studies (Wahl et al., 2009). These types of studies are considered to be the gold standard of clinical research and produce the type of data that are required to justify policy change, but their validity for environmental research is difficult to defend. In contexts in which interventions cannot be randomly assigned nor the environment controlled, randomized controlled trials, and blinded studies in particular, are based more on an inappropriate research paradigm than one that is likely to produce valid and generalizable results.
Randomized controlled trials have been used for interventions that have introduced assistive technologies and environmental strategies into the home (e.g., Gitlin et al., 2001a) 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/
nonrandomized, or controlled/uncontrolled pre-post). 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 environmental 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. As a result, the field is dominated by studies of convenience. These include cohort studies of assistive technologies, evaluations of environments in use (e.g., postoccupancy evaluations), and case study evidence from practice that benefitted from programs that were already implementing environmental interventions. While these studies help to understand the effects of environmental features, set precedents, and suggest trends, there is a basic lack of the critical evidence about the benefits of environmental interventions and their effect on health outcomes that is necessary for policy change.
Clearly, a myriad of issues confound environmental studies. However, these issues further complicate research when the physical environment is the intervention. As such, the most practical approach is to use quasi-experimental pretest and posttest designs that leverage the naturally occurring context rather than creating or altering it. The most likely design, and probably the most commonly used quasi-experimental design in social research, is the nonequivalent groups design, which requires a pretest and posttest for a treated and a comparison group. It is structured like a pretest-posttest randomized experiment but lacks random group assignment.
Although the lack of random assignment complicates statistical analyses in quasi-experimental designs, the experimental approach permits the research to fit seamlessly into and capitalize on naturally occurring situations. This suggests that funders and programs with vested interests in effecting positive activity and health outcomes must be more proactive in supporting the evaluation of intervention effectiveness. However, unlike clinical drug trials, there are rarely prescribed dosages of environmental attributes that can be varied and tested for efficacy, safety, and level across individuals. Rather, prescriptions for environmental interventions must be individualized and context-specific. As a result, it is imperative that research endeavors to understand what works, for whom, and under what circumstances. To do so, measures of efficacy must be defined that are relevant to individuals, programs, and government agencies on both the supply and demand sides of the equation. Therefore, in addition to experimental and quasi-experimental designs, relevant environmental factors should be included as a health covariate in standardized longitudinal studies, such as future versions of the National Long Term Care Survey, the Survey of Income and Program Participation, and other annual health surveys, such as the National Health Care Disparities
Report. Finally, to ensure that the appropriate and relevant environmental factors are being examined in contextually meaningful ways, it is of utmost importance that experts in environmental assessment, analysis, and intervention are involved in these research efforts.
While health programs and housing programs in the United States operate independently of each other, the needs of individuals would suggest they should not. For individuals with functional limitations and chronic conditions, housing and health are inextricably intertwined and, with innovations in design and technology, are likely to become even more so. These interconnections are bolstered by the public health community itself, as embraced by the model of health embodied in the World Health Organization’s International Classification of Functioning, Disability and Health, in which the environment is seen as both a therapeutic health care milieu and a prosthetic health intervention.
Although decisions about the most effective environmental intervention (assistive technologies, accessible design, or UD) are context specific, UD is the intervention that is most compatible with the ICF model. However, a variety of interconnected barriers have limited the adoption of universally designed products, technologies, and spaces as environmental interventions. 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.
The most conspicuous barrier to adoption of this innovation is the policy paradigm that rewards specialized technology and personal assistance with limited and calculated benefits rather than everyday universal design, which has potential for multiple and far-reaching benefits. While the increased application of universal design principles requires changes in consumer and provider behavior, it most significantly requires fundamental changes in regulatory policy, from building and zoning codes to reimbursement. This includes allowances in the codes to permit health-related environmental interventions that are necessary for people to remain in their homes. It also requires changes in reimbursement that recognize and support environmental assessments and interventions as part of discharge planning and continue to support them on an ongoing basis as conditions change and throughout the life span. Nonetheless, to overcome biases entrenched
in the medical model, policy decision makers must also recognize that non-randomized, pre-post designs undertaken by experts in the environment will produce the most valid and reliable data regarding the effectiveness of physical environmental interventions.
Demonstration programs, such as the Money Follows the Person (MFP) Program, can also provide valuable evidence. The MFP Program provides a mechanism for monies to follow the person into the community at levels equitable to those allocated for institutional/nursing home care. In addition, the MFP Program requires the coordination of information, supports, services, and funding across systems, as well as the need for consumer direction and control throughout the process. As of 2010, funding in 31 states enabled more than 27,000 people to transition out of nursing homes and other institutions to community housing (National Council on Disability, 2010).
While the MFP Program is demonstrating that the home environment can function in lieu of institutional care, it does not specifically allocate funds for environmental interventions, nor does it designate the home as a health care setting. As a result, the MFP Program is more of a paradigm adjustment than a fundamental change in thinking. As long as housing and health remain separate, decisions about the allocation of monies from each will be driven by bureaucratic rules rather than by the needs of individuals and their health care providers. 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. Typically that is because universally designed products are designed better, are easier to use, and are more desirable. An example is a $300 smart phone compared with other cell phones, many of which are given away. However, the cost of specialized design for a few individuals is even more expensive. Going back to the case of Kara Lynn, when the cost of the $300 iPhone is compared with an $8,000 augmentative communication device that didn’t work as well, the cost savings for the American public per device can be significant. Taken to another level, the cost of new UD housing—or even of retrofitting existing housing with UD modifications that will benefit those who occupy the home now as well as those in the future—will be small compared with the costs of institutional care or having to repeatedly modify the same home to meet the activity and health needs of each occupant over the life span of the residence. The question, therefore, is not about the costs of housing if UD is made a health care intervention, but about the costs of care if nothing is done.
ABOUT THE AUTHOR
Jonathan Sanford is director of the Center for Assistive Technology and Environmental Access in the College of Architecture at the Georgia Institute of Technology and a research architect at the Rehabilitation Research and Development Center of the Atlanta Department of Veterans Affairs. He is an architecturally trained researcher engaged in universal design and the design of accessible environments for older adults.
Allen, S., Resnik, L., and Roy, J. (2006). Promoting independence for wheelchair users who live alone: The role of home accommodations. Gerontologist, 46(1), 115-123.
Andersen, L., Schnohr, P., Schroll, M., and Hein, H. (2000). All-cause mortality associated with physical activity during leisure time, work, sports, and cycling to work. Archives of Internal Medicine, 60, 1,621-1,628..
Anderson, G.F. (2005). Medicare and chronic conditions. New England Journal of Medicine, 353(3), 305-309.
Anemaet, W.K., and Moffa-Trotter, M.E. (1999). Promoting safety and function through home assessments. Topics in Geriatric Rehabilitation, 15(1), 26-55.
Belser, S.H., and Weber, J.A. (1995). Home builders’ attitudes and knowledge of aging: The relationship to design for independent living. Journal of Housing for the Elderly, 11(2), 123-137.
Brooke, J. (2009, September 15). Japanese masters get closer to the toilet nirvana. New York Times. Available: http://www.nytimes.com/2002/10/08/international/asia/08JAPA.html [accessed June 2010].
Bruce, C., and Sanford, J.A. (2009). Assessment for workplace accommodation. In T. Oakland and E. Mpofu (Eds.), Assessment in rehabilitation and health (pp. 205-221). Upper Saddle River, NJ: Prentice Hall.
Bureau of Labor Statistics. (2006). Career guide to industries, 2006-2007 edition. Washington, DC: U.S. Department of Labor. Available: http://www.bls.gov/oco/cg/cgs035.htm [accessed June 2010].
Carter, S.E., Campbell, E.M., Sanson-Fisher, R.W., Redman, S., and Gillespie, W.J. (1997). Environmental hazards in the homes of older people. Age and Aging, 26, 195-202.
Center for Technology and Aging. (2009). Technologies for remote patient monitoring in older adults. Draft position paper, December.
Center for Universal Design. (1997). The principles of universal design, version 2.0. Raleigh: North Carolina State University. Available: http://www.design.ncsu.edu/cud/about_ud/udprincipleshtmlformat.html [accessed February 2010].
Clemson, L., Roland, M., and Cumming, R.G. (1997). Types of hazards in the homes of elderly people. Occupational Therapy Journal of Research, 17(3), 200-213.
Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century. (2002). Seniors commission report. Final Report to Congress, June 28. Available: http://govinfo.library.unt.edu/seniorscommission/pages/final_report/sencomrep.html [accessed September 2009].
Connell, B.R., and Sanford, J.A. (1997). Housing needs of older people to facilitate independence and safety. In S. Lanspery and J. Hyde (Eds.), Staying put: Adapting the places instead of the people. Amityville, NY: Baywood.
Connell, B.R., and Sanford, J.A. (2001). Difficulty, dependence, and housing accessibility for people aging with a disability. Journal of Architectural and Planning Research, 18(1), 3-18.
Connell, B.R., Sanford, J.A., Long, R.G., Archea, C.K., and Turner, C.S. (1993). Home modifications and performance of routine household activities by individuals with varying levels of mobility impairment. Technology and Disability, 2(4), 9-18.
Coyte, P., and Young, W. (1997). Applied home care research. International Journal of Health Care Quality Assurance, 10(1), i-iv.
Cumming, R.G., Thomas, M., Szonyi, G., Frampton, G., Salkeld, G., and Clemson, L. (2001). Adherence to occupational therapist recommendations for home modifications for falls prevention. American Journal of Occupational Therapy, 55, 641-648.
Cumming, R.G., Thomas, M., Szonyi, G., Salkeld, G., O’Neill, E., Westbury, C., and Frampton, G. (1999). Home visits by an occupational therapist for assessment and modification of environmental hazards: A randomized trial of falls prevention. Journal of the American Geriatrics Society, 47, 1,397-1,402.
Davis, S. (1997). The architecture of affordable housing. Berkeley: University of California Press.
Fange, A., and Iwarsson, S. (2003). Accessibility and usability in housing: Construct validity and implications for research and practice. Disability and Rehabilitation, 25, 1,316-1,325.
Fazzone, P.A., Barloon, L.F., McConnell, S.J., et al. (2000). Personal safety, violence, and home health. Public Health Nursing, 17, 43-52.
Ferrucci, L., Guralnik, J.M., Studenski, S., Fried, L.P., Cutler, G.B., Jr., and Walston, J.D. (2004). Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: A consensus report. Journal of the American Geriatrics Society, 52, 625-634.
Filion, P., Wister, A., and Coblentz, E.J. (1992). Subjective dimensions of environmental adaptation among the elderly: A challenge to models of housing policy. Journal of Housing for the Elderly, 10(1 and 2), 3-32.
Fisher, G.S., Coolbaugh, K. and Rhodes, C. (2006). A field test of the Cougar home safety assessment for older persons, version 1.0. Californian Journal of Health Promotion, 4(2), 181-196.
Fisher, G.S., Kintner, L. Bradley, E., Costulas, D., Kozlevcar, J. Mahonski, K, McMenamin, K., Rompilla, A. Woods, J., Stine, J., and Ewonishon, K. (2008). Home modification outcomes in the residences of older people as a result of Cougar home safety assessment (version 4.0) recommendations. Californian Journal of Health Promotion, 6(1), 87-110.
Frank, L., Engelke, P.O., and Schmid, T.L. (2003). Health and community design: The impact of the built environment on physical activity. Washington, DC: Island Press.
Freedman, V.A., Martin, L.G., and Schoeni, R.F. (2002). Recent trends in disability and functioning among older adults in the United States. Journal of the American Medical Association, 288, 3,137-3,146.
Frumpkin, H. (2003). Healthy places: Exploring the evidence. American Journal of Public Health, 93(9), 1,451-1,456.
Galinsky, T., Waters, T., and Malit, B. (2001). Overexertion injuries in home health care workers and the need for ergonomics. Home Health Care Service Quarterly, 20, 57-73.
Gershon, R.M., Pogorzelska, M.T., Qureshi, K.A., Stone, P.W., Canton, A.N., Samar, S.M., Westra, L.J., Damsky, M.M., and Sherman, M. (2008). Home health care patients and safety hazards in the home: Preliminary findings. Available: http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Gershon_88.pdf [accessed September 2009].
Gilderbloom, J.L., and Markham, J.P. (1996). Housing modification needs of the disabled elderly: What really matters? Environment and Behavior, 28(4), 512-535.
Gill, T.M., Williams, C.S., Robison, J.T., and Tinetti, M.E. (1999). A population-based study of environmental hazards in the homes of older persons. American Journal of Public Health, 89, 553-556.
Gill, T.M., Williams, C.S., and Tinetti, M.E. (2000). Environmental hazards and the risk of nonsyncopal falls in the homes of community-living older persons. Medical Care, 38(12), 1,174-1,183.
Gitlin, L.N. (2003). Conducting research on home environments: Lessons learned and new directions, Gerontologist, 43, 628-637.
Gitlin, L.N., and Corcoran, M. (2000). Helping homes be safe: Environmental adaptations for people with dementia. Alzheimer’s Care Quarterly, 1(1), 45-54.
Gitlin, L.N., Corcoran, M.A., Winter, L., Boyce, A, and Hauck, W.W. (2001a). A randomized, controlled trial of a home environmental intervention to enhance self-efficacy and reduce upset in family caregivers of persons with dementia. Gerontologist, 41, 15-30.
Gitlin, L.N., Liebman, J., and Winter, L. (2003). Are environmental interventions effective in the management of Alzheimer’s disease and related disorders? A synthesis of the evidence. Alzheimer’s Care Quarterly, 4, 85-107.
Gitlin, L.N., Mann, W., Tomita, M., and Marcus, S.M. (2001b). Factors associated with home environmental problems among community-living older people. Disability and Rehabilitation, 23(17), 777-787.
Gitlin, L.N., Winter, L., Corcoran, M., Dennis, M., Shinfeld, S., and Hauck, W. (2003). Effects of the home environmental sill-building program on the caregiver-care reciepient dyad: Six-month outcomes from the Philadelphia REACH initiative. Gerontologist, 43, 532-546.
Glass, T.A. (1998). Conjugating the tenses of function: Discordance among hypothetical, experimental and enacted function in older adults. Gerontologist, 38(1), 101-112.
Gosselin, C., Robitaille, Y., Trickey, F., and Maltais, D. (1992). Factors predicting the implementation of home modifications among elderly people with loss of independence, Physical and Occupational Therapy in Geriatircs, 12(1),15-27.
Hoenig, H., Sanford, J.A., and Griffiths, P. (2006). Development of a tele-technology protocol for in-home rehabilitation. Journal of Rehabilitation Research and Development, 43(2), 287-298.
Hyde, J., Talbert, R., and Grayson, P.J. (1997). Fostering adaptive housing: An overview of funding sources, laws and policies. In S. Lanspery and J. Hyde (Eds.), Staying put: Adapting the places instead of the people (pp. 223-236). Amityville, NY: Baywood.
Institute of Medicine. (1997). Enabling America: Assessing the role of rehabilitation science and engineering. J. Brandt and A.M. Pope (Eds.). Committee on Assessing Rehabilitation Science and Engineering. Division of Health Sciences Policy. Washington, DC: National Academy Press.
International Longevity Center-USA. (2006). Caregiving in America. The Caregiving Project for Older Americans. Available: http://www.ilcusa.org/media/pdfs/Caregiving%20in%20America-%20Final.pdf [accessed June 2010].
Iwarsson, S. (1999). The housing enabler: An objective tool for assessing accessibility. British Journal of Occupational Therapy, 62(11), 491-497.
Iwarsson, S. (2004). Assessing the fit between older people and their home environments: An occupational therapy research perspective. In H.-W. Wahl, R. Schiedt, and P. Windley (Eds.), Annual review of the Gerontological Society of America 2003, vol. 23: Focus on aging in context: Socio-Physical environments (pp. 85-109). New York: Springer.
Iwarsson, S. (2005). A long-term perspective on person-environment fit and ADL dependence among older Swedish adults. Gerontologist, 45, 327-336.
Iwarsson, S., and Isacsson, A. (1996). Housing standards, environmental barriers in the home, and subjective general apprehension of housing situation among the rural elderly. Scandinavian Journal of Occupational Therapy, 3(2), 52-61.
Joint Center for Housing Studies. (2000). The state of the nation’s housing 1999. Cambridge, MA: Author.
Kendra, M.A., Weiker, A., Simon, S., Grant, A., and Shullick, D. (1996). Safety concerns affecting delivery of home health care. Public Health Nursing, 13, 83-89.
Kochera, A. (2002). Falls among older persons and the role of the home: An analysis of cost, incidence and potential savings from home modification. AARP Public Policy Institute. Available: http://assets.aarp.org/rgcenter/il/inb49_falls.pdf [accessed June 2010].
LaPlante, M.P., Hendershot, G.E., and Moss, A.J. (1992). Assistive technology devices and home accessibility features: Prevalence, payment, need and trends. National Center for Health Statistics Advance Data, 217, 1,012.
Lau, D.T., Scandrett, K., Jarzebowski, M., Holman, K., and Emanuel, L. (2007). Health-related safety: A framework to address aging in place. Gerontologist, 47(6), 830-837.
Law, M., Baptiste, S., Carswell-Opzoomer, A., McColl, M.A., Polatajko, H., and Pollock, N. (1991). Canadian Occupational Performance Measure. Toronto, ON: CAOT.
Lawler, K. (2001). Aging in place: Coordinating housing and health care provision for America’s growing elderly population. Cambridge, MA: Joint Center for Housing Studies of Harvard University’s Neighborhood Reinvestment Corporation.
Lawton, M.P., and Nahemow, L. (1973). Ecology and the aging process. In C. Eisdorfer and M.P. Lawton (Eds.), The psychology of adult development and aging (pp. 619-674). Washington, DC: American Psychological Association.
Lehoux, P. (2004, October 5). Patients’ perspectives on high-tech home care: A qualitative inquiry into the user-friendliness of four interventions. BMC Health Services Research, 4(28). Available: http://www.biomedcentral.com/1472-6963/4/28 [accessed June 2010].
Lehoux, P., Richard, L., Pineault, R., and Saint-Arnaud, J. (2006). Delivery of high-tech home care by hospital based nursing units in Quebec: Clinical and technical challenges. Nursing Leadership, 19(1), 44-55. Available: http://220.127.116.11/longwoods/content/18048 [accessed June 2010].
Letts, L., Scott, S., Burtney, J., Marshall, L., and McKean, M. (1998). The reliability and validity of the safety assessment of function and the environment for rehabilitation (SAFER Tool). British Journal of Occupational Therapy, 61(3), 127-132.
Louie, J. (1999). Housing modifications for disabled elderly households. Cambridge, MA: Joint Center for Housing Studies of Harvard University.
Mace, R.L., Hardie, G.J., and Place, J.P. (1991). Accessible environments: Towards universal design. In W.E. Preiser, J.C. Vischer, and E.T. White (Eds.), Design intervention: Toward a more humane architecture. New York: Van Nostrand Reinhold.
Manangan, L.P., Pearson, M.L., Tokars, J.I., Miller, E., and Jarvis, W.R. (2002). Feasibility of national surveillance of health care associated infections in home care settings. Emerging Infectious Diseases, 8, 233-236.
Mann, W.C., Ottenbacher, K.J., Fraas, L., Tomita, M., and Granger, C.V. (1999). Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care costs for frail elderly: A randomized controlled trial. Archives of Family Medicine, 8, 210-217.
Markkanen, P., Quinn, M., Galligan, C., et al. (2007). There’s no place like home: A qualitative study of the working conditions of home health care providers. Journal of Occupational and Environmental Medicine, 49(3), 327-337.
Mathews, J.T. (2006). Existing and emerging healthcare devices for elders to use at home. Generations Journal of the American Society on Aging, 30(2), 13-19.
Mills, T., Holm, M.B., and Christenson, M.A. (2001). Public opinion of universal design in housing. Proceedings of the Annual RESNA Conference. Washington, DC: RESNA Press.
Myers, A., Jensen, R.C., Nestor, D., and Rattiner, J. (1993). Low back injuries among home health aides compared with hospital nursing aides. Home Health Care Services Quarterly, 14, 149-155.
National Council on Disability. (2010). The state of housing in America in the 21st century: A disability perspective. Washington, DC: Author.
Niva, B., and Skar, L. (2006). A pilot study of the activity patterns of five elderly persons after a housing adaptation. Occupational Therapy International, 13(1), 21-34.
Ono, Y., Lagerstrom, M., and Hagberg, M., et al. (1995). Reports of work related musculoskeletal injury among home care service workers compared to nursery school workers and the general population of employed women in Sweden. Occupational and Environmental Medicine, 52, 686-693.
Oswald, F., and Wahl, H.-W. (2004). Housing and health in later life. Reviews of Environmental Health, 19(3-4), 223-252.
Oswald, F., Schilling, O., Wahl, H.-W., and Gang, K. (2002). Trouble in paradise? Reasons to relocate and objective environmental changes among well-off older adults. Journal of Environmental Psychology, 22, 273-288.
Oswald, F., Wahl, H.-W., Schilling, O., Nygren, C., Fange, A., Sixsmith, A., Sixsmith, J., Szeman, Z., Tomsone, S., and Iwarsson, S. (2007). Relationships between housing and healthy aging in very old age. Gerontologist, 47, 96-107.
Pynoos, J. (1992). Strategies for home modification and repair. Generations: Journal of the American Society on Aging, 16(2), 21-25.
Pynoos, J. (1993). Toward a national policy on home modification. Technology and Disability, 2(4), 1-8.
Pynoos, J., and Regnier, V. (1997). Design directives in home adaptation. In S. Lanspery and J. Hyde (Eds.), Staying put: Adapting the places instead of the people (pp. 171-191). Amityville, NY: Baywood.
Pynoos, J., Angelleli, J., Tabbarah, M., and De Meire, M. (1996). Improving the delivery of home modifications. Los Angeles: National Resource Policy Center on Housing and Long Term Care.
Pynoos, J., Cohen, E., Davis, L., and Bernhardt, S. (1987). Home modifications: Improvements that extend independence. In V. Regnier and J. Pynoos (Eds.), Housing the aged: Design directives and policy considerations (pp. 277-303). New York: Elsevier.
Pynoos, J., Liebig, P., Overton, J., and Calvert, E. (1997). The delivery of home modification and repair services. In S. Lanspery and J. Hyde (Eds.), Staying put: Adapting the places instead of the people (pp. 171-191). Amityville, NY: Baywood.
Rubenstein, L.Z. (1999). The importance of including the home environment in assessment of frail older people. Journal of the American Geriatrics Society, 47, 111-112.
Saelens, B., Sallis, J., and Frank, L. (2003). Environmental correlates of walking and cycling: Findings from the transportation, urban design, and planning literature. Annals of Behavioral Medicine, 25(2), 80-91.
Sanford, J. (2002). Development of a comprehensive assessment for delivery of home modifications. Physical and Occupational Therapy in Geriatrics, 20(2), 43-55.
Sanford, J.A. (2004). Home modifications: Assessment, implementation and innovation. Presented at the American Occupational Therapy Association Annual Conference, May 19, Minneapolis, MN.
Sanford, J.A. (2010). Assessing universal design in the physical environment. In T. Oakland and E. Mpofu (Eds.), Rehabilitation and health assessment (pp. 255-278). New York: Springer.
Sanford, J., and Bruce, C. (2010). Measuring the impact of the physical environment. In T. Oakland and E. Mpofu (Eds.), Rehabilitation and health assessment (pp. 207-228). New York: Springer.
Sanford, J.A., and Butterfield, T. (2005). Using remote assessment to provide home modification services to underserved elders. Gerontologist, 45, 389-398.
Sanford, J., and Hammel, J. (2006). Impact of accessibility modifications to the home environment on community living and activity. Gerontological Society of American Annual Conference, Dallas, TX.
Sanford, J.A., and Megrew, M.B. (1995). An evaluation of grab bars to meet the needs of elderly people. Assistive Technology, 7(1), 36-47.
Sanford, J.A., Echt, K., and Malassigne, P. (1999). An E for ADAAG: The case for accessibility guidelines for the elderly based on three studies of toilet transfer. Journal of Physical and Occupational Therapy in Geriatrics, 16(3/4), 22-23.
Sanford, J.A., Griffiths, P.M., Richardson, P., Hargraves, K., Butterfield, T., and Hoenig, H. (2006). The effects of in-home rehabilitation on task self efficacy in mobility impaired adults: A randomized clinical trial. Journal of American Geriatrics Society, 54, 1,641-1,648.
Sanford, J.A., Griffiths, P.M., Richardson, P., Hargraves, K., Butterfield, T., and Hoenig, H. (2007). A comparison of televideo and traditional in-home rehabilitation in mobility impaired older adults. Journal of Physical and Occupational Therapy in Geriatrics, 25(3), 1-18.
Sanford, J.A., Jones, M.L., Daviou, P., Grogg, K., and Butterfield, T. (2004). Using telerehabilitation to identify home modification needs. Assistive Technology, 16(1), 43-53.
Sanford, J.A., Pynoos, J., Gregory, A., and Browne, A. (2001). Development of a comprehensive assessment for delivery of home modifications. Physical and Occupational Therapy in Geriatrics, 20(2), 43-55.
Sanford, J., Story, M., and Jones, M. (1997). An analysis of the effects of ramp slope on people with mobility impairments. Assistive Technology, 9, 22-33.
Scheidt, R., and Windley, P. (2006). Environmental gerontology: Progress in the post-Lawton era. In J.E. Birren and K.W. Schaie (Eds.), Handbook of the psychology of aging (6th edition, pp. 105-125). Amsterdam: Elsevier.
Scheschareg, R. (2006). Gaining access to the $300 billion+ consumer out-of-pocket spending market. Intuitive Care Advisors Advanced Home Healthcare Products and Services 2005 channel Report. Available: http://www.agingtech.org/documents/Advanced_Home_ Healthcare_P&S.pdf [accessed June 2010].
Sinding, C. (2003). Disarmed complaints: Unpacking satisfaction with end-of-life care. Social Science and Medicine, 57, 1,375-1,385.
Sohn, J. (1997). Older consumers’ pre- and post-trial perceptions of residential universal design features. Unpublished master’s thesis. Kansas State University, Manhattan.
Spillman, B.C. (2004). Changes in elderly disability rates and the implications for health care utilization and cost. Milbank Quarterly, 82, 157-194.
Stark, S. (2004). Removing environmental barriers in the homes of older adults with disabilities improves occupational performance. Occupation, Participation and Health, 24, 32-39.
Stark, S.L., and Sanford, J.A. (2005). Environmental enablers and their impact on occupational performance. In C. Christiansen and C.M. Baum (Eds.), Occupational therapy: Performance, participation, and well-being (pp. 298-337). Thorofare, NJ: Slack, Inc.
Steinfeld, E., and Shea, S. (1993). Enabling home environments. Technology and Disability, 2(4), 69-79.
Stineman, M.G., Ross, R.N., Masilin, G., and Gray, D. (2007). Population-based study of home accessibility features and the activities of daily living: clinical and policy implications. Disability and Rehabilitation, 8(2), 34-45.
Tinetti, M.E., Baker, D., Gallo, W.T., Nanda, A., Charpentier, P., and O’Leary, J. (2002). Evaluation of restorative care vs. usual care for older adults receiving an acute episode of home care. Journal of the American Medical Association, 287, 2,098-2,105.
Tinetti, M.E., Richman, D., and Powell, L. (1990). Falls efficacy as a measure of fear of falling. Journal of Gerontology, 45(6), P239-P243.
U.S. Access Board. (2002). ADA accessibility guidelines for buildings and facilities (ADAAG). Available: http://www.access-board.gov/adaag/html/adaag.htm [accessed June 2010].
U.S. Bureau of the Census. (1994). Statistical abstract of the United States, 114th edition. Washington, DC: U.S. Department of Commerce.
Vance, A. (2009, September 15). Insurers fight speech impairment remedy. The New York Times. Available: http://www.nytimes.com/2009/09/15/technology/15speech.html [accessed June 2010].
Vebrugge, L., and Sevak, P. (2002). Use, type and efficacay of assistance for disability. Journal of Gerontology. Series B. Psychological and Social Sciences, 57, S366-S379.
Wahl, H.-W. (2001). Environmental influences on aging and behavior. In J.E. Birren and K.W. Schaie (Eds.), Handbook of the psychology of aging, 5th edition (pp. 215-237). San Diego: Academic Press.
Wahl, H.-W., Fange, A., Oswald, F., Gitlin, L.N., and Iwarsson, S. (2009). The home environment and disability-related outcomes in aging individuals: What is the empirical evidence? Gerontologist, 49(3), 355-367.
Wolford, N. (2000). Universal design standards for single-family housing. Unpublished doctoral dissertation, Oregon State University.
Woodward, C.A., Abelson, J., Tedford, S., and Hutchison, B. (2004). What is important to continuity in home care? Perspectives of key stakeholders. Social Science and Medicine, 58, 177-192.
World Health Organization. (1980). The international classification of impairment, disability and health (p.143). Geneva: Author.
World Health Organization. (1991). Action for public health: Sundsvall statement on supportive environments. Sundsvall, Sweden: Author.
World Health Organization. (2001). International classification of functioning, disability and health. Geneva: Author.
Wu, S., and Green, A. (2000). Projection of chronic illness prevalence and cost inflation. Santa Monica, CA: RAND Corporation.