A Home Modification Research Agenda For Long

Term Care Jon Pynoos, Ph.D.

National Resource Center On Supportive Housing And Home Modification

Andrus Gerontology CenterUniversity Of Southern California

Los Angeles, CA 90089-0191homemods@usc.edu

www.homemods.org

Purpose Analyze Current Research

Concerning The Home Environment And Long-Term Care

Propose A Future Agenda That Will Benefit From More Sustained Investment

Nursing Home Bias LTC Bias Towards Nursing

Homes Has Been Accompanied By A Focus On Environmental Research In Institutional Settings

It Has Crowded Out Research In Conventional Settings Where Most Older Adults Live-- Their Own Homes And Apartments

Problem Even In Community-Based Care,

Home Modification (HM) Has Been A Sleeper Issue

It Has Taken A Backseat To The Delivery Of Personal Care And Health Services

Part Of The Problem Has Been Issues Of Measurement & Conceptualization

The Need For Research

Consequently, Few Data Sets And Investigator-Initiated Research Have Focused On Home Environment

Why Is The Home Environment Important?

The Physical Environment Can Enhance Or Impede One’s Functional Ability And Quality Of Life

Potential Mismatch In Fit Between Person And The Environment (Powell Lawton)

Strong Preference Of Older Adults To Age In Place Psychological Familiarity Ties To Neighborhood

Most Homes “Peter Pan” Housing

What Are Home Modifications?

Home Modification (HM) Refers To Converting Or Adapting The Environment To Make Performing Tasks Easier, Reduce Accidents, And Support Independent Living.

Examples Of Home Modification

Ramps And Stair Glides Hand-held Showers Grab Bars Roll-in Showers Better Lighting Chair Lifts Widened Hallways

Research Efforts Over The Last Decade,

Considerable Strides Have Occurred In Better Understanding The Home Environment And Its Role In LTC

Discuss Main Research Questions And Initial Findings

1. What Are The Problem Areas Of The Home?

Outside Steps To The Entrance

Inside Stairs To A Second Floor

Unsafe Bathrooms Source: HUD (2001)

2. Can HMs Along With Assistive Devices Make It Easier To Perform Tasks?

Findings With Bathing: 1. HMs Reduce Bathing Difficulty For

Those With High Levels Of Functional Impairment

2. HMs, in Combination With OT Assessment and Follow-up, Significantly Improved Bathing Ability Among Frail Elderly

Source: Matsuoka & Pynoos (2000); Gitlin et al. (1999).

3. Does HMs Prevent Falls? Contradictory Evidence

For Example: Gill et. al. (2000) Found Weak

Relationship Between The Presence of Environmental Hazards And Falls

Cumming et al. (1999) Found Among Those With A History of Falls, OT visits And Provision Of HM’s Reduced The Risk Of Falling

Source: Gill et al. (2000); Cumming et al. (1999)

4. Are HMs Cost-Effective? In A Controlled Intervention Study:

HMs In Combination With Assessment And Follow-up By An OT Reduced Health Care Costs And Delayed Institutionalization

Source: Mann et al. (1999)

5. How Do HMs Affect Caregiving?

1. Adequate Space Can Facilitate Caregiving

2. HMs May Help Reduce Challenges For Dementia Caregivers

•Caregivers in the treatment groups showed enhanced self-efficacy

Source: Newman (1985); Gitlin et al. (2001)

6. How Useful Are ADA Specifications For Older Persons In The Home Environment?

Findings:

Ergonomic Studies Indicate That ADA Specification Are Often Inappropriate For Older Persons

(e.g., Ramp Slope, Transfer Grab Bars In Back Of Toilet)

Source: Sanford and Megrew (1999)

7. What Has Been The Trend In HMs Over Time? Significant Increases In The Use Of

Assistive Devices & HMs over last decade

45.3% Of Older Persons Live In Homes That Have Special Features

Suggests That HMs Substitute For Personal Care Services, But Mechanism Unclear.

Source: Manton et al. (1993); American Housing Survey (1995)

8. How Large Is The Unmet Need?

1.14 Million Elderly Households With At Least One Functional Limitation Report Unmet Need For HMs

Source: HUD (1999)

Elderly Households With Unmet Needs For Home Modifications

8.4%

6.5%5.6%

3.9%3.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

Handrails orGrab Bars

Ramps Easy-AccessBathrooms

Specially-Equipped

Telephones

Easy-AccessKitchens

Types of HMs

Perc

ent

Source:American Housing Survey, 1995

9.What Do Consumers Consider The Barriers Related To HMs?

Source: Fixing to Stay (2000)

37%

36%

29%

25%

23%

0% 10% 20% 30% 40%

Unable to do it yourself

Cannot Afford It

Do Not Trust Contractors

Don't Know How To Do

Have No One To Do It

Rea

sons

Percent

How Does The Service Delivery System Impact HMs?

Fragmented Service Delivery System Makes It Difficult to Obtain HMs

Gaps In Services

Cursory Assessments

Source: Pynoos, et al. (1998)

What Have We Learned So Far?1. The Home Environment Matters

Makes Tasks Easier To Carry Out Facilitates Caregiving Can Reduce Health Care Costs And

Institutionalization

2. Significant Unmet Need

3. Problems in Service Delivery Fragmentation, Gaps, Affordability,

Assessment

Only Scratched The Surface In Our Understanding Of The Role And Potential Of HMs in LTC

Issues Related To The Environment Will Only Become More Important In The Future:

Increased Emphasis On Community Based Care And Implementation Of The Olmstead Decision

Advocacy By Younger Persons With Disabilities

Majority Of Housing Stock Not Subject To Fair Housing Amendments Act

Stairs Is An Increasing Problem

IN 1970, ALMOST 3/4 OF HOMES BUILT WERE ONE-STORY

IN 1993, MORE THAN HALF OF THE NEW HOMES BUILT HAD STAIRS

What Can We Do To Improve Research?

1. Insure That Longitudinal Data Sets On LTC Include Items Related To The Physical Environment

2. Insure That Housing Data Sets Include Items About Both Functioning And Home Modifications

3. Coordinate LTC And Housing Data Sets To Insure Consistency

4. Provide Greater Specificity About The Environment (e.g.,Types Of HMs.)

5. Test The Most Effective Ways To Integrate The Delivery Of HM Services With The Long-term Care System

Develop Best Practices Models To Encourage The Replication Of Successful Approaches

6. Test What Types Of HMs Work With Which Groups (e.g., Alzheimer’s, Parkinson’s)

7. Replicate Intervention Studies With Larger Samples

Overall, More Funding For: 1. Nationally-directed Research

Initiatives

2. Investigator-initiated Research

Recognize That Housing Is The “Where” In LTC