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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 [email protected]
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