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Universal Design, Home Modifications and Coalition Building
Florida Occupational Therapy Association Annual Conference
November 2-3, 2012
Margaret Christenson, MPH, OTR, FAOTA Lifease, Inc.
Carolyn Sithong, MS, OTR/L, CAPS, SCEM Home for Life Consulting and Design
The Occupational Therapy Practitioner ‘s Role in Promoting Universal Design, Home Modifications
and Coalition Building
The following presentation will:
1. Describe the opportunities for coalition building with other
organizations in the community and the unforeseen benefits for the
Occupational Therapy Practitioner.
2. Discuss articles citing evidence based practice in home
modifications and the outcomes in relation to community health.
3. Discuss Universal Design and where these components can be
included in the home.
4. Illustrate what changes need to be made in the design of a home to
accommodate a client
Understand Needs of Community • Healthcare is moving more and more into the home
• Increase in home and community-based services
• 1 in 4 people will be over 65 in the year 2020
• Most homes that people live in do not accommodate long term living
• Falls is the leading cause of death among seniors and most occur at home
• Issues facing older adults
• Alzheimer’s disease- Disease of the baby boomers
Silver tsunami
What Seniors Want Fixed to Stay, AARP 2001 • Over 80% of seniors want to
stay in their home for as long as possible, even if they need to receive healthcare or assistance
• Only 1 in 6 homes have made the changes necessary to support that desire
• Comfortable, home-like and hi-tech environments
Costs of Long Term Care
• Semi-Private Nursing Home
– $80,000 year
• Assisted Living Facility
– $ 40-60,000 year
• In-Home Care 24/7
– $30,000 year
What Else Are Baby Boomers Concerned With?
• 25% affordable healthcare
• 18% want to remain productive and useful
• 13% providing healthcare needs for self or spouse
The beliefs that guide your service delivery
• OT philosophies of practice
– Increasing independence in ADLs
– Promoting quality of life
– Addressing areas of work, self-care and leisure
– Client-centered, occupation based
– Evidenced-based practices
– AOTA Framework
Recommendations Based on Findings: Putting It All Together
Environment
Occupation Person
Law et, al. 2003, Baum and Christiansen,1997
Patient/Occupation Assessment Tools to Consider
• Canadian Occupational Performance Measure (COPM)
• Occupational Performance History Interview (Kielhofner, et. al., 1997)
• In-Home Occupational Performance Evaluation (I-HOPE) (Stark,S. et. al., 2010)
• Kohlman Evaluation of Living Skills (KELS, 3rd edition)
Assessment Tools-Environment
• SAFER- HOME Tool
• West Mead Home Safety Assessment
• Home Falls and Accident Screening Tool (HOME FAST)
• Home Environmental Assessment Protocol (HEAP)
SAFER-HOME TOOL
Safety Assessment of Function and the Environment for Rehabilitation
Health Outcome Measurement and Evaluation
Categories of Assessment • Living Situation • Mobility • Environmental Health • Kitchen • Household • Eating • Personal Care • Bathroom and Toilet • Medication, Addiction and Abuse • Leisure • Communication and Scheduling • Wandering
Scoring
Bathroom and Toilet
No Mild Moderate Severe
Bath/shower method X
Bath/shower transfers X
Bath/shower grab bars X
Non-slip aids X
• No identified problem (0) • Mild- 1-33% chance of negative consequences (x1) • Moderate- 34-66% chance of negative consequences (x2) • Severe- 67-100% chance of negative consequences (x3)
Prevention of falls and subsequent injuries in elderly people: a long way to go in both research and practice Dr. Pekka Kannus and Dr. Karim M. Khan CMAJ • September 4, 2001; 165 (5) © 2001 Canadian Medical Assoc. The environmental intervention was found to have had little effect on the
cumulative number of falls, the likelihood of participants having at least one fall during the 12-month follow-up period or the mean number of falls per person, although it is of interest that all the between-groups differences favored the intervention group. In addition, when the data for individuals who had had 2 or more falls within 3 months before study entry were analyzed separately, an individual in the intervention group was significantly less likely to fall and had a significantly longer time between falls than her or his counterpart in the control group. In the efficacy analysis, individuals in the intervention group who adhered more closely to the fall-prevention recommendations had fewer falls per person than those who adhered less closely to the recommendations
Gait and Balance Assessment
Haines et al (2007) Balance Impairment Not Predictive of Falls in Geriatric Rehabilitation Wards, Journal of Gerontology, 63:5
Background. Falls are common among hospital inpatients, particularly in rehabilitation wards. Standing balance impairment is widely held to be a contributing factor to falls, is a component of several falls risk screening tools, and has motivated the development of balance retraining programs for the reduction of in-hospital falls but little rigorous investigation of the link between standing balance impairment and in-hospital falls has been undertaken.
Methods. We identified optimal cut-off points of four commonly used balance measures (functional reach, Timed Up and Go, step test, and timed static stance) in a prospective multicenter cohort study. Admission data (n = 1373) were clustered and matched by center then randomly allocated to development and validation data sets. Results. Optimal cut-off points for each test were identified from the development data set. The predictive accuracy of all four balance tests was poor when the optimal cut-off was applied to the validation data set (Youden Index scores ranged between 0.02 and 0.15). Conclusions. These findings do not support an association between admission standing balance and falls in a geriatric rehabilitation setting. This result has implications for content of falls risk screening tools and interventions to prevent falls in a geriatric rehabilitation population.
Effectiveness of Assistive Technology and Environmental Interventions in Maintaining Independence and Reducing Home Care Costs for the Frail Elderly William C. Mann, OTR, PhD; Kenneth J. Ottenbacher, OTR, PhD; Linda Fraas, OTR, MA; Machiko Tomita, PhD; Carl V. Granger, MD Arch Fam Med. 1999;8:210-217. Context Home environmental interventions (EIs) and assistive technology (AT) devices have the potential to increase independence for community-based frail elderly persons, but their effectiveness has not been demonstrated.
Objective To evaluate a system of AT-EI service provision designed to promote independence and reduce health care costs for physically frail elderly persons.
1
Reduced Costs
Intervention All participants underwent a comprehensive functional assessment and evaluation of their home environment. Participants in the treatment group received AT and EIs based on the results of the evaluation. The control group received "usual care services.“
Results After the 18-month intervention period, the treatment groups showed significant decline for FIM total score and FIM motor score, but there was significantly more decline for the control group. Functional Status Instrument pain scores increased
significantly more for the control group. In a comparison of health care costs, the treatment group expended more than the control group for AT and EIs. The control group required significantly more expenditures for institutional care. There was no significant difference in total in-home personnel costs, although there was a large effect size. The control group had significantly greater expenditures for nurse visits and case manager visits.
Conclusion The frail elderly persons in this trial experienced functional decline over time. Results indicate rate of decline can be slowed, and institutional and certain in-home personnel costs reduced through a systematic approach to providing AT and EIs.
2
Evaluating the cost-effectiveness of fall prevention programs that reduce fall-related hip fractures in older adults. Frick KD, Kung JY, Parrish, Narrett MJ Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA. [email protected] J Am Geriatric Soc. 2010 Jan: 58(1):136-41.
OBJECTIVES: To model the incremental cost-utility of seven interventions reported as effective for preventing falls in older adults. DESIGN: Mathematical epidemiological model populated by data based on direct clinical experience and a critical review of the literature.
MEASUREMENTS: The last Cochrane database review and meta-analyses of randomized controlled trials categorized effective fall-prevention interventions into seven groups: medical management (withdrawal) of psychotropics, group tai chi, vitamin D supplementation, muscle and balance exercises, home modifications, multifactorial individualized programs for all elderly people, and multifactorial individualized treatments for high-risk frail elderly people. Fall-related hip fracture incidence was obtained from the literature. 1
RESULTS: Medical management of psychotropics and group tai chi were the least-costly, most-effective options, but they were also the least studied. Excluding these interventions, the least-expensive, most-effective options are vitamin D supplementation and home modifications. Vitamin D supplementation costs less than home modifications, but home modifications cost only $14,794/quality-adjusted life year (QALY*) gained more than vitamin D. In probabilistic sensitivity analyses excluding management of psychotropics and tai chi, home modification is most likely to have the highest economic benefit when QALYs are valued at $50,000 or $100,000. CONCLUSION: Of single interventions studied, management of psychotropics and tai chi reduces costs the most. Of more-studied interventions, home modifications provide the best value. These results must be interpreted in the context of the multifactorial nature of falls.
*QALY: Quality-adjusted life year A measure of disease burden, including both the quality and the quantity of life lived. It is used in assessing the value for money of a medical intervention. *The QALY is based on the number of years of life that would be added by the intervention. Each year in perfect health is assigned the value of 1.0 down to a value of 0.0 for death. If the extra years would not be lived in full health, for example if the patient would lose a limb, or be blind or use a wheelchair, then the extra life-years are given a value between 0 and 1 to account for this.
Evidenced-Based Practices
• Person-Environment approach produces best outcomes
• Seniors respond best to education via face-to-face
• Modification implementation is best when coming from a health professional like an occupational therapist
• Better functional outcomes when considered alone in the research
• When used in conjunction with vision screening and exercise, falls among older adults are reduced
• Decreased perceived level of difficulty with ADLs when modifications were implemented
• Home safety assessments implemented by OTs prior to discharge, reduced the number of long-term care placements
Partners for Implementation
Home Builders
Community Based Services
Medical Professional
Client
• Medical professional or social worker who works and is an expert in senior care and senior health
• Community-based services, like occupational therapists who are specially certified in environmental modifications. DME providers, Aging in Place Professionals , home modification services like Rebuilding Together
• Home builders are becoming more a part of our senior provider market place. CAPS professionals can help you determine their ability to be able to serve your clients
• How can you learn more about these partners?
Building Coalitions
• AOTA, AARP, HBA 1. Create consumer demand for remodelers who
understand aging in place concepts
2. Understand the benefits of partnering with OTs to better meet the needs of homeowners who wish to age in place
3. Learn the marketing language that speaks to seniors who are considering aging in place remodeling
4. Learn the importance of individualized customization in the aging in place market
Potential Partners
• Local health foundations
• Agencies on Aging
• Hospitals
• Non-Profits (Rebuilding Together)
• Department of Elder Affairs
• Home Builders Association
• Fire Departments
Ideas for Building Relationships
• Opportunities for education
• Networking events
• Speaking engagements
• TV/Radio interviews
• Opportunities for research
• Volunteer (AARP Home Fit)
• Health Fairs
“Being an occupational therapy
practitioner is more than being a
clinician.” It is about scanning your
environment and determining how your
present skills, combined with clinical
knowledge, can meet the needs of a
population,”
Y Yeung (2003) Educating Older Adults in
AT, OT Practice, 8(15)12-15
Universal Design
It is an approach to the design of products, services and environments to be usable by as many people as possible regardless of age, ability or situation. It links directly to the political concept of an inclusive society.
The term Universal Design (UD) was coined by Ron Mace when he was on the faculty at North Carolina State University (NCSU). Dr. Mace defined UD as: “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.”
Universal Design is the human-centered design of everything with everyone in mind.
This manual “A
Practical Guide to
Universal Home
Design” was
produced by
Seniors Agenda for
Independent Living,
Saint Paul,
Minnesota with
support from the
Minnesota
Department of
Human Services.
Universal Design Umbrella
Think of Universal Design as an umbrella and
design products and spaces to envelop as many
individuals as possible, we can widen and extend
the scope of the product or environment to allow an
increased number of users.
Approaches to Design
Being Proactive Not Reactive
(Done before the need arises)
Safety and Fall Prevention Essential
These components are a part of
Universal Design
One way of Getting Involved
The microwave is
placed on a shelf
above the
dishwasher. This
location allows the
ambulatory client to
be able to see into
the microwave.
If the client were in a
wheelchair, the
microwave would be
placed on the
counter or be
installed below the
counter level.
The 18 inch height allows the client to load and unload both racks
without bending. This height also works for someone in a wheelchair.
Raising the dishwasher must be evaluated carefully since the
wheelchair user needs counter space next to the sink as well. This
kitchen provides that type of arrangement.
The client’s neuropathic
shoulder condition
required several
modifications. Initially,
the shower control was
placed too high. This
was corrected.
The contractor was very involved in the decision making process. The
selected shower seat did not have a grab bar. A floor mounted bar was
added and an additional bar was cut off and placed under the left front
corner of the shower seat as an additional support for this 325 lb.
man.
Initially a hand held
shower was
included. However,
for this client with his
shoulder issues, the
location of a shower
nozzle overhead is
preferable.
A sun room near the great room houses multiple plants. The watering
wand makes it possible for the client to care for these plants.
A potting sink was installed in the sunroom. The 50 ft. lightweight
coiled hose with watering wand was attached to the faucet.
The dryer is
raised by placing
it on an eighteen
inch platform
making it much
easier to load
and unload the
dryer
A table has been placed in front and to the left of the dryer and a
clothes basket placed upon it. This allows the client to easily load and
unload the dryer.
Roll-in
Shower
The grout lines
between
2.25-in. x 2.25-
in. unglazed
bathroom floor
tile form
natural nonslip
properties.
UD PRODUCTS
Invisia Grab bar Collection www.invisiacollection.com
Kenmore Elite 30 in. Slide-In Electric Range: www.sears.com
Kenmore TRIO™ Side by Side Bottom Freezer
French Door Refrigerator www.sears.com
Kenmore Side by Side Washer and Dryer www.sears.com
Automatic Door Opener www.beyondbarriers.com
Delta pull-out Kitchen Faucet www.deltafaucet.com
Hard rubber transition ramps www.vanduerr.com
Rocker Light Switches www.leviton.com
Solar Tube Skylight www.solatube.com
Window Treatments www.hunterdouglas.com
Shower Dam www.adaptmy.com
Discuss how you would modify
the following home for
two different individuals.
one is a Quadriplegic
and the other has
Multiple Sclerosis.
www.homeforlifedesign.com
Margaret Christenson, MPH, OTR, FAOTA
Lifease, Inc. 2039 Osprey Woods Circle
Orlando, FL 32820 651-338-7651