A Home Modification Research Agenda For Long Term Care

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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 Center
• University Of Southern California
• Los Angeles, CA 90089-0191
• homemods_at_usc.edu
• www.homemods.org

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Purpose

• Analyze Current Research Concerning The Home
  Environment And Long-Term Care
• Propose A Future Agenda That Will Benefit From
  More Sustained Investment

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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

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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

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The Need For Research

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

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Why Is The Home Environment Important?

• The Physical Environment Can Enhance Or Impede
  Ones 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

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Most Homes Peter Pan Housing
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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.

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Examples Of Home Modification

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

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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

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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)
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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).

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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 HMs
  Reduced The Risk Of Falling
• Source Gill et al. (2000) Cumming et al. (1999)

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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)

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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)

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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)

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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)

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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)

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SourceAmerican Housing Survey, 1995
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9.What Do Consumers Consider The Barriers Related
To HMs?
Source Fixing to Stay (2000)
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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)

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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

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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

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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.)

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• 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

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• 6. Test What Types Of HMs Work With Which Groups
  (e.g., Alzheimers, Parkinsons)
• 7. Replicate Intervention Studies With Larger
  Samples

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Overall, More Funding For

• 1. Nationally-directed Research Initiatives
• 2. Investigator-initiated Research

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• Recognize That Housing Is The Where In LTC