Evaluating the Impact of the Built Environment on Community Living and Participation

1. Evaluating the Impact of theBuilt Environment on Community Living and Participation Presenter: Joy Hammel Research Team: Jon Sanford, Lou Fogg, Deb Walens, Jennifer Garcia Dahl, Andrea Gossett, Laurie Rockwell Dylla Collaborators: University of Illinois at Chicago, Chicago Department on Housing, Chicago Mayors Office for People with Disabilities, Extended Home Living Services, Access Living & Progress Center Centers for Independent Living This research has been funded in part through a grant from the Retirement Research Foundation

2. Presentation Goals • Examine how the built environment, and changes to it, impact community living and participation for people who are aging with disabilities. • Highlight assessment tools to document environmental impact • Provide evidence on the effectiveness of environmental interventions to a. justify services b. inform design (accessible and universal) and future research

3. Previous Research on HM • Research showing increasing unmet need for environmental access such as HM • Studies showing impact of AT; however, HM not included or funded in most • Many case examples of HM done with middle and upper SES, with few on low SES and/or in older, urban housing stock • Research on specific access guidelines (like grab bar placement in bathrooms) but not on overall impact of HM on community living & participation across large sample

4. RRF HM Outcome Study: 3 yr study • Phase I: Controlled Intervention Trial • 165 subjects (94 HM treatment, 71 wait list control) • Age: (ave: 63 yrs.)40-59yrs.: 72 (44%) 60-69: 30 (18%) 70+: 63 (38%) • Gender: 138 women (84%), 27 men (16%) • Race: 134 African American (81%), 27 Caucasian (16%), 3 Latino (2%), 1 Other • SES: Average: $13,136/yr. (range $0-$50,000); Median: $10,000 • No significant differences between treatment and control groups on age, sex, race, SES or functional status at baseline

5. Home Modifications Intervention • HM = structural modifications to the physical home environment to address functional access, mobility & participation in context • High Priority Areas 1. Getting in and out of the home • E.g., stairs outside: ramps & lifts, doorway access, accessible locks, railings in/out, threshold leveling, intercoms 2. Navigating inside stairs or level changes • E.g., Inside stair lifts, railings inside 3. Moving through the house and rooms within it • E.g., Hallway railings, doorway widening/changes, lighting 4. Performing self-care activities in the bathroom • E.g, Tub/shower adaptations, roll in or sit down shower stalls, grab bars, elevated toilet, accessible sink, accessible faucets/controls, nonslip flooring, safety adaptations

6. Community Collaborators & HM Providers

7. Data collection • Assessed in home by OTRs • Interview (qualitative & quantitative) coupled with accessibility audit & pictures • 3 times: baseline (no HM), 3 months post (right after HM for Tx), and 12 months post • Examined impact of HM upon function (OT & consumer ratings), home & community access & participation, & quality of life • Does the environment flexibly meet diverse needs of diverse consumers who are all aging in place?

8. Results: What did people get? • Type of HM received • Entry way access: 69% • Bathroom modifications: 41% • Mobility inside home: 5% • Inside stairs: 4% • Cost ranges: • $400 to 13,500 range • Average: $4822 • Median: $4462

9. Environmental Impact: CCAP: Client-Centered Assessment Protocol • By Gitlin & Corcoran, available through: Laura Gitlin at the Center for Applied Research on Aging and Health at Thomas Jefferson University: laura.gitlin@jefferson.edu • Assesses function in multiple ways: • independence, safety, efficiency & difficulty • consumer ratings & clinician ratings • across self care, IADL, and social

10. Functional Impact of HM: CCAP Independence • Significant independence improvements in: Control wait list (C) vs. Treatment (TX); Baseline to 3 mo. post

11. Impact of HM on Difficulty, Safety & Efficiency (CCAP observed) Control wait list (C) vs. Treatment (TX); Baseline to 3 mo. post

12. Clinical Significance: Effect Sizes SHORT TERM LONG TERM * Effect Size Interpretation (Cohen): 0=small; 1=medium; 2=large )

13. BEFORE AFTER Environmental Impact: Function, Safety & Efficiency

14. Environmental Impact: Function, Safety & Efficiency BEFORE AFTER

15. CASPAR: Comprehensive Assessment & Solution Process for Aging Residents • by Jon Sanford & Extended Home Living Services, Inc. (EHLS) • In home assessment of function & accessibility to inform HM planning & implementation • Adapted to include an Environmental Measure of Need, Difficulty and Magnitude across 4 functional areas

16. Specific EM Impact: Entry Way (CASPAR Environmental Measure) Control wait list (C) vs. Treatment (TX) scores at Time 2; 3 months post HM

17. Specific Impact: Bathroom (CASPAR Environmental Measure) Control wait list (C) vs. Treatment (TX) scores at Time 2 @ 3 months post HM

18. The Built Environment: Impact on Social Participation Cartoon from Don't Worry, He Won't Get Far on Foot, by John Callahan

19. bathroom community Environmental Impact on Community Participation • Life Space Profile (Owsley, Allman, Gossman, Kell, Sims, Baker, 1999) • Assesses access to different contexts of participation • Bedroom to bathroom • Bed to rest of house • Place where you can look out • Places attached: mailbox, yard, laundry, garage • Immediate block • Neighborhood/community/town • Outside community and outside state • Adaptation: Are you able to get to a place when you need to and/or want to? (versus frequency/how often you go there)

20. Participation Restriction(those that give up use of space over time)

21. Participation Expansion: Spread Effect of HM • HM affects participation across activities and across people in household • “Since I got the bathroom done, I go out a lot more because I can take care of myself and I’m not as worried about accidents or being clean when I go out.” • “I got the ramp for my mother who was declining. Now that I’ve got MS, I’m using it all the time and my husband doesn’t have to carry me up the front steps.” • “With the new bathroom, I feel safe using it and it also helps my attendant so he doesn’t hurt himself lifting me. It takes a lot less time. Less anxiety and I don’t feel like a burden.” • “(the ramp is) A blessing to me and to my grandchildren… I can now visit all 20 and the family can socialize! It has been a tremendous help.”

22. How HM can restrict or expand participation depending on design • Creating or maintaining “Surveillance zones” important strategy to increase sense of security & social connection with immediate community

23. Consumer Choice, Satisfaction and Long term Use Before HM After HM

24. Environmental Impact on Quality of Life: Effect Sizes SHORT TERM LONG TERM * Effect Size Interpretation (Cohen): 0=small; 1=medium; 2=large )

25. Implications for Service Delivery, Policy & Future Research • Modifications to the built home environment significantly affect functional independence, safety, efficiency and difficulty for people aging in place on limited or low incomes in urban, older housing stock • Even small changes have moderate and large effects across ages and across diverse needs • Even small amounts of $ invested show significant effects • Effects are maintained over time, and spread to other areas over time (e.g., added function, improved control, and QOL) • Changes within the home environment significantly influence community participation outside the home • Accessible and universal design intersect and can inform each other, including in the design of affordable and accessible housing • Environmental and participation measures can inform both accessible and universal design and could be applied to community environments and participation

26. What can’t be measured: Impact on freedom & control • “I haven’t left my house for over 2 years except being carried out for emergencies. I can’t tell you what this means to me.” • “It’s opened a whole new world to me. It’s been so long since I’ve been out. I couldn’t leave the house before this.” • “I’m free, thank God Almighty, I’m free at last!”

27. Added Impact: Flexible add-ons as universal practice