A Home Modification Research Agenda For Long Term Care

1. 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@usc.edu www.homemods.org

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

3. 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

4. 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

5. The Need For Research • Consequently, Few Data Sets And Investigator-Initiated Research Have Focused On Home Environment

6. 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

7. Most Homes “Peter Pan” Housing

8. 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.

9. Examples Of Home Modification • Ramps And Stair Glides • Hand-held Showers • Grab Bars • Roll-in Showers • Better Lighting • Chair Lifts • Widened Hallways

10. 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

11. 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)

12. 2. Can HMs Along With Assistive Devices Make It Easier To Perform Tasks? • Findings With Bathing: • 1. HMs Reduce Bathing Difficulty ForThose 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).

13. 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)

14. 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)

15. 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)

16. 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)

17. 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)

18. 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)

19. Source:American Housing Survey, 1995

20. 9.What Do Consumers Consider The Barriers Related To HMs? Source: Fixing to Stay (2000)

21. 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)

22. 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

23. 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

25. 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.)

26. 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

27. 6. Test What Types Of HMs Work With Which Groups (e.g., Alzheimer’s, Parkinson’s) • 7. Replicate Intervention Studies With Larger Samples

28. Overall, More Funding For: • 1. Nationally-directed Research Initiatives • 2. Investigator-initiated Research

29. Recognize That Housing Is The “Where” In LTC