Environments Final

home modifications definition

"Adaptations to living environments intended to increase usage, safety, security, and independence for the user. Home modifications are used in conjunction with assistive devices and home repairs"

toilet

"Comfort height" is 17"‐19" and better suits most adults Adequate support Flush on open side Adaptive seat

Quotes

"We could learn a lot from crayons... Some are sharp, some are pretty and some are dull. Some have weird names, and all are different colors, but they all have to live in the same box."

Evaluation (Development of Occupational Profile and Analysis of performance)

-Balance -Coordination -Endurance -Safety Awareness -Strength -Attention -Problem Solving -Vision -Communication -Home Environment -Caregiver support -**Many other functions while the individual performs daily tasks. -know their strengths, weaknesses, and resources

occupational profile

-Client's occupational history, patterns of living, interests, values and needs, and priorities. -Personal factors •The meaning the home has to the client, the relationship of the home to the client's sense of self and sense of place, and the expectations the client has of his or her own performance

What to Expect from today's presentation

-Overview of home modifications -Key accessibility features throughout the home -Making sound housing decisions -Resources for making home modifications a reality

ideal look

-does not scream this Is for a w/c -ascetically pleasing

process of home modifications for OT

1. Evaluate needs 2. Identify and implement solutions 3 .Educate and train on solutions 4. Evaluate outcomes that contribute to the home modification product -education amount depends on cog status

Guiding principles

32" minimum door clearance (36" + is more universal) 36" wide travel path (42" + better for all users) 5' turning space (6' is more usable for many w/c users) 30" x 48" clearance for approach 28" to 36" finished countertop height (may go to 38") 18" to 48" reach range 1 to 12 maximum slope for ramps (1 to 20 is gentler)

working with contractors

Accessibility certifications ◦ Executive Certificate in Home Modifications (ECHM) ◦ Certified Aging in Place Specialist (CAPS) Navigating the process ◦ AARP Livable Communities ◦ National Association of the Remodeling Industry ◦ Angie's List Ohio Attorney General's Office has a list of basic terms for a contract

ravel path

Accessible from driveway, sidewalk, home entry Wide Clear of barriers and debris

eliminate barriers

Aim for at least 36" travel route Remove excess furniture, cords, other trip hazards Allow space for mobility aids Eliminate barriers Open floor plans ideal for wheelchair users

product

Any alteration, adjustment, or addition to the home environment: ¤specialized, customized, off-the-shelf, or universally designed technologies, ¤equipment, ¤products, ¤hardware, ¤controls and cues, ¤finishes, ¤furnishings That affect the layout and structure to improve functional capability of or minimize environmental demands on individuals and their caregivers to meet the situational needs for promoting performance of daily activities as independently and safely as possible. -assessment, IP, treat, document, re-assess

7.Size and Space for Approach and Use

Appropriate size and space is provided for approach, reach, manipulation, and use regardless of user's body size, posture, or mobility

spacious layout

At least 5' turning space Door opening out

Funding and housing resources

Banks Housing‐related nonprofits ◦ Loans or small grants ◦ Technical assistance ◦ Tool lending library Habitat for Humanity/ReStore Rebuilding Together AARP Livable Communities

Exterior threshold

Beveled No more than 1⁄2" high Incorporated drainage Threshold ramp alternative to construction

refrigerator

Built‐in ice and water dispenser Counter or table space nearby to set food Best model depends on user

seating in the bathroom

Built‐in, fold‐down bench Bench with rubber feet Shower chair with back and arm rest Shower chair with back and arm rest Shower wheelchair Chair with backing and handles Bathtub lift chair

home assessments

By/for housing professionals Detail the environment Technical assessment ex: Universal Design & Green Home Survey Checklist from Universal of Iowa Clinical Law Program

Self assessments

Conducted by consumer or caregiver Limited technical info Various formats ex: Maintaining Seniors' Independence Through Home Adaptations

performances assessments

Conducted by medical professional Focus on ability to complete activities of daily living Most comprehensive ex: CASPAR from Extended Home Living Services, Inc.

process

Confluence of activities and delivery of services including: ¤assessing needs, ¤ identifying solutions, ¤ implementing solutions, ¤ training in use of solutions, and ¤evaluating outcomes To improve functional capability of or minimize environmental demands on individuals and their caregivers to meet the situational needs for promoting performance of daily activities as independently and safely as possible. -train them on how to us the device, so they know how to use it and care for it properly

MAHO is here for you!

Contact us for info, advice, ideas... ◦ Beth Glas or Mara Layne ◦ 216.231.0990 ◦ [email protected]

switches and outlets

Cover plates in contrasting color Switches at 33" to 44" above floor -Paddle switches -Sliding dimmer switches Outlets at least 18" above floor

Resources to learn more

Data: ◦ US Census Bureau: www.census.gov ◦ AARP: www.aarp.org/livable‐communities ◦ Genworth: www.genworth.com Home modifications: ◦ USC School of Gerontology www.homemods.org www.stopfalls.org

key principles to accessible design

Eliminate barriers Provide adequate space Base design on user need Consider frequency of use and importance Seek simple solutions -barriers = tripping hazards, room for w/c -adequate space = room for another person to help them in the bathroom if needed -based on user need = set to their height and capabilities/disabilities -frequency of use = focus on what they DO use the most -simple solutions for brief disabilities or ones that change over time

range

Front controls Easy to use dials, buttons, screen Smooth cooktop Mirror mounted above range

bedroom

Grab bar or safety rail by bed Sufficient space to maneuver and access storage Ceiling mount lift to transfer in and out of wheelchair Lift to move from bed to changing table Lift system to move from bed to bathroom

Shower head

Handheld showerhead Integrated grab bar Walk‐in with sliding door or curtain As small as 3' by 3' Shower chair good lighting roll in for w/c (with curtain) Small tiles for traction Sloped drainage Long wand on curtain water barrier

starways

Handrails on both sides Grab bar at top of steps Color contrast Adequate lighting Light switches at top and bottom of steps Lifts -Require electricity -Freestanding

Steps

Handrails on both sides Contrasting colors Nonskid material on stair treads Adequate lighting

Cabinetry

High toe kick D‐shaped handles Pull‐out storage ‐ Shelves ‐ Baskets ‐ Trash cans Prioritize storage of most‐ used items Open storage eliminates need to navigate around doors Drawers can be easier organize and access

Case Example Eugene is a 70 year old man who was diagnosed with Parkinson's Disease last year. He was referred by his physician to have a home evaluation by OT. Upon evaluation you discover he has problems bathing and transferring. What will you do next?

IT DEPENDS -what does his home look like? -does he have anyone to help him at home? -what are his disabilities? -what are his finances?

Home modification

Improvement or repair to the environment in order to: ◦ More easily perform tasks ◦ Reduce accidents ◦ Increase independence Most common home modifications: ◦ Minor modifications: grab bars, raised toilet seats ◦ Major modifications: ramp, auto door opener ◦ Repairs: loose handrails, windows ◦ Other: jar opener, secure loose floor items

Benefits of accessible living

Independence Aging in place Living experience Cost effectiveness Health and home safety Community

social services resources

Independent Living Centers ◦ Small grants ◦ Equipment ◦ Information and referral Disability‐related nonprofits ◦ UCP, MS Society, Muscular Dystrophy Association DIAL: 2‐1‐1 Legal Aid

Costs of home modifications

Less than $500 • Grab bars • Lever door handles • Raised toilet • Any many more... $500 to $1,500 • Automatic door opener • Ramp $1,500 to $10,000 • Stair lift• Roll‐in shower $10,000 + • Any significant remodel

Door honadles

Lever handles Usable deadbolt lockset ‐ Key‐ Number keypad ‐ Card or fob‐ Fingerprint

What can we do about it?

Make no changes at all and risk injury and dependency Assist the person in (re)developing skills Adjust the task Modify the environment

OT role in home modification

May begin with a referral ¨Referral for OT from a traditional health care setting ¨Payer source referral (Medicaid) ¨Area Office on Aging ¨County MR/DD Boards OR Client may be on your current caseload ¨Identification of strategies that enable individuals to modify their homes, thereby maximizing their ability to safely participate in daily tasks/activities and promote well-being -ID solutions -promotes well-being

doors

Minimum 32" clearance Lever door handle Swing clear hinges on a standard door Pocket door Barn door Curtain instead of door

Grab bars

Mount on studs or 3⁄4" plywood backing Provide backing for future grab bar installation Secure Mount Anchors Mount grab bars where the user(s) need them ‐ Angle ‐ Height ‐ Style Only grab bars are grab bars (do not use towel rods) can be permanent or temporary attachments

Switches and Controls

Mount switches and controls low ‐ Garbage disposal ‐ Range hood ‐ Outlet

Lighting

Multiple light sources Flooring with minimal glare Task lighting

Government resources: state

OH Home Care ◦ Benefit package include home modifications, adaptive/assistive devices ◦ Individuals with physical disabilities ages 0‐59 OH Passport Provides minor home mods‐maintenance and repair, home medical equipment and supplies, independent living assistance, Individuals ages 65 years and older, as well as people with physical disabilities aged 60‐64 OH Individual Options ◦ Provides environmental accessibility adaptations, adaptive and assistive equipment ◦ Individuals with IID/DD from ages 0+ OH Assisted Living ◦ Provides assisted living services and community transition services ◦ For physically disabled individuals ages 21‐64 and seniors aged 65+

Sink

Open underneath Drain in back Sink Mount faucet on side for sink that is not open underneath Single lever faucet Built in sprayer Touchless

Automatic door opener

Opening time and speed adjustable Requires electricity Activate with remote and/or push button

Who needs accessibility

People with disabilities Seniors Family and caregivers of people with disabilities and seniors

working with landlords

Request "reasonable modification" Physical changes to an existing structure to allow a person full enjoyment of premises ◦ Interior of own unit or common areas ◦ Modification must be related to disability Landlord can require proof of disability Can require tenant to return unit to original condition At tenant's own expense

Example recommendations - SPECIFIC!

SLIDE 26 Provide & Install ADA Stainless Steel Grab Bars (x2) to Upstairs Bathroom: 1. Install 24" grab bar on back long wall positioned horizontally at 16" up from tub edge and centered on wall, will require a wall anchor that can sustain max load of 300lbs. 2. Install 18" grab bar on right control wall positioned vertically with lowest attachment at 14" up from tub edge *Provider is responsible for supplying all materials and hardware, and debris removal *All grab bars must meet or exceed ADA guidelines and will support a max. load of 300lbs. ¨Training with client and family once modification is complete. ¨Training with caregiver so that assistance can be appropriately "phased out" ¨Training on integration and safe use of the home modifications ¨Training on care and maintenance of the device -more examples --> slide 37

Evidence for Home Modifications: What do we know?

Slide 48

no-step entry

Slope not to exceed 1 to 12 Level landings with at least 3' turning space Graded sidewalk easiest to maintain Ramp easiest, cheapest, to install Utilize non‐skid paint or strips (can add sand to paint) Handrails should extend 12" beyond end of ramp Handrails in contrasting color Garage ramps provide fully covered entry into home Carpet covering reduces slips and cleans off wheels/shoes Lifts most expensive option with regular maintenance Lifts good option for small yards Consider providing coverage

flooring

Smooth materials ‐ Hardwood‐ Low pile carpet Carpet adhered directly to floor Low‐maintenance materials Rubber thresholds Thresholds no more than 1⁄4" high and beveled

2.Flexibility in Use

The design accommodates a wide range of individual preferences and abilities

6.Low Physical Effort

The design can be used efficiently and comfortably and with a minimum of fatigue

4.Perceptible Information

The design communicates necessary information effectively to the user, regardless of ambient conditions or the user's sensory abilities

1.Equitable Use

The design is useful and marketable to people with diverse abilities

5.Tolerance for Error

The design minimizes hazards and the adverse consequences of accidental or unintended actions

controls

Thermostat and other controls no more than 48" from floor Usable controls ‐ Touchscreen or buttons ‐ Audible alerts ‐ Programmable

Assessments

Tool to facilitate conversations and decisions Can be done formally or informally Identify and prioritize necessary renovations ◦ Evaluate a home for accessibility ◦ Evaluate person's ability to perform tasks in the home environment Identify possible solutions Consumers are experts on their needs

working with our clients

Understand your client and their preferences ◦ What are the goals of your client? Change the conservation ◦ Shift talk from the client's inabilities to solving the environment's deficiencies Focus on solutions Give choices

Microwave

Usable style Place within easy reach Have space nearby to set hot dishes

3.Simple and Intuitive Use

Use of the design is easy to understand, regardless of the user's experience, knowledge, language skills, or current concentration level

Upper cabinetry

Utilize pantries and lower cabinets Mount upper cabinets as low as possible Pull down shelving units

Bathroom

VVV

exterior of the house

VVV

kitchen

VVV

making decisions

VVV

Understanding Individual Accessibility Needs

VVVV MAHO Presentation

HOME MODIFICATIONS

VVVV Objectives ¨Identify the components of home modifications ¨Review the role of OT within this setting ¨Discuss the current literature ¨Identify resources for future reference ¨Practice through case studies ¨Review CASPAR Home Evaluation Assessment for home eval assignment

Culture and Healthcare

VVVV Objectives •Reflect on our own culture in our own lives •Describe the complex nature of culture •Distinguish levels of cultural competency •Examine the importance of acknowledging the impact of culture on healthcare/health •Review a specific case example •Explore resources to further discover information on culture

interior

VVVVV

vanity and sink

Wall‐hung sink Mounted at 36" Drain in back Insulated piping with anti‐ scald temperature of 120 degrees Wall‐hung integrated sink Mounted at 32" Built‐in vanity Mirror extends to counter Undermount sink Traditional cabinetry Rounded countertop edges Mounted at 34" and 30" Lower counter has push‐in cabinet doors to provide open space Sink -Single‐lever faucet -Visible temperature indicators -Tap‐on faucet with color‐ changing temp indicator

Maximum Accessible Housing of Ohio (MAHO)

We advance accessibility, independence, and inclusion in homes and communities. Over 35 years of developing and operating fully accessible housing ◦ Vistas Apartment Communities ◦ Anderson Center for Accessible Living

Barriers to successful home modifications

We can make poor choices when forced into making changes Accessibility has a bad reputation Accessibility is complicated Fear of change Fear of growing older Cost taking down the barriers to accessibility (has a bad reputation and it is complicated, fear of change, fear of growing older, it costs a lot, we can make poor choices when force into making decisions), but it increases health, home safety and QoL. prepping the home allows for aging in place and independent living. long-term costs much higher and are annual

Government resources: Other options

What do I look for? • Loansforhomerepair • Grantsforhomerepair • Tool lending• Technicalassistance• Homeassessments• Benefitsassistance• Referral Where to look -County level • Department of Seniors, Aging services • Department of Development, Housing • Board of Developmental Disabilities -City level • DivisionofAging,ADACoordinator • Senior Centers -Area Agency on AgingVeterans Administration -Community Development Corporations

flexible layout

Wide travel path around islands and tables Space to access cabinets and appliances Multi‐height work surfaces

PEO

person, environment, and occupation create the occupational performance and participation -occupational performance is therefor affected by the environment (hinders or helps the individual) -in their home = most natural environment (focusing on environment and changing the environment)

Home Modifications Components

product and process

Evidence for Home Modifications: OT and home mods

slide 49

Current Housing reality

think about the home of the client Is there at least one zero‐step entrance into the home? Is there a bedroom, full bathroom, and kitchen on the main level? Are there extra‐wide doorways and hallways? Are the outlets and switches easy to reach from any height, standing or seated? Are there lever handles on doors and faucets?

specializing in home modifications

¨AOTA Board and Specialty Certification ¤Environmental Modification ¨Other Certifications ¤Certified Aging In Place Designation CAPS ¤Executive Certification in Home Modification ¤Living in Place Institute ¤Certification as Living in Place Professional (CLIPP)

Other Professionals Involved in Home Modification

¨Architects and Interior Designers ¨Contractors, Remodelers, and Tradespeople ¨Volunteer Agencies ¤Rebuilding Together: AOTA has a longstanding relationship with Rebuilding Together and encourages OT practitioners and students to get involved in their local Rebuilding Together affiliates to provide home assessments and recommendations.

evaluating needs

¨Assess the person ¨Assess the environment ¨Consider how the person and environment interact ¨Establish client-centered goals ¨Implement strategies

need for home modification

¨Children and adults with a range of disabilitieshave safety and accessibility issues in their homes ¨Last year, almost 2.5 million older adults visited the ER for injuries related to falls with significant adverse outcomes (AOTA) ¨Baby boomers want to age in their own home, but only 1 in 6 homeowners have made the modifications necessary to do so.

3. Educate and Train

¨Education and Consultation ¤Family ¤Case Manager ¤The OT will evaluate the need and appropriateness of home modifications and identify how the proposed modifications will change the need for assistance (caregiving) required by the client. ¨Education and Consultation ¤Pictures ¤Financial benefits (vs. putting client in nursing home) ¤Resources -Equipment ie. Videos of equipment being recommended -Contractors

Benefits of Home Modifications

¨Increased safety and accessibility in the home ¤Prevent falls ¤Increased quality of life ¨Individuals can age in place ¨Potential for individuals to save money ¤In Cleveland area, the average cost of a long-term care facility is $86,140 per year (AARP) -able to stay in your home, within your community, can socialize with people like you usually do and not forced into new long-term care

need for comprehensive care

¨It's not just home mods that keep people safe and independent ¨Mods should be part of comprehensive care ¤Client training ¤Making sure mods are actually used ¤Client behavior changes -giving and training, making sure they are using it and using it correctly -go through all 4 steps to have it be effective

bathing solution for Eugene

¨Modifications: 1)Grab bars 2)Shower seat 3)Curbless shower stall, handheld shower, and grab bars ¨Training: To incorporate use of modifications and establish bathing routine ¨Outcome: The client no longer needs assistance and showers independently

2. Identifying & Implementing Solutions

¨Once an occupational profile and occupational performance are completed, intervention plans and goals are established in collaboration with the client, the family, and other members of the team ¨Goals must reflect the client's potential to benefit from home modifications. ¨Need to consider financial constraints ¨Provide multiple solutions ¨Consider acuity of disability -take stage/type of disability into consideration (temporary/acute, progressive, static, etc.)

Principles of Universal Design

¨Principles of universal design are some of the factors that OT's consider when analyzing the demands of a client's activity. 1-7 below

typical modifications

¨Ramps ¨VPL (Vertical Platform Lift) ¨Hand railings ¨Grab bars ¨Barrier-free showers ¨Ceiling tracks ¨Door openers ¨Thresholds ¨Door widening ¨Alarms ¨Stair Glide

evaluating needs of the home

¨The occupational therapist will seek to understand the meaning of home and the daily routines and rituals that are part of that meaning. ¨The meaning of "home" must be respected and maintained as modifications occur

4. Evaluate Outcomes

¨Use of solution ¨Safety in the home ¨Independence with occupations ¨Well-being -are they using it, are they safer in the home, are they more independent with their occupations, and do they have an overall greater sense of well-being? -aka, was your treatment good?

parties involved with housing decision

• Client• Caregiver(s)• Other people living in the home• Social workers• Occupational and physical therapists • Other healthcare providers• Landlords• Contractors

Home Modifications Organizations

•AOTA has relationships with the following national organization to encourage collaboration and recognition of OT expertise in home modifications: •AARP: OTs are involved in HomeFit Guide presentations at the state level. •National Association of Home Builders: Occupational therapy representation on their Certified Aging in Place Specialist (CAPS) board. •Other Organizations:These non-profit organizations offer CE and other resources related to Home Modifications •American Society on Aging •Center for Inclusive Design and Environmental Access •Gerontological Society of America •International Council on Active Aging •National Association of Homebuilders •National Council on Aging •National Institute on Aging •Falls Prevention Center of Excellence

evaluating needs: vision

•American Foundation for the Blind -Recommends use of a checklist for Environmental Safety •Lighting •Furniture •Elimination of Hazards •Use of Color Contrasts •Hallways and Stairways •Signs •Telephones APPLIANCES: font size, color contrast, etc. We also considered some variables unique to each class of appliance, such as the location of controls on the door of a dishwasher. Special considerations for a class of appliance are listed with the category. -i.e., painting the inside of your cupboards/painting the shelves so white dishes stand out -i.e., color contrast with a white placemat and colored dishes

Example Eugene's symptoms have progressed over the past 10 years and he now needs to use a wheelchair for mobility. He is still able to safely transfer in/out of the wheelchair with increased time. The problem is that his only bathroom is up a flight of stairs and his bedroom is on 2nd floor. What will you do next?

•Modifications: -Commode chair -Hospital Bed -Stair glide Training: To incorporate use of modifications, safety, care and maintenance of glide Outcome: Client is able to toilet independently and sleep in his own bed. -BSC on the first floor -a lift -add bathroom to the first floor