by Susan Bachner, MA, OTR/L, FAOTA, SCEM, CAPS, CEAC
The 31-year-old newly married woman was in a serious automobile accident, sustained a C-6 incomplete spinal cord injury, and upon returning home from acute care and extended therapy found that her new life required many more changes than previously envisioned. The changes were both large and small, but all affected her quality of life. True, she still had a home, but it no longer “fit.” Getting into the home required a “fireman’s carry” because there were too many steps leading to the front door. Maneuvering inside was difficult: doorways too narrow; kitchen inaccessible; bathroom did not accommodate the durable medical equipment (DME). The list was long. She needed help to create a supportive and barrier-free environment, and looked to an occupational therapist with a specialization in home modifications.
The occupational therapist’s role as a home modifications specialist is to evaluate the client’s functional abilities and then, together with the client, develop plans for an accommodating environment that reflects that person’s values, roles, and lifestyle. It is essential that the therapist keeps track of the client’s medical realities while also recognizing that person’s level of client motivation, available support, and many other significant variables.
To begin with, the therapist selects from her repertoire of skills an assessment approach that will yield the desired outcomes. While there are many approaches for assessment and, in turn, creating a scope of work, in my practice I borrow a method from anthropologists and sociologists called “participant observation.” Why do this? The reason, as pointed out by Bernard (1994), is that some of the benefits of participant observation include that method’s ability to reduce the incidence of “reactivity.”1 In other words, people tend to act in a certain way when they know they are being observed. Familiarity, a by-product of participant observation, diminishes this inclination.
Another advantage to using participant observation is that it gives the therapist a view into the client’s lifestyle and serves to support (or negate) interpretations of the observations. The process of participant observation, as applied to a home modifications clinical practice, “requires discussion and observations by the occupational therapist and other key people to determine whether the client is likely to continue pursuing the activities and, if so, under what conditions. Do the activities allow for role continuity? Are the activities that are associated with preferred roles such as parent, student, spouse, and workers still available? If not, what are the barriers?”2
Participant observation, characterized by interactions and then observations, occurs with shifting movement between those two positions. It is similar to viewing a subject from a wide- and then narrow-angled lens and back to wide for another look. It begins with trust and good conversations. The therapist then “moves away” to look at the situation and put the actions or functional performance into a context. Identifying the environmental and personal barriers is essential. Creative problem solving flows from all of these facets.
In the June Rehab Management, “Easy Come, Easy Go! Easy Everything in-Between! Part I,” I described many universally designed home modification elements that were implemented for a healthy couple in their 70s. That article illustrated how the preferred activities associated with the couple were maintained: welcoming friends of all levels of physical function, cooking and entertaining with ease, performing activities of daily living in an environment that was comfortable and accessible. First-floor living became stepless and therefore safer: entering the home, accessing the screened-in porch, having a curbless shower, and accessible bathrooms.
Although Universal Design meets the needs of many people who have mixed levels of physical function, it was never intended to “do” everything. However, when “user-specific” elements (products and structural modifications) were included in this woman’s project, the out-of-sync spaces morphed into an aesthetically pleasing, flexible, and useable environment that fostered independence.
Achieving an Easy Come and Easy Go
Achieving an easy come and easy go was first on the list for environmental corrections so that the client could enter and leave independently. The house sat on the top of a steep incline, so the solution was found inside the garage: a vertical platform lift was installed. Additionally, for safety reasons, a second egress was created in the back of the home by constructing a cement porch that was flush with the threshold leading into the kitchen. The graded cement walkway’s (1:20—meaning that for every vertical inch, there was a 20-inch linear run) excursion had one point level with the cement porch with the other point terminating at the top of the driveway. Raised garden beds were placed adjacent to a section of the walkway. Note that a walkway is different from a ramp (1:12), and because of the gentleness of the walkway slope, no railings or resting spots are required.
Achieving an Easy Everything in-Between
The client’s team (occupational therapist specializing in home modifications, building professionals, case manager, and other individuals in the client’s support system) collaborated with a principal goal in mind: to create a home with “easy everything in-between.” The client and occupational therapist identified interior barriers; the respective solutions evolved. For instance, it was an easy fix to widen the interior doors to 32-inch clear space so the power chair and/or manual chair passed through easily—no more knuckle scraping on the frame. The bathroom was more complicated. The master bath was gutted and totally reconfigured to provide access, comfort, and aesthetics.
A ceiling lift was installed and the track traveled from the bedroom, down the hall, and into the bathroom. The particular positioning of the track enabled independence for getting in/out of bed, sitting on the commode, as well as sitting in the shower commode chair. The shower commode chair was stored in the 4-foot by 6-foot curbless shower (tiled to slope ¼-inch to 1 linear foot). Particular care was put into the planning for the glass French shower doors’ dimensions and positioning (180-degree swing) so that when the client approached the shower in her lift, she would clear both the door as well as shower controls. Of note was that the bathroom door required re-framing so that the track (mounted 3 inches below the ceiling) had an uninterrupted run.
A comfort height commode was installed; it worked well for the 6-foot husband. A bidet toilet seat was also installed so the client became independent in this aspect of self care. Both were very satisfied with the heated seat as well as the spray/dry features of the bidet seat. Fold-down grab bars were mounted on either side of the commode to boost balance and stability. The vanity height was determined by the client’s trunk control and functional reach. A tilting mirror enabled her to see herself. Bathroom independence? Rated A + by the users!
A Safe and Functional Kitchen
Transforming this home to meet the needs of the client included a major kitchen renovation. Cooking is a task that has enormous implications for safety. This homeowner’s sense of well-being was intricately woven into her ability to resume cooking. Therefore, the team collaborated closely to help her achieve this goal. The client’s rehabilitation therapists partnered with the occupational therapist managing the home modification to evaluate the best heights for various cooking tasks and cleanup. This evidence resulted in the installation of multiple vertically adjustable surfaces.
Keeping her upper trapeziums relaxed and preserving shoulder integrity was always in the mind of the client’s occupational therapist and physical therapists. The ability to vertically adjust many working surfaces in the kitchen helped meet these objectives. The side-hinged oven allowed for greater accessibility, and the induction cooktop reduced the risk of inadvertent burns. Raising the dishwasher enabled easier access, and installing a vertically adjustable sink made cleanup possible.
Creature Comforts and Beyond
The modifications continued: the main water shut-off was moved from under the house (in a crawl space) to inside a closet on the first floor; the peep hole in the front door was realigned with the client’s postinjury sight line; a moveable storage cart in the bathroom held personal supplies; an automatic gate was installed in the backyard so that the family dog would remain contained while the homeowner rolled in and out of the yard easily. Environmental controls were also installed to regulate temperature inside the home, unlock doors, turn on lights, and so forth—all managed from the client’s tablet computer.
This home transitioned into a fit that harmonized successfully with the client’s abilities/disabilities, needs and wants, and activities of daily living. In reviewing the outcome, the client described her daily life experiences as “much more normal” [than she had previously imagined possible]. Steinfeld and Danford (1999) wrote, “Disease or disorder need not be present for an impairment to exist, impairment need not be present for a disability to exist, and disability need not be present for a handicap to exist.”3
What that passage means essentially is that if an environment does not merge well with the person and his or her abilities, activities, or occupations may produce barriers that are sufficient to create impairment, disability, or handicap. Conversely, Steinfeld and Danford also noted that a physical environment that enables and sustains functional independence may prevent the occurrence of a disability or handicap, regardless of the presence of impairment.3
Payment for this project was primarily provided by workers’ compensation insurance. The recommendations for home adaptations (structure and products) were based on a very personalized evaluation report, supporting clinical evidence and measureable objectives and goals. Justifying the recommendations for equipment and structural changes was most doable. RM
Susan Bachner, MA, OTR/L, FAOTA, SCEM, CAPS, CEAC, of Susan Bachner Consulting LLC is an occupational therapist and home modifications consultant (www.susanbachnerconsulting.com) living in Lexington, Ky. Bachner earned a BS in occupational therapy from Tufts University – Boston School of Occupational Therapy, and holds a master’s degree in sociology and anthropology. For more information, visit RehabEditor@allied360.com.
- Russell BH. Research Methods in Anthropology: Qualitative and Quantitative Approaches. 2nd ed. Walnut Creek, Calif: AltaMira Press; 1994.
- Bachner S. Objects, physical environment, and self: Implications for home interventions. OT Practice. 2000;19-22.
- Steinfeld E, Danford GS. Theory as a basis for research on enabling environments. In: Steinfeld E and Donford GS, eds. Enabling Environments: Measuring the Impact of Environment on Disability and Rehabilitation. (Plenum Series in Rehabilitation and Health, pp 11-33.) New York: Kluwer Academic/Plenum; 1999.
Open House: Ramps, Door Openers, and Home Modification Strategy
by Frank Long
Tailoring a home modification to meet a mobility device user’s needs is rarely a cookie-cutter process. Home dwellers affected by physical disabilities may, in fact, discover that financial limitations or status as a renter set limitations on how they can shape a living space. For these situations, there are alternatives clients can choose in planning how to access a home and move safely and smoothly through its interior.
Among these choices are ramps constructed of lightweight metal or wood. Both types offer benefits, and both have been used extensively by Bob Vogel, a 55-year-old journalist and T10 paraplegic who is 30 years postinjury. Vogel has lived in five houses since his injury and has a history of accessing dwellings as both a houseguest and homeowner. He offers perspective about affordable, effective options ramp products provide, especially where architectural restrictions from homeowner associations or a rental agreement are in play.
Cost and Portability Are Key
“An aluminum ramp is less expensive than a wooden ramp,” Vogel says. He adds that among the other benefits assoicated with aluminum ramps are that they are engineered to be portable and do not require yearly paint and side rails. Nor do they need surface traction to be built in. As Vogel reflects on several rental homes in which he has lived, Vogel says aluminum ramps would have been the best choice, particularly because they are easy to take down, move, or resell.
In contrast, Vogel says, a wooden ramp must be maintained with annual maintenance and painting, and must be taken down and scrapped when moving.
Vogel also points out that aluminum ramps can be useful to those who host mobility device users in their own homes. “I’ve also used aluminum ramps at other people’s houses. They work well and are portable, which is a plus if you move a lot and/or only need the ramp when a relative or frequent friend visits,” he says.
Another mobility user well-acquainted with the challenges of home access is Tammy Wilber Stay, Ms. Wheelchair Washington 2006. She has been in a wheelchair for 22 years, lived all around the country, and moved many times. Wilber Stay says ramps provide her the freedom to allow independence in her living environment as well as peace of mind “for safety reasons” in the event of an emergency.
“I have had to make many home modifications to front doorways and have been fortunate that only a small ramp would need to be built or, in some cases, I would purchase an aluminum ramp online or from a local dealer,” she says.
For circumstances in which Wilber Stay required a ramp to be built, she had to hire a professional to assure the ramp would be solid for however long it was needed.
In the home Wilber Stay currently occupies with her husband—also a wheelchair user—the ramps are more permanent fixtures.
“We have two ramps: one at the front door and one in the garage. We have an aluminum ramp we bought online, which was very affordable for a 2-inch threshold,” Wilber Stay says.
Threshold height is an important variable in home modification calculus. This is especially true in right sizing a solution for what is required. Therefore, it is important to remember that most users need to accommodate only 3- to 6-inch steps to gain access to their homes, according to Jeff Christianson, ATP, CRTS, president, Southwest Medical.
“Custom-made ramps are nice, but the cost and permanence is more times not feasible for only 3 to 6 inches of rise,” Christianson says. He adds that while the cost of portable aluminum ramps is attractive, the ease of moving the ramp from place to place is an important convenience.
“We have found that consistently, users and caregivers choose the aluminum trifold and bifold-style ramps. These ramps are often utilized as an economical alternative to permanent concrete or custom-built ramps,” Christianson says.
Remote Door Opening Systems
After traveling the length of a ramp or path, a mobility user still must open a door to pass into a home. Depending on the user’s level of function, opening a door may be no simple task. This is where an automated door opening system can be of help. Such technologies help mobility device users enter a home and facilitate movement inside. Many of these types of systems are controlled remotely and/or by wall-mounted push buttons, and can be installed by manufacturer’s technicians.
Commercially available automatic door opening systems are designed to offer a convenient and secure means of entry and exit, and can be used for doors inside the home as well as doors that provide access to the exterior. Among home-based door-opening systems on the market are models that can be controlled by keyless entry pads or remote controls that can be connected to specialty switches and wheelchair controls. Installation for some systems is said to require as little as 2 hours.