Strategies OTs can use to increase client adherence for home modification recommendations.
By John V. Rider, PhD, OTR/L, MSCS, CEAS and Shannon Martin, OTD, OTR/L, BCG
Home safety evaluations and home modification interventions have been shown to reduce falls and fall risk, and improve occupational performance for older adults and people with various health conditions.1,2 However, the resulting home modification recommendations can only make a positive difference if the client implements those modifications in their home and continues to make use of them.
Home Safety Evaluations
A comprehensive home safety evaluation should include assessing the client’s functional ability in the home with particular attention to fall-risk situations. The evaluation should include the full range of potential hazards, raising awareness of the environment and how the client navigates and interacts with it daily, client and caregiver concerns, and problem-solving solutions. When performing a home safety evaluation, occupational therapists (OTs) identify environmental hazards based on the unique relationship between the person and their environment.
Multiple factors should be considered when identifying environmental hazards. These factors may include the client’s history of falls, patterns of usage in the home, protective and risk-taking behaviors, and functional visual, physical, and cognitive attributes that may impact mobility and task performance, as well as caregiver and family support, and fall risk in specific situations (e.g., reaching, bending down, showering, transferring, and completing daily activities).3 Using an existing and valid assessment tool as a part of the multi-component home safety evaluation is considered best practice and can help ensure OTs do not overlook any potential barriers, such as entrances to the home and access to mailboxes or garbage cans.1,2,3
OTs are trained to recognize how the environment affects the ability to perform desired occupations, evaluate client factors that may influence safety in the home (e.g., safety awareness, vision, balance, coordination, endurance, strength, attention, problem-solving, communication, cognition, etc.), and provide strategies to overcome barriers to performance.4 Evidence suggests that home safety interventions are most effective when delivered by an OT, possibly due to the specialized training they receive and their holistic approach to home safety.2,5 However, one challenge that OTs must constantly address with home safety interventions, such as recommendations for home modifications, is client adherence and carryover.
Believing the Risk
One of the most significant barriers to home modification adherence is that many clients do not believe they have a fall risk or that the home modifications will reduce their risk of falling.6 When clients are not aware of the dangers in their environment or the effectiveness of home modifications, they may not adhere to skilled recommendations to change their environment or adjust their daily routine. For example, oOne study found that partial or complete adherence to home modifications was only 52% on average, indicating many clients chose not to make the recommended changes.6
In general, we know that quality healthcare outcomes heavily depend on clients’ adherence to recommended treatment.7 Unfortunately, more than 40% of patients sustain significant risks by misunderstanding, forgetting, or ignoring healthcare advice across settings and providers.7 In the world of rehabilitation, fall risk, functional decline, injury, hospitalization, and healthcare costs can increase when clients do not adhere to evidence-based home modification recommendations.
This article will highlight the most common barriers to home modification adherence and the evidence-based strategies therapists can use to increase client adherence and more effectively reduce fall risk while improving occupational performance.
How Can OTs Improve Adherence?
While no single intervention strategy can improve the adherence of all clients, research among multiple healthcare settings suggests that several factors play an essential role. These factors include but are not limited to a realistic assessment of the client’s knowledge and understanding of their functional limitations and risk, clear and effective communication between the provider and the client, trust in the therapeutic relationship, and treating the client as a holistic person, considering their beliefs, values, attitudes, cultural context, socioeconomic supports, and emotional health challenges.6,7,8
When it comes to home modification recommendations within rehabilitation, predictors of adherence are very similar to those in other healthcare settings. For example, clients who speak the same language as their therapist are more adherent, indicating the importance of clear and effective communication in the client’s preferred language.6 Clients with previous injuries or falls are also more adherent, suggesting the importance of recognizing the risk and implications of falls.6 When clients believe it is possible to prevent falls and increase safety by making home modifications, adherence increases, pointing to the importance of addressing client beliefs throughout the evaluation and intervention process.6
Additional reasons commonly cited for nonadherence include the feasibility of making the recommendation (i.e., the client is physically incapable of removing the hazard or making the home more accessible); the cost of the suggested modification(s); aesthetics (e.g., when the client does not like how the modification looks or has the perception that it will make them appear old); and the homeowner not allowing major modifications.9 Lastly, another significant barrier to adherence is an inconsistent healthcare delivery method in the United States.10 For example, clients may receive varying recommendations from different healthcare team members or across the continuum of care. Each of these barriers needs to be addressed by OTs to improve client understanding, implementation, and carryover of suggested home modifications.
Including the Client and Caregivers
As part of the assessment and intervention process, OTs should include the client and their caregivers in the decision-making process. Using a client-centered approach, OTs can show the client that their preferences are valued and the recommendations are specific and meaningful. Recent research suggests that adherence is improved by presenting the client with several therapist-generated recommendations of specific home modifications and utilizing a problem-solving approach to assist the client in selecting the best option for their needs.11
For example, when working with a client on safe methods for transferring into a shower, OTs can first observe the client attempt the task in the current natural environment. The therapist would then make 2-3 specific recommendations for modifying the environment, such as adding grab bars, identifying a particular shower chair or bath lift, and possibly a more significant structural change to the shower itself, such as remodeling to accommodate a zero-entry shower with no barrier to step over. The therapist would discuss each recommendation with the client and identify the benefits and barriers to each option before making a final decision. This process ensures that the client has autonomy and self-direction in the home modification process and can provide input on strategies that will be both acceptable and useful to them.
OTs need to educate clients on their fall risks and the evidence supporting home modifications using lay terms. As mentioned previously, helping clients be aware of their fall risk and how home modifications can increase safety can overcome a significant barrier to home modification implementation. OTs can also improve adherence by providing a list of local resources to purchase adaptive and durable medical equipment and local contractors to facilitate more extensive modifications, such as installing grab bars in the bathroom or stairlifts to increase safety going up and down stairs. Including specific details such as contact information and cost can remove some common obstacles to initiating home modifications. Lastly, providing handouts or training videos of the recommended modifications can also improve the adoption of strategies, acceptance from caregivers, and continued adherence over time.
Addressing Lower Adherence
While the above recommendations are general strategies to consider when making home modification recommendations, OTs need to consider specific home areas that commonly present functional limitations or fall risks. Detailed consideration should be made to external pathways leading into the home, garages, major living areas, including the living room, bedrooms, bathrooms, the kitchen, hallways, and anywhere stairs are present.
Common Recommendations from Most to Least Adherence
Evidence indicates that some recommended home modifications have higher adherence than others. The following list demonstrates common recommendations from most to least adherence: using nonslip bathmats, using a shower chair, moving electrical cords, changing behavior, changing footwear, removing clutter, installing a grab bar in the bathroom, removing mats and rugs, using lights at night, and installing external railing for stairs.6 Highlighting the benefits of modifications with lower adherence rates can improve understanding and the belief that these items are advantageous to the client.
Offering Modification Alternatives
For example, when discussing clutter removal, it is helpful for the OT to understand the client’s routines and habits to address behavior change adequately. Considering the individual’s values and beliefs associated with items found in the home will increase their buy-in. OTs can provide alternative solutions for installing grab bars that may be less permanent. OTs can explore over-the-tub grab bars, find alternative strategies for transferring into the shower that are safe and do not require grab bars, or offer assistance and advocacy in speaking with the landlord about the need and benefit of installing grab bars.
Ramps are often necessary for individuals who use wheelchairs or have limited mobility. When the cost of installing a ramp is too high or renters are unable to gain approval for installation, portable ramps can be explored as an alternative solution. Installing pull-down shelving systems may be an option for individuals using wheelchairs that don’t want to rearrange items in cupboards. Another option for wheelchair users who have difficulty opening doors independently is to utilize door opening systems to increase access throughout the home. Many older adults become accustomed to having rugs or mats throughout their home, and the suggestion of removing them is often not followed through. Providing clients with safer options such as rug tape or nonslip layers under the rug can be effective. If the sentimental value of the rugs is the main reason for not wanting to remove them, another option is displaying the rugs on the wall.
Another frequent recommendation for older adults to reduce falls is the addition of lighting or night lights. Options such as motion-activated lights with low wattage and education to promote understanding of the benefit of lighting, particularly at night, can improve carryover. While external stair rails can be very helpful, the barrier to installing stair rails is typically a financial or resource limitation. Finding funding options and contractors in the client’s local area may increase client adherence. Considering the client’s values and preferences along with their identified deficits and functional limitations when identifying specific home modification strategies will promote the likelihood that these recommendations will actually be adopted.
Client-Centered Care and Communication
It is important to remember that although therapists are well-versed in the importance of home modifications and the evidence to support their efficacy, clients may not intuitively see the risks or benefits. Therapists must ensure they clearly communicate fall risks and safety concerns, as well as potential solutions for home modifications and behavior changes, along with supporting evidence. When clients recognize the risks, implications, and benefits of home and behavior modifications, they have a higher chance of implementing the recommendations.
Remember to treat each client holistically and take time to identify their perceived barriers to implementing your suggestions. Consider the client’s beliefs, attitudes, cultural norms, social supports, and emotional health challenges when providing recommendations. Use a problem-solving approach and present multiple solutions, followed by a collaborative discussion of what will be most effective for the client. Mutual collaboration fosters greater client satisfaction and reduces the risk of nonadherence. Lastly, provide them with available resources and consider a follow-up appointment after implementing and utilizing the recommendations.
John V. Rider, PhD, OTR/L, MSCS, CEAS, is an assistant professor at Touro University Nevada in the School of Occupational Therapy and works as a community-based occupational therapist for Good Life Therapy in Las Vegas, Nev.
Shannon Martin, OTD, OTR/L, BCG, is an associate professor and the doctoral capstone coordinator at Touro University Nevada in the School of Occupational Therapy and is board certified in gerontology from AOTA.
- Stark S, Keglovits M, Arbesman M, Lieberman D. Effect of home modification interventions on the participation of community-dwelling adults with health conditions: a systematic review. Am J Occup Ther. 2017:71(2);7102290010p1–7102290010p11.
- Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson L, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012:9;CD007146.
- Clemson L, Mackenzie L, Ballinger C, Close J, Cumming, R. Environmental interventions to prevent falls in community-dwelling older people. J Aging Health. 2008:20(8);954-9771.
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- Meucci M, Gozalo P, Dosa D, Allen S. Variation in the presence of simple home modifications of older Americans: findings from the National Health and Aging Trends Study. J Am Geriatr Soc. 2016;64(10):2081-2087.
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