Successful home modification incorporates client input to create spaces that go beyond mere accessibility.
by Joan Augustyn, OTD, OTR/L
People want to be able to live and stay in their homes. This simple truth applies regardless of whether one is thinking about planning to age in place, or has just completed a stay at a hospital or facility. Living at home should be safe. For people who are aging or experiencing disabilities or chronic conditions, living at home should not only be safe but the home itself should be “usable.”1 In the context of home modification, “usable” is a key term that is not interchangeable with “accessible.” The meaning of “usable” is much broader than “accessible,” which is a term that commonly relates to the Americans with Disabilities Act (ADA). While the ADA is an important policy, it’s lacking in many areas of actual usable features for people experiencing disability. “Usable” expands to mean a person may use the rooms in his home in the manner he wishes as well as enter and leave his home as he wishes. “Usable” can also include if the home is “visitable,” or if any person, regardless of mobility device, can visit the home. Sometimes, however, as homes grow older or as people transition to different kinds of homes, these usable features are not always present. With the COVID-19 pandemic, usability features of homes changed in meaning and have become even more important.
Occupational therapists (OTs) and physical therapists (PTs) have a unique role in care because they look beyond environmental screenings of homes. Therapists look at how a person moves within the environment, either independently or with a needed device, such as a walker or wheelchair. By looking at movement in authentic contexts, therapists can see which barriers and supports exist within the home. They also have insight into how the home can help or hinder a person from being social and being a part of her community. If entering the home is difficult, this may leave family, friends, and others from the community unable to visit a person who is affected by a disability; or leave that person feeling as if he or she cannot leave the home.
If leaving the home is difficult, being connected to the community is difficult. Not having a connection to people and the community can negatively affect the mental health of a person experiencing disability.5 The COVID-19 pandemic has highlighted the lack of connection to the community and mental health concerns.5 To combat circumstances that cause isolation, new assessments related to home safety, a person’s ability to participate in the home, and the ability to access communities are currently being tested due to the high need for these assessments and people’s desires to be able to do these things.2,3 These assessments are now even being provided via telehealth and other digital services such as apps on phones.
Therapists can provide unique assessments and intervention through “client-centered” care; in this model the client guides the selection of priorities, and the therapist provides support by contributing ideas, information, and assistance with community access (eg, how to contract for a ramp or modification that needs to be made). This model of service provision is different from a typical, medical, expert-based model. The client is the expert and the therapist is a support. Sometimes this model can be difficult for a client to understand but when explained in jargon-free terms, the power transfers from the professional to the client.4
Many times usability and safety go hand in hand. Home modification is currently a popular area of practice for occupational therapists. People are beginning to return home and stay there because of the assistance of technologies such as chair and stair lifts, door opening and pull-down shelving systems, portable ramps, grab bars, zero-entry showers, systems for managing the temperature of the water, and several other home modifications.2
One of the most common rooms needing modifications is the bathroom. Installing grab bars by the toilet stool can help a person safely move on and off the toilet. Often people will use something like a towel rack to hold on to while they move from one place to another; unfortunately, towel bars are not bolted into the wall the same way a grab bar is and are not safe. Having something that is securely bolted into the wall to hold on to while going from standing to sitting on the toilet stool is imperative for a person to remain safe. Zero-entry showers can also make it easy for someone who uses a wheelchair or other mobility device to get in and out of the shower; people do not have to worry about tripping or stepping over a lip of any size to enter the shower and equipment can easily be moved in and out.
New systems for managing water temperature in the bathroom via apps are also available, and this technology can decrease the risk of burns for people who may have cognitive differences. App technology has become much more popular for many home systems like garage door openers, home temperature, and home safety due to advances in technology as well as the pandemic. Many people now consider these technologies basic usability features. Along with the bathroom, getting around the home for someone who has difficulty on the steps can be safer with technology like chair lifts, instead of risking balance and movement on the stairs. In some cases, ceiling-mounted track systems or adjustable lifts may enable self-transfers for individuals who have lost the ability to transfer manually but who have retained limited range of motion and adequate muscle tone. These lifts may be especially useful for caregivers who need to safely assist loved ones with disabilities in order to age in place as well.
Cabinet and door opening systems may also provide helpful options for home usability. Cabinet systems can help in the kitchen to prevent lifting heavy objects overhead. Door opening systems that open automatically upon entering and leaving the home can make it easier for a person affected by a functional impairment to access the community. Portable ramps also offer the option of adding a ramp only for visits or when needed. Especially for people who use manual or power wheelchairs, having the ability to enter and leave their home is what can connect them to their surrounding communities and prevent isolation.
Technology Basics and Budgets
A wealth of new technology is available to support the goal of enabling a person experiencing disability to live in the home. Therapists must remember that some of the best modifications are the basics, such as clear surfaces and reachable countertops. Using technology just to use it or because it is the newest, most fashionable thing does not relate to the client’s needs. The most important aspect of home modification is that the therapist follows the client’s wishes while being mindful of the client’s financial means.
In home modification planning, financial issues oftentimes present a challenge to modification or usability goals. However, therapists can help by researching what is covered by insurance, what may be accessible through government funding by connecting the client to Centers for Independent Living (CILs), and what other purchase options exist within the community. Many funding options are available, but before they are considered the therapist must think about what the client wants and needs first.
Tips for Client-Centered Practice
The best way to serve an individual in the home:
1) Listen to what the client wants or needs first, either in person or virtually.
2) Evaluate the home and how the client moves within the home to assess safety concerns.
3) Talk with the client about what may be possible to address any issues.
4) Connect the client with contractors, sites, community resources to get those needed items. Make sure some telehealth or virtual options are available if needed.
5) Follow-up with the client for any needed training with new items and to see progress.
The following case study demonstrates the application of these steps:
Dan is a 60-year-old man who has multiple sclerosis (MS). He is having more difficulty using his right arm, walking to and from his bed at home, and fatiguing more quickly due to MS. He uses a walker at home and is starting to use a power chair more often. He also notes he has depression due to increased isolation from the pandemic. He lives in a one-level loft with his wife in an urban area.
After speaking to him at home and seeing how he moves, the OT learns that Dan wants to get in and out of bed more easily and to and from the toilet more easily (1). Currently, Dan is using the trash can on his right side to push up from the toilet stool (not a safe surface to push on) and takes a long time to get into bed due to having difficulty lifting his legs up into a high bed (2).
The OT offers the idea of installing a drop-down grab bar on the right side of the toilet and possibly using a strap, such as something even like a dog collar, to buckle onto his thigh so that he can lift his legs more easily into bed. Dan also notes he was already planning on purchasing a new bed, so the OT suggests looking into adjustable bases for the bed to offer changes in height. The OT also suggests that using his power chair to get to bed may save him some energy for doing other things around the home. Dan agrees that the grab bar is needed even though it looks more medical than he would like. He also likes the simplicity of the straps for lifting his legs into bed and the idea of an adjustable base for his bed. He notes he will have to think about using his power chair more because he wants to use the walker as long as he can (3).
Dan notes all considerations are within his financial means so the OT looks up places for where he can purchase the grab bar and have them installed. The OT also looks up where he can purchase some straps for his legs. The OT sends links related to these items to Dan via email, as is his preference (4). Later the OT checks on Dan’s ability to use the grab bars safely in the bathroom and how he gets into bed to ensure his concerns are met (5).
Freedom to Stay
Everyone has some kind of home or space they live in where they spend a great deal of their time. Occupational therapists devote their time and skills to making sure people’s homes are easy to enter and leave and that they are safe. Likewise, these professionals also assure that homes are usable and will enable people experiencing disability to remain in the home and do the things they wish to do. RM
Joan Augustyn, OTD, OTR/L, is a clinical assistant professor at the University of Kansas Medical Center (KUMC). She currently works in a community wellness program for those who have progressed MS. Her passion is community practice. For more information, contact [email protected].
- Granbom M, Evelyn-Gustave A, Gitlin L, Szanton SL. Helping older adults age in place: environmental modifications of the CAPABLE program. OT Practice. 2018;23(16):8-15.
- Stark SL, Somerville EK, Morris JC. In-home occupational performance evaluation (I-HOPE). Am J Occup Ther. 2010;64(4):580-589. https://doi.org/10.5014/ajot.2010.08065
- White GW, Simpson JL, Gonda C, Ravesloot CH, Coble Z. Moving from independence to interdependence: a conceptual model for better understanding community participation of centers for independent living consumers. J Disabil Policy Stud. 2010;20(4):233-240. doi: https://doi.org/10.1177/1044207309350561
- Mroz TM, Pitonyak JS, Fogelberg D, Leland NE. Client centeredness and health reform: key issues for occupational therapy. Am J Occup Ther. 2015;69(5):1-8. https://doi.org/10.5014/ajot.2015.695001
- Koon LM, Greiman L, Schulz JA, Goddard KS, Nzuki IM, Hall JP. Examining the effects of the COVID-19 pandemic on community engagement for people with mobility disabilities. Disabil and Health. 2021;in press: 1-6. https://doi.org/10.1016/j.dhjo.2021.101212