Aging in Place Home Modification Strategies Discussion

Melanie Hamilton-Basich:
Welcome. This is Melanie Hamilton-Basich, the chief editor of Rehab Management. For this podcast episode, I’m happy to be joined by two longtime occupational therapists who are well-versed in the subject of home modification for clients. Kirsten Davin, OTD, OTR/L, ATP, SMS, is a clinical assistant professor and the academic field work coordinator for Baylor University’s Occupational Therapy Doctorate Program. Bridget Scheidler, EdD, OTR, CAPS, is a Certified Aging-In-Place Specialist and a clinical assistant professor for Baylor University’s Occupational Therapy Doctorate Program. Today we will be talking about home modifications for clients, preparing for aging in place, and the education on this subject that’s available to therapists. Welcome, Kirsten and Bridget.

Kirsten Davin:
Thank you for having us. We’re happy to be here.

Bridget Scheidler:
Great to be here. Thank you.

Melanie Hamilton-Basich:
Now, Kirsten, you recently completed an article for Rehab Management on home modifications and accessibility. Why is it important as a therapist to be knowledgeable in the home modification arena?

Kirsten Davin:
I did, yes. Aging in place is defined by the CDC as “the ability to live in your own home and community safely and independently and comfortably, regardless of your age or income or ability level.” So in recent years, we’ve seen an abundance of new organizations around the globe who’ve implemented healthy aging initiatives that are designed to improve the quality of life for everyone during the aging process, and to keep them in their preferred environment. Now, the desire to stay in the home and to stay in the community that maybe you’ve been in for a number of years has been a desire of many. For example, let’s say we have a husband. He and his wife are still residing in their home that they built in the 1960s. They raised their children there, they retired there, and they’ve been there for over 60 years. There may be some strong sentimental ties to the home and to that residential area. Or take for example a wife who’s recently lost her husband. She may want to stay in the home that they shared together for a number of years.

Kirsten Davin:
Now, unfortunately, sometimes financial limitations or physical barriers or reduced social or familial support poses a challenge to achieving that goal of staying in the home. This is where occupational therapy or physical therapy or a Certified Aging-In-Place Specialist can come into play. Now, occupational therapy focuses on helping people do all the things that they want and that they need to do in their daily lives, including tasks related to work, their hobbies, their interests, social engagement, and household responsibilities as well. An interprofessional team complete with occupational therapy, physical therapy, and in some cases a contractor or construction personnel can be a valuable asset in giving someone the ability to reside safely and independently in their home. And as we go through today, we’ll talk about what OT can specifically bring to the table along with the specialty certification that Bridget will touch on in a few minutes.

Melanie Hamilton-Basich:
Why do you feel in recent years there has been a push to keep older adults within their homes and to age in place, as opposed to options that may include a nursing home, assisted living, or living with another family member?

Bridget Scheidler:
As older adults are aging and they’re making the decision to go to the nursing home or age in place, when they’re in their house, they just feel that greater independence and a greater quality of life. Their comfort is in their home. As Kirsten was saying, it’s where a lot of them raise their kids or spent their retirement years, so they have all those memories, all that happiness of pictures on the walls, their favorite La-Z-Boy chair, their bed, all those meaningful areas around the home that make it routine for them.

Bridget Scheidler:
To leave that is a struggle. It can be a loss of dignity. When you stay in the home, you do feel a higher sense of dignity along with that better quality of life. You also have the sense of the independence where you’re not going somewhere where someone else is going to have to take care of you, and that really can snowball. When you lose that dignity, it can really snowball into other areas, such as mental health and depression, so that’s why a lot of older adults are choosing to stay in their home. It’s where they are comfortable and have a better quality of life.

Melanie Hamilton-Basich:
There are many useful home modification products out there. What are some of the technologically advanced solutions that can help your clients make their homes safer and easier to live in as they age?

Kirsten Davin:
I love this question first of all, and second of all, I love the fact that I’m answering it in 2022, and not 2001 when I graduated from OT school. The reason for that is that home modification has never been easier. When I reflect on, and Bridget, you can probably vouch for this as well, when Bridget and I first started our careers in occupational therapy, in order to have what was termed at that time a smart home, it would involve significant wiring around the house. It would involve very labor-intensive, costly adaptations and updates to the home that for a lot of people, was just really not in the cards.

Kirsten Davin:
Now today, thanks to recent technological advancements, the creation of a smart home is virtually at everyone’s fingertips. If Wi-Fi is present, you can incorporate an abundance of human interface devices. Now, human interface sounds like a really big technological word, right? A human interface device is the Google Home that’s sitting on the counter in the kitchen. It’s the Alexa that we say, “Hey, Google,” ask it a question, and it answers.

Kirsten Davin:
Now, you can incorporate that with a lot of home tasks. What I mean by that is you can set up these devices, and it doesn’t necessarily have to be those two companies, of course. There’s a lot of options out there. But you can set these devices up to lock and unlock your doors, to give you reminders about your medication regimen, to adjust the thermostat in your home. You can, in many communities, order groceries, make a grocery list, pay for your groceries, all with a verbal cue to some of these devices. You can control the lighting in your home. In the ’80s, we had The Clapper. Remember The Clapper? You’d clap, clap and it’d turn your light on and off? Well, it’s a little more advanced now, but you can control the lighting in your home, opening and closing curtains and blinds, and also improve safety.

Kirsten Davin:
One of the concerns that we hear a lot of times from some older adults that are desiring to stay in their home is the safety factor. You know, “I’m not as young as I used to be. When the dog barks, I can’t hop up and run and look out the window to see who’s there.” So, you can also incorporate the use of cameras and other devices to give them better security within their home. These types of tech advancements have also given us the opportunity to provide fall notification, so there are devices out there that will tell you … well, they would probably tell a relative, “We detected a fall or a hard hit on mom’s watch. You might want to check on mom.”

Kirsten Davin:
The degree of technology that’s out there is amazing compared to what there was 20 years ago. It’s amazingly easy to implement. It’s a matter of going to your local store, getting Wi-Fi on board, picking up a few devices, and downloading some of those apps. Now these devices could be set up relatively easily, again with the use of a smartphone, laptop, or tablet, and the Wi-Fi.

Kirsten Davin:
What’s also interesting is that occupational therapists, as OTs, we look at the entire picture, right? So we look at the home, we also look at social engagement, access to healthcare, all those components as well. With the use of these devices, you can incorporate the use of video calls, so if that family member has a sister who is 10 states away, or a neighbor who’s right next door and they just want to check in every morning, the use of video calls or talk-to text features can make that very easy as well, along with access to healthcare. There are some telehealth platforms that the individual could use to be able to access physicians, rather than having to transfer to the car, find someone to take them, or find a service to take them to the doctor’s appointment, and so on and so forth. Some areas of their medical care can be addressed on a telehealth component more than likely.

Bridget Scheidler:
Kirsten, you made me go down memory lane with the technology advancement when you were talking about when we graduated. I remember doing the smart home tour in my master’s OT class, and it was just like, “Wow.” But it was so high tech, you did think, “Who can afford this?” And this week on a Facebook marketplace Letgo app, I saw a new device I had never seen before, a medication management device that had a video installed in it that was for mild cognitive impairments that would dispense the medicine and alert the loved one if their loved one, their parent, their sibling, did or did not take their medicine. I mean, so, cliche as it sounds, technology is growing exponentially and becoming so much more affordable.

Bridget Scheidler:
And I even remember those simple Life Alerts where clients, older adults, couldn’t wear them in the shower, and now they’re waterproof. So even something as simple as that is becoming waterproof in the shower. It’s so important, and the range they have. So, the amount of technology that’s helping older adults keep that dignity in the home is growing every day.

Kirsten Davin:
I always enjoyed the irony of that. The most dangerous place in the home is where you could not take your Life Alert button.

Bridget Scheidler:
You want to go down that road? Because that’s a long conversation.

Melanie Hamilton-Basich:
Thank you for going over some of the technological advancements that can be used to modify the home. Are there cost-efficient products or concepts that can also be implemented to help your clients be able to stay at home?

Kirsten Davin:
Sure. In addition to the tech-based options that we talked about above, and again, compared to what they used to be, they are relatively cost-effective. But there are also so many simple adaptations that can be made in the home that really, it’s beneficial to have an occupational therapist on board because we oftentimes see the home through a bit of a different filter. When we walk into a room, we are kind of programmed to look for safety factors and convenience factors and home efficiency factors and energy conservation options that may be in there. Some very simple adaptations that can be implemented could be to incorporate brighter lighting. I’ll talk more about that in just a second. Some home organization techniques, including the placement of the most frequently used items in an easy to reach location.

Kirsten Davin:
Take, for example, the difference in being able to work in a room that has poor lighting versus adequate lighting. Now consider that you are an older adult, possibly with some compromised vision. As we age, we have some vision changes. Now let’s say you’re in a fairly dimly-lit room and you’re trying to identify the difference between the two very small pills that are sitting in your hand, right, or the two small pill bottles along with the 12 other pill bottles that you have that you are trying to read the label on. So something that is oftentimes overlooked, which can be as simple as changing a light bulb, or having a light bulb changed, is the lighting. When you walk into the hardware store, if you walk down the lighting aisle, they now have displays where they’ll have four or five different light bulbs in those little compartments, and one is a daylight and it’s super bright, like surgical room OR type of bright. And then there’s soft white, which is a little bit easier on the eyes, in my opinion.

Kirsten Davin:
But we can work with a client and decide what works best for them. So in some rooms, in some situations, maybe over the counter where they do their medication regimen, maybe that’s an area for that daylight bulb where it’s a really bright surgical-type quality white light to allow them to see that contrast, and to see maybe the coloration of the pills or to identify them better. And then maybe in a different area of the home, a different type of lighting would be beneficial as well.

Kirsten Davin:
Some other cost-efficient modifications could include the simple implementation, and this is probably literally $4 or $5 at a hardware store, texture strips in the bathtub that you can place in the tub that will prevent slippage. And it sounds like little menial things, but it can mean the difference between a fall and remaining safe, and that can mean the difference between remaining in your home and having to look at another option.

Kirsten Davin:
You can very easily pick up showerheads, or handheld showerheads to conserve energy. If you are utilizing a wheelchair, I’ll refer to my seating background here, but if you’re using a wheelchair, many times the wheelchair is very close to the size of the door, and unfortunately, sometimes it’s a little wider than the door. So if you’re looking at a doorway and you’re looking at the chair and you’re thinking, “Okay, this is going to be really, really close,” a very simple, actually a free adaptation, if it’s a room that … if it would work for that room, you can simply have the door taken off. That would buy them another inch and a half in that doorway. So, there are some very small things that we can do on a limited budget or on no budget that will allow them to be a little more independent.

Kirsten Davin:
Now, sometimes there are some larger-scale modifications that are necessary, and that’s the case sometimes. If that’s the case, there are quite a few programs in place which can assist financially if needed. Now, some states have a non-Medicaid, a state financial assistance program, which is specifically designed to help older adults who are living in their homes. There are some grant options and some loan options that are out there to help with assistive devices, durable medical equipment, and home modifications, should that be needed. Some states have programs that are called Nursing Home Diversion Programs, and the goal of that is to offer money to help with home renovation to keep individuals in their homes as well.

Bridget Scheidler:
Kirsten, you made me laugh talking about those texture stickers. I have been in so many bathtubs-

Kirsten Davin:
[inaudible 00:16:34]

Bridget Scheidler:
… putting them in. I remember I had one wonderful older lady who wanted to take a bath. She did not want to do a shower in a shower chair. She wanted to have her biweekly baths, so we did that. I put those texture stickers down. We put the grab bar. We had a handyman from her church install a grab bar, and we worked on those safety transfers so she can keep that independence and that quality of life that she really held dear in taking those warm baths. And it’s beautiful to work with the interprofessional team of handymen, contractors, interior designers with the lighting. And OT brings to the table just understanding that mind-body connection as you were talking about so much in that we understand not only what’s going on in the body with lighting, but possibly the mind and the disease progress, so how it progresses.

Bridget Scheidler:
A lot of individuals might just look at the right now. Well, what’s going to happen a year from now, two years from now, five years from now? Do you want to spend that $100, that $20,000, for the right now? Or do you want an OT to come in and help you spend that money most effectively for a longer quality? And we were talking about medication management [inaudible 00:18:03] and if you don’t have that money for that device I was talking about that helps you, the OT comes in and understands the vision that you were talking about, identifying pills, and the possible cognitive impairment of why you can’t manage these five, six pills, and comes in with these low-cost solutions, whether it be signs, different labeling, to help the older adults age in place and keep that independence.

Kirsten Davin:
I had a flashback when you were talking about the texture strips, so remember the shapes? You could get sea shell shape, you could get fish shape, you could get all the different options.

Bridget Scheidler:
I’d sometimes show my clients, “Which ones do you want? Do you want the colorful fish ones?”

Kirsten Davin:
Yes, of course.

Bridget Scheidler:
“The white ones that will blend in a little bit more?”

Kirsten Davin:
Of course.

Bridget Scheidler:
“Or flowers?”

Kirsten Davin:
Something else to think about too, I’ve had this experience before where I’ll go into a home and make recommendations and the wife is 100% on board, “Great, when can we start? Let’s swap this out. Let’s do this. This looks great.” And the husband is an absolute no. So as we’re talking about this, and if you’re out there listening, think about, for lack of better term, the marketing of this. And I don’t mean marketing as product marketing, I mean marketing as, if you have two individuals living in a home and one says, “Great, let’s go,” and the other one says, “You’re not touching my house and we’re not doing any changes. This is the way it’s been since 1964 and I’m not changing anything,” how are we going to present that? And how are we going to work with that? And how are we going to show them and demonstrate to them that this is, in our opinion, a safer route that will keep them in their home longer? So, keep that in mind as we discuss some of the options today, because sometimes you will get pushback.

Melanie Hamilton-Basich:
You bring up some great points. As OTs are thinking about where these changes need to be made and how they can convince homeowners to change them, when considering home accessibility or safety, what are the most dangerous places in the home?

Bridget Scheidler:
Oh, well, honestly, the bathroom is where most falls do occur for older adults and is potentially the most dangerous room in the home for other factors besides falls. It’s medication management also occurs in there. But the kitchen also holds its own challenges, and so those are two areas that OTs do tend to concentrate on highly are the bathroom and the kitchen.

Bridget Scheidler:
In the bathroom, we’re wet, we’re slippery, we’re naked. We’re climbing over bathtubs. We’re sitting down on low toilet seats. We’re reaching under cabinets for towels and toiletries. We’re reaching high. And that twisting and body mechanics also occurs so often in the kitchen too. I believe Kirsten was mentioning this earlier, is just one of the low-cost adaptations for aging in place, it’s placement of where you put everything, within reach, so you don’t have that fall risk. And you have so many different adaptations to decrease the fall risk in the bathroom, such as the shower chair we mentioned, those texture strips. You can raise toilet seats.

Bridget Scheidler:
One of my favorite adaptive equipment to recommend is a bidet. I mean, the twisting of bowel movement management and all the injuries that can occur from that versus pushing a button can be a huge difference. And again, I know I keep on going back to it, but just that dignity. So, that’s one of my favorite products to recommend.

Bridget Scheidler:
And also the throw rugs. I mean, the different floor textures in both the bathroom and the kitchen, those are two places where you do have a lot of throw rugs. And so that’s what an OT will come in and see, are you walking with an adaptive equipment, with a cane, a walker, a wheelchair? Or do you have a trip hazard with them? Where are you putting them when you’re going to the bathroom and showering and cooking? And are the rugs safe? Sometimes you do want to step on a dry area when you get out of the shower or the bathtub, so you want to make sure it’s a non-stick throw rug to put there.

Bridget Scheidler:
And then I’m an advocate of removing any unnecessary rugs for tripping, but as Kirsten was saying, sometimes you have to kind of pick your battles with clients, and what’s going to keep them the most safe. Those walk-in tubs are very popular, and until I had a client get one … They’re that kind, you open a door and you walk into them and you sit down? One client said she was so upset she spent the money on it because she had to sit there in the cold while the water drained. So, just having that experience and knowing what to tell your clients if the product is good for them, and that client-centered care that OTs can offer, is really helpful to decrease the dangers of falls and other risks associated in the home.

Kirsten Davin:
Yeah, Bridget, you alluded to that tough sell sometimes. The bidet is oftentimes a tough sell for someone who’s never used it and isn’t familiar with the benefits.

Kirsten Davin:
Another easy adaptation that you can incorporate into the kitchen and bath, Bridget, like you were mentioning, was sometimes if a homeowner, or if the individual in the home, has some sensation limitations, a very common injury can occur from just a water heater that’s set up too high. So if you have a water heater that is heating water to the point where it can cause a burn if it is turned up too high, that’s a free and easy adaptation to make. It’s a simple turn of a knob on the water heater to bring that temperature down to ensure that degree of safety, at least from that aspect as well.

Bridget Scheidler:
Yes, and as you made me think about what you were talking about earlier is OTs also think about social engagement. So, the older adults living in the home aren’t the only people visiting the home. Sometimes it can be their children, their grandchildren, and if they’re bathing their grandchildren, that hot water temperature is another safety factor to consider. So, you also have to think about all the other individuals that are coming in and out of this home, with child safety locks on doors or on the oven handles, so you do have to think about the whole picture.

Melanie Hamilton-Basich:
For a therapist who may be interested in further looking into the world of home accessibility, home modification, or aging in place, how can they gain additional information or education to learn more about all these things you’ve been talking about?

Bridget Scheidler:
Great question. One certification that I have is a Certified Aging-In-Place Specialist that you mentioned at the beginning, and that is a certification through the National Association of Home Builders. It’s a three-day course, at least it was when I went in 2013. I think it still is. And when you’re sitting there, you’re sitting with contractors and interior decorators, so not just healthcare providers, and it’s a beautiful place to learn from one another.

Bridget Scheidler:
And then at the end of those three days, you do take an examination, and they’re required to keep up a certain number of continuing education hours every three years. So, whether you have your CAPS certification or not, there are an abundance of continuing education opportunities that you can take virtually or in person to continue to learn about the latest and greatest in home modifications and what different options are out there. There’s also conferences you can go to for a lot of the fun high tech ideas that are out there, or how to incorporate some low tech with the high tech. Whether you want to become CAPS certified or not, there are a lot of options out there to continue your education if you’re going to be working with this population and helping them age in place successfully.

Kirsten Davin:
Another option that’s out there, and what I hold my specialty certification in, is wheelchair seating and positioning. And while that doesn’t directly correlate with home accessibility and home modification, it absolutely plays a role, because in order for someone to be mobile within the home, we have to ensure that the equipment that we’re recommending is going to work within their home environment. So, if you are interested more on the seating and positioning side of it, you can look into RESNA, which is the Rehabilitation, Engineering, and Assistive Technology Society of North America. Their website is resna.org, and they offer two certifications, the Assistive Technology Professional Certification, and the Seating and Mobility Specialist Certification. And again, not as direct of a connection with Bridget’s CAPS certification, but also plays a role in terms of home mobility.

Bridget Scheidler:
It does, and as we were talking about the disease progression, when an older adult might be not with a device right now, but they might have a progressive disease where you know a wheelchair’s going to be needed down the road, or even for a short period of time, if they suffer a broken hip or a broken femur. So, to consider that with home modifications, the wheelchair adaptation is highly, highly useful in that.

Melanie Hamilton-Basich:
Thank you so much, Kirsten and Bridget, for sharing your expertise and insights with us, and thank you to our listeners. Be on the lookout for more podcasts from Rehab Management, Physical Therapy Products, and the rest of the MEDQOR podcast network wherever you listen to podcasts. For more great content from Rehab Management, including articles written by Kirsten Davin, visit us online at rehabpub.com. And while you’re there, subscribe to the publication and to our newsletter.