Universal Design, Home Modifications and Coalition Building

Florida Occupational Therapy Association Annual Conference

November 2-3, 2012

Margaret Christenson, MPH, OTR, FAOTA Lifease, Inc.

Carolyn Sithong, MS, OTR/L, CAPS, SCEM Home for Life Consulting and Design

The Occupational Therapy Practitioner ‘s Role in Promoting Universal Design, Home Modifications

and Coalition Building

The following presentation will:

1. Describe the opportunities for coalition building with other

organizations in the community and the unforeseen benefits for the

Occupational Therapy Practitioner.

2. Discuss articles citing evidence based practice in home

modifications and the outcomes in relation to community health.

3. Discuss Universal Design and where these components can be

included in the home.

4. Illustrate what changes need to be made in the design of a home to

accommodate a client

Understand Needs of Community • Healthcare is moving more and more into the home

• Increase in home and community-based services

• 1 in 4 people will be over 65 in the year 2020

• Most homes that people live in do not accommodate long term living

• Falls is the leading cause of death among seniors and most occur at home

• Issues facing older adults

• Alzheimer’s disease- Disease of the baby boomers

Silver tsunami

What Seniors Want Fixed to Stay, AARP 2001 • Over 80% of seniors want to

stay in their home for as long as possible, even if they need to receive healthcare or assistance

• Only 1 in 6 homes have made the changes necessary to support that desire

• Comfortable, home-like and hi-tech environments

Costs of Long Term Care

• Semi-Private Nursing Home

– $80,000 year

• Assisted Living Facility

– $ 40-60,000 year

• In-Home Care 24/7

– $30,000 year

What Else Are Baby Boomers Concerned With?

• 25% affordable healthcare

• 18% want to remain productive and useful

• 13% providing healthcare needs for self or spouse

See the Need, Fill With OT

OT

Community Partners

Solutions for

Community Health

The beliefs that guide your service delivery

• OT philosophies of practice

– Increasing independence in ADLs

– Promoting quality of life

– Addressing areas of work, self-care and leisure

– Client-centered, occupation based

– Evidenced-based practices

– AOTA Framework

Recommendations Based on Findings: Putting It All Together

Environment

Occupation Person

Law et, al. 2003, Baum and Christiansen,1997

Patient/Occupation Assessment Tools to Consider

• Canadian Occupational Performance Measure (COPM)

• Occupational Performance History Interview (Kielhofner, et. al., 1997)

• In-Home Occupational Performance Evaluation (I-HOPE) (Stark,S. et. al., 2010)

• Kohlman Evaluation of Living Skills (KELS, 3rd edition)

Assessment Tools-Environment

• SAFER- HOME Tool

• West Mead Home Safety Assessment

• Home Falls and Accident Screening Tool (HOME FAST)

• Home Environmental Assessment Protocol (HEAP)

SAFER-HOME TOOL

Safety Assessment of Function and the Environment for Rehabilitation

Health Outcome Measurement and Evaluation

Categories of Assessment • Living Situation • Mobility • Environmental Health • Kitchen • Household • Eating • Personal Care • Bathroom and Toilet • Medication, Addiction and Abuse • Leisure • Communication and Scheduling • Wandering

Scoring

Bathroom and Toilet

No Mild Moderate Severe

Bath/shower method X

Bath/shower transfers X

Bath/shower grab bars X

Non-slip aids X

• No identified problem (0) • Mild- 1-33% chance of negative consequences (x1) • Moderate- 34-66% chance of negative consequences (x2) • Severe- 67-100% chance of negative consequences (x3)

What Does Research Say?

Prevention of falls and subsequent injuries in elderly people: a long way to go in both research and practice Dr. Pekka Kannus and Dr. Karim M. Khan CMAJ • September 4, 2001; 165 (5) © 2001 Canadian Medical Assoc. The environmental intervention was found to have had little effect on the

cumulative number of falls, the likelihood of participants having at least one fall during the 12-month follow-up period or the mean number of falls per person, although it is of interest that all the between-groups differences favored the intervention group. In addition, when the data for individuals who had had 2 or more falls within 3 months before study entry were analyzed separately, an individual in the intervention group was significantly less likely to fall and had a significantly longer time between falls than her or his counterpart in the control group. In the efficacy analysis, individuals in the intervention group who adhered more closely to the fall-prevention recommendations had fewer falls per person than those who adhered less closely to the recommendations

Gait and Balance Assessment

Haines et al (2007) Balance Impairment Not Predictive of Falls in Geriatric Rehabilitation Wards, Journal of Gerontology, 63:5

Background. Falls are common among hospital inpatients, particularly in rehabilitation wards. Standing balance impairment is widely held to be a contributing factor to falls, is a component of several falls risk screening tools, and has motivated the development of balance retraining programs for the reduction of in-hospital falls but little rigorous investigation of the link between standing balance impairment and in-hospital falls has been undertaken.

Methods. We identified optimal cut-off points of four commonly used balance measures (functional reach, Timed Up and Go, step test, and timed static stance) in a prospective multicenter cohort study. Admission data (n = 1373) were clustered and matched by center then randomly allocated to development and validation data sets. Results. Optimal cut-off points for each test were identified from the development data set. The predictive accuracy of all four balance tests was poor when the optimal cut-off was applied to the validation data set (Youden Index scores ranged between 0.02 and 0.15). Conclusions. These findings do not support an association between admission standing balance and falls in a geriatric rehabilitation setting. This result has implications for content of falls risk screening tools and interventions to prevent falls in a geriatric rehabilitation population.

Effectiveness of Assistive Technology and Environmental Interventions in Maintaining Independence and Reducing Home Care Costs for the Frail Elderly William C. Mann, OTR, PhD; Kenneth J. Ottenbacher, OTR, PhD; Linda Fraas, OTR, MA; Machiko Tomita, PhD; Carl V. Granger, MD Arch Fam Med. 1999;8:210-217. Context Home environmental interventions (EIs) and assistive technology (AT) devices have the potential to increase independence for community-based frail elderly persons, but their effectiveness has not been demonstrated.

Objective To evaluate a system of AT-EI service provision designed to promote independence and reduce health care costs for physically frail elderly persons.

1

Reduced Costs

Intervention All participants underwent a comprehensive functional assessment and evaluation of their home environment. Participants in the treatment group received AT and EIs based on the results of the evaluation. The control group received "usual care services.“

Results After the 18-month intervention period, the treatment groups showed significant decline for FIM total score and FIM motor score, but there was significantly more decline for the control group. Functional Status Instrument pain scores increased

significantly more for the control group. In a comparison of health care costs, the treatment group expended more than the control group for AT and EIs. The control group required significantly more expenditures for institutional care. There was no significant difference in total in-home personnel costs, although there was a large effect size. The control group had significantly greater expenditures for nurse visits and case manager visits.

Conclusion The frail elderly persons in this trial experienced functional decline over time. Results indicate rate of decline can be slowed, and institutional and certain in-home personnel costs reduced through a systematic approach to providing AT and EIs.

2

Evaluating the cost-effectiveness of fall prevention programs that reduce fall-related hip fractures in older adults. Frick KD, Kung JY, Parrish, Narrett MJ Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA. kfrick@jhsph.edu J Am Geriatric Soc. 2010 Jan: 58(1):136-41.

OBJECTIVES: To model the incremental cost-utility of seven interventions reported as effective for preventing falls in older adults. DESIGN: Mathematical epidemiological model populated by data based on direct clinical experience and a critical review of the literature.

MEASUREMENTS: The last Cochrane database review and meta-analyses of randomized controlled trials categorized effective fall-prevention interventions into seven groups: medical management (withdrawal) of psychotropics, group tai chi, vitamin D supplementation, muscle and balance exercises, home modifications, multifactorial individualized programs for all elderly people, and multifactorial individualized treatments for high-risk frail elderly people. Fall-related hip fracture incidence was obtained from the literature. 1

RESULTS: Medical management of psychotropics and group tai chi were the least-costly, most-effective options, but they were also the least studied. Excluding these interventions, the least-expensive, most-effective options are vitamin D supplementation and home modifications. Vitamin D supplementation costs less than home modifications, but home modifications cost only $14,794/quality-adjusted life year (QALY*) gained more than vitamin D. In probabilistic sensitivity analyses excluding management of psychotropics and tai chi, home modification is most likely to have the highest economic benefit when QALYs are valued at $50,000 or $100,000. CONCLUSION: Of single interventions studied, management of psychotropics and tai chi reduces costs the most. Of more-studied interventions, home modifications provide the best value. These results must be interpreted in the context of the multifactorial nature of falls.

*QALY: Quality-adjusted life year A measure of disease burden, including both the quality and the quantity of life lived. It is used in assessing the value for money of a medical intervention. *The QALY is based on the number of years of life that would be added by the intervention. Each year in perfect health is assigned the value of 1.0 down to a value of 0.0 for death. If the extra years would not be lived in full health, for example if the patient would lose a limb, or be blind or use a wheelchair, then the extra life-years are given a value between 0 and 1 to account for this.

Evidenced-Based Practices

• Person-Environment approach produces best outcomes

• Seniors respond best to education via face-to-face

• Modification implementation is best when coming from a health professional like an occupational therapist

• Better functional outcomes when considered alone in the research

• When used in conjunction with vision screening and exercise, falls among older adults are reduced

• Decreased perceived level of difficulty with ADLs when modifications were implemented

• Home safety assessments implemented by OTs prior to discharge, reduced the number of long-term care placements

Partners for Implementation

Home Builders

Community Based Services

Medical Professional

Client

• Medical professional or social worker who works and is an expert in senior care and senior health

• Community-based services, like occupational therapists who are specially certified in environmental modifications. DME providers, Aging in Place Professionals , home modification services like Rebuilding Together

• Home builders are becoming more a part of our senior provider market place. CAPS professionals can help you determine their ability to be able to serve your clients

• How can you learn more about these partners?

Building Coalitions

• AOTA, AARP, HBA 1. Create consumer demand for remodelers who

understand aging in place concepts

2. Understand the benefits of partnering with OTs to better meet the needs of homeowners who wish to age in place

3. Learn the marketing language that speaks to seniors who are considering aging in place remodeling

4. Learn the importance of individualized customization in the aging in place market

Potential Partners

• Local health foundations

• Agencies on Aging

• Hospitals

• Non-Profits (Rebuilding Together)

• Department of Elder Affairs

• Home Builders Association

• Fire Departments

Ideas for Building Relationships

• Opportunities for education

• Networking events

• Speaking engagements

• TV/Radio interviews

• Opportunities for research

• Volunteer (AARP Home Fit)

• Health Fairs

Home Fit Workshop

Information and Tips for a Comfortable, Safe and Livable Home

Take care of the

NOW

Look toward the

FUTURE

“Being an occupational therapy

practitioner is more than being a

clinician.” It is about scanning your

environment and determining how your

present skills, combined with clinical

knowledge, can meet the needs of a

population,”

Y Yeung (2003) Educating Older Adults in

AT, OT Practice, 8(15)12-15

As you are scanning the environment

put on your “UD Glasses” Bill Owens, Contractor

Who is this?

Universal Design

“Hidden in plain sight”

Universal Design

It is an approach to the design of products, services and environments to be usable by as many people as possible regardless of age, ability or situation. It links directly to the political concept of an inclusive society.

The term Universal Design (UD) was coined by Ron Mace when he was on the faculty at North Carolina State University (NCSU). Dr. Mace defined UD as: “The design of products and environments to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design.”

Universal Design is the human-centered design of everything with everyone in mind.

This manual “A

Practical Guide to

Universal Home

Design” was

produced by

Seniors Agenda for

Independent Living,

Saint Paul,

Minnesota with

support from the

Minnesota

Department of

Human Services.

Universal Design Umbrella

Think of Universal Design as an umbrella and

design products and spaces to envelop as many

individuals as possible, we can widen and extend

the scope of the product or environment to allow an

increased number of users.

Approaches to Design

Being Proactive Not Reactive

(Done before the need arises)

Safety and Fall Prevention Essential

These components are a part of

Universal Design

One way of Getting Involved

Patio

Front Door

Back Entrance

Solar Tube Skylight

www.solatube.com

Back Entrance to Garage

Automatic Door Opener

www.beyondbarriers.com

Ramp in Garage and Back Door

For vertical transitions up to 3“: “SAFEPATH”

www.vanduerr.com

Floors, Door Handles, Switches and Outlets

40” to 44”

15” to 24”

Lever Door Handle

Openness

Living and Dining Area

Table leaves with

no apron

Kitchen

Kitchen

Kenmore Appliances

Kitchen

Kitchen

Delta Pull-out Kitchen Faucet www.delta.com

The microwave is

placed on a shelf

above the

dishwasher. This

location allows the

ambulatory client to

be able to see into

the microwave.

If the client were in a

wheelchair, the

microwave would be

placed on the

counter or be

installed below the

counter level.

Raised

Dishwasher

This dishwasher

is eighteen inches

from the floor.

The 18 inch height allows the client to load and unload both racks

without bending. This height also works for someone in a wheelchair.

Raising the dishwasher must be evaluated carefully since the

wheelchair user needs counter space next to the sink as well. This

kitchen provides that type of arrangement.

China Cabinet

Before

After

After

Back Bedroom and Bathroom

Window Treatments

www.hunterdouglas.com

DEN

HALL

BE

DR

OO

M

2nd Bathroom Shower

Dam

The client’s neuropathic

shoulder condition

required several

modifications. Initially,

the shower control was

placed too high. This

was corrected.

The contractor was very involved in the decision making process. The

selected shower seat did not have a grab bar. A floor mounted bar was

added and an additional bar was cut off and placed under the left front

corner of the shower seat as an additional support for this 325 lb.

man.

Initially a hand held

shower was

included. However,

for this client with his

shoulder issues, the

location of a shower

nozzle overhead is

preferable.

A sun room near the great room houses multiple plants. The watering

wand makes it possible for the client to care for these plants.

A potting sink was installed in the sunroom. The 50 ft. lightweight

coiled hose with watering wand was attached to the faucet.

Laundry

Side-by-Side Washer and Dryer www.sears.com

In the laundry, strip lighting placed under upper cupboards provides

supplementary lighting.

The dryer is

raised by placing

it on an eighteen

inch platform

making it much

easier to load

and unload the

dryer

A table has been placed in front and to the left of the dryer and a

clothes basket placed upon it. This allows the client to easily load and

unload the dryer.

Master Bedroom and Study

Master Bathroom

Grab bars

Grab bars replace towel bars

Grab Bars used as Towel Bars

5 foot min.

5ft.Turning

As much as 7 ft.

Master Bathroom

Shower Chairs

Roll-in

Shower

The grout lines

between

2.25-in. x 2.25-

in. unglazed

bathroom floor

tile form

natural nonslip

properties.

UD PRODUCTS

Invisia Grab bar Collection www.invisiacollection.com

Kenmore Elite 30 in. Slide-In Electric Range: www.sears.com

Kenmore TRIO™ Side by Side Bottom Freezer

French Door Refrigerator www.sears.com

Kenmore Side by Side Washer and Dryer www.sears.com

Automatic Door Opener www.beyondbarriers.com

Delta pull-out Kitchen Faucet www.deltafaucet.com

Hard rubber transition ramps www.vanduerr.com

Rocker Light Switches www.leviton.com

Solar Tube Skylight www.solatube.com

Window Treatments www.hunterdouglas.com

Shower Dam www.adaptmy.com

Questions?

Discuss how you would modify

the following home for

two different individuals.

one is a Quadriplegic

and the other has

Multiple Sclerosis.

The Cottages of

Silver Lake

Front Door

Front Door

Wall Switches and

Outlets

Door to

Garage

Back Bathroom

Model

Kitchen

Kitchen

Counter

Laundry

Model

Bedroom to Master

Bathroom

Bathroom to Master

Bedroom

Model

Master Bathroom

Master Bathroom

How would

you modify

this design

for Corey

who is a

quadriplegic

?

Look at Your Floor Plan

and determine, what

other things do you need

to know?

How would you modify

this plan for

Diane and Jerry?

She has

Multiple Sclerosis.

This couple is very

realistic about the

possibility Diane may

need more assistance

in the future.

Residence for Donna and Joe – She has Multiple

Sclerosis

csithong@homeforlifedesign.com

www.homeforlifedesign.com

Margaret Christenson, MPH, OTR, FAOTA

Lifease, Inc. 2039 Osprey Woods Circle

Orlando, FL 32820 651-338-7651

www.mclifease@aol.com