Out of the Spotlight: Housing and Home Modifications

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Out of the Spotlight Housing and Home
Modifications

• Jon Pynoos, Ph.D.
• National Resource Center On Supportive Housing
  And Home Modification
• Andrus Gerontology Center
• University Of Southern California
• Los Angeles, CA 90089-0191
• homemods_at_usc.edu
• www.homemods.org

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Why Is The Home Environment Important?

• The Physical Environment Can Enhance Or Impede
  Ones Functional Ability And Quality Of Life
• Potential Mismatch In Fit Between Person And The
  Environment (Powell Lawton)
• Strong Preference Of Older Adults To Age In Place
• Psychological
• Familiarity
• Ties To Neighborhood

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What Are Home Modifications?

• Home Modification (HM) Refers To Converting Or
  Adapting The Environment To Make Performing Tasks
  Easier, Reduce Accidents, And Support Independent
  Living.

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Examples Of Home Modification

• Ramps And Stair Glides
• Hand-held Showers
• Grab Bars
• Roll-in Showers
• Better Lighting
• Chair Lifts
• Widened Hallways

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Most Homes Peter Pan Housing
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3 Major Problem Areas Of The Home

• Outside Steps To The Entrance
• Inside Stairs To A Second Floor
• Unsafe Bathrooms

Source HUD (2001)
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Purpose

• To Understand Why Housing and Home Modifications
  Have Been Neglected Issues
• To Analyze Why They Have Been Rising on the
  Public Agenda
• To Speculate on the Future

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Why Has It Taken So Long to Get HMs on the Agenda?

• Use Kingdons Model of Agenda Setting as a Guide
• Problem Stream
• Politics Stream
• Policy Stream

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Issues in the Problem Stream

• 1. Indicators Understanding the Magnitude of the
  Conditions
• Few Empirical Studies on the Dimension of the
  Problem
• Estimates of Unmet Need Have Varied Over Time
  From 865,000 to 14 Million

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A Complex of Problems
SourceAmerican Housing Survey, 1995
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• 2. Little Feedback From Existing Programs About
  HMs As a Problem
• HMs Considered a Small Component of Their
  Activities
• Not on Par With Transportation, Nutrition and
  Even Home Repair Services
• 3. Few Policy Entrepreneurs to Promote the Issue

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• 4. Conditions in Peter Pan Housing Are Not
  Recognized As Problems
• Lack of Consumer Awareness (Often Change Behavior
  Instead of Environment)
• Often Easier to Provide Personal Care Services
  Than Modify Homes
• False Belief That the Americans With Disabilities
  Act and the Fair Housing Amendments Act of 1988
  Solve the Problems

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Issues in the Politics Stream

• 1. Interest Groups and Organizations
• No One Individual Policy Community (e.g., Trade
  Association or Consumer Group) Owns the Problem
  or Might Benefit From Working to Solve It
• Issue Crosses Different Policy Communities
  (Housing, LTC, Aging Services, Disability,
  Rehabilitation)
• Any Savings From Addressing the Problem (e.g.,
  Long Term Care Costs) Unlikely to Accrue to the
  Program Making the Investment (Housing).

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• 2. The Service Delivery System Is Very
  Fragmented, Diverse, Uncoordinated, and Under
  Funded
• Difficulty Identifying a Service System to Solve
  the Problem
• HMs a Stepchild of Housing and Community Based
  Care, Two Different Systems
• A Patchwork System With Many Gaps
• Because HMs Not an Entitlement Competition at
  the State and Local Level With Many Other Needs
• Lack of Skilled Providers

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Issues in the Policy Stream

• Unrealistic Proposals
• National Policy on Home Modifications
• Overhaul Medicare

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Indications That HMs Are Rising on the Agenda

• Progress in the Problem Stream

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Research Indicates That HMs Are Cost Effective/
Save LTC Expenditures

• In A Controlled Intervention Study
• HMs In Combination With Assistive Devices and
  Assessment And Follow-up By An OT Reduced Health
  Care Costs And Delayed Institutionalization
• Source Mann et al. (1999)

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Research Indicates That HMs Are Beneficial

• HMs Make It Easier to Perform Tasks Such As
  Bathing
• 1. HMs Reduce Bathing Difficulty For Those With
  High Levels Of Functional Impairment
• 2. HMs, in Combination With OT Assessment and
  Follow-up, Significantly Improved Bathing Ability
  Among Frail Elderly
• Source Matsuoka Pynoos (2000) Gitlin et al.
  (1999).

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Research Suggesting That HMs May Prevent Falls

• For Example
• Cumming et al. (1999) Found Among Those With A
  History of Falls, OT Visits And Provision Of HMs
  Reduced The Risk Of Falling
• However, Gill et al. (2000) Found Weak
  Relationship Between The Presence of
  Environmental Hazards And Falls

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Research Suggests That HMs Support Caregiving

• 1. Adequate Space Can Facilitate Caregiving
• 2. HMs May Help Reduce Challenges For Dementia
  Caregivers
• Caregivers in the Treatment Groups Showed
  Enhanced Self-efficacy
• Source Newman (1985) Gitlin et al. (2001)

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Increase in Use of HMs Over Time

• Significant Increases In The Use Of Assistive
  Devices HMs Over Last Decade
• 45.3 Of Older Persons Live In Homes That Have
  Special Features
• Suggests That HMs Substitute For Personal Care
  Services, But Mechanism Unclear
• Source Manton et al. (1993) American Housing
  Survey (1995)

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Better Estimates of Need Suggest Problems are
Manageable

• One Recent Estimate 1.14 Million Elderly
  Households With At Least One Functional
  Limitation Report Unmet Need For HMs (HUD, 1999)

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Increase in Awareness

• Older Persons and Caregivers More Aware That the
  Home Itself Can Cause Problems
• Greater Consumer Information Available AARPs
  Independent Living Strategy
• Involvement of Younger Persons With Disabilities

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Indications That HMs Are Rising on the Agenda

• Progress in the Politics Stream

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Increased Involvement of Interest Groups/
Organizations

• Trade Associations Such As National Association
  of Home Builders Realize That There Might Be a
  Market in HMs
• National Home Modification Coalition and
  Blueprint for Action

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Indications that HMs are Rising on the Agenda

• Progress in the Policy Stream

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Recent Policy Strategies

• Attention at Local Level on Provision of HMs
  (e.g. CDBG)
• State Grant and Loan Programs
• Medicaid Waiver Programs Include HMs
• Income Tax Deductions for HMs

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What is Next?

• A Multi- Pronged Strategy

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Expect Continued Progress In

• Nationally-directed and Investigator- Initiated
  Research Initiatives
• Increasing Awareness Among Consumers, Policy
  Makers, and Practitioners
• Increasing Involvement of Interest Groups and
  Organizations

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Additional Strategies

• Coalition-building
• Lawsuits
• Development of a Model Visitability Law/
  Ordinance
• Coordinated Effort by Health, Long-term Care, and
  Housing Agencies
• Collect Policy and Public Expenditure Data on HMs

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Conclusion

• A Manageable Problem
• Big Benefits
• Cost-effective
• Meets Older Adults Preferences
• Growing Constituency and Movement
• Progress Will Be Incremental Through Small
  Windows of Opportunity

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