BMC Health Services Research, 4(28). Rather, there is a fragmented system of social service, health service, and construction providers that varies not only by state, municipality, and organization but also by the client’s point of entry. However, educating the range of professionals involved in home health interventions, including health care professionals, social service personnel, and workers in the building industry will require policy change not only at the level of the professional organizations but also at the regulatory level. Its goal is to lay the groundwork for a thorough integration of human factors research with the design and implementation of home health care devices, technologies, and practices. supports all types and levels of ability. In addition to provider and payer issues, a large number of other confounding contextual factors impact decisions. The model suggests that the disabling process is the dislocation of an individual from his or her prior integration in an environment due to increasing needs relative to the environment. Berkeley: University of California Press. Tinetti, M.E., Richman, D., and Powell, L. (1990). Vance, A. Available: [accessed June 2010]. (1997). However, many local zoning ordinances restrict cohabitation by unrelated adults or control multifamily housing (i.e., more than one kitchen) in many communities. In so doing, UD, unlike accessible design, makes access the norm, rather than the exception. Nursing Leadership, 19(1), 44-55. While the barriers to residentially focused environmental interventions are numerous and varied, they can be traced back to the origins of federally funded health and housing subsidies, which were designed to operate as separate systems, each achieving separate public goods. The field of mind-body studies includes research on the relationship between our surroundings and our health. Patients’ perspectives on high-tech home care: A qualitative inquiry into the user-friendliness of four interventions. private individuals, limiting their availability as demonstration homes on a long-term basis. Wahl, H.-W. (2001). (2001). Home modifications: Improvements that extend independence. Similarly, agencies that pay for modifications often introduce system bias by requiring assessments that adhere to their guidelines and result in recommending only interventions that will be reimbursed. It is therefore important to remember that any products and technologies that are brought into home, regardless of their purpose, should be residential in appearance and tailored to meet the personal needs and tastes of the users. Gerontologist, 45, 389-398. Physical and Occupational Therapy in Geriatrics, 20(2), 43-55. These include cohort studies of assistive technologies, evaluations of environments in use (e.g., postoccupancy evaluations), and case study evidence from practice that benefitted from programs that were already implementing environmental interventions. It includes a measure of ability under standardized conditions (e.g., turn on a light switch, open a drawer, and turn a doorknob); activity-related problems (e.g., going up steps and stepping over the side of a tub); and detailed measures of activity-relevant environmental attributes, such as the number of steps and the height of the tub. Health problems related to the environment are complex and develop for a variety of reasons, including how likely a person’s genes are to develop a disease or condition (scientists call this genetic susceptibility). Delivery of high-tech home care by hospital based nursing units in Quebec: Clinical and technical challenges. Los Angeles: National Resource Policy Center on Housing and Long Term Care. As a result, the field is dominated by studies of convenience. Pynoos, J., Angelleli, J., Tabbarah, M., and De Meire, M. (1996). If, like health benefits, cost benefits are consumer driven, they can involve a number of factors, such as added value, aesthetic value, functional value, and emotional value. Like other technologies, there will be issues with the design of sensor networks that fit unobtrusively in the home environment (e.g., visibility of packaging and antennas), are easy to install and maintain, and are integrated with each other and with other home technology systems. Archives of Family Medicine, 8, 210-217. Enabling home environments. As a result, there are few published cohort studies that have described and compared the types of UD interventions used by people within and across user groups or have evaluated the effectiveness of specific ones in meeting needs across individuals. In addition, for people with vision loss, it is important to control glare by using sheer curtains or translucent shades (as opposed to metal miniblinds that reflect light) to buffer bright sunlight and reduce dark-light transitions between rooms. Share a link to this book page on your preferred social network or via email. This concern is particularly relevant in the current health policy context (Coyte and Young, 1997), in which high-tech home care is increasingly seen as a quick solution to budgetary constraints and a growing elderly population. Raleigh: North Carolina State University. Securing a traditional loan is always an option. While the number of potential mediators is large, cost is by far the most common and most influential. Scheschareg, R. (2006). While health programs and housing programs in the United States operate independently of each other, the needs of individuals would suggest they should not. Home builders’ attitudes and knowledge of aging: The relationship to design for independent living. Exposure to environmental noise, mainly noise produced by leisure activities, accounts for about 3% of debilitating tinnitus. However, it is not clear who benefits. (1999). (2006). The residents of those cities have certainly changed the physical structure of their communities over the past centuries in countless ways. Mineral Resources: The crust of the earth is full of various mineral resources. Sanford, J.A., Jones, M.L., Daviou, P., Grogg, K., and Butterfield, T. (2004). Lau, D.T., Scandrett, K., Jarzebowski, M., Holman, K., and Emanuel, L. (2007). However, unlike clinical drug trials, there are rarely prescribed dosages of environmental attributes that can be varied and tested for efficacy, safety, and level across individuals. On October 1 and 2, 2009, a group of human factors and other experts met to consider a diverse range of behavioral and human factors issues associated with the increasing migration of medical devices, technologies, and care practices into the home. 277-303). Gerontologist, 47(6), 830-837. Nonetheless, with the Americans with Disabilities Act and its mandated accessibility guidelines clearly forging the way (although it has no jurisdiction in home environments), accessible design is inextricably tied to U.S. civil rights legislation. Housing modification needs of the disabled elderly: What really matters? In a recent article in the New York Times, Ashlee Vance (2009) paints a grim portrait of the reimbursement system as a process so invested in the medical model that specialized medical devices and equipment are preferred over universally designed everyday designs, even when the latter are less expensive, work better, and are preferred by the user. Regular maintenance and upkeep of a home, particularly for individuals who are in poor health or have functional declines, may become unmanageable or unaffordable (Lawler, 2001). Health determinants are the biomedical, genetic, behavioural, socio-economic and environmental factors that impact on health … Projection of chronic illness prevalence and cost inflation. Register for a free account to start saving and receiving special member only perks. Unpublished doctoral dissertation, Oregon State University. In fact, less than one-fourth of home modifications are paid for. Disarmed complaints: Unpacking satisfaction with end-of-life care. Birren and K.W. Gitlin, L.N. Fostering adaptive housing: An overview of funding sources, laws and policies. In addition, there is a need to continue to pull together the research that has been done (e.g., Wahl et al., 2009) and to identify the types of research designs that can be appropriately undertaken to answer relevant human factors questions, including: (a) benchmarking of environmental effects on ADLs, health, and injury; (b) environmental impacts based on individual and subgroup differences; (c) effectiveness of specific environmental interventions as they relate to home health; and (d) barriers to and facilitators of social participation. Finally, to ensure that the appropriate and relevant environmental factors are being examined in contextually meaningful ways, it is of utmost importance that experts in environmental assessment, analysis, and intervention are involved in these research efforts. Treatment technologies commonly found in the home are often large pieces of equipment that are used to provide a variety of therapies and to assist bodily functions, including assistance in breathing, medicine delivery, body function, and suction (see Chapter 8). Mace, R.L., Hardie, G.J., and Place, J.P. (1991). Environmental hazards and the risk of nonsyncopal falls in the homes of community-living older persons. For example, in Philadelphia, the local AAA, the Philadelphia Corporation for Aging, provides an extensive in-home modification and repair service from assessment to implementation. Using telerehabilitation to identify home modification needs. In contrast, environmental facilitators reduce barriers and have positive impacts on functioning of individuals and their caregivers. Research is still needed to identify the best methods of service delivery; adequacy of training; types of interventions that work for whom, where, and when; environmental impacts of various interventions; value added by UD; and effectiveness and cost benefits of interventions for care recipients, care providers, and society. Mobility in the Home. Social impacts on health are embedded in the broader environment in which we live. Perspectives of key stakeholders. In addition, several universities, including the University of Southern California and Georgia Institute of Technology, offer certificates for online programs. 298-337). (1997). Social Science and Medicine, 58, 177-192. To increase safety and mobility, sufficient space should be available at the toilet, bathtub, shower, and sink for mobility aids and caregiver assistance. Gitlin, L.N., Winter, L., Corcoran, M., Dennis, M., Shinfeld, S., and Hauck, W. (2003). Like assessments and service programs, home modifications are delivered by a variety of professions. To reduce injury and facilitate caregiver assistance, a number of products and devices have been developed to make moving around the home and transferring easier, safer, more efficient, and more dignified, both for the care recipient and the caregiver (see Chapter 8). (2010). Differences between medical and social models have important implications for health and independent living in the home and community. Examples of leisurely physical activity include hiking, biking, and walking. New England Journal of Medicine, 353(3), 305-309. The success of the home as a health care environment is therefore more complicated than simply modifying the physical environment of the home to fit activity and health care needs. abilities, activities performed, and environmental attributes; analyze the information; and use clinical reasoning to translate the information into appropriate interventions that will best fit the situation (Steinfeld and Shea, 1993; Pynoos et al., 1997; Anemaet and Moffa-Trotter, 1999; Gitlin and Corcoran, 2000; Niva and Skar, 2006). Second, the consumer’s prime directive is that products, technologies, and modifications that go into the home must be residential in scale and appearance (i.e., look like they belong). White (Eds. For example, occupational therapists can perform home assessments, modify products (i.e., use duct tape and Velcro), and provide off-the-shelf products in states in which they are licensed, but they are not permitted to engage in home remodeling as occupational therapists. Home Health Care Service Quarterly, 20, 57-73. Jump up to the previous page or down to the next one. Although the lack of random assignment complicates statistical analyses in quasi-experimental designs, the experimental approach permits the research to fit seamlessly into and capitalize on naturally occurring situations. Gerontologist, 49(3), 355-367. Insurers fight speech impairment remedy. Washington, DC: Island Press. Physical environment refers to the level of upkeep, ambient noise, lighting, indoor air quality and/or thermal comfort of the school’s physical building and its location within the community. There is nothing inherent in rugs themselves that would make them a potential hazard. As a result, UD is compatible with the ICF, which suggests that disability is not a single point requiring specialized intervention, but a continuum of ability that would benefit from less demanding design. (2004). As a result, the MFP Program is more of a paradigm adjustment than a fundamental change in thinking. Although these two outcomes measure different constructs (e.g., problems encountered with or without assistance versus level of assistance required, respectively), they often are used interchangeably. “We would not cover the iPhones and netbooks with speech-generating software capabilities because they are useful in the absence of an illness or injury,” said Peter Ashkenaz, a spokesman for the federal Centers for Medicare & Medicaid Services. Assessing universal design in the physical environment. These included construction of more one-story, slab-on-grade and one- to two-step ranch homes that are more conducive to ramps than older homes, which are often 36 inches or more above grade level; increased size of spaces, such as larger master bedrooms and baths and larger kitchens that facilitate easier wheelchair access; and changes in spatial layout, such as the master bedroom on the main floor and more open floor plans that provide opportunities for easier and safer mobility. Building owners, managers, tenants, and most of all building occupants are beginning to demand that their indoor environment be not just comfortable (not too hot or too cold, not too noisy, etc. In fact, in a review article, Wahl and colleagues (2009) questioned the validity and reliability of assessment procedures of more than half the studies they examined. • The quality of air for breathe, the water for drink, exposure to noise, harmful orgasms, radiation from the sun and other sources. (2004). Series B. (2000). In C. Christiansen and C.M. In J.E. © 2020 National Academy of Sciences. Importantly, although the physical environment plays an important role in activity performance and health, it neither dictates nor determines activity performance or health behavior. However, they may also supply assistive devices and equipment. Municipalities often offer tax credits, particularly to developers who build accessible homes. When an individual is in poor health, is impaired, or has functional declines due to aging, health concerns are virtually indistinguishable from housing concerns, particularly in an aging housing stock (Lawler, 2001). The challenge, however, is to design and incorporate modifications, health care products, technologies, and devices into the home environment without violating two basic principles. Existing and emerging healthcare devices for elders to use at home. Presented at the American Occupational Therapy Association Annual Conference, May 19, Minneapolis, MN. In fact, small changes in measurable health outcomes, even if they are not statistically significant, may equate to big gains in the quality of people’s lives. These include the location of housing in unsafe neighborhoods, overheated room temperatures, poor indoor air quality, and unsanitary conditions. In C. Eisdorfer and M.P. In addition, individuals with functional limitations on dexterity, vision, hearing, or cognition may have difficulty manipulating, seeing, hearing, or understanding technology interfaces. Washington, DC: Author. Although problems can and do occur throughout the home, research and experience suggest that environmental barriers to the safety and health of individuals in the home are linked to three primary activities: (1) getting into and out of the house, (2) moving around the house, and (3) performing. Still, modifications for healthy, independent living in the community should be a public health concern for which funding is made available. It is structured like a pretest-posttest randomized experiment but lacks random group assignment. American Journal of Public Health, 93(9), 1,451-1,456. No one would expect a private or public third-party payer to help modify one’s home, such as by adding a nursery, to accommodate such a lifestyle change. Clearly, mobility and transfer tasks are integral to each of these activities. British Journal of Occupational Therapy, 62(11), 491-497. In addition, home modifications have been shown to increase caregivers’ effectiveness, well-being, and self-efficacy, as well as to decrease caregiver stress and upset (Gitlin et al., 2001a, 2003). In addition, some assessments are based on expected abilities and activity performance, and others assess actual activity performance (Sanford and Bruce, 2010). Another option for consumer education is the use of demonstration homes (such as Eskaton), in which people can actually try out different design features (e.g., Mills, Holm, and Christenson, 2001). Journal of Architectural and Planning Research, 18(1), 3-18. Pynoos, J. Occupational and Environmental Medicine, 52, 686-693. ), The psychology of adult development and aging (pp. Development of a comprehensive assessment for delivery of home modifications. ADA accessibility guidelines for buildings and facilities (ADAAG). Assistive Technology, 9, 22-33. Zoning ordinances must also recognize and support the role of the home as a health care environment. In contrast, building professionals focus primarily on changes to the physical environment, ranging from installing grab bars to moving fixtures to adding lifts to full-scale remodeling. Such studies have focused on associating outcomes with the presence or absence of specific environmental barriers or facilitators (e.g., presence or absence of a grab bar or handrail) rather than the measurable attributes (e.g., height and diameter) of those features, the demands they exert, and valid measures of those demands (Stark and Sanford, 2005; Sanford and Bruce, 2010). In multifamily housing, these improved conditions may be due to governmental regulations for accessibility that went into effect in the 1980s and 1990s (e.g., the Fair Housing Act Amendments and the Americans with Disabilities Act) to prevent discrimination against people with disabilities in housing and public environments. Fazzone, P.A., Barloon, L.F., McConnell, S.J., et al. Journal of Rehabilitation Research and Development, 43(2), 287-298. Gerontologist, 45, 327-336. Factors predicting the implementation of home modifications among elderly people with loss of independence, Physical and Occupational Therapy in Geriatircs, 12(1),15-27. For individuals with mobility issues, typical modification strategies to ensure activity, increase safety, and improve health are similar to those for outdoor environments, although stair lifts are commonly used instead of ramps between levels of a home. Improving the delivery of home modifications. UD, in contrast, is a 21st-century model, which, like the ICF, is predicated on the notion that activity and participa-. (2005). Older consumers’ pre- and post-trial perceptions of residential universal design features. The classification system not only associates specific environmental factors with positive or negative outcomes but also provides a mechanism for measuring the level of P-E fit or misfit by rating the strength of a particular factor as a facilitator (from 0 to +4) or barrier (from 0 to −4). For example, if you are standing in adverse weather conditions, your conversation would be hampered because you would not be able to pay full attention to what the other person is saying. There is a direct relationship between health and housing. Get resources on specific hazards and their control, including identification, risk assessment and inspections, to keep your workplace healthy and … The American Medical Association should support and promote environmental interventions as a health care issue. Overall the level of E. Coli compliance has fluctuated over the second half of the 1990s from a low of 81 percent in 1998 to a high of 86 percent in 1996 and 2000. However, the vast majority of disabled elderly households do not live in newer housing or multifamily units. A field test of the Cougar home safety assessment for older persons, version 1.0. Trouble in paradise? Instead … if Ms. Lynn and others like her want insurance to pay, they must spend 10 to 20 times as much for dedicated, proprietary devices that can do far less. Demonstration programs, such as the Money Follows the Person (MFP) Program, can also provide valuable evidence. A randomized, controlled trial of a home environmental intervention to enhance self-efficacy and reduce upset in family caregivers of persons with dementia. However, it is not a practice that is used in assessing needs for therapeutic home interventions. Environmental influences on aging and behavior. Galinsky, T., Waters, T., and Malit, B. Gerontologist, 41, 15-30. Randomized controlled trials have been used for interventions that have introduced assistive technologies and environmental strategies into the home (e.g., Gitlin et al., 2001a) when the physical environment is the intervention, but most real-world circumstances make it difficult to use these and other experimental intervention designs (e.g., random/. Similarly, consumers are often uninformed or harbor misperceptions about environmental innovations. The importance of including the home environment in assessment of frail older people. A comparison of televideo and traditional in-home rehabilitation in mobility impaired older adults. Communication technology to foster social connectedness and prevent deterioration in psychological health, particularly among individuals who have transportation difficulties, is an important, although sometimes overlooked, component of the home-based care system (see Chapter 9). To further complicate provision of home health, studies have identified a number of additional concerns about the safety of home environments that can negatively impact care providers and thus the provision of care. To compound the problem, changes must occur in a number of different and mutually exclusive systems that are not particularly aware of the role of the environment in supporting activity and health needs or of each other. Hyde, J., Talbert, R., and Grayson, P.J. nonrandomized, or controlled/uncontrolled pre-post). Kendra, M.A., Weiker, A., Simon, S., Grant, A., and Shullick, D. (1996). ing taxpayer dollars on unnecessary remodeling that increases the comfort and wealth of individuals, even if homeowners themselves do not perceive that these changes will increase value. Niva, B., and Skar, L. (2006). Center for Universal Design. Effects of the home environmental sill-building program on the caregiver-care reciepient dyad: Six-month outcomes from the Philadelphia REACH initiative. Physical environmental barriers, such as stairs, lack of toilet and tub grab bars, poor lighting, and poor visual contrast, and lack of space can reduce accessibility; create dangers in the home and community; put community-dwelling individuals with chronic conditions and functional limitations at significant risk for adverse health events (such as falls) and injuries, loss of independence, or difficulty in performing activities of daily living (ADLs); minimize the effectiveness of caregivers, assistive technologies, and health care devices; and even lead to relocation or early institutionalization (Carter. Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century. For example, assistive devices, such as lifts, tub benches, and toilet seats, are typically more intrusive than structural changes to the home that might provide more space and better performance. Washington, DC: RESNA Press. As a consequence, the researchers were perhaps misled to an overgeneralized conclusion at the expense of understanding perhaps the more salient environmental factors that impact falls. Gitlin, L.N., and Corcoran, M. (2000). American Journal of Occupational Therapy, 55, 641-648. Anemaet, W.K., and Moffa-Trotter, M.E. Even as the home has become a centerpiece of health care in the United States, the lack of supportive housing to promote activity, health, and health care needs is exacerbated by the striking disconnect between these needs and the U.S. health care system (Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century, 2002). The principles guide both better activity performance (i.e., works better) and better integration (i.e., fits better) in the social and physical context. In the late 1990s and early 2000s, a large number of model smart homes were constructed on many university campuses (e.g., Drexel University, Georgia Institute of Technology, Iowa State University, Massachusetts Institute of Technology, University of Florida) as demonstration homes and laboratories to develop and test new technologies. Water, land formations, minerals, air, and vegetation are examples of natural physical surroundings. The reliability and validity of the safety assessment of function and the environment for rehabilitation (SAFER Tool). Stairs, in particular, account for a greater number of falls than any other single location in the home (Kochera, 2002). (2002). In S. Lanspery and J. Hyde (Eds. Neither is housing designed to accommodate health care equipment, health care providers, or the communications infrastructure necessary to share health information with remote care providers. Design directives in home adaptation. (1995). A variety of standalone and integrated devices are available that enable patients to actively manage their own health and reduce acute episodes. The Centers for Disease Control and Prevention have determined that our physical and social environment contributes over 50 percent to our state of health. Building codes, which are intended to protect the health, safety, and welfare of the public, should include requirements for accessible or universal housing—but they do not. 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