Out of the Spotlight: Housing and Home Modifications Jon Pynoos, Ph.D. National Resource Center On Supportive Housing And Home Modification Andrus Gerontology.

Out of the Spotlight: Housing and Home

Modifications

Jon Pynoos, Ph.D.National Resource Center On Supportive Housing

And Home ModificationAndrus Gerontology Center

University Of Southern CaliforniaLos Angeles, CA 90089-0191

[email protected]

Why Is The Home Environment Important?

The Physical Environment Can Enhance Or Impede One’s 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

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.

Examples Of Home Modification

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

Most Homes “Peter Pan” Housing

3 Major Problem Areas Of The Home:

Outside Steps To The Entrance

Inside Stairs To A Second Floor

Unsafe Bathrooms Source: HUD (2001)

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

Why Has It Taken So Long to Get HMs on the

Agenda?

Use Kingdon’s Model of Agenda Setting as a Guide

•Problem Stream•Politics Stream•Policy 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

Issues in the Problem Stream:

Elderly Households With Unmet Needs For Home Modifications

8.4%

6.5%5.6%

3.9%3.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

Handrails orGrab Bars

Ramps Easy-AccessBathrooms

Specially-Equipped

Telephones

Easy-AccessKitchens

Types of HMs

Per

cent

Source:American Housing Survey, 1995

A Complex of Problems

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

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

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).

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

Issues in the Policy Stream

Unrealistic Proposals:

National Policy on Home Modifications

Overhaul Medicare

Indications That HMs Are Rising on the Agenda

Progress in the Problem Stream

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)

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).

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 HM’s Reduced The Risk Of Falling

However, Gill et al. (2000) Found Weak Relationship Between The Presence of Environmental Hazards And Falls

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)

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)

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)

Increase in Awareness Older Persons and Caregivers

More Aware That the Home Itself Can Cause Problems

Greater Consumer Information Available: AARP’s Independent Living Strategy

Involvement of Younger Persons With Disabilities

Indications That HMs Are Rising on the Agenda

Progress in the Politics Stream

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

Indications that HMs are Rising on the Agenda

Progress in the Policy Stream

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

What is Next?

A Multi- Pronged Strategy

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

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

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