277-303). Second, and perhaps more influential, is that environmental modifications are not considered to be medical interventions under the old medical model. While many of the technologies had isolated functions, some were integrated systems that worked as a smart home. In addition to provider and payer issues, a large number of other confounding contextual factors impact decisions. Even among specialists, intervention decisions often vary by discipline and level of expertise of the individual delivering services. Enabling America: Assessing the role of rehabilitation science and engineering. A second study reviewed 64 studies of environmental interventions for the management of Alzheimer’s disease (Gitlin, Liebman, and Winter, 2003) and reported that environmental interventions had some level of success in 90 percent of the studies, resulting in significant improvement in experimental group participants in 10 of 11 randomized clinical trials. Many homes are not designed to support either prosthetic or therapeutic needs. In contrast, social models suggest that positive outcomes involve changing either the person or the environmental circumstances or both. Vebrugge, L., and Sevak, P. (2002). Environmental hazards in the homes of older people. In addition, misperceptions about the additional cost of UD are manifest in a reluctance to use it as a design strategy. The international classification of impairment, disability and health (p.143). Bruce, C., and Sanford, J.A. Show this book's table of contents, where you can jump to any chapter by name. Journal of Architectural and Planning Research, 18(1), 3-18. It is important to recognize that there are no national standards for provision of home modification services. There are many practical and ethical concerns, such as the high initial costs of many physical environmental interventions, the costs of changing interventions in crossover designs, the disruption of installing or constructing environmental interventions, and the ethics of withholding intervention/treatment in the control group if the intervention is the only alternative or of exposing patients to an inferior intervention when an alternative is deemed more appropriate. Journal of Physical and Occupational Therapy in Geriatrics, 16(3/4), 22-23. (1995). Disability and Rehabilitation, 23(17), 777-787. In single-family housing, these findings may be attributed in part to changes in home design that occurred around 1980. While these perceptions have a firm basis in the many assistive and health care technologies and accessible design solutions that have an institutional or medical appearance, there are many newer UD products that have been designed specifically for homes. These technologies use networks of sensors, transmitters, and receivers embedded in the home environment to (1) monitor activity and location, (2) identify and reduce potential safety hazards, and (3) communicate physiological status to health care providers. Fisher, G.S., Kintner, L. Bradley, E., Costulas, D., Kozlevcar, J. Mahonski, K, McMenamin, K., Rompilla, A. Regardless of purpose, however, the effectiveness of devices is impacted by and has unique implications for the design of the home environment. Not surprisingly, the independent living and home health goals that should be mutually supportive—that is, independent living should promote health and home health should promote independent living—often are addressed without consideration for each other. Amityville, NY: Baywood. Center for Technology and Aging. Not coincidentally, they also have a much larger impact on the use of space in the home environment. ), Handbook of the psychology of aging, 5th edition (pp. However, it is a rare physician who considers environmental interventions as part of a care plan. Galinsky, T., Waters, T., and Malit, B. Home visits by an occupational therapist for assessment and modification of environmental hazards: A randomized trial of falls prevention. Physical and Occupational Therapy in Geriatrics, 20(2), 43-55. Given the strenuous nature of these tasks and the clutter, lack of space, and other safety risks in the home (Gershon et al., 2008), it is not surprising that caregivers experience considerable difficulty and have an increased incidence of injury compared with other health care and human services workers (Myers et al., 1993; Ono et al., 1995; Galinsky, Waters, and Malit, 2001). The most conspicuous barrier to adoption of this innovation is the policy paradigm that rewards specialized technology and personal assistance with limited and calculated benefits rather than everyday universal design, which has potential for multiple and far-reaching benefits. Simply put, better design solutions are needed, and UD provides them. (1995). However, demonstration homes provide only one example of each UD feature, thus restricting comparison across alternatives; they are geographically restricted, which limits their exposure to a broad audience; and, unlike Eskaton, most have been built by local builders and ultimately sold to. Ferrucci, L., Guralnik, J.M., Studenski, S., Fried, L.P., Cutler, G.B., Jr., and Walston, J.D. Availability of resources to meet daily needs, such as educational and job opportunities, living wages, or healthful foods 2. Clearly, a myriad of issues confound environmental studies. 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. Louie, J. Clearly, the larger the number of different systems and biometric tools that are introduced into the home, the more space is required. Ready to take your reading offline? In new construction and remodeling, a number of municipalities have changed local building codes to require or offer tax breaks for basic access for wheelchair users. Each profession tends to have its own disciplinary perspective that influences its understanding of needs and intervention solutions. (2001). Sanford, J.A. In C. Eisdorfer and M.P. In the United States there is a growing movement toward visitable housing, which, while still based on access rather than health, is a step toward broader regulation of private housing. Iwarsson, S. (2004). The most likely design, and probably the most commonly used quasi-experimental design in social research, is the nonequivalent groups design, which requires a pretest and posttest for a treated and a comparison group. Finally, to compound the problem, the home environment itself is often the source of impediment, inadequately designed or poorly maintained and unable to support the. Clearly, mobility and transfer tasks are integral to each of these activities. Connell, B.R., and Sanford, J.A. Rather, prescriptions for environmental interventions must be individualized and context-specific. In S. Lanspery and J. Hyde (Eds. Proceedings of the Annual RESNA Conference. At the heart of the problem is a lack of understanding and consensus about both independent and dependent variables. 171-191). Milbank Quarterly, 82, 157-194. Reviews of Environmental Health, 19(3-4), 223-252. U.S. Access Board. As part of the Swedish public health program, for example, each municipality provides needed services to individuals with functional limitations, including the modifications necessary (regardless of cost and income level) to continue living in their own homes for as long as possible. New York: Van Nostrand Reinhold. Aging in place: Coordinating housing and health care provision for America’s growing elderly population. For example, social factors might include the impact of other individuals in a home, who may or may not be providing care, as well as the impact of modifications on those individuals (Gitlin, 2003). The physical environment can be virtually anything concrete that children may encounter in their lives. Annals of Behavioral Medicine, 25(2), 80-91. An environment that fits an individual will facilitate positive performance and health outcomes that are manifest in his or her ability to participate in activities when, where, and with whom he or she desires. These include the local area agency on aging (AAA), natural occurring retirement community (NORC) initiative, or center for independent living (CIL); municipal agencies, such as a mayor’s office for people with disabilities (MOPD) and department of housing; and state assistive technology programs, departments of veterans affairs, and volunteer organizations like Rebuilding Together. Environmental gerontology: Progress in the post-Lawton era. 9 Information Technology and Systems in Home Health Care--George Demiris, 11 Impact of Cultural, Social, and Community Environments on Home Care--Steven M. Albert, The National Academies of Sciences, Engineering, and Medicine, The Role of Human Factors in Home Health Care: Workshop Summary, http://www.nytimes.com/2002/10/08/international/asia/08JAPA.html, http://www.design.ncsu.edu/cud/about_ud/udprincipleshtmlformat.html, http://govinfo.library.unt.edu/seniorscommission/pages/final_report/sencomrep.html, http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Gershon_88.pdf, http://www.ilcusa.org/media/pdfs/Caregiving%20in%20America-%20Final.pdf, http://assets.aarp.org/rgcenter/il/inb49_falls.pdf, http://www.biomedcentral.com/1472-6963/4/28,, http://www.agingtech.org/documents/Advanced_Home_ Healthcare_P&S.pdf, http://www.access-board.gov/adaag/html/adaag.htm, http://www.nytimes.com/2009/09/15/technology/15speech.html, 2 The People Who Receive and Provide Home Health Care, 6 The Health Care Challenge: Matching Care to People inTheir Home Environments--Neil Charness, 7 Informal Caregivers in the United States: Prevalence, Caregiver Characteristics, and Ability to Provide Care--Richard Schulz and Connie A. Tompkins, 8 Medical Devices in Home Health Care--Molly Follette Story, 10 The Physical Environment and Home Health Care--Jonathan Sanford, 12 Effects of Policy, Reimbursement, and Regulation on Home Health Care--Peter A. Boling, Appendix: Workshop Agenda and Participants. In addition, the list of hazards, such as throw rugs, lack clear definition of the attributes that actually are associated with falls. includes both outdoor and indoor surroundings. Available: http://assets.aarp.org/rgcenter/il/inb49_falls.pdf [accessed June 2010]. Researchers have found convincing evidence that people who live in communities characterized by mixed land use (e.g., with stores in walking distance of homes); well-connected street networks; and high residential density are more active, especially for transportation, than those who live in communities … 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. Better initial design would greatly improve usability for everyone and reduce the need for modifications later on. 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. However, while individuals who suffer from trauma or chronic illness are placed into the rehabilitation system, others, such as seniors with declining abilities, are typically on their own to find out how and where to enter a complex system of services that could be provided by any number of programs. (1993). Seniors commission report. • The quality of air for breathe, the water for drink, exposure to noise, harmful orgasms, radiation from the sun and other sources. In contrast, the enabling process is either the restoration of the individual’s function or environmental modification to remove barriers that limit performance. To achieve these aims, housing and technology must be appealing to consumers as well as supportive of people with a wide range of functional abilities and health conditions, their caregivers, families, and health care providers. In contrast to active technologies, there are passive home-based systems that do not depend on active engagement of individuals in the home. ), The psychology of adult development and aging (pp. 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. 1. Fange, A., and Iwarsson, S. (2003). ronments that promote independence could reduce health care needs and those that promote health could facilitate independence. Kansas State University, Manhattan. Yet a major influence on the safety, quality, and effectiveness of home health care will be the set of issues encompassed by the field of human factors research--the discipline of applying what is known about human capabilities and limitations to the design of products, processes, systems, and work environments. New technologies enable active self-management and passive monitoring of safety and activity. However, because the reimbursement system is client-centric, it is concerned with meeting the needs of individual clients. For zoning, this is to maintain the character of a neighborhood, while building codes are designed minimize the amount of impervious (impenetrable) surfaces (e.g., concrete or a roofed structure) to limit water runoff onto adjacent properties. To accomplish this, reimbursement must overcome its “hands-off-the-home” policy, create incentives for universal design, incorporate access into local building codes, make environmental interventions a medical issue, and certify providers of prosthetic and therapeutic interventions. Action for public health: Sundsvall statement on supportive environments. At the same time, new rating systems have been created, including WELL and Fitwel, that focus exclusively on occupant health and productivity. National Council on Disability. In addition, several different types of integrated monitoring devices exist. Implementation is somewhat more complex than merely finding someone to install or supply the necessary modifications. Like home modifications and assistive technologies, medical devices and technologies for self-management can have a large impact on the home environment and on the individuals living there. Occupational and Environmental Medicine, 52, 686-693. (1999). 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). New York: Springer. Gitlin, L.N., Winter, L., Corcoran, M., Dennis, M., Shinfeld, S., and Hauck, W. (2003). Series B. Pynoos, J., Cohen, E., Davis, L., and Bernhardt, S. (1987). (2004). BMC Health Services Research, 4(28). Scheschareg, R. (2006). Requiring individuals to demonstrate how they perform routine activities would provide an accurate sense of how the individual interacts with the environment (Pynoos et al., 1997). Washington, DC: American Psychological Association. 1. Health and community design: The impact of the built environment on physical activity. Disposal of medical supplies, particularly used needles, and a backup generator in case of a power outage are also major considerations. Washington, DC: National Academy Press. The design or the physical condition of the home itself can be a barrier to environmental innovation. An example is a $300 smart phone compared with other cell phones, many of which are given away. Journal of the American Medical Association, 288, 3,137-3,146. We are now moving onto the Physical environment. More specifically, these models predict that impairment causes functional limitations, which in turn result in negative performance and health outcomes. Disability and Rehabilitation, 25, 1,316-1,325. In J.E. Available: http://govinfo.library.unt.edu/seniorscommission/pages/final_report/sencomrep.html [accessed September 2009]. Strategies for home modification and repair. While people are not the only animals that alter their environment – think of beavers or termites – we tend to do it in much more -drastic and permanent ways. Lehoux, P., Richard, L., Pineault, R., and Saint-Arnaud, J. In fact, 45 percent of the community-dwelling U.S. population have at least one chronic medical condition, and about half of these, 60 million people, have multiple chronic conditions (Wu and Green, 2000). Hyde, J., Talbert, R., and Grayson, P.J. (2009). Medicaid may cover some home modifications, depending on the state. Survey data further suggest that homes built after 1980 and multifamily structures are significantly more likely to meet some of the prosthetic needs of older adults than units built in any earlier time period (Louie, 1999). The number of people with chronic conditions is growing rapidly. However, it is not a practice that is used in assessing needs for therapeutic home interventions. For example, bathrooms in most homes are inaccessible to people with physical limitations and disabilities because the doors are too narrow, the floor space is too limited, the layout of fixtures is ill conceived, the fixtures themselves are often poorly designed, and there are no supporting features. Wahl, H.-W. (2001). Occupational Therapy International, 13(1), 21-34. While assessments of expected demand link environmental attributes to expected levels of ability and activity performance, few assessments examine all three: (1) ability, (2) activity, and (3) attributes. Center for Universal Design. Gilderbloom, J.L., and Markham, J.P. (1996). The challenge, however, is to design and incorporate modifications, health care products, technologies, and devices into the home environment without violating two basic principles. Cambridge, MA: Joint Center for Housing Studies of Harvard University. Sanford, J., Story, M., and Jones, M. (1997). However, these issues further complicate research when the physical environment is the intervention. Therefore, in addition to experimental and quasi-experimental designs, relevant environmental factors should be included as a health covariate in standardized longitudinal studies, such as future versions of the National Long Term Care Survey, the Survey of Income and Program Participation, and other annual health surveys, such as the National Health Care Disparities. Reduce exposure to motor vehicle exhaust by limiting physical activity near heavy traffic areas, particularly at rush hour. Traditional medical models (World Health Organization, 1980) attribute activity performance and health outcomes primarily to an individual’s functional abilities. Nonetheless, while no one really expects physicians to prescribe home modifications, they should be knowledgeable enough to suggest them, just as they would suggest diet and exercise as an intervention, and recommend a consultation with an expert in the area, such as an occupational therapist, which could be reimbursable. Such is the case in many countries where home modifications are considered medical interventions. Enabling home environments. Overall health and well-being require a good balance of mental, physical, social, emotional, and spiritual health. However, regardless of the program, eligibility for services depends on one’s situation, unlike Sweden. It also requires changes in reimbursement that recognize and support environmental assessments and interventions as part of discharge planning and continue to support them on an ongoing basis as conditions change and throughout the life span. Although environmental studies are easy to identify, they are not easy to undertake in real-world environments in which contextual factors are impossible to control. Sinding, C. (2003). Journal of Gerontology, 45(6), P239-P243. Older consumers’ pre- and post-trial perceptions of residential universal design features. To compensate for and help manage health conditions, the physical environment of homes can be both prosthetic and therapeutic. Intuitive Care Advisors Advanced Home Healthcare Products and Services 2005 channel Report. 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). 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. Understanding the physical characteristics of the indoor environment that affect human health and wellbeing is the key requirement underpinning the beneficial design of a healthcare facility (HCF). Journal of Housing for the Elderly, 11(2), 123-137. 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). supports all types and levels of ability. Dismayed by the PC’s limitations and clunky design, Ms. Lynn turned to a $300 iPhone 3G from Apple running $150 text-to-speech software. Assistive technology devices and home accessibility features: Prevalence, payment, need and trends. Not surprisingly therefore, there is a general lack of a coordinated and comprehensive system of services that would permit expanded health care and housing options, promote self-sufficiency and independence, and offset social isolation (Lawler, 2001). For example. For example, one study (Sohn, 1997) found that older consumers’ perceptions of the usefulness and attractiveness of UD features increased after trying them out, although they still believed that the products were too expensive. The major difference between a smart home and a smart technology that resides in the home is the integration of systems in the smart home into a controlled network that connects systems and appliances to each other and to the outside world. Despite the widespread acknowledgment and acceptance of the UD principles across many professions and among many manufacturers, application of the principles to the design of housing, as well as to consumer products and technologies, has been slow to take place. However, the most critical consideration in defining positive health outcomes is identifying ones that are important to the target group of individuals for whom the only issue is simple: Does it make a difference in my life? (1999). (2002). Trouble in paradise? This raises the question, what measures should facility managers be focusing on? (1997). Nonetheless, because these devices are less expensive, more often reimbursable, more familiar to health care providers, and more readily obtained, they are much more likely to be installed. Like assessors, there are many providers, who come from different programs and disciplinary backgrounds that can impact what they are able to provide and how they provide it. The Physical Environment Physical environment include buildings, rooms, windows, equipment that should be considered. As a result, there are few accessibility-focused regulations that cover residential facilities and even fewer that comprehensively regulate the design and modification of private housing specifically for people who have functional or health limitations (Hyde, Talbert, and Grayson, 1997). Gill, T.M., Williams, C.S., Robison, J.T., and Tinetti, M.E. Thorofare, NJ: Slack, Inc. Steinfeld, E., and Shea, S. (1993). Medicare, for example, will pay for personal assistance, assistive devices, and medical technologies but not home modifications (i.e., accessible design). in the medical model, policy decision makers must also recognize that non-randomized, pre-post designs undertaken by experts in the environment will produce the most valid and reliable data regarding the effectiveness of physical environmental interventions. nonrandomized, or controlled/uncontrolled pre-post). Niva, B., and Skar, L. (2006). While the number of potential mediators is large, cost is by far the most common and most influential. Public Health Nursing, 13, 83-89. First, while space might be the great equalizer, the builder’s prime directive is that the home cannot increase in size (i.e., cost). Rubenstein, L.Z. Occupational Therapy Journal of Research, 17(3), 200-213. As a result, these individuals often underestimate the importance of the physical environment and may not recommend environmental interventions. However, linking specific environmental barriers and facilitators in the home directly to activities is a formidable task (Connell et al., 1993; Connell and Sanford, 1997). If actual ability and activity performance are not assessed, how can one be sure that performance based on expectations of what individuals can do accurately reflects what they actually do and, consequently, the effectiveness of the environmental modifications for a particular client? Where CMS leads, private insurers will follow. Joint Center for Housing Studies. Journal of American Geriatrics Society, 54, 1,641-1,648. Available: http://www.access-board.gov/adaag/html/adaag.htm [accessed June 2010]. Pynoos, J., and Regnier, V. (1997). Report. Washington, DC: Island Press. In the United States there is a patchwork of potential funders, ranging from government agencies, to private insurers and workers compensation to social service organizations, such as AAAs and NORCs, to nonprofit volunteer organizations, such as Rebuilding Together. Movement into and Out of the Home. (1996). However, the cost of specialized design for a few individuals is even more expensive. Ultimately, the universal home sets a baseline from which assistive technologies and accessible design can be introduced when and if they are needed. 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. Legally binding or affiliated with any professional licensure endeavors to understand what works.! On practice rather than try something new ( Belser and Weber, 1995 ) is... Our physical and environmental interventions in maintaining independence and reducing home care 2002 ) elderly population Consider. Features have been linked to other health outcomes of other physical environmental features have been linked to health. 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