10
The Physical Environment and Home Health Care

Jonathan Sanford


There is a direct relationship between health and housing. 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). To compensate for and help manage health conditions, the physical environment of homes can be both prosthetic and therapeutic. As a prosthetic environment, the home can compensate for limitations in functional abilities to enable individuals to carry out basic activities associated with daily living safely and independently, participate in social roles, and receive personal assistance from caregivers as needed. Therapeutically, the environment can facilitate health maintenance and management by supporting health-promoting behaviors and provision of health care services.

Many homes are not designed to support either prosthetic or therapeutic needs. They contain potential hazards that can lead to accidents, are deficient in design features that permit safe and independent functioning in daily activities, and lack sufficient space and layout for assistive technologies and personal assistance. 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. As a result, there is often a lack of fit between the independent living and health needs of community-dwelling individuals and the places in which they live.

Exacerbating the lack of fit between needs and the design of homes, activity performance and health promotion are typically treated autonomously and with different environmental implications, even though envi-



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10 The Physical Environment and Home Health Care Jonathan Sanford There is a direct relationship between health and housing. When an individual is in poor health, is impaired, or has functional declines due to aging, health concerns are virtually indistinguishable from housing con- cerns, particularly in an aging housing stock (Lawler, 2001). To compensate for and help manage health conditions, the physical environment of homes can be both prosthetic and therapeutic. As a prosthetic environment, the home can compensate for limitations in functional abilities to enable indi- viduals to carry out basic activities associated with daily living safely and independently, participate in social roles, and receive personal assistance from caregivers as needed. Therapeutically, the environment can facili- tate health maintenance and management by supporting health-promoting behaviors and provision of health care services. Many homes are not designed to support either prosthetic or thera- peutic needs. They contain potential hazards that can lead to accidents, are deficient in design features that permit safe and independent functioning in daily activities, and lack sufficient space and layout for assistive technolo- gies and personal assistance. Neither is housing designed to accommodate health care equipment, health care providers, or the communications infra- structure necessary to share health information with remote care providers. As a result, there is often a lack of fit between the independent living and health needs of community-dwelling individuals and the places in which they live. Exacerbating the lack of fit between needs and the design of homes, activity performance and health promotion are typically treated autono- mously and with different environmental implications, even though envi- 201

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202 HUMAN FACTORS IN HOME HEALTH CARE ronments that promote independence could reduce health care needs and those that promote health could facilitate independence. In fact, the World Health Organization has suggested that an important goal in health pro- motion is the creation of environments that support healthy living and well-being (World Health Organization, 1991). Nonetheless, the environ- ment is perceived quite differently by the individuals who function in it and the systems that regulate it. On one hand, a home should provide a prosthetic environment in which individuals can live and function safely as long as they choose to remain there. On the other hand, a number of factors, including the cost of health care and advances in communications and medical technologies, have made the home a preferred environment for health care delivery. Thus, the home has become, not by choice and often in spite of its design, a de facto therapeutic 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. To engender a more holistic approach to activity and health needs and to provide home environments that are more supportive of those needs, a number of policy, public, and personal constraints must be overcome. These include (1) a reimbursement system that provides only limited coverage for the costs of environmental assessments and modifications for activity limitations only, and particularly lacks incentives for the use of solutions that have broader benefits beyond the specific health-related problems or individuals for whom they were intended; (2) a delivery system that is fragmented, so that the array of health care services, including assistive technologies, health care technologies, environmental modifications, home therapy, and home health, are provided by many different and disconnected providers and funding mechanisms; (3) a regulatory system of building and zoning codes that enables housing to continue to be built as if people will never have activity or health care needs (Pynoos and Regnier, 1997); and (4) a reluctance on the part of homeowners to make changes in their homes due to lack of awareness of, and misperceptions about, the importance of the home environment in effecting engagement, comfort, novelty, and stimulation as well as participation in meaningful activities (Gitlin, 2003). 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. For such interventions to occur, there must be fundamental paradigm shift with regard to the importance of the home environment in promoting activity, health, and health 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.

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20 THE PHYSICAL ENVIRONMENT AND HOME HEALTH CARE This chapter examines the prosthetic and therapeutic roles of the environment in promoting positive activity and health outcomes, identi- fies barriers to supportive home environments, and proposes that univer- sal design—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 (Mace, Hardie, and Place, 1991)—be adopted as the conceptual basis for the paradigm shift that is needed to promote indepen- dent living and health management. Specifically, the chapter presents (1) a theoretical background to support the role of the environment in inde- pendent living and home health care; (2) a discussion of the relationship between prosthetic environmental interventions and improved activity out- comes through facilitating both independence and caregiver assistance; (3) a use of the home as a therapeutic environment in which communication and monitoring technologies can improve health management and treat- ment through facilitating access to health care; (4) new housing concepts, including smart homes and universal design, that can minimize the impact of prosthetic and therapeutic interventions on the home environment; (5) the barriers to adoption of new housing innovation; (6) the policy changes necessary to improve adoption of housing innovation; and (7) a research agenda that can provide the evidence needed to justify changes in home health policy. THE ROLE OF THE ENVIRONMENT IN INDEPENDENT LIVING AND HOME HEALTH CARE Home and community settings are complex environments comprised of physical as well as social, cultural, personal, and temporal environmental factors. 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). While a number of environmental factors exist across a variety of contexts (e.g., community, work, school), this chapter specifically focuses on the physical barriers and facilitators (both prosthetic and therapeutic) of positive activ- ity and health outcomes in the home. Other chapters in this volume address social and policy environments. 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

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20 HUMAN FACTORS IN HOME HEALTH CARE et al., 1997; Clemson, Roland, and Cumming, 1997; Cumming et al., 1999, 2001; Oswald et al., 2002; Fange and Iwarsson, 2003; Stark, 2004; Iwarsson, 2005; Lau et al., 2007). Barriers, particularly environmental hazards, are common and pervasive (Gill et al., 1999). For example, one study of factors associated with home environmental problems among older adults reported an average of 13 problems with the environment that posed barriers to safe and independent performance (Gitlin et al., 2001b). In contrast, environmental facilitators reduce barriers and have posi- tive impacts on functioning of individuals and their caregivers. In fact, one study (Freedman, Martin, and Schoeni, 2002) suggests that gains in func- tioning of older adults over the past few decades may be the result, in part, of the introduction of facilitators and the reduction of environmental bar- riers. 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. More broadly, in a review article of studies on the home environment and disability, Wahl and colleagues (2009) reported that the majority of studies provided supportive evidence that improving the home environment reduces disability-related outcomes. More broadly, home modifications and assistive and communication technologies have been found to prevent functional decline and disability, promote independent activity and safety, increase task self-efficacy, and enhance health outcomes (Connell and Sanford, 1997, 2001; Mann et al., 1999; Gitlin et al., 2001a; Freedman, Martin, and Schoeni, 2002; Tinetti et al., 2002; Gitlin, 2003; Ferrucci et al., 2004; Oswald and Wahl, 2004; Spillman, 2004; Allen, Resnick, and Roy, 2006; Sanford and Hammel, 2006; Sanford et al., 2006; Oswald et al., 2007) by reducing task demand (Verbrugge and Sevak, 2002). 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). Similarly, research has shown that physical environment facilitators can reduce sedentary behaviors, promote community mobility, and enhance health (e.g., Andersen et al., 2000; Frank, Engelke, and Schmid, 2003; Frumpkin, 2003; Saelens, Sallis, and Frank, 2003). 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). Traditional medical models (World Health Organization, 1980) attribute activity performance and health outcomes primarily to an individual’s functional abilities. More specifically, these models predict that impairment causes functional limitations, which in turn result in negative performance and health outcomes.

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20 THE PHYSICAL ENVIRONMENT AND HOME HEALTH CARE Although the physical environment has long been associated with individual functioning and disability (Rubenstein, 1999; Wahl, 2001; Iwarsson, 2004; Scheidt and Windley, 2006), social models of health have only recently become more accepted. These models suggest that, whereas physiological factors set the threshold on functional ability and health, environmental factors set the threshold on the point at which limitations in ability become a disability (Stineman et al., 2007). Outcomes are therefore situational, the result of the interaction between an individual’s abilities (as opposed to limitations) and the demands of the environment, according to the environmental press model (Lawton and Nahemow, 1973). As a result, activity performance, participation, and health are expressions of the fit or misfit between an individual and his or her environment. Optimal person- environment (P-E) fit occurs when an individual’s abilities and the demands of the environment are compatible. Conversely, P-E misfit occurs when the environment is either too challenging (i.e., demands exceed abilities) or not challenging enough (i.e., abilities exceed demands). 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. In contrast, an environment that does not fit an individual will result in negative performance outcomes or performance deficits that may prevent him or her from participating in an activity altogether. Whereas Lawton’s environmental press model suggests the role of the environment in activity and health, the enabling-disabling process model of the Institute of Medicine specifically identifies the environment as a pathway for intervention (Institute of Medicine, 1997). 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. In contrast, the enabling process is either the restoration of the individual’s function or environmental modification to remove barriers that limit performance. Two decades after proposing its medical model, the World Health Organization developed the International Classification of Functioning, Disability and Health (ICF), a new classification system based on a more robust social model (World Health Organization, 2001). The ICF attributes differences between what individuals can do (capacity to engage in activi- ties and participation based on body function and structure) and what they actually do (performance of activities) to the influence of personal and environmental (both social and physical) factors. 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).

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20 HUMAN FACTORS IN HOME HEALTH CARE Differences between medical and social models have important implica- tions for health and independent living in the home and community. Medi- cal models suggest that achieving positive outcomes involves changing the person (i.e., eliminating or minimizing impairment) or compensating for a functional limitation (i.e., providing assistive technology). In contrast, social models suggest that positive outcomes involve changing either the person or the environmental circumstances or both. Importantly, although the physical environment plays an important role in activity performance and health, it neither dictates nor determines activity performance or health behavior. Rather, the environment simply creates opportunities for activity or behaviors to occur. It is up to individuals and care providers to either take advantage of any opportunities presented by prosthetic and therapeutic environmental facilitators or overcome the demands of any barriers that are present. PROSTHETIC INTERVENTIONS: HOME MODIFICATIONS TO IMPROVE ACTIVITY OuTCOMES Reducing environmental demands to improve P-E fit can be accom- plished through a variety of home modification strategies (i.e., prosthetic facilitators), including assistive technologies and accessible design features (i.e., specialized equipment and environmental features intended to support people with specific disabilities) and universally designed products and spaces (i.e., environmental features intended to support people regardless of ability), that meet the activity and health needs of individuals and their care providers. Furthermore, the process of environmental intervention is a confluence of activities and delivery of services that begins with assess- ing needs and includes identification and implementation of solutions, training in the use of solutions, and evaluating outcomes (Sanford, 2004). Of particular relevance here are the following: (1) assessing the demands and needs for eliminating barriers, (2) prosthetic interventions that meet the functional needs of both individual and caregiver, (3) delivery and reimbursement systems to supply and fund best-fit interventions, and (4) choice and impacts of best-fit interventions that must ultimately meet the real-world needs of the situation. Assessment: Determining Fit, Demands, and Modification Needs Research suggests that residents’ perceptions of their own abilities and environments differ from those of experts and significantly underreport the presence of environmental barriers (Steinfeld and Shea, 1993; Iwarsson and Isacsson, 1996). As a result, a systematic process, performed by skilled specialists, is needed to acquire information about the fit between a person’s

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20 THE PHYSICAL ENVIRONMENT AND HOME HEALTH CARE 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). To be effective, assessments must produce unbiased, objective informa- tion that is both valid and reliable. Yet assessments are conducted by an array of home health service providers—occupational therapists, rehabilita- tion engineers and technologists, home health nurses, and social workers— and, to a lesser extent, building professionals—remodelers, architects, and interior designers. In addition, some assessments are based on expected abilities and activity performance, and others assess actual activity perfor- mance (Sanford and Bruce, 2010). Although both are common and have their benefits, the results of each are subject to different levels of bias, valid- ity, and reliability that can impact the fit between therapeutic interventions and the individual as well as the home environment. Of equal importance, few assessments have proven psychometric properties. 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. Expected Performance: Predicting Needs from Attributes Assessments that measure a specified set of environmental attributes based on expected rather than actual measures of ability and activity per- formance result in a prediction of potential, rather than actual, environ- mental demands. As a result, interventions based on such information are determined irrespective of the actual abilities of the individuals for whom the interventions are intended. This type of assessment is illustrated by a number of instruments, such as the Housing Enabler (Iwarsson, 1999) and the Cougar Home Safety Assessment (Fisher, Coolbaugh, and Rhodes, 2006; Fisher et al., 2008). Both instruments assess the severity of environ- mental barriers in the absence of an assessment of a client’s actual ability or performance. For example, the Housing Enabler, one of the few tools with known psychometric properties, uses a set of typical impairments and functional limitations as a surrogate for individual disability/incapacity. Various environmental attributes are then systematically rated in relation to their expected impact on performance. Clearly, the measurement of potential demands is helpful when there is no single client whose abilities can be determined (such as for the acces- sibility of public buildings) or when actual performance of specific activities cannot be determined, such as assessing the home environment for a patient prior to his or her discharge from a clinic. However, measuring potential demands has its limitations. Going back to the discussion of the ICF, con-

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208 HUMAN FACTORS IN HOME HEALTH CARE textual factors (including environmental demands and personal factors) account for the difference between an individual’s hypothetical capacity to function (i.e., what people can do) and actual performance (i.e., what they actually do) or enacted function (Glass, 1998). 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 modi- fications for a particular client? Actual Performance: Assessing Needs from Actiity Requiring individuals to demonstrate how they perform routine activi- ties would provide an accurate sense of how the individual interacts with the environment (Pynoos et al., 1997). Thus, when performance outcomes can be determined, as is the case when an individual is living at home, then mea- surement of actual demands will provide a more accurate picture of envi- ronmental demands than will prediction of demand potential. The Canadian Occupational Performance Measure (COPM) (Law et al., 1991) and the Safety Assessment of Function and the Environment for Rehabilitation- Health Outcome Measurement and Evaluation (SAFER-HOME v. 3) (Letts et al., 1998) are two performance-based instruments that can identify actual home modification needs as well as changes in performance after modifi- cation interventions. However, these instruments are purely performance- based; they do not assess either environmental attributes or ability. Without a measure of ability, one cannot determine if there is a difference between what an individual can do and what an individual actually does. Moreover, without a measure of environmental attributes, it is not possible to deter- mine what specific changes should actually be made. Linking the Three A’s: Ability, Actiity, and Attributes 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. Without all three, it is not possible to determine best-fit interventions for a particular individual. The Comprehensive Assessment and Solutions Process for Aging Residents (CASPAR) is one of the few instruments that measure all three factors (Sanford et al., 2001; Sanford, 2002; Sanford and Butterfield, 2005). 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. However, CASPAR, like

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20 THE PHYSICAL ENVIRONMENT AND HOME HEALTH CARE other home assessments, requires a specialist onsite to collect the required information. Remote Assessment: Oercoming Limitations of Time and Distance To overcome travel time and distance that increase costs and limit the ability of experts to access clients’ homes, a number of studies have demonstrated that real-time, interactive videoconferencing can be used by specialists to successfully identify needs and provide sufficient informa- tion to recommend interventions (Sanford et al., 2004, 2007; Sanford and Butterfield, 2005; Hoenig, Sanford, and Griffiths, 2006), thus potentially eliminating the need for a specialist to travel long distances to perform an assessment. These studies suggest that relatively inexpensive video- conferencing technology (e.g., as little as $1,200 for two videophones and a video camera) that uses the telephone system enables specialists to con- duct remote assessment in a manner similar to in-home assessments, thus maintaining the integrity of the therapist-patient interaction, and provides a practical alternative to traditional home visits by a therapist for improv- ing task self-efficacy. Nonetheless, to date, teleconferencing technology has been limited to research studies and has not been translated into practice in any ongoing home assessment programs. Home Modifications: From Needs to Prosthetic Interventions Providing a facilitating environment in the home is different from pro- viding an accessible environment in community settings. In public places, the Americans with Disabilities Act accessibility guidelines (U.S. Access Board, 2002) are intended to ensure at least basic levels of usability and access for people with acknowledged disabilities. These guidelines apply neither to private residences nor to individuals who have functional losses that do not “qualify” as a disability. Therefore, whether these interven- tions are assistive technologies, accessible designs, or universal designs, they should be individualized, customized, and personalized to best fit the functional needs of individuals for independent living and their caregivers for providing assistance. Improing Independent Actiity: Prosthetic Modifications for Mobility and Self-Care 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

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210 HUMAN FACTORS IN HOME HEALTH CARE self-care (toileting, bathing, and grooming). Clearly, mobility and transfer tasks are integral to each of these activities. Not surprisingly, therefore, the majority of home environmental interventions have traditionally focused on modifying entrances, circulation paths and stairs, and the bathroom to facilitate mobility and transfer tasks. Moement into and Out of the Home. Many houses are built above ground level and have a set of steps leading up to a porch, deck, or landing at the door. Not only are stairs a barrier to wheelchair users, they also can become a safety hazard and an obstacle to independence for individuals with gait and balance problems and those who use walking aids. In addition, walk- ways and stairs frequently are in poor condition and lack handrails for support and adequate lighting at night. To increase safety and mobility, walkways should have smooth, slip-resistant surfaces; steps should be in good repair, with handrails on both sides and with contrasting nosings (the rounded edges of stair treads), or should be replaced with a ramp, sloping walkway, or mechanical lift. In addition, the threshold should be reduced to minimize tripping, doorways should be widened, sufficient space should be provided to maneuver, and an automatic opening system should be installed to eliminate twisting and turning of doorknobs. There should also be adequate lighting operated by motion detectors or timers at all walkways and doors to help maintain independence and ensure the safety of individu- als with mobility issues as well as those with vision loss. Mobility in the Home. Inside the home, people who use mobility aids, such as wheelchairs, frequently lose access to rooms, particularly bathrooms, because hallways or doors are too narrow, furniture obstructs the path of travel, or stairs prevent travel to other floors in the home. Stairs, slippery floors, and obstacles are also potential safety hazards. Stairs, in particular, account for a greater number of falls than any other single location in the home (Kochera, 2002). And the number of multistory homes being con- structed has increased precipitously since 1970 (U.S. Bureau of the Census, 1994). 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. 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. Transfer Safety and Self-Care Actiities. The bathroom, with its wet, slip- pery surfaces, small, cramped spaces, and hard surfaces can easily lead to falls and serious injury, even for people without functional limitations.

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211 THE PHYSICAL ENVIRONMENT AND HOME HEALTH CARE Bathroom floors are extremely dangerous when wet. For many individuals who have difficulty raising and lowering themselves, including those who use wheeled or ambulatory mobility aids, health, safety, and fall risks are associated with difficulty transferring to the toilet, bathtub, or shower. While individuals who use wheelchairs often lack space to maneuver or get close enough to a fixture, ambulatory individuals with gait and bal- ance problems often lack support (i.e., something to hold onto) to safely lower themselves down onto a toilet or the bottom of a tub or, conversely, to pull themselves back up from these positions. To increase safety and mobility, sufficient space should be available at the toilet, bathtub, shower, and sink for mobility aids and caregiver assistance. In addition, safety can be enhanced by reducing the distance an individual must raise and lower himself or herself (e.g., raising the height of the toilet) or the need to lift one’s legs over the side of the tub (e.g., walk-in tub) or the shower curb (e.g., a curbless shower). In addition, safety can be increased and transfers facilitated by adding supports (such as grab bars, safety frame, or floor-to- ceiling pole) or using a fixture with integral supports and increasing the visibility (e.g., contrasting color of the toilet or toilet seat from walls) of all fixtures. Improing Caregier Assistance: Prosthetic Deices for Mobility and Transfer Although mobility and transfer tasks are the most strenuous and dif- ficult activities for caregivers, they are also the most frequent tasks with which both formal and informal caregivers provide assistance (Gershon et al., 2008). 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). To reduce injury and facilitate caregiver assistance, a number of prod- ucts 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). These include lift systems for moving individuals through the home as well as products that assist with, or eliminate the need for, transfers in bathing and toileting. Regardless of purpose, however, the effectiveness of devices is impacted by and has unique implications for the design of the home environment.

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2 HUMAN FACTORS IN HOME HEALTH CARE nonrandomized, or controlled/uncontrolled pre-post). There are many practical and ethical concerns, such as the high initial costs of many physi- cal environmental interventions, the costs of changing interventions in crossover designs, the disruption of installing or constructing environmen - tal 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. As a result, the field is dominated by studies of convenience. 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. While these studies help to understand the effects of environmental features, set precedents, and sug- gest trends, there is a basic lack of the critical evidence about the benefits of environmental interventions and their effect on health outcomes that is necessary for policy change. Clearly, a myriad of issues confound environmental studies. However, these issues further complicate research when the physical environment is the intervention. As such, the most practical approach is to use quasi- experimental pretest and posttest designs that leverage the naturally occur- ring context rather than creating or altering it. 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. It is structured like a pretest- posttest randomized experiment but lacks random group assignment. 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. This suggests that funders and programs with vested interests in effecting positive activity and health outcomes must be more proactive in supporting the evalu- ation of intervention effectiveness. 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. Rather, prescrip- tions for environmental interventions must be individualized and context- specific. As a result, it is imperative that research endeavors to understand what works, for whom, and under what circumstances. To do so, measures of efficacy must be defined that are relevant to individuals, programs, and government agencies on both the supply and demand sides of the equa- tion. 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

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2 THE PHYSICAL ENVIRONMENT AND HOME HEALTH CARE Report. 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 interven- tion are involved in these research efforts. CONCLuSIONS While health programs and housing programs in the United States operate independently of each other, the needs of individuals would suggest they should not. For individuals with functional limitations and chronic conditions, housing and health are inextricably intertwined and, with inno- vations in design and technology, are likely to become even more so. These interconnections are bolstered by the public health community itself, as embraced by the model of health embodied in the World Health Organiza- tion’s International Classification of Functioning, Disability and Health, in which the environment is seen as both a therapeutic health care milieu and a prosthetic health intervention. Although decisions about the most effective environmental intervention (assistive technologies, accessible design, or UD) are context specific, UD is the intervention that is most compatible with the ICF model. However, a variety of interconnected barriers have limited the adoption of universally designed products, technologies, and spaces as environmental interventions. Limited information contributes to a lack of consumer demand; limited demand for home modification services results in few experienced providers and remodelers; inexperienced providers and remodelers produce poorly crafted, ill-suited modifications; small, scattered, little-known, and under- utilized funding sources produce a patchwork of public service programs and make it hard for low-income households to undertake projects. Con- sumers are often frustrated by the process of obtaining and making home modifications and are discouraged by the results. The most conspicuous barrier to adoption of this innovation is the policy paradigm that rewards specialized technology and personal assis- tance with limited and calculated benefits rather than everyday universal design, which has potential for multiple and far-reaching benefits. While the increased application of universal design principles requires changes in consumer and provider behavior, it most significantly requires fundamental changes in regulatory policy, from building and zoning codes to reimburse- ment. This includes allowances in the codes to permit health-related envi- ronmental interventions that are necessary for people to remain in their homes. 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. Nonetheless, to overcome biases entrenched

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28 HUMAN FACTORS IN HOME HEALTH CARE 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. Demonstration programs, such as the Money Follows the Person (MFP) Program, can also provide valuable evidence. The MFP Program provides a mechanism for monies to follow the person into the community at levels equitable to those allocated for institutional/nursing home care. In addi- tion, the MFP Program requires the coordination of information, supports, services, and funding across systems, as well as the need for consumer direc- tion and control throughout the process. As of 2010, funding in 31 states enabled more than 27,000 people to transition out of nursing homes and other institutions to community housing (National Council on Disability, 2010). While the MFP Program is demonstrating that the home environment can function in lieu of institutional care, it does not specifically allocate funds for environmental interventions, nor does it designate the home as a health care setting. As a result, the MFP Program is more of a paradigm adjustment than a fundamental change in thinking. As long as housing and health remain separate, decisions about the allocation of monies from each will be driven by bureaucratic rules rather than by the needs of individuals and their health care providers. Ultimately, the adoption of the physical environment, and UD in particular, as a broad-based intervention strategy will require fundamental paradigm shifts in both housing and health that recognize the home environment and everything in it as an integral part of the medical milieu. Today, most UD products and homes are generally more expensive than other consumer products. Typically that is because universally designed products are designed better, are easier to use, and are more desirable. An example is a $300 smart phone compared with other cell phones, many of which are given away. However, the cost of specialized design for a few individuals is even more expensive. Going back to the case of Kara Lynn, when the cost of the $300 iPhone is compared with an $8,000 augmenta- tive communication device that didn’t work as well, the cost savings for the American public per device can be significant. Taken to another level, the cost of new UD housing—or even of retrofitting existing housing with UD modifications that will benefit those who occupy the home now as well as those in the future—will be small compared with the costs of institutional care or having to repeatedly modify the same home to meet the activity and health needs of each occupant over the life span of the residence. The question, therefore, is not about the costs of housing if UD is made a health care intervention, but about the costs of care if nothing is done.

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2 THE PHYSICAL ENVIRONMENT AND HOME HEALTH CARE ABOuT THE AuTHOR Jonathan Sanford is director of the Center for Assistive Technology and Environmental Access in the College of Architecture at the Georgia Institute of Technology and a research architect at the Rehabilitation Research and Development Center of the Atlanta Department of Veterans Affairs. He is an architecturally trained researcher engaged in universal design and the design of accessible environments for older adults. REFERENCES Allen, S., Resnik, L., and Roy, J. (2006). Promoting independence for wheelchair users who live alone: The role of home accommodations. Gerontologist, (1), 115-123. Andersen, L., Schnohr, P., Schroll, M., and Hein, H. (2000). All-cause mortality associated with physical activity during leisure time, work, sports, and cycling to work. Archies of Internal Medicine, 0, 1,621-1,628. . Anderson, G.F. (2005). Medicare and chronic conditions. New England Journal of Medicine, (3), 305-309. Anemaet, W.K., and Moffa-Trotter, M.E. (1999). Promoting safety and function through home assessments. Topics in Geriatric Rehabilitation, 1(1), 26-55. Belser, S.H., and Weber, J.A. (1995). Home builders’ attitudes and knowledge of aging: The relationship to design for independent living. Journal of Housing for the Elderly, 11(2), 123-137. Brooke, J. (2009, September 15). Japanese masters get closer to the toilet nirvana. New York Times. Available: http://www.nytimes.com/2002/10/08/international/asia/08JAPA.html [accessed June 2010]. Bruce, C., and Sanford, J.A. (2009). Assessment for workplace accommodation. In T. Oakland and E. Mpofu (Eds.), Assessment in rehabilitation and health (pp. 205-221). Upper Saddle River, NJ: Prentice Hall. Bureau of Labor Statistics. (2006). Career guide to industries, 200-200 edition. Washington, DC: U.S. Department of Labor. Available: http://www.bls.gov/oco/cg/cgs035.htm [accessed June 2010]. Carter, S.E., Campbell, E.M., Sanson-Fisher, R.W., Redman, S., and Gillespie, W.J. (1997). Environmental hazards in the homes of older people. Age and Aging, 2, 195-202. Center for Technology and Aging. (2009). Technologies for remote patient monitoring in older adults. Draft position paper, December. Center for Universal Design. (1997). The principles of uniersal design, ersion 2.0. Raleigh: North Carolina State University. Available: http://www.design.ncsu.edu/cud/about_ud/ udprincipleshtmlformat.html [accessed February 2010]. Clemson, L., Roland, M., and Cumming, R.G. (1997). Types of hazards in the homes of elderly people. Occupational Therapy Journal of Research, 1(3), 200-213. Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century. (2002). Seniors commission report. Final Report to Congress, June 28. Available: http:// govinfo.library.unt.edu/seniorscommission/pages/final_report/sencomrep.html [accessed September 2009]. Connell, B.R., and Sanford, J.A. (1997). Housing needs of older people to facilitate indepen- dence and safety. In S. Lanspery and J. Hyde (Eds.), Staying put: Adapting the places instead of the people. Amityville, NY: Baywood.

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