|
||||||||||||||||
|
||||||||||||||||
The following HTML text is provided to enhance online readability. Many aspects of typography translate only awkwardly to HTML. Please use the page image as the authoritative form to ensure accuracy. 10
|
||||||||||||||||
 |
 |
Page 201 |
 |
 |
 |
|
| ||||||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||||
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 201
The Role of Human Factors in Home Health Care: Workshop Summary
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-
OCR for page 202
The Role of Human Factors in Home Health Care: Workshop Summary
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 promotion is the creation of environments that support healthy living and well-being (World Health Organization, 1991). Nonetheless, the environment 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.
OCR for page 203
The Role of Human Factors in Home Health Care: Workshop Summary
This chapter examines the prosthetic and therapeutic roles of the environment in promoting positive activity and health outcomes, identifies barriers to supportive home environments, and proposes that universal 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 independent living and health management. Specifically, the chapter presents (1) a theoretical background to support the role of the environment in independent living and home health care; (2) a discussion of the relationship between prosthetic environmental interventions and improved activity outcomes 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 treatment 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 activity 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
OCR for page 204
The Role of Human Factors in Home Health Care: Workshop Summary
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 positive impacts on functioning of individuals and their caregivers. In fact, one study (Freedman, Martin, and Schoeni, 2002) suggests that gains in functioning of older adults over the past few decades may be the result, in part, of the introduction of facilitators and the reduction of environmental barriers. 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.
OCR for page 205
The Role of Human Factors in Home Health Care: Workshop Summary
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 activities 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).
OCR for page 206
The Role of Human Factors in Home Health Care: Workshop Summary
Differences between medical and social models have important implications for health and independent living in the home and community. Medical 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 accomplished 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 assessing 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
OCR for page 207
The Role of Human Factors in Home Health Care: Workshop Summary
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 information that is both valid and reliable. Yet assessments are conducted by an array of home health service providers—occupational therapists, rehabilitation 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 performance (Sanford and Bruce, 2010). Although both are common and have their benefits, the results of each are subject to different levels of bias, validity, 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 performance result in a prediction of potential, rather than actual, environmental 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 environmental 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 accessibility 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-
OCR for page 208
The Role of Human Factors in Home Health Care: Workshop Summary
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 modifications for a particular client?
Actual Performance: Assessing Needs from Activity
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). Thus, when performance outcomes can be determined, as is the case when an individual is living at home, then measurement of actual demands will provide a more accurate picture of environmental 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 modification 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 determine what specific changes should actually be made.
Linking the Three A’s: Ability, Activity, 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
OCR for page 209
The Role of Human Factors in Home Health Care: Workshop Summary
other home assessments, requires a specialist onsite to collect the required information.
Remote Assessment: Overcoming 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 information 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 videoconferencing technology (e.g., as little as $1,200 for two videophones and a video camera) that uses the telephone system enables specialists to conduct 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 improving 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 providing 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 interventions 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.
Improving Independent Activity: 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
OCR for page 210
The Role of Human Factors in Home Health Care: Workshop Summary
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.
Movement 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, walkways 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 individuals 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 constructed 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 Activities. The bathroom, with its wet, slippery surfaces, small, cramped spaces, and hard surfaces can easily lead to falls and serious injury, even for people without functional limitations.
OCR for page 211
The Role of Human Factors in Home Health Care: Workshop Summary
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 balance 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.
Improving Caregiver Assistance: Prosthetic Devices for Mobility and Transfer
Although mobility and transfer tasks are the most strenuous and difficult 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 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). 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.
OCR for page 236
The Role of Human Factors in Home Health Care: Workshop Summary
nonrandomized, or controlled/uncontrolled pre-post). 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. 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 suggest 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 occurring 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 evaluation 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, prescriptions 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 equation. 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
OCR for page 237
The Role of Human Factors in Home Health Care: Workshop Summary
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 intervention 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 innovations 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 Organization’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 underutilized funding sources produce a patchwork of public service programs and make it hard for low-income households to undertake projects. Consumers 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 assistance 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 reimbursement. This includes allowances in the codes to permit health-related environmental 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
OCR for page 238
The Role of Human Factors in Home Health Care: Workshop Summary
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 addition, the MFP Program requires the coordination of information, supports, services, and funding across systems, as well as the need for consumer direction 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 augmentative 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.
OCR for page 239
The Role of Human Factors in Home Health Care: Workshop Summary
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, 46(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. Archives of Internal Medicine, 60, 1,621-1,628..
Anderson, G.F. (2005). Medicare and chronic conditions. New England Journal of Medicine, 353(3), 305-309.
Anemaet, W.K., and Moffa-Trotter, M.E. (1999). Promoting safety and function through home assessments. Topics in Geriatric Rehabilitation, 15(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, 2006-2007 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, 26, 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 universal design, version 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, 17(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 independence and safety. In S. Lanspery and J. Hyde (Eds.), Staying put: Adapting the places instead of the people. Amityville, NY: Baywood.
OCR for page 240
The Role of Human Factors in Home Health Care: Workshop Summary
Connell, B.R., and Sanford, J.A. (2001). Difficulty, dependence, and housing accessibility for people aging with a disability. Journal of Architectural and Planning Research, 18(1), 3-18.
Connell, B.R., Sanford, J.A., Long, R.G., Archea, C.K., and Turner, C.S. (1993). Home modifications and performance of routine household activities by individuals with varying levels of mobility impairment. Technology and Disability, 2(4), 9-18.
Coyte, P., and Young, W. (1997). Applied home care research. International Journal of Health Care Quality Assurance, 10(1), i-iv.
Cumming, R.G., Thomas, M., Szonyi, G., Frampton, G., Salkeld, G., and Clemson, L. (2001). Adherence to occupational therapist recommendations for home modifications for falls prevention. American Journal of Occupational Therapy, 55, 641-648.
Cumming, R.G., Thomas, M., Szonyi, G., Salkeld, G., O’Neill, E., Westbury, C., and Frampton, G. (1999). Home visits by an occupational therapist for assessment and modification of environmental hazards: A randomized trial of falls prevention. Journal of the American Geriatrics Society, 47, 1,397-1,402.
Davis, S. (1997). The architecture of affordable housing. Berkeley: University of California Press.
Fange, A., and Iwarsson, S. (2003). Accessibility and usability in housing: Construct validity and implications for research and practice. Disability and Rehabilitation, 25, 1,316-1,325.
Fazzone, P.A., Barloon, L.F., McConnell, S.J., et al. (2000). Personal safety, violence, and home health. Public Health Nursing, 17, 43-52.
Ferrucci, L., Guralnik, J.M., Studenski, S., Fried, L.P., Cutler, G.B., Jr., and Walston, J.D. (2004). Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: A consensus report. Journal of the American Geriatrics Society, 52, 625-634.
Filion, P., Wister, A., and Coblentz, E.J. (1992). Subjective dimensions of environmental adaptation among the elderly: A challenge to models of housing policy. Journal of Housing for the Elderly, 10(1 and 2), 3-32.
Fisher, G.S., Coolbaugh, K. and Rhodes, C. (2006). A field test of the Cougar home safety assessment for older persons, version 1.0. Californian Journal of Health Promotion, 4(2), 181-196.
Fisher, G.S., Kintner, L. Bradley, E., Costulas, D., Kozlevcar, J. Mahonski, K, McMenamin, K., Rompilla, A. Woods, J., Stine, J., and Ewonishon, K. (2008). Home modification outcomes in the residences of older people as a result of Cougar home safety assessment (version 4.0) recommendations. Californian Journal of Health Promotion, 6(1), 87-110.
Frank, L., Engelke, P.O., and Schmid, T.L. (2003). Health and community design: The impact of the built environment on physical activity. Washington, DC: Island Press.
Freedman, V.A., Martin, L.G., and Schoeni, R.F. (2002). Recent trends in disability and functioning among older adults in the United States. Journal of the American Medical Association, 288, 3,137-3,146.
Frumpkin, H. (2003). Healthy places: Exploring the evidence. American Journal of Public Health, 93(9), 1,451-1,456.
Galinsky, T., Waters, T., and Malit, B. (2001). Overexertion injuries in home health care workers and the need for ergonomics. Home Health Care Service Quarterly, 20, 57-73.
Gershon, R.M., Pogorzelska, M.T., Qureshi, K.A., Stone, P.W., Canton, A.N., Samar, S.M., Westra, L.J., Damsky, M.M., and Sherman, M. (2008). Home health care patients and safety hazards in the home: Preliminary findings. Available: http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Gershon_88.pdf [accessed September 2009].
Gilderbloom, J.L., and Markham, J.P. (1996). Housing modification needs of the disabled elderly: What really matters? Environment and Behavior, 28(4), 512-535.
OCR for page 241
The Role of Human Factors in Home Health Care: Workshop Summary
Gill, T.M., Williams, C.S., Robison, J.T., and Tinetti, M.E. (1999). A population-based study of environmental hazards in the homes of older persons. American Journal of Public Health, 89, 553-556.
Gill, T.M., Williams, C.S., and Tinetti, M.E. (2000). Environmental hazards and the risk of nonsyncopal falls in the homes of community-living older persons. Medical Care, 38(12), 1,174-1,183.
Gitlin, L.N. (2003). Conducting research on home environments: Lessons learned and new directions, Gerontologist, 43, 628-637.
Gitlin, L.N., and Corcoran, M. (2000). Helping homes be safe: Environmental adaptations for people with dementia. Alzheimer’s Care Quarterly, 1(1), 45-54.
Gitlin, L.N., Corcoran, M.A., Winter, L., Boyce, A, and Hauck, W.W. (2001a). A randomized, controlled trial of a home environmental intervention to enhance self-efficacy and reduce upset in family caregivers of persons with dementia. Gerontologist, 41, 15-30.
Gitlin, L.N., Liebman, J., and Winter, L. (2003). Are environmental interventions effective in the management of Alzheimer’s disease and related disorders? A synthesis of the evidence. Alzheimer’s Care Quarterly, 4, 85-107.
Gitlin, L.N., Mann, W., Tomita, M., and Marcus, S.M. (2001b). Factors associated with home environmental problems among community-living older people. Disability and Rehabilitation, 23(17), 777-787.
Gitlin, L.N., Winter, L., Corcoran, M., Dennis, M., Shinfeld, S., and Hauck, W. (2003). Effects of the home environmental sill-building program on the caregiver-care reciepient dyad: Six-month outcomes from the Philadelphia REACH initiative. Gerontologist, 43, 532-546.
Glass, T.A. (1998). Conjugating the tenses of function: Discordance among hypothetical, experimental and enacted function in older adults. Gerontologist, 38(1), 101-112.
Gosselin, C., Robitaille, Y., Trickey, F., and Maltais, D. (1992). Factors predicting the implementation of home modifications among elderly people with loss of independence, Physical and Occupational Therapy in Geriatircs, 12(1),15-27.
Hoenig, H., Sanford, J.A., and Griffiths, P. (2006). Development of a tele-technology protocol for in-home rehabilitation. Journal of Rehabilitation Research and Development, 43(2), 287-298.
Hyde, J., Talbert, R., and Grayson, P.J. (1997). Fostering adaptive housing: An overview of funding sources, laws and policies. In S. Lanspery and J. Hyde (Eds.), Staying put: Adapting the places instead of the people (pp. 223-236). Amityville, NY: Baywood.
Institute of Medicine. (1997). Enabling America: Assessing the role of rehabilitation science and engineering. J. Brandt and A.M. Pope (Eds.). Committee on Assessing Rehabilitation Science and Engineering. Division of Health Sciences Policy. Washington, DC: National Academy Press.
International Longevity Center-USA. (2006). Caregiving in America. The Caregiving Project for Older Americans. Available: http://www.ilcusa.org/media/pdfs/Caregiving%20in%20America-%20Final.pdf [accessed June 2010].
Iwarsson, S. (1999). The housing enabler: An objective tool for assessing accessibility. British Journal of Occupational Therapy, 62(11), 491-497.
Iwarsson, S. (2004). Assessing the fit between older people and their home environments: An occupational therapy research perspective. In H.-W. Wahl, R. Schiedt, and P. Windley (Eds.), Annual review of the Gerontological Society of America 2003, vol. 23: Focus on aging in context: Socio-Physical environments (pp. 85-109). New York: Springer.
Iwarsson, S. (2005). A long-term perspective on person-environment fit and ADL dependence among older Swedish adults. Gerontologist, 45, 327-336.
OCR for page 242
The Role of Human Factors in Home Health Care: Workshop Summary
Iwarsson, S., and Isacsson, A. (1996). Housing standards, environmental barriers in the home, and subjective general apprehension of housing situation among the rural elderly. Scandinavian Journal of Occupational Therapy, 3(2), 52-61.
Joint Center for Housing Studies. (2000). The state of the nation’s housing 1999. Cambridge, MA: Author.
Kendra, M.A., Weiker, A., Simon, S., Grant, A., and Shullick, D. (1996). Safety concerns affecting delivery of home health care. Public Health Nursing, 13, 83-89.
Kochera, A. (2002). Falls among older persons and the role of the home: An analysis of cost, incidence and potential savings from home modification. AARP Public Policy Institute. Available: http://assets.aarp.org/rgcenter/il/inb49_falls.pdf [accessed June 2010].
LaPlante, M.P., Hendershot, G.E., and Moss, A.J. (1992). Assistive technology devices and home accessibility features: Prevalence, payment, need and trends. National Center for Health Statistics Advance Data, 217, 1,012.
Lau, D.T., Scandrett, K., Jarzebowski, M., Holman, K., and Emanuel, L. (2007). Health-related safety: A framework to address aging in place. Gerontologist, 47(6), 830-837.
Law, M., Baptiste, S., Carswell-Opzoomer, A., McColl, M.A., Polatajko, H., and Pollock, N. (1991). Canadian Occupational Performance Measure. Toronto, ON: CAOT.
Lawler, K. (2001). Aging in place: Coordinating housing and health care provision for America’s growing elderly population. Cambridge, MA: Joint Center for Housing Studies of Harvard University’s Neighborhood Reinvestment Corporation.
Lawton, M.P., and Nahemow, L. (1973). Ecology and the aging process. In C. Eisdorfer and M.P. Lawton (Eds.), The psychology of adult development and aging (pp. 619-674). Washington, DC: American Psychological Association.
Lehoux, P. (2004, October 5). Patients’ perspectives on high-tech home care: A qualitative inquiry into the user-friendliness of four interventions. BMC Health Services Research, 4(28). Available: http://www.biomedcentral.com/1472-6963/4/28 [accessed June 2010].
Lehoux, P., Richard, L., Pineault, R., and Saint-Arnaud, J. (2006). Delivery of high-tech home care by hospital based nursing units in Quebec: Clinical and technical challenges. Nursing Leadership, 19(1), 44-55. Available: http://120.72.90.83/longwoods/content/18048 [accessed June 2010].
Letts, L., Scott, S., Burtney, J., Marshall, L., and McKean, M. (1998). The reliability and validity of the safety assessment of function and the environment for rehabilitation (SAFER Tool). British Journal of Occupational Therapy, 61(3), 127-132.
Louie, J. (1999). Housing modifications for disabled elderly households. Cambridge, MA: Joint Center for Housing Studies of Harvard University.
Mace, R.L., Hardie, G.J., and Place, J.P. (1991). Accessible environments: Towards universal design. In W.E. Preiser, J.C. Vischer, and E.T. White (Eds.), Design intervention: Toward a more humane architecture. New York: Van Nostrand Reinhold.
Manangan, L.P., Pearson, M.L., Tokars, J.I., Miller, E., and Jarvis, W.R. (2002). Feasibility of national surveillance of health care associated infections in home care settings. Emerging Infectious Diseases, 8, 233-236.
Mann, W.C., Ottenbacher, K.J., Fraas, L., Tomita, M., and Granger, C.V. (1999). Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care costs for frail elderly: A randomized controlled trial. Archives of Family Medicine, 8, 210-217.
Markkanen, P., Quinn, M., Galligan, C., et al. (2007). There’s no place like home: A qualitative study of the working conditions of home health care providers. Journal of Occupational and Environmental Medicine, 49(3), 327-337.
Mathews, J.T. (2006). Existing and emerging healthcare devices for elders to use at home. Generations Journal of the American Society on Aging, 30(2), 13-19.
OCR for page 243
The Role of Human Factors in Home Health Care: Workshop Summary
Mills, T., Holm, M.B., and Christenson, M.A. (2001). Public opinion of universal design in housing. Proceedings of the Annual RESNA Conference. Washington, DC: RESNA Press.
Myers, A., Jensen, R.C., Nestor, D., and Rattiner, J. (1993). Low back injuries among home health aides compared with hospital nursing aides. Home Health Care Services Quarterly, 14, 149-155.
National Council on Disability. (2010). The state of housing in America in the 21st century: A disability perspective. Washington, DC: Author.
Niva, B., and Skar, L. (2006). A pilot study of the activity patterns of five elderly persons after a housing adaptation. Occupational Therapy International, 13(1), 21-34.
Ono, Y., Lagerstrom, M., and Hagberg, M., et al. (1995). Reports of work related musculoskeletal injury among home care service workers compared to nursery school workers and the general population of employed women in Sweden. Occupational and Environmental Medicine, 52, 686-693.
Oswald, F., and Wahl, H.-W. (2004). Housing and health in later life. Reviews of Environmental Health, 19(3-4), 223-252.
Oswald, F., Schilling, O., Wahl, H.-W., and Gang, K. (2002). Trouble in paradise? Reasons to relocate and objective environmental changes among well-off older adults. Journal of Environmental Psychology, 22, 273-288.
Oswald, F., Wahl, H.-W., Schilling, O., Nygren, C., Fange, A., Sixsmith, A., Sixsmith, J., Szeman, Z., Tomsone, S., and Iwarsson, S. (2007). Relationships between housing and healthy aging in very old age. Gerontologist, 47, 96-107.
Pynoos, J. (1992). Strategies for home modification and repair. Generations: Journal of the American Society on Aging, 16(2), 21-25.
Pynoos, J. (1993). Toward a national policy on home modification. Technology and Disability, 2(4), 1-8.
Pynoos, J., and Regnier, V. (1997). Design directives in home adaptation. In S. Lanspery and J. Hyde (Eds.), Staying put: Adapting the places instead of the people (pp. 171-191). Amityville, NY: Baywood.
Pynoos, J., Angelleli, J., Tabbarah, M., and De Meire, M. (1996). Improving the delivery of home modifications. Los Angeles: National Resource Policy Center on Housing and Long Term Care.
Pynoos, J., Cohen, E., Davis, L., and Bernhardt, S. (1987). Home modifications: Improvements that extend independence. In V. Regnier and J. Pynoos (Eds.), Housing the aged: Design directives and policy considerations (pp. 277-303). New York: Elsevier.
Pynoos, J., Liebig, P., Overton, J., and Calvert, E. (1997). The delivery of home modification and repair services. In S. Lanspery and J. Hyde (Eds.), Staying put: Adapting the places instead of the people (pp. 171-191). Amityville, NY: Baywood.
Rubenstein, L.Z. (1999). The importance of including the home environment in assessment of frail older people. Journal of the American Geriatrics Society, 47, 111-112.
Saelens, B., Sallis, J., and Frank, L. (2003). Environmental correlates of walking and cycling: Findings from the transportation, urban design, and planning literature. Annals of Behavioral Medicine, 25(2), 80-91.
Sanford, J. (2002). Development of a comprehensive assessment for delivery of home modifications. Physical and Occupational Therapy in Geriatrics, 20(2), 43-55.
Sanford, J.A. (2004). Home modifications: Assessment, implementation and innovation. Presented at the American Occupational Therapy Association Annual Conference, May 19, Minneapolis, MN.
Sanford, J.A. (2010). Assessing universal design in the physical environment. In T. Oakland and E. Mpofu (Eds.), Rehabilitation and health assessment (pp. 255-278). New York: Springer.
OCR for page 244
The Role of Human Factors in Home Health Care: Workshop Summary
Sanford, J., and Bruce, C. (2010). Measuring the impact of the physical environment. In T. Oakland and E. Mpofu (Eds.), Rehabilitation and health assessment (pp. 207-228). New York: Springer.
Sanford, J.A., and Butterfield, T. (2005). Using remote assessment to provide home modification services to underserved elders. Gerontologist, 45, 389-398.
Sanford, J., and Hammel, J. (2006). Impact of accessibility modifications to the home environment on community living and activity. Gerontological Society of American Annual Conference, Dallas, TX.
Sanford, J.A., and Megrew, M.B. (1995). An evaluation of grab bars to meet the needs of elderly people. Assistive Technology, 7(1), 36-47.
Sanford, J.A., Echt, K., and Malassigne, P. (1999). An E for ADAAG: The case for accessibility guidelines for the elderly based on three studies of toilet transfer. Journal of Physical and Occupational Therapy in Geriatrics, 16(3/4), 22-23.
Sanford, J.A., Griffiths, P.M., Richardson, P., Hargraves, K., Butterfield, T., and Hoenig, H. (2006). The effects of in-home rehabilitation on task self efficacy in mobility impaired adults: A randomized clinical trial. Journal of American Geriatrics Society, 54, 1,641-1,648.
Sanford, J.A., Griffiths, P.M., Richardson, P., Hargraves, K., Butterfield, T., and Hoenig, H. (2007). A comparison of televideo and traditional in-home rehabilitation in mobility impaired older adults. Journal of Physical and Occupational Therapy in Geriatrics, 25(3), 1-18.
Sanford, J.A., Jones, M.L., Daviou, P., Grogg, K., and Butterfield, T. (2004). Using telerehabilitation to identify home modification needs. Assistive Technology, 16(1), 43-53.
Sanford, J.A., Pynoos, J., Gregory, A., and Browne, A. (2001). Development of a comprehensive assessment for delivery of home modifications. Physical and Occupational Therapy in Geriatrics, 20(2), 43-55.
Sanford, J., Story, M., and Jones, M. (1997). An analysis of the effects of ramp slope on people with mobility impairments. Assistive Technology, 9, 22-33.
Scheidt, R., and Windley, P. (2006). Environmental gerontology: Progress in the post-Lawton era. In J.E. Birren and K.W. Schaie (Eds.), Handbook of the psychology of aging (6th edition, pp. 105-125). Amsterdam: Elsevier.
Scheschareg, R. (2006). Gaining access to the $300 billion+ consumer out-of-pocket spending market. Intuitive Care Advisors Advanced Home Healthcare Products and Services 2005 channel Report. Available: http://www.agingtech.org/documents/Advanced_Home_ Healthcare_P&S.pdf [accessed June 2010].
Sinding, C. (2003). Disarmed complaints: Unpacking satisfaction with end-of-life care. Social Science and Medicine, 57, 1,375-1,385.
Sohn, J. (1997). Older consumers’ pre- and post-trial perceptions of residential universal design features. Unpublished master’s thesis. Kansas State University, Manhattan.
Spillman, B.C. (2004). Changes in elderly disability rates and the implications for health care utilization and cost. Milbank Quarterly, 82, 157-194.
Stark, S. (2004). Removing environmental barriers in the homes of older adults with disabilities improves occupational performance. Occupation, Participation and Health, 24, 32-39.
Stark, S.L., and Sanford, J.A. (2005). Environmental enablers and their impact on occupational performance. In C. Christiansen and C.M. Baum (Eds.), Occupational therapy: Performance, participation, and well-being (pp. 298-337). Thorofare, NJ: Slack, Inc.
Steinfeld, E., and Shea, S. (1993). Enabling home environments. Technology and Disability, 2(4), 69-79.
OCR for page 245
The Role of Human Factors in Home Health Care: Workshop Summary
Stineman, M.G., Ross, R.N., Masilin, G., and Gray, D. (2007). Population-based study of home accessibility features and the activities of daily living: clinical and policy implications. Disability and Rehabilitation, 8(2), 34-45.
Tinetti, M.E., Baker, D., Gallo, W.T., Nanda, A., Charpentier, P., and O’Leary, J. (2002). Evaluation of restorative care vs. usual care for older adults receiving an acute episode of home care. Journal of the American Medical Association, 287, 2,098-2,105.
Tinetti, M.E., Richman, D., and Powell, L. (1990). Falls efficacy as a measure of fear of falling. Journal of Gerontology, 45(6), P239-P243.
U.S. Access Board. (2002). ADA accessibility guidelines for buildings and facilities (ADAAG). Available: http://www.access-board.gov/adaag/html/adaag.htm [accessed June 2010].
U.S. Bureau of the Census. (1994). Statistical abstract of the United States, 114th edition. Washington, DC: U.S. Department of Commerce.
Vance, A. (2009, September 15). Insurers fight speech impairment remedy. The New York Times. Available: http://www.nytimes.com/2009/09/15/technology/15speech.html [accessed June 2010].
Vebrugge, L., and Sevak, P. (2002). Use, type and efficacay of assistance for disability. Journal of Gerontology. Series B. Psychological and Social Sciences, 57, S366-S379.
Wahl, H.-W. (2001). Environmental influences on aging and behavior. In J.E. Birren and K.W. Schaie (Eds.), Handbook of the psychology of aging, 5th edition (pp. 215-237). San Diego: Academic Press.
Wahl, H.-W., Fange, A., Oswald, F., Gitlin, L.N., and Iwarsson, S. (2009). The home environment and disability-related outcomes in aging individuals: What is the empirical evidence? Gerontologist, 49(3), 355-367.
Wolford, N. (2000). Universal design standards for single-family housing. Unpublished doctoral dissertation, Oregon State University.
Woodward, C.A., Abelson, J., Tedford, S., and Hutchison, B. (2004). What is important to continuity in home care? Perspectives of key stakeholders. Social Science and Medicine, 58, 177-192.
World Health Organization. (1980). The international classification of impairment, disability and health (p.143). Geneva: Author.
World Health Organization. (1991). Action for public health: Sundsvall statement on supportive environments. Sundsvall, Sweden: Author.
World Health Organization. (2001). International classification of functioning, disability and health. Geneva: Author.
Wu, S., and Green, A. (2000). Projection of chronic illness prevalence and cost inflation. Santa Monica, CA: RAND Corporation.
OCR for page 246
The Role of Human Factors in Home Health Care: Workshop Summary
This page intentionally left blank.