Home Modifications to Improve Function and Safety in the United States

A Systematic Review of Home Modifications for Aging in Place in Older Adults

Background/Objectives: The aging population has increased the demand for home modifications to support aging in place. However, existing research primarily focuses on fall prevention and physical safety, leaving gaps in understanding long-term sustainability, social engagement, and cost-effectiveness. Additionally, the interaction between home modifications and health-related changes remains under-explored. This study systematically reviews home modifications, addressing these gaps by considering functional independence, quality of life, caregiving burden, and technological advancements. Methods: A systematic review was conducted following PRISMA 2020 guidelines. One researcher and an external expert performed study selection, data extraction, and quality assessment. Thematic analysis and narrative synthesis were applied to compare study results. Results: Among 20 studies, 13 (65%) confirmed the effectiveness of home modifications in fall prevention, functional independence, and cost savings. Seven studies (35%) highlighted housing accessibility and lifestyle factors. However, few studies examined personalized interventions, smart home technologies, and long-term adaptability. Conclusions: This study emphasizes the need for personalized, technology-driven, and long-term adaptable home modifications. Future research should explore smart home innovations, interdisciplinary approaches, and policy implementation feasibility to develop sustainable aging-in-place strategies. By adopting a holistic perspective, this study provides a new framework for advancing aging-in-place strategies.

Differences in Daily Activity Performance Between Inpatient Rehabilitation Facility and Home Among Stroke Survivors

BACKGROUND

Stroke survivors are one of the largest consumer groups of rehabilitation services. Despite improvement in daily activities while in inpatient rehabilitation, many have difficulty performing daily activities at home after discharge. The difference in performance between a standard clinical context and at home is poorly understood.

OBJECTIVE

To better understand differences in activity performance during transition from inpatient rehabilitation facility (IRF) to home, we examined daily activity performance scores from 2 different environments (IRF and home) at the same time point (discharge).

METHODS

This was a cross-sectional analysis using baseline data from a randomized controlled trial. Participants were stroke survivors aged ≥50 who planned to discharge home from the IRF. The Functional Independence Measure and Section GG codes (both converted to International Classification of Functioning, Disability, and Health scores) were conducted per protocol first at home and then in the IRF at discharge (≤3 days apart, order not randomized).

RESULTS

Among 57 participants, activity scores at home were significantly worse than scores at IRF discharge. Over 40% of participants had discharge scores indicating no-to-mild impairment for shower/tub transfer, walking, and going up/down stairs, while home visit scores indicated moderate-to-complete impairment for those activities. The greatest differences in scores were for shower/tub transfer (median difference 1.5, 95% CI 1.00-2.00) and going up/down stairs (median difference 1.50, 95% CI 1.00-2.00).

CONCLUSION

The environment plays an important role in stroke survivors' functioning at home. Future studies should further examine how the environment impacts activity performance upon returning home following stroke.

Environmental Modifications for People With Intellectual and Developmental Disabilities: A Policy Analysis of Medicaid Home- and Community-Based Services

IMPORTANCE

Environmental modifications are targets for occupational therapy intervention because they support activities of daily living, self-efficacy, personal control, independence, and community living for people with intellectual and developmental disabilities (IDDs).

OBJECTIVE

To examine how environmental modifications were provided to people with IDDs through Medicaid home- and community-based services (HCBS) waivers across the United States in fiscal year (FY) 2021.

DESIGN

Using a mixed-methods policy analysis, we examined FY 2021 Medicaid HCBS 1915(c) waivers from across the United States to examine whether, and how, states provided environmental modifications to people with IDDs.

RESULTS

In FY 2021, 35 states projected spending $68.8 million on environmental modifications for 12,671 people with IDDs. The purpose of environmental modifications was most often to promote the health, welfare, and safety of people with IDDs (82.68%), and to promote their independence (69.29%). The most common examples of environmental modifications included ramps and/or lifts (70.08%), widening doorways and/or hallways (61.42%), bathroom modifications (58.27%), specialized electrical and/or plumbing for medical equipment (54.33%), and grab bars and/or handrails (53.54%).

CONCLUSIONS AND RELEVANCE

HCBS waiver data on environmental modifications for people with IDDs enhances an understanding of this funding source and provides a foundation of advocacy for occupational therapy practitioners to support people with IDDs with living, as well as aging, in the community rather than in institutions. An expansion of environmental modifications in HCBS for people with IDDs aligns with the aim of Medicaid HCBS waivers to promote community integration, self-determination, and independence, which are all benefits of environmental modifications. Plain-Language Summary: This study can help occupational therapy practitioners determine what funding sources are available in their state to help their clients with intellectual and developmental disabilities access environmental modifications. The findings can also help guide advocacy and lobbying efforts to expand access to environmental modifications.

Common home hazards among healthy older aged adults and potential modifications required for age-friendly housing

INTRODUCTION

The creation of age-friendly home environments enables middle-aged and older aged people to live independently at home while adapting to age-related changes. Little is currently known about existing home hazards that may potentially hinder healthy older people as they age.

METHODS

Prospective cohort study of healthy adults who received an age-friendly home environment assessment conducted by an occupational therapist. Adults aged 60 and over, without significant disability, living in homes within metropolitan Adelaide, South Australia were recruited through community advertising.

RESULTS

Sixty age-friendly home environment assessments were conducted. Common areas where potential hazards were identified, and modifications recommended were bathrooms, toilets and backyards. Gardens were commonly identified as potentially requiring modifications in the future. Participants were more likely to consider moving to new housing if additional modifications were needed to their homes.

CONCLUSION

Affordable and accessible age-friendly housing is required to support an ageing population. Education on age-friendly housing for healthy middle and older aged people is required enabling proactive planning rather than awaiting health crises.

A mobile application-based home assessment tool for patients undergoing joint replacement surgery: A qualitative feasibility study

BACKGROUND

Most adults prefer to age in place. However, the majority of homes are not designed to support resident needs, especially for adults undergoing joint replacement surgeries such as total knee arthroplasty (TKA) or total hip arthroplasty (THA). It is of paramount importance to proactively assess and modify the homes of adults undergoing TKA/THA such that they can safely transition home following surgery. Several tools utilize emerging technology like virtual reality, augmented reality, or teleconferencing to assess home environments. These are meant to be used by professionals like occupational therapists. However, the acceptance and uptake of simple technology like mobile applications for assessing homes proactively by residents has not been explored.

OBJECTIVE

A qualitative exploratory study was conducted to evaluate the feasibility and potential acceptance of a mobile application for resident-initiated home assessment.

METHODS

Semi-structured interviews were conducted with 22 patient-care partner dyads before and after THA/TKA to understand the perceived usefulness, likelihood of using a mobile application-based home assessment tool, and perceived barriers and facilitators of using the tool.

RESULTS

About 68% of the patient-care partner dyads interviewed for this study perceived benefits of using a mobile application-based tool. All the participants who perceived the tool to be useful showed high likelihood of using it. A comparison of responses between pre-and post-surgery interviews revealed that around 50% of participants showed an increased intention of using an assessment tool after experiencing challenges in their homes post-surgery. Participants provided recommendations for key content, potential features to include in the assessment tool, and preferred formats (e.g., checklists, visuals, and videos).

CONCLUSIONS

To increase acceptance of a mobile application-based home assessment tool, it is crucial that residents are made aware of the home environment challenges and the importance of an assessment tool to improve their safety and independence. The content, features, formats, and usability suggestions from the participants in this study provide a framework for health mobile application and interface developers to design a home assessment tool.

Adoption of Major Housing Adaptation Policy Innovation for Older Adults by Provincial Governments in China: The Case of Existing Multifamily Dwelling Elevator Retrofit Projects

(1) Background: The housing environment is crucial to the health of older Chinese people and is becoming an urgent policy initiative. This study explores factors that facilitate or impede the adoption of policy innovation on major housing adaptation (HA) by Chinese provincial governments using the framework of policy innovation and diffusion theory. (2) Methods: This study constructs an event history dataset on HA policy related to elevator retrofitting in existing multifamily dwellings in China; the lack of elevators constitutes an insurmountable barrier in older adults’ daily lives in China. The hypotheses were tested by using a traditional event history analysis (EHA) model and a piecewise constant exponential (PCE) model, which is a modified EHA model. The dataset was summarized as “province-year” event history data on 30 Chinese provinces from 2008 to 2019. (3) Results: In addition to internal determinants (e.g., population aging level and financial dependency), diffusion mechanisms can significantly facilitate or impede the adoption of major HA policy innovation by provincial governments. Policy adoption by neighboring governments helps facilitate policy adoption by nonadopters, but policy adoption by subordinate city governments impedes provincial governments’ adoption of major HA policy innovation. (4) Conclusions: This study concludes that provincial governments’ adoption of major HA policy innovation should be given a higher policy priority. The central government can promote provincial governments’ adoption of major HA that primarily benefits older adults by using fiscal transfer payments and enhancing the legitimacy of such policy.

Examining Older Adults' Home Functioning Using the American Housing Survey

Identifying individuals at risk of experiencing functional difficulty at home would support timely home safety assessment and modification services, which could lead to reducing home incidents such as falls. The objective of this study was to calculate older adults’ functional difficulty at home scores using the 12 physical function items in the American Housing Survey National and Metropolitan Data (AHS). Among the 28,474 older adults selected for this study, we used 19,932 for measurement model development and 8542 for model testing. Confirmatory factor analysis confirmed an adequate fit of the one-dimensional model with all AHS 12 items loading on one latent construct (functional difficulty at home) (RMSEA: 0.034, CFI: 0.990, and TLI: 0.988). Based on our model selection process, we determined that the Graded Response Model was an optimal model for our analysis and separated two detected differential functioning items for each sex. Using the testing dataset, we validated that the estimated functional difficulty scores showed an expected item hierarchy and statistically significant differences in their association with housing and demographic conditions (p < 0.001). Our results demonstrated the process of using the 12 AHS physical function at home items to produce validated scores of older adults’ functional difficulty at home.

Current Condition of Home Environment and Necessary Home Modifications for Elderly in Community

This study aimed to investigate the home environment conditions of the elderly living in the community and to confirm the needs of the residential environment. This study was conducted from January 15th to 25th, 2018, in 12 elderly households in Chungcheongnam-do, using a structured questionnaire and a home environment checklist. The elderly did not feel uncomfortable with their current home, but they wanted to modify their home environment to improve their quality of life. Investigation using home environment checklists showed that demands for supportive design were lacking in the overall areas. On the results of this study, it was confirmed that it is essential to reflect the residents’ occupation, physical characteristics, and needs when constructing the home environment for the healthy life of the elderly in the community.

Understanding key home and community environment challenges encountered by older adults undergoing total knee or hip arthroplasty

BACKGROUND AND OBJECTIVES

Older adults undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) experience significant challenges while navigating their homes post-surgery and are at higher risk for falls and injuries. This study explored specific home and community physical environment challenges faced by community-dwelling older adults while performing daily activities and actions taken to modify their homes before surgery.

RESEARCH DESIGN AND METHODS

Using a qualitative descriptive methodology, semi-structured interviews were conducted with 22 older adult-care partner dyads pre- and post-surgery to identify key built environment barriers and facilitators in addition to home modifications made pre-and post-surgery.

RESULTS

Challenges anticipated by participants to perform daily activities pre-surgery varied from those experienced post-surgery. Lack of support along stairs or in bathrooms, flooring material, and transitions were significant concerns raised by participants pre-surgery. Size and layout of home and ergonomics of resting furniture were recognized as issues post-surgery. Modifications ranged from easy fixes like rearranging furniture, removing clutter, installing grab bars to high-cost structural changes like remodeling critical spaces like bathrooms. Although participants agreed on the importance of conducting proactive home assessments and modifications before surgery, perceived costs, and lack of knowledge or services limit older adults from implementing some changes.

DISCUSSION AND IMPLICATIONS

Home modifications must be considered proactively before an event such as a THA or TKA. These should be done within the context of the specific needs, abilities, financial capabilities, and social and physical home environments of the individual and the residential caregivers.