This law was intended to protect society from squalid living conditions that were associated with smallpox and tuberculosis epidemics. Consumers are often frustrated by the process of obtaining and making home modifications and are discouraged by the results. “We would not cover the iPhones and netbooks with speech-generating software capabilities because they are useful in the absence of an illness or injury,” said Peter Ashkenaz, a spokesman for the federal Centers for Medicare & Medicaid Services. Home visits by an occupational therapist for assessment and modification of environmental hazards: A randomized trial of falls prevention. However, CASPAR, like. Frank, L., Engelke, P.O., and Schmid, T.L. In contrast, environmental facilitators reduce barriers and have positive impacts on functioning of individuals and their caregivers. (2004). 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). Only recently have professional organizations created certification programs, although none is sufficiently comprehensive to ensure a broad knowledge of home environmental interventions. 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. New York: Elsevier. 207-228). Stairs, in particular, account for a greater number of falls than any other single location in the home (Kochera, 2002). According to the World Health Organization in its 1948 constitution, “Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” While it may seem that energy is one of the largest contributors to costs in buildings, according to the World Economic Forum and others, salary/benefits make up 90 percent of those costs, rent/operations 9 percent and energy just 1 percent. Alzheimer’s Care Quarterly, 4, 85-107. Available: http://assets.aarp.org/rgcenter/il/inb49_falls.pdf [accessed June 2010]. After three decades of debate, there are few empirical data and a general lack of psychometrically sound measures (Gitlin, 2003). However, because the reimbursement system is client-centric, it is concerned with meeting the needs of individual clients. Housing standards, environmental barriers in the home, and subjective general apprehension of housing situation among the rural elderly. ), Staying put: Adapting the places instead of the people (pp. In C. Eisdorfer and M.P. 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. Seniors commission report. (2006). Oswald, F., Schilling, O., Wahl, H.-W., and Gang, K. (2002). For example, Matsushita has been developing a variety of health-enabled bathroom products, such as a toilet seat with embedded passive monitoring sensors to monitor and send weight and body fat ratio, heartbeat, blood pressure, and glucose levels to the patient’s doctor via the Internet (Brooke, 2009). Environmental influences on aging and behavior. ), Annual review of the Gerontological Society of America 2003, vol. Consumers also may believe that the costs of environmental modifications are prohibitive, even when they know the benefits. With LEED, the focus became more holistic, addressing broad sustainability goals, including interrelated operational issues such as energy efficiency, water use, materials, waste management, and indoor environmental quality, as well as some measures to improve occupant health. Available: http://www.nytimes.com/2002/10/08/international/asia/08JAPA.html [accessed June 2010]. New York: Springer. Connell, B.R., and Sanford, J.A. Journal of Gerontology, 45(6), P239-P243. Topics in Geriatric Rehabilitation, 15(1), 26-55. includes both outdoor and indoor surroundings. nonrandomized, or controlled/uncontrolled pre-post). 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. British Journal of Occupational Therapy, 61(3), 127-132. Many home modifications would be unnecessary if homes had originally been designed to better meet people’s needs. Difficulty and dependence are common outcomes that can measure performance either directly, through observations or self-report (e.g., Connell et al., 1993; Connell and Sanford, 2001), or indirectly, through self-efficacy (Tinetti, Richman, and Powell, 1990; Sanford et al., 2006). In addition, many home modification programs in the United States have capped costs from $5,000 to $10,000, which will generally cover only a ramp and some bathroom modifications. Disability and Rehabilitation, 23(17), 777-787. Bathroom floors are extremely dangerous when wet. Its goal is to lay the groundwork for a thorough integration of human factors research with the design and implementation of home health care devices, technologies, and practices. 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. 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. In its stead, there is a fragmented system of services provided by various public and private health care and social service organizations (Pynoos et al., 1997; Lau et al., 2007) that are hampered by a lack of information, experience, funding, and resources. An analysis of the effects of ramp slope on people with mobility impairments. Yet the earliest example of a building law—the New York City Tenement House Act of 1867—was precisely a means to social policy (Davis, 1997). Connell, B.R., and Sanford, J.A. (1997). 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). 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. Gerontologist, 49(3), 355-367. Ecology and the aging process. Aging in place: Coordinating housing and health care provision for America’s growing elderly population. ), Staying put: Adapting the places instead of the people (pp. Clearly, maintaining independence and transplanting medical care to the home in the 21st century will have impacts on the physical environment that go well beyond ramps and grab bars. Certain community designs have strong potential to contribute to increased physical activity. 277-303). Home modifications: Assessment, implementation and innovation. Although CMS already requires licensure/certification for some services (e.g., licensed occupational therapists can perform functional assessments, certified assistive technology practitioners can perform assistive technology assessments), certification for all of the various types of home intervention services (e.g., assessment, medical remodeling, training) should be included. Examples of physical barriers that prevent individuals from effective communication include: Environment - Some barriers are due to the existing environment. 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. 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. Japanese masters get closer to the toilet nirvana. These homes were designed to monitor daily activities, particularly of older adults, to enable them to have a greater degree of independence and remain at home longer. self-care (toileting, bathing, and grooming). As a result, technology complements, integrates, and reinforces the physical elements of UD to promote health and wellness, social and health provider connectivity, and safety. Gaining access to the $300 billion+ consumer out-of-pocket spending market. No one would expect a private or public third-party payer to help modify one’s home, such as by adding a nursery, to accommodate such a lifestyle change. 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. (1992). In the United States there is no single model for home modification service delivery. 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). Filion, P., Wister, A., and Coblentz, E.J. Since many are familiar with accessible design, they often misuse the term “universal design” as a synonym for the former. Share a link to this book page on your preferred social network or via email. New York Times. Nonetheless, to date, teleconferencing technology has been limited to research studies and has not been translated into practice in any ongoing home assessment programs. While such solutions are yet to be fully embraced by today’s housing market, innovations that embrace smart home technologies and universal design principles offer promise for the future. Physical and Occupational Therapy in Geriatrics, 20(2), 43-55. 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). Bureau of Labor Statistics. (2002). An E for ADAAG: The case for accessibility guidelines for the elderly based on three studies of toilet transfer. In a recent article in the New York Times, Ashlee Vance (2009) paints a grim portrait of the reimbursement system as a process so invested in the medical model that specialized medical devices and equipment are preferred over universally designed everyday designs, even when the latter are less expensive, work better, and are preferred by the user. Measuring the impact of the physical environment. In multifamily housing, these improved conditions may be due to governmental regulations for accessibility that went into effect in the 1980s and 1990s (e.g., the Fair Housing Act Amendments and the Americans with Disabilities Act) to prevent discrimination against people with disabilities in housing and public environments. The number of people with chronic conditions is growing rapidly. No single discipline or systematic program provides training that encompasses a comprehensive understanding of the person and the environment sides of the equation, resulting in disciplinary bias that separates the health professions from the building professions (Pynoos et al., 1987). Lawton (Eds. Many inaccessible … Assistive Technology, 7(1), 36-47. ), Staying put: Adapting the places instead of the people (pp. Statistical abstract of the United States, 114th edition. Vance writes: Kara Lynn has amyotrophic lateral sclerosis, or A.L.S.… A couple of years ago, she spent more than $8,000 to buy a computer … that turns typed words into speech…. This includes allowances in the codes to permit health-related environmental interventions that are necessary for people to remain in their homes. Demonstration programs, such as the Money Follows the Person (MFP) Program, can also provide valuable evidence. However, accessible design is perhaps the largest impediment to adoption of universal design. 1992), and also that people in need often adapt to their current environment, rather than change their home to meet their needs, particularly when the alterations are related to aging or disability (Filion, Wister, and Coblentz, 1992; Gilderbloom and Markham, 1996; Pynoos et al., 1997). (1993). The document also contains guidance to ensure that Unlike Sweden and other countries that include home environmental interventions as an option to support independent and healthy living, the U.S. reimbursement system does not. There’s no place like home: A qualitative study of the working conditions of home health care providers. The field of mind-body studies includes research on the relationship between our surroundings and our health. 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. Building occupants are beginning to demand that their indoor environment not just be comfortable, but also contribute to their own health and wellness. Archives of Internal Medicine, 60, 1,621-1,628.. Anderson, G.F. (2005). The technology products need to be easy to use and to learn, and they should take into account declining skills of older adults, such as vision, dexterity, and memory. (2002). Kendra, M.A., Weiker, A., Simon, S., Grant, A., and Shullick, D. (1996). Glass, T.A. Providing a facilitating environment in the home is different from providing an accessible environment in community settings. BMC Health Services Research, 4(28). 171-191). Second, the consumer’s prime directive is that products, technologies, and modifications that go into the home must be residential in scale and appearance (i.e., look like they belong). Even though the building codes use the same requirements as accessibility standards (i.e., ADA accessibility guidelines) for such features as handrails, stairs, and ramps, these requirements are based on safety, not access. Ready to take your reading offline? However, measuring potential demands has its limitations. Most water supplies serving large popul… While people are not the only animals that alter their environment – think of beavers or termites – we tend to do it in much more -drastic and permanent ways. Physical and Occupational Therapy in Geriatrics, 20(2), 43-55. 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. Understanding the physical characteristics of the indoor environment that affect human health and wellbeing is the key requirement underpinning the beneficial design of a healthcare facility (HCF). 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. Report. 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. As a result, the field is dominated by studies of convenience. The architecture of affordable housing. Technology and Disability, 2(4), 1-8. Available: http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Gershon_88.pdf [accessed September 2009]. Whereas smart home technologies enable compatible products (e.g., appliances and devices that act as receivers and remote controls or keypads that are transmitters) to talk to each other over a network, the technologies are being developed independently of each other. Lifestyle and health behaviors come next, then medical care, and then genetics. The residents of those cities have certainly changed the physical structure of their communities over the past centuries in countless ways. The home may need to support round-the-clock care, which frequently requires live-in caregivers. Medical Care, 38(12), 1,174-1,183. Wahl, H.-W. (2001). As a result, activity performance, participation, and health are expressions of the fit or misfit between an individual and his or her environment. 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. At the same time, new rating systems have been created, including WELL and Fitwel, that focus exclusively on occupant health and productivity. It is important to recognize that there are no national standards for provision of home modification services. International Longevity Center-USA. 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. New York, Singapore, Hong Kong, once wild places thinly populated by hunter-gatherers, farmers, and fishermen, now are covered in concrete and rise with buildings hundreds of meters tall. Lehoux, P., Richard, L., Pineault, R., and Saint-Arnaud, J. Lamps were often replaced with minimal concern for improving lighting quality, and mechanical systems were replaced and controlled with only moderate concern for indoor air quality. Sundsvall, Sweden: Author. Recent trends in disability and functioning among older adults in the United States. Large pieces of equipment have obvious space requirements, but smaller items, such as a pulse oximeter or a blood pressure cuff, need to be stored somewhere, as do medical supplies. The Physical School Environment: An Essential Component of a Health-Promoting School includes information to create a healthy school environment, and to identify and modify aspects of the physical environment that jeopardize safety and health. How the Physical Environment Affects Health and Wellness, Health and Wellness: New Standards Address Age-Old Concerns, Financial Benefits of Health and Wellness, How Healthy Buildings Create Healthy Communities. © 2020 National Academy of Sciences. The principles guide both better activity performance (i.e., works better) and better integration (i.e., fits better) in the social and physical context. 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. (1997). Many houses are built above ground level and have a set of steps leading up to a porch, deck, or landing at the door. At the same time, assistive technologies in particular, and to a lesser extent accessible design, are reinforced by medical model–based reimbursement policies. The logic: Insurance is supposed to cover medical devices…. As a result, interventions based on such information are determined irrespective of the actual abilities of the individuals for whom the interventions are intended. As a result, these individuals are more likely to shoulder a housing cost burden and live in units with moderately to severely inadequate overall structure and physical systems (Louie, 1999). 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). In addition to provider and payer issues, a large number of other confounding contextual factors impact decisions. Nonetheless, because these devices are less expensive, more often reimbursable, more familiar to health care providers, and more readily obtained, they are much more likely to be installed. Of particular relevance and importance is the applicability, or lack thereof, of randomized controlled trials and longitudinal studies (Wahl et al., 2009). Although environmental studies are easy to identify, they are not easy to undertake in real-world environments in which contextual factors are impossible to control. 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. 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. 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. 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. Our "environment" includes both social determinants of health and physical environmental determinants of health. Sanford, J.A. Gerontological Society of American Annual Conference, Dallas, TX. 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