Aging in Place: Task Force Meeting
Obstacles to Home Safety and Independent Living
Meeting Minutes
GEM (Gerontological Environmental Modifications)
November 13, 2000
Rosemary Bakker called the meeting to order
I. GEM's Main Goals
The main goal of Project GEM is to increase the availability of home modifications so that frail older persons, especially low-income renters, can remain in their own apartments. GEM's basic premise is that typical living environments, designed for young, healthy adults, are inhospitable to older adults, the majorities of whom have chronic health conditions. Limited range of reach, reduced mobility, and visual and hearing impairments were not taken into account when homes, apartments and daily living products were designed. However, many elders experiencing functional and sensory loss still continue to use their homes in the same way they always have. Elders have become accustomed to living with environmental conditions that have become difficult and unsafe for them to use.
Both inaccessible building structures and age-inappropriate interior furnishings and present numerous obstacles to safety. Small bathrooms without grab bars, low light levels with environmental clutter, dangerously low chairs and soft, highly flammable mattresses pose fall, fire, and burn risks. In addition, unsupportive design features can decrease an older person's ability to carry out daily tasks, creating excess disability and unnecessarily increasing health care costs. Currently research is being conducted throughout the country on the efficacy of home modifications in reducing health care costs and increasing functional independence. One impressive study, conducted by the Rehabilitation Engineering Research Center on Aging, at the University at Buffalo, tested the effectiveness of assistive technology and home modifications in maintaining independence and reducing health care costs for the frail elderly (Arch Fam Med/Vol8, May/June 1999). The treatment group's health care costs for 18 months was only $11,553 as compared to the control groups costs of $31,166!
Even though home modifications are now recognized as a key element in successful aging-in-place, problems to invention abound:
- Environmental hazards that are overlooked until injuries or health crises occur.
- Misperceptions, thinking that the problem is the aging person, not the poor environment-person fit.
- Dilemmas regarding who will make the assessments, how to assess for problems, and how to connect clients with needed resources.
- Lack of providers' awareness of the no or low cost services and products available to low income elders in Manhattan.
- Lack of understanding of the low cost of many modifications. The National Resource Center on Supportive Housing and Home Modification states that 90% of elders need minor, low-tech low-cost solutions to help them function at their maximal capacity.
- Lack of consumer and provider awareness and resistance to change.
II. Significant Obstacles to Home Safety and Independent Living
Through both an informal discussion and a written survey completed by Task Force Members, the following issues, grouped into eight main categories, were identified as the most significant obstacles to home safety and independent living that clients, caregivers and service providers face. The contributions from the Task Force were invaluable in formulating the list – many of the following are direct quotes.
1. Prevalence of Environmental Hazards Associated with Safety Issues- Falls due to home hazards including lack of grab bars in both the bath and toilet areas, high bathtubs without transfer benches or bath chairs, clutter, unsecured scatter rugs, door sills, low, deep chairs, loose wires, low light levels, furniture with sharp corners, and sagging mattresses.
- Doors with no peepholes.
- Burns from hot water and fires due to smoking and food left cooking unattended on the stove.
- Lack of elevators in many buildings – many seniors live in old buildings such as tenements and walkups that have landmark status and cannot easily be modified.
- Stairs with inadequate lighting and handrails.
- Lack of wheelchair accessibility, especially in the bathroom and the kitchen.
- Getting prepared food from kitchen to table when client depends on walker.
- Lack of affordable housing – housing costs have risen rapidly in NYC. Some seniors living in rentals may face eviction because they can no longer afford the rent. Government subsidized senior housing exists mostly at the margins.
- Who performs the assessment?
- What do you assess for?
- Lack of adequate assessment tool.
- Poor assessment skills on the part of providers.
- After the assessment then what happens? Problems may be recognized but solutions and when they will be implemented are often left out of the assessment process.
- Lack of creativity in creating and implementing low cost solutions.
- Coordinating services to get the job done.
- Negotiating with landlord on modifications needed.
- Inadequate funding of necessary repairs or furnishings. Reimbursement and other regulatory requirements that put many types of environmental modifications, especially if preventive in nature, beyond the reach of many low income or underinsured individuals needing such to attain or maintain independence.
- Lack of knowledge of reimbursable items by Medicare and Medicaid.
- Dealing with client's resistance to accepting government assistance (e.g., "I don't want to take charity – I've always paid my own way.").
- High cost of assistive devices for purchase by seniors living on a limited income. Many seniors are not convinced that the benefit is worth the cost.
- Loss of mobility skills due to lack of escort services to take people out for a walk.
- Limited understanding by clinicians of need for functional assistance versus clinical intervention.
- Lack of familiarity with intervention strategies aimed at minimizing handicaps caused by identified functional deficits.
- Lack of medical professionals' involvement in educating clients on home safety. As clients visit doctors on a regular basis, home safety should be a routine part of discharge plans and care plans.
- Lack of awareness of existing home modification services.
- Poor training in use of assistive devices and safety.
- Inadequate home care services – frail seniors in need of some assistance in the home find the cost of hiring help prohibitive, while the availability of government financed home care is very limited.
- Development of a dependency relationship with professional caregivers.
- Lack of direction to home care aides from family.
- Denial and resistance to change.
- Challenges presented by different ethnic and cultural groups.
- Denial – stigma of being thought of as a "frail" or "disabled" person, and reluctance to think of themselves as disabled.
- Lack of awareness of the severity of situations – circumstances have come on gradually, the person has incrementally accommodated herself to the situation, and does not have a realistic view of the actual situation or is convinced that he/she is handling it very well.
- Resistance from clients who refuse to use necessary ambulation devices (e.g., canes and walkers).
- Resistance to change.
- If a change requires home modification or repair, people do not have the information of who does this work, and they do not know whom to ask to find out this information.
- Fear of being removed from one's home if client acknowledges a problem.
- Resistance/lack of motivation to exercising, especially after injuries.
- Higher levels of impairments and frailties that severely effect ability to perform activities of daily living.
- Deficits in cognition that include problems in short-term memory, planning, problem-solving and judgment. Specific safety issues for people with dementia including clutter and hoarding, falls, fires, and wandering.
- Chronic mental problems, especially paranoia and hoarding.
- Increasing prevalence of anxiety and depression.
- Problems with isolation; elders who are homebound because they can no longer negotiate stairs or who cannot communicate with others due to lack of communication tools (e.g. lack of telephones and hearing aids).
- Access to adequate nutrition and provision of groceries and assistance with meal preparation.
