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Jon Pynoos, Ph.D. Background The growing number of frail older adults and younger persons with disabilities who would benefit from home modifications has not yet been matched by a delivery system capable of responding to their needs. The current system has been characterized as suffering from fragmentation, the absence of home modification programs in many areas, and gaps in services. Consequently, it is often difficult to obtain appropriate home assessments, access services, and pay for modification. Little has been known about how they are staffed, how they operate, their sources of referrals, how they conduct assessments, etc. The purpose of this study is to better understand how home modifications are delivered and then to develop case studies of exemplary home modification programs that can serve as models of service delivery for developing new programs and improving existing programs. Methods To better understand how home modification programs operate, a telephone survey was conducted of over 200 programs. Questions related to targeting, assessment, funding, and types of modifications performed. The information was analyzed using descriptive statistics to create a national profile of home modification programs. Then, five cases were selected as exemplary/successful models of service delivery and case studies were conducted. Two of the programs (South East Senior Housing Initiative, the Philadelphia Corporation on Aging, and the Santa Clarita Valley Commission on Aging) are non-profits and two are for-profit (Extended Home Living Services and Access Remodeling). All of these programs have been operating for over five years, offering an opportunity to analyze how they have changed over time. Material on the programs has been collected through a mail-out questionnaire, telephone follow-ups, on-site visits, and analysis of information collected. A structured format was used to analyze the case studies that included: origins of the program, auspices, program objectives, organizational structure, funding, budgets, client characteristics, service menu, service delivery, referral, assessments, and outreach and education. National Profile of Home Modification Programs Home modification programs repair and rehabilitate, as well as, make accessible the homes of the persons they serve. (see Figure 1).
In terms of the most common modifications performed, virtually all program directors stated that they provide some sort of minor home repair (87.5%). Because accessibility is an important issue for most programs, its no surprise that ramp installation is among the most common modification performed (74.9%). Furthermore, grab bar installation is ranked amongst the top three services provided (37.9%), in part because they are inexpensive, which allow programs to serve greater numbers of people. The frequent installation of grab bars is also partially a result of the high demand for bathroom modifications (see Figure 2). On average, the programs serve approximately 272 persons per year. The range of clients served ranges from 5 persons per year to 3000 persons per year. Programs that provide only home modifications generally serve a smaller number of people, while home modification and repair programs have a higher volume of clientele because of their larger budgets. Many programs specifically target the older population.
Of the programs interviewed, 66% serve those age 60 and over. Many
of the programs have a combination of target criteria, the most
common being older, low-income homeowners. The majority of programs had some kind of assessment protocol. Although the protocol varies from program to program, most included a basic set of guidelines that either the program has developed or is borrowed from another source, such as HUD or AARP. The greatest variation among programs is who conducts the assessments. Often, program staff conduct the overwhelming majority of assessments. This can be the director of the program, employed handymen, or assessment personnel. On the other hand, case managers conduct about 17% of assessments. Programs that use case managers are typically part of a larger organization, such as a commission on aging or an Area Agency on Aging. Furthermore, it is interesting to note that 14.4% of programs typically subcontract with occupational therapists to perform assessments (see Figure 4). This could be a result of the increasing awareness about occupational therapists who are trained and experienced in assessing homes for hazards.
Summary of Case Study #1 The Philadelphia Corporation on Aging is a nonprofit organization that began in 1973 and is the designated Area Agency on Aging for Philadelphia County. Its stated mission is to improve the quality of life of older Philadelphians by promoting their health, independence, and productivity. PCA's Senior Housing Assistance Repair Program (SHARP) strives to maintain independence for these persons through the provision minor home repairs and modifications for homeowners 60 years and over. In total, hundreds of homes have received major adaptations and more than 5,400 have received minor adaptations installed by SHARP during the last 14 years. The SHARP program now serves 625 very low-income older homeowners aged 60 and over and has a budget of $1.1 million annually. PCA's Adaptive Modification Program has provided major modifications, such as stairglides and first floor bathrooms, to over 400 homes since 1989. The goal of the program is to help persons with disabilities to live in safe, affordable, barrier-free housing. The program started with $166,000 in funding and is currently funded at $2 million dollars a year for the next five years through Community Development Block Grants. Unfortunately, the demand for AMP's services is greater than the program's capacity. There are currently 849 people on the waiting list, a wait of about five years. PCA's strength is in its intra-agency coordination. Within the Housing Department itself, coordination between the Occupational Therapist (OT) and the construction staff is the key to successfully implementing modifications that will be used to the fullest extent by their clients. Nevertheless, in the future, the Housing Department should encourage the OT and mechanic to inspect the client's home together in order to avoid any miscommunication. Stable funding levels for both SHARP and AMP has been key for providing consistency in the numbers of persons served per year and the service menu. The mismatch between demand and available funding is a dominant concern of PCA. However, the reality for PCA and many other home modification programs may be that this gap may never be bridged.
The South East Senior Housing Initiative (SESHI) began when local
organizations in the community recognized the growing needs of the
aging population in South East Baltimore. These organizations raised
concerns about physical and environmental restrictions experienced
by a large portion of older residents living in row homes, the challenges
older residents confront in preserving their homes, and the lack
of affordable housing alternatives within the community. Several
organizations met to formulate strategies for addressing the problems
identified. The outcome from these meetings resulted in a coordinated
effort of non-profit organizations and a coalition known as SESHI.
Overtime SESHI has become the primary organization in a comprehensive
community delivery system whose principal goal is to assist older
adults in remaining safely in their homes. To date its largest source of funding has come from a grant from the Robert Wood Johnson Foundation (RWJF). SESHI will be the lead agency in a demonstration project, Home Intervention and Support for Low-Income Persons (HISLIP), that seeks to promote independent living for low to moderate income seniors in their own homes, via a program of integrated home intervention and support. Through coordination of existing community-based services and home adaptations, SESHI, along with its coalition members, is testing the value of preventative health and the impact on the community in assisting older adults to live independently. It is based on the concept of coordinated social, health and housing services. The goals of HISLIP include: Summary of Case Study #3 The Santa Clarita Valley Commission on Aging (SCVCoA), a charitable,
not-for-profit organization was formed in 1972 as grass roots effort
in response to the growing needs of older persons living within
the community. The founding principles were designed to enhance
the independence, dignity, and quality of life for senior citizens.
SCVCoA accomplishes such goals through direct service provision,
community resource management and coordination, program development,
as well as advocacy. Within its community the SCVCoA has surfaced as a leader in home modification capacity building, by becoming the steering organization for a local coalition. The coalition brings together the building industry including, remodelers, builders, suppliers with social workers, caregivers, and other agencies within the community to provide home improvements. The coalition plans activities for consumers, service delivery professionals, public decision makers, and the corporate sector. Thus far the coalition has acted as a means by which to increase community awareness of the services for home modifications already in existence at SCVSS. Even more it has been an avenue the SCVCoA has used to create and enhance public and private collaboration.
Access Remodeling is a private, for-profit business, founded by Louis Tennenbaum, that has provided residential accessibility services to clients in the Washington, D.C. and Potomac, Maryland areas since 1987. AR provides all aspects of the remodeling services for customers: a home visit, environmental assessment, design plans, a proposal with specifications about recommendations, and the installation of home modifications and construction work. The firms objectives encompass remodeling homes such that changes
and modifications made to the environment render it safe and accessible
for individuals with disabilities. AR wants to reach the "planners"--
individuals preparing to age in place within their own homes. In
this respect, it is important to note that AR does not solely work
with aging population but also the disability community and younger
individuals. Today AR is a business that views two aspects of the client: an individual and a home, each possessing particular characteristics that need to be recognized and taken into consideration with home modifications. As a remodeling company, AR attempts to integrate program and design to make homes modifications effective. A critical component of AR's construction process involves the actual design of home adaptations and renovations to make the environment barrier free. AR subcontracts with an interior designer, who specializes in Universal Design, to ensure that the layout and design are aesthetically pleasing as well as safe and secure. The designer is involved in the evaluation of the home and is part of the design team that provides the client with suggestions for adaptations. Additionally, AR employs a full-time designer and sales consultant who has worked with the company for many years.
Extended Home Living Services (EHLS) was developed in 1991 as a private for-profit business to deliver HM to younger persons with disabilities and older adults living in the Chicago suburbs. The original plan to provide home modifications to older adults aging in place, proved uneconomical as the initial demand was low and jobs were small. Thus the company had to shift its focus include younger adults with disabilities. The company founders realized that they had to rely on their customers to identify problems they wanted addressed and then propose solutions, in comparison to telling their customers what they need. EHLS provides all aspects of HM service under one roof for customers- - an initial home visit, an environmental assessment, design plans, a proposal with specifications recommended, referral and assistance finding local funding sources, and the actual installation of home modifications. Having an in-house staff did not prove to be economically feasible, as such EHLS use subcontractors. Other Findings " Profit-oriented programs rely extensively on private payments but also refer clients to other funding sources and work with insurance companies." " All of the programs report an unmet need for home modifications
for low and moderate-income persons. " Staffing can be a problem when the economy is doing well." " The private sector markets to a variety of sources while the publicly funding programs carry out only limited outreach." " Programs vary in terms of whether they actually provide home modifications or subcontract and use affiliate non-profit organizations to carry out the home modifications." " Securing funding and business continues to be a problem for providers." " Although several of the programs seem to have achieved stability and even growth." " Programs that performed mainly home repair have branched out to include home modifications in their menu of services." |
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