By Jon Pynoos, Ph. D.
Home modification and repair have emerged as public policy and service delivery issues because they can help older people age in place. When older people become frail, the home environment needs to be more supportive to compensate for their limitations or disabilities (Lawton, 1980; Pynoos, 1988; Pynoos, in press; Pynoos et al., 1987). A significant number of the elderly, however, live in housing that has in fact deteriorated, lacks supportive features, or presents barriers to mobility. These types of problems make it difficult to safely carry out activities such as cooking meals, bathing, climbing stairs, reading, or doing housework. In order to increase the incidence of home modification and repair, improvements need to be made in assessing homes, expanding public awareness, and developing programs.
Federal legislation supporting home modifications and repair would greatly enhance these efforts.
PROBLEMS ENCOUNTERD BY THE ELDERLY
Because the elderly tend to live in the oldest parts of the housing stock, their dwelling units are often difficult to maintain. Approximately 6.3 percent of elderly households experience problems such as leaking roofs, inadequate wiring, and poorly functioning plumbing (Mikelsons and Turner, 1991). In addition, elderly households often have inefficient heating and cooling systems and insufficient insulation.
While the overall rate of inadequate housing conditions is low, serious problems exist among particular segments of the elderly population. For example, 4 percent of elderly white owner-households live in moderately to severely inadequate housing, in contrast to 23 percent of elderly black and 13 percent of elderly Hispanic owner-households. Similarly, 6 percent of elderly white renter-households live in moderately to severely inadequate housing, compared to 21 percent of elderly black and 16 percent of elderly Hispanic renter-households (Mikelsons and Turner, 1991). Dramatic differences also exist among different income groups: of elderly households with incomes between $10,000 and $15,000, 4.4 percent live in moderately to severely inadequate housing compared to 8.7 percent of those with incomes between $5,000 and $10,000 and 17.4 percent of those with incomes below $5,000.
Of equal importance to the condition of housing is the availability of features that support the ability of older people to carry out tasks and activities. Most housing occupied by the elderly was built for active persons who function independently. Such dwelling units often have stairs, high thresholds between rooms, inadequate lighting, and bathing facilities that are difficult for older people to use easily and safely. Only about 6.6 percent of dwelling units occupied by elderly-headed households with health or mobility problems have such basic features as grab bars and handrails (Struyk, 1987). Almost 50 percent of severely frail elderly living alone reside in dwelling units with no special supportive features (Soldo and Longino, 1988). An estimated 20 percent of the dwelling units of the elderly are in need of modification or repair.
STRATEGIES TO INCREASE HOME MODIFICATION AND REPAIR
Strategies to increase the incidence of home modification and repair include more widespread and systematic home assessments, increased public awareness about the role of the environment, and the creation of more programs that provide affordable home modification and repair services.
Improving assessments An important element in creating a home environment that is safe and supportive is an assessment of its condition and suitability, but very, few dwelling units are systematically assessed. Professionals who assess the environment include occupational therapists, case managers, inspectors associated with neighborhood rehabilitation programs, and energy specialists from weatherization programs.
Considerable variation exists in what is evaluated and the emphasis given to the environment. For example, staff who work for weatherization or home security programs generally concern themselves only with attributes of the dwelling unit that their agencies can change. They usually do not assess the suitability of the home in terms of its supportiveness for frail residents. On the other hand, case managers often overlook physical aspects of the environment or underestimate their importance. Consequently, physical modifications that could obviate or reduce the need for services are not part of the care plan.
Methods of assessment vary widely. Some assessments systematically evaluate features of the environment while others are open-ended, relying on the professional judgment of the assessor. Comprehensive assessments link an older person's ability to carry out activities of daily living and instrumental activities of daily living independently with an evaluation of the home's ability to provide support (Trickey, 1989). Typically, such an assessment relies on a questionnaire and a visual inspection of the home, using a checklist of areas and features. In some cases, a nurse or an occupational therapist observes how an older person carries out a particular task, thereby providing, a more accurate sense of both personal capabilities and interaction with the environment. This type of assessment is especially appropriate for frail elderly and should be used more frequently. In reality, however, many homes of even very frail elderly go unassessed, and the supportive qualities of the dwelling units of the rest of the population receive scant attention. Home assessments, using a common method that includes a minimal set of home environmental features, need to be more available.
Expanding public awareness. Even if home assessments become more widespread and better methods are developed, realistically only a relatively few elderly will benefit directly because of the costs of assessment and a lack of appreciation of the importance of the environment. Therefore, an accompanying strategy is to raise the awareness of older people and the public about the role played by the home environment in avoiding accidents and promoting 'independence. This awareness can lead to increased advocacy for publicly funded home modification/repair and more interest in making "preventive" changes.
A number of programs that include slides or videos to educate older people about the home environment have been developed and could be used in group settings like senior centers and daycare centers (AARP, 1986; Creedon et al., 1989; Johns Hopkins University Injury Prevention Center, 1991). Individuals can also be encouraged to use materials developed to help them in (1) assessing their own home environments; (2) solving problems (e.g. how to tack down a throw rug or lower a threshold); (3) obtaining products; and (4) locating providers who can make changes (Branson, 1991; Ostroff, 1989; Pynoos and Cohen, 1990; Pynoos, Cohen and Lucas, 1988).
Most educational programs focus on safety, but many older people do not alter their environment until an accident has occurred or until they can no longer perform tasks because of chronic health problems. Peer group discussions, in which participants talk about accidents they have had and ways to avoid them, may heighten awareness. Resource centers that include displays of homelike and attractive ways to modify homes may also raise awareness. Rather than focusing only on safety, it may be better to emphasize how alterations can also make life easier and the home more comfortable.
Developing home modification and repair programs. There is an adage to the effect that we do a disservice to clients if they are "all assessed with nowhere to go." A predominant problem has been the lack of providers who have the trust of older clients and the skills to make home modification and repairs. Home repairs are often done by residents themselves as evidenced by the "do it yourself" movement, but many older women (whose gender roles did not encompass making repairs) and find elderly may not have the experience or ability to make alterations. This is especially true if the changes are complicated, numerous, and requite special skills, strength, or tools as in constructing a ramp. Even apparently simple changes can be complicated. For example, grab bars should be attached to studs in the wall and installed at the correct knee and height in relation to the person using them. Hence, it may be necessary to employ a provider such as a remodeler, a handyman, a medical supply company, or an agency to make changes. Remodelers have generally preferred larger jobs such as complete kitchens or bathrooms, and medical supply companies have focused on installing hardware items that they sell. Older people are often concerned about the reliability, skills, and honesty of such private sector providers.
Over the past decade, hundreds of nonprofit programs have been created to make home modifications and repairs. While the total number of agencies providing such services is unknown, a recent survey has catalogued at least 300 programs (Long Term Care National Resource Center, 1991). The programs tend to be small and serve, on average, about 240 clients per year with an annual budget of $268,000. Budgets range from zero for programs using donated labor and materials to several million dollars for programs involved in major rehabilitation or weatherization. On the average, about half of all program budgets are spent on repairs, with the remaining money split fairly evenly among modifications, safety/security, and upkeep/weatherization services. Most of these programs are part of larger organizations, such as community action and weatherization agencies, and city and county governments.
Programs that carry out home modification and repairs must deal with a variety of service delivery tasks like ordering and storing materials, dealing with specialized trades and unions, securing tools, estimating costs, licensing, subcontracting, and managing liability and quality control. These tasks can prove challenging and difficult for agencies like visiting nurses associations, whose work has primarily involved providing professional human services.
Programs deliver modification and repair services using a variety of models. Some carry out all the work using their own staff in order to ensure accountability and responsiveness. Other programs employ some staff supervisors/assessors and handymen, for example -- to carry out routine, smaller jobs but subcontract work requiring licensed tradespeople such as electricians and plumbers. An increasing number of programs use volunteers. In addition, some programs allow older people to make their own modifications and supply them with tools. More comprehensive programs combine models of service delivery so that they can provide more service in a timely and cost-effective manner.
INCREASING FINANCIAL SUPPORT TO PAY FOR REPAIRS AND MODIFICATIONS
While many alterations are low cost, others are too expensive for persons with low incomes -- those who need them most. There are several sources to help the elderly pay for alterations to their homes. With a prescription from a doctor, Medicare and Medicaid will pay for some approved assistive devices related to recovery from acute health incidents (e.g., a hip fracture). These devices are generally medically-oriented hardware items such as hospital beds, walkers, and raised toilet seats. Other programs, such as Community Development and Social Service Block Grants, the Farmer's Home Administration, and the Older Americans Act, have been tapped to provide funds for ramps, security (e.g., new locks), and a variety of general repairs. These programs operate on a loan, sliding fee, or grant basis. Some programs provide free labor if the client pays for materials.
Programs have very limited budgets and are often restricted by their funding sources in the number of clients they can serve and in the types of alterations they can make. Many programs serve only one or two communities or even small neighborhoods, leaving many areas uncovered. Therefore, many older people have to use their own money to pay for alterations, a disincentive if the changes are costly, income is low, and functional status is such that they will have to move in a short period of time.
Because there is no national home modification and repair program, as noted above, agencies turn to a variety of sources for funds and must compete with many other needs. According to a recent survey of home modification and repair programs (Pynoos et al ., in press), the two most frequently cited funding sources are Older Americans Act Title III and Title V funds (39 percent) and block grants (38 percent). Title III and Title V, however, contribute only 5 percent of total program budgets whereas block grants contribute 39 percent. Block grants are generally oriented toward housing rehabilitation in specific neighborhoods, leaving other less-well-funded programs such as Title III to pay for smaller repairs and modifications.
Neither the appropriations for the Older Americans Act nor Community Development Block Grants have grown much over the last five years. Programs, therefore, also rely on cities, counties, and states, and on foundations and charitable contributions. Of these sources, only state funds contributed a substantial proportion (16 percent) of overall budgets. Thirty-two percent of programs reported receiving client payments, which contributed only an average of 5 percent to program budgets-understandable given that most programs serve low- and moderate-income persons.
State-supported home modification and repair programs seem to be on the increase, although how they will fare in a recessionary period is yet to be seen. In 1990, Ohio allocated $4.1 million to create and expand innovative housing options, including home repair and modification. In that same year, Maryland awarded grants to local organizations, including area agencies on aging (AAAs), to provide minor repairs and maintenance of properties occupied by low-income elderly and handicapped individuals. Similarly, the Rhode Island Housing Mortgage Finance Corporation and the Minnesota Home Finance Agency have provided low-interest loans for home repairs and improvements. Maine voters approved a bond issue in 1989 that established a state-funded low-interest loan program for adaptive equipment.
PROMOTING UNIVERSAL HOUSING
Many problems that existing home environments present for aging in place would be eliminated if supportive, adaptable, and accessible housing were built in the first place, the goal of a worldwide movement toward universal housing. A universal house would include features such as wheelchair-accessible entryways, kitchens, and bathrooms; single lever faucets; nonsolid flooring, easy to reach temperature controls; antiscald devices; and grab bars. The principles of universal housing are encapsulated in the Fair Housing Act of 1988, which requires that buildings containing over four units provide basic accessibility and provisions for adding features like grab bars. New construction, however, adds only about 2 percent to the housing stock each year, and the act exempts smaller buildings and single family homes. Hence, efforts are still needed to make the existing stock more suitable for frail older and disabled younger persons.
CREATING A NATIONAL HOME MODIFICATION PROGRAM
The current system for making the existing housing stock suitable for older people is fragmented, uncoordinated, inadequately funded, and full of gaps in coverage. Most of the funds are spent on repairs and energy conservation. Consequently, the homes of many frail elderly go unassessed and unmodified. Strategies such as improving assessments, expanding public awareness, and enhancing programs could help increase the incidence of home modification and repair. In addition, expanding Medicare and Medicaid coverage to include more types of assistive devices and modifications would help.
Home repair and modification agencies could also attempt to gain more resources through Housing and Urban Development (HUD) programs that emanate from the National Affordable Housing Act (NAHA) of 1990, which places a new emphasis on supportive housing and aging in place. For example, NAHA's HOME Investment Partnership program will provide funds through formula grants and model projects to expand the supply of affordable housing with an emphasis on rental units. HOME includes a provision for home repair services for elderly and disabled homeowners, with preference given to very low income families and individuals with physical and mental disabilities. Another opportunity for programs is active participation in the Comprehensive Housing Affordability Strategy (CHAS), a five-year planning process mandated by NAHA to establish housing priorities for state and local areas. The process of developing a CHAS requires conferring with appropriate social services agencies regarding the housing needs of the elderly. Repair and modification would be greatly accelerated by the creation of a National Home Modification Program. It could be modeled on a HUD-funded eight-site demonstration program that occurred in the 1980s. A similar and larger experiment, "Assisted Agency Services," took place in England from 1985 to 1990 (Leather and Mackintosh, 1990). The English version involved 74 agencies, each of which received 50 percent of approximately a $200,000 budget from the national government and the rest from a variety of other sources including cities and towns. Drawing on the British and United States experience, the National Home Modification Program would focus on increasing the suitability of existing dwelling units for lower income frail elderly and younger people with disabilities. Measures of frailty and disability could be based on activities of daily living and instrumental activities of daily living. The program would provide local agencies with core public funding to carry out assessment and home modifications related to safety, accessibility, and functioning. Sponsoring agencies could include weatherization programs, nursing associations, area agencies on aging, and housing authorities. Agencies would be required to use a common, broad-based environmental and functional assessment instrument, set up a professional advisory committee, and keep data for evaluation. Even though client payments or fees would be expected to make up only a small percentage of agency budgets, they would be mandated to help ensure service choice and critical feedback. Incentives would be provided for using donated labor and materials as well as for coordinating services and benefits with other programs such as Medicare, Medicaid, and weatherization.
The passage of a National Home Modification program would face a number of obstacles related to the federal budget. It would become a reality only if it had widespread support from the aging and disabled communities. For such support to exist, home modification and repair need to be seen by professionals, older people, and public officials as a key factor in supporting aging in place.
Jon Pynoos, Ph.D., is UPS Foundation Professor of Gerontology and Director, Division of Policy and Services Research, Andrus Gerontology Center, University of Southern California, Los Angeles.
Preparation of this article was supported, in part, by grant number 90AM 0498601, from the Administration on Aging, Department of Health and Human Services. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view, or opinions do not, therefore , necessarily represent official Administration on Aging policy.
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Reprinted with permission from Generations, Journal of the American Society on Aging, Vol. 16(2) Spring 1992, pp. 21-25. Copyright ASA.