Home modifications produce improved outcomes when they are embedded in a reablement approach and focus on early intervention, write Dr Courtenay Harris, Hilary O’Connell and Kelly McAuliffe.
There is worldwide evidence supporting the physical, social and cost saving benefits of home modifications.
The WA Home and Community Care (HACC) program recognised that due to a range of funding sources and criteria, there were multiple pathways to accessing home modifications and assistive technology services in the state, and approaches to service provision were inconsistent.
In response, the HACC Home Modifications and Assistive Technology project was launched in 2013 with the overall aim of developing a sustainable best practice service delivery model that would improve outcomes for clients.
To begin to develop a best practice model, the Independent Living Centre WA (ILCWA) initiated a partnership with the Curtin University School of Occupational Therapy and Social Work to review the current literature specifically in home modification service delivery. This scoping review supported other research undertaken by the ILCWA in 2014 to improve the pathways by which WA HACC clients access non-complex assistive technology.
The review was undertaken during September 2014 to January 2015 and drew on a range of sources such as international databases, textbooks, websites such as the Home Modification Information Clearinghouse NSW, Home Modifications Australia, the Australian Housing and Urban Research Institute and experts in the field.
The report, released earlier this year, analysed areas such as the purpose and types of home modifications, their impact, components of best practice and the range of environmental factors impacting on service delivery.
Why home mods are necessary
The review found that the overall purpose of home modifications was to facilitate older adults’ desire to remain at home and benefit from a higher quality of life, regardless of a decline in health and mobility.
Home modifications were often required for access to facilities for self-care such as bathrooms, to ensure safety, reduce caregiver support, assist mobility in and around the home and facilitate participation in interests. Evidence suggested that home modifications could assist in slowing the rate of functional decline, improve quality of life and social relationships and reduce symptoms, for example reducing pain following the installation of grab rails. Home modifications have been shown to also have a positive impact on mental wellbeing, with a well-designed adaptation reducing symptoms of depression.
For the caregiver, benefits involved a reduction in burden and concern, allowing for improved relationships, health and sense of security. Where formal home care services were provided home modifications improved the working environment for care staff. Benefits to society were found in areas such as fewer hospital and residential care admissions, reduced care hours and the prevention of potential illness and injury such as falls resulting in reduced healthcare costs. Rates of hospitalisation in older adults are strongly linked to the nature and quality of the home environment.
Improving service delivery
In regards to best practice service delivery guidelines, themes identified in the review related to reablement, accessibility, service assessment, follow-up and evaluation, workforce education and training.
The outcomes of home modifications were identified to be significantly improved when embedded in a reablement approach. The findings suggest that a reablement approach should underpin all aspects of service delivery including assessment, where a holistic assessment should identify and harness a person’s strengths with recommendations to be goal-orientated and chosen to improve independence and safety. In order to complement a holistic assessment and facilitate reablement, it is recommended that a combined home modification and assistive technology service would maximise the benefit for the client and all solutions are considered prior to modification.
Access to timely home modification services was important to ensure reported benefits, this could be facilitated by technology solutions and streamlined and transparent processes that were well-communicated to clients. Additionally, access to home modification services needed to be flexible to accommodate the geographical, social and cultural diversity in Australia’s population.
The service process needed to involve timely and purposeful client-centred assessment, focused on function and client/caregiver needs. Earlier intervention can often result in cheaper solutions or encouragement to self-fund improvements. This implies that educating consumers about the availability of services earlier may decrease the need for more complex modifications in the future, therefore freeing up resources.
Follow-up and service evaluation were found to be important to ensure safety and quality service provision, for both minor and major modifications. Several different modes of follow-up were identified, including in-home review, postal questionaries, tele-technology and telephone calls being the most common. There was not sufficient evidence demonstrating the most effective method.
The home mods workforce
The research identified that occupational therapists were central to the home modification process as experts in identifying and quantifying the environmental factors that impact on occupational performance and implementing services. Home modification services were best undertaken with an interdisciplinary team, including both health and building-related professionals, and roles differed depending on the nature and complexity of the home modification service. In order to encourage collaboration and integration of occupational therapists into service delivery, co-location of OTs and home modification providers should be considered.
Complex home modifications often require specialised skills and a coordinated approach between client, the occupational therapist and building-related professionals. For complex home modifications a joint visit between the OT and builder is recommended.
Further education and training across organisations is required for quality outcomes including specialised training for therapists, together with clear allocation of home modification team roles and differentiation between non-complex and complex service delivery.
The review identified that non-health professionals such as handymen and therapy assistants have a role in minor/non-complex home modifications under the supervision and guidance of an occupational therapist.
General recommendations for improving the client experience during the home modification process include providing:
- clear visuals of complex adaptations
- a step-by-step guide to the process including timescales
- single point of contact through the process
- alternate pathways when a service is unavailable.
The policy and funding context
Lastly, the impact of environmental factors such as policy and funding are important to consider.
For best practice service delivery in an environment of increasing demand for services, well-designed policy, legislation and funding models are required to ensure that individuals can continue to access services to maintain their health, safety and quality of life.
A nationally recognised and coordinated policy that integrates the areas of ageing, health, community care, housing and funding options across jurisdictions is recommended to address the current mismatch that exists between client needs and to minimise existing confusion around policy instructions in many areas.
Although the review was completed with the aim of guiding the development of an improved service delivery model for WA HACC clients, its findings provide practical guidance and suggestions that have relevance at a national level.
Intended outcomes of a proposed service delivery model include enabling consumers and their carers to be better informed about home modifications and assistive technology options and to have greater control over decision-making, aligning with trends of reablement, consumer choice and control in sector reforms.
Dr Courtenay Harris is head of the occupational therapy department at Curtin University. Hilary O’Connell is service manager and Kelly McAuliffe is a senior project officer at the Independent Living Centre WA.
To read the full report and for further details about the HACC Home Modifications and Assistive Technology project click here.
This article appears in the current edition of Community Care Review magazine.
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