2. Out of the Spotlight: Housing and Home Modifications Jon Pynoos, Ph.D. National Resource Center On Supportive Housing And Home Modification Andrus Gerontology Center University Of Southern California Los Angeles, CA 90089-0191 homemods@usc.edu www.homemods.org

4. Why Is The Home Environment Important? The Physical Environment Can Enhance Or Impede One’s Functional Ability And Quality Of Life Potential Mismatch In Fit Between Person And The Environment (Powell Lawton) Strong Preference Of Older Adults To Age In Place Psychological Familiarity Ties To Neighborhood

5. What Are Home Modifications? Home Modification (HM) Refers To Converting Or Adapting The Environment To Make Performing Tasks Easier, Reduce Accidents, And Support Independent Living.

6. Examples Of Home Modification Ramps And Stair Glides Hand-held Showers Grab Bars Roll-in Showers Better Lighting Chair Lifts Widened Hallways

7. Most Homes “Peter Pan” Housing

8. 3 Major Problem Areas Of The Home: Outside Steps To The Entrance Inside Stairs To A Second Floor Unsafe Bathrooms Source: HUD (2001)

9. Purpose To Understand Why Housing and Home Modifications Have Been Neglected Issues To Analyze Why They Have Been Rising on the Public Agenda To Speculate on the Future

10. Why Has It Taken So Long to Get HMs on the Agenda? Use Kingdon’s Model of Agenda Setting as a Guide Problem Stream Politics Stream Policy Stream

11. 1. Indicators: Understanding the Magnitude of the Conditions Few Empirical Studies on the Dimension of the Problem Estimates of Unmet Need Have Varied Over Time From 865,000 to 14 Million Issues in the Problem Stream:

12. Source:American Housing Survey, 1995 A Complex of Problems

13. 2. Little Feedback From Existing Programs About HMs As a Problem HMs Considered a Small Component of Their Activities Not on Par With Transportation, Nutrition and Even Home Repair Services 3. Few Policy Entrepreneurs to Promote the Issue

14. 4. Conditions in “Peter Pan” Housing Are Not Recognized As Problems Lack of Consumer Awareness (Often Change Behavior Instead of Environment) Often Easier to Provide Personal Care Services Than Modify Homes False Belief That the Americans With Disabilities Act and the Fair Housing Amendments Act of 1988 Solve the Problems

15. Issues in the Politics Stream: 1. Interest Groups and Organizations No One Individual Policy Community (e.g., Trade Association or Consumer Group) Owns the Problem or Might Benefit From Working to Solve It Issue Crosses Different Policy Communities (Housing, LTC, Aging Services, Disability, Rehabilitation) Any Savings From Addressing the Problem (e.g., Long Term Care Costs) Unlikely to Accrue to the Program Making the Investment (Housing).

16. 2. The Service Delivery System Is Very Fragmented, Diverse, Uncoordinated, and Under Funded: Difficulty Identifying a Service System to Solve the Problem HMs a “Stepchild” of Housing and Community Based Care, Two Different Systems A “Patchwork” System With Many Gaps Because HMs Not an Entitlement: Competition at the State and Local Level With Many Other Needs Lack of Skilled Providers

18. Issues in the Policy Stream Unrealistic Proposals: National Policy on Home Modifications Overhaul Medicare

19. Indications That HMs Are Rising on the Agenda Progress in the Problem Stream

21. Research Indicates That HMs Are Cost Effective/ Save LTC Expenditures In A Controlled Intervention Study:  HMs In Combination With Assistive Devices and Assessment And Follow-up By An OT Reduced Health Care Costs And Delayed Institutionalization Source: Mann et al. (1999)

22. Research Indicates That HMs Are Beneficial HMs Make It Easier to Perform Tasks Such As Bathing: 1. HMs Reduce Bathing Difficulty For Those With High Levels Of Functional Impairment 2. HMs, in Combination With OT Assessment and Follow-up, Significantly Improved Bathing Ability Among Frail Elderly Source: Matsuoka & Pynoos (2000); Gitlin et al. (1999).

23. Research Suggesting That HMs May Prevent Falls: For Example : Cumming et al. (1999) Found Among Those With A History of Falls, OT Visits And Provision Of HM’s Reduced The Risk Of Falling However, Gill et al. (2000) Found Weak Relationship Between The Presence of Environmental Hazards And Falls

24. Research Suggests That HMs Support Caregiving  1. Adequate Space Can Facilitate Caregiving  2. HMs May Help Reduce Challenges For Dementia Caregivers Caregivers in the Treatment Groups Showed Enhanced Self- efficacy Source: Newman (1985); Gitlin et al. (2001)

25. Increase in Use of HMs Over Time Significant Increases In The Use Of Assistive Devices & HMs Over Last Decade 45.3% Of Older Persons Live In Homes That Have Special Features Suggests That HMs Substitute For Personal Care Services, But Mechanism Unclear Source: Manton et al. (1993); American Housing Survey (1995)

26. Better Estimates of Need Suggest Problems are Manageable One Recent Estimate: 1.14 Million Elderly Households With At Least One Functional Limitation Report Unmet Need For HMs (HUD, 1999)

27. Increase in Awareness Older Persons and Caregivers More Aware That the Home Itself Can Cause Problems Greater Consumer Information Available: AARP’s Independent Living Strategy Involvement of Younger Persons With Disabilities

28. Indications That HMs Are Rising on the Agenda Progress in the Politics Stream

29. Increased Involvement of Interest Groups/ Organizations Trade Associations Such As National Association of Home Builders Realize That There Might Be a Market in HMs National Home Modification Coalition and Blueprint for Action

30. Indications that HMs are Rising on the Agenda Progress in the Policy Stream

31. Recent Policy Strategies: Attention at Local Level on Provision of HMs (e.g. CDBG) State Grant and Loan Programs Medicaid Waiver Programs Include HMs Income Tax Deductions for HMs

32. What is Next? A Multi- Pronged Strategy

33. Expect Continued Progress In: Nationally-directed and Investigator- Initiated Research Initiatives Increasing Awareness Among Consumers, Policy Makers, and Practitioners Increasing Involvement of Interest Groups and Organizations

34. Additional Strategies: Coalition-building Lawsuits Development of a Model Visitability Law/ Ordinance Coordinated Effort by Health, Long-term Care, and Housing Agencies Collect Policy and Public Expenditure Data on HMs

35. Conclusion: A Manageable Problem Big Benefits: Cost-effective Meets Older Adults’ Preferences Growing Constituency and Movement Progress Will Be Incremental Through Small Windows of Opportunity