Falls Prevention and Home Modification

Home , Falls in older adults, Occupational therapist

Focus On...

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reventing falls and aging in place—these are two of the biggest concerns for Americans as they age, and occupational therapy researchers, clinicians, and educators are doing a great deal to help, as detailed in the articles and other materials brought Ptogether here as part of AOTA’s “Focus On” edition on falls prevention and home modifications. Along with fact sheets, a how-to guide, and links to evidence supporting occupational therapy’s key role in these areas, the articles and resources here cover the many types of community-based programs that occupational therapy practitioners can help create to help people prevent or reduce falls, provide advice on evaluating homes for poor lighting and other hazards, and offer profiles of occupational therapy practitioners working with other rehabilitation professionals and home contractors to allow residents to engage safely and as conveniently as possibly in valued occupations..

Reducing Fall Risk: Home Modification and the Therapeutic Value A Guide to Community-Based Programs of Advocacy Elizabeth W. Peterson John Hurtado OT Practice, September 12, 2011 OT Practice, September 26, 2011

Standing Tall: A Self-Management Approach Occupational Therapy and Rebuilding Together: to Fall Prevention Intervention Working to Advance the Centennial Vision Elena Espiritu Wong Claudia E. Oakes and Cathy Leslie OT Practice, September 9, 2013 OT Practice, September 10, 2012

Light the Way: Providing Effective Home Modifications Occupational Therapy Gives Rebuilding Together That for Clients With Low Vision “Little Sweetness” Debra Young Andrew Waite OT Practice, September 10, 2012 OT Practice, September 9, 2013

Bathroom Safety: Environmental Modifications to Caroline Bartlett Crane’s Everyman’s House: Enhance Bathing and Aging in Place in the Elderly Historical Home Design and Home Modification Today Tacy Van Oss, Michael Rivers, Brianna Heighton, Cherie Macri, Carla Chase and Suzanne Roche and Bernadette Reid OT Practice, September 26, 2011 OT Practice, September 10, 2012 AOTA Official Document: AOTA’s Societal Statement on Home Teams: Practitioners Partner With Contractors for Livable Communities Home Modifications Andrew Waite AOTA Fact Sheet: Occupational Therapy and the OT Practice, September 26, 2011 Prevention of Falls

Home Sweet Home: Interprofessional Team Helps Older AOTA Fact Sheet: Home Modifications and Occupational Adults Age in Place Safely Therapy Allysin E. Bridges, Sarah L. Szanton, Allyson I. Evelyn-Gustave, Felicia R. Smith, and Laura N. Gitlin AOTA Tip Sheet: Remaining in Your Home as You Age OT Practice, September 9, 2013 AOTA Tip Sheet: Helping Your Older Parents Remain Whose Safety Is It Anyway? Evaluating Outcomes at Home of Home Modifications Claudia E. Oakes Falls Prevention Presentation How-To Guide Home & Community Health SIS Quarterly Newsletter, June 2013 For More Information: AOTA Evidence and Research Resources

Note: At the time individual items were published, prices and products were up to date. Copyright © 2014 The American Occupational Therapy Association, Inc. Please check http://store.aota.org or www.aota.org for current information. Reducing Fall Risk A Guide to Community-Based Programs

Elizabeth W. Peterson

ccupational therapy Community-based programs can draw from participants’ practitioners’ commitment to fall prevention everyday experiences to help create individualized fall increasingly involves linking older adults to com- prevention strategies. Omunity-based programs designed to reduce fall risk. This trend is fueled by improved availability of these programs the psychological and physical energy and apply fall risk management skills as well as high demand. Community- needed to begin fall prevention efforts that can be generalized to a variety of based programs can extend benefits in earnest. situations. These programs address associated with clinical intervention. The dynamic nature of occupation diverse factors contributing to falls Many older adults are seen by occupa- requires older adults to routinely make and help participants understand how

hoto tional therapy practitioners in tradi- good activity choices to avoid falls. risk factors work together to increase p tional medical or home care settings Therefore, community-based programs the chance of falling. This is important immediately after a fall-related injury— that draw from participants’ day-to- because although falls can be caused a time when many clients prioritize day experiences to help them create by “stand alone” problems such a heart managing immediate self-care needs individualized fall prevention strategies arrhythmia, most result from interact- over learning about longer-term fall are valuable. Programs such as Matter ing risk factors. These risk factors may h © issaurinko / istock p prevention strategies. Once clients’ of Balance1–2 and the Stepping On Falls be physical, environmental, behavioral, medical status and lives have stabilized, Prevention Program (Stepping On),3 or attitudinal, as in the case of an older

Photogra however, they are more likely to have foster participants’ ability to develop adult who develops a fear of falling. The

OT PRACTICE • SEPTEMBER 12, 2011 15 influence of fear of falling on fall risk Otago. Because occupational therapists (including occupational therapists) should not be underestimated. Although were centrally involved in the develop- can use to evaluate clients’ fall risk and some concerns about falling are protec- ment of Matter of Balance and Stepping develop effective intervention plans. tive and keep a person from engaging On, expanded details of those programs Occupational therapy practitioners are in activities with demands that exceed are provided. uniquely prepared to contribute to fall abilities, research suggests that many prevention efforts due to their atten- people who are afraid of falling enter a A Growing Public Health Problem tion to diverse influences on occupa- debilitating spiral of loss of confidence, Falls are a serious public health prob- tional performance13 and ability to use restriction of physical activities, physical lem in the United States and interna- a variety of intervention approaches. frailty, falls, and loss of independence.4–5 tionally. Approximately 30% of older These approaches range from preven- Further, these studies show that people adults (i.e., people aged >65 years) tion and remediation to modification who limit activity because of fear of living in the community fall each year,6 and disability prevention.14 falling are at particularly high risk of and the likelihood of falling increases becoming fallers.4–5 rapidly with advancing age.7 Matter of Balance Community-based exercise pro- For healthy and active older adults, Matter of Balance is a multicomponent, grams designed to reduce fall risk are a serious fall-related injury can be the group intervention explicitly aimed increasingly available to older adults introduction to old age. For more vul- at reducing excessive concerns about in the Unites States. It is important to nerable seniors, falls can be a marker falling and activity avoidance.2 The pro- recognize that Stepping On and Mat- for frailty and the result of a larger geri- gram was developed by an interdisci- ter of Balance complement exercise- atric syndrome that ultimately leads plinary team at Boston University that based interventions because they help to disability, dependence, and death.8 included an occupational therapist, participants develop attitudes that sup- The financial costs associated with falls and has been evaluated through two port engagement in healthy behaviors, are staggering, with the direct medical randomized trials that used health care emphasize the importance of exercise costs of fall injuries totaling more than professionals as interventionists.1–2 to fall risk reduction, and include exer- $26.3 billion annually.9 Both trials demonstrated the program’s cises during most program sessions Both single factor interventions ability to accomplish its primary objec- (see Table 1 on p. 17). The Centers for (e.g., exercise programs; withdrawal tive, which is to increase falls self- Disease Control and Prevention (CDC) of drugs for improving sleep, reduc- efficacy (i.e., perceived self-efficacy

has undertaken a major initiative to ing anxiety, treating depression) and or confidence at avoiding falls during AGING Y

disseminate two exercise programs: the interventions with multiple compo- essential, nonhazardous activities of TH L A

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nents are effective in preventing falls daily living). In the most recent trial, H Tai Chi: Moving for Better Balance

Program, and the Otago Exercise among community-dwelling older there were significantly fewer recur- OR P F Programme (Otago), as well as Step- adults.10–11 Individualized evaluation rent fallers in the intervention group.2 RSHI E

ping On. leading to identification of a person’s The conceptual model used in Mat- TN This article describes falls as a prev- unique fall risk factors is essential ter of Balance is based on the work of AR E P TH

alent but preventable problem among to developing effective treatment Bandura, a leading social theorist, and F O

16 Y community-dwelling older adults plans. The recently updated American cognitive behavioral theory (CBT). S E and summarizes key features of four Geriatrics Society/British Geriatrics Matter of Balance addresses attitudes COURT programs that have been rigorously Society Clinical Practice Guideline for and beliefs about falls, and the ability to HS evaluated and are available in many Prevention of Falls in Older Persons12 manage concerns about falls while fos- P states: Matter of Balance, Stepping On, highlights this point and describes a tering adaptive behavioral changes such HOTOGRA

Tai Chi: Moving for Better Balance, and decision-making process that clinicians as engaging in exercise, communicating P

16 SEPTEMBER 12, 2011 • WWW.AOTA.ORG The Volunteer Lay-Led model of Matter of Balance, a licensed program available through MaineHealth’s Partnership for Healthy Aging, targets community-based older adults who curtail activity due to fear of falling. assertively, and mitigating fall hazards Matter of Balance VLL Model to uphold high standards for program in the home.17 In Matter of Balance, With funding from the Administration quality and foster participant reten- cognitive restructuring techniques are on Aging, a VLL model of Matter of Bal- tion. As part of the Matter of Balance used extensively to help participants ance was developed and subsequently VLL, a guest health care professional identify, evaluate, and change maladap- evaluated through a repeated measures is invited to present specific content tive beliefs regarding falls and fall risk. study.19 Matter of Balance VLL is now during one of the eight sessions. Occu- Additional intervention strategies, a licensed program available through pational therapists often serve in this based on CBT, range from generaliza- MaineHealth’s Partnership for Healthy role and share their expertise on topics tion (applying lessons learned through Aging, which uses numerous strategies including physical fall risk factors (e.g., CBT to future situations) and self- assessment of behavior, to role playing and training in problem solving. Table 1. Matter of Balance and Stepping On: Fast Facts The group process is very important in Matter of Balance. Program Matter of Balance Stepping On participants model adaptive behavior, Key program • Reduce fear of falling and • Increase knowledge of factors persuade each other that steps can outcomes increase falls self-efficacy that can contribute to falls be taken to reduce falls, and brain- • Increase activity levels • Increase engagement in fall storm strategies to accomplish goals • Reduce falls prevention behaviors described in personal action plans. • Reduce falls These positive peer experiences are carefully fostered by the program facili- Who delivers the • Original version: health care • Original version: occupational tators because they are essential to program? professionals therapists building participants’ falls self-efficacy. • Volunteer Lay-Led Model: • U.S. version: a professional who Homework activities include apply- trained lay leaders works with older adults. ing the program content and help to bridge one session to the next. Matter Number of • Original version: 8 or 9 • 7 sessions plus a home visit of Balance facilitators use a manual to sessions • Volunteer Lay-Led Model: 8 (recommended) and a booster maintain program fidelity. Although the session program sessions are highly structured, numerous discussions and activities Target audience • Community-based older • Community-based older adults support participants’ efforts to apply adults who curtail activity who are at risk of falling, have a program content to their daily lives. due to fear of falling fear of falling, or have fallen one Evidence demonstrating that low or more times. 18 falls self-efficacy is a fall risk factor Shared • Use of manual to maintain fidelity has grown tremendously in recent years features of the • Emphasis on diverse fall risk factors and has contributed to the popularity interventions3 • Use of groups of Matter of Balance. The program’s • Dedication to client-centered practice availability across the United States has • Use of social cognitive theory also improved dramatically over the past • Use of diverse content delivery methods 5 years due to the success of a second • Instruction in exercise version of Matter of Balance, the Volun- • Improved falls self-efficacy as an outcome teer Lay-Led (VLL) model.

OT PRACTICE • SEPTEMBER 12, 2011 17 Falls Prevention Awareness Day is September 23 Go to www.aota.org/news/aotanews/falls-prevention for ideas on how to promote occupational therapy’s role in fall prevention.

orthostatic hypotension, leg weakness, facilitators is a key influence on the ance and increase lower limb strength. compromised balance) and how to get program’s success. The strength training is of moderate up from the floor after a fall. The topics emphasized in Stepping intensity, using ankle cuff weights. The The 2-day master training sessions, On are widely recognized priorities in balance retraining exercises increase in which prepare master trainers to train fall prevention: exercise, balance, and difficulty and progress from exercises and supervise coaches, cover Matter mobility; home safety; management using support to free-standing activi- of Balance VLL content, logistics, and of visual impairment; and medica- ties.24 Delivered in participants’ homes, group process skills. Master trainers tion review and management.23 The Otago is intended for people who do not participate in quarterly conference calls, program’s attention to the interplay want to attend or cannot reach a group and the Partnership for Healthy Aging between physical abilities and envi- exercise program or recreation facil- has dedicated staff members who sup- ronmental stressors reflects Clemson’s ity.25 The program consists of four home port master trainers as needed. The expertise as an occupational therapist. visits over a 2-month period, telephone program is now offered in 36 states calls to maintain motivation, and a and has reached more than 25,000 Stepping On in the United States booster session.25 older adults. With funding primarily from the CDC Developed and tested by a research and with Clemson’s guidance, Step- team at the University of Otago Medical Stepping On ping On has been adapted for use in School, New Zealand, the program is Stepping On is a multifaceted, commu- the United States. Efforts to adapt and now used worldwide. A meta-analysis of nity-based program that uses a small disseminate Stepping On are being led the home-based trials showed an overall group learning environment to improve by Jane Mahoney, MD, of the Wisconsin fall reduction, and fall-related injury falls self-efficacy, encourage behavioral Institute for Healthy Aging (WIHA). reduction of 35%.26 Eager to increase change, and reduce falls.2 Developed by Stepping On is now a licensed program the availability of Otago in the United a research team led by Lindy Clem- available through WIHA. In the United States due to its strong evidence base, son, PhD, occupational therapist and States, program sessions are facilitated the CDC is beginning to find program associate professor at the University of by a two-person team: a professional sponsors and to demonstrate Otago’s Sydney in Australia, Stepping On was who works with older adults, and an reimbursement potential. There is also evaluated through a randomized trial older adult. potential for the program to be deliv- that demonstrated a 31% reduction Numerous resources and processes ered by home health providers. The in falls among intervention subjects.2 have been developed by Mahoney and CDC is developing a train-the-trainer In that trial, the intervention was her team to maintain the program’s program to deliver Otago and is cur- delivered by an occupational therapist fidelity and support the effectiveness rently targeting physical therapists for experienced in group work and with 12 of professionals delivering the program. those training programs. years of experience in geriatrics.2 The For example, a 3-day training program program targets older adults who are at has been developed for individuals who Tai Chi: risk of falling, have a fear of falling, or will be delivering the program to older Moving for Better Balance who have fallen one or more times. adults. The Stepping On training for Tai Chi is an alternative exercise form Stepping On incorporates Bandura’s facilitators covers the program content that emphasizes weight shifting, pos- social cognitive theory, which empha- (which includes exercises, a recom- tural alignment, and coordinated move- sizes influences on self-efficacy20; mended home visit, and a booster ses- ments with synchronized breathing.27 recognizes decision-making processes sion that occurs 3 months after the 7th Tai Chi: Moving for Better Balance is a applicable to adopting behaviors Stepping On session); program man- specific Tai Chi program that has been intended to reduce fall risk21; and uses agement (e.g., logistical details associ- evaluated through two randomized con- evidence-based strategies to sustain ated with the delivery of the program); trolled trials. Those trials demonstrated prevention behaviors.22 Program facilita- principles of adult learning; and the role the efficacy of the program in improving tors use their group management skills of the Stepping On facilitator. functional balance, strength, and flex- and apply adult-learning principles to ibility and, consequently, reducing fear foster participation, mutual support, and Exercise-Based Fall Prevention of falling and the risk of falls in sample problem solving. Together, these skills Programs: Otago and Tai Chi populations of healthy community- enhance participants’ falls self-efficacy. The Otago Exercise Programme is a dwelling older adults.28–30 The supportive and empowering social home-based, individualized, exercise In a 2005 trial, Tai Chi: Moving for environment created by Stepping On program designed to improve bal- Better Balance was provided by experi-

18 SEPTEMBER 12, 2011 • WWW.AOTA.ORG FOR MORE INFORMATION CONNECTIONS Discuss this and other articles on Matter of Balance AOTA Analysis of Medicare Policy in Relation to For more information on the original version, Preventing Falls Among Older Adults the OT Practice Magazine public forum contact Elizabeth Peterson at [email protected]. www.aota.org/Practitioners/PracticeAreas/Aging/ at http://www.OTConnections.org. For more information on the volunteer Lay-Led Falls/Key/Analysis.aspx?FT=.pdf Model, visit www.mainehealth/pfha or e-mail Patti League at [email protected]. Online Course: Falls Module I: Falls Among Community-Dwelling Older Adults: Overview, to safely live meaningful, occupation- Stepping On Evaluation, and Assessments ally rich lives. n For information regarding facilitator trainings Presented by E. W. Peterson & R. Newton, 2011. and U.S.-based dissemination efforts, contact Bethesda, MD: American Occupational Therapy [email protected]. Association. (Earn .6 AOTA CEU [6 NBCOT PDUs/6 References contact hours]. $210 for members, $299 for 1. Tennstedt, S., Howland, J., Lachman, M., Otago Exercise Programme nonmembers. To order, call toll free 877-404- Peterson, E., Kasten, L., & Jette, A. (1998). A The instruction guide is available at www.acc. AOTA or shop online at http://store.aota.org/ randomized, controlled trial of a group interven- co.nz/injury-prevention/home-safety/older-adults/ view/?SKU=OL34. Order #OL34. Promo code MI) tion to reduce fear of falling and associated otago-exercise-programme/index.htm. For more activity restriction in older adults. Journals of information, e-mail M. Clare Robertson at Online Course: Falls Sustained Among Older Gerontology: Psychological Sciences and Social [email protected]. Adults in the Hospital Setting Sciences, 53B, 384–392. Presented by R. Newton & E. W. Peterson, 2011. 2. Zijlstra, G. A. R., van Haastregt, J. C. M., Amber- Tai Chi: Moving For Better Balance Bethesda, MD: American Occupational Therapy gen, T., van Rossum, E., van Eijk, J. T. M., Yard- For a program package, call Fuzhong Li of the Association. (Earn .45 AOTA CEU [4.5 NBCOT ley, L., et al. (2009). Effects of a multicomponent Oregon Research Institute at 541-484-2123 or PDUs/4.5 contact hours]. $158 for members, cognitive behavioral group intervention on fear e-mail [email protected]. For additional information $225 for nonmembers. To order, call toll free 877- of falling and activity avoidance in community- regarding the CDC’s initiative to disseminate Otago 404-AOTA or shop online at http://store.aota.org/ dwelling older adults: Results of a randomized and Tai Chi: Moving For Better Balance, contact view/?SKU=OL35. Order #OL35. Promo code MI) controlled trial. Journal of the American Geri- Margaret Kaniewski at [email protected]. atrics Society, 57, 2020–2028. SPCC: Strategies to Advance Gerontology 3. Clemson, L., Cumming, R., Kendig, H., Swann, State Coalitions on Fall Prevention: Excellence: Promoting Best Practice in M., Heard, R., & Taylor, K. (2004). The effec- A Compendium of Initiatives Occupational Therapy tiveness of a community-based program for www.healthyagingprograms.org/content.asp? Presented by S. Coppola, S. J. Elliott, & P. E. Toto, reducing the incidence of falls in the elderly: sectionid=69&ElementID=746&FromSearch 2008. Bethesda, MD: American Occupational Therapy A randomized trial. Journal of the American Result=State%20coalitions Association. (Earn 3 AOTA CEUs [30 NBCOT PDUs/ Geriatrics Society, 52, 1487–1494. 30 contact hours]. $490 for members, $590 for 4. Friedman, S. M., Munoz, B., West, S., Rubin, G. AOTA/CDC Falls Prevention Project nonmembers. To order, call toll free 877-404-AOTA or S., & Fried, L. P. (2002). Falls and fear of falling: www.aota.org/practitioners/practiceareas/ shop online at http://store.aota.org/view/?SKU=3024. Which comes first? A longitudinal prediction aging/falls Order #3024. Promo code MI) model suggests strategies for primary and secondary prevention. Journal of the American Geriatrics Society, 50, 1329–1335. 5. Delbaere, K., Crombez, G., Vanderstraeten, G., enced Tai Chi instructors in community number of resources available to them Willems, T., & Cambier, D. (2004). Fear-related settings such as local senior centers (see For More Information). The CDC avoidance of activities, falls and physical frailty. A prospective community-based cohort study. and adult activity centers, and included is developing an infrastructure that will Age and Ageing, 33, 368–373. 24 Tai Chi forms. Synchronized give older adults access to evidence- 6. Hausdorff, J. M., Rios, D. A., & Edelberg, H. breathing aligned with Tai Chi move- based programs. The CDC has also K. (2001). Gait variability and fall risk in community-living older adults: A 1-year prospec- ments was integrated into the move- provided new funding to Oregon, tive study. Archives of Physical Medicine and ment routine.29 Each session included Colorado, and New York to increase Rehabilitation, 82, 1050–1056. instructions in new movements as well their capacity to disseminate Step- 7. O’Loughlin, J. L., Robitaille, Y., Boivin, J. F., & Suissa, S. (1993). Incidence of and risk factors as review of movements from previ- ping On, Tai Chi: Moving for Better for falls and injurious falls among the com- ous sessions and incorporated musical Balance, and Otago. The Partnership munity-dwelling elderly. American Journal of accompaniment.29 for Healthy Aging continues to guide Epidemiology, 137, 342–354. 8. Inouye, S. K., Studenski, S., Tinetti, M. E., & To convert this proven falls preven- a well-informed community of Matter Kuchel, G. A. (2007). Geriatric syndromes: tion intervention into a community- of Balance trainers and coaches across Clinical, research, and policy implications of a based program, Li et al. developed a the country. The National Council on core geriatric concept. Journal of the American Geriatrics Society, 55, 780–791. package of materials that provided Aging is facilitating a national coalition 9. Stevens, J. A., Corso, P. S., Finkelstein, E. A., & a solid foundation for larger scale and a growing state coalition work- Miller, T. R. (2006). The costs of fatal and non- implementation and evaluation of the group to promote national awareness fatal falls among older adults. Injury Preven- 31 tion, 12, 290–295. program. The program, which targets of the importance of fall prevention 10. Chang, J. T., Morton, S. C., Rubenstein, L. Z., older adults with low to moderate risk and to support education and training Mojica, W. A., Maglione, M., Suttorp, M. J., et of falls, is being disseminated by the of providers who can deliver effec- al. (2004). Interventions for the prevention of falls in older adults: Systematic review and CDC nationwide through state health tive community interventions. Finally, meta-analysis of randomised clinical trials. departments and local YMCAs. AOTA is working hard to improve British Medical Journal, 328, 680. doi:10.1136/ opportunities for reimbursement of bmj.328.7441.680 11. Gillespie, L. D., Robertson, M. C., Gillespie, Conclusion community-based programs. The W. J., Lamb, S. E., Gates, S., Cumming, R. G., Occupational therapy practitioners growing dedication to fall preven- et al. (2009). Interventions for preventing falls who want to be part of the exciting tion among so many has created new in older people living in the community. Cochrane Database of Systematic Reviews, effort to disseminate community-based opportunities for occupational therapy 2, Art. No.: CD007146. doi:10.1002/14651858. programs that reduce fall risk have a practitioners to empower older adults CD007146.pub2

OT PRACTICE • SEPTEMBER 12, 2011 19 12. American Geriatrics Society and British Geri- 20. Bandura, A. (1977). Self-efficacy: Toward a uni- 29. Li, F., Harmer, P., Fisher, K. J., McAuley, E., atrics Society Panel on the Clinical Practice fying theory of behavioral change. Psychological Chaumeton, N., Eckstrom, E., et al. (2005). Tai Guideline for the Prevention of Falls in Older Review, 8, 191–215. chi and fall reductions in older adults: A ran- Persons. (2010). AGS/BGS clinical practice 21. Janis, I. L., & Mann, L. (1977). Decision making: domized controlled trial. Journals of Gerontolo- guideline: Prevention of falls in older persons A psychological analysis of conflict, choice, and gy: Psychological Sciences and Social Sciences, (2010). Retrieved June 21, 2011, from http:// commitment. New York: Macmillan. 60A, 187–194. www.americangeriatrics.org/health_care_pro 22. Cole, H., Berger, P., & Garrity, T. (1988). Ana- 30. Wolf, L. S., Barnhart, H. X., Kutner, N. G., fessionals/clinical_practice/clinical_guidelines_ logues between medical and industrial society McNeely, E., Coogler, C., Xu, T., et al. (1996). recommendations/2010 research on compliance behavior. In D. Goch- Reducing frailty and falls in older persons: 13. Peterson, E., & Clemson, L. (2008). Understand- man (Ed.), Health behavior: Emerging research An investigation of tai chi and computerized ing the role of occupational therapy in fall perspectives (pp. 337–353). New York: Plenum balance training. Journal of the American prevention for community-dwelling older adults. Press. Geriatrics Society, 44, 489–497. OT Practice, 13(3), CE-1–CE-8. 23. Clemson, L., & Swann, M. (2007). Stepping On: 31. Li, F., Harmer, P., Glasgow, R., Mack, K. A., Sleet, 14. American Occupational Therapy Association. Building confidence and reducing falls (2nd D., Fisher, K. J., et al. (2008). Translation of an (2008). Occupational therapy practice frame- ed.). Sydney, Australia: University of Sydney effective tai chi intervention into a community- work: Domain and process (2nd ed.). American Press. based falls-prevention program. American Journal of Occupational Therapy, 62, 625–683. 24. Campbell, A. J., & Robertson, M. C. (2010). Journal of Public Health, 98, 1195–1198. 15. Tinetti, M. E., Richman, D., & Powell, L. (1990). Comprehensive approach to fall prevention on a Falls efficacy as a measure of fear of falling. national level: New Zealand. Clinics in Geriat- Elizabeth W. Peterson, PhD, OTR/L, FAOTA, is a clini- Journals of Gerontology: Psychological Sci- ric Medicine, 26, 719–731. ences and Social Sciences, 45B, P239–P243. 25. Stevens, J. A., & Sogolow, E. D. (2008). Prevent- cal associate professor and director of professional 16. Lachman, M. E., Jette, A., Tennstedt, S., How- ing falls: What works: A CDC compendium of education at the University of Illinois at Chicago. land, J., Harris, B. A., & Peterson, E. W. (1997). effective community-based interventions from Peterson has been involved in fall prevention A cognitive behavioral model for promoting around the world. Retrieved June 21, 2011, physical exercise in older adults. Journal of from http://www.cdc.gov/ncipc/preventingfalls/ research for more than 2 decades. She has served as Psychology, Health, and Medicine, 2, 251–261. CDCCompendium_030508.pdf AOTA’s representative to the NCOA-led Falls Free 17. Peterson, E. (2003). Using cognitive behavioral 26. Robertson, M. C., Campbell, A. J., Gardner, M. Initiative and on the Expert Panel to Update the Fall strategies to reduce fear of falling: A Matter of M., & Devlin, N. (2002). Preventing injuries in Balance. Journal of the American Society on older people by preventing falls: A meta-analysis Prevention Guideline of the American Geriatrics Aging, 25, 53–59. of individual-level data. Journal of the Ameri- Society and the British Geriatrics Society. Peterson 18. Cumming, R. G., Salkeld, G., Thomas, M., & Szo- can Geriatrics Society, 50, 905–911. was co-investigator of the Boston University study nyi, G. (2000). Prospective study of the impact of 27. Li, F., Harmer, P., Mack, K. A., Sleet, D., Fisher, fear of falling on activities of daily living, SF-36 K. J., Kohn, M. A., et al. (2008). Tai chi: Moving that led to the development and evaluation of Matter scores, and nursing home admission. Journals for better balance—Development of a commu- of Balance and is currently an invited member of the of Gerontology: Biological Sciences and Medi- nity-based falls prevention program. Journal of CDC’s Fall Prevention Expert Panel. cal Sciences, 55, M299–M305. Physical Activity and Health, 5, 445–455. 19. Healy, T. C., Peng, C., Haynes, M. S., McMahon, 28. Li., F., Fisher, K. J., Harmer, P., & McAuley, E. E. M., Botler, J. L., & Gross, L. (2008). The fea- (2005). Falls self-efficacy as a mediator of fear sibility and effectiveness of translating a Matter of falling in an exercise intervention for older of Balance into a volunteer lay leader model. adults. Journals of Gerontology: Psychological Journal of the Applied Gerontology, 27, 34–51. Sciences and Social Sciences, 60B, 34–40.

20 SEPTEMBER 12, 2011 • WWW.AOTA.ORG Standing Tall A Self-Management Approach to Fall Prevention Intervention

Elena Wong Espiritu

By incorporating an evidence-based self-management approach into fall prevention interventions, occupational therapy practitioners can support their clients in taking a more active role in managing fall risk on a daily basis.

previous fall is one of the mental modification). Yet therapists can strongest risk factors for falling incorporate a self-management approach again1; therefore, for some into their fall prevention interventions to older adults, being at risk complement their current practice and for falls can be considered a enable older adults to safely continue Achronic state. Although many adults who their engagement in valued activities. have fallen stop participating in valued activities out of fear of doing so again, Self-Management: Definition, many others prefer to maintain their Tasks, Core Principles, and Skill regular routines and roles.2 They accept Development that fall risk is a reality, but instead of Self-management includes the atti- stopping participation in valued activ- tudes, beliefs, and skills that enable ities, they prefer to focus on how to a person to manage the effects of a prevent a fall rather than not participate chronic condition on his or her life.9,10 at all.2 Managing fall risk requires older Self-management is also a process that adults to make daily choices about how individuals engage in as they collaborate they participate in valued occupations. with their health care providers to more A self-management approach has actively manage their conditions.9 It is a been widely implemented with clients continuous process that can change as . 3 . with chronic disease (e.g., arthritis, dia- a person’s situation changes ; therefore, ES DEL MAG betes, asthma, heart failure) as a means learning to self-manage a condition takes I A MO IS TTY

9 of supporting them to become more time and experience. E ED / G R r active in their own care, facilitating bet- To be a successful self-manager, a U CT I

ter daily management, and mitigating the client must engage in medical manage- eusle a ON P S H

3,4 R E burden of chronic disease. Evidence ment, role management, and emotional th . P Y supports the effectiveness of this type of management.11 When clients success- L / Judi ON

5–8 ra u

self-management. fully manage these three things, they SES t

Occupational therapy practitioners are more active in their health care and, RPO U P E V

have primarily focused on a remedial or overall, experience increased quality of I

compensative approach to fall preven- life. See Table 1 on page 15 for defini- TRAT

tion intervention (e.g., exercise, environ- tions of self-management tasks. PHOTOGRAPH © Cul ILLUS

14 SEPTEMBER 9, 2013 • WWW.AOTA.ORG Principles are core elements or rules pations. Promoting a person’s health and (COPD), coronary artery disease, and that govern behavior and processes. participation in life through engagement gout. During a recent hospitalization Core principles that guide self-manage- in occupation is core to occupational for a COPD exacerbation, Fred also ment efforts include: (1) a focus on well- therapy practice.19 By collaborating experienced a gout flare up that kept ness as opposed to illness8; (2) clients, with clients, occupational therapists can him in bed for almost a week due to not health care professionals, accepting help them identify what they both need the pain, which led to pneumonia and responsibility for managing the illness, and want to do. Occupational therapists a deconditioned state. Since his hospi- including making necessary behavior have the skills and abilities to observe a tal discharge, Fred had been receiving Standing Tall 12 changes ; (3) clients taking control of person participating in a valued activity home health physical and occupational their situation and accepting autonomy and help him or her identify objective therapy services to help him increase his to make their own decisions13; (4) an and subjective supports and barriers to activity tolerance and overall strength individualized approach, with clients occupational performance. so he could return to his prior level of defining the problems and interventions functioning. tailored to meet their specific needs8; Case Example: Fred Fred lived in a two-story town- and (5) a collaborative relationship in Fred was a 62-year-old widower living house. His bedroom and bathroom which the health care professional and in Dallas, Texas. Fred’s medical his- were located on the second floor. Fred the client work together in a mutually tory included hypertension, diabetes, noted that the stairs were getting more beneficial, respectful partnership,14 with chronic obstructive pulmonary disease difficult to manage, especially after each person bringing an expertise to the relationship. The health care professional knows information about the Table 1: Self-Management Tasks Definitions8 condition and treatment options, and the Medical management Clients are knowledgeable about their conditions, able to client is an expert in his or her own life monitor signs and symptoms, and understand and engage in and circumstances.15,16 their treatments. In a self-management approach, respect for client choice is founda- Role management Clients are able to maintain, change, and create new mean- tional9 and overarching. By exploring ingful behaviors or life roles to maintain quality of life, such and developing specific self-manage- as taking on new job responsibilities, delegating household ment skills, clients can better manage tasks to others in the family, and modifying the way they their chronic conditions. Six important participate in hobbies. self-management skills for chronic dis- Emotional management Clients address the emotional aspects of having a chronic ease management are self-monitoring, condition, which can alter one’s view of the future, by learn- problem solving, decision making, ing to manage emotions such as anger, fear, frustration, and action planning, finding and using depression. resources, and communicating.3,8,17 By developing and integrating these skills into their daily routines as they approach problems, clients’ abilities and Table 2: Self-Management Skills Definitions3,8,17 confidence in managing chronic conditions will improve.15,17 See Table 2 for Skill Definition definitions of self-management skills. Self-monitoring Identifying and recording symptoms or events that positively or negatively affect outcomes or abilities to support informed decision Self-Management Support making Self-management support is what health care professionals do to assist Problem solving Defining problems, generating possible solutions, implementing clients who are engaged in a self- solutions, and evaluating results 10,18 management process. Profession- Decision making Choosing the best option on the basis of sufficient and appropriate als do this through educating, sharing information and its appeal to the client information, and supporting skill development.18 Health care professionals also Action planning Developing a short-term plan that outlines a specific action or set of create situations in which clients can actions that a client wants and can realistically expect to accomplish trial, modify, and increase their ability in 1 to 2 weeks Y. P E R S ON I CT U ED IS A MO DEL . Y. to use self-management skills within the Finding and using Knowing where to go for help or information and knowing how to context of their daily lives. t u ra / Judi th H a eusle r G E TTY I MAG ES . resources use or obtain those resources Occupational therapy practitioners are well qualified to support their clients Communicating Expressing thoughts, feelings, and information in a way that another in developing self-management skills person understands, resulting in needed help or information

PHOTOGRAPH © Cul I V E P U RPO SES ON L ILLUS TRAT because of their expertise in daily occu-

OT PRACTICE • SEPTEMBER 9, 2013 15 Service Learning in Fall Prevention at TWU–Dallas

Lacy Jackson and Noralyn Pickens

s part of Falls Prevention Aware- and social lives (www.masterpieceliving. of the 2012 AOTA Certificate of Apprecia- ness Day last year, the Master of org). Masterpiece Living works to quanti- tion for sustained philanthropic service to Occupational Therapy students tatively and qualitatively evaluate clients in occupational therapy education, is a retired at Texas Woman’s University the aforementioned areas in order to identify occupational therapist and health advo- (TWU)–DallasA campus contributed to a those areas where residents might benefit cate. TWU–Dallas Student Occupational local senior living community by facilitating from therapeutic intervention and through Therapy Association (SOTA) President fall prevention screenings. involvement in activities Katie Springer; and Debbie Buckingham, Edgemere is an independent living already offered at community in the heart of Dallas, where Edgemere. residents are able to live independently in Through Virginia apartments while having on-site access to Chandler-Dykes, a assisted living, skilled nursing, and memory resident of Edgemere, care services and facilities, in anticipation of the administration their changing needs (www.edgemeredallas. invited the occupa- com). In keeping with Edgemere’s mission tional therapy master’s of providing health-and-wellness programs, students from TWU to it has teamed up with the Masterpiece participate in completing Living program, a lifestyle and wellness part of the Masterpiece resource developed from the McArthur Living assessments. Foundation Study on Aging that promotes Chandler-Dykes, a independence and healthy lifestyles in recipient (along with TWU students with Edgemere resident perform the Chair Sit and residents’ spiritual, physical, intellectual, her husband, Roland) Reach test.

his recent hospitalization. Fred had a Since his gout flare-up, Fred’s feet Fred stated that he was concerned home office on the first floor that he had been swollen and tender, so he had about falling, as he was not as strong or had been thinking about converting into primarily worn his house slippers rather steady as he used to be. He specifically his bedroom; however, he had felt so than his regular shoes. The slippers were identified walking up and down the stairs overwhelmed with making this conver- easier for him to slip his feet into, but to get to his bedroom and being able sion that he had not moved forward they made his gait more unsteady. As a to continue gardening, which was one with this plan. The conversion would result, there were times at church and in of his most valued activities, as two of have involved painting the room, adding the grocery store when people inadver- his top priorities to address during his a walk-in shower to the current main tently bumped into him and he almost occupational therapy sessions. Megan floor bathroom, and moving several lost his balance because of the crowded decided that incorporating some educa- heavy boxes of old paperwork to the environment. Fred was concerned about tion, information sharing, and self-man- garage. falling in the future. agement skill development into her Although the physical therapist rec- Fred enjoyed working in his yard—in treatment sessions with Fred would be a ommended that Fred use a wheelchair particular, tending to his small vegetable beneficial way of collaborating with him when out in the community because of garden. He stored his gardening tools on and allowing him to take an active role in E leg weakness, he had chosen not to do a top shelf in his garage and stood on a decreasing his fall risk. R E M so because he did not want to inconve- ladder to access them. Since his hos- To address his concerns about gar- E G nience his son with loading and unload- pitalization, Fred’s garden had become dening, Megan asked Fred to record over ED & S N ing it from the trunk. Two other factors overgrown with weeds, which made it a 1-week period the signs, symptoms, E CK influenced Fred’s decision about the difficult for him to maneuver when he and situations that made gardening more I YN P wheelchair: It blocked the aisle in the went to pick his vegetables. difficult. As they reviewed his list, Fred L church sanctuary, and when he used it Fred’s home health occupational noticed that it was more difficult for him

at the grocery store, he could not reach therapist, Megan, identified a number of to get up and down from the ground Y OF NORA ES

items off the top shelves. Therefore, he fall risk factors during her initial evalu- when his blood sugar was low and on RT preferred to steady himself while walk- ation of Fred, and she also asked Fred the days when he chose (depending U ing in the community by reaching out what concerned him about his current on how he felt that day) not to take his for external surfaces like furniture, door physical condition, home environment, Lasix medications, making his breathing

frames, and rolling grocery carts. and activities. more labored because of his COPD (an PHOTOGRAPH CO

16 SEPTEMBER 9, 2013 • WWW.AOTA.ORG OTR, MS, SOTA advisor, coordinated 17 one another. Tests included the Get Up the fall, so administrators can see areas in students to administer the physical portion and Go test, functional reach, and Tinetti which residents have improved and areas from the Masterpiece Living battery of balance assessment, among others that that still need work. assessments, which emphasizes balance, were developed for the Masterpiece Living The students were familiar with many strength, and flexibility (for more infor- assessment battery. Residents came away of the assessments from classroom learn- mation, go to www.mymasterpieceliving. with experiential knowledge of their own ing, and this opportunity took that learning com). Eighty-four residents at the facility strengths and weaknesses, helping them to a new level of skill. One student noted, participated in the assessments. Students to make safe choices in daily activities. “It was satisfying to feel comfortable with prepared before the fall prevention screen- The scores for each test will be the process of interviewing, interacting, ing event by reviewing the assessment compared with nationwide norms, and and explaining the specific objectives battery with faculty and by practicing with recommendations will be made for and procedures necessary to follow the activities and therapies assessment.” TWU students were eager offered at Edgemere that to take advantage of the opportunity to might help residents to further their own learning and practice increase their strength, while contributing to fall prevention for the flexibility, endurance, and/ residents at Edgemere. n or general physical health. Specifically, some resi- Lacy Jackson is a master of occupational therapy student dents who are currently and graduate assistant at Texas Woman’s University’s living independently were School of Occupational Therapy. referred to occupational therapy to address balance Noralyn Pickens, OT, PhD, is an associate professor issues that might create fall and associate director of the School of Occupational risks. The same battery of Therapy–Dallas Campus. Pickens’ clinical practice and An Edgemere resident performs the Functional Reach Test as tests will be administered research focuses on older adults who are aging in place, directed by a TWU student. to the residents again in environmental modifications, and fall prevention.

example of self-monitoring). Megan things became easier. If Fred was still next Sunday when he came to pick him reiterated the importance of Fred taking experiencing difficulty, they could refer up for church (an example of communi- his prescribed medications, including back to the list for alternative solutions. cating). By breaking down the task into his Lasix, as ordered by the physician, Fred was excited to try out this solution smaller, concrete steps, Fred was not as as his breathing was affecting his ability and see whether it helped him feel safer overwhelmed with the idea of moving to participate in gardening. Fred also from falling when gardening. He also felt his bedroom downstairs, and he felt identified that the current location of empowered that he had been part of the confident that he could accomplish these his gardening tools were putting him at problem-solving process. tasks over the next week. a higher risk for falls because he had to Fred also decided that he would like Megan actively involved Fred in the climb a ladder to reach them. Megan and to start making plans to move his bed- process of identifying areas to work on Fred brainstormed and generated a list room downstairs. Megan worked with during his occupational therapy ses- of other places he could store his tools Fred to look up phone numbers of local sions. She provided information and that were more accessible and decreased contractors who could repaint the room created situations for him to trial using his chances for injury (an example and install a walk-in shower (an example his self-management skills and modify of problem solving). Of the possible of finding and using resources). Fred his actions, leading to Fred’s increased E

R options, Fred decided he wanted to buy made a plan to call three of the compa- ability to develop realistic steps to E M E a rolling garden cart that could serve nies by his next occupational therapy decrease his fall risk. This also increased G

ED two purposes: He could store his tools session to schedule appointments for his emotional management of his fear of & S N

E in it, and by rolling instead of carrying estimates (an example of action plan- falling, which meant a decreased fear of CK I his tools, he could conserve energy that ning). When Megan asked how confi- it. The self-management skills that Fred YN P L could be spent on gardening (an exam- dent he felt that he could accomplish learned could be applied to other aspects ple of decision making). He could also this goal, in order to measure his self- of his life as he continued to participate

Y OF NORA sit on the cart as needed, limiting the efficacy, he reported having a confidence in meaningful activities while effectively ES

RT number of times he would have to get level of 9 on a 10-point scale. Finally, managing his fall risk. U up and down from the ground. Megan Fred said that he would inform his chil- encouraged Fred to try out the rolling dren about his plans and specifically talk Conclusion garden cart over the next week and to his son about helping him move the A self-management approach is highly

PHOTOGRAPH CO monitor his symptoms to see whether boxes of paperwork into the garage the consistent with the values and core

OT PRACTICE • SEPTEMBER 9, 2013 17 beliefs of occupational therapy. Occupa- tional therapy practitioners have a great FOR MORE INFORMATION opportunity to truly engage their clients AOTA/CDC Falls Prevention Project tact hours]. $158 for members, $225 for nonmem- in collaborative relationships, support- www.aota.org/en/practice/productive-aging/falls/ bers. To order, call toll free 877-404-AOTA or shop ing them in continued participation in cdc online at http://store.aota.org/view/?SKU=OL36. Order #OL36. Promo code MI) meaningful activities. By incorporating Falls Prevention Resources an evidence-based self-management www.aota.org/practice/productive-aging/falls AOTA CEonCD™ or Online Course approach into current fall prevention An Occupation-Based Approach in Postacute Care AOTA Fact Sheet to Support Productive Aging interventions, occupational therapy Occupational Therapy and the Prevention of Falls By D. Chisholm, C. Dolhi, & J. L. Schreiber, 2011. practitioners can support their clients in http://tinyurl.com/o66wse2 Bethesda, MD: American Occupational Therapy taking a more active role in managing fall Association. (Earn .6 AOTA CEU [7.5 NBCOT PDUs, Toolkit for Preventing Falls in Hospitals 6 contact hours]. CD Course: $210 for members, risk on a daily basis as they implement http://tinyurl.com/mnuwwne $299 for nonmembers, Order #4875. Online specific skills when encountering an Course: $200 for members, $289 for nonmembers. issue related to fall prevention. n AOTA Online Course Order #OL4875. To order, call toll free 877-404- Falls Module I—Falls Among Community- AOTA or shop online at http://store.aota.org/. References Dwelling Older Adults: Overview, Evaluation, Promo code MI) 1. Clemson, L., Mackenzie, L., Ballinger, C., Close, J. and Assessments C., & Cumming, R. G. (2008). Environmental inter- By E. W. Peterson & R. Newton, 2011. Bethesda, Occupational Therapy Practice Guidelines for ventions to prevent falls in community-dwelling MD: American Occupational Therapy Association. Home Modifications older people: A meta-analysis of randomized trials. (Earn .6 AOTA CEU [7.5 NBCOT PDUs, 6 contact By C. Siebert, 2005. Bethesda, MD: AOTA Press. Journal of Aging and Health, 20, 954–971. http:// hours]. $210 for members, $299 for nonmembers. ($59 for members, $84 for nonmembers. To order, dx.doi.org/10.1177/0898264308324672 To order, call toll free 877-404-AOTA or shop online call toll free 877-404-AOTA or shop online at http:// 2. Peterson, E., Kielhofner, G., Tham, K., & von Koch, at http://store.aota.org/view/?SKU=OL34. Order store.aota.org/view/?SKU=1197C. Order #1197C. L. (2010). Falls self-efficacy among adults with #OL34. Promo code MI) Promo code MI) multiple sclerosis: A phenomenological study. OTJR: Occupation, Participation and Health, AOTA Online Course CONNECTIONS 30(4), 148–157. http://dx.doi.org/10.3928/15394492- Falls Module III—Preventing Falls Among 20091123-02 Community-Dwelling Older Adults: Intervention Discuss this and other articles on Strategies for Occupational Therapy Practitioners 3. Barlow, J., Wright, C., Sheasby, J., Turner, A., & the OT Practice Magazine public forum Hainsworth, J. (2002). Self-management approach- By E. W. Peterson & E. W. Espiritu, 2011. Bethesda, es for people with chronic conditions: A review. MD: American Occupational Therapy Association. at http://www.OTConnections.org. Patient Education & Counseling, 48, 177–187. (Earn .45 AOTA CEU [5.63 NBCOT PDUs, 4.5 con- http://dx.doi.org/10.1016/S0738-3991(02)00032-0 4. Osborne, R. H., Elsworth, G. R., & Whitfield, K. (2007). The Health Education Impact Question- naire (heiQ): An outcomes and evaluation measure 11. Corbin, J., & Strauss, A. (1988). Unending work 19. American Occupational Therapy Association. for patient education and self-management and care: Managing chronic illness at home. San (2008). Occupational therapy practice framework: interventions for people with chronic conditions. Francisco: Jossey-Bass. Domain and process (2nd ed.). American Journal Patient Education and Counseling, 66, 192–201. 12. Lake, A. J., & Staiger, P. K. (2010). Seeking the of Occupational Therapy, 62, 625–683. http:// http://dx.doi.org/10.1016/j.pec.2006.12.002 views of health professionals on translating chron- dx.doi.org/10.5014/ajot.62.6.625 5. Chodosh, J., Morton, S. C., Mojica, W., Maglione, ic disease self-management models into practice. This article: http://dx.doi.org/10.7138/otp.2013.1816f2 M., Suttorp, M. J., Hilton, L.,…Shekelle, P. (2005). Patient Education and Counseling, 79, 62–68. Meta-analysis: Chronic disease self-management http://dx.doi.org/10.1016/j.pec.2009.07.036 programs for older adults. Annals of Internal Med- 13. Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Elena Wong Espiritu, OTD, OTR/L, earned her doctoral icine, 143, 427–438. http://dx.doi.org/10.7326/0003- Motivational interviewing in health care: Helping 4819-143-6-200509200-00007 patients change behavior. New York: Guilford Press. degree from the University of Illinois at Chicago, 6. Effing, T., Monninkhof, E. E. M., van der Valk, P. 14. Du, S., & Yuan, C. (2010). Evaluation of patient a master’s degree in biblical studies from Dallas P., Zielhuis, G. G. A., Walters, E. H., van der Palen, self-management outcomes in health care: A Theological Seminary, and a bachelor’s degree in occu- J. J., & Zwerink, M. (2007). Self-management systematic review. International Nursing Review, education for patients with chronic obstructive 57, 159–167. http://dx.doi.org/10.1111/j.1466- pational therapy from Texas Woman’s University. She pulmonary disease (Review). Cochrane Database 7657.2009.00794.x is an assistant professor in the School of Occupational of Systematic Reviews, 4, Art. No.: CD002990. 15. Bodenheimer, T., Lorig, K., Holman, H., & Therapy at Belmont University in Nashville, Tennessee. http://dx.doi.org/10.1002/14651858.CD002990.pub2 Grumbach, K. (2002). Patient self-management of 7. Jovicic A., Holroyd-Leduc, J. M., & Straus, S. E. chronic disease in primary care. Journal of the Prior to her academic appointment, Espiritu worked in (2006). Effects of self-management intervention on American Medical Association, 288, 2469–2475. both inpatient rehab and acute care at the University of health outcomes of patients with heart failure: A http://dx.doi.org/10.1001/jma.288.19.2469 Illinois Hospital and Health Sciences Systems, where systematic review of randomized controlled trials. 16. Dow, B., Haralambous, B., Bremner, F., & Fearn, BMC Cardiovascular Disorders, 6, Art. No.: 43. M. (2006). What is person-centred health care? she participated in a number of research projects and http://dx.doi.org/10.1186/1471-2261-6-43 A literature review. Victoria, Australia: Victorian teaching opportunities. Espiritu’s scholarly interests 8. Lorig, K. R., & Holman, H. (2003). Self-manage- Government Department of Human Services. include self-management, community reintegration, ment education: History, definition, outcomes, Retrieved from http://www.mednwh.unimelb.edu. and mechanisms. Annals of Behavioral au/pchc/pchc_literature.html clinical education, and cognition. For her doctoral Medicine, 26, 1–7. http://dx.doi.org/10.1207/ 17. McGowan, P. (2005). Self-management: A back- project, Espiritu co-authored an online continuing edu- S15324796ABM2601-01 ground paper. Victoria, BC, Canada: Centre on cation course on fall prevention intervention, featuring 9. Lawn, S., McMillan, J., & Pulvirenti, M. (2011). Aging, University of Victoria. Retrieved from Chronic condition self-management: Expecta- http://www.selfmanagementbc.ca/uploads/ content describing how a self-management approach tions of responsibility. Patient Education and Support%20for%20Health%20Professionals/ can be applied to fall prevention. Counseling, 84, e5–e8. http://dx.doi.org/10.1016/j. Self-Management%20support%20a%20background pec.2010.07.008 %20paper%202005.pdf 10. Lawn, S., & Schoo, A. (2010). Supporting self-man- 18. Adams, K., Greiner, A. C., & Corrigan, J. M. (Eds.). agement of chronic health conditions: Common (2004). Report of a summit. The 1st annual approaches. Patient Education and Counsel- crossing the quality chasm summit—A focus on ing, 80, 205–211. http://dx.doi.org/10.1016/j. communities. Washington, DC: National Acade- pec.2009.10.006 mies Press.

18 SEPTEMBER 9, 2013 • WWW.AOTA.ORG Light the Way Providing Effective Home Modifications for Clients With Low Vision

Each client, as well as each home environment, has its own set of unique needs that requires a holistic and personalized approach.

Debra Young

s the population continues desire to age in place safely. Each cli- 30 footcandles (fc; or 300 lux) and to age, eye diseases like ent, as well as each home environment, task lighting levels should be at least macular degeneration, has its own set of unique needs that 100fc (or 1,000 lux).8 Along with glaucoma, and diabetic requires a holistic and personalized these two general guidelines, there are Aretinopathy, among many others, approach. Home/environmental modifi- specific light level guidelines for dif- continue to affect older adults’ per- cations for low vision are no exception. ferent spaces within the home as well. formance of activities of daily living. A Consider using a light meter when you recent study completed by Northwest- Consider the Light are completing any home assessment, ern University’s Department of Medi- The first consideration in a home modi- and definitely use one when completing cine reported that although data taken fications assessment for a person with a home assessment for a person with from 1984 to 2010 show visual impair- low vision is lighting. Most of what we any vision concerns. Light meters can ment in those 65 and older is on the know of our world comes to us through be purchased at hardware and home decline, 9.7% of older adults continue our eyes, and we have learned that the supply stores. to report a visual problem that affects way we see things depends on how Although lighting guidelines are everyday life.1 Age-related macular they are lighted.6–7 There are three important, always consider your client’s degeneration is the leading cause of main categories of light to consider in a specific needs. Using a light meter blindness and visual impairment among space: task lighting, which illuminates combined with the IESNA standards is people aged 65 and older. Macular specific areas where work is being a good starting point, but lighting needs degeneration affects more than 1.75 performed; accent lighting, which is are unique to each individual and for million individuals in the United light added to provide extra attention each space. Providing 100fc of light for States, and this number is expected to a selected area within the space; one client with low vision may be just to increase to almost 3 million by 2020 and ambient or space lighting, which right; for another client, it may be too due to the rapid aging of the U.S. is the overall lighting that defines the much light and/or cause too much glare. population.2 The rate of visual impair- whole area. But how do you know there Either insufficient or intense lighting ment increases with age, with 15% of is enough light in the room for safely may be problematic depending on the individuals aged 45 to 64 years, 17% of performing functional tasks? client’s specific type of vision loss. those 65 to 74 years, and 26% of those Appropriate light levels depend on Also important to consider is the over the age of 75 reporting some form the type of activity and the environ- change of the natural lighting through- of visual impairment.3–5 ment for which the activity is to be out the day and how this affects the Home modifications cover a large completed. According to the Illumi- client’s movement within the home spectrum, meeting the needs of those nating Engineering Society of North from one room to the next. Whether with illness, injury, and/or disability America (IESNA) Lighting Handbook, the building or house faces north,

as well as those who are healthy and ambient light levels should be at least south, east, or west, and how much sun © DON BISHOP / JUPITER IMAGES ILLUSTRATION

8 SEPTEMBER 10, 2012 • WWW.AOTA.ORG The author uses a light meter during an assessment.

your clients see in their home environment.9 Determining the type of light that best meets your clients’ needs is a trial-and-error process and, if feasible, should be done for both ambient as well as task lighting during the completion of a functional activity. Your clients will determine which light source provides the best illumination, most contrast, minimal glare, and overall comfort for their eyes. The color-rendering index is especially important because many clients with low vision have difficulty distin- guishing certain colors. We know that as we age we need more light; it has been estimated that the typical 60 year old needs three times as much light as a 20 year old to properly distinguish color and contrast in a given target.4 The typical aging process diminishes the pupil size, allowing less light into the eye. There is also a thickening of the lens, which decreases the amount of light that reaches the retina. These age-related changes, combined with a exposure the home receives through- mer switches can also help control the low vision diagnosis (especially macular out the day, may change the light levels amount of light in each space. degeneration, as this affects the cone within the space. Consideration must cells of the eye—the ones that detect be given for controlling the changing Types of Light detail, color, and contrast) are sure to light levels throughout the home to Along with determining the amount affect how clients perceive color and help the eyes adjust to these transitions of light, find out what type of light contrast and can compromise safety. by filtering and/or shielding light com- best meets your client’s needs. This ing into rooms and into the user’s eyes. ideal level may not be what the client Balance Light Levels These light transitions include chang- is currently using within the home. After you have determined the amount ing from dark to very bright and/or for Determining clients’ preferences for and type of light, evaluating the uni- when previously light areas become incandescent, fluorescent, halogen, formity of light is of equal importance. much darker throughout the day. This LED, etc. is imperative to increasing Ensure that the light levels are bal- can be accomplished using blinds or comfort and safe navigation throughout anced throughout rooms and the home. shades that the client would manu- the home, as well as providing appropri- As we age, our visual systems cannot ally open or close as desired, although ate light to complete functional tasks. In completely adapt to dim conditions. this scenario requires that the client addition, understand the differentiating Light levels in transitional spaces such actively transition into the space with characteristics of each type of lampbulb. as hallways and entrance foyers should either low or intense light to adjust the This knowledge includes the correlated be balanced with those of the adjacent blind or shade accordingly. A high-tech color temperature (a description of spaces. Create intermediate light levels option is a lighting control system that the color appearance of a light source, in transitional spaces that lead from automates the opening and closing of measured on the Kelvin scale) as well bright to dim areas.7 This will enable shades and/or turning on and off lights as the color-rendering index (a method your clients with low vision to adapt set to a certain light level via a timer for describing the effect of a light source more completely as they move through COURTESY OF THE AUTHOR COURTESY or schedule to adjust natural daylight, on the color appearance of objects being the different spaces. manage glare, and maintain even light illuminated) for each type of lamp and Uniformity of light on stairways hotograph

P transitions throughout the home. Dim- how these characteristics affect how increases safety and decreases falls

OT PRACTICE • SEPTEMBER 10, 2012 9 risk. Light levels on the stairs should occurs even when the client has had an be at least as high as in adjacent areas appropriate amount of time to adapt to in the home. The lighting should make the ambient lighting. the tread nosings (the horizontally Using blinds, shades, and/or sheers projecting edge of a stair tread) visible to help filter light as it comes into and not cause any glare or shadows. the room, as well as rearranging the Light switches at each point of stairway furniture or sitting with your back to access are also recommended.10 the sun, are always good options to Many great new products on the minimize glare coming into a space market can help illuminate the not-so- from outside. Also, for task lighting, typical spaces within the home. These positioning the lamp over your shoul- products include under-cabinet lights, der on the side with the better eye, so backlit cabinets, LED rope and string that the light falls only on what you are pathway lighting, lighted closet rods, doing, helps to reduce glare. However, lighted toilet seats, and even lighted the goal is to minimize the glare but not glass countertops and shelving. Part decrease the light level in the space. of the evaluation process is taking the Take care to maintain an appropriate time to analyze available products and amount of light that meets the needs then matching their features to clients’ of your clients. Having more than current and potential future needs. one lamp in a room to create evenly There are many variables to consider distributed light throughout the space, when recommending a product, includ- versus one source of light in one area ing usability, safety, ease of mainte- of a room, will help decrease glare and nance, aesthetics, and price. Always provide a more uniform, balanced light consider the product’s flexibility of use level. to ensure that it can be used by clients with their current vision and potential Contrast and Glare Filters future vision changes. If clients continue to have concerns with glare even after minimizing it Top: Unbalanced light in a hallway. Understanding Glare Above: Various colors of glare filters. from outside and inside, contrast and The IESNA defines glare as one of glare filters may help. These filters are two conditions: too much light and/or available in virtually all colors. Each excessive contrast, meaning the range Discomfort glare occurs when light client will have a specific individual of luminance in the field of view is too reaches a level of intensity at which preference for which color filter best great. Glare sensitivity is associated the eye is unable to adapt naturally, minimizes glare and enhances contrast. with the aging eye as well as with many resulting in true eye discomfort and Therefore, try a range of color tints to eye diseases that cause low vision. reduced ability to see. Discomfort glare assist the client in determining which But what exactly is glare? Glare is a is caused by everyday bright light. This filter works best for both indoor and visual sensation caused by excessive can even occur on a cloudy day, caus- outdoor glare conditions. Traditional and uncontrolled brightness.11 Glare ing squinting and eye fatigue, as the sunglasses may not provide the correct is caused by stray or scattered light ultraviolet light still penetrates through filtering and will only provide protec- that raises the visual brightness (or the clouds on the cloudiest of winter tion from light directly in front of the luminance) of both the visual target days. Veiling glare (or disabling glare) eye. The filters should wrap around the and the background to the same levels. is caused by excessive intense light that face, providing glare protection later- It can cause visual discomfort and/or blocks vision—the eye’s ability to adapt ally as well as overhead. When outside, be disabling. When the eye is exposed is exceeded, and the ability to discern a visor or a hat with a wide brim also to glare, the pupils constrict and limit detail is significantly compromised. Eye provides protection from overhead the amount of light transmitted to the discomfort becomes significant, and glare. To further minimize glare within retina, limiting the image that the eye vision can be impaired. An example of the home, forego using materials that perceives. This forms a veil of lumi- veiling glare is the shining of headlights create a glossy surface. Opt for matte nance, which reduces the contrast and or a flashlight in your eyes, or even the style paints, carpet, and/or unpolished visibility of the target. bright reflection of the sun off of water tiles. Pay attention to the placement It is important to know the different or the hood of a car on a sunny day, of picture frames and mirrors in the types of glare in order to determine reflecting into your eyes and temporar- home, especially within the bathroom, how they can be managed within the ily blocking your vision. Dazzling glare so lighting does not reflect off of them

home as well as just outside the home is the abnormal visual sensitivity to and create added glare. OF THE AUTHOR S COURTESY environment. According to Ludt, there the intensity of ambient light, typically According to the American Founda- are three types of glare to consider caused by the dysfunction of the iris tion for the Blind, contrast sensitivity

12 hotograph with regard to clients with low vision. and retinal disease. This type of glare refers to the ability to detect differ- P

10 SEPTEMBER 10, 2012 • WWW.AOTA.ORG ences between light and dark areas.13 Therefore, by increasing the contrast between an object and its background, Falls Prevention Awareness Day 2012 the object will be more visible. Using alls Prevention Awareness Day is September 22 (the first day of fall). The following contrast is key to maximizing indepen- are some ways that occupational therapy practitioners can let others know about dence within the home for persons with F their role in this area: low vision, although it is important to n Write a brief article for your local paper describing some of the ways in which practi- consider what colors create the most tioners help prevent falls, providing tips for readers on what to be aware of and how amount of contrast for clients, as it to make their own environments safer. may not always be as clear as black n Pitch a story to local TV news organizations offering to demonstrate an in-home and white. assessment to prevent falls. Some ideas for creating contrast n Provide a free workshop to members of your community. Many libraries, places of within the home include painting door worship, senior centers, and community centers provide free space for educational frames in colors that contrast with programs. the colors of the doors, and creating n Work with other staff members (e.g., physical therapists, nurses) to develop or bring contrast between the floor and the a fall prevention program to your facility as a community service or part of patient walls and between the furniture and services. the flooring. This will increase visibility n Offer to do a show-and- tell presentation of products and equipment to prevent falls for navigation within the home and at your local hardware or home store using products that can be bought there. decrease falls risk. Providing a con- n Post information on your Facebook page, Twitter feed, Pinterest page, or other social media venues. Describe how occupational therapy can help and link to resources. n Visit www.ncoa.org/improve-health/center-for-healthy-aging/falls-prevention/falls- prevention-awareness.html for more information on organizing and participating in local events for Falls Prevention Awareness Day.

with all recommendation is very client specific. Changing tions, texture changes from one set of glasses to two brings should be individual a host of potential new issues, includ- specific; changing ing forgetting where the other pair is, floor textures may be having to change glasses throughout contraindicated for the day to manage different tasks (e.g., some clients if there is taking a break from reading to stand up a chance it can create and walk to the bathroom), and paying a falls risk. Another for two sets of spectacles. Creating a texture contrast dialogue with clients to increase their trasting edge on countertops and tables option is placing a tactile cue at the awareness of these concerns and deter- will decrease the chance of clients edge of a handrail to alert clients that mine their preferences is the founda- dropping items on the floor during meal they have reached the top and bottom tion of client-based practice. prep and dining as well as accidentally steps. Both visual and tactile texture bumping into corners and edges. Also cues can be used to distinguish surfaces Consider Client Routines consider using color switches and on hand rails and any placed grab bars. Most of us have a very specific traffic outlets that contrast with their covers Another consideration is what kind pattern within our homes. “A place for as well as with the adjacent walls to of glasses your clients wear. Are they everything, and everything in its place,” maximize visibility. With stairways, con- bifocals (including progressives), as the saying goes, and our clients with sider marking landings and/or nosings trifocals, or single vision lenses (near or low vision are no exception; they rely of stair treads with highly contrasting distance vision only)? Research shows heavily on the familiar. Reflect on the colors, preferably with paint or stain, increased falls when wearing bifocals changes you are recommending to cli- because tape can pull up and become, and walking down a stairway, due to ents’ homes and consider how they may a falls risk. Lighting can also be used to looking through the bottom portion affect navigation and safety. One option, enhance contrast. (near view) of the lens versus main- as appropriate, is to place handrails taining line of sight through the top along the hallways and/or frequently fotosearch / Texture Changes (distance) portion.14 This risk will also used pathways to act as a guide and

images Contrast is not always in color; it can occur when clients are looking at their maximize safety. To maintain clear path-

be in texture changes as well. This can feet while walking down a stairway. ways, remove clutter, unsecured throw fancy

© be done by having a change of floor One option is to have two pairs of rugs, and any other décor or furniture texture when navigating from one room glasses, one for near vision and one for that may interfere with functional mobil- to another. This change should not be distance, to eliminate this concern on ity. Obstacles include hanging décor, the hotograph

P so severe as to create a falls risk. As a stairway. However, this recommenda- undersides of open stairways, and other

OT PRACTICE • SEPTEMBER 10, 2012 11 FOR MORE INFORMATION FIELDWORK ISSUES Preparing Students for Ethical Practice AOTA/CDC Falls Prevention Project Occupational Therapy Interventions www.aota.org/falls for Adults With Low Vision continued from page 7 By M. Warren & E. A. Barstow, 2011. Bethesda, 6 years of attending AOTA Online Course MD: AOTA Press. ($89 for members, $126 for McMaster University Low Vision in Older Adults: Foundations for nonmembers. To order, call toll free 877-404- Rehabilitation AOTA or shop online at http://store.aota.org/ in Ontario, Canada. By R. Cole, G. Rovins, & A. Schonfeld, 2005. view/?SKU=1252. Order #1252. Promo code MI) The program of Bethesda, MD: American Occupational Therapy study was based Association. (Earn .8 AOTA CEU [8 NBCOT PDUs/8 Occupational Therapy Practice Guidelines contact hours]. $158 for members, $225 for for Home Modifications on the pedagogical nonmembers. To order, call toll free 877-404- By C. Siebert, 2005. Bethesda, MD: AOTA Press framework of problem-based learning, AOTA or shop online at http://store.aota.org/ ($59 for members, $84 for nonmembers. To order, incorporating small group and case-based view/?SKU=OL28. Order #OL28. Promo code MI) call toll free 877-404-AOTA or shop online at http:// store.aota.org/view/?SKU=1197C. Order #1197C. study with substantial development of AOTA Self-Paced Clinical Course Promo code MI) the ethics content in the coursework. Low Vision: Occupational Therapy Evaluation and Students completed the DIT within 1 Intervention With Older Adults, Revised Edition Occupational Therapy Practice Guidelines By M. Warren, 2008. Bethesda, MD: American for Productive Aging for Community-Dwelling month of entry into the professional Occupational Therapy Association. (Earn 2 AOTA Older Adults occupational therapy or physical therapy CEUs [25 NBCOT PDUs/20 contact hours]. $259 for By N. Leland, S. J. Elliott, & K. Johnson, 2012. program and during the final academic members, $359 for nonmembers. To order, call toll Bethesda, MD: AOTA Press. ($69 for members, free 877-404-AOTA or shop online at http://store. $98 for nonmembers. To order, call toll free 877- term. In this study, the moral reason- aota.org/view/?SKU=3025. Order #3025. Promo 404-AOTA or shop online at http://store.aota.org/ ing of students in both the occupational code MI) view/?SKU=2220. Order #2220. Promo code MI) therapy and physical therapy programs

AOTA Self-Paced Clinical Course significantly improved over time spent in Occupational Therapy and Home Modifications: CONNECTIONS the professional program (P<0.001). No Promoting Safety and Supporting Participation differences were found in scores across Edited by M. Christenson & C. Chase, 2011. Discuss this and other articles on gender, program of study, year of entry, Bethesda, MD: American Occupational Therapy the OT Practice Magazine public forum Association. (Earn 2 AOTA CEUs [25 NBCOT PDUs, or previous education, suggesting that at http://www.OTConnections.org. 20 contact hours]. $259 for members, $359 for differences were due to the quality of nonmembers. To order, call toll free 877-404- AOTA or shop online at http://store.aota.org/ the educational program provided. The view/?SKU=3029. Order #3029. Promo code MI) findings suggested that directed attention to contextual learning in ethics education, which can be accomplished in both tripping hazards such as pet beds or sources for general lighting. Report DG-10-98. the academic and fieldwork components shoes left near doorways. Client involve- New York: Author. of the curriculum, can help prepare new 9. Lighting Research Center. (2004). Light sources ment throughout the process is key to and color. Retrieved from http://www.lrc.rpi. practitioners for the ethical dilemmas successful home modification. n edu/programs/nlpip/lightinganswers/lightsources/ they may encounter as health care pro- abstract.asp fessionals. n 10. Pauls, J. (2011). Checklist for home stairways. References Retrieved from http://www.stairusabilityandsafety. 1. Tanna, A. P., & Kaye, H. S. (in press). Trends com/downloads/downloads_for_webpage/Check References list-HomeStairways.pdf in self-reported visual impairment in the 1. Kinsella, E., Ji-Sun Park, A., Appiagyei, J., 11. Lighting Research Center. (2007). What is glare? United States: 1984 to 2010. Ophthalmology. Chang, E., & Chow, D. (2008). Through the eyes Retrieved from http://www.lrc.rpi.edu/programs/ doi:10.1016/j.ophtha.2012.04.018 of students: Ethical tensions in occupational NLPIP/lightingAnswers/lightPollution/glare.asp 2. Centers for Disease Control and Prevention. therapy practice. Canadian Journal of Occupa- 12. Ludt, R. (1997). Three types of glare: Low vision (2009) Common eye disorders. Retrieved from tional Therapy, 75(3), 176–182. O&M assessment and remediation. RE:view, 29, http://www.cdc.gov/visionhealth/basic_informa 2. Penny, N.H., & You, D. (2011). Preparing occupa- 101–113. tion/eye_disorders.htm#3 tional therapy students to make moral decisions. 13. American Foundation for the Blind. (2012). 3. American Occupational Therapy Association. Occupational Therapy in Health Care, 25(2–3), Contrast and color. Retrieved http://www.vision (2010). Low vision FAQ. Retrieved from http:// 150–163. aware.org/section.aspx?FolderID=8&SectionID= www.aota.org/Practitioners-Section/Productive- 3. Rest, J. (1979). Development in judging moral 121&DocumentID=3240 Aging/FAQ/LV-FAQs.aspx issues. Minneapolis, MN: University of Minne- 14. Haran, M. J., Cameron, I. D., Ivers, R. Q., 4. Leonard, R. (2002). Statistics on vision impair- sota Press. Simpson, J. M., Lee, B. B., Tanzer, M.,…Lord, ment: A resource manual (5th ed.). New York: 4. Geddes, E., Salvatori, P., & Eva, K. (2008). Does S. R. (2010). Effect on falls of providing single Lighthouse International. moral judgement improve in occupational lens distance vision glasses to multifocal 5. Prevent Blindness America. (2008). Vision therapy and physiotherapy students over the glasses wearers: VISIBLE randomised controlled problems in the U.S: Prevalence of adult vision course of their pre-licensure training? Learning trial. British Medical Journal, 340, c2265. impairment and age-related eye disease in in Health and Social Care, 8(2), 92–102. America. Retrieved from http://www.prevent- doi:10.1136/bmj.c2265 blindness.net/site/DocServer/VPUS_2008_ update.pdf Debra Young, MEd, OTR/L, SCEM, ATP, CAPS, is the Debra Hanson, PhD, OTR/L, is the academic field- 6. Illuminating Engineering Society of North founder of EmpowerAbility, in Newark, Delaware, work coordinator at the University of North Dakota, America. (2003). Light in design: An applica- which provides accessibility services to builders, which has campuses in Grand Forks, North Dakota; tion guide. Retrieved from http://www.iesna.org/ PDF/Education/LightInDesign.pdf remodelers, architects, and designers, as well as and Casper, Wyoming. Hanson has more than 20 7. Figueiro, M. G. (2001). Lighting the way: A key other professionals and consumers. She has 17 years years of experience working with fieldwork educa- to independence. Retrieved from http://www.lrc. of clinical experience, working in hospital, educators and students. She is the academic fieldwork rpi.edu/programs/lightHealth/AARP/index.asp 8. Illumination Engineering Society of North Amer- tional, and community settings as an occupational coordinator representative for AOTA’s Commission ica. (1998). IESNA guide for choosing light therapy and assistive technology consultant. on Education.

12 SEPTEMBER 10, 2012 • WWW.AOTA.ORG Tracy Van Oss Michael Rivers Brianna Heighton Cherie Macri Bernadette Reid Bathroom Safety Environmental Modifications to Enhance Bathing and Aging in Place in the Elderly

he Centers for Disease Helping older adults age in place includes recommendations Control and Prevention (CDC) estimated that by for environmental modifications in the bathroom, where falls 2020, the medical costs most commonly occur. for falls for adults 65 years Tof age and older will be greater than $54.9 billion each year.1 The chance of falling among older adults increases to 40% after the age of 80.2 Two thirds can lessen occupational performance and integrated into the community as of adults over the age of 65 who fall disruption by enhancing the perfor- possible.10 However, as people age, will then have another incident within mance capabilities through personal- limitations in physical and cognitive 6 months of their first fall.3 Six out ized assessment and intervention. abilities increase their need for social, of 10 falls will occur in the home Occupational therapy practitioners are medical, and environmental supports. environment, most of which involve uniquely educated to emphasize the The physical environment directly environmental hazards.4 Falls occur appropriate individualized fit between impacts older adults’ functional abili- most commonly in the bathroom, often clients’ abilities and the environment ties, safety, and productivity. Environ- due to unsuitable toilet height or the in which they live to safely engage in mental modifications, particularly in absence of grab bars and mats on the chosen occupations. the bathroom, are needed to provide floor of the bathtub or shower.5–6 physical support to maintain indepen- Occupational therapy practitioners Reducing Physical Barriers dence in the home. can play a pivotal role in helping older in the Home adults age in place, including through As our population ages, it is important Project Purpose recommendations and training in the to investigate new strategies to reduce Naik and Gill showed that bathroom use of environmental modifications. physical barriers in the home environ- modifications were being underutilized The authors define environmental ment. Aging in place and preventing and in some cases were absent in older modification to include anything that relocation from their homes are impor- adults’ homes.5 The purpose of the has been added to an environment tant goals for most older persons.8 authors’ graduate capstone project at to assist people with participating in Goals of aging in place include enhanc- Quinnipiac University in Hamden, Con- activities and occupations. Environ- ing the quality of life for older adults necticut, was to evaluate the bathroom mental modifications can enhance in their home environment by making environments of four older adults safety for aging persons with or without the necessary modifications for them residing in an independent living com- chronic health conditions to maintain to participate in valued activities.9 munity, provide free adaptations and or improve function and increase According to the AARP/Roper Public modifications to enhance performance overall independence. Ahluwalia et Affairs and Media Group, in 2005, 91% and safety, and follow up to determine HOTO al. indicated the need for more client- of adults between the ages of 65 and which modifications were most effec- CKP TO

centered interventions because of 74, and 95% of adults over the age of tive. Students were supervised by an / IS RT

the varied attitudes older adults may 75, reported that they would prefer to occupational therapist during the home ZZI have toward bathing and the need for age in place for as long as possible.10 In visits, which included training in use of A h © J individualized bathing interventions addition to aging in place, older adults new equipment or modifications. p specific to preferences of each patient.7 have expressed that they would like to Between January and March 2012,

This client-centered focus in turn be as safe, independent, productive, four older adults volunteered to partici- Photogra

14 SEPTEMBER 10, 2012 • WWW.AOTA.ORG Bathroom Safety

pate in a client-centered study to iden- of the bathroom, including tify potential home modifications that accessibility, environmen- may decrease risk of injury in the home tal barriers, and general bathroom environment. All participants safety of the space. The were 65 years of age or older, able to MMSE was used to deter- follow multi-step commands, and able mine cognitive functioning to bathe without assistance. Exclu- of the participants, includ- sion criteria included persons already ing orientation, attention, receiving occupational therapy ser- memory, comprehension, vices for the purpose of environmental and perception. Follow-up modification or those who already surveys using a 5-point used more than four pieces of adaptive Likert scale were adminis- equipment in the bathroom. One occu- tered to gather information pational therapy student researcher about usefulness, satisfac- was paired with one study participant tion, and frequency of use throughout the entire 2-month process of equipment provided to Occupational therapy and nursing students and a participant in the client’s home. the participants immedi- in the project. Equipment was ordered and installed at no Data were collected through the ately and 1 month after cost to participants using a grant from Quinnipiac University’s use of informal interview; Functional the modifications were Center for Interprofessional Healthcare Education. Reach Test12; a modified version of put in place, and train- the I-Hope to include sections related ing on appropriate and safe usage was continued along in their traditional to the bathroom13; the TVO bathroom provided by the occupational therapy clinical experience. The other four assessment, developed by lead author student, to determine whether the nursing students accompanied the hoto;

ckp Tracy Van Oss; the Mini Mental Status modifications created a lasting effect. occupational therapy students on their

to 14

is Examination (MMSE) ; and follow- The occupational therapy students initial home visits with older adults to up participant surveys. Occupational were teamed with eight senior nurs- acquire an understanding of the role oung/ Y therapy student researchers developed ing students from the same institution. of occupational therapy in this context a F. a F.

is a 13-item information questionnaire to This was structured as a secondary as well as to provide input for compre-

ght, L ght, gather relevant demographic data, daily purpose to promote understanding of hensive care. Results from the pre- and i r p bathroom routines/occupations, and occupational therapy among nursing posttest surveys of all eight students past medical history. The Functional students. Pre-planning was required for showed that the four nursing students tty; to tty; e Reach was used to assess balance, scheduling to provide an interprofes- who interacted with the occupational

mat/g safety, and possible influences on bath- sional collaboration. A nine-question therapy students on a weekly basis ci s room performance. A modified version survey was administered as a pre- increased their overall perception mat S mat

ci of the I-Hope was used to determine and posttest to evaluate the nursing of the occupational therapy practice author , S e T areas in the bathroom routine that may students’ knowledge of occupational domain. A $2,000 grant ($500 for each th f P LEF

y o have been causing the participant dif- therapy services. Four of the students study participant) from Quinnipiac TO es ficulty as well as satisfaction and per- were randomly selected to participate University’s Center for Interprofes- hS ©: p ourt

c formance within these noted areas. The in the control group and did not experi- sional Healthcare Education funded the TVO bathroom assessment was con- ence working with an occupational project for recommended environmen-

Photogra bottom, ducted to determine physical contexts therapy student on the project, but tal modifications.

OT PRACTICE • SEPTEMBER 10, 2012 15 FOR MORE INFORMATION CONNECTIONS

AOTA/CDC Falls Prevention Project AOTA Online Course Discuss this and other articles on http://www.aota.org/falls Falls Module I: Falls Among Community-Dwelling the OT Practice Magazine public forum Older Adults: Overview, Evaluation, and at http://www.OTConnections.org. Occupational Therapy Practice Guidelines for Assessments Home Modifications By E. W. Peterson & R. Newton, 2011. Bethesda, By C. Siebert, 2005. Bethesda, MD: AOTA Press MD: American Occupational Therapy Association. ($59 for members, $84 for nonmembers. To order, (Earn .6 AOTA CEU [7.5 NBCOT PDUs, 6 contact question after 1 week. Equipment used call toll free 877-404-AOTA or shop online at http:// hours]. $210 for members, $299 for nonmembers. three or more times within that week store.aota.org/view/?SKU=1197C. Order #1197C. To order, call toll free 877-404-AOTA or shop online included the magnified mirror, raised Promo code MI) at http://store.aota.org/view/?SKU=OL34. Order #OL34. Promo code MI) toilet seat, magnifying glasses, and jar/ AOTA Self-Paced Clinical Course bottle gripper. The items that were Occupational Therapy and Home Modification: AOTA CEonCD™ used two times within the week were Promoting Safety and Supporting Participation An Occupation-Based Approach in Postacute Care Edited by M. Christenson & C. Chase, 2011. to Support Productive Aging the nonslip bath strips, foot scrubber, Bethesda, MD: American Occupational Therapy By D. Chisholm, C. Dolhi, & J. L. Schreiber, 2011. two-tiered shelf, cabinet drawers, and Association. (Earn 2 AOTA CEUs [25 NBCOT PDUs, Bethesda, MD: American Occupational Therapy reacher. The bath mat, tub seat, and 20 contact hours]. $259 for members, $359 for Association. (Earn .6 AOTA CEU [7.5 NBCOT nonmembers. To order, call toll free 877-404- PDUs, 6 contact hours]. $210 for members, $299 nonslip bath strips were used once a AOTA or shop online at http://store.aota.org/ for nonmembers. To order, call toll free 877-404- week. Results suggested that, overview/?SKU=3029. Order #3029. Promo code MI) AOTA or shop online at http://store.aota.org/ all, participants frequently used the view/?SKU=4875. Order #4875. Promo code MI) Occupational Therapy Practice Guidelines equipment. Follow-up interviews and for Productive Aging for Community-Dwelling results of the 1-month survey indicated Older Adults that participants found their overall By N. Leland, S. J. Elliott, & K. Johnson, 2012. Bethesda, MD: AOTA Press. ($69 for members, safety to be higher in the bathroom $98 for nonmembers. To order, call toll free 877- postintervention. 404-AOTA or shop online at http://store.aota.org/ view/?SKU=2220. Order #2220. Promo code MI) Clinical Implications Our study evaluated which bathroom modifications are most effective in The occupational therapy students reducing the risk of injury and enhanc- collaborated with the nursing students ing bathing for older adults aged 65 and to determine individual client abilities older. Results showed that equipment or limitations along with environmental such as nonslip bath strips, padded barriers related to safety and optimal bath mat, foot scrubber, raised toilet performance with activities of daily understanding and safe use of the new seat, and tub seat were useful, visually living in the bathroom. Discussions modifications. During the fourth and satisfactory, and frequently used each occurred among the occupational final visit, clients completed satisfac- week. The majority of the equipment therapy students, the nursing students, tion surveys to measure their percep- that was individually recommended and the faculty member to synthesize tion of how useful the enhancements (client centered) and provided for the the information based on the inter- were, how satisfied they were in the participants was being used throughout view, observation, and data collected appearance of the equipment, and how the week. These findings suggest that from the first visit to offer creative often they used the modifications. if bathroom modifications are client and appropriate solutions. The follow- centered as demanded by occupational ing week a second meeting with the Results therapy best practice, and the client is clients in their homes was conducted to The items rated most useful were properly instructed in safe use by the discuss and review bathroom modifica- nonslip bath strips, a suction-bottom occupational therapist, the likelihood of tion options to enhance independent foot scrubber, a tub seat, a bath mat for adherence and utilization of equipment bathroom task performance. Research- outside the tub, a reacher, a magni- is positive. ers presented individualized adaptation fied mirror, a pill bottle magnifier, a In addition to funding helpful inter- and modification options for each client raised toilet seat, and a jar gripper. ventions, this grant allowed students to and discussed which modifications The most common rating for the items work together with another discipline would be best for them. Equipment provided fell between moderately to to develop attitudes and skills to facili- was then ordered and installed using extremely useful. Participants were tate effective teamwork and leadership. HOTO CKP

the grant money (and at no cost to most satisfied with the appearance of Furthermore, it helped students learn TO / IS participants). After the modifications the nonslip bath strips, foot scrubber, and understand the roles and responsi- p a were put in place during the following tub seat, bath mat, magnified mirror, bilities of each discipline and how those He n e v

visit, the occupational therapy students bathrobe, cabinet drawers, automatic roles can complement one another e

instructed the participants on how shampoo dispenser, reacher, raised in client-centered care in the home © St H to properly use the equipment and toilet seat, magnifying glasses, and jar/ environment. P had them perform the tasks, requir- bottle gripper. The participants initi- HOTOGRA ing participants to safely demonstrate atelly answered the frequency-of-use P

16 SEPTEMBER 10, 2012 • WWW.AOTA.ORG Conclusion 2. Harling, A., & Simpson, J. P. (2008). A systematic EmergingAreas/PA/Home-Mod.aspx review to determine the effectiveness of Tai 10. Safran-Norton, C. E. (2010). Physical home envi- Environmental barriers increase the Chi in reducing falls and fear of falling in older ronment as a determinant of aging in place for risk of injury in the home environ- adults. Physical Therapy Reviews, 13, 237–248. different types of elderly households. Journal of ment, and these barriers may threaten 3. Chang, H. J., Glass, R. M., & Lynm, C. (2010). Housing for the Elderly, 24, 208–231. Falls and older adults. Journal of the American 11. Hutchings, B. L., Olsen, R. V., & Moulton, H. older adults’ abilities to age in place Medical Association, 303, 288. J. (2008). Environmental evaluations and successfully. Home modifications and 4. National Institute on Aging. (2012). Falls and modifications to support aging at home with a adaptations, particularly in the bath- older adults. Retrieved from http://nihsenior developmental disability. Journal of Housing health.gov/falls/homesafety/01.html for the Elderly, 22, 286–310. room, increase the chances that older 5. Naik, A. D., & Gill, T. M. (2005). Underutilization 12. Duncan, P. W., Weiner, D. K., Chandler, J., & adults can continue to reside in their of environmental adaptations for bathing in Studenski, S. (1990). Functional reach: A new homes independently. Occupational community-living older persons. Journal of the clinical measure of balance. Journal of Geron- American Geriatrics Society, 53, 1497–1503. tology, 45, M192–M197. therapy practitioners can facilitate 6. Wyman, J. F., Croghan, C. F., Nachreiner, N. M., 13. Stark, S. L., Somerville, E. K., & Morris, J. C. planning, preparing, and evaluating Gross, C. R., Stock, H. H., Talley, K., & Monigold, (2010). In-Home Occupational Performance injury prevention projects to remain M. (2007). Effectiveness of education and indi- Evaluation (I–HOPE). American Journal of vidualized counseling in reducing environmental Occupational Therapy, 64, 580–589. doi:10.5014/ leaders in this area of practice. Occupa- hazards in the homes of community-dwelling ajot.2010.08065 tional therapy practitioners are trained older women. Journal of the American Geriat- 14. Folstein, M. F., Folstein, S. E., & McHugh, P. R. to view the person, the environment, rics Society, 55, 1548–1556. (1975). “Mini-mental state.” A practical method 7. Ahluwalia, S. C., Gill, T. M., Baker, D. I., & Fried, for grading the cognitive state of patients for and the transaction between the two to T. R. (2010). Perspectives of older persons on the clinician. Journal of Psychiatric Research, create and implement client-centered bathing and bathing disability: A qualitative 12(3), 189–198. care. The time is now to promote our study. Journal of the American Geriatrics Society, 58, 450–456. profession and work toward prevent- 8. Iwarsson, S., Wahl, H. W., Nygren, C., Oswald, Tracy Van Oss, DHSc, OTR/L, is clinical assistant ing unintentional injuries and facilitate F., Sixsmith, A., Szeman, Z., & Tomsone, S. professor of occupational therapy at Quinnipiac older persons’ ability to age in place. n (2007). Importance of the home environment University in Hamden, Connecticut. for healthy aging: Conceptual and methodological background of the European ENABLE-AGE Michael Rivers, Brianna Heighton, Cherie Macri, References Project. The Gerontologist, 47(1), 78–84. and Bernadette Reid are master’s degree students 1. Centers for Disease Control and Prevention. 9. American Occupational Therapy Association. at Quinnipiac University. (2012). Cost of falls among older adults. (2012). Productive aging: Aging in place and Retrieved from http://www.cdc.gov/Homeand home modifications. Retrieved from http:// RecreationalSafety/Falls/fallcost.html www.aota.org/Practitioners/PracticeAreas/

OT PRACTICE • SEPTEMBER 10, 2012 17 Home Teams Practitioners Partner With Contractors for Home Modifications

Andrew Waite

It’s a good thing Occupational therapists and contractors—including many Rick Davis likes husbands and wives—are teaming up to provide better his boss. home modification and aging-in-place services. Rick, who lives in San Antonio, Texas, Maybe that’s because, whether married Lizette realized that she could make used to work for himself as a private to them or not, occupational thera- all the right recommendations in the contractor. But in 2009 he went along pists entering the emerging practice world, but if her clients’ homes were with his wife, Lizette’s, vision and setting must have strong relationships not properly equipped with, say, a started a home remodeling business with contractors and the rebuilding ramp or bedrails, what good would the that specializes in modifications and community—groups that they don’t recommendations serve? What kind of aging in place. Lizette Davis, OTR, typically engage. And although spouses lives could her clients actually lead? CAPS, who’s worked in all realms of working together can make for a nice “Especially out in the rural areas, rehabilitation, including inpatient, story, nuptials are not the only way you’d see [clients] come back more outpatient, and home health, uses her for occupational therapists to achieve debilitated a year after their injury, and occupational therapy background to strong collaboration with builders. more depressed and more dependent consult with homeowners and develop on their caregiver. So it really became hoto p recommendations, and Rick takes care Better Follow Through one of these heartfelt situations,” of the construction. As a practicing occupational therapist Lizette says. “Technically, she is my boss. It’s not in home health, Lizette spent a good That’s when it dawned on Lizette: bad. I like it to a certain degree,” Rick chunk of her career traveling around her husband, Rick, was a licensed con- says. “She’s a very good boss. She’s very Texas evaluating people’s function and tractor, and, together, they could imple- personable, so it’s pretty easy.” environments. She’d see a client in Flo- ment her home recommendations. h © mark wragg / istock p Turns out, it’s pretty easy for a lot resville with a bilateral lower extremity “It just made perfect sense, so I of couples to enter the home modifi- amputation and another in San Marcos asked him to join me in my mission,”

Photogra cations and aging-in-place business. who’d had a stroke. At these visits, Lizette says. “I really feel that I should

OT PRACTICE • SEPTEMBER 26, 2011 9 be doing this with him and creating a If I didn’t have a husband who was able “If she sees something that’s not safer environment for the patients that to do the work himself, the business right, she’s not afraid to voice her I really love and care for. It just became, would be very difficult, because it’s so opinion or suggestions when it comes to ‘Well, I need to help people, and I know important to have a trustworthy coun- her area of expertise,” Rick says. “But that being blessed with his abilities we terpart to handle the clients and the job we pretty much have a separation of can do it.’” with TLC.” trades. It’d be like me trying to tell the Like Lizette Davis, Carolyn Sithong, Amy McManamay, OTR, works as a electrician how to run wiring. I’m not OTR/L, CAPS, SCEM, had the same con- clinical specialist at a major rehabilita- an electrician. And I’m not an OT. So cerns about making recommendations tion center and is trying to start a home we’ll go back and forth a lot with our to clients for home improvements that, remodeling/construction business. Like communication.” without the guidance of an occupational Lizette, Amy felt distanced from the therapist, might never get done prop- contracting world and was searching for Building Relationships erly—if at all. About 4 years ago, when a way to get her occupational therapy Of course, occupational therapy Carolyn was working in acute care, she voice heard. So she recruited her hus- practitioners need not be married to had a client recovering from a stroke band, Eric, a licensed contractor. contractors to be successful in home who was released from a local hospital. “The contractors are the experts in modifications. Take it from Marnie Carolyn realized that her client was building. They are proud of their work, Renda, MEd, OTR/L, CAPS, who lives going to need a ramp and a few other as they should be. Oftentimes when I in Cincinnati, Ohio: “The toilet broke improvements to make the home acces- suggest a change, such as an adjustable at our house the other day, and I fixed sible, and she suggested that the client countertop or a beveled threshold, they it,” she says with a laugh. Her husband ask the hospital to recommend some question my knowledge or perspective. works in sales, and she started her own contractors who could install the ramp. I need to build my confidence in the home modifications business in 2007. “The social worker at the hospital industry, and my husband definitely Similar to Lizette Davis and Carolyn said they pretty much just tell patients helps support that need,” Amy says. Sithong, Marnie, who previously worked to look in the phone book for a contrac- The key to a good aging-in-place in long-term care, saw how recommen- tor,” Carolyn recalls. “And I thought, remodeling business, says Lizette, is dations could not always be put into ‘That’s your answer for somebody like even if roles are clearly defined, part- practice without the right environment. this? How could you just feed them to ners must work well as a team. “I had a lot of experience helping the wolves?’” “The way we figure it, it’s kind of like people transition, but I always felt that So she started her own home modifi- in our home and in our life: We both there was a gap. No matter what I did, cation business in Orlando, Florida. have our areas of expertise, and he gets people still needed help to implement “I was surprised that there was such to call the shots in some spots in life, my recommendations,” Marnie says. a lack of information to help bridge and I get to wear the pants for the other Marnie understands that, to be [clients] to home after having a new dis- parts.” successful, she needs to have a good ability,” she says. “And I don’t fault the Rick says the business would, relationship with contractors. hospital; I just think they didn’t know obviously, be impossible with- So how does she make it the resources available. I thought, ‘You out Lizette’s expertise. happen? An important know what? I can help these people. I can be this liaison and tell a contractor what, medically, this person is going through. And, together, I’m sure we can come up with a great design.’”

Division of Labor

hoto Although Lizette says she’s learned p more about the actual construction side of things and jokes, “I’m probably the prettiest smelling contractor in the lines at Lowe’s and Home Depot,” she’s happy to have Rick handle the job site and the building crew. “The contractor stuff was difficult hens and fcafotodigital/ istock hens and fcafotodigital/ p for me at the beginning,” Lizette says. “You have to be strong and establish a rapport with ‘the guys,’ because although it’s not neces- hs © jacom ste p sarily completely a man’s world anymore, there have been trying

Photogra times––but nothing I can’t handle.

10 SEPTEMBER 26, 2011 • WWW.AOTA.ORG step is to understand what exactly she’s I think you have to be very confident,” Foundation of Knowledge looking for. Marnie says. “When I start a relation- For therapists who are not “do it “A lot of it just has to do with commu- ship with a builder, they assume I know yourself” inclined, there are plenty of nication and spending the time to build a nothing, and so I have to be confident resources available for learning more trusting relationship,” Marnie says. and comfortable with what I’m saying.” about the building sector. Another step is becoming comfort- Marnie teaches classes to occupa- Karen Smith, OT, CAPS, an AOTA able. Marnie watched a lot of programs tional therapists looking to enter the practice associate and AOTA’s Approved on HGTV and DIY and remodeled her aging-in-place and adaptive equipment Provider Program manager, recom- own bathroom before starting her realms and always stresses the impor- mends that practitioners interested in business. tance of learning. aging in place and home modifications “OTs are predominantly female, so “You need to be really familiar with look into the Certified Aging in Place you’re a female who is trying to talk to how construction works so you can Specialist (CAPS) designation from the a man who’s in construction and those speak their language and not just be National Association of Home Builders two don’t necessarily align very well. So bowled over,” she says. as well as AOTA’s Specialty Certifica-

Debra Young The more resources we, as providers, are Assembling the Team aware of, both on a national and local level, the better service we are able to provide our Occupational Therapy and the Building Profession clients.

ome modification is very much a local resources, is essential to spreading the Educating Others team process, in which each player word about the role of occupational therapy While working on building local connections on the home modification team in environmental modifications. The National and resources, it is important to educate your provides valuable information on Aging in Place Council (NAIPC) is a “senior community and state agencies on the role of theH client’s behalf. Increasing our knowledge support network, founded on the belief that occupational therapy services within environ- of each player’s role is integral in successful most older Americans want to remain in their mental modifications, as they may not always home modifications. The Certified Aging in homes for as long as possible, but lack aware- consider our profession in this setting. Place Specialist (CAPS) program, a designa- ness of home- and community-based services Taking the education this one step further tion program through the National Associa- that make independent living possible.”2 The delineates occupational therapy as a unique tion of Home Builders (NAHB), is one way to council’s mission is to be an informational asset, allows for agencies to fully understand become more aware of the building industry resource to seniors for aging in place. the scope of our services, and demonstrates perspective. For an occupational therapy Through NAIPC, local chapters can be the importance of our role in both traditional practitioner, this 3-day program is a means to founded. The role of the local chapter is to and nontraditional settings. network and collaborate with other providers emulate the mission of NAIPC and to increase Consider getting involved with your state within the building industry as well as be a awareness and educate the local community council on housing and/or universal design voice for occupational therapy as an integral about aging in place as well as the resources initiatives. Occupational therapy representa- player on the home modifications team.1 within the area available to seniors. This tion in these areas will demonstrate the Networking with other building professionals grassroots effort would benefit from having importance of our input on housing for the (e.g., architects, general contractors, interior more occupational therapy representation. aging and persons with disabilities and further designers, product vendors) creates a dialogue Local chapters are a diverse group of individu- support our profession as an important player between the two industries and continues to als, from general contractors and interior in state and local policy decision making. n support the importance of the occupational designers to bathroom equipment vendors References therapy profession in this venue. and reverse mortgage consultants. The local 1. National Association of Home Builders. (2011). Certified aging-in-place specialist To further develop rapport and increase chapter is a community network of aging-in- (CAPS). Retrieved July 21, 2011 from http:// visibility, consider becoming a member of place professionals and creates an opening www.nahb.org/category.aspx?sectionID=686 your local home builder’s association (HBA). for health care professionals to have a voice. 2. National Aging in Place Council. (2009). What is NAIPC? Retrieved July 21, 2011, from Becoming a member of your local HBA Through chapter meetings and networking http://www.ageinplace.org/about_us/what_is_ simultaneously gives you membership to events, occupational therapy practitioners naipc.aspx the NAHB and provides further leverage educate both building professionals and local Debra Young, MEd, OTR/L, SCEM, ATP, CAPS, is the for practitioners to be seen as team communities on our role with aging in place founder of EmpowerAbility, in Newark, Delaware, which players along side the building industry. and environmental modifications. Occupa- provides accessibility consulting to builders, remodelers, tional therapy involvement on this level not architects, and designers, as well as other professionals Building a Community only promotes our profession, but also solidi- and consumers. She has 16 years of clinical experience, Creating a dialogue not only with fies our role as a player on the environmental working in hospital, educational, and community settings as an occupational therapy and assistive technol- the building industry, but also with modifications team. ogy consultant.

OT PRACTICE • SEPTEMBER 26, 2011 11 then being able to see how equipment recommendations and modifications “[The Homeowner is] an integral part of the make a difference is really key.” team. We may bring the expertise, but it is the client that communicates what activities are Sharing Best Practices The building community nationwide meaningful, and/or what areas of the house seems willing, as evidenced by CAPS are a priority or of greatest importance to be training and continued involvement of accessible and why,” Young says. “We may occupational therapists, to implement make the recommendations, but it is the client aging-in-place recommendations. Per- haps this attitude is buoyed by an aging that makes the final decisions.” baby boomer generation who, according to recent AARP surveys, prefer to age in their own homes and are willing tion in Environmental Modifications ing with people who don’t have any to look to technologies to assist with (SCEM). idea about your scope of practice. The aging in place.1–2 Although CAPS is geared more CAPS certification falls in line with that But the practice setting will continue toward contractors and prepares them because [builders with the CAPS have] to grow only if occupational therapists for working with homeowners who are already shown the understanding and continue to cultivate relationships with aging in place or have a disability, it the respect of why an OT needs to be builders and other relevant players as also presents a good educational and involved, and they are trying to relay well as each other, says Van Oss, an networking opportunity for occupa- that [to other builders]. So to be in the assistant clinical professor at Quinnipiac tional therapists, Smith says. (See also classroom to support it, [CAPS] is a University’s Department of Occupational “Assembling the Team: Occupational good thing.” Therapy in Hamden, Connecticut. Therapy and the Building Profession” Young also emphasizes how impor- “We do need an open dialogue so on p. 11.) tant the homeowner is in the remodel- that people can share ideas and say, “We recognize the value of OTs ing process. ‘This is working for me, this is how I did taking the CAPS courses because you “They are an integral part of the it,’ and say, ‘What’s working for you? learn their language and learn their team. We may bring the expertise, but What are you using that’s great?,’” Van world, and it may help you find a better it is the client that communicates what Oss says, noting that dialogue should way to fit into it and to be a collabora- activities are meaningful, and/or what also involve occupational therapy stu- tor with them,” Smith says. areas of the house are a priority or of dents and younger practitioners. SCEM is another valuable resource greatest importance to be accessible “Although working in this area may for practitioners looking to enter home and why,” Young says. “We may make not be entry level, it is imperative for modifications, says Tracy Van Oss, the recommendations, but it is the cli- students to learn about this emerging DHSc, OTR/L, SCEM, CAPS. ent that makes the final decisions.” practice area,” Van Oss says. “This will “The Specialty Certification in Envi- Smith says occupational therapists ensure future OT practioners have the ronment Modifications is a process that should also consider getting involved skill set and foundational knowledge to encourages reflection on practice and with the nonprofit Rebuilding Together remain a vital player in this field.” scholarly work,” Van Oss says. “Having (www.rebuildingtogether.org) to Carolyn Sithong, stressing how this distinction from AOTA can posi- provide home evaluations and recom- important it is for occupational therapy tively impact practitioners to network mendations to and further involve practioners to engage in successful with others on their expertise in the occupational therapy with members of long-term relationships with construc- areas of aging in place and environmen- the home-repair community. tion companies, in 2009 started an tal modification.” “[Being involved with Rebuilding Orlando chapter of the National Aging Debra Young, MEd, OTR/L, SCEM, Together] is a way of letting the world in Place Council (NAIPC). ATP, CAPS, who owns her own home know that OTs really do have some- “It’s a network of health care people modifications business in Delaware, thing to add to helping people stay in plus builders and architects, and says she found the CAPS training to be their homes. It’s a way of bringing vis- together we network. We educate them IMAGES very beneficial. ibility to our skill set. It also gives OTs on what aging disabilities look like, and

“By completing that certification, the opportunity to refine their skills in they educate us on what resources are ITER UP J

I met a lot of builders and remodel- this area and to be in touch with actual available for the home to help accom- Z /

ers, and it gave me an opportunity to homeowners in their homes, because modate that,” Carolyn says. “We’re so ELAE P network. It’s about making connections what a lot of OTs do is make recom- used to working with social workers IS U L and bridging that gap,” Young says. mendations from an inpatient setting, and nurses and doctors that contrac- é JOS

“[In home modifications], you have to and they are not always in the person’s tors and architects are kind of out of © H do a lot of things that are outside the home,” Smith says. our traditional network. But as OTs, the P OT field, and you’re maintaining your “Having exposure to how people environment is something that we look HOTOGRA scope of practice, but you’re work- actually function in their homes and at all the time, and I think being able to P

12 SEPTEMBER 26, 2011 • WWW.AOTA.ORG use our skills to work with people who get older.’ Then as Chris was building design the environment is essential.” with his partner, they started keeping FOR MORE INFORMATION In addition to joining NAIPC chap- those things in mind,” Kathleen says. Occupational Therapy Practice Guidelines for ters, occupational therapy practioners Chris recognized Kathleen’s sug- Home Modifications working in home modifications can also gestions as useful and valid, and they By C. Siebert, 2005. Bethesda, MD: AOTA Press. ($59 for members, $84 for nonmembers. network with others through AOTA’s realized that the two of them working To order, call toll free 877-404-AOTA or OT Connections at http://otconnec together would be more powerful than shop online at http://store.aota.org/view/ tions.aota.org/forums/81.aspx or the the two of them working separately. ?SKU=1197C. Order #1197C. Promo code MI) Association’s Facebook and Twitter Fifteen years, at least 10 universally Self-Paced Clinical Course: Occupational accounts, at www.aota.org/facebook accessible houses built, and countless Therapy and Home Modifications: Promoting and www.aota.org/twitter, respectively. remodels later, they are still in business Safety and Supporting Participation Edited by M. Christenson & C. Chase, 2011. together, even though it means they Bethesda, MD: American Occupational Therapy Intangible Benefits hire babysitters so they can take CAPS Association. (Earn 2 AOTA CEUs [20 NBCOT Kathleen Pauli, MOT, OTR/L, CAPS, training or see clients instead of going PDUs/20 contact hours]. $370 for members, $470 for nonmembers. To order, call toll free is another occupational therapist who to the movies. 877-404-AOTA or shop online at http://store. happens to be married to her business Not only are they still in business aota.org/view/?SKU=3029. Order #3029. partner, Chris, who previously ran a together, they are still married, Chris Promo code MI) home remodeling business with one of notes. Self-Paced Clinical Course: Strategies to Ad- his friends. Kathleen says that, back “And you know,” Kathleen points vance Gerontology Excellence: Promoting Best then, she would frequently offer unso- out, “He’s my best working partner.” n Practice in Occupational Therapy By S. Coppola, S. J. Elliott, and P. E. Toto, 2008. licited aging-in-place advice. Bethesda, MD: American Occupational Therapy “I would go on jobs with him, and I’d References Association. (Earn 3 AOTA CEUs [30 NBCOT be like, ‘Wow, what about this?’ We’d 1. AARP Research & Strategic Analysis. (2011). PDUs/30 contact hours]. $490 for members, Voices of 50+ America dreams and challenges. $590 for nonmembers. To order, call toll free just kind of talk and problem solve the Retrieved May 19, 2011, from http://assets.aarp. 877-404-AOTA or shop online at http://store. general things about construction that org/rgcenter/general/voices-america-dreams- aota.org/view/?SKU=3024. Order #3024. I’d see––pretty narrow hallways and challenges-national.pdf Promo code MI) 2. Barrett, L. L. (2008). Healthy @ Home. Retrieved pretty narrow doors––and I’d say, ‘You May 19, 2011, from http://www.aarp.org/relation know, this isn’t going to work as people ships/caregiving/info-03-2008/healthy_home.html Andrew Waite is the associate editor of OT Practice.

OT PRACTICE • SEPTEMBER 26, 2011 13 Home Sweet

Allysin E. Bridges Sarah L. Szanton Home Allyson I. Evelyn-Gustave Felicia R. Smith Laura N. Gitlin Interprofessional Team Helps Older Adults Age in Place Safely Pictured: Carol Glover, CAPABLE program participant

Ms.V, 68 years old, has The Baltimore-based CAPABLE program combines the talents chronic bronchitis, depression, and of occupational therapists, registered nurses, and handymen painful arthritis. She lives in a two-story row home in Baltimore with her 20-year- to address clients’ self-identified problems in home safety, old granddaughter, JJ, and her husband. fall prevention, and basic and instrumental activities of She needs assistance from JJ to get in and out of the tub and wash her back. daily living. She has trouble walking more than two blocks due to shortness of breath. She also experiences pain from bending and her spouse and doing housework. Most many areas. The washer and dryer are stooping due to arthritis, which makes importantly to her, she has no time too low, and there are no railings on the it difficult for her to pick up mail that for herself, especially to take part in 14 steps leading to the second floor. has been delivered through the door slot organized social or leisure activities, like or get pots and pans from low cabinets. gardening or going to church. The Problem Ms. V is the primary caregiver for her Ms. V has been in her home for Ms. V’s case is not unlike that of the husband, who is recovering from several more than 20 years. Her home tour more than 39 million older adults in the strokes and is not able to leave their revealed several issues and challenges. United States.1 It is estimated that by home. She receives little assistance from There are eight front steps to enter the 2050, the same population will more her family, except for JJ. Ms. V used to house, with bilateral railings, and a back than double to 88.5 million.1 walk around a nearby reservoir for daily turf-covered porch that has seven steps. Older adults almost universally VE

O exercise, but now she rarely walks or Ms. V’s living room is tidy and unclut- report wanting to age in their own L goes anywhere, including her church tered, yet there are 13 scatter rugs homes. However, as the population HART

IS (a place she loves), because she doesn’t throughout her home. In the first floor ages, so do the homes in which they HR have the time due to caregiving respon- bathroom, the floor is collapsing, the rug reside. Many older adults live on a fixed h © C p sibilities, is unable to leave her husband slides, there are no grab bars in the tub, income, and they have high fixed costs, alone, and has declining endurance. and the tub surface has no tread. The such as medical and prescription bills.

Photogra Her time is consumed by caring for basement flooring is loose and torn in This can make repairing and maintain-

OT PRACTICE • SEPTEMBER 9, 2013 9 ing a home difficult. Low-income and minority older adults are also more likely to live in deteriorated housing2 and to lack the resources necessary to modify their homes to compensate for their declining capabilities. At the federal, state, and local levels, there are few programs that address both appropriate housing and health needs for seniors, as they usually address one or the other but do not link health needs and housing conditions.3 Because housing conditions can pose health hazards and functional challenges,4 both the person and the environment are important consider- ations when helping older adults stay safe and independent in their own homes. To address this gap in the care of older adults, a team of researchers at the Johns Hopkins Center for Innovative Care in Aging is testing a program that includes occupational therapists, regis- that provides evidence-based services. on providing education, identifying tered nurses, and handymen. ABLE involves up to five home visits barriers to function as directed by the by an occupational therapist; one home client, making goals, solving problems, A Possible Solution visit by a physical therapist; and rec- and conducting training. All visits are The Johns Hopkins School of Nursing ommendations for and training in home customized to the particular functional program, called Community Aging modifications to address client-identi- needs of the participant. Following in Place, Advancing Better Living for fied functional difficulties, home safety a home evaluation conducted by the Elders (CAPABLE), uses the three- concerns, fear of falling, and fall risks. occupational therapist, the handyman pronged approach of an occupational In a randomized trial of 319 older adults receives instructions on home repairs; therapist, registered nurse, and handy- in Philadelphia from 2000 to 2005, modifications; and assistive devices, man working in a coordinated fashion to ABLE reduced functional difficulties, assistive technology, or durable medical address clients’ self-identified problems improved home safety, enhanced effi- equipment specified by the occupational in the areas of home safety, fall risk and cacy in carrying out everyday activities therapist. The handyman’s organiza- prevention, and carrying out activities at 6 and 12 months, and reduced tion, CivicWorks, in Baltimore, orders of daily living (ADLs) and instrumen- mortality risk up to 3 years from study the items, with an average of $1,200 in tal ADLs (IADLs). The occupational enrollment.5,8 CAPABLE expands ABLE grant money covering the materials and therapy component specifically tackles to include two additional components. labor. CivicWorks is also an AmeriCorps dysfunction in ADLs, IADLs, functional First, it adds a nurse to help older adults site and therefore is able to provide an mobility, and leisure and socialization address pain, depression, and medica- apprentice plus an experienced handy- and how the home environment, as tion issues that contribute to functional man for the cost of one handyman. described in Ms. V’s case, contributes to difficulties, to provide strength and As in ABLE, an essential feature of daily functional challenges. balance training, and to facilitate skills in CAPABLE is that the areas addressed Through a $4-million, 5-year grant communicating effectively with primary are driven by the client and his or her from the National Institutes of Health, care clinicians about medical issues.9 self-perceived needs. Also, there is CAPABLE builds on and extends the Second, CAPABLE provides home interdisciplinary coordination, as team Advancing Better Living for Elders repairs in addition to home modifications members consult one another regularly (ABLE) program, a previous occupa- to address housing conditions that pose via e-mail, text messages, phone calls, tional therapy intervention with low- a risk to daily functioning. and in-person team meetings. One of the income older adults in Baltimore City CAPABLE involves up to 10 in-home occupational therapists is the central that was developed by author Laura visits (six occupational therapy visits liaison for all issues with the handyman VE O

N. Gitlin and her colleagues at Thomas and four registered nurse visits) over a aspect of CAPABLE and receives weekly L Jefferson University (TJU) and is 4-month period, and the visits are stag- updates to ensure that the client’s goals HART designed to maximize functionality in gered, so that the occupational therapist are being met in a coordinated fashion. IS HR older adults aging with a disability.5–7 visits twice before the registered nurse For more on this process, see Table 1 on h © C ABLE is currently used by some home visits for the first time. The first two visits page 11. p care agencies, including Jefferson Elder focus on evaluating the participant and On the first visit, the occupational

Care, a home care program at TJU the home, and the later visits focus therapist issues the participant a folder Photogra

10 SEPTEMBER 9, 2013 • WWW.AOTA.ORG Table 1. OT, HM, and RN Visits Over a 4-month Period for Each CAPABLE Client

Occupational therapist (OT) Handyman and Registered nurse (RN) and participant together apprentice and participant together

Visit 1* Introduction; evaluate activities of daily living (ADLs) Introduction and assessment of pain, and instrumental ADLs and mobility; issue fall preven- mood, strength, balance, polypharmacy tion and recovery pamphlet (from CDC). and primary care provider access/communication. Visit 2 Determine goals and conduct house tour/evaluation. Determine goals together, start to brainstorm goal #1.

After visit 2 Develop work order for handyman (HM). Send to HM Review medication list, including interac- and receive pricing. tions and possible deletions.

Visit 3 Brainstorm and develop action plan with client for HM conducts Brainstorm and provide develop action identified goal #1. site visit then plan for client identified goal #2. gives OT pricing; starts work and continues until complete. Visit 4 Brainstorm and develop action plan with client for Brainstorm and provide action plan for identified goal #2; issue assistive equipment/durable client identified goal #3. medical equipment when available.

Visit 5 Brainstorm and develop action plan with client for identified goal #3; review HM work with participant.

Visit 6 Wrap up, help participant generalize solutions for future problems; review goals.

*The visits are staggered so that OT visit 1 and 2 occur before RN visit 1. RN has four visits; the OT has six. to keep CAPABLE appointment calen- shopping, using the telephone, taking occupational therapy sessions, the client dars, hard copies of the brainstorming medicines, managing finances, main- receives a booklet of strategies, initially and action plans the participant does taining health, prepping and cleaning developed in ABLE and now expanded with the registered nurse and occu- for meals, caring for pets, partici- to include a broader range of tips pational therapist, and fall prevention pating in leisure activities, working reflecting the nurse component (given pamphlets for reference. To date, all or volunteering, and participating in by the registered nurse on the last visit) clients have preferred paper copies, but organized social activities that is also reviewed by the occupational electronic versions are also offered. The therapist with the client, focusing on participant and occupational therapist The participant works with the ADLs, falls, and safety. use a standardized assessment tool, occupational therapist to set three To complement the occupational the Clinician and Client Assessment goals based on difficulties found in the therapy work on functional goals, the Protocol (C-CAP), initially developed in self-report and observation during the nurse addresses medical issues that ABLE,10 in which the client and occupa- C-CAP. On the next visit, the occupa- inhibit daily function, such as pain, tional therapist work together to identify tional therapist finalizes goals with the mood, medication adherence and side areas of concern. Specifically, the areas participant and completes a home-risk effects, and strength and balance. For examined include: evaluation, plus introduces fall preven- example, when a client has pain that 1. ADLs: bathing, grooming, eating and tion and recovery strategies. interferes with his or her ability to cook, drinking, toileting, taking undergar- To address the participant’s cho- the registered nurse reviews current ments on and off (hooks, fasteners, sen goals, the occupational therapist pain medication, tailors an exercise buttons, zippers, snaps), taking brainstorms and develops an action plan program suited to the individual, and clothing on and off, donning and with the client to discover why problems encourages increased communication doffing socks and shoes (including may be occurring, what the possibilities with the client’s primary care provider Velcro and ties), resting and sleeping, are of fixing them, and two things the to address unresolved pain. The occu- and engaging in sexual activity client will implement for the upcoming pational therapist evaluates the need for 2. IADLs: housekeeping, bed making, week or two until a strategy that works assistive devices, assistive technology, washing dishes by hand, grocery is established. At the end of all six of the and/or durable medical equipment;

OT PRACTICE • SEPTEMBER 9, 2013 11 examines environmental factors that improved ability to perform their ADLs The occupational therapist also issued could exacerbate pain while standing and IADLs. The number of domains they a long-handled sponge to make bathing or sitting; and introduces strategies to reported difficulties in improved from an easier for Ms. V and her husband. The decrease pain while the client performs average of 2.1 ADL difficulties at base- handyman added a railing on the back IADLs (e.g., recommending weight line to 0.7 ADL difficulties postinterven- steps, fixed and replaced wood planks shifting or sitting vs. standing, ordering tion, and from an average 2.3 different on the ramp and deck, and removed a high back chair with arms). Then the IADL difficulties to 1.2 postintervention, the deteriorating turf on the steps for occupational therapist gets the handy- along with a decrease in their fear of safer mobility. The front top step was man involved for any modifications that falling. Of those who received CAPABLE re-cemented to increase stability, which could be implemented (e.g., lowering or services, 100% indicated it helped them, also increased safety for others coming raising a cooking surface, checking for and 94% stated that their lives had been and going. Bilateral railings were placed floor stability). made easier, their quality of life had inside to the second level, making it easier and safer for Ms. V to climb the stairs. The basement floor was removed and new linoleum was placed in needed Whereas traditional occupational therapy and areas to reduce fall risk. The dryer was raised by a 4-inch platform to ensure registered nurse home care is client centered, proper body mechanics during use. CAPABLE is client directed. Scatter rugs were removed or double-sided taped to reduce fall risk. The occupational therapist also issued Ms. V a reacher for easier access to overhead CAPABLE differs from traditional improved, and ADLs and IADLs became and floor items. The nurse readjusted home care in important ways. In easier.12 CAPABLE is now being imple- Ms. V’s medications with her primary CAPABLE, the attention is directed to mented with 500 people in the CMS care provider by using generic forms the ability of the person to function in demonstration project and 300 people in and re-examining her intake; began an his or her home environment versus the NIA randomized trial. Results will be exercise routine using a combination of addressing a specific injury or impair- available sometime in 2015 or 2016. the Otago Programme (fall prevention ment. The occupational therapist acts as exercises for older adults developed in a consultant, observing and discussing Ms. V, Revisited New Zealand)13 and Tai Chi to alleviate with clients the difficulties they encoun- Here were the three goals Ms. V her pain; and changed her husband’s ter performing valued daily activities. identified: insulin to a generic brand to save money, Importantly, the condition of the home n Walk one lap around a reservoir near which reduced stress. The occupational itself is considered in terms of how it her home with one rest break (prob- therapist and Ms. V addressed each of can best support the client. Whereas lem addressed: decreased exercise her goals through the brainstorming and traditional occupational therapy and due to caregiving responsibilities and action plan activities during sessions 3 registered nurse home care is client cen- declining endurance). to 5 and gained the following results. tered, CAPABLE is client directed. This n Attend church at least once a month At the end of Ms. V’s 4-month par- is an important difference. The func- (problem addressed: decreased ticipation in the study, she was walking tional areas addressed are those that the socialization due to lack of family for pleasure (and exercise) at least client self-identifies as most important. support). once and often twice a day, in the mall, Personal goals such as walking around n Safely reach items on the floor and on streets, at the reservoir, and else- a nearby lake or getting to church at above the shoulder with modified where. Ms. V stated that she had gained least twice a month become the focus of independence using adaptive equip- strength, endurance, and the determi- treatment. ment (problem addressed: difficulty nation to do something good for herself CAPABLE was initially tested in a stooping, crouching, bending, reach- every day, and that she was having less Johns Hopkins University Institutional ing overhead). pain because of it. She began ushering Review Board–approved pilot study at church every other Sunday and felt in 2010 with 40 low-income adults in Besides working on specific func- relief in realizing through the brain- Baltimore City, Maryland, and is now tional goals, there are a few safety items storming process that her husband did being tested in a larger, more rigorous CAPABLE offers every participant. In not need around-the-clock assistance to randomized trial funded by the National Ms. V’s case, this meant that the handy- be safe. In response to her not attending Institute on Aging (NIA) as well as in man installed a grab bar for Ms. V’s tub to all his demands, Mr. V. began doing a demonstration project funded by the and fixed the bathroom floor so that more for himself, which reduced stress Centers for Medicare & Medicaid Ser- it was safe and usable for all members for Ms. V and was also likely healthy for vices as part of the Patient Protection of the household. The occupational Mr. V. By using the reacher issued by and Affordable Care Act.11 therapist added a tub clamp bar, placed the occupational therapist, there was Results from this pilot phase are nonskid tread tape on the tub surface, not much Ms. V could not grab. Ms. V encouraging; participants reported and laid nonskid bath rugs on the floor. had gained a new spirit by the second

12 SEPTEMBER 9, 2013 • WWW.AOTA.ORG FOR MORE INFORMATION

AOTA/CDC Falls Prevention Project Occupational Therapy Practice Guidelines CONNECTIONS www.aota.org/en/practice/productive-aging/falls/ for Productive Aging for Community-Dwelling Discuss this and other articles on cdc Older Adults By N. Leland, S. J. Elliott, & K. Johnson, 2012. the OT Practice Magazine public forum AOTA Fact Sheet Bethesda, MD: AOTA Press. ($69 for members, at http://www.OTConnections.org. Home Modifications and Occupational Therapy $98 for nonmembers. To order, call toll free 877- http://tinyurl.com/pahjq43 404-AOTA or shop online at http://store.aota.org/ view/?SKU=2220. Order #2220. Promo code MI) 8. Gitlin, L. N., Hauck, W. W., Winter, L., Dennis, AOTA SPCC M. P., & Schulz, R. (2006). Effect of an in-home Occupational Therapy and Home Modification: AOTA SPCC occupational and physical therapy intervention Promoting Safety and Supporting Participation Strategies to Advance Gerontology Excellence: on reducing mortality in functionally vulnerable Edited by M. Christenson & C. Chase, 2011. Promoting Best Practice in Occupational Therapy older people: Preliminary findings. Journal of the Bethesda, MD: American Occupational Therapy By S. Coppola, S. Elliott, & P. E. Toto, 2008. American Geriatrics Society, 54, 950–955. http:// Association. (Earn 2 AOTA CEUs [25 NBCOT PDUs, Bethesda, MD: American Occupational Therapy As- dx.doi.org/10.1111/j.1532-5415.2006.00733.x 20 contact hours]. $259 for members, $359 for sociation. (Earn 3 AOTA CEUs [37.5 NBCOT PDUs, 9. Pho, A. T., Tanner, E. K., Roth, J., Greeley, M. E., nonmembers. To order, call toll free 877-404-AOTA 30 contact hours]. $245 for members, $345 for Dorsey, C. D., & Szanton, S. L. (2012). Nursing or shop online at http://store.aota.org/view/?SKU= nonmembers. To order, call toll free 877-404-AOTA strategies for promoting and maintaining function 3029. Order #3029. Promo code MI) or shop online at http://store.aota.org/view/?SKU= among community-living older adults: The CAPA- 3024. Order #3024. Promo code MI) BLE intervention. Geriatric Nursing, 33, 439–45. Occupational Therapy Practice Guidelines for http://dx.doi.org/10.1016/j.gerinurse.2012.04.002 Home Modifications Ways of Living: Intervention Strategies to Enable 10. Petersson, I., Fisher, A. G., Hemmingsson, H., & By C. Siebert, 2005. Bethesda, MD: AOTA Press. Participation, 4th Edition Lilja, M. (2007). The client-clinician assessment ($59 for members, $84 for nonmembers. To order, By C. H. Christiansen & K. M. Matuska, 2011. protocol (C-CAP): Evaluation of its psychomet- call toll free 877-404-AOTA or shop online at http:// Bethesda, MD: AOTA Press. ($89 for members, ric properties for use with people aging with store.aota.org/view/?SKU=1197C. Order #1197C. $126 for nonmembers. To order, call toll free 877- disabilities in need of home modifications. OTJR: Promo code MI) 404-AOTA or shop online at http://store.aota.org/ Occupation, Participation and Health, 27(4), view/?SKU=1970B. Order #1970B. Promo code MI) 140–148. 11. Patient Protection and Affordable Care Act, Pub. L. No. 111–148, § 3502, 124 Stat. 119, 12442 U.S.C. §§ 18001-18121 (2010). occupational therapist visit. “You both difficulties by integrating a home repair 12. Szanton, S. L., Thorpe, R. J., Boyd, C., Tanner, E. K., Leff, B., Agree, E,…Gitlin, L. N. (2011). taught me that it’s okay to take time for and home modification perspective Community aging in place, advancing better living myself and that I deserve it!” she said. in health care provision and using a for elders: A bio-behavioral-environmental intervention to improve function and health-related client-directed approach. n quality of life in disabled older adults. Journal of Challenges and Successes the American Geriatrics Society, 59, 2314–2320. Because the work involves a team of References http://dx.doi.org/10.1111/j.1532-5415.2011.03698.x three professionals, scheduling conflicts 1. U.S. Census Bureau. (2013). American commu- 13. Thomas, S., Mackintosh, S., & Halbert, J. (2010). nity survey, 2007–2011. Retrieved from http:// Does the “otago exercise programme” reduce often arise with clients, such as when www.census.gov/population/age/data/2011.html mortality and falls in older adults? A systematic participants have other appointments 2. Golant, S. M. (2008). Low-income elderly review and meta-analysis. Age and Ageing, 39, or when they do not feel well and need homeowners in very old dwellings: The need for 681–687. public policy debate. Journal of Aging and Social This article: http://dx.doi.org/10.7138/otp.2013.1816f1 to reschedule. Also, clients need many Policy, 20(1), 1–28. http://dx.doi.org/10.1300/ more housing repairs than can be J031v20n01_01 Allysin E. Bridges, MA, OTR/L, is an occupational ther- handled within the CAPABLE approach. 3. Lawler, K. A. (2001). Aging in place: Coordi- nating housing and health care provision for apist at Johns Hopkins University School of Nursing There is also a learning curve in transi- America’s growing elderly population. Retrieved who has been practicing for 11 years and is a graduate tioning from clinician to consultant and from http://www.jchs.harvard.edu/research/ publications from New York University. not treating but guiding clients through 4. Committee on the Role of Human Factors in their journey with us and toward their Home Health Care: National Research Council. Sarah L. Szanton, PhD, CRNP, is an associate professor (2011). Health care comes home: The human fac- goals. at the Johns Hopkins University School of Nursing, a tors. Washington, DC: National Academies Press. Improving safety in homes via strat- 5. Gitlin, L. N., Winter, L., Dennis, M. P., Corcor- principal faculty member at the Center on Innova- egies and modifications and keeping an, M., Schinfeld, S., & Hauck, W. W. (2006). A tive Care in Aging at the Hopkins Center for Health randomized trial of a multicomponent home people in their homes (usually a source Disparities Solutions, and a Robert Wood Johnson intervention to reduce functional difficulties in of meaning) is a success for older adults, older adults. Journal of the American Geriatrics Nurse Faculty Scholar for 2011 to 2014, in Baltimore, their families, and our society. Because Society, 54, 809–816. http://dx.doi.org/10.1111/ Maryland. the home is such an intimate setting, a j.1532-5415.2006.00703.x 6. Gitlin, L. N., Hauck, W. W., Dennis, M. P., Winter, Allyson I. Evelyn-Gustave, OTR/L, is an occupational bond can occur between team members L., Hodgson, N., & Schinfeld, S. (2009). Long-term and participants that can promote cul- effect on mortality of a home intervention that therapist at Johns Hopkins University School of reduces functional difficulties in older adults: Nursing. tural experiences for all parties involved. Results from a randomized trial. Journal of the Observing clients transform into a safer American Geriatrics Society, 57, 476–481 http:// Felicia R. Smith, MS, OTR/L, CBIS, is an occupational and more efficient people in their homes dx.doi.org/10.1111/j.1532-5415.2008.02147.x 7. Clemson, L., Fiatarone Singh, M. A., Bundy, A., therapist at Johns Hopkins University School of is very rewarding as well. Cumming, R. G, Manollaras, K., O’Loughlin, P., Nursing. If proven efficacious and cost effec- & Black, D. (2012). Integration of balance and tive by this larger study, CAPABLE has strength training into daily life activity to reduce Laura N. Gitlin, PhD, is a professor at the Johns Hop- rate of falls in older people (the LiFE study): kins University School of Nursing, and the founder of the potential to change the paradigm Randomised parallel trial. BMJ, 345, e4547. http:// of care for older adults with functional dx.doi.org/10.1136/bmj.e4547 the Center on Innovative Care in Aging.

OT PRACTICE • SEPTEMBER 9, 2013 13 Special Interest Section Quarterly Home & Community Health Sponsored in part by Dysphagia Diet, a Division of Med-Diet Volume 20, Number 2 • June 2013 Published by The American Occupational Therapy Association, Inc.

Whose Safety is it Anyway? Evaluating Outcomes of Home Modifications n Claudia E. Oakes, PhD, OTR/L safety. Safety within the home involves a transaction between the person (who may have impairments such as low vision), the envi- t is well documented that most members of the aging popu- ronment (which may have low lighting), and the occupation (peo- lation want to remain in their homes as long as possible, ple may be engaged in a range of meaningful activities within the Imaintaining both safety and independence (Bayer & Harper, home, such as reading, preparing meals, or cleaning). In an article 2000). Home modifications are one way to help older adults do so. discussing bathing disability, Murphy, Gretebeck, and Alexander Adaptations such as grab bars, improved lighting, and stair rails can (2007) identified safety as a component of the environment when promote older adults’ safety, independence, and autonomy (Wahl, using a PEO model but I would counter that safety is a feature of Fange, Oswald, Gitlin, & Iwarsson, 2009). Occupational therapy the environment, the occupation, and the person (as demonstrated practitioners are well suited to recommend appropriate modifica- by safety judgment). While there are some features of an environ- tions after completing a careful evaluation of the older adults, the ment that are inherently unsafe for anyone, such as exposed live activities they value, and the physical contexts in which they func- electrical wires or broken glass, more commonly a safety hazard tion. However, more information is needed to better understand is a relative risk depending on the person, the environment, and the effectiveness of home modifications (Cabrera & Chase, 2008; the task in which he or she is engaged. For example, descending Ivanoff, Iwarsson, & Sonn, 2006). A better understanding of the a flight of stairs without a handrail poses a greater safety hazard outcomes of home modification interventions will improve our evi- for a person with lower extremity weakness than for a person dence base, assist with grant-funded projects, and optimize the use with intact strength. Likewise, the occupation of climbing a step of scarce resources. stool to change a light bulb is a riskier behavior for a person with I propose that the construct of safety be used as an outcome impaired balance who is wearing flip flops than for someone with measure for home modifications. Safety is an important feature of intact balance wearing laced-up sneakers. An effective measure of the context in which older adults live and has an impact on their safety needs to include the relative risk that a hazard poses based on ability to function independently in their homes. However, safety is the interaction between the person, the occupation, and the a complex construct that defies easy measurement. This article will environment. explore the challenges in using safety as an outcome measure for There is often a gulf between objective measures of home home modifications and will provide recommendations on evaluat- safety that may be used by occupational therapy practitioners and ing safety for older adults. occupants’ perceptions of the risks that are present. Overloaded The Occupational Therapy Practice Framework: Domain and outlets, electrical cords that snake from room to room, inadequate Process, 2nd Edition (Framework-II; American Occupational Therapy lighting, loose stair rails, and excessive clutter are routinely found Association [AOTA], 2008) lists “safety and emergency mainte- in clients’ homes, yet the residents may perceive their homes to be nance” as an instrumental activity of daily living (IADL). It is safe. This divide can result in difficulty in evaluating the outcomes defined as “Knowing and performing preventive procedures to of modifications that are intended to improve safety and function. maintain a safe environment as well as recognizing sudden, unex- If the occupants of the dwelling did not feel that there were safety pected hazardous situations and initiating emergency action to hazards before the modifications were installed, how are they going reduce the threat to health and safety” (p. 631). An awareness of to determine the impact of the modifications? Issues about whether safety hazards; a willingness to implement recommendations to older adults actually follow through with home modification improve safety; the financial, physical, and cognitive ability to recommendations are also worthy of consideration, but they are make the changes; and appropriate use of the modifications after beyond the scope of this article. they are completed are all required for modifications to increase the I will address these issues on two fronts: first, those related to safety of the living context. objective safety evaluations that are likely to be used by occupa- The Person-Environment-Occupation Model (PEO; Law et al., tional therapy practitioners; and second, issues involved in asking 1996) provides a useful framework in which to contextualize home older homeowners to evaluate the safety of their environments. —2— Issues Related to Objective Measures impact of home modifications may be intertwined with their feelings about what their home means to them. Many researchers Identifying safety hazards present in an environment may seem (e.g., Dahlin-Ivanoff, Haak, Fange, & Iwarsson, 2007; Golant, 2011; like a straightforward task, but researchers are at the early stages of Heywood, 2005; Petersson, Lilja & Borell, 2012) have explored the understanding how to evaluate environments in concrete, quantifi- idea that people’s perceptions of their homes is rich with mean- able ways. Whiteneck and Dijkers (2009) pointed to methodologi- ing. A home that is a place of longstanding memories and well- cal and conceptual difficulties in measuring the environment for established routines may be satisfying to the person who lives disability research. there, even if it does not meet the objective criteria of a home that In preliminary investigations, they [scientists] might be willing to is “functional” or “safe.” In a qualitative study, elderly residents accept the number of steps taken from wall to wall as a quantification of the length of a room, but sooner or later they note that different described the meaning of home in two major categories: home people have different stride lengths, and rulers are invented. In dis- means security, and home means freedom (Dahlin-Ivanoff et al., ability and rehabilitation research, when it comes to quantifying 2007). Interestingly, security was not linked with safety but with environments, we are still in the ‘steps taken’ era, with incomplete and unsatisfactory progress to inventing rulers (p. S29). familiarity, functionality, and memories. As Gitlin (1998) noted,

Their point is certainly relevant to this discussion. The constructs An intervention may need to first change a person’s perception of their environment and the risk it may pose. The evidence suggests related to safety need to be clearly defined, and effective tools to that older adults may not perceive a situation as hazardous, par- measure the constructs must be developed and validated. ticularly when the environmental condition represents a life-long Gitlin (1998; 2003) reported that there is a risk of collecting circumstance and set of habits (p. 213). invalid data when using environmental checklists that have not This concept was supported by Reid’s (2004) study of how those been evaluated for reliability or validity. Additionally, it is impor- who survived a stroke perceived their environment. The partici- tant that pre–post data collection be completed by a person other pants reported that they generally felt that the homes were suitable than the one who made the home modification recommendations. for completing daily tasks, despite the presence of “noxious physi- Also, it is likely that different instruments are needed to assess the cal environments” (p. 207) observed by the researchers, including safety of private versus congregate housing options. steep stairs and ramps, poor lighting, and inadequate space to On a related note, several difficulties in conducting research maneuver. Heywood (2005) suggested a resident is less likely to with the geriatric population were clearly described by Faes, Van be satisfied with home modifications if the house is altered to the Iersel, and Olde Rikkert (2007) and Jacelon (2007). They noted point where it is no longer consistent with the resident’s perception that geriatric research can be made difficult by several broad issues of the home, regardless of the modifications’ impact on function such as recruitment, selection, informed consent, and study design. or safety. Individuals may have difficulty objectively evaluating the Particular challenges are inherent because the senior population safety of their homes because they cannot disentangle safety from is heterogeneous, thus creating a need for instruments that can their other feelings. measure at both the high and low ends of the spectrum of whatever Additionally, seniors may experience variability in day-to- construct is being measured. Many instruments were validated in day functioning due to disease processes, fatigue, stress, or pain an adult—but not geriatric—population, and therefore these tools (Johansson, Josephsson, & Lilja, 2009; Porter, 2007). A person’s per- may not be valid for the frail elder population. Researchers must be ception of safety may vary based on the time of day; some hazards aware of the ethical and practical issues related to older adults with may be greater at night when limited lighting impedes visibility. cognitive, hearing, visual, and/or motor impairments. Additionally, Safety may also vary based on the day of the week based on per- older adults may be fearful of instrumentation or assessment pro- sonal routines. Sunday routines may be less strenuous and therefore cedures that they perceive as risky. For example, Faes et al. (2007) involve fewer potentially risky behaviors. Or they might be more reported that 25% of the inpatient geriatric population they were strenuous if the person is going to a place of worship and it is the sampling would not consent to having their height measured only day he or she is rushing to be somewhere on time. because they were afraid of falling or had difficulty standing. Safety may also vary based on who is present to give support Issues Related to Older Adults’ Self-Assessment of How (Petersson et al., 2012). For instance, an older woman who lives Home Modifications Have Impacted Safety alone may feel safest when her daughter visits. Adults actively engage in their environments in a dynamic, fluid way, and attempts Asking older adults to evaluate the safety of their living environ- to capture a construct such as safety may be hampered if it is treatment is a complicated endeavor. Older adults’ perceptions of the ed as a static concept. Researchers have described how older adults sometimes frame Published quarterly by The American Home & Occupational Therapy Association, responses in relative terms. In a study of older adults who lived Inc., 4720 Montgomery Lane, Bethesda, in assisted living facilities, Warren and Williams (2008) noted Community MD 20814-3449; subscriptions@aota. org (e-mail). Periodicals postage paid that the residents qualified their answers to questions about their Health at Bethesda, MD. POSTMASTER: Send happiness and well-being “relative” to living in a private home address changes to Home & Community Special Interest Section Health Special Interest Section Quarterly, or “relative” to living in a nursing facility. Additionally, Porter Quarterly AOTA, 4720 Montgomery Lane, Suite #200, (2007) noted that older women struggled with rating the difficulty Bethesda, MD 20814-3449. Copyright © 2013 by The American Occupational that they had with activities of daily living (on a scale of 1 to 5) Therapy Association, Inc. Annual mem- because difficulty was an ambiguous term to them. For instance, (ISSN 1093-7218) bership dues are $225 for OTs, $131 for OTAs, and $75 for Student members. All some women reported that tasks took more time or required more SIS Quarterlies are available to mem- work, but because the tasks were highly valued, they did not bers at www.aota.org. The opinions and positions stated by the contributors are necessarily perceive them as being more difficult. The concept of those of the authors and not necessarily safety may be equally challenging for older adults to describe in those of the editor or AOTA. Sponsorship is accepted on the basis of conformity with objective terms. They may characterize their home’s safety rela- AOTA standards. Acceptance of sponsor- tive to the perceived safety of their friends’ or family’s homes, or Chairperson: Tracy Van Oss ship does not imply endorsement, official Editor: Amy Wagenfeld attitude, or position of the editor or AOTA. their current situation compared with how it was in the past; Production Editor: Cynthia Johansson for instance, when the house was littered with children’s toys. —3— Alternatively, they may be so used to it being a certain way that cations, do you think differently about what makes a house safe?” things like clutter are not seen as safety issues. may help to bridge the gap between professionals’ and residents’ Helping older adults to articulate their feelings about the rela- perceptions of safety. n tionship between home modifications and perceptions of safety may be difficult because it encourages them to think about and References articulate their strengths and limitations. Gitlin (1998) noted that seniors struggle with their feelings about adaptive devices that on American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of the one hand enhance their physical independence but simulta- Occupational Therapy, 62, 625–683. doi:10.5014/ajot.62.6.625 neously elicit feelings of vulnerability because they are forced to Aminzadeh, F., & Edwards, N. (2001). Exploring seniors’ views on the use face their frailties. Admitting that they might not be as safe as they of assistive devices in fall prevention. Public Health Nursing, 15, 297–304. Bayer, A. H., & Harper, L. (2000). Fixing to stay: A national survey of housing had been in the past may force older adults to cross the “thresh- and home modification issues. Washington, DC: AARP. old” of aging so that they cannot deny the realities of the aging Cabrera, C., & Chase, C. (2008, September). Measuring outcomes in home process (Whitbourne & Collins, 1998). This type of thinking may modifications: Making a difference. Home & Community Health Special Interest also be reflected in studies that have shown that older adults may Section Quarterly, 15(3), 1–4. Dahlin-Ivanoff, S., Haak, M., Fange, A., & Iwarsson, S. (2007). The mul- not use adaptive bathroom equipment or mobility aides due to tiple meaning of home as experienced by very old Swedish people. Scandinavian denial, embarrassment, or social stigma associated with their use Journal of Occupational Therapy, 14, 25–32. (Aminzadeh & Edwards, 2001). These emotions may also come into Faes, M., Van Iersel, M., & Olde Rikkert, M. (2007). Methodological issues in geriatric research. Journal of Nutrition, Health, & Aging, 11, 254–259. play when asking older adults to consider the effect of home modi- Gitlin, L. N. (1998). Testing home modification interventions: Issues of fications on their daily activities. theory, measurement, design, and implementation. In R. Schulz, G. Maddox, Finally, practitioners who collect data related to outcomes must & M. P. Lawton (Eds.), Annual Review of Gerontology and Geriatrics (Vol.18): also be aware that the older adults may not completely understand Intervention research with older adults, pp. 190–246. New York: Springer. Gitlin, L. N. (2003). Conducting research on home environments: Lessons the purpose of the questions that are being asked (Wenger, 2001). learned and new directions. The Gerontologist. 43, 628–637. Despite attempts to explain the purpose of collecting outcomes Golant, S. M. (2011). The quest for residential normalcy by older adults: data, participants may fear that the information will be used to pro- Relocation but one pathway. Journal of Aging Studies, 25, 193–205. Heywood, F. (2005). Adaptation: Altering the house to restore the home. vide evidence that they should move out of their homes. Housing Studies, 20, 531–547. Ivanoff, S. D., Iwarsson, S., & Sonn, U. (2006). Occupational therapy Recommendations research on assistive technology and physical environmental issues: A literature review. Canadian Journal of Occupational Therapy, 73, 109–119. Occupational therapy practitioners may want to begin with qualita- Jacelon, C. (2007). Older adults’ participation in research. Nurse Researcher, tive studies to better understand how older adults give meaning to 14, 64–73. the term safety. This may be helpful on two counts. First, it may help Johansson, K., Josephsson, S., & Lilja, M. (2009). Creating possibilities for practitioners to understand the divide between their determination of action in the presence of environmental barriers in the process of ‘ageing in place’. Ageing and Society, 29, 49–70. safety and their client’s. Second, the findings from qualitative studies Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The may provide a useful framework for developing better quantitative person-environment-occupation model: A transactive approach to occupational measures to use in evaluating the outcomes of home modifications. performance. Canadian Journal of Occupational Therapy, 63, 9–23. Murphy, S. L., Gretebeck, K. A., & Alexander, N. B. (2007). The bath envi- Golant (2011) developed a model of residential normalcy that ronment, the bathing task, and the older adult: A review and future directions could provide a useful framework for creating open-ended ques- for disability research. Disability and Rehabilitation, 29, 1067–1075. tions suitable for qualitative interviews. Golant’s model, which was Petersson, I., Lilja, M., & Borell, L. (2012). To feel safe in everyday life at developed to help explain why older adults relocate, suggests that home—A study of older adults after home modifications. Aging & Society, 32, 791–811. when there is a fit between older adults’ mastery (competence and Porter, E. J. (2007). Scales and tales: Older women’s difficulty with daily control) and their comfort (pleasurable feelings, freedom from has- tasks. The Journals of Gerontology, 62, S153–S159. sle, and good memories), they are unlikely to consider relocation. Reid, D. (2004). Accessibility and usability of the physical housing environment of seniors with stroke. International Journal of Rehabilitation Research, 27, However, incongruence between the two will require the person 203–208. to initiate one of two coping strategies: accommodative strate- Wahl, H. W., Fange, A., Oswald, F., Gitlin, L. N., & Iwarsson, S. (2009). The gies such as using mental strategies to reframe the incongruence home environment and disability-related outcomes in aging individuals: What is the empirical evidence? The Gerontologist, 49, 355–368. in a more positive light, or assimilative strategies, including using Warren, C. A., & Williams, K. N. (2008). Interviewing elderly residents in active strategies that involve making changes. Interviews that help assisted living. Qualitative Sociology, 31, 407–424. to uncover incongruence between the realities of the environment Wenger, G. C. (2001). Interviewing older people. In J. F. Gubrium, & J. A. and subjects’ feelings about it may be enlightening. Perhaps asking Holstein (Eds.), Handbook of interview research (pp. 259–278). Thousand Oaks, CA: Sage. questions about the “hassles” in their home would elicit insights Whitbourne, S. K., & Collins, K. J. (1998). Identity processes and percep- into seniors’ perceived threats to safety. tions of physical functioning in adults: Theoretical and clinical implications. Questions about safety should make reference to the context in Psychotherapy: Theory, Research, Practice, Training, 35, 519–530. Whiteneck, G., & Dijkers, M. P. (2009). Difficult to measure constructs: which it is being considered. “Tell me about any hassles you expe- Conceptual and methodological issues concerning participation and environ- rienced when you showered this morning” may yield important mental factors. Archives of Physical Medicine and Rehabilitation, 90 [Suppl. 1], insight about the variable nature of safety. Asking about people’s S22–S35. perceptions of safety in their home compared with other homes Claudia Oakes, PhD, OTR/L, is the Program Director for Health Sciences they have visited may also shed light on perceptions of what at the University of Hartford, 200 Bloomfield Ave., 429 Dana Hall, West makes a home safe and whether their home has those attributes. Hartford, CT 06117; [email protected]. Additionally, there may be wisdom in asking people to reflect on Oakes, C. (2013, June). Whose safety is it anyway? Evaluating outcomes of their perceptions of safety after home modifications have been home modifications. Home & Community Health Special Interest Section Quarterly, implemented. A question such as “Now that you have the modifi- 20(2), 1–3. In the clinic Home Modification and the Therapeutic Value of Advocacy

John Hurtado

s a Level II occupational therapy ADL status and her living environment. presented a safety hazard. In addi- assistant fieldwork student, I We noted that her home is a handicap- tion, she was unable to independently recently learned first hand how accessible public housing apartment lift her legs over the side of the tub. we as occupational therapy fitted with extra-wide doorways, a As we began to better understand practitioners can facilitate ramp leading to the front door, and her dilemma, we realized that she occupational engagement a wheelchair-accessible bathroom. was unable to perform the ADL of through the use of adaptations, However, during the assessment, we bathing—which greatly concerned modifications, and advocacy. learned that Mrs. Jones had significant her—because the environment created During the third week of my difficulty transferring into and using physical barriers. fieldwork experience with Well Care her shower due to her large physical Mrs. Jones explained that she had Home Health, an agency in Wilm- size. She reported that, despite owning spoken about the problem with the Aington, North Carolina, my clinical a tub chair, she was unable to fit into property manager, who had told her instructor, Cindy Evans, COTA/L, and I the tub comfortably and sit on the that there was nothing the building’s arrived at the doorstep of a client with standard chair and, in addition, had management could do to enable her to a challenging set of life circumstances difficulty stepping over the side of the bathe successfully. Through consulta- that were affecting her ability to be tub, a concern that made the simple tion with Mrs. Jones, we determined fully functional in her activities of daily addition of a bariatric shower chair that the best course of action was living (ADLs). not feasible. When asked about the to take her case to the Wilmington Mrs. Jones kept a very clean and possible use of a tub transfer bench, Housing Authority, to which we would orderly apartment and had a specific she explained that she did not like the explain that she was receiving occu- home management routine. During idea of a seat that extended over the pational therapy and that we believed our initial meeting with her, my clinical bathroom floor, as she feared water modifications to her bathroom were instructor and I assessed her self-care would pour onto the floor. Because she needed, particularly to the bathtub. was overweight and required a walker We explained to Mrs. Jones that we for ambulation, it would be difficult for could not guarantee a successful her to clean up spilled water, which outcome because she lived in a public housing complex that relied Within 6 weeks, Mrs. Jones had a on government funding, but that we completely redesigned walk-in shower, would present her case to the Housing with a long-handled shower head, grab Authority and her building’s man- bars, and a bariatric shower chair. agement and explain the importance of the modifications. Mrs. Jones was very interested and enthusiastic about this as well as the other aspects of the treatment plan we created and demonstrated, including techniques for decreasing arthritic pain in her hands and protecting joints while performing ADLs and instrumental ADLs, a home exercise program to improve

PHOTOGRAPHS COURTESY OF THE AUTHOR PHOTOGRAPHS COURTESY bilateral shoulder range of

OT PRACTICE • SEPTEMBER 26, 2011 7 Through advocacy, we can make necessary and unexpected I am so glad to be in a profession that focuses on client-centered care and change happen; change that will make a difference in the lives of enhances the quality of life for our clients clients by addressing their needs and concerns. by addressing and advocating for their needs. From this experience, I learned to not automatically accept financial or motion and strength, and assistive equip- designed walk-in shower to bathe safely. bureaucratic barriers that impede my ment for independently cleaning herself Four days later, I received a call from ability to provide for clients. Through after bowel movements. the director of the Wilmington Housing advocacy, we can make necessary and After leaving Ms. Jones’ home, my clini- Authority, who scheduled a meeting at unexpected change happen; change cal instructor and I met with our supervis- Mrs. Jones’ home to discuss the pro- that will make a difference in the lives ing occupational therapist for suggestions posed modifications. At the meeting, we of clients by addressing their needs and on how to move forward regarding the provided the director with examples and concerns. I am proud to be a part of the bathroom modifications. Our supervi- variations of well-planned walk-in shower profession of occupational therapy and sor’s main recommendation: present our designs and discussed Mrs. Jones’ unique to have played a role in helping a client request in a formal letter instead of simply needs. The meeting was a success: the receive adaptations to her home environ- speaking with the agency over the phone. director agreed that the need was relevant ment that allow her independence with We contacted the Wilmington Housing and would be of benefit to Mrs. Jones and one of her basic ADLs. n Authority to pick up a Reasonable Request to the dwelling. Form and a Release of Information Form, It took some time for the paperwork to to explain the nature and purpose of the be completed and the money to be allo- John Hurtado, COTA/L, is a recent graduate of the request and to get permission from Mrs. cated, but within 6 weeks, Ms. Jones had Occupational Therapy Assistant Program at Cape Fear Jones to allow the Wilmington Hous- a completely redesigned walk-in shower, Community College in Wilmington, North Carolina. ing Authority to speak with us directly complete with a long-handled shower He currently works as a certified occupational concerning her needs. We then drafted head, grab bars, and a bariatric shower therapy assistant with Carolina Therapy Services at a letter explaining our evaluation of Mrs. chair, that was now safe and functional the Haymount Rehabilitation and Nursing Center in Jones’ home and her need for a universally and allowed her to meet her bathing goals. Fayetteville, North Carolina.

8 SEPTEMBER 26, 2011 • WWW.AOTA.ORG In the clinic Occupational Therapy and Rebuilding Together Working to Advance the Centennial Vision

Claudia E. Oakes Cathy Leslie

hen most Americans and unskilled workers, a tremendous envision where they amount of effort goes into ensuring a will live out their senior successfulNational Rebuilding Day. years, they usually RT’s Safe at Home Initiative strives picture their current to improve the safety and accessibility home. However, as people of homes, making the organization a age, their homes may no natural fit for involvement by occupa- longer support participa- therapy practitioners and students tional therapy practitioners. Currently, tion in occupations and, in can contribute knowledge and insight there are occupational therapy practi- fact, may become barriers that inhibit because of their appreciation of the tioners working with approximately 50 participation. Making the necessary relationship between a person, the affiliates. Whome repairs and modifications can be environment, and the occupations in expensive and time-consuming. For which the person engages. By volun- How Can Practitioners low-income homeowners, this burden teering, practitioners and students Contribute to RT? can be overwhelming. directly help people in their communi- Occupational therapy practitioners Fortunately, nonprofit organiza- ties while also promoting the role of can be involved with RT in a variety of tions such as Rebuilding Together occupational therapy to the public. ways. First, practitioners can complete work to help low-income, disabled, This presents a unique opportunity to home assessments and make recom- and intergenerational families age in enact the Centennial Vision by linking mendations for modifications that place by providing free repairs and education, research, and practice will enhance the safety and function home modifications. Occupational and making the role of occupational of homeowners. Additionally, they therapy visible to the public.1 can assist with the house selection process. House selection refers to the What Is Rebuilding Together? steps involved in determining which Rebuilding Together (RT) is a non- applicants will be chosen for National profit organization that provides free Rebuilding Day or other projects home repairs and home modifications throughout the year. Members of to low-income homeowners. There are RT’s House Selection committee take nearly 200 affiliates of RT across the into consideration a prioritized list country. Although many affiliates do of recommendations that practition- year-round projects, the cornerstone ers believe will support homeowners’ of the organization has been National safety and function. Rebuilding Day, a 1-day event, typi- After houses have been selected, cally held on the last Saturday in April, practitioners can work with the in which volunteers come together house captains (the project managers to perform home modifications and assigned to each home) to clarify the ewitt H repairs on multiple houses. Although occupational therapy recommenda- National Rebuilding Day receives the tions. At some affiliates, practition- most media attention, the behind- ers participate in training groups of the-scenes work occurs all year. From house captains to ensure that they h courtesy Pam Pam h courtesy p selecting the houses to evaluating the adequately understand the role of needs of each homeowner, ordering occupational therapy and the recom-

Photogra supplies, and coordinating skilled mendations that are provided.

OT PRACTICE • SEPTEMBER 10, 2012 17 In other affiliates, practitioners work one and after intervention could prove useful. on one with house captains to address The Modified Falls Efficacy Scale is a the needs of specific homeowners. 14-item tool that asks clients to rate their Practitioners may be instrumental in fear of falling while completing everyday negotiating reduced rates on adaptive activities on a 1 to 10 Likert scale.5 equipment that is provided for projects. Additionally, there are logistical issues On the actual National Rebuilding Day, to consider when completing outcomes practitioners fulfill a variety of roles, research. These include: from assisting with clutter management n Who should measure the outcome? to troubleshooting when issues arise Should it be an occupational therapist regarding grab bar installation or other or a volunteer or staff member of RT? recommendations. The expectation of what can reason- Practitioners can also play an impor- ably be assessed differs considerably tant role in collecting data related to the depending on who is collecting the outcome of interventions. data. n How long after modifications are Why Assess Outcomes? installed should the outcomes be Outcomes are important to measure assessed? What is a reasonable not just to ensure that homeowners are amount of time for homeowners to getting the best possible interventions, get a sense of how the modifica- but also to ensure that RT is spending tions are having an impact on their resources on interventions that are most performance? beneficial to the homeowners. Nonprofit n Will the data be collected during a organizations have limited resources and face-to-face interview with the home- must ensure that they are providing the owner or through a mail-in survey or most cost-effective and valuable services phone interview? possible. n Does the assessment need to include Additionally, nonprofit organizations observation of occupational perfor- such as RT depend on funding from mance or can it rely on self-report? foundations and charitable-giving organizations. Many grant funders demand Case Example evidence that interventions are effective, Cathy Leslie, MOTR/L, completed a and outcome studies are a requirement FOR MORE INFORMATION research study while she was a gradu- for grant reporting. Additionally, having ate student in the occupational therapy established outcome processes can open To locate a Rebuilding Together affili- program at Bay Path College in Long- the door for new funding opportunities. ate in your area, search the RT Web site meadow, Massachusetts. She worked with Assessing outcomes is also neces- at www.rebuildingtogether.org or call the Hartford affiliate of RT to complete sary for the profession of occupational the Rebuilding Together National Office her research, under the supervision of therapy.2 Although there is emerging at 800-473-4229.Additional information, Claudia Oakes, PhD, OTR/L, and Karen research related to the effectiveness of including detailed information about set- Sladyk, PhD, OTR/L. Her study attempted home modifications, there is still much ting up a Level I Fieldwork experience for to answer the following questions: to learn.3 Outcomes research provides students, is available in the Rebuilding Does the provision of home modifica- the evidence so that the best practices Together section of the AOTA Web site at tions in the bathrooms of older adults related to home modifications can be www.aota.org/practitioners/awareness. improve their occupational performance operationalized and disseminated. during the ADLs of toileting and bathing? In what ways did the provisions of Measurement Issues Because most of the homeowners home modifications improve homeown- A critical issue regarding home modifica- are functioning relatively independently ers’ occupational performance during tions for older adults is what to measure at home, a standardized assessment of toileting and bathing? To answer these

in order to show the effectiveness of the activities of daily living (ADL) may lack questions, Leslie completed face-to-face ES K OA modifications. There is no single answer the sensitivity to detect change. Assess- interviews in the homes of nine of the 11 IA to this question and many factors must be ments of higher-demand instrumental homeowners who received grab bars in D AU L C

taken into consideration. One potential ADL (IADL) function may more accu- April 2009. (Two of the recipients were F O starting place is to learn about the fre- rately reflect improvements. unavailable by mail or phone.) Interviews quency with which the homeowners use Because many RT efforts are geared were conducted between 8 and 9 months COURTESY the modifications, and their satisfaction at fall prevention, falls are a potential after the installation. HS with them. Additionally, an assessment of area of exploration. Collecting data about Of the eight participants who received P homeowners’ perceptions of safety, inde- actual incidence of falls is notoriously grab bars in or around the shower area,

4 HOTOGRA pendence, or function may be useful. difficult. Data about fear of falling before 75% said they used the grab bars “all of P

18 SEPTEMBER 10, 2012 • WWW.AOTA.ORG the time” when bathing, and the remain- Finally, Leslie noted that the occupa- 2. Cabrera, C., & Chase, C. (2008, September). Mea- ing 25% reported that they used them tional therapy recommendations were suring outcomes in home modifications: Making a difference. Home & Community Health Special “sometimes.” All participants felt that not consistently implemented. Some grab Interest Section Quarterly, 15(3), 1–4. bathing was easier with the grab bars and bars were not installed while others were 3. Gitlin, L. (2003). Conducting research on home that they were safer and more indepen- installed in a different location from what environments: Lessons learned and new directions. The Gerontologist, 43, 628–637. dent in bathing with the addition of the had been recommended. Further research 4. Cumming, R. G., Kelsey, J. L., & Nevitt, M. C. grab bars. is required to understand the discrepancy. (1990). Methodologic issues in the study of Six of the nine respondents received frequent and recurrent health problems. Falls in the elderly. Annals of Epidemiology, 1, 49–56. grab bars around the toilet. Five of the Future Directions 5. Hill, K., Schwarz, J., Kalogeropoulos, J., & Gib- six recipients reported that they used Practitioners are encouraged to think son, S. (1996). Fear of falling revisited. Archives the grab bars “every time” they used the about ways in which they may collabo- of Physical Medicine and Rehabilitation, 77, 1025–1029. commode; the other participant reported rate with RT to advance its Safe at Home “sometimes” using the grab bars. All Initiative. Partnerships with RT can ben- respondents felt safer and more indepen- efit homeowners in need, occupational Claudia Oakes, PhD, OTR/L, is on the faculty in the dent in toileting while using the grab bars. therapy practitioners, students, and Health Science Department at the University of Interestingly, one third of the respon- educators, and the profession as a whole. Hartford. She is on the Rebuilding Together Hartford dents reported feeling less fearful of This opportunity to bridge practice, edu- Board of Directors. She coordinates projects with falling since the grab bars were installed, cation, and research allows practitioners Rebuilding Together Hartford and students from Bay despite the fact that no question specifi- to enact the Centennial Vision and make Path College and Quinnipiac University. She can be cally addressed fear of falling. Several a difference in the lives of older adults in reached at [email protected] or 860-768-5746. respondents also reported that they used our communities. n the grab bars “more than they thought Cathy Leslie, MOTR/L, is a 2010 graduate of Bay Path they would,” with one respondent not- References College in Longmeadow, Massachusetts. She is cur- ing, “The grab bars have been a pleasant 1. American Occupational Therapy Association. rently working as an occupational therapist at the (2006). AOTA’s Centennial Vision and executive surprise for me because I had not used summary. American Journal of Occupational Child Guidance Clinic’s Early Intervention Program them before.” Therapy, 61, 613–614. doi:10.5014/ajot.61.6.613 in Springfield, Massachusetts.

OT PRACTICE • SEPTEMBER 10, 2012 19 perspectives Occupational Therapy Gives Rebuilding Together That “Little Sweetness”

Andrew Waite

ittle sweetness.” “Julee is good. She is really That’s what Dollie Courtney good,” Courtney says. says Julee Leipprandt Lockard, Lockard made sure important MS, OTR/L, CAPS, brought to construction details, what Court- her home. ney calls “little sweetness,” were Lockard was introduced completed during the remodel. to Courtney through the local Per Lockard’s suggestions, the chapter of Rebuilding construction team modified an Together, which provides existing ramp to enter the home, critical repairs and renovations installed grab bars, brought in a for low-income homeown- bathtub seat, widened doorways, Lers across the United States. and made many other smaller Each year, occupational therapy touches to improve accessibil- practitioners and students are ity, including lowering the toilet active in many of the nearly paper holder and installing lever 200 Rebuilding Together local handles on doors instead of round affiliates. knobs. Lockard even worked Occupational therapy practi- with Courtney to show her tioners bring a special expertise how to best navigate the home in home safety and modification modifications. to these projects that is fre- Courtney wasn’t the only one quently needed by older adults, impressed with Lockard. family members, and remod- “She is essential to the success elers. The primary goal of of the project,” says occupational therapy practi- Brian Stupay, who leads tioners is to provide safer, more a group called Hammer accessible home environments Heads, which volun- for residents. Recommending teers with Rebuilding the appropriate location for grab bars, Lockard started Together. “She takes calculating optimal lighting levels or her work with the time to talk to people the most suitable ramp incline, and Rebuilding Together and find out what is providing other helpful suggestions by reaching out to really going on in their are some of the ways that occupational her local affiliate lives and how we can therapy practitioners share their skills 3 years ago to work help. My group of handy- on project teams. as a member of the scoping team. That men and women comes in almost like a Lockard has taken on a big role in meant she visited applicants’ homes to SWAT team to try to fix stuff that needs the Aurora, Illinois, chapter. evaluate what repairs would need to be fixing, and Lockard brings the warmth “It’s a great way to showcase made. She has since become a house and interaction to the project.” what occupational therapists can do, co-captain, so she displays even more Erin Carlisle, program manager at from assessing family members’ daily leadership in specific home builds. It’s in Rebuilding Together Aurora, says Lock- function to recommending the home this role that she met Courtney during ard’s occupational therapy background modifications to training clients,” the 2013 build week, which occurs in keeps rebuild projects focused on the

PHOTOGRAPHS COURTESY OF JULEE LEIPPRANDT LOCKARD PHOTOGRAPHS COURTESY Lockard says. the final week of April each year. homeowner.

OT PRACTICE • SEPTEMBER 9, 2013 7 “I think most of us can serve in some way. functional level, how they use their home space, and what is really important to Whether we have worked in home health them in their home.” To learn more about how you can get or are preparing our clients to return home, involved, visit http://rebuildingtogether. we evaluate the needs org and www.promoteot.org/ai_rebuild ingtogether.html. for home all the time.” Lockard says the effort is worth it when she meets people like Courtney, who now safely lives in a house she is proud to call home. “I love staying in my own place,” Courtney says. “I have my own garden “Julee [Lockard] brings so much ensure homeowners can use and benefit and flowers, and I put in what I want to technical knowledge and ideas that no from the repairs we do.” have.” n one else here in the office or construction Lockard encourages other occupa- company can provide for us. She helps tional therapy practitioners to reach Andrew Waite is the associate editor of OT Practice. us ensure that the work we are providing out to their local Rebuilding Together He can be reached at [email protected]. for our homeowners truly changes and chapters and volunteer, because she sees impacts the homeowner’s daily life,” says it as a natural fit. Carlisle. “There is so much involved in “I think most of us can serve in some Occupational Therapy trying to truly impact a homeowner who way,” Lockard says. “Whether we have may have mobility issues. We can install worked in home health or are preparing a walk-in shower, but do they have the our clients to return home, we evaluate Living Life right equipment and placement of grab the needs for home all the time. They ® bars to use that shower? This is [Lock- are so obvious to us, but other evalua- To Its Fullest ard’s] part with Rebuilding Together, to tors don’t think about the individual’s

8 SEPTEMBER 9, 2013 • WWW.AOTA.ORG Caroline Bartlett Crane’s Everyman’s House Historical Home Design and

Carla Chase Home Modification Today Suzanne Roche

in new homes did not provide proper Caroline Bartlett Crane on the household task of washing dishes: ventilation or lighting and was not “Dishwashing is warm and pleasantly sudsy and has this advantage, conveniently arranged within the home that you can think of something else meanwhile.” (p. 104)1 layout for ease of use. When making design decisions to “I would take a seat unashamed on that kitchen stool, from which every- meet the needs of a homemaker, Crane thing needful for the operation is in easy reach, on the walls, or in the found that she was able to incorporate 1 drawers.” (p. 105) elements that met the needs of the older children and her husband as well. She also pointed out that even those nspiration and ideas can come The Work of without children would find her home from anywhere and often Caroline Bartlett Crane design efficient and attractive. In fact, catch us by surprise. While vis- Caroline Bartlett Crane was very well she included two chapters in her book iting our local history museum educated as a young woman and, with that describe the adaptable design of in Kalamazoo, Michigan, in an her father’s encouragement, she gradu- the home and how the space can be attempt to learn more about ated from an elite university, which used in a variety of ways. Her home my new community, I (first was unusual for a woman in her day. design concepts, which focused on the authorI Carla Chase) noticed a large She had several roles during her early comfort and convenience of the occu- model of a home sitting on a tabletop. adult life, including Unitarian minister, pants, were revolutionary. Although As an occupational therapist working supporter of the women’s suffrage her primary focus was on the home- in home modifications, I am always movement, advocate for clean streets maker—who actually spent the most interested in home design ideas. I was and sanitary butcher shops, and various time and did most of the work within intrigued by the museum plaque that other roles supporting a healthy com- the space—and her young children, she read that this was a model of “Every- munity. These experiences appeared also made choices based on workflow man’s House,” designed by Caroline to give her the confidence and skills to patterns, efficiency, and the overall Bartlett Crane. I learned it was the make a difference in the lives of many physical and emotional health needs of winner of the 1924 Better Homes of and led to her creation of Everyman’s each family member. America Award and that the real home House. was built in a nearby neighborhood. Crane reported that she originally Workflow Patterns and Further exploration and research led designed Everyman’s House to meet Efficiency in Everyman’s House to Everyman’s House1—the book that her needs as a busy homemaker and From the beginning of the design pro- Crane wrote about her design ideas mother of young children, unlike cess, Crane chose the basic pathway and and her motivation behind them—and many of the homes built during that layout of the home to support efficiency. to boxes of this local historical figure’s time period. Houses back then were It was possible for the mother to walk plans and notes held in the archives designed by men who often did not in a circle around the main level of the at Western Michigan University, in regularly use rooms such as the kitchen home—stopping at the front door to Kalamazoo. and laundry areas. A typical kitchen pick up any packages received, then into

14 SEPTEMBER 26, 2011 • WWW.AOTA.ORG Figure 1. Kitchen interior with sink, window and cupboards, Everyman’s House

the living room/common area, where she Crane’s practical, thoughtful consideration of all aspects of could stoke the fire and check on the children sitting at the table doing their the home and its impact on its occupants was a very early studies. From there she could enter the application of UD as well as an indication of her creative kitchen area, drop off items as needed or check on what was on the stove, and problem-solving skills. then walk through to the nursery area to check on the littlest child—ending up again at the front of the house, thus completing the circuit. Smaller elements support working night, the mother could sit up, pull the express her ideas, and the resources smarter rather than harder as well. small bed on wheels up to her to nurse to see them through to creation. She

HIGAN UNIVERSITY ARCHIVES Her kitchen was organized by task so and change a diaper as needed, then recognized that she and her husband c someone could be standing in one area place the baby back on the bed and were fortunate to be able to pay for the to make biscuits while another area push it slowly away—thus never having construction of her home; however, was used to clean and chop vegetables to leave the warmth of her own bed. she was extremely aware of every cent (see Figure 1). One ingenious solution spent. Throughout the process, she Y COLLECTIONS. to a common problem of a busy new Meeting the Physical and attempted to make decisions that were mother was the creation of a small bed Emotional Needs of Each fiscally responsible—not just in the on wheels that was elevated and placed Family Member initial outlay, but also with choices that across the foot of her bed (see Figure 2 Crane seemed to have a balance of would require less maintenance and AND REGIONAL HISTOR PHOTOGRAPH COURTESY OF WESTERN MI PHOTOGRAPH COURTESY on p. 16). When her infant woke in the common sense, the confidence to remodeling in the future.

OT PRACTICE • SEPTEMBER 26, 2011 15 Figure 2. Mother’s Room, Everyman’s House to “enjoy to the full that delightful, refreshing basement shower” (p. 157) after work, before greeting any visitors his wife may have in the family living area.1 Furniture was chosen to encourage her husband to rest when needed, so quality time with the family could be more pleasant because he felt more refreshed. Crane felt that all family members should feel comfortable and welcome so they would want to return home to get refreshed and nourished after a busy, stressful day. Crane’s Better Homes of America winning design of Everyman’s House was a part of a larger, national movement to provide housing for working- class people. Although it isn’t clear how her work specifically influenced future homes, her work has encouraged discussions about how design affects people and their functions within the home. The home in Kalamazoo she had Figure 3. Living-Dining Room Area, Everyman’s House built and then lived in with her family is still being used today, and the only addition has been an attached garage. It recently sold—quickly, even in today’s market—and the selling point listed in the description stated that the original Crane design was still intact in this historic home.

Comparisons to Universal Design Concepts Crane was ahead of her time. Even the title of her book, Everyman’s House, has tones of universal design concepts. Universal design (UD), as coined by architect Ronald Mace 60 years after Crane had her home built, is a term used to describe the design of products and environments that can be used by all people and as much as possible without the need for specialized or individualized design.2 This concept is used by many occupational therapy practitioners who work in home modifications and design. HIGAN UNIVERSITY ARCHIVES

She wasn’t afraid to instruct those an anterior pelvic tilt, thus minimizing Environments designed to be usable c building her house to make sure that fatigue and discomfort while sitting to by a variety of people with a variety shelves, counters, and window seats do dishes. of skills, abilities, and needs were the were of the proper height to support The emotional needs of her family primary goal of Crane’s work as well good posture and comfortable use by a were analyzed and met through some as Mace’s. Design that does not need Y COLLECTIONS. variety of family members (see Figure of her design elements as well. When specialized or individualized modifica- 3 on p. 16). She even designed her she writes about the man of the house, tion, but instead has flexibility and own multipurpose stool and stepladder Crane shares her realization that he ease of use and is also attractive, is a that had the two front legs cut lower needed a way to get directly from part of both Crane’s home design and AND REGIONAL HISTOR than the back in order to encourage the front door down to the basement general UD concepts. Crane’s practical, OF WESTERN MI PHOTOGRAPHS COURTESY

16 SEPTEMBER 26, 2011 • WWW.AOTA.ORG The focus of our home modifications practice should not FOR MORE INFORMATION be just meeting the needs of those with a new physical Everyman’s House Collection: or emotional challenge through medical-looking Caroline Bartlett Crane www.wmich.edu/library/digi/collections/ modifications, but to incorporate ideas that are everyman more easily used by all and are as attractive as possible. AOTA Self-Paced Clinical Course: Occupational Therapy and Home Modifications: Promoting Safety and Supporting Participation Edited by M. Christenson & C. Chase, 2011. Bethesda, MD: American Occupational Therapy Association. (Earn 2 AOTA CEUs [20 NBCOT PDUs/20 contact hours]. $370 for members, $470 for nonmembers. To order, call toll free thoughtful consideration of all aspects but to incorporate ideas that are more 877-404-AOTA or shop online at http://store. of the home and its impact on its easily used by all and are as attrac- aota.org/view/?SKU=3029. Order #3029, Promo Code MI) occupants was a very early application tive as possible. Staying open to new of UD as well as an indication of her ideas (new to us, at least) can expose Occupational Therapy Practice Guidelines for creative problem-solving skills. solutions that better meet the needs of Home Modifications By C. Siebert, 2005. Bethesda, MD: AOTA Press. our clients. Perhaps visiting your local ($59 for members, $84 for nonmembers. Application to OT Practice museum can invigorate your practice To order, call toll free 877-404-AOTA or shop What does all this mean to occupational and provide a few surprises. Museums online at http://store.aota.org/view/?SKU= 1197C. Order #1197C, Promo Code MI) therapy practitioners who work in the that have displays about furniture area of home modifications or who design, architectural milestones, or AOTA Self-Paced Clinical Course: Strategies to do home evaluations? According to a urban planning, or that organize tours Advance Gerontology Excellence: Promoting Best Practice in Occupational Therapy review of the literature by Wahl et al. of historic buildings, can lead to a By S. Coppola, S. J. Elliott, & P. E. Toto, 2008. in 2009, consideration of and planning deeper understanding of the use and Bethesda, MD: American Occupational Therapy for a good person–environment fit power of space within and around Association. (Earn 3 AOTA CEU [30 NBCOT 3 PDUs/30 contact hours]. $490 for members, supports better functional outcomes. buildings. Home designs and styles can $590 for nonmembers. To order, call toll free This approach supports the role of the also vary across the country depending 877-404-AOTA or shop online at http://store. occupational therapy practitioner in on climate, terrain, and local history. aota.org/view/?SKU=3024. Order #3024, Promo Code MI) home modifications and home design A simple Internet search can lead to planning, as our background includes sources for identifying these styles and the skills and training to analyze occu- where to learn more. pations and to evaluate the person and We were fortunate in the serendipi- the environment. As lifelong learners, tous discovery of Crane’s work to have CONNECTIONS we gather ideas from a broad range Western Michigan University’s regional Discuss this and other articles on of sources to add to our idea toolbox. archives to visit to gather information the OT Practice Magazine public forum When we make recommendations for and study her home-designing jour- at http://www.OTConnections.org. our clients who need to make changes ney. In the book chronicling her home to their home, we pull pieces and parts design and building experiences, Crane from what we’ve learned, what we’ve provided recommendations and lessons Iwarsson, S. (2009). The home environment and seen, and what we’ve experienced, and sprinkled with humor and kindness— disability-related outcomes in aging individuals: then creatively apply them in a client- another important lesson from her What is the empirical evidence? The Gerontolo- gist, 49, 355–367. focused approach. work. n Recommending home modifications with Caroline Bartlett Crane’s The authors wish to thank Shannin Carla Chase, EdD, OTR/L, CAPS, is an associ- work and general UD concepts in mind VanArk, who, when she was a stu- ate professor of Western Michigan University’s can help create suggestions that are dent at Western Michigan University, Occupational Therapy Program. Chase’s work as a more appealing and more likely to be spent hours going through boxes in gerontologist and occupational therapist at Western accepted by our clients. Crane’s work, the archives and then got us started Michigan University centers on meeting the needs of in particular, is a reminder that the on this project with her enthusiasm elders in the community by researching the impact analysis of each occupation as well as and energy. of environmental modifications to support participa- the role of each household member tion and promote safety. can lead to better and more support- References ive design decisions. The focus of our 1. Crane, C. B. (1925). Everyman’s house. New Suzanne Roche is a student at Western Michigan York: Doubleday, Page & Company. home modifications practice should not University’s Occupational Therapy Program. Roche 2. Mace, R. (1985). Universal design: Barrier free be just meeting the needs of those with will begin her Level II Fieldwork soon and is excited environments for everyone. Designers West, a new physical or emotional challenge 33(1), 147–152. about exploring a variety of occupational therapy through medical-looking modifications, 3. Wahl, H. W., Fange, A., Oswald, F., Gitlin, L. N., & practice settings.

OT PRACTICE • SEPTEMBER 26, 2011 17

AOTA’s Societal Statement on Livable Communities he demographic profile of the United States is rapidly changing with an increasing number of older adults and persons with disabilities who desire to remain in their T homes and communities as they grow older, a concept referred to as aging-in-place. According to the United Nations (2007), persons with disabilities have the same right as all other members of society to live in the community with opportunities to choose their place of residence, and to have equal access to support services that promote full participation in all aspects of community living. To support these rights, society must create communities that enable all residents to live, work, play, and participate in locations of their choice (National Council on Disability, 2004; AARP, 2005). “A livable community is one that has affordable and appropriate housing, supportive community features and services, and adequate mobility options, which together facilitate personal independence and engagement of the residents in civic and social life” (AARP, 2005, p. 4). The American Occupational Therapy Association’s (AOTA’s) Core Values and Attitudes of Occupational Therapy Practice and Occupational Therapy Code of Ethics support equali- ty for all individuals (AOTA, 1993, 2005), and are congruent with the goals of livable communities. Occupational therapy practitioners plan and implement strategies that promote their client’s participation in community life by creating opportunities to establish, restore, or maintain the skills used in activities of daily living and other meaningful occupations, and by supporting clients’ who are advocating for their own and others’ rights. Further, occupational therapy practitioners advocate for universal design and environmental modifications that remove barriers in homes and communities to ensure access to supportive community services, including transportation, personal care, health care, education, employment, and other services, and to facilitate engagement in social and civic activities. Occupational therapy promotes public health and civic engagement by advocating for and assisting in the creation of more livable communities through effective partnerships with individuals, private organizations, and government agencies. Supporting health and participation through active engagement in meaningful activities in the home and community contributes to health, wellness, and quality of life for all individuals (AOTA Ad Hoc Committee on Health and Wellness, 2006).

References AARP Public Policy Institute. (2005). Beyond 50.05–A Report to the Nation on Livable Communities: Creating Environments for Successful Aging. Washington, DC: AARP.

American Occupational Therapy Association. (1993). Core values and attitudes of occupational therapy practice. The American Journal of Occupational Therapy, 47, 1085-1086.

American Occupational Therapy Association (2005). Occupational therapy code of ethics. American Journal of Occupational Therapy, 59, 639–642.

Continued on next page.

AOTA, Inc., PO Box 31220, Bethesda, MD 20824-1220 • 800-SAY-AOTA • TDD: 800-377-8555 • www.aota.org AOTA’s Societal Statement on Livable Communities American Occupational Therapy Association. (2006). AOTA Board Task Force on Health and Wellness: Report to the Executive Board. Retrieved February 4, 2008, from www.atoa.org/News/Centennial/AdHoc/2006/40407.aspx

National Council on Disability. (2004, December). Livable Communities for Adults with Disabilities: The 2004 Report, Executive Summary. Retrieved from http://www.ncd.gov/newsroom/publications/2004/pdf/livablecommunities.pdf

United Nations. (2007). Rights and Dignity of Persons with Disabilities, Article 19. Retrieved May 11, 2008, from http://www.un.org/disabilities/documents/convention/ convoptprot-e.pdf

Authors Lisa Ann Fagan, MS, OTR/L Cheri Cabrera, OTR

For The Representative Assembly Coordinating Council (RACC) Deborah Murphy-Fischer, MBA, OTR, BCP, IMT, Chairperson Brent Braveman, PhD, OTR/L, FAOTA René Padilla, PhD, OTR/L, FAOTA Kathlyn Reed, PhD, OTR, FAOTA, MLIS Janet V. DeLany, Ded, OTR/L, FAOTA Pam Toto, MS, OTR/L, BCG, FAOTA Barbara Schell, PhD, OTR/L, FAOTA Carol H. Gwin, OT/L, Staff Liaison

Adopted by the Representative Assembly 2008CS85

AOTA, Inc., PO Box 31220, Bethesda, MD 20824-1220 • 800-SAY-AOTA • TDD: 800-377-8555 • www.aota.org Fact Sheet

Occupational Therapy and The Prevention of Falls

Slips, trips, and falls in and around the home are frequently the cause of injuries to older adults. In 2009, 2.2 million older adults visited the emergency room for injuries related to falls, with many of these injuries resulting in decreased independence, a need for long-term-care support, and increased risk for early death. Falls remain the leading cause of injury or death among older adults, with a 2010 estimated total medical cost for fatal and nonfatal fall injuries of $28.2 billion (Centers for Disease Control and Prevention, 2011).

Occupational therapy practitioners are uniquely suited to address fall prevention with older adults. Research has shown the cause of falls to be multi-factorial in nature, influenced by conditions within the individual, within the environment, and as a result of the interaction between the two. The most successfully proven falls prevention initiatives are those that use a multi-faceted approach. Occupational therapy practitioners are skilled at evaluating and addressing both the person and the environment to maximize independence for older adults. Linking clients’ goals and priorities with modifications and adaptations that support their ability to participate in meaningful activities are hallmarks of occupational therapy. The Role of Occupational Therapy Occupational therapy practitioners work with the client and his or her caregivers to scan the home environment for hazards and evaluate the individual for limitations that contribute to falls. Recommendations often include a combination of interventions that target improving physical abilities to safely perform daily tasks, modifying the home, and changing activity patterns and behaviors. Occupational therapy services regularly include training clients, families, and interdisciplinary team members on strategies to support these fall prevention initiatives.

In addition to direct care for older adults, occupational therapy practitioners can assist in falls prevention on a larger scale through consultation to staff of community centers, nursing homes, and assisted living environments. Identifying environmental factors that contribute to falls and implementing the occupational therapy recommendations to remove these elements can improve safety and reduce health care costs while enhancing the participation of older adults in those communities. Addressing Broader Ramifications Fear of falling can be both a risk factor for falls and a consequence of falling. Defined as a lasting concern about falling that leads to an individual avoiding activities that he or she remains capable of doing, fear of falling often leads to self-limitation in performing activities and tasks that people need to complete in order to remain as independent as possible. As a consequence of these self-limiting behaviors, older adults experience decreased physical functioning which then contributes to an increased risk for falls. Occupational therapy practitioners assist older adults in recognizing and addressing fear of falling through focusing on the client’s individual, specific concerns. For example, a client may avoid sleeping in bed after falling at night while attempting to walk to the bathroom. The intervention then focuses on strategies designed to reduce falls risk, such as bed mobility, nighttime bathroom needs, and safety, which enhances the client’s confidence in his or her ability to go from the bed to the bathroom during the night.

www.aota.org 4720 Montgomery Lane, Bethesda, MD 20814-3425 Phone: 301-652-2682 TDD: 800-377-8555 Fax: 301-652-7711 Occupational therapy practitioners assist in breaking the cycle of inactivity and sedentary lifestyle that increases the risk of falling. Staying active and safe are common goals of older adults. By helping them reach these goals, occupational therapy practitioners empower older adults to maximize their ability to live life to its fullest. Conclusion Preventing falls and alleviating the fear of falling are cost-effective interventions that promote the safety and well-being of older adults. Many payers, including Medicare, will pay for these services as part of a covered occupational therapy benefit.

The profession of occupational therapy focuses on a person’s ability to participate in desired daily life activities or “occupations.” Aging can affect this ability, whether we continue to live in familiar surroundings or transition to new ones. As people age, occupational therapy practitioners use their expertise to help them prepare for and perform important activities and to fulfill their roles as community dwellers, family members, friends, workers, leisure devotees, or volunteers.

Examples of Fall Risk Factors Addressed by Occupational Therapy

• Lower-extremity weakness • Impaired balance • Cognitive impairment Intrinsic • Urinary incontinence • Sensory impairment • Fear of falling • Throw rugs and loose carpets • Lighting glare • Pets Extrinsic • Clutter • Uneven sidewalks • Thresholds • Unstable handrails

Reference Centers for Disease Control and Prevention. (2011). Falls among older adults: An overview. Retrieved from http://www.cdc.gov/ HomeandRecreationalSafety/Falls/adultfalls.html

Revised by Pamela Toto, PhD, OTR/L, BCG, FAOTA, for the American Occupational Therapy Association. Copyright © 2012 by the American Occupational Therapy Association. This material may be copied and distributed for personal or educational uses without written consent. For all other uses, contact [email protected].

Occupational therapy enables people of all ages live life to its fullest by helping them to promote health, make lifestyle or environmental changes, and prevent—or live better with—injury, illness, or disability. By looking at the whole picture—a client’s psychological, physical, emotional, and social make-up—occupational therapy assists people to achieve their goals, function at the highest possible level, maintain or rebuild their independence, and participate in the everyday activities of life. Fact Sheet Home Modifications and Occupational Therapy

Occupational therapy provides clients with the tools to optimize their home environments relative to individual abilities and promote full participation in daily life activities. As the population of older adults continues to grow, home modifications are a key factor in enabling individuals to “age in place,” or live in the place or home of choice. An AARP study found that more than 80% of people older than age 50 want to age in their own homes.1 Home modifications also can benefit clients of all ages with health conditions, sensory or movement impairments, or cognitive disorders by supporting the performance of necessary and desired daily activities (occupations), safety, and well-being.

Home modifications are “adaptations to living environments intended to increase usage, safety, security, and independence for the user. Home modifications are used in conjunction with assistive devices and home repairs” (p. 28).2 The home modification process includes evaluating needs, identifying and implementing solutions, training, and evaluating outcomes that contribute to the home modification product.2 The results of this process may be recommendations for alterations, adjustments, or additions to the home environment through the use of specialized, customized, off-the-shelf, or universally designed technologies; low- or high-tech equipment, products, hardware controls and cues, finishes, furnishings, and other features that affect the layout and structure of the home.3 The Role of Occupational Therapy in Home Modifications Occupational therapy plays a key role in identifying strategies that enable individuals to modify their homes, thereby maximizing their ability to participate in daily tasks/activities. Occupational therapy practitioners are skilled at recognizing how the environment affects the ability to perform desired occupations. An occupational therapist evaluates balance, coordination, endurance, safety awareness, strength, attention, problem solving, vision, communication, and many other functions while the individual performs daily tasks. In addition to the individual’s performance abilities, occupational therapists also evaluate the home environment to identify barriers to performance. For instance, features can be identified that increase the risk of falls (e.g., loose banisters) or present other hazards (e.g., overloaded electrical outlets). Occupational therapists also review aspects of the home that may require modification to facilitate performance. For example, secure upper-body supports such as handrails or grab bars can assist someone who has difficulty balancing during functional mobility and self-care activities. As part of the evaluation, occupational therapists analyze how a person interacts with his or her environment to complete a task or activity. Through this process, modifications and intervention strategies are selected to improve the fit between these elements, with a goal of maximizing safety and independence in the home. The intervention plan may include but is not limited to strategies such as adaptive equipment, lighting, family caregiver training, or remodeling.

www.aota.org 4720 Montgomery Lane, Bethesda, MD 20814-3425 Phone: 301-652-2682 TDD: 800-377-8555 Fax: 301-652-7711 Occupational therapy services can be provided directly to clients who are experiencing a decline in safety or independence, or are planning for future needs. Occupational therapy practitioners provide client-focused intervention to adapt the environment in order to increase independence, promote health, and prevent further decline or injury. For example, falls often result from home hazards in combination with declining physical abilities.4 One strategy to reduce the incidence of falls is to have an environmental assessment and recommendations for modifications completed by an occupational therapist.5 In this type of situation, an occupational therapist performing an environmental assessment can observe and evaluate all occupations (activities) occurring at and around the home, from activities of daily living (ADLs; bathing, dressing, other self-care activities) to instrumental activities of daily living (IADLs; preparing meals, doing laundry, and performing home maintenance chores) to play and/or leisure activities (playing cards, exercising, playing a musical instrument, entertaining friends, enjoying hobbies). Based on that evaluation, recommendations can be made for modifications or client training to promote safety in the home.

Occupational therapy services are available in many places in the community: hospitals, home health agencies, clinics, rehabilitation or community agencies, or through private practice. They may be reimbursable under Medicare and some private health insurance plans when coverage criteria are met, including a physician referral.

Occupational therapy practitioners provide a valuable perspective to a team of professionals (e.g., other health care workers, builders, architects), caregivers, and the client during the home modification process.

References 1. Bayer, A.-H., & Harper, L. (2000). Fixing to stay: A national survey on housing and home modification issues. Research Report.Retrieved June 23, 2006, from http://www.aarp.org/research/reference/publicopinions/aresearch-import-783.html 2. Siebert, C. (2005). Occupational therapy practice guidelines for home modifications. Bethesda, MD: American Occupational Therapy Association. 3. Sanford, J. A. (2004, May). Definition of home modifications. Included in L. A. Fagan & J. A. Sanford, Home modifications: Assessment, implementation, and innovation. Presented at the 84th Annual Conference & Expo of the American Occupational Therapy Association, Minneapolis, MN. 4. Lord, S. R., Menz, H. B., & Sherrington, C. (2006). Home environment risk factors for falls in older people and the efficacy of home modifications. Age and Ageing, 35(S2), 55–59. 5. Tse,. T (2005). The environment and falls prevention: Do environmental modifications make a difference? Australian Occupational Therapy Journal, 52(4), 271–281

Developed by Lisa Ann Fagan, MSD, OTR/L, and Dory Sabata, OTD, OTR/L, SCEM, for the American Occupational Therapy Association. Revised and copyright © 2011 by the American Occupational Therapy Association. This material may be copied and distributed for personal or educational uses without written consent. For all other uses, contact [email protected].

Occupational therapy enables people of all ages live life to its fullest by helping them to promote health, make lifestyle or environmental changes, and prevent—or live better with—injury, illness, or disability. By looking at the whole picture—a client’s psychological, physical, emotional, and social make-up—occupational therapy assists people to achieve their goals, function at the highest possible level, maintain or rebuild their independence, and participate in the everyday activities of life. For Living Life REMAINING IN TIPS To Its Fullest YOUR HOME AS YOU AGE

ARE YOU PLANNING TO REMAIN IN YOUR OWN HOME as you grow older? Are you finding it more difficult to manage some daily tasks in your home? Do you or your family and friends have safety concerns about you living alone? As abilities diminish as part of the normal aging process, assistance or changes might be needed to maintain your independence and age safely at home. An occupational therapist will work with you to ensure that recommendations to increase independence and safety are specific to your wants and needs, skills, environment, budget, and other criteria. The following tips come from occupational therapy practitioners who work with older adults to help them stay in their homes.

An occupational therapy If you want to: Consider these activity tips: practitioner offers expertise to:

Think honestly about those things your are having trouble with, and ask for assistance when possible. You may be able to do a “swap” with Provide an evaluation in your home to Be safe and independent neighbors (e.g., offer to sign for packages if they work during the day assess your skills, abilities, and safety, and in your home. in exchange for help changing light bulbs in hard-to-reach places). make recommendations that meet your Hire professionals for regular cleaning and lawn care, arrange for needs and reassure your family members. Meals on Wheels, etc.

If you’re concerned about your driving skills, consider asking a friend or neighbor to provide a ride whenever possible; offering gas money Consider all the options to help you get or a service in return can make this easier. If you haven’t taken public around in the community. These may transportation in the past, you may be surprised at the number include conducting a driving evaluation Get to the grocery store, of options available. Many communities offer a free bus or van to with the goal of addressing problem doctor’s appointments, shopping centers or even medical appointments. areas so you can drive safely, providing and social events. non-driving options for you to get If you are still driving, attend a CarFit event in your community to be around the community, helping you sure your vehicle’s adjustments are best for you (www.car-fit.org). become comfortable with the public Avoid driving during rush hour, at night, on busy roads, or in transportation system, etc. inclement weather.

Watch you as you do the things you Remove unnecessary throw rugs to reduce the risk of falling; decrease want and need to do, and recommend clutter; repair furniture that isn’t sturdy; reduce electrical cords, keep changes to increase safety, ease, Make changes that them away from walking paths, and be sure all outlets are grounded; and ability now and in the future. will help you live and purchase “universal design” products to improve their ease of use. Suggestions may include adding adaptive equipment such as grab bars independently and safely. Share your schedule with friends and neighbors, and/or set up or stair lifts, lowering counter heights, a regular social event so others will be alerted if something has adding railings, replacing door knobs happened to you. with lever style handles, widening doorways, etc.

An occupational therapy If you want to: Consider these activity tips: practitioner offers expertise to:

Suggest low-cost equipment and other changes, such as increasing wattage for better lighting, using a reacher to Explore community-based groups, such as Rebuilding Together, avoid bending over or standing on a Modify your home on whose volunteers help repair and modify homes for those who can’t stool, using the microwave and not the a limited budget. afford to do so. stove to reduce fire hazards, etc. An occupational therapist will also provide training on adaptive equipment to be sure the recommendations are right for you and will be used.

Need More Information? If you are interested in having an occupational therapist help you stay in your home, ask your physician for a referral. You can also contact an occupational therapist in private practice who specializes in home modifications (these individuals may have CAPS or SCEM among their credentials).

If you have had a recent medical change and qualify for home health services, a home health agency will be able to provide an occupational therapist. Some Area Agencies on Aging also employ occupational therapists to address aging in one’s home.

Occupational therapy is a skilled health, rehabilitation, and educational service that helps people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities (occupations).

Copyright © 2011 by the American Occupational Therapy Association. This material may be copied and distributed for personal or educational uses without written consent. For all other uses, contact [email protected]. For Living Life HELPING YOUR OLDER TIPS To Its Fullest PARENT REMAIN AT HOME

ARE ONE OR BOTH OF YOUR PARENTS finding it more difficult to manage daily tasks in the home? Do you worry about the health and safety of a parent living alone? As abilities diminish as part of the normal aging process, families and other caregivers must often help the older person obtain the assistance needed to maintain independence and live safely at home. An occupational therapist works with the person and family to ensure that recommendations to increase independence and safety are specific to their wants and needs, skills, environment, budget, and other criteria. The following tips come from occupational therapy practitioners who work with families to help older adults stay in their homes.

An occupational therapy If you want to: Consider these activity tips: practitioner offers expertise to:

Ideally, talk about living arrangements before safety Provide an evaluation in your parent’s home to assess issues become paramount, and encourage your parent skills, abilities, and safety, and make recommendations to share concerns. Emphasize that having difficulties that meet the needs of your parent and other family Determine whether your does not have to mean leaving one’s home. Watch members. An occupational therapist will also evaluate parent is safe living at for clues that certain daily activities have become too your parent’s ability to get around in the community to home. difficult because of physical or mental changes. Are bills get groceries, go to doctor appointments, attend going unpaid? Is your parent neglecting grooming or religious services, participate in social activities, etc., skipping meals? Does the home appear neglected? and provide options for doing so.

Focus on your concerns, not on your parent’s possible Suggest ways to approach this topic while respecting deficits (“I worry about you falling on those dark your parent’s autonomy. Occupational therapists can basement stairs. As a birthday gift, we are going to recommend simple to complex home modifications, make sure your stairs are safe and well lit”). community support groups, options for getting around in the community, and other services that will help your Introduce small modifications as gifts or services when Provide your parent with parent continue to do valued activities safely and easily. you notice a need (e.g., when replacing hard-to-reach assistance without being light bulbs, upgrade the wattage for improved visibility, Evaluate how well your parent is able to do the things he too intrusive. hire professionals for regular cleaning and lawn care, or she wants and needs to do, and provide personalized arrange to have a weekly meal delivered from your recommendations to increase safety, ease, and ability parent’s favorite restaurant, etc.). now and in the future. Suggestions may include adding adaptive equipment such as grab bars or stair lifts, Emphasize that helping your parent is not a chore, but lowering counter heights, adding railings, replacing door that you are happy to be able to assist. knobs with lever style handles, widening doorways, etc.

Suggest low-cost equipment and other changes (e.g., increase wattage or change the type of fixture for better Modify your parent’s Explore community-based groups, such as Rebuilding lighting or reduced glare, use a reacher to avoid bending home on a limited Together, whose volunteers help repair and modify over or standing on a stool, use the microwave and not budget. homes for those who can’t afford to do so. the stove to reduce fire hazards, etc.). An occupational therapist will also provide training on adaptive equipment and address any concerns to be sure it will be used. Need More Information? If you are interested in having an occupational therapist help your parents stay in their home, ask the physician for a referral. You can also contact an occupational therapist in private practice who specializes in home modifications (these individuals may have CAPS or SCEM among their credentials). If your parent has had a recent medical change and qualifies for home health services, a home health agency will be able to provide an occupational therapist. Some Area Agencies on Aging also employ occupational therapy practitioners to address aging in one’s home.

Introduction and Acknowledgements

This toolkit will help you prepare and deliver a presentation on falls prevention. It is intended to be used by occupational therapy practitioners to educate the public on strategies and resources to reduce fall risk, and on the role of occupational therapy in falls prevention. The presentation can be given to a variety of groups and populations in health care and community settings in conjunction with Falls Prevention Awareness Day and throughout the year. Content includes two different versions of a PowerPoint presentation, with scripts, handouts, a resource list, and a flyer to help promote your presentation. The toolkit also provides helpful suggestions about arranging, preparing, and delivering a presentation. This presentation should be used for general educational purposes only. For all other purposes, including reprints, please contact [email protected].

This Falls Prevention Toolkit was developed by Elizabeth Peterson, PhD, OTR/L, FAOTA, Clinical Professor, University of Illinois at Chicago; and Bonita Lynn Beattie, PT, MPT, MHA, Vice President, Injury Prevention & Lead, Falls Free® Initiative, Center for Healthy Aging, National Council on Aging. A special thanks to AOTA staff Karen Smith, Laura Collins, and Chris Metzler and AOTA student Melissa Stutzbach for their contributions.

Falls Prevention Awareness Day

September 22nd, the first day of fall, is also National Falls Prevention Awareness Day, sponsored annually by the National Council on Aging (NCOA). This national initiative seeks to unite professionals, older adults, caregivers, and family members to play a part in raising awareness and preventing falls in the older adult population. More than 40 states have participated in Falls Prevention Awareness Day, joining more than 70 national organizations, including the American Occupational Therapy Association as well as other professional associations and federal agencies that comprise the Falls Free© Initiative. If your organization participates in a falls prevention activity, please contact your State Falls Prevention Coalition to make sure you are counted in your state’s inventory of events. For more information on Falls Prevention Awareness Day, visit the NCOA Web site and the AOTA Web site. Scheduling a Presentation

You may already have a venue in mind for your presentation. If not, there are likely many options available to you. Many communities have local senior and community centers, nonprofit organizations, senior housing facilities, retirement communities, faith- based organizations, local area Agencies on Aging, recreation programs, public health departments, health care facilities and organizations, and other community organizations such as the YMCA of the USA, the Lions Club, Elks, or Veterans’ groups that are interested in educational opportunities for older adults. If you have difficulty finding a site that is well suited for the purpose of the presentation, utilize the Eldercare Locator, a public service provided by the U.S. Administration on Aging that can help you connect with services for older adults in your community, or contact your local Agency on Aging to see if someone might be able to help you with your search.

Once you have determined a site or multiple sites that you feel would benefit from a presentation, follow these helpful suggestions to schedule your event:

 E-mail, call, or visit the site to inquire about scheduling a presentation at least a month prior to when you anticipate presenting. Visiting the site in person is often the most effective method of getting the attention of those who might be interested in helping you schedule a presentation. Many sites schedule programming months ahead of time.  Keep in mind that persistence is key. Follow up on your inquiries if you have not received a response from a site after a few days. Have multiple sites in mind in case your first choice is not available.  Provide information about the purpose of the presentation, time required, and equipment and facilities needed (e.g., laptop, projector, projector screen, comfortable seating for the audience).  Schedule a date that works for you and the site.  Inquire about how the presentation will be advertised at the facility (e.g., newsletters, listserv, social media, announcements, calendar posting, flyers, etc.). Assist with the promotion of the presentation as needed, such as by filling out the AOTA Falls Falls Prevention Presentation Flyer and posting it at the site.  Ensure that there are accessibility options (e.g., wheelchair ramps, restrooms, etc.) at the site to accommodate all populations.  Contact the site a week prior to remind them of your presentation and confirm any last minute details.

Preparing Materials

Materials provided include:

 A 15-minute PowerPoint presentation  A script for the 15-minute PowerPoint presentation  A 30-minute PowerPoint presentation  A script for the 30-minute PowerPoint presentation

As a presenter, you can decide which version of the presentation you prefer to use. Both presentations have similar content but vary in the time required, length and detail of descriptions, examples given, and topics covered. Feel free to make minor modifications in the presentation as needed.

Note: if your presentation varies too far from the themes and suggestions outlined in the Falls Prevention Toolkit, please create your own presentation and do not use the UIC, AOTA, and NCOA logos and credits.

The two handouts listed below should be provided to everyone in the audience. Make sure you print enough copies for your anticipated audience and a few extras in case more people attend. You can download resources through the following links on the AOTA Web site:

 Falls Prevention Resources o Learn about falls prevention-related services offered by the site and in the local community that you might add to this resource list.  Tips for Living Life to its Fullest: Fall Prevention for Older Adults

Other handouts that you might consider providing include:

 A copy of the PowerPoint presentation  Tips for Living Life to its Fullest: Remaining in Your Home as You Age  CDC Fall Prevention Materials, including Check for Safety: A Home Fall Prevention Checklist for Older Adults and the brochure What You Can Do to Prevent Falls Delivering the Presentation

Follow these helpful suggestions to ensure that you have an effective presentation:

 Practice the presentation by yourself and in front of others.  Dress professionally.  Visit the site prior to the presentation to troubleshoot the PowerPoint and room set up.  Bring more than one copy of the presentation in an additional format (e.g., flash drive, CD, computer desktop, etc.) in case one of the versions does not work. Keep in mind that not all sites have Internet access.  Do not read directly off of the script or the slides. Become familiar with the content and talk based on your own experience and knowledge.  Be aware of literacy levels. Keep it simple and avoid jargon and technical terms that the audience might not be familiar with.  Project your voice and talk slowly and clearly.  Face the audience and maintain eye contact.  Keep an eye on the time to avoid going too far over or under the allotted time.  Keep the audience engaged through interactive discussions and questions about their own experiences. Suggestions for audience involvement are provided throughout the script.  Recommend site and community programs and services to your participants.  Thank the audience for their participation and interest in preventing falls.

Presentation Follow up

Be sure to thank the site for hosting the presentation. Maintaining a relationship with the site may be valuable when scheduling future presentations or utilizing resources and opportunities the site may offer for older adults.

Let AOTA know how your presentation went by contacting Karen Smith at [email protected] or share your experience on the Gerontology Special Interest Forum on OT Connections . We welcome any questions or feedback you may have about the Falls Prevention Toolkit. Thank you for reaching out to your community and helping to fulfill the need for falls prevention education!

For More Information AOTA Evidence and Research Resources

Unprecedented Opportunities in Fall Prevention for Occupational Therapy Practitioners Elizabeth W. Peterson, Marcia Finlayson, Sharon J. Elliott, Jane A. Painter, and Lindy Clemson American Journal of Occupational Therapy, March/April 2012

Occupational Therapy in Fall Prevention: Current Evidence and Future Directions Natalie E. Leland, Sharon J. Elliott, Lisa O’Malley, and Susan L. Murphy American Journal of Occupational Therapy, March/April 2012

Resources for Evidence-Based Practice & Research may also be found at www.aota.org/practice/researchers

For additional articles on home accessibility and environmental modification, visit http://ajot.aota.org/solr/topicResults.aspx?- fl_Categories=Home+Accessibility%2fEnvironmental+Modification&resourceid=31056&fd_JournalID=167.