Meeting the Needs of Older Persons to Age in Place:

Findings and Recommendations for Action

Jon Pynoos, Ph.D., Director

On Behalf of

The National Resource Center for Supportive Housing and Home Modification

Andrus Gerontology Center

University of Southern California

Los Angeles, CA 90089-0191

www.homemods.org

Submitted to the Commission on Affordable Housing and Health Facility Needs for Seniors in the 21^st Century

November 7, 2001

San Diego, CA

Executive Summary

The dominant preference of older adults is to remain in their own homes. Home modifications create a supportive home environment, a key factor in assisting older persons to achieve their goal of aging in place. Modifying existing environments can:

• Promote independence by making it easier to perform tasks
• Facilitate caregiving
• Reduce accidents
• Enable older adults to engage in major life activities
• Reduce health care costs and delay institutionalization

Unfortunately, much of the existing housing stock is ill-suited to aging in place.  It has problems such as inaccessible entrances, difficult to climb stairs and unsafe bathrooms.  Over 1 million older persons have unmet needs for home modifications such as ramps, kitchen and bathroom access.

There are several barriers that prevent home modifications from becoming more widespread:

• Many home modifications are costly and unaffordable
• A confusing patchwork of funding sources and providers confronts consumer
• A lack of awareness exists about problems in the physical environment and the benefits of home modifications
• Landlords are reluctant to modify the environment to meet the needs of older residents and tenants hesitant to request changes
• A slow government response to retrofitting subsidized housing
• Inadequate laws  and codes related to accessibility in housing

Recommendations:

To address these problems and increase the environmental supportiveness of housing, the public sector needs to create a 3-pronged “Aging in Place Initiative” that will:

• Increase the availability of home modifications
• Retrofit existing multi-unit housing, and
• Facilitate the building of suitable housing in the first place

Over 90% of the elderly population lives in conventional single family homes and apartments.  Unfortunately, much of this housing stock was not designed to meet their needs. Currently, over 1 million older persons with physical disabilities live in housing with problems such as inaccessible entrances and stairs as well as unsafe kitchens and bathrooms.  Such problems reduce independence, make tasks difficult, hamper caregiving, contribute to accidents, and put the elderly at risk of forced moves to more institutional settings.  At the broadest level, such problems impede aging in place.  To address these problems and increase the environmental supportiveness of housing, the public sector needs to create a 3-pronged “Aging in Place Initiative” that will:

• Increase the availability of home modifications
• Retrofit existing multi-unit housing, and
• Facilitate the building of suitable housing in the first place

Aging in Place is the Most Strongly Held Housing Preference of Older Persons

Over 90% of the elderly population lives in single-family homes and multi-unit apartments.  The overwhelming majority of these older persons express a strong desire to age in place (See Table 1). For example, in an AARP survey of persons age 45 and over, over 80 percent of respondents agreed with the statement: “What I’d really like to do is stay in my own home and never move.” Such strong attachment to place is understandable; in 1995, nearly half of all elderly homeowners had lived in the same home for more than 25 years. For such residents, their current housing represents a sense of security, proximity to friends and familiar services, and a homelike setting.  This sentiment is just as strong for the 1.7 million low-income residents who live in  government assisted housing.

Table 1.

Home Modifications Provide Many Benefits

Evidence indicates that a supportive home environment provides several key benefits. First, a supportive environment makes it easier to carry out tasks such as getting in and out of a home or apartment, bathing, cooking and cleaning.

Second, adequate space and features facilitate caregiving by relatives and the formal service system. For example, a bathroom with enough space can make it possible for a caregiver to help a frail older person use a tub or shower.  In multi-unit housing the conversion of spaces for on-site health clinics or meals can make services much more accessible to residents.

Third, the addition of supportive features helps reduce accidents such as falls, a leading cause of death for older Americans.  Six out of 10 falls occur in homes which typically contain a high prevalence of hazards such as loose throw rugs, the lack of tub/shower grab bars, and obstructed pathways. Home modifications can reduce the demands of the environment while making the home safer and more supportive.

Fourth, modifications can allow persons to more easily engage in major life activities.  For example, increased lighting can make it possible for older persons to a variety of tasks (e.g., sewing, reading, and cooking) and, in combination with good signage, to navigate the outside environment.

Fifth, home modification is a cost-effective strategy to reduce health care costs and delay institutionalization. For example, a study by Mann et al. (1999) compared the health care costs of a treatment group of older persons living in the community that received assessment by an occupational therapist, provision of assistive devices and home modifications, and follow-up to a control group that received the “usual care services” over an 18-month period. The results indicated that the treatment group's expenditures for institutional care, nurse visits, and case manager visits were significantly smaller than the control group.

Much of Our Current Housing Stock is Ill- Suited for an Aging Society

Unfortunately, most single-family homes and apartment complexes in which older persons live were developed for independent residents.  These dwelling units have been referred to as “Peter Pan” housing, designed for persons who will never grow old.  Typical areas that cause older persons problems are:

• outside steps to the entrance
• inside stairs to a second floor, and
• unsafe bathrooms

Such housing generally lacks appropriate handrails, grab bars, wide hallways, and other features that would make the housing more supportive for frail older persons.

Although the needs for environmental modifications are widespread among the elderly, those in the greatest need are the old-old, the fastest growing segment of the population.  The rates of disability and need for supportive features in housing increases significantly at such advanced old age. In 1995, 20 percent of the dwelling units occupied by 62 year or older heads of households included someone with one or more ADL problems such as ambulating, feeding oneself, and toileting (11.2 percent); mobility problems (12.1 percent); vision (6.5 percent); and hearing (6.7 percent).  The prevalence of such physical disabilities increases with age.  Almost 23 percent of persons aged 65-74 experience difficulties with ADLs compared with 45 percent of those aged 85 and over.

Over 1 Million Older Persons Need Home Modifications

Because we add less than 2% to the new housing stock, existing housing is where the majority of older persons will continue to reside.  But much of the current housing stock lacks physical features needed by frail older persons. Approximately 1.14 million older persons with health and mobility problems have unmet needs for additional supportive features in their dwelling units (see Table 2) that include:

• Single lever faucets
• Kitchen access
• Elevators or stair lifts
• Bathroom access and
• Ramps

Table 2.

Source: Joint Center for Housing Studies (2000). Housing America’s Seniors.
Harvard: Joint Center for Housing Studies.

Current Laws that Address Accessibility are Inadequate

Current laws inadequately address the unmet needs of older adults. For example, the Fair Housing Amendments Act of 1988 which requires basic accessibility in entrances, hallways, and individual units, applies only to buildings of four or more units, thereby excluding single family housing and small buildings that still make up the largest component of new construction.

Despite the limitations of existing laws, innovative models of accessibility do exist. Recently, a movement to promote “visitability” in all homes has been gaining momentum. Visitability benefits persons with disabilities, especially those in wheelchairs, in gaining entrance and using the first floor of a home by mandated zero-step entrances and other features such as accessible hallways and bathrooms on the first floor The first visitability city ordinance was passed in 1992 in Atlanta, which mandated zero-step entrances in certain private, single-family homes. Since then, 8 cities and states have passed similar laws.

A more comprehensive approach to addressing accessibility is based on the principles of universal design. Instead of modifying existing environments after the functional abilities of older adults’ decline, universal design targets persons of all ages, sizes, and abilities with products and environments that can be used without the need for major adaptation or specialized design.  Examples include an accessible and level entrance that makes it easier for baby strollers, bicycles, and wheelchairs; work surfaces of varying heights so the entire family can prepare meals; and easier to access controls for the bath or shower for persons with limited reaching ability. Universally designed homes allow for living on one level and can be easily adapted to the particular needs of residents. The universal design concept would make future housing better able to meet the needs of a wide variety of potential residents.

Several Barriers Impede Home Modifications

Why don’t older persons who need supportive environments and environmental modifications have them? First, many home modifications are costly and unaffordable to low and moderate income individuals (see Table 3). Over three-quarters of home modifications are paid for out of pocket. Costs range from less than $100 for the purchase and installation of a simple handrail or grab bar to more than $2000 for a roll-in shower or a stair lift. A recent study found that over one-third person of persons with unmet needs indicated that the primary reason was unaffordability.

Table 3.

Source: AARP (1996). Understanding Senior Housing Into the Next Century.
Washington, D.C.: AARP.

For persons with several home modification needs, it is difficult to patch together funds from diverse sources such as Community Development Block Grants, Older Americans Act Title III, HUD modernization, Title VII Rehabilitation Act, special state and local funds, and Medicaid Waivers. Each potential source has its own eligibility requirements, caps on how much can be spent per client, and restrictions on the types of modifications. Conventional Medicare and Medicaid only fund assistive devices that are considered medically necessary; they do not pay for structural changes.  It is possible for a person with a hip fracture upon discharge from a hospital to be provided with a wheel chair and find it unusable because of narrow hallways or doors in the home. Overall, programs that provide modifications operate with relatively small budgets that are insufficient to meet the needs of older persons, have low caps (e.g., $200-$500) and are restricted to specific geographic areas.

Second, residents often can’t make the changes themselves and have no one else to whom they can turn.  They are faced with a fragmented system and large gaps in the availability of services.  Few providers are well trained in assessing the environment or in specifying appropriate solutions.  Moreover, there is a profound mistrust of private sector contractors who might take advantage of vulnerable older persons.

Third, a lack of awareness of problems in the physical environment and the effectiveness of home modifications limit the demand for adaptations. Older persons often adapt to their environment rather than change their settings to meet their needs. Even housing managers, doctors or case managers may overlook the role of the environment in supporting frail older persons.  It often seems easier to prescribe personal care services than to arrange for environmental modifications.

Fourth, landlords are reluctant to modify the environment to meet the needs of older residents. The Fair Housing Amendments Act of 1998 calls for landlords to make “reasonable accommodations” for persons with disabilities in common areas and allows tenants to make adaptations in their own units at their own expense.  But the vagueness of the statute and the reluctance of older tenants to use legal means to rectify problems have limited its impact. 

Fifth, the government’s response to retrofitting existing government  subsidized housing has been slow to evolve. This housing was originally intended for independent older persons. But the 20,000 government subsidized housing complexes in which older persons reside have aged themselves and increasingly serve the old-old.  For example, the average age of older persons in housing such as Section 202 has risen from 72 years on 1983 to 75 years in 1999.  In addition, over 20% of the residents of older projects are over age 80 years. This housing represents a very large investment that has served older persons with low incomes well. It now needs rehabilitation and modification to meet the needs of its frail residents who require more supportive individual units and common spaces to accommodate services and to age in place.

Recommendations to Enhance Aging in Place and Home Modifications

The importance of modifying the physical environment will increase as the elderly population continues to expand and in response to the desire of older persons to age in place.  In order to meet the needs of the elderly for supportive environments and to capitalize on the benefits of home modifications, a concerted effort is needed to create a 3 pronged Aging in Place Initiative that will:

• Increase the availability of home modifications
• Retrofit existing multi-unit housing, and
• Facilitate the building of suitable housing in the first place.

1.Make Home Modifications More Available

Home modifications can be made more available through:

A Campaign to Raise Public Awareness About the Benefits of Home Modifications

• Extend  HUD’s successful  public relations campaign on lead paint and home safety to  ’Healthy Homes’ that support aging in place
• Support a campaign to inform tenants about their rights under the “Reasonable Accommodations” section of the Fair Housing Amendments Act of 1988

Enhanced Planning and Coordination Efforts

• Require HUD’s Consolidated Plan, Housing Elements, and master plans by area agencies on aging address the needs for home modifications and retrofitting of multi-unit housing.
• Create Aging in Place Councils/Coalitions or add aging in place to the agendas of existing coordinating groups to raise awareness about home modifications and develop strategies to create more supportive environments.

Increased Funding for Home Modifications:

• Reform Medicare and Medicaid to pay for home environmental assessments by occupational therapists or other health care professionals and allow broader coverage for home modifications.
• Include home modifications in home and community based waiver programs, including those intended to implement the Olmstead decision. 
• Change IRS and state income tax rules to more easily allow home modifications as a deductible expense and/or provide a tax credit 
•  Encourage states and localities to use revolving loan programs, grants and housing trust funds for home modification and retrofitting of multi-unit housing.

Demonstration Projects that:

• Test the most effective ways of delivering services to modify single family homes and apartments
• Serve as Best Models that encourage organizations to replicate successful approaches.

Research that Analyzes the Need for and Effectiveness of Home Modification.

• Large data sets that should systematically and regularly collect information about home modifications include: the U.S. Census and the  Annual Housing Survey as well as longitudinal studies such as  the National Long Term Care Survey, Self-Care and Aging, and AHEAD.

2. Retrofit Existing Multi-Unit Housing to Meet the Needs of Its Aging Residents

• Facilitate the retrofitting of multi-unit housing by:
• Provide incentives to owners and sponsors of apartment buildings to modify their buildings to meet the needs of persons with disabilities

3. Promote the Building of Suitable Housing in the First Place:

Suitable housing needs to be built in the first place by implementing the principles of:

• Visitability
• Universal Design

The focus of these recommendations is how to make the best use of the existing stock of housing to allow older persons to age in place.  This is a very high priority given the preferences of older persons themselves and the lack of affordable alternatives that are residential in nature.  But in the long run it is imperative to build new housing correctly in the first place. In the meantime, however, we need to modify our current housing stock so that the current generation of older persons can successfully  age in place.

References

AARP (1996).Understanding senior housing into the next century: Survey of consumer preferences, concerns, and needsWashington, D.C.: American Association of Retired Persons.

Joint Center for Housing Studies (2000). Housing America’s Seniors. Harvard: Joint Center for Housing Studies.

Mann, W., Ottenbacher, K., Fraas, L., Tomita, M., & Granger, C. (1999). Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care costs for the frail elderly. Archives of Family Medicine, 8, 210-217.