Home modifications (HMs) can prevent accidents, facilitate caregiving, make it easier to carry out tasks such as cooking and cleaning, engage in major life activities, and even minimize the need for costly personal care services or institutional care. Unfortunately, the growing number of older adults and younger persons with disabilities who would benefit from HMs has not yet been matched by a delivery system capable of responding to their needs. A limited number of home modification programs specialize in the needs of older persons, younger persons with disabilities and caregivers. A recent workshop, "Home Modification Capacity Building: Strategies from Programs in Action," held at the 1998 American Society on Aging Annual Conference showcased the experiences of local projects working to increase HM for older persons and younger persons with disabilities.

The Home Modification Action Project: The Importance of Local Coalitions

While federal and state officials grapple with the issues of an aging America, at the local level it is increasingly important that individuals with various types of expertise come together to solve issues that impact their community. Although states and localities implement environmental modifications in public places as required by the Americans with Disabilities Act, there is an absence of task forces that address the service delivery needs of individuals in their own homes. In response, the USC Andrus Gerontology Center, with support from The Archstone Foundation, created "Promoting Successful Aging in Place: The Home Modification Action Project (Home Mods.)." One key component of Home Mods. is to create model home modification action coalitions (HMACs) in two Southern California communities. An HMAC involves the organized participation of professionals and constituencies involved in HM to increase awareness about HM needs and increase availability. Home Mods. selected the cities of Pasadena and Santa Clarita after a Request for Assistance process including site visits. Ultimately, these coalitions will serve as models to be replicated throughout California and the nation.

Home Mods. provides the leadership to mobilize major stakeholders and resources, and to organize ongoing community support for HMs through several steps. First, Home Mods. and the coalition lead agency (e.g., the Pasadena Senior Center) identified key community groups who need to be involved in HM: the building/housing industry; the health, voluntary and social service sectors; advocacy agencies; centers for independent living; the aging network; consumers, and caregivers. Home Mods. then conducted an introductory training session to assure that coalition members began with a common knowledge base about HM. The HMAC then determined its goals and objectives based on focus groups and a needs assessment/analysis. The coalitions plan HM activities for four main groups: consumers, service delivery professionals, public decision makers, and the corporate sector. Activities include open houses of successfully modified homes, speaker's bureaus for HM professionals, and local design awards for creative solutions to accessibility problems.

An Area Agency on Aging's Commitment to Home Modifications

The Philadelphia Corporation on Aging (PCA) Inc., the third largest Area Agency on Aging in the country, administers six HM and repair programs under the direction of Susan Klein, PCA's Director of Housing. PCA's history, reputation, and commitment to HM for almost 20 years have allowed it to develop HM programs with specific target populations and different types of HM services all under the auspices of one agency.

• The Senior Housing Assistance Repair Program (SHARP) started in 1980. Currently supported by the Pennsylvania Lottery and Community Development Block Grant Funds, SHARP provides minor repairs and adaptations to more than 500 homes of older persons annually, though nearly 2000 individuals apply each year.
• The Family Caregivers' Support Program (FCSP), supported by state General Funds since 1989, provides services, adaptations and assistive devices to support caregivers.
• The Options Care Management Program provides services, repairs and HMs to persons with disabilities who are 18 years of age and older. With support from Pennsylvania Aging Block Grant Funds, PCA served 427 homes in 1997; however, nearly 2000 people are on the waiting list.
• Since 1989, the Adaptive Modification Program (AMP) has provided major adaptations (e.g., stair glides, first floor bathrooms) to people of any age with permanent physical disabilities. AMP is funded through HUD's Community Development Block Grant program at approximately $2 million annually. To build on its capacity to serve both younger disabled and older persons, PCA forged alliances with agencies who represent people with disabilities to increase cross referrals.
• Through a Medicaid Waiver, PCA has helped maintain nursing home and Medicaid eligible older persons in their owns homes since 1996. Major and minor repairs/modifications were delivered to over 200 elderly individuals in 1997, most of whom were renters.
• To test whether environmental interventions support family caregiving, PCA, with the Community and Homecare Research Division of Thomas Jefferson University, received funding from the National Institute on Aging in 1996 to conduct a controlled study, Resources for Enhancing Alzheimer's Caregiver Health (REACH).

The Nearest Place: Lessons From an Emerging Non-Profit Program

The Nearest Place (TNP), a new and growing non-profit organization, provides home assessments and HMs to older and younger persons with disabilities in the Houston area. It was developed in 1997 by Patricia Jakobi, Associate Director of the University of Texas Center on Aging, and George Jakobi, who has a background in economic development. In Galveston, a suburb for Houston, TNP's targeted housing stock presents challenges to individuals with disabilities. About one third of the homes are Victorian and most are elevated in case of hurricanes or storms. The staff and board members of TNP spent over a year using different approaches to develop awareness of their services and a referral network. As with many new HM programs, TNP initially encountered resistance to their services due to: 1) a lack of awareness of the benefits of HMs by consumers and providers; 2) a lack of interest among housing and remodeling professionals who had little HM expertise; 3) the unwillingness of many consumers to pay for HM services; and 4) competition for funds among government agencies.

TNP avoided extensive start up costs (e.g., payroll, overhead) by recruiting staff members who are retired or fully employed elsewhere. A part-time team consisting of an occupational therapist, an estimator, physical therapists, registered nurses, and a master gardener work on a contractual basis on evenings and weekends. Volunteers also perform services. To promote their services, TNP actively participates in a Monthly Providers Breakfast that attracts local health and aging professionals. It also serves as a resource for local reporters, participates in radio programs directed toward seniors, established an 800-telephone number, and placed advertisements in the yellow pages. To expand their client base, TNP plans to provide more consumer education that addresses the four points above, and establish themselves with HMOs as a service provider that offers an alternative to institutional long term care.

Home Modification: A Remodeler's Perspective

Since 1987, Access Remodeling (AR) has provided residential accessibility services to clients in the Washington D.C. and Potomac, Maryland area. President and Founder Louis Tenenbaum, a remodeling contractor, views an AR client as a unit composed of two entities: a person and a home. Each one has very unique characteristics that must be taken into consideration with HM. For housing professionals, Mr. Tenenbaum stresses the importance of understanding both how the housing environment impacts the person and how the person impacts the housing environment. Knowledge of remodeling and construction is not sufficient to deliver effective HMs.

Access Remodeling strives to get the client involved in the HM decision making process as soon as possible so that they are psychologically ready to make major changes in their home. However, AR has had difficulty achieving this goal when working with the medical community. While HMs are often necessary for individuals being discharged from the hospital, AR has found that the medical community sometimes views HMs as a sign of their failure and brings AR into the process late. This rushes the decision making process and the comprehensiveness and quality of the modifications. AR continually works to address this problem by increasing dialogue and communication with professionals in the fields of medicine, aging, and disability.

Extended Home Living Services: HM Services by Demand

Extended Home Living Services, Inc. (EHLS) was developed in 1991 by Alan and Joanie Browne as a private, for profit business to deliver HM to younger persons with disabilities and older adults living in the Chicago suburbs. Their original plan to provide HMs to older adults aging in place proved to be uneconomical, as the initial demand was low and the jobs were small. After a year, the company shifted its focus to include younger persons with disabilities. As a private, for-profit program, EHLS learned early on to rely on their customers to identify the problems they want addressed and then propose solutions, as opposed to using a standardized assessment tool and telling their customers what they need.

EHLS provides all aspects of HM service "under one roof" for customers--an initial home visit, an environmental assessment, design plans, a proposal with specifications about their recommended HMs, referral and assistance locating funding sources, and finally, the HM installation and construction work. While EHLS initially planned to have all construction staff in-house, it was not economically feasible, and they continue to increase their use of subcontractors. EHLS services include installation of lifts, stairway chair lifts, residential elevators, specialized equipment such as personal hygiene systems and toilets, specialized grab bars, custom bathing and showering equipment. EHLS serves approximately 600 clients annually with a sales volume of $3.5 million, almost all of which comes from out of pocket payments. Approximately 20% of EHLS clients are over 65 years of age and the remaining are younger persons with disabilities.

Conclusion

A supportive home environment is key to maximizing independence for people of all ages. To increase home modification awareness and availability, there must be more coordination between the housing, aging, medical and disability sectors to mobilize resources and provide leadership. The five programs described above demonstrate the challenges and opportunities of home modification service delivery. Knowledge of successful models and approaches such as these would encourage the development of new programs more rapidly into the 21st Century.

Julie Overton, MSG/MHA is the Project Manager of "Promoting Successful Aging in Place: The Home Modification Action Project" at the USC Andrus Gerontology Center in Los Angeles, CA. (213) 740-1364. homemods.@usc.edu