Case Studies of Successful Home Modification Programs
Jon Pynoos, Ph.D.
Lena Perelman, M.S.G., M.P.A.
Christy Nishita, B.A.
The growing number of frail older adults and younger persons with
disabilities who would benefit from home modifications has not yet
been matched by a delivery system capable of responding to their
The current system has been characterized as suffering from fragmentation,
the absence of home modification programs in many areas, and gaps
in services. Consequently, it is often difficult to obtain appropriate
home assessments, access services, and pay for modification. Little
has been known about how they are staffed, how they operate, their
sources of referrals, how they conduct assessments, etc. The purpose
of this study is to better understand how home modifications are
delivered and then to develop case studies of exemplary home modification
programs that can serve as models of service delivery for developing
new programs and improving existing programs.
To better understand how home modification programs
operate, a telephone survey was conducted of over 200 programs.
Questions related to targeting, assessment, funding, and types of
modifications performed. The information was analyzed using descriptive
statistics to create a national profile of home modification programs.
Then, five cases were selected as exemplary/successful models of
service delivery and case studies were conducted. Two of the programs
(South East Senior Housing Initiative, the Philadelphia Corporation
on Aging, and the Santa Clarita Valley Commission on Aging) are
non-profits and two are for-profit (Extended Home Living Services
and Access Remodeling). All of these programs have been operating
for over five years, offering an opportunity to analyze how they
have changed over time. Material on the programs has been collected
through a mail-out questionnaire, telephone follow-ups, on-site
visits, and analysis of information collected. A structured format
was used to analyze the case studies that included: origins of the
program, auspices, program objectives, organizational structure,
funding, budgets, client characteristics, service menu, service
delivery, referral, assessments, and outreach and education.
National Profile of Home Modification Programs
Home modification programs repair and rehabilitate, as well as,
make accessible the homes of the persons they serve. (see Figure
In terms of the most common modifications performed, virtually
all program directors stated that they provide some sort of minor
home repair (87.5%). Because accessibility is an important issue
for most programs, its no surprise that ramp installation is among
the most common modification performed (74.9%). Furthermore, grab
bar installation is ranked amongst the top three services provided
(37.9%), in part because they are inexpensive, which allow programs
to serve greater numbers of people. The frequent installation of
grab bars is also partially a result of the high demand for bathroom
modifications (see Figure 2).
On average, the programs serve approximately 272 persons per year.
The range of clients served ranges from 5 persons per year to 3000
persons per year. Programs that provide only home modifications
generally serve a smaller number of people, while home modification
and repair programs have a higher volume of clientele because of
their larger budgets.
Many programs specifically target the older population.
Of the programs interviewed, 66% serve those age 60 and over. Many
of the programs have a combination of target criteria, the most
common being older, low-income homeowners.
The majority of programs had some kind of assessment protocol.
Although the protocol varies from program to program, most included
a basic set of guidelines that either the program has developed
or is borrowed from another source, such as HUD or AARP. The greatest
variation among programs is who conducts the assessments. Often,
program staff conduct the overwhelming majority of assessments.
This can be the director of the program, employed handymen, or assessment
personnel. On the other hand, case managers conduct about 17% of
assessments. Programs that use case managers are typically part
of a larger organization, such as a commission on aging or an Area
Agency on Aging.
Furthermore, it is interesting to note that 14.4% of programs typically
subcontract with occupational therapists to perform assessments
(see Figure 4). This could be a result of the increasing awareness
about occupational therapists who are trained and experienced in
assessing homes for hazards.
Lastly, securing funding and business continues to be a problem
for service providers, although many have been able to achieve stability
and even growth. Public programs are using various funding sources
as a means for providing home modifications and repairs. Such sources
include funding obtained through the Older Americans Act, Community
Development Block Grants, Medicaid Waivers, and Foundations (see
Summary of Case Study #1
Philadelphia Corporation on Aging
The Philadelphia Corporation on Aging is a nonprofit organization
that began in 1973 and is the designated Area Agency on Aging for
Philadelphia County. Its stated mission is to improve the quality
of life of older Philadelphians by promoting their health, independence,
PCA's Senior Housing Assistance Repair Program (SHARP) strives
to maintain independence for these persons through the provision
minor home repairs and modifications for homeowners 60 years and
over. In total, hundreds of homes have received major adaptations
and more than 5,400 have received minor adaptations installed by
SHARP during the last 14 years. The SHARP program now serves 625
very low-income older homeowners aged 60 and over and has a budget
of $1.1 million annually.
PCA's Adaptive Modification Program has provided major modifications,
such as stairglides and first floor bathrooms, to over 400 homes
since 1989. The goal of the program is to help persons with disabilities
to live in safe, affordable, barrier-free housing. The program started
with $166,000 in funding and is currently funded at $2 million dollars
a year for the next five years through Community Development Block
Grants. Unfortunately, the demand for AMP's services is greater
than the program's capacity. There are currently 849 people on the
waiting list, a wait of about five years.
PCA's strength is in its intra-agency coordination. Within the
Housing Department itself, coordination between the Occupational
Therapist (OT) and the construction staff is the key to successfully
implementing modifications that will be used to the fullest extent
by their clients. Nevertheless, in the future, the Housing Department
should encourage the OT and mechanic to inspect the client's home
together in order to avoid any miscommunication.
Stable funding levels for both SHARP and AMP has been key for providing
consistency in the numbers of persons served per year and the service
menu. The mismatch between demand and available funding is a dominant
concern of PCA. However, the reality for PCA and many other home
modification programs may be that this gap may never be bridged.
Summary of Case Study #2
South East Senior Housing Initiative
The South East Senior Housing Initiative (SESHI) began when local
organizations in the community recognized the growing needs of the
aging population in South East Baltimore. These organizations raised
concerns about physical and environmental restrictions experienced
by a large portion of older residents living in row homes, the challenges
older residents confront in preserving their homes, and the lack
of affordable housing alternatives within the community. Several
organizations met to formulate strategies for addressing the problems
identified. The outcome from these meetings resulted in a coordinated
effort of non-profit organizations and a coalition known as SESHI.
Overtime SESHI has become the primary organization in a comprehensive
community delivery system whose principal goal is to assist older
adults in remaining safely in their homes.
From its inception, SESHI never wanted to be the service provider
but more of an educator. SESHI's service delivery does not entail
installation of home modifications. Rather, they are the entry point
for many seniors lacking knowledge, awareness, and funds, to procure
appropriate home adaptations and social services that will enable
them to remain living independently. The organizations strong presence
within the community was created and is enhanced through their coalitions
and partnerships with various aging service providers
To date its largest source of funding has come from a grant from
the Robert Wood Johnson Foundation (RWJF). SESHI will be the lead
agency in a demonstration project, Home Intervention and Support
for Low-Income Persons (HISLIP), that seeks to promote independent
living for low to moderate income seniors in their own homes, via
a program of integrated home intervention and support. Through coordination
of existing community-based services and home adaptations, SESHI,
along with its coalition members, is testing the value of preventative
health and the impact on the community in assisting older adults
to live independently. It is based on the concept of coordinated
social, health and housing services.
The goals of HISLIP include:
" Demonstrating the client value by showing improved health
" Maintaining functional status, and client satisfaction
" Assessing the health care cost savings associated with prevention
by using home modifications and coordinated services
" Analyzing the benefits to the community of retaining older
residents as active participants and homeowners in their neighborhood
Summary of Case Study #3
Santa Clarita Valley Commission on Aging
The Santa Clarita Valley Commission on Aging (SCVCoA), a charitable,
not-for-profit organization was formed in 1972 as grass roots effort
in response to the growing needs of older persons living within
the community. The founding principles were designed to enhance
the independence, dignity, and quality of life for senior citizens.
SCVCoA accomplishes such goals through direct service provision,
community resource management and coordination, program development,
as well as advocacy.
One component of the commissions programs is a focus on home modifications,
which emerged as a goal out of the Handyworker program that provided
repair and rehabilitation. The program provides free-home repairs
to owner and renter occupied single family homes in the city of
Santa Clarita Valley and beyond. The Handyworker program is aimed
at low to moderate income homes targeting all ages and individuals.
The home modification aspect of the program targets seniors and
Within its community the SCVCoA has surfaced as a leader in home
modification capacity building, by becoming the steering organization
for a local coalition. The coalition brings together the building
industry including, remodelers, builders, suppliers with social
workers, caregivers, and other agencies within the community to
provide home improvements. The coalition plans activities for consumers,
service delivery professionals, public decision makers, and the
corporate sector. Thus far the coalition has acted as a means by
which to increase community awareness of the services for home modifications
already in existence at SCVSS. Even more it has been an avenue the
SCVCoA has used to create and enhance public and private collaboration.
Summary of Case Study #4
Access Remodeling is a private, for-profit business, founded by
Louis Tennenbaum, that has provided residential accessibility services
to clients in the Washington, D.C. and Potomac, Maryland areas since
1987. AR provides all aspects of the remodeling services for customers:
a home visit, environmental assessment, design plans, a proposal
with specifications about recommendations, and the installation
of home modifications and construction work.
The firms objectives encompass remodeling homes such that changes
and modifications made to the environment render it safe and accessible
for individuals with disabilities. AR wants to reach the "planners"--
individuals preparing to age in place within their own homes. In
this respect, it is important to note that AR does not solely work
with aging population but also the disability community and younger
Furthermore, AR emphasizes removing environmental barriers that
prohibit independence. In essence, AR makes an effort to identify
problems and design solutions so that physical disability, now or
later, is not and does not become an impediment to independent living.
AR stresses that a change in health does not mean a change in residence.
Today AR is a business that views two aspects of the client: an
individual and a home, each possessing particular characteristics
that need to be recognized and taken into consideration with home
modifications. As a remodeling company, AR attempts to integrate
program and design to make homes modifications effective.
A critical component of AR's construction process involves the
actual design of home adaptations and renovations to make the environment
barrier free. AR subcontracts with an interior designer, who specializes
in Universal Design, to ensure that the layout and design are aesthetically
pleasing as well as safe and secure. The designer is involved in
the evaluation of the home and is part of the design team that provides
the client with suggestions for adaptations. Additionally, AR employs
a full-time designer and sales consultant who has worked with the
company for many years.
Summary of Case Study #5
Extended Home Living Services
Extended Home Living Services (EHLS) was developed in 1991 as a
private for-profit business to deliver HM to younger persons with
disabilities and older adults living in the Chicago suburbs. The
original plan to provide home modifications to older adults aging
in place, proved uneconomical as the initial demand was low and
jobs were small. Thus the company had to shift its focus include
younger adults with disabilities. The company founders realized
that they had to rely on their customers to identify problems they
wanted addressed and then propose solutions, in comparison to 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 recommended, referral and assistance
finding local funding sources, and the actual installation of home
modifications. Having an in-house staff did not prove to be economically
feasible, as such EHLS use subcontractors.
" Profit-oriented programs rely extensively on private payments
but also refer clients to other funding sources and work with insurance
" All of the programs report an unmet need for home modifications
for low and moderate-income persons.
Many non-profits have long waiting lists."
" Staffing can be a problem when the economy is doing well."
"Programs tend to have difficulty hiring experienced occupational
therapists and handymen."
" The private sector markets to a variety of sources while
the publicly funding programs carry out only limited outreach."
" Programs vary in terms of whether they actually provide
home modifications or subcontract and use affiliate non-profit organizations
to carry out the home modifications."
" Securing funding and business continues to be a problem
" Although several of the programs seem to have achieved stability
and even growth."
" Programs that performed mainly home repair have branched
out to include home modifications in their menu of services."