(1994). It includes reducing work-related injury, illness and disability by addressing the hazards and risks of the physical environment. While the increased application of universal design principles requires changes in consumer and provider behavior, it most significantly requires fundamental changes in regulatory policy, from building and zoning codes to reimbursement. Action for public health: Sundsvall statement on supportive environments. In S. Lanspery and J. Hyde (Eds. We are now moving onto the Physical environment. However, it is not a practice that is used in assessing needs for therapeutic home interventions. However, the gaps in the knowledge base related to state of the physical environment and home health are wide enough to drive a truck through. Stark, S. (2004). However, it is not. Jonathan Sanford. This chapter describes physical and environmental determinants of the health of Australians, providing a background to the development of successful public health activity. Though physical in nature, the environment … This chapter examines the prosthetic and therapeutic roles of the environment in promoting positive activity and health outcomes, identifies barriers to supportive home environments, and proposes that universal design—the design of products and environments to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design (Mace, Hardie, and Place, 1991)—be adopted as the conceptual basis for the paradigm shift that is needed to promote independent living and health management. This need for repairs and systems updating is not surprising. No one would expect a private or public third-party payer to help modify one’s home, such as by adding a nursery, to accommodate such a lifestyle change. Better initial design would greatly improve usability for everyone and reduce the need for modifications later on. The legislation included not only policies to protect the health of the New York’s citizens but also enforceable building regulations that mandated design features for cleaner, safer, and better built housing and designated public agencies to carry out those regulations. More specifically, these models predict that impairment causes functional limitations, which in turn result in negative performance and health outcomes. Tinetti, M.E., Richman, D., and Powell, L. (1990). Our "environment" includes both social determinants of health and physical environmental determinants of health. Despite a reluctance to make changes, the strongest predictor of adapting one’s home is recognizing the need for environmental interventions (Pynoos et al., 1987). ing taxpayer dollars on unnecessary remodeling that increases the comfort and wealth of individuals, even if homeowners themselves do not perceive that these changes will increase value. On the other hand, there is a need to identify key performance measures and appropriate outcome (dependent) measures—such as the physical and mental health of individuals and their caregivers as well as their acceptance of health technologies in the home. In C. Eisdorfer and M.P. Conducting research on home environments: Lessons learned and new directions, Gerontologist, 43, 628-637. The majority of New Zealanders are supplied with community drinking water that is free of micro-organisms. (1992). Sign up for email notifications and we'll let you know about new publications in your areas of interest when they're released. Santa Monica, CA: RAND Corporation. Home health care patients and safety hazards in the home: Preliminary findings. World Health Organization. There is a direct relationship between health and housing. Clearly, for the home to succeed as a health care environment, zoning ordinances and building codes must be changed to recognize cohabitation or multifamily units for health reasons. Although these two outcomes measure different constructs (e.g., problems encountered with or without assistance versus level of assistance required, respectively), they often are used interchangeably. Gerontologist, 49(3), 355-367. Connell, B.R., and Sanford, J.A. For example, assistive devices, such as lifts, tub benches, and toilet seats, are typically more intrusive than structural changes to the home that might provide more space and better performance. However, regardless of the program, eligibility for services depends on one’s situation, unlike Sweden. The National Demonstration Home, completed in 2008 on the Eskaton Village campus in Roseville, California, provides an innovative approach to healthy, independent living by combining UD, smart home health care technologies, and green living features. The bathroom, with its wet, slippery surfaces, small, cramped spaces, and hard surfaces can easily lead to falls and serious injury, even for people without functional limitations. No single discipline or systematic program provides training that encompasses a comprehensive understanding of the person and the environment sides of the equation, resulting in disciplinary bias that separates the health professions from the building professions (Pynoos et al., 1987). Relationships between housing and healthy aging in very old age. However, physical interventions alone will not suffice. Amityville, NY: Baywood. Career guide to industries, 2006-2007 edition. Adherence to these principles will require new approaches to product and housing design that integrate technological systems with each other and in the home environment so that the home remains a home and does not become a hospital. Clearly, the larger the number of different systems and biometric tools that are introduced into the home, the more space is required. While it is unlikely that every design will be usable by everyone, UD can eliminate the need for many adaptive, add-on, specialized accessibility products that are commonly used today. Yet assessments are conducted by an array of home health service providers—occupational therapists, rehabilitation engineers and technologists, home health nurses, and social workers—and, to a lesser extent, building professionals—remodelers, architects, and interior designers. In fact, it provides economic disincentives for UD by supporting specialized assistive technology and (to some extent) accessible design solutions, which may have lower initial costs, but greater long-term costs and far less benefit to multiple individuals or society. For example, Matsushita has been developing a variety of health-enabled bathroom products, such as a toilet seat with embedded passive monitoring sensors to monitor and send weight and body fat ratio, heartbeat, blood pressure, and glucose levels to the patient’s doctor via the Internet (Brooke, 2009). In the United States there is a patchwork of potential funders, ranging from government agencies, to private insurers and workers compensation to social service organizations, such as AAAs and NORCs, to nonprofit volunteer organizations, such as Rebuilding Together. As a result, there is often a lack of fit between the independent living and health needs of community-dwelling individuals and the places in which they live. Iwarsson, S., and Isacsson, A. British Journal of Occupational Therapy, 62(11), 491-497. Whereas Lawton’s environmental press model suggests the role of the environment in activity and health, the enabling-disabling process model of the Institute of Medicine specifically identifies the environment as a pathway for intervention (Institute of Medicine, 1997). To be effective, assessments must produce unbiased, objective information that is both valid and reliable. For example, the density of alcohol retail outlets has been linked to alcohol-related health complications (Campbell et al., 2009; Popova et al., 2009), including injury and violence (Cunradi et al., 2012; Toomey et al., 2012). For example, enabling an individual to perform a controlled versus an uncontrolled transfer to a toilet will not only decrease speed of transfer but also increase safety. Cambridge, MA: Joint Center for Housing Studies of Harvard University. Because salary and benefits account for such a high percentage of building costs, saving energy or rent at the expense of occupant/employee health, wellness, and productivity appears to be a poor business decision. As of 2010, funding in 31 states enabled more than 27,000 people to transition out of nursing homes and other institutions to community housing (National Council on Disability, 2010). Allen, S., Resnik, L., and Roy, J. 277-303). A range of other physical environmental features have been linked to other health outcomes. Reasons to relocate and objective environmental changes among well-off older adults. • The quality of air for breathe, the water for drink, exposure to noise, harmful orgasms, radiation from the sun and other sources. Mace, R.L., Hardie, G.J., and Place, J.P. (1991). As a result, there are few accessibility-focused regulations that cover residential facilities and even fewer that comprehensively regulate the design and modification of private housing specifically for people who have functional or health limitations (Hyde, Talbert, and Grayson, 1997). Health-related safety: A framework to address aging in place. Sundsvall, Sweden: Author. Amityville, NY: Baywood. Social Science and Medicine, 58, 177-192. Committee on Assessing Rehabilitation Science and Engineering. Technology and Disability, 2(4), 69-79. On October 1 and 2, 2009, a group of human factors and other experts met to consider a diverse range of behavioral and human factors issues associated with the increasing migration of medical devices, technologies, and care practices into the home. (2006). ), but that it contribute to their own health and well-being. (1996). If the goal of research is to inform and affect practice both directly and through legislation and regulatory policy, then it is imperative that research create an evidence base that demonstrates not only the efficacy and effectiveness of interventions (i.e., what works and for whom) but, more importantly, their cost-effectiveness and benefits. Pynoos, J. As a case in point, I am not a licensed therapist, contractor, or architect, yet I not only provide all of these services but also have trained professionals in all three disciplines to do so as well. The international classification of impairment, disability and health (p.143). Also, you can type in a page number and press Enter to go directly to that page in the book. Facilities, such as a clean, tidy and well-decorated reception area, can help reassure customers of the quality of products/services and build trust in your company. On the demand side, the fragmented delivery system also ensures that consumers are uninformed about the benefits and costs of UD and other environmental modifications. An underlying principle in making access and usability the norm is that a home should look like a home, not like an institutional setting. On the other hand, policy responses to support independent living and home health care, like the system itself, have been piecemeal and fragmented, leaving many people in homes that are unsupportive and in communities that offer them few housing options. Reduce exposure to motor vehicle exhaust by limiting physical activity near heavy traffic areas, particularly at rush hour. Frank, L., Engelke, P.O., and Schmid, T.L. Tinetti, M.E., Baker, D., Gallo, W.T., Nanda, A., Charpentier, P., and O’Leary, J. 85-109). Even among specialists, intervention decisions often vary by discipline and level of expertise of the individual delivering services. In addition, some assessments are based on expected abilities and activity performance, and others assess actual activity performance (Sanford and Bruce, 2010). Improving the delivery of home modifications. (2006). Gerontologist, 43, 532-546. Wahl, H.-W., Fange, A., Oswald, F., Gitlin, L.N., and Iwarsson, S. (2009). To further complicate provision of home health, studies have identified a number of additional concerns about the safety of home environments that can negatively impact care providers and thus the provision of care. Examples of leisurely physical activity include hiking, biking, and walking. Yet a major influence on the safety, quality, and effectiveness of home health care will be the set of issues encompassed by the field of human factors research--the discipline of applying what is known about human capabilities and limitations to the design of products, processes, systems, and work environments. To increase safety and mobility, sufficient space should be available at the toilet, bathtub, shower, and sink for mobility aids and caregiver assistance. Bathroom floors are extremely dangerous when wet. Medical Care, 38(12), 1,174-1,183. Similar policy changes that require or create incentives for UD features, such as curbless showers, bathrooms with a 5-foot turning radius, and wider hallways, through tax breaks or fast-tracked approvals by municipal or state officials, are needed to overcome accessible design mentality. Home visits by an occupational therapist for assessment and modification of environmental hazards: A randomized trial of falls prevention. Clemson, L., Roland, M., and Cumming, R.G. Professional organizations should focus on developing practitioner expertise by designing certification programs that promote uniform and accurate assessments, ensure appropriate intervention recommendations, and result in successful and efficacious interventions. Niva, B., and Skar, L. (2006). Sanford, J., Story, M., and Jones, M. (1997). When an individual is in poor health, is impaired, or has functional declines due to aging, health concerns are virtually indistinguishable from housing concerns, particularly in an aging housing stock (Lawler, 2001). Use, type and efficacay of assistance for disability. Ultimately, the universal home sets a baseline from which assistive technologies and accessible design can be introduced when and if they are needed. New York: Springer. It also requires changes in reimbursement that recognize and support environmental assessments and interventions as part of discharge planning and continue to support them on an ongoing basis as conditions change and throughout the life span. Cumming, R.G., Thomas, M., Szonyi, G., Frampton, G., Salkeld, G., and Clemson, L. (2001). In V. Regnier and J. Pynoos (Eds. Generally the assumption is that the faster one can perform a task, the better. Therefore, whether these interventions are assistive technologies, accessible designs, or universal designs, they should be individualized, customized, and personalized to best fit the functional needs of individuals for independent living and their caregivers for providing assistance. 1. It is structured like a pretest-posttest randomized experiment but lacks random group assignment. The success of the home as a health care environment is therefore more complicated than simply modifying the physical environment of the home to fit activity and health care needs. Seniors commission report. At the same time, assistive technologies in particular, and to a lesser extent accessible design, are reinforced by medical model–based reimbursement policies. Although environmental studies are easy to identify, they are not easy to undertake in real-world environments in which contextual factors are impossible to control. Sanford, J.A., Echt, K., and Malassigne, P. (1999). Reports of work related musculoskeletal injury among home care service workers compared to nursery school workers and the general population of employed women in Sweden. Recent trends in disability and functioning among older adults in the United States. Zoning ordinances must also recognize and support the role of the home as a health care environment. Rather, prescriptions for environmental interventions must be individualized and context-specific. The Canadian Occupational Performance Measure (COPM) (Law et al., 1991) and the Safety Assessment of Function and the Environment for Rehabilitation-Health Outcome Measurement and Evaluation (SAFER-HOME v. 3) (Letts et al., 1998) are two performance-based instruments that can identify actual home modification needs as well as changes in performance after modification interventions. (2002). On the supply side, service providers are typically constrained by resources, the scope and geographical area of support services, their general lack of knowledge of UD and home modifications in general, and a dearth of educational opportunities to learn more about them. However, these instruments are purely performance-based; they do not assess either environmental attributes or ability. Environmental health is the public health field that monitors and addresses those physical, chemical, and biological factors that we might not have direct control over, but can impact our health anyway. At the same time, new rating systems have been created, including WELL and Fitwel, that focus exclusively on occupant health and productivity. New York: Springer. Moreover, because UD and other environmental intervention strategies are the exceptions to home design rather than the norm, there are few traditional marketing strategies (e.g., TV advertisements) to inform consumers about their benefits. Based on falls reported over a 3-year period, the risk of a nonsyncopal fall was only significantly elevated for 1 of the 13 hazards. Available: http://www.access-board.gov/adaag/html/adaag.htm [accessed June 2010]. Schaie (Eds. This type of assessment is illustrated by a number of instruments, such as the Housing Enabler (Iwarsson, 1999) and the Cougar Home Safety Assessment (Fisher, Coolbaugh, and Rhodes, 2006; Fisher et al., 2008). (1980). Washington, DC: RESNA Press. While these studies help to understand the effects of environmental features, set precedents, and suggest trends, there is a basic lack of the critical evidence about the benefits of environmental interventions and their effect on health outcomes that is necessary for policy change. private individuals, limiting their availability as demonstration homes on a long-term basis. As a result, many studies have used inappropriate and invalid environmental measures that have underestimated the contribution of environmental factors to health outcomes. Unpublished doctoral dissertation, Oregon State University. On one hand, a home should provide a prosthetic environment in which individuals can live and function safely as long as they choose to remain there. For example, social factors might include the impact of other individuals in a home, who may or may not be providing care, as well as the impact of modifications on those individuals (Gitlin, 2003). While individuals who use wheelchairs often lack space to maneuver or get close enough to a fixture, ambulatory individuals with gait and balance problems often lack support (i.e., something to hold onto) to safely lower themselves down onto a toilet or the bottom of a tub or, conversely, to pull themselves back up from these positions. Neither is housing designed to accommodate health care equipment, health care providers, or the communications infrastructure necessary to share health information with remote care providers. Davis, S. (1997). In the late 1990s and early 2000s, a large number of model smart homes were constructed on many university campuses (e.g., Drexel University, Georgia Institute of Technology, Iowa State University, Massachusetts Institute of Technology, University of Florida) as demonstration homes and laboratories to develop and test new technologies. Spillman, B.C. Ferrucci, L., Guralnik, J.M., Studenski, S., Fried, L.P., Cutler, G.B., Jr., and Walston, J.D. This concern is particularly relevant in the current health policy context (Coyte and Young, 1997), in which high-tech home care is increasingly seen as a quick solution to budgetary constraints and a growing elderly population. Debilitating tinnitus causes constant disruption of a person’s emotional, cognitive, psychological or physical state. Researchers have found convincing evidence that people who live in communities characterized by mixed land use (e.g., with stores in walking distance of homes); well-connected street networks; and high residential density are more active, especially for transportation, than those who live in communities … As a result, there are critical methodological challenges for studies in this field (Wahl et al., 2009). Environmental research has suffered from studies, many firmly entrenched in epidemiological models, that lacked a basic understanding of the key environmental factors that impact activity and health outcomes. Other systems combine patient monitoring and video that enables patients and providers to interact in real time. Do you want to take a quick tour of the OpenBook's features? These models suggest that, whereas physiological factors set the threshold on functional ability and health, environmental factors set the threshold on the point at which limitations in ability become a disability (Stineman et al., 2007). Brooke, J. Home modifications: Assessment, implementation and innovation. Environmental research has also suffered from a lack of a set of mutually agreed-upon health outcomes. It is up to individuals and care providers to either take advantage of any opportunities presented by prosthetic and therapeutic environmental facilitators or overcome the demands of any barriers that are present. (2001). Unpublished master’s thesis. The challenge, however, is to design and incorporate modifications, health care products, technologies, and devices into the home environment without violating two basic principles. Most water supplies serving large popul… Ultimately, the adoption of the physical environment, and UD in particular, as a broad-based intervention strategy will require fundamental paradigm shifts in both housing and health that recognize the home environment and everything in it as an integral part of the medical milieu. Two decades after proposing its medical model, the World Health Organization developed the International Classification of Functioning, Disability and Health (ICF), a new classification system based on a more robust social model (World Health Organization, 2001). Occupation, Participation and Health, 24, 32-39. They contain potential hazards that can lead to accidents, are deficient in design features that permit safe and independent functioning in daily activities, and lack sufficient space and layout for assistive technologies and personal assistance. (2000). Iwarsson, S. (2004). (2002). Strategies for home modification and repair. Instead, most live in older single-family homes built before 1940, of which slightly more than one-third need structural repairs (e.g., new roof) or updated systems (e.g., electric) compared with slightly less than one-quarter of housing units in general (Louie, 1999). The environment can influence mood. LaPlante, M.P., Hendershot, G.E., and Moss, A.J. Sanford, J.A., Griffiths, P.M., Richardson, P., Hargraves, K., Butterfield, T., and Hoenig, H. (2006). Alzheimer’s Care Quarterly, 1(1), 45-54. As a result, assessments undertaken by construction professionals may overestimate the need for environmental interventions. A variety of certifications are associated with home modifications, although none is legally binding or affiliated with any professional licensure. The document also contains guidance to ensure that Of particular relevance here are the following: (1) assessing the demands and needs for eliminating barriers, (2) prosthetic interventions that meet the functional needs of both individual and caregiver, (3) delivery and reimbursement systems to supply and fund best-fit interventions, and (4) choice and impacts of best-fit interventions that must ultimately meet the real-world needs of the situation. Such is the case in many countries where home modifications are considered medical interventions. Building owners, managers, tenants, and most of all building occupants are beginning to demand that their indoor environment be not just comfortable (not too hot or too cold, not too noisy, etc. Not surprisingly, the independent living and home health goals that should be mutually supportive—that is, independent living should promote health and home health should promote independent living—often are addressed without consideration for each other. This includes allowances in the codes to permit health-related environmental interventions that are necessary for people to remain in their homes. Available: http://www.nytimes.com/2009/09/15/technology/15speech.html [accessed June 2010]. However, while individuals who suffer from trauma or chronic illness are placed into the rehabilitation system, others, such as seniors with declining abilities, are typically on their own to find out how and where to enter a complex system of services that could be provided by any number of programs. environmental innovations due to disrepair, inadequate systems, and lack of space. Although this is primarily because many home modifications either need to be installed (e.g., grab bars) or are too big to transport (e.g., chair lift), many smaller items, such as tub benches or thermostats, could be included in an assessment. The Physical Environment Physical environment include buildings, rooms, windows, equipment that should be considered. Population-based study of home accessibility features and the activities of daily living: clinical and policy implications. Like assessments and service programs, home modifications are delivered by a variety of professions. Exposure to environmental noise, mainly noise produced by leisure activities, accounts for about 3% of debilitating tinnitus. 298-337). Social impacts on health are embedded in the broader environment in which we live. Not surprisingly therefore, there is a general lack of a coordinated and comprehensive system of services that would permit expanded health care and housing options, promote self-sufficiency and independence, and offset social isolation (Lawler, 2001). To reduce injury and facilitate caregiver assistance, a number of products and devices have been developed to make moving around the home and transferring easier, safer, more efficient, and more dignified, both for the care recipient and the caregiver (see Chapter 8). However, unlike clinical drug trials, there are rarely prescribed dosages of environmental attributes that can be varied and tested for efficacy, safety, and level across individuals. 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