ENVIRONMENTAL TECHNOLOGY AND HOME MODIFICATIONS BEYOND THE GRAB BAR Suzie Wiley OTR/L & Debbie Hartzler OTR/L, CAPS

Presenters 

Suzie Wiley Suzie graduated from The Ohio State University with a degree in Occupational Therapy and has worked at Rehabilitation Institute of Kansas City in various capacities. Her clinical background in neurorehabilitation brought a team of therapists at RIKC to recognizing the limitations individuals experience for written and spoken communication and the potential that technology could offer. In 1989, the Adaptive Computer & Communication Technology Program (ACCT) was developed to assist individuals and their families through the process of learning the technology adaptations available to bridge that gap. ACCT has lent itself to becoming an area resource for home modifications over the past 7 years by combining the experience of assistive technology with extensive rehabilitation.

Presenters 

Debbie Hartzler A graduate of The Ohio State University, Debbie has practiced occupational therapy in the Kansas City area since 1981. Specializing in adult and geriatric rehabilitation, she has experience working in acute care, skilled care, rehabilitation, and outpatient settings. Debbie is licensed in both Kansas and Missouri, with over 30 years of experience as a supervisor and educator. She has specialized in home modifications since 2009, working with LifeWise Renovations, and received her Certified Aging in Place (CAPS) certification in 2012.

Objectives The participant will be able to:  Define the principles of universal design and aging in place.  Relate universal design and aging in place principles to specific home modifications.  Identify common safety and structural barriers within the home.  Develop specific solutions to common barriers within the home.  Name 3 home modifications that can increase safety and function.  Expand knowledge of the specialty products used in home modifications.  Compare different residential lift systems used when retrofitting multi-level homes.  Identify transfer lift systems that can be managed individually or by a caregiver.  Identify current technology for environmental controls that can be utilized through minimal movements or voice input.  Discuss general funding sources for home modifications.

UNIVERSAL DESIGN

Universal Design Concept developed in the mid-90’s by Ron Mace.  Defined as the design of products and environments to be usable by all people regardless of age or ability level.  Takes into consideration aesthetics, engineering options, industry standards, safety concerns, and cost.  Broken down into 7 principles. 

7 Principles of Universal Design Equitable Use  Flexibility in Use  Simple and Intuitive Use  Perceptible Information  Tolerance for Error  Low Physical Effort  Size and Space for Approach and Use 

Equitable Use Meaning:  The design accommodates people with diverse abilities. Guidelines:  Provide the same means of use for all users.  Avoid segregating or stigmatizing any users.

Equitable Use

Flexibility in Use Meaning:  The design accommodates a wide range of individual preferences and abilities.

Guidelines:  Provide choice in methods of use.  Accommodate right- or left-handed access and use.  Provide adaptability to user’s pace.

Flexibility in Use

Simple and Intuitive Use Meaning:  Use of the design is easy to understand, regardless of the user’s experience or knowledge. Guidelines:  Eliminate unnecessary complexity.  Be consistent with user expectations and intuition.  Arrange information consistent with its importance.

Simple and Intuitive Use

Perceptible Information Meaning:  The design communicates necessary information effectively to the user.

Guidelines:  Provide adequate contrast.  Maximize legibility of essential information.  Differentiate objects in ways that can be described by making it easy to give directions or instructions.

Perceptible Information

Tolerance for Error Meaning:  The design minimizes hazards and the adverse consequences of accidental or unintended actions. Guidelines:  Arrange items to minimize hazards and errors: most used items are the most accessible while hazardous items are eliminated, isolated, or shielded.

Tolerance for Error

Low Physical Effort Meaning:  The design can be used efficiently and comfortably and with a minimum of fatigue. Guidelines:  Allow user to maintain a neutral body position.  Minimize repetitive actions.  Minimize sustained physical effort.

Low Physical Effort

Size and Space for Approach and Use Meaning:  Appropriate size and space is provided for approach, reach, manipulation, and use regardless of user’s body size, posture, or mobility.

Size and Space for Approach and Use Guidelines :  Provide a clear line of sight to important elements for any seated or standing user.  Make reach to all components comfortable for any seated or standing user.  Accommodate variations in hand and grip size.  Provide adequate space for the use of assistive devices or personal

Size and Space for Approach and Use

AGING IN PLACE

Aging-in-Place 

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The Center for Disease Control defines aging in place as "the ability to live in one's own home and community safely, independently, and comfortably, regardless of age, income, or ability level.“ 90 percent of adults over the age of 65 report that they would prefer to stay in their current residence as they age. (AARP) One-third of American households are home to one or more residents 60 years of age or older. (AARP)

Aging-in-Place  

Technology can be an enabler for aging in place Four categories of technology that acts as an enabler Communication and Engagement  Health and Wellness  Learning and Contribution  Safety and Security (Wikipedia) 

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Caregiving technologies help those who care for older adults provide that care in the most effective way and include new technologies for smart phones and tablets, as well as websites (ie Caring.com or AARP.org/Caregiving) (Wikipedia)

Aging-in-Place Aging in place can be divided into categories: 

Aging in place without urgent needs: This group includes individuals who want to stay in their current home, are not experiencing immediate health/mobility issues, and prefer aging in place.

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Aging in place with progressive condition-based needs: This group is made up of those with chronic or progressive conditions that will require special modifications for aging in place. These individuals are usually aware of their needs but meeting them is not necessarily urgent. Many have chronic conditions such as diabetes and lung/heart disease that challenge them.

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Aging in place with traumatic change needs: This group includes those who experienced an abrupt or immediate change that demands adjustments in the living environment for aging in place such as home modifications or universal design. (Wikipedia)

Aging-in-Place Some aging statistics:  Motor functioning: In a 2002 study by Min Soo Kang, reported that the elder population in America, 18% will have a disability. This calculates to 51 million Americans who have difficulty in functioning every day. 32% over the age 65 will have difficulty walking which may require use of wheelchairs and canes. (Translates to barrier free showers, wider doorways, grab bars, etc)  Fine motor functioning: Elders will have difficulty using their fingers which can be problematic. (Translates to D shaped handles, lever or touch faucets, etc)  Cognitive functioning: Reported in Kochera (2002) that 1 out of 5 people over the age of 55 will have a mental health disorder. Due to the deterioration, the five senses and cognitive capability decrease cause slow response. (Translates to automatic shut off stove, hot water temperature controls, video and medication monitors, etc) (Wikipedia)

Aging-in-Place A viable alternative to an independent or assisted living facility.  Visitability  Certified Aging-in-Place Specialist (CAPS) designation. 

HOME SAFETY

Fall Statistics

Fall Statistics Recent studies have shown:  Every 17 seconds an older adult is treated in the ER for a fall.  1 and 3 adults age 65 and older fall each year.  Approximately 20 – 55% of unintentional falls occur inside the home with 75% of those occurring during the performance of routine daily tasks (e.g. getting in and out of a chair, bathing, toileting, going up and down stairs).

CAUSES OF FALLS

Causes of Falls The 2 Major Causes:  Health and age related changes  Hazardous situations

Health and Age Related Changes Changes in physical activity  Problems with balance.  Slow reflexes. Changes in eyesight Use of certain medications. Underlying health conditions  Urgency and frequency of bathroom needs.  Blood pressure issues

FALL PREVENTION

Remove Home Hazards

Remove Home Hazards Lighting: • Use brighter bulbs. • Increase natural lighting. • Place nightlights where there is the most night activity. • Place an easy to reach lamp beside the bed. • Keep a flashlight handy. • Consider remote control systems.

Solution: Better Lighting

Solution: Remote Control System

Remove Home Hazards Flooring: • Repair or replace worn and torn carpeting (short, dense pile carpets are best). • Remove throw rugs and other items that are easy to trip over. • Secure area rugs with double-sided tape or carpet mesh.

Remove Home Hazards Flooring: • Use non-slip, non-wax flooring. • Make thresholds even with floor. • Remove clutter and loose cords from pathways.

Solution: Non slip flooring, Even Thresholds

Remove Home Hazards Stairs: • •

•

•

Slipping is the primary cause of stair falls. Most stairway falls that cause injuries occur while people are walking down the stairs. Absence of handrails account for a large percentage of falls on stairs. Unexpected location of stairs lead to many falls. For example, stairs of just one or two steps in a hallway or doorway can be especially hazardous.

Remove Home Hazards Stairs: • Install handrails on both sides of the stairwell. • Add reflective, non-slip tape or paint on the top edge of non-carpeted steps. • Add a light switch at the top and bottom of staircase. • Make sure carpeting is firmly attached on steps and worn spots are repaired.

Solution: Lighting, Handrails, Grippers

Remove Home Hazards Storage: • Store frequently used items at a height between shoulders and knees. • Use a stepstool with handrails if necessary to reach higher cabinets.

Remove Home Hazards Storage: • Use pull-down shelving for cabinets. • Use pull-down rods for closets. • Install lever handles on doors and faucets for ease of use. • Install D handle hardware on cabinet doors and drawers for ease of use.

Solution: Functional, Accessible Storage

Solution: Improved Hardware and Faucetry

FALLL PREVENTION Bathroom Statistics

Bathroom Statistics

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According to the CDC Morbidity and Mortality Report published 6/2011 About 235,000 people over age 15 visit the ER annually because of injuries suffered in the bathroom About 2/3 of accidental injuries happen in the tub or shower (9.2% occurred when getting out of the tub/shower) People over 85 suffer more than ½ of their injuries near the toilet 81% of the injuries were caused by falls

Bathroom Statistics

Taken from CDC study published 6/2011 republished

Bathroom Statistics

Taken from CDC study published 6/2011republished

Bathroom Statistics

Taken from CDC study published 6/2011republished

Bathroom Statistics

Taken from CDC study published 6/2011republished

FALL PREVENTION

Home Modifications Bathroom Solutions

Bathroom Modifications: Barrier Free Showers

Recognize the long term needs…

Long-term function is critical…

Bathroom Modifications: Walk-In Bathtubs

Bathroom Modifications: Shower seats vs. Tub seats

Bathroom Modifications: Grab Bars • Come in various lengths to accommodate a wide range of needs and ability levels. • Customizable finishes. • Can be substituted in place of a towel bar. • Must be placed in wall blocking or studs, or use of specialty brackets and fixtures • Suction cup grab bars are not consistently reliable

Bathroom Modifications: Slide bars and Hand Helds

Bathroom Modifications: Comfort Height Toilets

Bathroom Modifications: Hands Free Toilets

Bathroom Modifications: Hands Free Toilets

Bathroom Modifications: Wall Mounted Toilets

Bathroom Modifications: Sloped Skirt Vanities

Bathroom Modifications: Functional Storage

FALL PREVENTION

Home Modifications Kitchen Solutions

Kitchen Modifications: Pull Out Drawers and Pull Down Shelving

Kitchen Modifications: Touch Faucets and Sloped Skirt Vanities

Kitchen Modifications: Appliance Placement, Contrasting Colors

Kitchen Modifications: Functional Storage

Kitchen Modifications: Variable Counter Heights, Non Glare Surface

Kitchen Modifications: Larger doorways, Traffic Flow

FALL PREVENTION

Home Modifications Other Internal Solutions

Other Interior Solutions: Doorways

Other Interior Modifications: Doorways

Other Interior Modifications: Off Setting Door Hinges

Other Interior Modifications: Automatic door openers

Other Interior Modifications: Thresholds and Flooring

FALL PREVENTION

Home Modifications Exterior Solutions

Ramps…points to remember… Ramp run:rise ADA is 12:1…a power w/c can navigate 10:1 o

For a ramp covering a 30” rise, a 5’ level landing is needed. •

Materials should be pressure treated or rated for outdoor use. Use stainless steel or galvanized carriage bolts and screws. •

A 5’ x 5’ landing is needed at the top of a ramp to allow someone using a wheelchair to turn and open the door. •

‘Portable ramps’ may lose their portability at approximately 6’ (this would allot for a 6” rise). They weigh approximately 70#+ beyond 6’. •

Portable ramps

Threshold ramps

Ramp access

Emergency acces

LIFT SYSTEMS

Talking the same language Floor lift (Hoyer-type lift)  Sit to stand lift  Stair lift  Vertical lift  Incline platform lift  Ceiling lift  Elevators 

Floor lift

Sit to stand lifts

Stair lift Considerations: • Transfer • Postural control • Mobility at both ends • Power • Straight or turn in stairs

Vertical Lift Considerations: Access •

•

Adjacent or Straight Thru

Exterior or Interior •

Shaft needs?

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Height

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Safety features •

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Power outage back up system(s) Interlock

Vertical Lift

Vertical lift for interior use Before…

During…pantry removal

Shaft in process… Shaft completed…

Interior vertical lift completed

Incline platform lift Considerations:  No transfer required  Less construction required than vertical lift  Type of stairway?  Adequate space? Requires approx. 9’ straightaway

Ceiling lifts

Considerations: • Dependent transfers • Single or multiroom • Sling can be removed from

Bedroom: Before & after modification

Ceiling lift for transfer to wheelchair or shower chair

ELEVATORS

Residential elevator Consideration s: • Space • Cost

EADL A.K.A ECU’S Electronic Aids to Daily Living Environmental Control Units

The questions to ask… 

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What do you want to be able to do?  To what degree do you want to do that function?  What is the typical input control for that device?  X-10 – runs across home wiring  Infrared What motor function can we use to perform access to an ECU?  Simple to complex

Common equipment Television  DVD player  Fan/heater  Music  Lights  Telephone 

…Universal Remote

Affordable for adapted input needs… Mini Relax Package Infrared

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Switch scanning – auditory and visual feedback •

Limited to 6 IR functions

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Retail ~ $385 (NanoPac) Mini Relax with X-10 feature Infrared + One X-10 module

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One Buddy switch

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Allows 5 IR functions and 1 X10 •

Retail ~ $446 (NanoPac)

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Increased device control for adapted input needs… Relax II •

Switch scanning

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Control 4 IR devices for 10 functions each

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Control 10 X-10 functions

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Auditory and visual feedback

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Retail ~ $675 (NanoPac)

Relax II System Package Includes the X-10 transmitter and 2 modules Retail ~ $799 (NanoPac) Relax 3 all functions of Relax II + •

Adds a telephone function

Scan thru 10 preset phone 5 preset numbers •

•

Retail ~ $2250 (NanoPac)

functions and

High end input needs with full control… REACH Remote Electronic Access & Control-Handsfree Input options – Touch control

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Voice control

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Head mouse

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Switch scanning

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IR, X-10, Phone, Bed,

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Manufacturer Break Boundaries

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Retail starts at ~ $6450

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HOME MODIFICATIONS

Participants Funding

Who might participate? Family

Payer Source

Identify needs.

This may determine the other parties involved. May require a vendor contract, license, etc.

General Contractor

DME Provider

Construction & Equipment sale, remodeling work. install & service. • May do all the • May subwork contract with contractor to • May subcollaborate to contract with finish job. DME If private pay – • Do they sub opens up all of the • May out the entire options for who will subcontract all job? be involved. of the work

OT, PT, Case Mgr. Svc. Coord. Input into any or all areas.

Seeing things through different eyes

The ‘fine print’ disclaimer… “This summary and its recommendations are intended to be a guide for potential contractors…  Their expertise should be deferred to regarding structural changes, feasibility, materials, city codes, and the cost effectiveness of some options.  This summary should be shared with potential contractors prior to acceptance and initiation of the job.  It is recommended that each potential contractor provide a customer reference from a job that required similar work.  The family/funding agency are responsible for following up on that reference and using the

…Experience we can learn

from…

Resources for home modification funding 

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VA Grants MO Assistive Technology Low Interest Loan KS Assistive Technology Low Interest Loan Missouri Medicaid for individuals with developmental disabilities KS Medicaid Waiver for individuals with physical disabilities Tax deduction with physicians prescription Long term care policy County funds (Jackson, Platte) for individuals aging with DD Worker’s Compensation Private pay

Presenter Contact Information 

Debbie Hartzler, OTR, CAPS  [email protected]  816-289-2762



(cell) or 816-363-0600

Suzie Wiley, OTR  [email protected]  816-751-7950

or 816-751-7783

CASE STUDIES

Sylvia’s Story Diagnosis  Motorcycle accident in 20’s resulting in TBI with right-sided hemiparesis and expressive aphasia. Now in 60’s experiencing left side knee and shoulder problems. Primary mode of mobility is manual wheelchair. Has to pull up to transfer. Environmental Barriers  Limited ability with meal prep, accessing storage, transporting hot food items, laundry, bathing, toileting, bed transfers, completing toilet and tub transfers

Bathroom Before

Solution: barrier free shower, grab bars, hand held shower on slide bar, tilted mirror, raised toilet seat, super pole

Solution: Custom built functional storage and food prep area

Solution: Sloped skirt vanity at kitchen sink

Dennis and Linda’s Story Diagnosis  Early onset Parkinson’s with progressive mobility issues.

Environmental Barriers  Inaccessible shower and toilet area, thick carpeting throughout master bedroom and bathroom, inaccessible laundry area, insufficient access to closet and storage.

Bedroom Before

Solution: replaced carpeting with hardwood floor;

converted existing bathroom into accessible laundry room and closet.

Bathroom Before

Solution: Opened up wall and converted existing office space into fully accessible bathroom

Shower Before

Solution: barrier-free shower and fully accessible toileting area with Toto Neorest toilet

Robert and Marilyn’s Story Diagnosis  CVA with right-side hemiparesis.

Environmental Barriers  Inaccessible entry into bathroom, inaccessible toilet and shower, inaccessible front and back door entry, high pile carpeting.

Bathroom Before

Solution: barrier-free shower with flip-down shower seat; opened up toilet area and installed flip-down grab bar; built ramp at front and back door location; replaced all carpeting with low pile option.

Donna and Lauren’s Story Diagnosis  Stroke survivor with left-side hemiparesis, walking short distances with hemi-cane, and manual wheelchair backup. Environmental Barriers  Carpet in master bedroom, inaccessible shower, toilet area, and vanity, and access to bathroom and master bedroom.

Bathroom Before

LifeWise Solution: barrier free shower with built in seat, slope skirt vanity

Solution: hand held shower on slide bar, increased natural light

Solution: comfort height toilet with grab bar

Solution: Widened doorways to master bedroom and bathroom; eliminated carpeting in master and replaced with hardwood slip resistant flooring

Jeff and Lisa’s Story Diagnosis  Spinocerebellar Ataxia III which has affected speech, gait, vision, and fine motor coordination. Uses a U-Step walker and manual wheelchair. Environmental barriers  Front entryway and mailbox access; access to bathroom vanity; limited functionality and access in kitchen.

Kitchen Before

Solution: widened doorway, removed island to reorganize traffic flow, task lighting

Solution: hard wood slip resistant flooring, relocation of microwave oven

Solution: Built a ramp with platform access to the mailbox (installed slope skirt vanity in the bathroom)

Mike and Alice’s Story Diagnosis  Brain tumor with resulting left-side hemiparesis. Walks short distances with hemi-cane and uses a manual wheelchair backup. Environmental Barriers  The existing bathroom had too narrow an entrance, an inaccessible shower, and carpet throughout.

Bathroom Before

Solution: A wall was removed to create a larger, barrier-free bathroom; vanity was sloped in bathroom; doorway was widened at garage and bathroom entry.

Tom and Pam’s Story Diagnosis  Motorcycle accident resulting in T6-7 paraplegia with bilateral wrist fractures.

Environmental Barriers  Inaccessible entry into the home, inaccessible soaker tub, toilet, and shower; carpeting in master bedroom and bathroom; narrow doorways into closet and other storage; inaccessible bathroom vanity

Bathroom Before

Solution: Replaced carpet with slip resistant tile, added slope skirt vanity, converted water closet to roll in shower

Solution: removed soaker tub and replaced with accessible comfort height toilet and grab bars

Solution: built accessible storage cabinets and reorganized closet, widened bedroom and closet doorways

Solution: widened doorway from garage and built ramp entry

Barry’s Story Diagnosis  Diving accident in his teens resulting in C5-6 quadriplegia. Environmental Barriers  Recently purchased new home with inaccessible bathroom

Solution: Converted existing bathroom into shower room that allowed for 2 caregivers to assist with showering.

Presenter Contact Information 

Debbie Hartzler, OTR, CAPS  [email protected]  816-289-2762



(cell) or 816-363-0600

Suzie Wiley, OTR  [email protected]  816-751-7950

or 816-751-7783