Blue Print for ACTION

Key Issues

"A great deal of knowledge exists about how to improve important living environments; the next step is how to make these improvements part of the mainstream consumer marketplace"

Consumer Knowledge

Better, safer, and easier-to-use home environments are important in a society that is aging and has an increasing number of individuals with disabilities. Unfortunately, only a small proportion of people who need more accessible living environments modify or adapt their homes. There are reasons why improved living environments have not caught on. While there are many excellent educational programs and materials for educating consumers, most approaches have targeted the consumer as the problem rather than the environment. In addition, suggested modifications have often been inconsistent with consumer preferences. A great deal of knowledge exists about how to improve living environments; the next step is how to make these improvements part of the mainstream consumer marketplace.

Perspective

The scope of home modifications depends on one's perspective. Many think of home modifications and assume the discussion is about individuals experiencing losses in their abilities to manage effectively and safely within their home environment. Home modifications have been .2 defined as "conversions or adaptations to the environment of individuals with disabilities intended to make tasks easier, reduce accidents, and support independent living" (Pynoos, 1993). This perspective is that home modifications are corrective for problems related to diminished abilities of an individual.

An alternate perspective is that home modifications are preventive. Home modifications are an important component of a home improvement and can prevent injury and improve ease-of-use and efficiency. Home modifications, from this preventive perspective, pinpoint the environment as the problem irrespective of the consumer's abilities. From the corrective perspective, consumers are only individuals with disabilities or functional limitations that impact their ability to conduct basic life activities in their home. From the preventive home improvement perspective, consumers include everyone.

Level of Consumer Knowledge

Perhaps the best indicator of home modification is consumer adoption of modifications. Struyk and Katsura (1987) reported at least one modification 19% of elderly-occupied homes with one or more family members with activity limitations, compared to 4% with at least one modification of those occupied by the non-elderly. LaPlante, Hendershot and Moss (1992) revealed that 2.9% of all households have some type of home accessibility feature (e.g., ramp, extra-wide doors, elevator or stair lift, hand rails, raised toilet, adapted door locks, lowered counters, slip-resistant floors). Reschovsky and Newman (1990) found that 10.1% of "frail households" had added special dwelling features. A survey of older adults by AARP (1990) revealed that almost one-fourth of the households over age 55 have undertaken home modification.

Nevertheless, concern exists that many persons who could benefit from home modifications do not have them. For example, fewer than one-fifth of the "at risk" users have home modifications. Even if consumers know about home modification and home repair programs, they may not use them. Mitchell (1995) found that 46.5% of 868 non-institutionalized elderly in eastern North Carolina knew about home repair services, but only 4% had used the service.

Old man and baby reading picture Other persons may reject home modification services because they are not tailored to their needs. McCaslin (1988) reported general knowledge and acceptance of the formal service system are better predictors of use than are the demographic and functional capacity variables usually studied. Well elderly persons who use formal services appear to select a package of programs to match their interests, whereas frail elderly draw on specific support programs to offset particular functional deficits. it is not sufficient to develop policies and programs based on professional definitions of need. Rather, home modification services must be available so that elderly persons view them as viable solutions to their problems.

Awareness of Programs

Princeton Survey Research (1995), in a recent survey of older adults, found that 71% were unaware of programs to help with home repairs. Homeowners were as likely as renters to be uninformed about programs that provide assistance with property taxes and home repairs. Sixty-three percent said it would be useful to know more about programs. The respondents' greatest barriers to finding out about government programs were knowing the programs exist in the first place (62%) and knowing where to get information (66%). older people in rural areas are more likely than others to say they do not know where to go for information about programs (76% versus 62% for city dwellers). People interested in learning more about government programs were most eager for a local directory of programs (79%); 70% would like telephone "help lines."

How Consumers Learn About Home Modifications.

Consumers generally learn about products and services through traditional methods such as advertising. However, consumers wishing to upgrade their living environments often rely on references from friends or relatives to select contractors and remodelers. This traditional scenario breaks down when the home improvements are modifications. Consumers are accustomed to adjusting to what they have and do not know about alternative products and building designs that may be more convenient and safer. There are few advertisements, if any, on television or in consumer publications that tout the desirability, beauty and benefits of modifications.

The 15% to 20% of individuals with functional limitations who receive services might learn of home modifications through formal service providers, particularly when a worker visits the individual within his or her home. Unfortunately, most service providers are likely to lack knowledge about home modifications.

Another Source of information about home modifications can be professional home builders. However, Belser and Weber (1995) found that few builders are aware of modifications or use access features in their work.

Current Situation

Lack of knowledge of consumers, home builders and remodeling professionals, and intermcdiaries continues to inhibit the supply and demand for home modifications. Pynoos, Cohen, Davis and Bernhardt (1987) reported that there is no systematic program to educate professionals about assessing the needs of the elderly or handymen about the changing physical needs of older residents. Builders lack knowledge of the need, importance, and benefits from home modification solutions. Home modifications are perceived as solutions only for individuals with disabilities. People with disabilities are usually viewed as only those with wheelchairs. Thus, unless the clientis in a wheelchair, the home builder, remodeler, or handyman is unlikely to think about home modifications.

Part of the problem with consumer education efforts is that home modifications and accessibility have been approached from the "disability perspective. Additionally, home modifications are often relegated to the medical realm. This influence pushes the consumer/supplier to focus on medically necessary modifications and reimbursement questions rather than independence and quality-of-life changes. The focus has also been toward maintenance rehabilitation instead of prevention. This approach has influenced individuals to consider home modification after problems occur rather than as safety and convenience measures to prevent accidents and loss of independence.

House remodeling picture To summarize, consumers do not perceive themselves as "disabled" and do not identify with messages directed to people with disabilities. They have limited access to information about accessbile living environments, associate accessibility with disability, do not see examples of good accessible design, and do not have access to a variety of products or options that promote ease of use and accessibility. For example, several general consumer outlets (e.g. K-Mart, Target, Wal-Mart, Walgreens, K&B Drugs, HQ, Central Hardware) and other building supply stores offer products for individuals with functional limitations. Unfortunately, there is often only a single model of each typeof product, and frequently the products are placed on top shelves or so low they are not readily visible pr accessible to the consumer.

Additionally, builders, remodelers, and service providers are not adequately positioned to assist consumer understanding. While many landlords, developers, and builders are aware of the Americans with Disabilities Act and the Fair Housing Amendments Act, they are unaware of the benefits and functions of a more supportive setting. They have limited knowledge and information about universal design and rely upon tried and true construction methods. The builder, lender, and appraiser communities have a partially negative bias toward accessibility and equate accessible environments with loss of resale value of homes. Builders are unaware that the small changes they make now will make significant differences to homeowners later.

Too often, the membership associations representing architects, builders, appraisers, and interior designers relegate universal design to the "special populations" category and do not include educational programs that emphasize this design movement as part of the mainstream.

Funding / Resources

In recent years, there has been increased understanding of the need for, and benefits of, home modifications. However, this widened appreciation is hampered by a lack of awareness of resources and threats to many existing funding and financing sources. Consumers have limited familiarity with the private and public resources for home modification projects that are available to households of all incomes. For example, one of the most frequently asked questions of The Center for Universal Design's national information services is how to pay for home modifications.

Resource Assessment

Lots of Money picture Funding can come from public or private sources, but many households pay for modifications out of pocket. in one's search for government assistance funds, lack of awareness is compounded by limited eligibility, limited funding, and funding that may have much competition from other members of the public as well as competition for other uses. For example, the aging network has access to two programs that are targeted to low income seniors and that use a combination of federal, state, and local funds. The Social Services Block Grant from the Department of Health and Human Services (Title XX) allows expenditures for home modifications, but, as with all other block grants, home modification priorities must compete with many other essential services. The Home and Community Care Block Grant from the Administration on Aging (Title lllb) is targeted to seniors, but is stretched by many competing demands. Still, some home repair services are provided with these funds through area agencies o n aging, local aging councils, or other non-profit organizations. To receive services under either of these two government programs, one must meet age and income criteria and be fortunate enough to live in an area with funding for modifications or repairs. In addition, a household member must find out about the program and hope to apply successfully before the year's allocated funds have been expended. This scenario is repeated with many government programs which are targeted to low income households.

Money picture Resources for home modifications resist easy categorization. Access or eligibility can be determined by income, age, employment status, location, and health status. Resources can originate at federal, state, city, or county levels. No fewer than seven federal departments have programs where funds can be used for home modifications: Agriculture, Energy, Education, Health and Human Services (HHS), Housing and Urban Development (HUD), Treasury, and Veterans' Affairs. The U.S. Department of Housing and Urban Development's HOME program and the U. S. Department of Agriculture's Rural Community Development office both have loan and grant features. The Federal Housing funds directly to a household. Administration (part of HUD) and Rural Community Development (RCD) offer loan guarantees while RCD also has subsidized loans. Non-federal sources exist at the state and community levels, in both the public and private sectors. State agencies may have their own programs using tax or bond revenues, often through a housing finance agency. Foundations, private medical insurers, and charitable organizations, as well as lending institutions can be resources for assistance. Some private medical insurers and Medicaid and Medicare pay for the limited home assessments, durable medical equipment, or certain modifications. Private sector loan programs are available from commercial banks or through remodeling professionals.

Home modifications can be paid for in a variety of ways depending on a number of factors, including the type of modification, the income, and tenure status of the household, and the individual's age. The following examples illustrate the contrasts:

Medicare will pay for some durable medical equipment but not structural changes which equity financing will pay for.

Many sources of public funding (however limited) are targeted at low income home owners, while renters have only a few resource options.
Special resources exist for disabled veterans and persons with specific disabilities (e.g., cerebral palsy). Some programs provide services instead of providing funds directly to a household.
Tax credits and tax deductions help reduce income tax liabilities. Local property tax abatements can help free up funds for modifications.

The opportunities, even for federally-funded programs, vary by state and town. States decide how to spend funds for programs such as Medicaid from the Health Care Finance Agency and Block Grants from HHS and HUD.

Current Situation

A family's search to obtain financial assistance < with home modifications is likely to become more difficult in the future. Low- and moderate-income families will be particularly vulnerable. As with almost all affordable housing initiatives , those home modification and repair programs directed at helping people with low incomes are plagued with insufficient funds to meet the demand. Waiting lists are common and many are turned away. Families may be caught in gaps between eligibility requirements for income or age limits.

CAD drawing picture Federal initiatives that provide millions of dollars of support for home modifications for lowand moderate-income households are currently in danger of elimination or reduced funding. There is much discussion of providing even more discretion for funding decisions at the state and local level. This will create greater competition for the remaining funds and new demands on funding arising within states. While local decision making can better tailor programs to individualized area needs, it raises the spectre of zero-sum competition among many worthy programs. Unless advocates become aggressive, home modifications will lose in battles with medical reimbursement and other affordable housing initiatives.

Service Delivery

The delivery of home modifications is best characterized as a patchwork of services, involving a large diversity of providers, types of modifications, and methods of service delivery. It is a very fragmented, uncoordinated system with significant gaps in types of services available and geographic coverage. Consumers and providers alike find it difficult to 1) access services, 2) locate skilled providers or products, and 3) coordinate the many facets of home modifications.

Several barriers have especially impeded the effective delivery of home modification services including:

the lack of systematic and uniform assessments;

the under utilization of home modifications by social service/home care providers;
the low priority of home modifications in housing programs;
the medical bias of the health care system;
the instability of government-funded home modification programs; and,
the limited role of the for-profit sector.

The continuing unmet need for home modifications can be attributed to several interrelated factors such as a low level of consumer awareness, unaffordability, and lack of government funding. Additional factors include fragmentation in the delivery system, the lack of providers in many areas, and gaps in the types of home modifications, especially for low- and moderate-income persons. The delivery system for home modifications consists of providers such as remodelers, contractors, tradesmen (e.g. plumbers, electricians), handymen, medical supply companies, housing organizations, social service agencies, and volunteers. while multiple providers theoretically enhance consumer choice, the reality is that the system of home modifications is very fragmented and difficult to access. Many providers have responsibility for only one aspect of the process (e.g. information and referral, assessment, planning, funding) or supply only specific modifications. In most communities, there is no cen tral place to find out about or obtain home modifications. Part of the problem is that home modifications fall into a limbo among housing, social, and health services. None of these systems has taken full responsibility for accurately assessing or modifying homes.

Very few non-profit, public agency, or private sector providers are in a position to meet the diverse needs of persons with disabilities for home adaptations. Driven by categorical funding sources, faced with the multiple facets of home modifications, and confronted with a segmented market, most providers specialize in particular aspects of adapting homes. For example, medical supply companies sell specific products such as assistive devices or grab bars whereas remodelers or contractors make structure related changes such as widening hallways or installing ramps and curbless showers. Oc@upational therapists and case managers bring the broadest perspective to home modifications. In addition to recommending structural changes or assistive devices, they are likely to suggest ways of enhancing functioning through behavioral changes, moving objects within the home, or helping relocate to another setting.

Handicapped person going down walkway picture. In spite of the growth in home modifications, there are very few comprehensive programs. While this may not be a serious problem for consumers who require only a few simple modifications, it harms persons who have complex needs. Rural areas appear to be especially underserved. Even where home modification programs exist, they are usually very limited in terms of how many clients they can enroll and the types of modifications they make. Most programs that focus primarily on home modifications have quite modest budgets and long waiting lists. They concentrate their limited resources on low cost modifications such as grab bars, hand rails, and ramps. Consequently, they are unable to address needs for major modifications.

Current Situation

Specialization, gaps in services, and the absence of comprehensive programs make it difficult for both consumers and professionals to organize the delivery of home modification services. As a result, the procurement of products and adaptations is often piecemeal, never proceeding much beyond those modifications that are easy to access and low cost.

Several recent promising developments include new models of service delivery, more sophisticated assessment tools, a greater availability of useful and attractive products and information, and systems building efforts and new policy initiatives including the Technology Related Assistance for individuals with Disabilities Act of 1988 (the Tech Act) and the Fair Housing Amendments Act of 1988. New models include agencies that provide modifications for diverse age groups and Medicaid waiver programs that include home modifications as a covered service, and private companies that have carved out a market niche. These developments can be the springboard for many improvements in the delivery of home modifications.

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