Making Homes User Friendly for Wheelchairs and Walkers

Leave a comment

Lady in wheelchairWhen Dan Bawden teaches contractors and builders about aging-in-place, he has them sit in a wheelchair to feel what it’s like to function from this perspective. That’s when previously unappreciated obstacles snap into focus. 

Bathroom doorways are too narrow to navigate through. Hallways do not allow enough room to turn around. Light switches are too high and electrical outlets too low to easily reach. Cabinets beneath a kitchen sink prevent someone from rolling up close and wash dishes, etc.

It’s an “aha moment” for most of his students, who have never actually experienced these examples of limitations or realized so keenly how home design can interfere with — or promote — the daily functions for an individual.

About 2 million older adults in the United States use wheelchairs, according to the U.S. Census Bureau; another 7 million use canes, crutches or walkers.

That number is set to increase with the aging population: Twenty years from now, 17 million U.S. households will include at least one mobility-challenged older adult, according to a December 2016 report from Harvard University’s Joint Center for Housing Studies.

How well has the housing industry accommodated this population?

“Very poorly,” said Bawden, chairperson of the remodelers division at the National Association of Home Builders and president of Legal Eagle Contractors in Bellaire, Texas. “I give them a grade D.”

Researchers at the Harvard center found that fewer than 10 percent of seniors live in homes or apartments outfitted with basic features that enhance accessibility — notably, entrances without steps and extra-wide hallways or doors needed for people with wheelchairs or walkers.

Even less common are features that promote “usability” — carrying out the activities of daily life with a measure of ease and independence.

Laws that guarantee accessibility for people with disabilities are limited. The Americans with Disability Act applies only to public buildings. And while the Fair Housing Act covers apartments and condominiums built after March 1991, its requirements are not comprehensive and enforcement is inconsistent.

We asked several experts to describe some common issues mobility-challenged seniors encounter at home, and how they can be addressed. The following is what the experts suggested may need attention with alterations, however is not a comprehensive list.

 Getting inside.

A ramp will be needed for homes with steps leading up to the front or back door when someone uses a wheelchair, either permanently or temporarily. The estimated price for a five-to-six foot portable nonslip version is $500 to $600.

One consideration is to take out the weather strip at the bottom of the front or back door and replace it with an automatic door bottom. “You want the threshold to be as flat as the floor,” Bawden said. Consider installing an electronic lock that prevents the need to lean forward and insert a key.

Doors.

Getting through doorways easily is a problem for people who use walkers or wheelchairs. They should be 34 to 36 inches wide to allow easy access.

Widening a doorway structurally is expensive, with an estimated cost of about $2,500. A reasonable alternative is swing-free hinges, which wrap around the door trim and add about 2 inches of clearance to a door.

Clearance.

Ideally, people using wheelchairs need a five-foot-wide path in which to move and turn around, Bawden said. Often that requires removing some furniture in the living room, dining room, and bedroom.

Another rule of thumb: People in wheelchairs have a reach of 24 to 48 inches. That means they will not be able to reach items in cabinets above kitchen counters or bathroom sinks.

Also, light switches on walls will need to be placed no more than 48 inches from the floor and electrical outlets raised to 18 inches from their usual 14 inch height.

Older eyes need more light and distinct contrasts to see well. A single light fixture hanging from the center of the dining room or kitchen most likely will not offer enough illumination.

It is suggested to distribute balanced lighting throughout each room and repaint the walls so their colors contrast sharply with the floor materials.

“If someone can afford it, I place recessed LED lights in all four corners of the bedroom and the living room and install closet rods with LED lights on them,” Bawden said. LED lights do not need to be changed as often as regular bulbs.

Kitchen.

Mark Lichter, director of the architecture program for Paralyzed Veterans of America, recommends that seniors who use walkers or wheelchairs take time to navigate around in the kitchen of a unit they are thinking of moving into and imagine preparing a meal or other tasks.

Typically, cabinets need to be removed from under the sink, to allow someone with a wheelchair to get up close, Lichter said. The same is true for the stovetop, understanding that the area underneath needs to be open and control panels placed in front.

Refrigerators with side-by-side doors are preferable to those with freezer areas on the bottom or top. Slide out full-extension drawers maximize storage space, as can carousel shelves in bottom corner cabinets.

Laundry.

A side-by-side front-loading washer and dryer works best to allow for easy access, instead of stacked machines.

Bathroom.

When Jon Pynoos’ frail father-in-law, Harry, who was in his 80s, came to live in a small cottage in back of his house, Jon put in a curbless shower with grab bars, a shower seat and a handheld shower head that slides up and down on a pole.

Even a relatively small lip at the edge of the shower can be a fall risk for someone whose balance or movement is compromised.

Also, Pynoos, a professor of gerontology, public policy and urban planning at the University of Southern California, installed nonslip floor tile and grab bars around a “comfort height” toilet.

Cabinets under the bathroom sink should be removed and storage space for toiletries placed lower for better accessibility. A free-standing toilet paper holder is better than a wall-based unit for someone with arthritis who has trouble extending their arm sideways.

“It really would not take much effort or expense to design homes and apartments appropriately in the first place, to make aging-in-place possible,” Pynoos said. Although “this still does not happen very often,” he noted the awareness of requirements is growing and well-designed, affordable products are becoming more widely available.

The housing industry has failed to accommodate an aging population, experts say.

Is There A Medicare Doctor In The House?

Leave a comment

Medical Nurse

Searching for ways to save money and improve care, Medicare officials are returning to an old-fashioned idea: house calls. 

But the experiment, called Independence at Home, is more than a nostalgic throwback to the way medicine was practiced decades ago when the doctor arrived at the patient’s door carrying a big black bag. Done right and paid right, house calls could prove to be a better way of treating very sick, elderly patients while they can still live at home.

“House calls go back to the origins of medicine, but in many ways this is the next generation,” said Dr. Patrick Conway, who heads the Center for Medicare and Medicaid Innovation, which oversees Independence at Home.    

In the first year of the experiment, Housecall Providers of Portland, Oregon, which had been operating at a loss, saved Medicare an average of almost $13,600 for each patient in the pilot project. Its share of the savings was $1.2 million. The house calls practice at MedStar Washington Hospital Center in Washington, D.C., cut the cost of care an average of $12,000 per patient.

Medicare reported overall savings of $25 million in the pilot’s first year, officials reported June 2015. From that money, nine practices earned bonuses totaling nearly $12 million, including a $2.9 million payment to a practice in Flint, Michigan.

After three practices dropped out, there are now 14 around the country participating in the project — including five sites run by the Visiting Physicians Association.

By all accounts, saving any money on these patients is a surprise. Independence at Home targets patients with complicated chronic health problems and disabilities who are among the most expensive Medicare beneficiaries. But a key study, published in 2014 in the Journal of the American Geriatrics Society, found that primary care delivered at home to Medicare patients saved 17 percent in health spending by reducing their need to go to the hospital or nursing home.

In addition to Medicare’s usual house calls payment, doctors in the Independence at Home project get a bonus if patients have at least 5 percent lower total Medicare costs than what is expected for a similar group of beneficiaries. Medicare keeps the first 5 percent of the savings and the house call providers can receive the rest. The doctors must meet at least three of the six performance goals — such as reducing emergency room visits and hospital readmissions, and monitoring patients’ medications for chronic conditions such as diabetes, asthma and high blood pressure.

Under the law creating the program, practices could join only if they make house calls to at least 200 patients with traditional Medicare who have been hospitalized and received rehab or other home health care within the past year. These patients also must have trouble with at least two activities of daily living, such as dressing or eating. The health care providers must be available 24 hours a day, seven days a week. They make visits at least once a month to catch any new problems early, and more often if patients are sick or there’s an emergency.

“You never know what you’re walking into,” said Terri Hobbs, Housecall Providers’ executive director. “This is a very sick group of people, with multiple chronic conditions, taking multiple medications and [they] have a very long problem list.” About half the Portland patients have some degree of dementia.

Yet the Medicare reimbursement for house calls is about the same as an office visit and doesn’t cover travel time or the extra time needed to take care of complex patients. It’s not enough to convince most doctors “to leave the relatively comfortable controlled environment of an office or hospital to do this sort of work,” said Dr. William Zafirau, medical director for Cleveland Clinic’s house calls program in Ohio, which has 200 patients in the Medicare pilot and plans to add 150 more.

A house calls doctor can see only five to seven patients a day. One reason is that a house call visit can take longer than an office visit, even after taking travel time into account. After Dr. Zafirau examines his patients, he also takes a look around the home. He may open their refrigerators to make sure they have enough food or see if medicine bottles are running low. He may arrange home-delivered meals or other social services.

How people are functioning is often the best indicator of their overall health.

The care can also extend to other professional services. Portland’s Housecalls Providers hired a nurse and a social worker to serve as an advocate for patients who enter the hospital. When the patient returns home, they visit. For example, an antibiotic, a hospital bed or oxygen.

Hospital admissions dropped so significantly that Hobbs expanded the transition team to serve house calls patients who were not part of the pilot program when they were hospitalized.

A similar team serves MedStar Washington Hospital Center’s house calls patients, said Dr. Eric De Jonge, director of geriatrics at the hospital and president-elect of the American Academy of Home Care Medicine. “When patients go to the hospital, there is very little contact from the primary care doctor with the hospital care,” he said. Independence at Home “is actually pushing back to reverse that trend.”

Ironically, Medicare doesn’t pay for the transition team even though Hobbs said it saves Medicare “a tremendous amount of money.”

Congress has authorized the Independence at Home program through October 2017, but some lawmakers hope there is enough support to extend it nationwide.  If not, Conway said his agency will not be able to continue the program.