Making Homes User Friendly for Wheelchairs and Walkers

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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.

Independence – What Older People Want

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Senior MenWe already have an idea of what older people want. A study from the National Conference of State Legislatures and AARP, plus other studies, confirm that the vast majority of us want to live in our homes and communities as we age. And, if possible, avoid dependence on others and institutionalization. 

Meeting this deeply personal goal requires that we design and provide good care in our hospitals and clinics, and expand that care beyond traditional boundaries. It requires the involvement of both health care and community-based service providers; a skilled paid workforce; and a well-supported, family-based “care force.” It also, of course, requires the correct blend of policies and funding.

This is an increasingly urgent concern. A person turns sixty-five every eight seconds, and according to Census numbers, the population of people age eighty-five and older, which doubled in the past thirty years, is projected to almost triple to more than 14 million people by 2040.

One obstacle we face is that our country spends almost twice as much on health care as on social services. To enable more older people to get the care and the outcomes they seek, we must find ways to balance our investment between these types of services, work together across sectors, and use our resources in forward-looking ways.

A good framework for this approach can be found in the work of the Institute of Medicine’s Forum on Aging, Disability, and Independence. A collaboration of the National Academies of Sciences, Engineering, and Medicine, the forum provides a critically needed and neutral venue to bring together aging and disability stakeholders from around the country, accelerate the transfer of research to practice and policy, and identify levers of change.

Supporting this type of transition and building the coalitions to carry it out are, in many ways, the essential role of philanthropy. The John A. Hartford Foundation, is committed to promoting better care for older people. To help more of us remain independent, they are supporting research and evidence-based programs in two broad areas: integrating community-based services with traditional health care and providing more coordinated care focused on older people’s own goals.

Supporting family and community resources…

Our health care system has been developed to perform life-saving and critically needed interventions and procedures, such as stents, transplants, radiation, and chemotherapy. But such high-tech care, while important, is often not well matched with the wants and needs of older adults, particularly those who require help with their personal care and daily activities.

A much more common need for older people and their families is coping with multiple chronic conditions and the complications they can bring. Clinics and hospitals need to be better designed to support this chronic care, but the vast majority of care actually takes place in our homes and communities. To remain at home and successfully manage one’s chronic conditions, many more older adults need excellent long-term services and supports—such as transportation, mobility aids, housing modifications, and accessible home care. Without these, they struggle.

Their caregivers need help, as well, and the Institute of Medicine’s Study on Family Caregiving for Older Adults, which was released in the spring of 2016 with funding from the John A. Hartford Foundation and fourteen other sponsors, should create a blueprint for how we can best support the family and friends who provide unpaid care worth an estimated $470 billion annually. 

The Affordable Care Act and the new emphasis on value-based payment to accountable care organizations are changing incentives and placing a new focus on the importance of social services and supports for patients and caregivers alike. But how do we best structure and provide these services?

The John A. Hartford Foundation, is supporting work in California by the Partners in Care Foundation, and in Massachusetts by Elder Services of Merrimack Valley and Hebrew SeniorLife, to create more integrated care systems that link community-based, social service agencies to the health care sector.

They are also working with the federal Administration for Community Living, the SCAN Foundation, and the Tufts Health Plan Foundation to help representatives of the aging services network in eleven communities build their business acumen so they can work more effectively with health care providers, fill in service gaps, and meet the needs of older adults.

Reshaping care delivery, promoting teams…

Good care must be team care, and good teams don’t just happen. The foundation has a long-standing commitment to improving team care—for example, it has supported a Geriatric Interdisciplinary Team Training program at several universities and team-based practice models in clinic, hospital, and long-term care settings.

Meeting the whole range of health and social needs of frail older adults in each of these settings requires care coordination, reliable communication among team members (who may be in other practices or specialties or outside of the formal health system), and technology that promises to facilitate and monitor care.

The Mobile Acute Care Team (MACT) model is a good example. MACT is a hospital-at-home approach for older adults, where a team of nurses, physicians, social workers, and allied health care professionals provide acute-level care through home visits and monitoring. Studies have found that this approach lowers costs by nearly one-third and reduces infections and other complications. It is highly rated by patients and caregivers alike. Initially developed at Johns Hopkins University with support from the John A. Hartford Foundation, MACT is now being tested at Mount Sinai Medical Center in New York City with a substantial amount of funding from the federal Center for Medicare and Medicaid Innovation.

Making these kinds of services widely available will require significant changes in how care is delivered, and that is not easy. But with older adults becoming an ever-larger part of our population and our health care system continuing to experience rapid change because of market and policy forces, the focus must be on delivering care that people actually want. By working together, services and supports can be provided that meet people where they are and honor their goals. That’s a definition of better care.