considering successful rehabilitation aging in place and

Home Modification Evaluation

Presented by Kohll’s Pharmacy and HomecareOctober 2020

speakerBevVan Phillips, OTR/L, CAPS, ECHM

This session focuses on residential environmental modification and assistive technology. There are significant benefits for home modifications when considering successful rehabilitation aging in place and quality of life.

Participants will be able to:

• Identify structural changes or assistive technology to improve the quality of life for one patient/client.

• List at least three items used in home modifications that can be purchased and installed in a home.

• Participate in self assessment on non therapeutic background information that facilitates the therapist’s role in home modifications in order to self - direct further learning in the topic.

• Determine if a home modification service is potentially billable as a therapeutic service or not using AOTA guidelines.

Objectives Home Modification Evaluation

Myth – Home Modification is only for old or disabled people

• AND it ends up looking ugly and weird

• AND probably smells funny too.

Reality – Home Modification can be for everyone.

Home Modification is simply changing the home with intention to match what the home requires to what the person can do to improve

engagement in occupations within the home.

The environment impacts engagement in occupation and quality of life.

Accessibility -Barrier Free -Universal Design -Adaptable –Forgiving- are NOT the same, but can be combined.

Myth – Home Modifications can be done by “the book” OR people who do it a lot “just know”

OR it always requires a “gut”

Magic

Access Wand

•Home Modification Evaluation and Intervention is a process of matching environment to person and occupation.•Different professionals bring different tools and perspectives to the process.•Can be large or small, high tech or low tech.

williamsonhomepage.com

Who knows home mods best? The architect knows best, the therapist knows best, the contractor knows best, the funding source knows best, the salesperson knows best, Mom knows best, the client knows best….*

Reality – No one person in the home modification process knows “Best”– Different professionals bring something different and good to the table.The client is the only consistent person through the process, but they need to be able to figure out who to listen to.

Citation 8

Area of expertise, method of payment, method of working influence how a professional approaches home modifications and works with others.

What are the building professional’s focus and concerns?Citation 8

When people ask, “Why involve Occupational Therapists or other medical professionals

in Home Modifications?”

While it is possible and tempting for the non-professional to assess the modifications required to make a home both accessible and safe for the elderly and people who have disabilities, the use of a professional occupational therapist can be worth the additional effort and is sometimes paid for by Medicare for people who are aging and who have disabilities.

People Aging and those with disabilities are facing progression and modifications to accommodate needs today might not be sufficient for needs in the future. Being able to project how one’s needs will change is of critical importance if one hopes to make lifelong modifications in a single project.

An Occupational Therapist will analyze the dynamic relationship between people and

their occupations within environment or context of performance to develop interventions.

Solutions can involve Architectural changes, equipment, or behavioral changes or a combination of the three.

Citation 10

Home Modifications Multi step Process from AOTA Guidelines1. Comprehensive evaluation of person and environmental factors and daily

activities. Analysis of Occupational Performance/ Task Analysis.• Specific area of occupation in relationship to the context and

environment• Assessment of ability to perform regular occupations in that setting• Performance skills and performance patterns• Client factors and roles• Physical spaces and equipment in use

2. Develop intervention plan to resolve the incompatibilities between the person and environment.

3. Facilitate obtaining or installation of the modifications or equipment.4. Train in the use of the modifications.

Citation 10

https://media.salford.ac.uk/assoc_files/56081302.pdf Citation 4, 9

Step 2. Develop intervention plan to resolve the incompatibilities between the person and environment.

Types of Intervention• Prevent or reduce risk for occupational performance problems.

Examples: prevent falls, prevent functional decline, prevent caregiver stress.

• Modify activity demands. Examples: reducing environmental barriers • Create/Promote a healthy lifestyle. Examples: adherence to

medication, appropriate diet.• Maintain or increase performance by providing environmental.

support to facilities performance. Examples: Equipment to improve transfers.

Prioritize results from comparing demands of the occupation with unique abilities and then examine the environment for existing barriers and supports.

Incorporate • Type and ownership of home• Condition and layout• Needs of all residents• Costs and preferences• Upkeep/maintenance abilities and costs

Home Modifications Multi step Process from AOTA Guidelines

Citation 10

A, J

2. Develop intervention plan to resolve the incompatibilities between the person and environment. Types of intervention• Prevent or reduce risk for occupational performance problems. Examples:

prevent falls, prevent functional decline, prevent caregiver stress• Modify activity demands. Examples: reducing environmental barriers • Create/Promote a healthy lifestyle. Examples: adherence to medication,

appropriate diet• Maintain or increase performance by providing environmental support to

facilitate performance. Examples: Equipment to improve transfers


Forgiving Home Concepts :Create Zones:Danger Zones – off limitsRespite Zones – for CaregiverSafe Zones – for safe, independent movement and occupation

PREVENT

Image from http://www.gatekeepersafe.com/

Caregiver Friendly Transfer Equipment image from www.SureHands.com

Citation 10,11


Ramp

Vertical Platform Lift

O step entry

Low rise, deep tread steps

Step 2 Types of Intervention - Modify Activity Demands


Medication Management

Personal Emergency Response System Supporting nutrition

Step 2 Types of Intervention Create/Promote a healthy lifestyle

Home Modifications Multi step Process from AOTA GuidelinesTypes of Intervention Maintain or Increase Performance

Extend a Hand Grab BarToilevator

Toilet safety frame

Superpoleor other Floor to ceiling pole with bar

A, K

Citation 5

Step 2 Develop intervention plan to resolve the incompatibilities between the person and environment. Summary of OPTION TYPES

Home modification interventions can include architectural solutions, equipment both adaptive and off the shelf, and behavioral changes or a blend of all three. This often makes our Home Modification intervention different than that of other professions involved in Home Modification.


Citation 10

Home Modifications Multi step Process from AOTA GuidelinesStep 2 OPTION TYPES Doorway examples: architectural, adapted equipment,

behavioral change

Power door opener, remove door, widen door, barnstyle door, reverse door swing, swing clear hinges, threshold ramps or nosings, pull cords for door closure, learning new ways or using new rooms.

Step 3. During the intervention. Facilitate obtaining or installing the modifications or equipment.• Communication and collaboration with the team• Procure equipment or modifications : Trials, Community Resources,

Referrals• Monitor the construction to ensure intervention plan is implemented


BAD – grab bars

Step 4. Train in the use of the modifications Citation 10

Audits or checklists: • Can be conducted without the person and/or environment present• Based on generalities or general rules and do not take into consideration unique abilities/preference, habits, needs

•Home Modification Assessment:•Begins with client and client’s specific activities in the home•Identify specific incompatibilities affecting client engagement•Identify specific modifications that fit needs and preference of client and other occupants of the home.

• Consider the population/need the evaluation is focused on.

Specific Home Modification Evaluations

Citation 10

Types of assessments

Citation 10

Additional Home Modification AssessmentsName Purpose Description CostSafety Assessment Scale

Specific for dementia. Canada. Short Form – indicates a level of risk Long Form – in-depth evaluation and interventionPlanning. Short and long can be used to get a conversation started. AS the literature suggested even discussing and ansering the questions caused participants to start analyzing safety.

The short screeningversion takes 5 to 6 minutes to complete. Scores from the short form suggest:Individuals with a score of 12+ should be under close attention of health care professionals, A score of 15+ suggests the individual is at serious risk of injury .The long version (30 min) can be used in total or in sections depending on the risks tobe evaluated for a specific patient and the utilization time will vary

You can obtain a PDF of the French and English versionsof the scale at www.caot.ca

COPM Canadian occupational performance measure

COPM measures performance and satisfaction in self-care, productivity and leisure from the client’s perspective. Designed for use by occupational therapists, the measure serves to identify issues of personal importance to the client and to detect changes in a client’s self-perception of occupational performance over time.

Home for Life well suited for aging in place, fall reduction, caregiving . client-centered, occupation-based approach to home modifications http://www.homeforlifedesign.com

app for data input on site and data updated to centralized on line reporting structure. Has data base with options/descriptions.

subscription $250/year

Industry Checklist Designing home environment for people with problems with cognition who display aggressive or self injurious behavior

Paper checklisthttps://www.homemods.info/resources/hminfo-research-publications/consumer-factsheets/consumer-factsheet-designing-home-environments-for-people-who-experience-problems-with-cognition-and-who-display-aggressive-or-self-injurious-behaviour-

A look at more potential bathing solutions We make take starting with an assessment for granted. But most home modifications by non therapists do not always include assessment, but leap to potential solutions.

Home Modification Assessment:•Begins with client and client’s specific activities in the home•Identify specific incompatibilities affecting client engagement•Identify specific modifications that fit needs and preference of client and other occupants of the home.

This was a case in which equipment was provided without an assessment and the family could not understand why it didn’t work.

Sliding, pivoting , and arm rest features for bath seats and tub transfer benches.

Three piece slider systems

NuProdx one manufacturers of bath slider systems. Upright/tilt/tub/shower

Link: https://youtu.be/R5-oHvt-a3s

Bath lift for soaking or for showers with lower risk of falls.

Cutting away wall of the tub. Does not change plumbing requirements.

Plumbing requirements for tubs vs showers

Citation 12

Picture taken from outside the recessed tile shower being built. Centered drain. Note shower floor is recessed to accommodate shower pan and tile. It will end up level with tile bathroom floor at the shower entrance then slope to about ¼” per foot to the drain. A rubber water dam will be used.

Rubber water dam. Must be used in conjunction with a heavy curtain draped on the floor.

Construction for roll in showers

Accessories for showers

Rubber water dam. Must be used in conjunction with a heavy curtain draped on the floor.

INSERT hand held showers and places to put them.

Attractive showers and wet room

What else do you need to know to communicate with other team members involved with home modifications OR to function on an advanced level?

Therapists learn about the structure of the body and how the body works to be able to assess for problems and develop interventions.

It is possible to identify problems with person and environment without understanding the structure of a house and how it works.

A therapist can make better suggestions, communicate better with team members, and help educate and engage the client/patient if you understand the environment you are suggesting changes to.

Plumbing

Two subsystems impact Home Modifications:

1. Water supply: adequate pressure to deliver flow of the desired temperature.

2. DWV drain/waste/ventmoves waste liquid, solids, gases out of the house.

Citation 8,12

Three issues impact home modificationand technology:

1. Capacity2. Moving switches3. Code requirements for locations and clearance

Electrical

Citation 8

Three issues impact home modificationand technology:

1. Capacity2. Moving switches3. Code requirements for locations and clearance

Electrical

Citation 7,11

Issues that impact home modification

and technology:• 1. Working around them or

moving them when modifying other structures.

• 2. Adding capacity when increasing square footage

HVAC heating/ventilation/air conditioning

Citation 7,11

Issues that impact home modification

and technology:• Solid Lumber or

Engineered Lumber• Bears the load of the floor

or roof. • Direction and type of

material influence modifications

Structure-floor, wall, roof

Citation 8

Studs

Studs bear the weight of the roof down to the floor joists.Size, height, spacing regulated by building code: usually 2 x 4 or 2 x 6 and usually 16” or 24” OC but adjusted to accommodate doors, windows, or other walls

Studs are not wide enough to accommodate commercial grab bar flanges. Blocking or ANSI compliant fasteners.

Citation 7,11

Flooring

•Considerations are friction, durability, hygiene, and repairs when other modifications , especially around doorways are made. •Materials:❑Vinyl❑Tile,❑Wood,❑Carpet,❑Cork,❑Rubber

Consideration: Do you want to increase or decrease friction?

Citation 8

Communication with scaled drawings and floor plans

Citation 2

Are home modifications a covered service under Medicare? Who pays for the service? Can the patient pay

out of pocket? The short answer is, it’s complicated.

Review of AOTA guidelines for Medicare coverage.

Medicare-covered clients are entitled, under law, to medically necessary services. Occupational therapy practitioners do NOT have the right, under current statutes, to “opt out” of Medicare. Any occupational therapy practitioner, even those who are not Medicare providers, must directly bill

Medicare for any medically necessary skilled therapy services provided to Medicare-covered clients.

Whether or not to bill Medicare for home modification OT services must be based on the occupational therapy practitioner’s clinical determination of whether the services are medically

necessary.

The foundation of a profession’s scope of practice is inclusion in the educational curriculum, a history

of application in practice, and language in state licensure laws/regulations that defines a legally recognized scope of practice. Occupational therapy practitioners have a long established proficiency

in addressing the impact of the environment on occupational performance. As such, home modification recommendations and services fall well within the scope of occupational therapy and

are recognized in most state practice acts.

Citation 6

Scenario 1Occupational therapy receives a referral from a medical provider to evaluate a client at home who

has decreasing functional performance due to a recent acute illness. An occupational therapist completes a functional assessment, reviews the home environment, and makes recommendations

for environmental modification as part of the plan of care .

In this scenario, the occupational therapist is providing a service under a therapy plan of care . The home modification evaluation is part of the skilled therapy service being provided to the client. The home modification evaluation would be billed to Medicare using the most appropriate occupational

therapy evaluation CPT® code. Further, any additional treatment interventions carried out under the client’s plan of care would also

be viewed as medically necessary under Medicare and billed to CMS.

Where do home modification evaluations fall under Medicare coverage requirements? Let’s take a look at three case scenarios.

Reverse door swing to provide access to work surface – compensate for balance or weakness

Identify location that will work best for balance supports based on PEO. Specify products and why they are specified based on PEO. Info addressed in the medical record as well.

Citation 6

Scenario 1 continued

The home modification evaluation is part of the skilled therapy service being provided to the client.

Scenario 2An occupational therapist is asked by an older client to review and recommend modifications to their

home to support aging in place in anticipation of potential future needs . •No referral from a medical provider exists. • No current medical need. Example: Even though the client had a stroke a year ago, they are doing much better now and all rehabilitative intervention post-stroke has been completed. Example: Couple with no medical issues requiring treatment who want aging in place consultation. •The occupational therapist completes a functional assessment and determines the client has no current therapeutic needs. •They determine that a formal plan of care is not required, but they make multiple suggestions to the client to promote safety and facilitate ease of navigation within the environment as preventative measures.

This scenario is less black and white. In this instance, the occupational therapist meets with a client and performs a functional assessment. The process is similar to the process in scenario 1, except the therapist ultimately determines that the client does not need to be placed under a Medicare

plan of care, which requires setting goals for skilled occupational therapy interventions.

Instead, only home modification recommendations are needed. It could be grab bars or a ramp which in other circumstances could fall under an occupational therapy skilled service, but based on the therapist’s clinical determination that there is no need for skilled medically necessary therapy,

the evaluation is deemed to be non-covered by Medicare.

This scenario requires the patient to be issued an ABN in order to bill the patient for the OT evaluation services. A claim must then be filed to Medicare utilizing a GA modifier for denial.

Citation 6

In addition, services that may be considered skilled in some (but not all) circumstances still have to be billed to Medicare to protect the Medicare-eligible client.

This process requires several important steps. The client can be charged privately for these non-covered services, but only if an Advanced Beneficiary Notice of Non-Coverage (ABN) i s provided and signed by the

patient prior to the service being rendered, with the appropriate billing option selected.

The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. ….healthcare providers and suppliers must complete the ABN … in order to transfer potential financial liability to the beneficiary, and deliver the notice prior to providing the items

or services that are the subject of the notice.

Payment may be obtained up front, but must be refunded should Medicare pay any part of the service.

A claim must then be filed to Medicare utilizing a GA modifier to notify Medicare that an ABN has been obtained, if the beneficiary elects to bill Medicare.

Link to Instructions and forms for new ABN form required for use by January 2021 Link to CMS ABN forms and Instructions


Citation 1, 6

Citation 1


•Aging in place goals•No physician referral•No medical conditions requiring skilled treatment thought medical history and general health considered.•Time spent preparing literature/specifications•Education about health conditions•Education about products•Work with the contractor

Lower microwave placement. Work and prep surfaces

Planning space for mobility equipment.

Planning openings for mobility equipment. Discussion of door swing- not all suggestions taken.

Education/location of products. Induction stove top. Safety products.

Scenario 2 continuedBathroom remodel involving construction• Physician referral for evaluation and OT treatment plan which includes home modifications to increase ADL performance• Project specifications and scaled drawing that are within the therapist’s training and skills, part of home modification, but are not direct – point of service – hands on skilled treatment per Medicare definitions require ABN for private pay billing.

Scenario 2 continuedBathroom remodel involving construction- continued• Physician referral for evaluation and OT treatment plan which includes home modifications to increase ADL performance• Project specifications and scaled drawing that are within the therapist’s training and skills, part of home modification, but are not direct – point of service – hands on skilled treatment per Medicare definitions require ABN for private pay billing.• Ongoing direct, point of service – hands on skilled treatment for the underlying performance deficits or health conditions that require the modification can be billed to Medicare using appropriate CPT codes.

Whether or not to bill Medicare for home modification OT services must be based on the occupational therapy practitioner’s clinical determination of whether the services are medically necessary.

Citation 6

Scenario 3An occupational therapist is contracted by a third party such as a non profit organization, home builder, or

workman’s compensation company to make recommendations for a client’s home.

In this scenario, the occupational therapist’s client is the third party . In this instance the therapist is not directly in contact with the Medicare beneficiary, and the occupational therapist can receive payment from the

third party as a contractor.

Under this scenario Medicare does not have to be billed at all. This service is not covered or paid for by Medicare under any circumstance. A voluntary ABN may be issued to the client to make them aware of their

financial obligation; however, it is not required.

Example: Payer workman’s compensation carrier contracted with therapist for assessment, design, and design supervision. In addition to the injury requiring use of a power wheelchair, the individual was obese.

So assessment and task analysis included special attention to changes in reach, tissue distribution, size of equipment and changes to typical space requirements, weight capacity of adaptive equipment. Collaboration with a structural engineer was required to insure structural integrity of the floor structure and ceiling structure

for lift systems.

There is an increasing prevalence of bariatric clients in health settings. A good guide for considering home modifications is the Peninsula Health Care Network guide to Home modifications for bariatric clients .

Citation 6,7

Scenario 3

Accepted plan for construction had more features that decreased home value because most people would not need them. Additional cost for joist and flooring reinforcement.

Scenario 3

Lift system to reduce staffing to one for transfers and bed mobility. Still a difficult task for staff – limiting staffing availability. Extra cost forMotor with sufficient weight capacity and for structural support.

Traverse lift system allows multidirectional transfers for accurate bed positioning as well as transfer to wheelchair or shower chair. He had hx of pressure sores since injury.

Citations1. ABN Form Instructions. (n.d.). Retrieved from

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/ABN-Form-Instructions.pdf

2. Ainsworth, E., Jonge, D. D., & Baigent, K. (2011). An occupational therapist's guide to home modification practice. Thorofare, NJ: Slack.

3. Designing home environments for people who experience problems with cognition and who display aggressive or self- injurious behaviour. Ed. 2. (2019, December 10). Retrieved from https://www.homemods.info/resources/hminfo-research-publications/consumer-factsheets/consumer-factsheet-designing-home-environments-for-people-who-experience-problems-with-cognition-and-who-display-aggressive-or-self-injurious-behaviour-4. Home Modification Process Protocol. (n.d.). Retrieved from https://media.salford.ac.uk/assoc_files/56081302.pdf5. Laporte, D.M,, Chan. D., & Sveistruip. H (1999). Rising from sitting in elderly people, part 1: Implications of biomechanics and physiology. British Journal of Occupational Therapy, 62 (1). 6. Navigating Home Modifications Billing for Medicare-Covered Clients. (2020, January 17). Retrieved from https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/News/2020/Home-Modifications-Billing-Medicare.aspx7. Occupational Therapy evidence-based practice guidelines for the prescription of bariatric home modifications. (n.d.). Retrieved September 14, 2020, from https://www.homemods.info/resources/publications-by-others/ageing/occupational-therapy-evidence-based-practice-guidelines-for-the-prescription-of-bariatric-home-modificati on8. Phillips, B. (2020). Technology and environmental interventions for the home environment. In L. Gitlow & K. Flecky (Authors), Assistive technologies and environmental interventions in healthcare: An integrated approach . Hoboken, NJ: Wiley-Blackwell.9. Russell, R., Ormerod, M., & Newton, R. (2018). The Development of a Design and Construction Process Protocol to Support the Home Modification Process Delivered by Occupational Therapists. Journal of Aging Research, 2018, 1-13. doi:10.1155/2018/490437910. Siebert, C., Smallfield, S., & Stark, S. (2014). The AOTA Practice Guidelines Series Occupational THerapy Practice Guidelines for Home Modifications . Bethesda, MD: AOTA Press.11. Warner, M. L. (2000). The complete guide to Alzheimer's-proofing your home . West Lafayette, IN: Purdue

University Press.12. Wormer, A. (1998). The builder's book of bathrooms . Newtown: The Taunton Press.

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