Anna is a 78-year-old widow who lives by herself. She was recently hospitalized for a right hip fracture as a result of a fall at home. During the hospital admission and the continuum of care, Anna’s injury is treated but little is done to address the physical home environment.
Anna’s injury, her age, and the fact that she lives alone doubles her risk of a repeat fall within 6 months. With a quality home assessment, we can alter this statistic and decrease Anna’s likelihood of suffering another fall.
Fall Prevention Begins at Home
An evidence-based approach to fall prevention includes the following:
- Medication evaluation
- Vision screening
- Exercise program changes
- Home modifications
Most medical models effectively address three out of four of these components through doctor, nurse and therapy interventions, but who in this model addresses home modifications? Despite the positive outcomes and patient benefits, most hospitals have done away with home visits prior to discharge.1
Many in the medical community may assume a home assessment is delivered through home healthcare. Unfortunately, the OASIS form used in home health to guide treatment and determine plans of care does not adequately facilitate a meaningful home modification intervention for the patient.
Specific home assessment tools are needed for clinicians to understand how a home environment can impact function and increase fall risk. For home health providers, researching the tools available can be the first step for making quality home assessment performance a standard practice.
Questions to Guide a Home Assessment
Ideally, Anna would be evaluated by an occupational and physical therapist in the hospital or acute care setting. During this time information about the home can be gathered and home modification resources can be provided based on findings. Initiating the home assessment process at the acute level of care can expedite a home modification plan that ensures a safe discharge home. Using Anna as an example, here are some sample questions that will help gather important data about Anna’s life in her home environment:
- What type of home do you live in? A split-level home
- Do you plan to stay there for the long term? Yes, I have lived there for over 30 years and my family lives down the street.
- Do you have steps to get into the home? Yes, one step to get in the house.
- Do you have stairs? Yes, to get to each level of the home I have a six to ten stairs.
- Where are your bedroom and bathroom located? On the third floor
- Where did the fall occur? In my bathroom
- What tasks were you performing at the time of the fall? I was stepping into my bathtub shower.
- Do you have any assistive devices like grab bars or seats in your bathroom? No
- Do you prefer taking a bath or standing in the shower? I love to soak in the tub, but it is too hard for me to get out, so I just stand in the shower.
- How did you call for help? I waited for my daughter to come to the house, she was coming over to have lunch with me and I fell around 9 that morning.
- How safe do you feel returning to taking a shower in your bathroom? Not very safe, I am afraid to fall again.
- Are there other activities that are difficult for you in the home? It is hard to get off of my toilet and I know that my hip precautions will make that more difficult.
During the process of asking these questions, it’s important for the therapist to keep in mind the meaning of home for Anna. Her personal attachment to that environment is likely linked to her hesitancy to make changes or admit that there is something wrong. Reminding Anna that it is the environment that is unhealthy and needs the modification helps to shift the problem of aging and disability off of the person and onto the home. Encourage her by sharing solutions and practices to make her environment safer. In this way, we can support her independence and continued engagement in meaningful activity in her home.
Using the Results
Presenting the evidence and statistics of the likelihood of a repeat fall is necessary and may help Anna move forward with the modifications. Making changes to the home will almost always cost less than long-term care placement. Cost-effective items like tub transfer benches, grab bars and stair glides can be presented as possible solutions. Never assume that the patient cannot afford or has the knowledge that these items exist. Education, reassurance and inclusion of the patient during important healthcare decisions are the role of the therapist.
This evaluation information is also important to share with the family. In this case, they may not know their mother’s intentions for remaining in her home, the struggles she has getting around, her hip precaution status, nor her fear of falling. Families will also appreciate the resources provided to make the home safer.
In home modification practice, our goal is to take them 99.9% of the way there, with assessment findings, suggestion solutions, and resources. As a trusted healthcare professional we can be confident that some, if not all, of the steps will be taken to avoid another negative consequence.
Resources to Aid Evaluations
One resource available is an online tool developed by Home for Life Design®. This personal home evaluation tool, allows users and healthcare providers to do a basic, easy home assessment and become familiar with home modification solutions. It is occupation-based and links to easy-to-install product solutions based on data input, that can be emailed to the patient or family.
Learning and gaining competence in fall prevention best practices and home modifications through education and research will help therapists feel confident in addressing the home environment in every area of practice.
- Harris, S. James, E. & Snow, P. (2008). Predischarge occupational therapy home assessment visits: Towards an evidence base. Australian Occupational Therapy Journal, 55, 85-95.