Occupational Therapy & Home Modification: 5 Domains to Consider

home modification

As the baby boomer generation ages and people live longer, home modification services are becoming more prevalent. Ramp-building events, tub-to-shower conversions, and grab-bar installation services continue to rise as more and more people choose to age in place.

Occupational therapy practitioners often ask about the best ways to break into the homebuilding industry or showcase home design skills among a strong, proven history in medical models of service. The answer lies in current evidence, the Occupational Therapy Practice Framework, and the profession’s practice theories.

OT’s Essential Role in Home Modification

Research shows that occupational therapy is essential to home modification best practice. Comprehensive home assessments performed by OTs have resulted in fall prevention,1 enhanced occupational performance,2 and decreased caregiver burden in the home.3 Understanding how to complete quality home assessments begins with recalling the foundational knowledge that an environment and all of its aspects has a direct impact on a client’s ability to function.

The American Occupational Therapy Association’s Occupational Therapy Practice Framework: Domain and Process-III (OTPF-III) provides a pathway to assessing critical domains that underlie occupational performance. These domains are:

  • Occupations
  • Performance patterns
  • Performance skills
  • Environment and context
  • Client factors4

Carefully and intentionally assessing each one of these areas provides occupational therapy practitioners with an effective foundation, resulting in the creation and implementation of healthy home environments.

The 5 Domains & Home Assessment

Let’s look at each domain more closely as it relates to home assessment practice.5

1. Occupations—What is meaningful and what is necessary for this client in their daily life that the environment needs to support? According to the OTPF-III, these needs include but are not limited to:

  • Activities of daily living such as bathing, dressing, and toileting
  • Instrumental activities of daily living such as home maintenance, caregiving, and care of pets
  • Work activities
  • Leisure activities
  • Education
  • Rest and sleep
  • Play and social participation

2. Performance Patterns—What are the client’s daily routines or habits that require reinforcement from the environment? These might include taking a shower every day, making dinner for the family, or placing a hand on the towel bar to enter the shower. What important life roles such as boss, caregiver, or parent need to be maintained and facilitated?

3. Performance Skills—How does the client move their body, maintain their balance, reach for an item, manipulate the kitchen faucet, or lift their lower extremities as they perform those identified meaningful and necessary occupations? Does the environment force them to perform the skill in an unsafe way? Assessing performance skills necessitates a performance-based analysis, and this can be a true measure when in the client’s actual home environment.

4. Environment and Context—The OTPF-III lists physical and non-physical aspects of an environment, and all contribute to the participation or lack of participation in daily activities: physical, social, temporal, cultural, and virtual.

What are the physical and social components in the home that disable or enable function? For example, physical components might include the five stairs that lead to the entryway or high cabinets in the bathroom while social components might include the presence of a caregiver or the absence of a spouse. What situations might support or inhibit occupational performance? As examples, these might include the person’s stage of disease or their access to technology.

5. Client Factors—What mental, sensory, muscle, movement, or cardiovascular functions need to be considered when designing the home environment? For instance, can a particular doorknob be utilized by someone who presents with decreased grip strength? Can the flooring in the home be supportive for a client who has a shuffled gait pattern?

From Theoretical Underpinnings to Therapeutic Outcomes

Theoretical underpinnings in occupational therapy reflect that engagement in meaningful activity leads to overall health and wellness. Identifying barriers and providing supports to activity engagement is a standard occupational therapy process, particularly in home-assessment practice. Here, a practitioner addresses each of the practice domains and looks to enhance or eliminate aspects of the home environment that support or disable function.

Home design to facilitate aging in place or functional independence requires the professional skills of occupational therapy. OT unveils the deeply complex person, uniquely shaped by client factors, values, routines, and motor and social skills, and consults with the builder to modify the environment and meet occupational needs.

Disability does not arise from disease, injury, or aging. Disability stems from inaccessible environments.

As the environment presents more and more barriers to function for a person, the person feels a greater incapacity to perform activities. In highlighting this critical knowledge of the person-environment fit, the occupational therapy practitioner shifts the difficulties associated with aging and disability onto the environment and suggests modifications and opportunities for re-design.

Once they are living in the new space, the client feels empowered and encouraged, able to live their life to the fullest and participate in meaningful activities.

  1. Chase, C. A., Mann, K., Wasek, S., & Arbesman, M. (2012). Systematic review of the effect of home modification and fall prevention programs on falls and the performance of community-dwelling older adults. American Journal of Occupational Therapy, 66: 284–291.
  2. Stark, S. (2004). Removing environmental barriers in the homes of older adults with disabilities improves occupational performance. OTJR: Occupation, Participation and Health, 24(1): 32­–40.
  3. Gitlin, L. N., Corcoran, M., Winter, L., Boyce, A., & Hauck, W. W. (2001). A randomized, controlled trial of a home environmental intervention: effect on efficacy and upset in caregivers and on daily function of persons with dementia. The Gerontologist, 41(1): 4–14.
  4. American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process, 3rd ed. American Journal of Occupational Therapy, 68 (Supplement 1): S1-S48.
  5. Siebert, C., Smallfield, S., & Stark, S. (2014). Occupational therapy practice guidelines for home modifications. Bethesda, MD: AOTA Press.