Erin dos Santos, Melissa Stutzbach, Scott A. Trudeau, and Shivanti Kariyawasam
Home repairs and modifications to enable aging in place are most effective when occupational therapy practitioners play a central role on the home modification team. For more than 20 years, the American Occupational Therapy Association (AOTA) and the national home repair nonprofit Rebuilding Together have been active partners. Working together, we are seeking to advance home modification programming across the country that includes evidence-based practice strategies and services that integrate occupational therapy practitioners when possible. This partnership was revitalized over the last 18 months during the COVID-19 pandemic to strengthen occupational therapy’s role on the home modification team during these challenging times.
The Need for Home Modifications
Aging in place and the meaning of home has never been more important. Stay-at-home orders during the COVID-19 pandemic shed light on housing conditions that put health and safety at risk, especially to avoid unnecessary hospitalizations and skilled nursing facility admissions that can be prevented. Prevalent substandard housing conditions disproportionately affect communities of color, who risk displacement as it becomes too costly to remain in rapidly gentrifying neighborhoods (Jacobs, 2011).
According to the State of the Nation’s Housing Report for 2021 from the Joint Center for Housing Studies at f Harvard University, low-income households of color are at higher risk of eviction and foreclosure than the rest of the population, even though the economy is rebounding post-pandemic. Aging in place provides a means for families preserve financial resources, remain in beloved communities, and maintain health and wellness while promoting quality of life during stressful times.
However, remaining at home does have challenges. The current aging housing stock often comes with hidden maintenance costs and annual repairs. These can be very expensive, and if not addressed, homes can quickly fall into disrepair. In addition, most of the existing housing stock in the United States is not designed to accommodate the physical and cognitive changes that come with age. Most market-rate housing, including affordable housing, lacks basic accessibility features. Fewer than 4% of single-family homes have the three most critical accessibility features of universal design: zero-step entrances, extra-wide hallways, and single-floor living (Office of the Surgeon General, 2011). Many homeowners, especially older adults on fixed incomes, cannot afford home modifications and expensive repairs; therefore, they may learn to survive without them, with grave consequences to their health and safety (Aliberti & Covinsky, 2019). Despite these challenges, most older homeowners prefer to stay in their homes as long as possible (Binette & Vasold, 2018).
About Rebuilding Together
In 1973, a small group of neighbors in Midland, Texas, realized a growing need in their community when local homes had fallen into disrepair and their neighbors could not afford to fix them on their own. This set the wheels in motion to develop a nonprofit to address these unmet needs. Rebuilding Together has grown into a leading national nonprofit organization in home and community rehabilitation, preservation, and revitalization. Since 1988, Rebuilding Together has leveraged more than 4 million volunteers and $1.86 billion in cash and in-kind resources to repair and rehabilitate more than 200,000 homes, nonprofit facilities, and community spaces, improving the lives of an estimated 6 million low-income neighbors in need.
Safe and healthy housing is the foundation of Rebuilding Together’s home repair work, targeting significant safety and health hazards based on the Eight Principles of Healthy Homes (U.S. Department of Housing and Urban Development [HUD], n.d.):
- keep it dry,
- clean,
- pest-free,
- safe,
- contaminant-free,
- well-ventilated,
- maintained, and
- thermally controlled.
Rebuilding Together’s Safe at Home program empowers low-income older adult homeowners to remain in their homes and communities by removing and addressing in-home health and safety hazards and providing critical home modification services. The Safe at Home program provides free preventative home modifications to people with mobility issues and other disabilities to improve accessibility, reduce falls, increase independence, and facilitate aging in place by modifying their home environment to meet their specific needs.
In 2019, a program evaluation conducted by an external evaluator surveyed a sample of Rebuilding Together’s homeowners who received home repairs and home modification services such as a grab bar, wheelchair ramp, handrails, adaptive tub and toilet installations, lighting improvements, flooring replacement, and clearing away tripping hazards. Outcomes included the following:
- 45% of residents served had fallen or had a close call in the 6 months before repairs; after repairs were made, nearly 70% of all respondents felt they had a “low chance” or “no chance” of falling.
- 91% of residents with poor health felt they would be able to age in place after receiving services from affiliates, compared with 82% before.
- Repairs made it possible for nearly 100% of residents to have safe and accessible ingress to and egress from their home.
- 60% of residents felt more confident about coping with stress after the repairs (Actionable Insights, 2020).
Rebuilding Together volunteers improving bathroom function and safety.
Occupational Therapy’s Partnerships With Rebuilding Together
Since the inception of the Safe at Home program, and the launch of the Rebuilding Together and AOTA partnership in 2001, Rebuilding Together affiliate leaders are increasingly aware of the distinct value of occupational therapy practitioners on the home modification team. The partnership between occupational therapy practitioners, construction staff, and volunteers has proven to be beneficial for all parties and the communities being served. Using extensive construction expertise, Rebuilding Together affiliate leaders provide safe and healthy housing repairs and modifications such as fixing electrical hazards, addressing active water leaks and moisture problems, installing grab bars and wheelchair ramps, and improving ventilation. Occupational therapy practitioners often play an important role by providing home modification recommendations based on homeowner needs, functional status, interests, and goals. In addition to initial recommendations, occupational therapy practitioners often return after the home modifications are complete to provide consultation for proper fit, adaptive equipment training, and falls prevention strategies. Rebuilding Together has connected with occupational therapy practitioners primarily through service provision, academic partnerships, leadership roles, and program development opportunities.
Local Occupational Therapy Partnerships
Multiple models have successfully promoted partnerships for Rebuilding Together affiliates with occupational therapy practitioners, such as private practitioners who specialize in home modifications, as well as local health care systems that provide occupational therapy services. For instance, Rebuilding Together Kansas City works with occupational therapists employed by a local hospital who refer clients who need home modifications. The occupational therapists then conduct in-home assessments and provide recommendations. Rebuilding Together Kansas City completes the installation plus any safety repairs that need to be done. Rebuilding Together of the Triangle in North Carolina partners with Carol Siebert, OTD, OTR/L, FAOTA, of the Home Remedy, PLLC, who assists with project selection, home assessments, and the recommendation process. Siebert’s assistance has proven to be an invaluable resource to Rebuilding Together of the Triangle, and Siebert reflects that she has learned a lot about home repair and construction throughout the process.
Occupational therapy practitioners can also serve an important role in contributing to leadership with Rebuilding Together. Affiliate Boards of Directors often look for board members who come from a variety of professional backgrounds who can contribute to strategic planning, which often includes setting directions for home modification programming. Occupational therapy practitioners and students can also contribute to programming outside of the home visits, such as by hosting fall prevention training sessions for the community, assisting with program evaluation, training staff members and volunteers on client-centered approaches, and providing new strategies for community outreach. Most recently, occupational therapy practitioners are exploring staff member leadership roles, including starting new Rebuilding Together affiliates in communities that have a need for home modification providers.
Occupational Therapy Academic Programs
Occupational therapy academic programs provide a natural connection for Rebuilding Together partnerships. Students and faculty are in need of hands-on, direct experience in the community, and affiliates are in need of help with home assessments, home modification recommendations, and program improvements.
Rebuilding Together Philadelphia partners with Anna Y. Grasso, OTD, MS, OTR/L, CAPS, ECHM, Fieldwork Coordinator and Assistant Professor at Salus University, to involve occupational therapy fieldwork students as part of Level I and II fieldwork experiences. These students work with Grasso to complete home assessments, follow-up visits to deliver adaptive equipment, and client-centered education sessions. Further community outreach from this partnership has included providing community education classes for older adults who wish to age in place. Students learn valuable skills such as effective client interactions, including cultural humility, as well as how to perform a client-centered assessment to provide sustainable and impactful recommendations to support client safety, comfort, and independence. Similarly, Rebuilding Together Twin Cities has partnered with the occupational therapy program at St. Catherine University for 10 years to engage students with hands-on experiences. The students complete thorough assessments on the interaction between the homeowner, valued occupations, and their home, and they report their findings to Twin Cities with recommendations for home modifications. Twin Cities Executive Director Kathy Greiner says, “Our partnership with St. Kate’s has increased our funding and given more personalized services to homeowners.”
Inspired by these past successful partnerships and the need for fieldwork and capstone placements during COVID-19, Rebuilding Together’s national office is partnering with AOTA to match more academic programs with Rebuilding Together affiliates across the country. Rebuilding Together East Bay North indicated early interest in partnering with an occupational therapy program to enhance home modification programming. AOTA identified Samuel Merritt University’s doctorate and master’s program as a good fit, and Rebuilding Together connected the affiliate and academic program. Fieldwork coordinator Dr. Domenique Embrey says, “After a year of having to postpone fieldwork for students, it is so exciting to be working with Rebuilding Together. They have enthusiastically embraced our program and in every meeting have new ideas on ways we can help our students better meet the needs of our own community. This partnership is one of the silver linings of the COVID-19 pandemic.”
Expanding Opportunities for OT’s Role in Home Modifications
The importance of aging in place has gained momentum in both the public and private sectors on the tails of the COVID-19 pandemic; for example, President Biden mentioned “Aging in Place” and “occupational therapy” in a speech during his 2020 presidential campaign. Social determinants of health are increasingly recognized as critical drivers to health care costs, with substandard housing and housing insecurity consistently identified as critical issues. While Medicare and Medicaid funding for home modifications continues to evolve, in March 2021 the Department of Housing and Urban Development (HUD) announced that they would provide up to $30 million to nonprofit organizations, state and local governments, and public housing authorities that provide repairs and home modifications for low-income older adults through the Older Adults Home Modification Program (OAHMP). This program mandates that an occupational therapy practitioner must be involved in projects to ensure that the client receives the proper home modifications based on their individual goals to allow for full participation in their desired daily activities (HUD, 2021). This grant demonstrates significant federal government support for the role of an occupational therapy practitioner to oversee the home modification process, setting the stage for occupational therapy to align our profession as a bridge between health care and community programs. This funding recognizes occupational therapy practitioners’ distinct understanding of how home modifications can maximize an individual’s participation within their home environment and enhance their overall well-being, which may result in more partnerships between these organizations and occupational therapy practitioners in the future.
Historically, occupational therapy practitioners have consulted with Rebuilding Together on a volunteer basis because home modifications are provided free of charge and funding is limited. Although volunteer contributions are valued and essential to continue this work, it is not the most sustainable method for consultative services and does not compensate for the value of the occupational therapy role on the home modification team. In response, a small number of affiliates have secured status as Medicaid waiver–approved providers for environmental modifications, developed partnerships with health care systems that cover the cost of occupational therapy services, and navigated vendor referrals from managed care organizations. State regulatory compliance is often a stumbling block for this route of funding; however, grants provide new opportunities for reimbursement. AOTA and Rebuilding Together are working collaboratively to explore additional grant opportunities and equip Rebuilding Together affiliates with the tools to include occupational therapy in future grant proposals.
Call to Action
As a profession, we must continue to capitalize on opportunities to bridge the gap between the health care system, communities, and essential home repairs and modifications using our ability to integrate the impact of person and environmental factors on occupational performance and participation. The safer and healthier a community is, the fewer hospitalizations and skilled nursing facility admissions there will be, ultimately lightening the load on the medical system. We are being called to stand up and help make our communities more safe and more accessible. AOTA members have already had a big impact on clients who have received services through Rebuilding Together by enhancing programming for safe and healthy housing. You can join this group of people and make a true difference in your community. For more information, please visit The AOTA and Rebuilding Together Partnership.
References
Actionable Insights. (2020). Impact Measurement Pilot 2019 Report. Rebuilding Together.
Aliberti, M., & Covinsky, K. (2019). Home modifications to reduce disability in older adults with functional disability. JAMA Internal Medicine, 179, 211–212. doi:10.1001/jamainternmed.2018.6414
Binette, J., & Vasold, K. (2018, August). 2018 home and community preferences: A national survey of adults ages 18-plus. https://www.aarp.org/research/topics/community/info-2018/2018-home-community-preference.html
Jacobs, D. E. (2011). Environmental health disparities in housing. American Journal of Public Health, 101(Suppl 1), S115–S122. https://doi.org/10.2105/AJPH.2010.300058
Joint Center for Housing Studies of Harvard University. (2021.). The state of the nation’s housing 2021. https://www.jchs.harvard.edu/state-nations-housing-2021.
Office of the Surgeon General. (2011). “The Surgeon General’s call to action to promote healthy homes. http://www.ncbi.nlm.nih.gov/books/NBK44192/
U.S. Department of Housing and Urban Development. (n.d.). Healthy homes for healthy families https://www.hud.gov/program_offices/healthy_homes/healthyhomes
U. S. Department of Housing and Urban Development. (2021, March 11). HUD announces funding opportunities for older adult home modification programs (OAHMP) that showcase the role of occupational therapy. https://www.aota.org/Advocacy-Policy/Congressional-Affairs/Legislative-Issues-Update/2021/HUD-older-adult.aspx
Erin dos Santos, OTR/L, ECHM, is a University of Southern California doctoral student completing her residency at Rebuilding Together.
Melissa Stutzbach, OTR, ECHM, is Vice President of National Programs and Impact Measurement at Rebuilding Together.
Scott A. Trudeau, PhD, OTR/L, is a Practice Manager with the Workforce Capacity Building group at AOTA.
Shivanti Kariyawasam, MSG, is a third-year OTD student at Washington University in St. Louis completing her capstone at Rebuilding Together.
TBI Rehabilitation 