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Aging in Place: An Occupational Therapy and CAPS Perspective

Aging in Place: An Occupational Therapy and CAPS Perspective
Sara Story, EdD, OTD, OTR/L, BCG, CAPS
October 22, 2021

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Editor’s note: This text-based course is a transcript of the webinar, Aging in Place: An Occupational Therapy and CAPS Perspectivepresented by Sara Story, EdD, OTD, OTR/L, BCG, CAPS.

Learning Outcomes

  • After this course, participants will be able to identify the unique role of occupational therapy practitioners as it relates to Aging in Place.
  • After this course, participants will be able to identify the specialty certification, CAPS, and how it relates to AIP.
  • After this course, participants will be able to recognize assessments, evaluative measures, and interventions that can be used when taking an AIP approach.

Introduction

Today, we will be talking about all the factors that we should be doing for ourselves and our clients for prevention or for those in the early phases of dementia to potentially change their disease course. You may have seen several articles come across and perhaps wondered about some of the studies behind these findings. We will explore these. I am incredibly excited to talk to you about an area of practice that I love.

Key Terms

  • AIP: Aging in Place
  • CAPS: Certified Aging in Place Specialist
  • NAHB: National Association of Home Builders

Some key terms that I'll be utilizing today would be the abbreviations of AIP, CAPS, and NAHB. AIP stands for Aging in Place, CAPS stands for Certified Aging in Place Specialist, and NAHB stands for the National Association of Home Builders.

Aging In Place (AIP): Defined

  • Defined by the CDC (2009) as “the ability to live in one’s own home and community safely, independently, and comfortably, regardless of age, income, or ability level” (para. 7).
  • Cole & Macdonald (2015) describe aging in place as “the most cost-effective way to meet the needs of the aging population…provide supportive services that enable them to remain in their communities, living in their own homes, for as long as possible” (pg. 52). 

Depending on your practice, you may be familiar with the term aging in place. For those unfamiliar with the term, I will define it for you from a couple of different sources. First, the CDC in 2009 defined aging in place as the ability to live in one's own home and community safely, independently, and comfortably, regardless of age, income, or ability level.

Additionally, Cole & MacDonald, which produce a textbook that is often used in occupational therapy higher education, described aging in place as "The most cost-effective way to meet the needs of the aging population and provide support services that enable them to remain in their home, their communities, living in their own homes for as long as possible." Occupational therapy practitioners understand why aging in place may be of the utmost importance to those working with aging clients.

Overview of AIP

  • Empowering
    • Continue contributions to one’s community
  • Enabling
    • Facilitating one’s level of independence
  • Estate Building
    • One may own their home and maintain for safety and leaving a legacy 

When I put this together, I wanted you to understand my perspective as a certified aging-in-place specialist and someone who has predominantly worked with a productive aging population in the field of occupational therapy. I see the overview of AIP being three things. Empowering, enabling, and even estate building. I will elaborate on that in a second.

Empowering

As occupational therapists, we can empower clients with the choice to live in their preferred residence. In school, many of us learned the PEO model or the person-environment-occupation model. Looking at that frame of reference, empowering may fall under the "E" for the environment. The environment can be the area of residence, any home modifications to the environment, or the community. We certainly want our clients to contribute to the larger community.

Enabling

Enabling can mean facilitating independence for the client. Going back to the PEO model, this could stand for the P and the O, meaning the person and the occupation of that model. A significant focus in this area of enabling is fostering the management of one's finances, specific ADLs, preventative healthcare and medical care, leisure, and spiritual aspects, along with focusing on one's self-worth. Self-worth is reinforced for one who owns their own home.

Estate Building

The concept of estate building is crucial. I work with one of the AIP programs in Kentucky. Clients that we are serving have friends and family in the larger community. They can leave or contribute to a legacy as they define it. One example could be in the west end of our city. Many individuals desire to age in place. They may have purchased their home, and as they have aged, they can no longer stay safely in that environment. However, the house has equity and a wealth-building opportunity for that individual and their family. Additionally, it is also tied to their self-worth and how they see themselves in their community.

The individual may own their own home, but if repairs or adaptations are needed, that may impact their home and independence. An OT with a Certified Aging in Place (CAPS) credential may facilitate an assessment for home preservation.

CAPS

  • Certified Aging in Place Specialist (CAPS): specialty credentialing
  • Created and supported by the National Association of Home Builders (NAHB)
  • Structured Curriculum
    • CAPS I – Marketing & Communicating
    • CAPS II – Design Concepts
    • CAPS III - Solutions

I am a Certified Aging in Place Specialist and want to provide you with a brief overview of my experience. I am simply sharing my knowledge and not necessarily endorsing the training or the credentialing process. However, I want occupational therapy practitioners to be informed of what options there are in the greater community. It is a way to advance your skillset if you desire.

The Certified Aging in Place Specialist was created and supported as a program and credentialing from NAHB, the National Association of Home Builders. There is a structured curriculum with three courses. CAPS I relates to marketing and communication. This is one thing that occupational therapy practitioners do well. We communicate with our clients and have complex in-depth conversations. But, how do we market our skillset and new knowledge? This is what this course entails. CAPS II relates to design concepts. Today, we will go a little deeper into those concepts. Lastly, CAPS III focuses on solutions. This was my most favorite class to take in the certification process. I felt that my experience as an occupational therapist working in the aging population was where I could shine. I knew many solutions because of the clinical experiences I had had over the years. Pulling it together with the CAPS and the AIP focus allows me to serve my clients better.

CAPS Courses

  • Sequential Order
  • Course Offerings across the U.S.
  • Variety of formats
  • Virtual
  • In-Person
  • Blended
  • Locating a course

CAPS courses are offered in sequential order. Much like other training, you need to have your foundation first and then build upon that. The courses are offered across the US. Before COVID, it was mainly in-person offerings, but now it is very different. There are a variety of formats, with some virtually, some in person, and then some CAPS training has a blended option. You can locate the courses and see what may be available close to you. After going through the CAPS process, you can take the classes to pass the certification exams successfully. 

Education Beyond CAPS

  • Post-certification
    • CE requirements
    • Annual renewal
  • Post-certification literature of interest
    • Universal Design and Aging
    • Power of Discovery
    • Common Sense Universal Design
    • Universal Design for Safety
  • Presentations and Publications

After CAPS, what do you do? You have taken the courses, acquired the knowledge, and now you are ready to take that knowledge and blend it with your skillset as an occupational therapy practitioner. My experience was very rich in knowledge building and developing a new foundation for an area of practice that I truly love. As with OT, we have continuing education requirements. To maintain the credentialing of CAPS, there are annual CE and renewal requirements. 

Post-certification literature is where I found my passion for aging in place, home assessments, and modifications. I was able to go beyond a CAPS certification, meaning I could collaborate with CAPS professionals. I found value in continuing my education in the CAPS realm through courses, webinars, and literature reviews. Many opportunities are out there, and others can present themselves in a larger resource pool, such as courses you are taking today on OccupationalTherapy.com, or it could be attending a district, state, or national conference. I have yet to have the privilege to participate in an NAHB national conference, but I have heard that those are wonderful for networking. There are many areas to learn about, including the books "Universal Design and Aging," "The Power of Discovery," "Common Sense Universal Design," and then "Universal Design for Safety." Those are four books that I have found over the years that provide a very rich amount of literature and knowledge to me as an occupational therapist. It has been enjoyable to advance my understanding of aging in place and CAPS alongside home design and modification. The instructor was terrific and had the opportunity to work alongside many occupational therapists. This specialty certification is another way to advocate for the field of OT, which I thought was wonderful.

Many presentations and publications focusing on aging in place, home modifications, and home assessments, have come out recently. There are a few systematic reviews about the concept of aging in place within the field of OT and some outside the field of OT. These reviews can provide a larger scope of the challenges potential clients may face. Every day, I read something new and discover a new approach. I had the opportunity to advise and advance the understanding and knowledge of the field in my local community and through the mentorship of entry-level doctoral capstone students and their experiences. 

Now that you have heard a little bit of my experience and background with CAPS, I hope it helps you understand how an OT practitioner can see the value of pursuing additional training in this area.

OT and Home Assessments

  • Home Safety and Modification
    • Accessible Design
    • Universal Design
      • 7 Principles
  • Level of Care
    • Rehab to Home
      • Assessments
    • Specialist
      • Assessments and Apps

Do you remember your onboarding to the assessment process? Did you have formal training? I remember my first home assessment in the clinic. If I had not referred back to the PEO frame or the OTPF, the Occupational Therapy Practice Framework, I am not sure I would have survived that first home experience.

Home assessments can be overwhelming, but most of the time, they can genuinely be rewarding and show the value of our knowledge base and unique skillset. Where do you start? Often, this was a question I would ask myself before the completion of my CAPS training. CAPS courses reinforced the concepts that I learned in OT school and gave me a broader knowledge of ADA accessibility. In the next couple of slides, I hope to provide you with a brief definition and an overview of accessible design, including the seven principles.

When do many of us complete a home assessment? So my experience lends exposure to two areas of practice. We see patients going home after a skilled stay and desire to return home or with an independent contractor for assessments related to aging in place. We can work with an independent contractor to assess barriers or even help to design homes from the blueprint stages with the contractors and the draftsman.

Over time, this is where I found the OT knowledge base to be very critical. Contractors and draftsmen may not always provide true AIP recommendations and design. I have had this experience. They may not truly understand or grasp the concepts from a CAPS perspective. This is where I find occupational therapy practitioners to be vital. We can advocate and educate.

Some home design apps may provide additional insight for client-specific approaches rather than addressing universal design principles within AIP.                                                                                                                                                                                                                                                                                                                                                                                

Home Safety Assessments

  • Home Assessment Profile (HAP)
  • Home Environmental Assessment Protocol (HEAP)
  • Home Safety Self Assessment Tools v.3 (HSSAT)
  • In-Home Occupational Performance Evaluation  (I-HOPE)
  • Safety Assessment of Function and the Environment for Rehabilitation Health Outcome Measurement and Evaluation (SAFER-HOME)

The home safety assessments that I mentioned previously are how we, as OT practitioners, may assess someone's living space. It could be when someone is discharged from a skilled area, and it is a consultative model where you are an independent contractor. Either way, we are looking at assessing one's living space.

What assessment do you use? Does your facility have their home safety assessment that they ask you to complete? Or, are you just getting into this area of practice and need a repository of evaluations to reference as you move forward? I hope to provide you with an overview of a few assessments that are out there. Some of these are screening tools that may be helpful to you as you develop and cultivate this interest in aging in place and home assessments.

This is not an exhaustive list, but it is a few of them that are available. Additional assessments and literature can be found under the productive aging umbrella, in AOTA's resources for home modifications, or other areas out there such as NAHB.

Home Assessment Profile (HAP)

The Home Assessment Profile is abbreviated as HAP and was published in 2001 by Chandler et al. It is a quantitative home assessment that focuses on functional performance and safety. It includes risk factors for falls and a wonderful subsection that specifically addresses the client's home environment.

To conduct this assessment, you need the score sheet and a writing utensil. It is pretty straightforward. Procedurally, you observe the client's mobility, and then you have the client participate or simulate a typical performance of activities. It measures hazards, and the score is based on the interaction between the person and the environment. One reason I favor this one is based on my interest in the PEO frame of reference.

Home Environmental Assessment Protocol (HEAP)

The next one is the HEAP which stands for Home Environmental Assessment Protocol. The HEAP was published in 2002 by Gitlin et al. and was in the Disability and Rehabilitation Journal. It is an objective assessment of the home environment with a focus on dementia. There is a revised HEAP version that was discussed in OTJR in 2020. The primary focus of this tool is 190 plus items in eight areas with the ability to collect data in three ways: the caregiver interview, direct observation, and then direct observation with caregiver clarification. It is very client-centered, and it gives you a good perspective of what may be going on with the individual.

Home Safety Self Assessment Tools v.3 (HSSAT)

The next one is the Home Safety Self Assessment Tool, the third version, the HSSAT. It was initially published in 2011, and it was presented in 2012 by Dr. Tomita at a conference for geriatric practitioners. The primary focus is to identify and correct fall hazards in the home. It takes 20 to 30-minutes to complete a checklist in the home. It is very quick and easy to administer. There is a fifth version produced in 2017 to keep up with the times.

In-Home Occupational Performance Evaluation (I-HOPE)

The next one is the In-Home Occupational Performance Evaluation, also known as the I-HOPE. The I-Hope was initially published in 2010 by Stark et al. This is an excellent assessment to use with someone going from an inpatient stay to back home. It includes a performance-based observation and a card-sorting task to assist the examiner in understanding the fit between the client and their home environment. The purpose is genuinely to measure improvements and activity performance pre and post-home modification.

Safety Assessment of Function and the Environment for Rehabilitation Health Outcome Measurement and Evaluation (SAFER-HOME)

The last home safety assessment I want to bring your attention to is the Safety Assessment of Function and the Environment for Rehabilitation Health Outcome Measurement and Evaluation. We refer to it as SAFER-HOME, which makes a lot of sense. The third version was produced in 2006 by Chui et al. It is an interview and observation tool to assess the client's ability in functional activities. It can be used as an outcome measure to evaluate intervention effectiveness.

Some of these tools are open access, while others may have a minimal fee. These may be an excellent starting point for you.

Accessible Design

  • An approach used in homes to make operation, access, or manipulation easier for all
  • Features: determined by the individual need and a fixed in place, permanently

Let's now talk about accessible design, an approach using homes to make operation, access, or manipulation easier for all. The individual's need determines its features. What does the individual truly need? The typical approach is fixed design or a fixed solution, or as many refer to as permanent. Often, the term accessible design may be viewed with a different connotation than what we mean when talking to the client, so there may be a discrepancy. I have experienced this with some clients who look at the word "accessible" through a medical lens or negatively. I think that education and advocacy are crucial to helping individuals understand the difference.

As OTs, we want to educate that accessible can take on one or a blend of three angles: adaptable design, transgenerational design, and universal design. Let me give you an example. When looking at a pull-down sprayer faucet or an adjustable stovetop, these are considered accessible designs that demonstrate adaptable and universal design principles. Who doesn't love a pull-down sprayer faucet? I think many times people think the word accessible is very medical, instead of being what many can purchase and install.

Adaptable design is an accessible design feature used for an individual with a specific disability or deficit in mind. It is not saying they have to use it, but that is the focus and what this person could benefit from in their environment.

Transgenerational is a way to see design principles from an AIP viewpoint, like flush shower entrances or a shower with built-in seating. Kids and adults of all ages and abilities could benefit from a flush transition into the shower and a built-in seat. The other thing is bathing and showering across the lifespan. Grab bars, for example, can be beneficial for kids to aging adults.

Lastly, universal design is the last subset of the accessible design umbrella. Let's look at what universal design represents as we focus on aging in place from an OT perspective.

Universal Design

  • Ron Mace “Father of Universal Design”
    • 7 Principles (Mace, 1997) –
      • Equitable Use
      • Flexible in Use
      • Simple and Intuitive Use
      • Perceptible Information
      • Tolerance for Error
      • Low Physical Effort
      • Size and Space for Approach and Use

Deardorff defined universal design in 2003 as the design of products and environments that can be used and experienced by people of all ages and abilities to the greatest extent possible without adaptation. A universal design considers every age, every ability, every function, and every use. It is truly the epitome of inclusive design.

The design process is when we incorporate inclusive approaches in the development phases and not focus on adaptation later. Smart homes are perfect for those that want to age in place and are a fantastic example of universal design, including age, ability, function, and inclusivity. New things are being developed every day.

Ron Mace generated the concept of universal design in 1997, and he is known as the father of universal design. He is still referenced at the Center for Universal Design in Raleigh, North Carolina. Universal design can be looked at as a guide to the design process and evaluate and assess current and or new designs.

There are seven principles that we use. I am going to go in-depth to give you at least one example for each principle. 

Equitable Use

  • Useful to people with diverse abilities
  • Example: Sidelight or long windows provides an opportunity for all to look outside.

It is useful to people with diverse abilities. Figure 1 is an example of this principle.

Figure 1

Figure 1. A tall window that extends to the floor for a better view of the outside.

The floor to window seal height is very minimal, and the long elongated window allows anyone of any ability to look outside. I also like to say it is marketable. When designing in the drafting stages as a CAPS occupational therapist, I try to emphasize ability and resale ability later. Think about what will work best for everyone now and what may work down the road for someone else.

Flexibility in Use

  • Accommodates a wide range of preferences and abilities
  • Large and lower height island for individuals who have difficulty with mobility, young children, preference to stand or sit regardless of the seating system

The following design principle is flexibility in use. Flexibility in use accommodates a wide range of tastes and abilities. For instance, lower or higher height islands for individuals may help those with difficulty with mobility, young children, or those with a preference to sit or stand regardless of the seating system (Figure 2).

Figure 2

Figure 2. Lower height kitchen island.

Islands can be very functional if the space is set up accordingly. Remember, some of these principles start in the drafting stages when the house has yet to be built. This flexibility and use example can be viewed as a blend of AIP techniques with ADA regulations in mind. If you know anything about ADA regulations, the ADA recommends a maximum height of 36 inches for all accessible counters with clear floor space in front and to the side. The example shown in Figure 2 follows that principle. Someone who wishes to stand can do so as the island is tall enough for them to use. For someone who wishes to sit on a stool or a chair, it is the right height. Additionally, someone using a wheelchair would have the ability to roll up underneath the island overhang and have the correct height.

Simple and Intuitive Use

Simple and intuitive use means that something is easy to understand by eliminating unnecessary complexity (Figure 3).

Figure 3

Figure 3. One handle faucet.

It is intuitive that when you move the lever, it will turn the water on.

Perceptible Information

Perceptible information communicates necessary information effectively to the user. In Figure 4, there is a redundant presentation of essential information and provides adequate contrast between essential information and its surroundings (Figure 4).

Figure 4

Figure 4. White light switch and plug on a contrasting gray wall and a lever door handle.

There are three examples in this picture: the lever door handle, the panel switch light, and the outlet. The switch and plug contrast with the gray walls, and the dark door handle contrasts with the white door. The doors are the same throughout the home. 

Tolerance for Error

  • Design minimizes hazards and consequences of accidental or unintended actions
  • Provides fail-safe features and discourages unconscious action in tasks

Tolerance for error means the design minimizes hazards and consequences of accidental or unintended actions. One example is a slow closing drawer or cabinet.

Figure 5

Figure 5. Slow closing kitchen drawer.

It can prevent or decrease the likelihood of slamming injuries, and it is a fail-safe feature. 

Low Physical Effort

  • Can be used with a minimum of fatigue
  • Used efficiently and comfortably

For the principle of low physical effort, we can look at the same picture. Universal design can meet multiple principles (Figure 6). 

Figure 6

Figure 6. Lever light switch and door handle.

Low physical effort means minimal fatigue. The switch and lever door handles are efficient and comfortable, and these are throughout the home.

Size and Space for Approach and Use

  • Appropriate regardless of user’s size, posture, or mobility
  • A clear line of sight with  reach to all  components and adequate space for device or assistance

This principle is defined as appropriate regardless of user size, posture, or mobility. In Figure 7, you see an open floor plan.

 

Figure 7

Figure 7. Home with an open floor plan.

It has wider doorways, hallways, and a clear line of sight of all components, and adequate space for devices or assistance of any kind. This open floor plan represents the design that I worked with a draftsman to create. Generationally, what works for the young will also work for the aged. All doorways are a minimum of 36 inches, and we also utilized pocket doors for accessibility. For instance, there is a large walkway on the right that leads to the master bedroom. And, the master bedroom and bathroom had a door debacle when we were in the drafting stage, and I had to advocate for what I thought would work best without changing the aesthetic purpose of the home. There were many doors and tight turnaround space. Instead, I suggested a 36-inch door as the main door that would swing out to allow the individual to wheel into the bathroom easily. They could also consider a pocket door for someone to open and close with ease. 

Levels of Care

  • Assessments
    • OT Assessments
      • Client Factors- Tinetti, Falls Efficacy Scale, COPM, etc.
    • Facility specific forms/assessments
  • Apps
    • Independent contractors
    • Specialists

As I previously referenced, occupational therapy practitioners should look at occupational therapy assessments. Many that we use or have will give us a greater understanding of the client's abilities and approaches to potential barriers. I have listed some that lend themselves to client factors like the Tinetti, the Fall Efficacy Scale, COPM, etc. Know what resources are out there and supported by the profession. Research and evidence reinforce the why behind what we use and what we do. If you are working in an inpatient facility or for a specific company, their forms, and assessments, as they relate to aging in place and home assessment, may be helpful. Additional resources and knowledge allow us to reinforce our value.

Another item beyond assessments would be apps. Many of us are accustomed to that old pen and paper home assessment approach. However, over the last decade, digital advancements have been a boost to completing home assessments. There are measurement, level, design, and home assessment apps. We have a wealth of information at our fingertips.

There are independent contractors from the field of occupational therapy that are flourishing with home assessment businesses. Often, they decided to make their business model due to the lack of resources they had when they were working in facilities. If you help in this area beyond your current knowledge, seek out a specialist. Find out who is in your area and refer. Perhaps this presentation contributed to your investment into the realm of aging in place, specifically CAPS or home modification, and you are considering advancing your skillset. If not, OT is a unique profession with talented practitioners ready and willing to help clients maximize their independence and meet their goals.

Case Study- Beth

  • Beth
    • Aging parents, agreeable to move in before necessary
    • Design plans with AIP focus
    • Following the 7 principles of Universal Design
    • Gathering data to know contextual factors of aging parents
    • Goal- maximize (I) with private MIL suite/apartment, AIP focus, accessibility features with style

The case example is Beth, who has aging parents and a growing family. She wanted the design to be relevant 10-15 years in the future. Beth said, "My parents are aging. They're agreeable to moving in before it's deemed necessary. What do I do?" We drafted some design plans with an aging-in-place focus using my CAPS and occupational therapy knowledge. I followed the seven universal design principles and explained to Beth how she could still have an aesthetically pleasing house to serve all of her needs.

We gathered data, primarily contextual factors of her aging parents. I explained my role and hoped to help them become a multi-generational blended family, where everyone had their own space. The goal was to maximize independence with a private "mother-in-law suite" or apartment with stylish accessibility features throughout as Beth's parents were lovers of HGTV and design shows.

  • Design fully accessible bathroom
    • Roll-in, doorless shower
    • Grab bars in client-specific areas
    • A taller toilet, with space to modify with DME if needed
  • Eat-in kitchen
  • Open floorplan
  • Accessible, wide doorways

They decided to build so they could draft and build their aging in place home. I provided them with educational resources to understand what life might be like down the road. I also discussed how using universal design principles would save them in the long run for needing remodeling in the future.

Bathrooms are where many individuals need to remodel as they age. So, we designed a fully accessible bathroom. At first, they were concerned that is would like an accessible bathroom you see in a hotel. We worked with the draftsman and contractor to develop a beautiful bath that was accessible. We installed a roll-in shower without a door that was very sleek and stylish and could accommodate shower adaptive equipment if needed down the road. We also had grab bars in the client-specific areas by having the clients do a "dry run" where they might walk or need to hold on. Identifying these areas from the ground up with the contractor allowed him to install studs in the areas requiring the grab bars.

The parents also advocated for a taller toilet. We made sure that there was plenty of room around the toilet to accommodate a wheelchair later if needed. Typically, only 18 inches is allotted between the toilet and the tub/shower, and we were trying to get away from that.

We also advocated and designed an eat-in kitchen incorporating the open floor plan and proper counter height. We also included wider doorways and archways throughout the home. 

Modifications to Promote AIP

  • As the occupational therapy practitioner, am I responsible for completing the modifications?
    • No! The OT is responsible for educating the client/caregiver.
  • Provide the client options for resources as it relates to the recommended modifications.
    • Options may include:
      • The client, caregiver, or friend may complete the modifications
      • Community Partners & Agencies may offer programs to assist
      • Remodeling Hobbyist/Handyperson
      • Contractor

Let's talk about modifications to promote aging in place. The OT is not responsible for making modifications. You are responsible for educating the clients and caregivers about the options and resources. I was part of the design process in the case study as I worked closely with the contractor. Some of the options may include having resources and delivering those with community partners or agencies that may offer programs to assist. In my town, we have an aging-in-place program funded by a nonprofit agency that receives grant funding. We focus on individuals that may not have the financial means to make all the repairs themselves. Find out if there are resources available in your area that has expertise in remodeling to help your clients should the need arise.

It is also essential to know the contractors in your area with an AIP focus. You may find someone with a wealth of experience and knowledge, whether from a design or a remodeling lens. Another thing that is not on the slide is finding realtors that have an AIP focus. They may have an additional resource pool for you to use.

AIP Programs and Research

  • Liu et al. (2021) Single-blind, two-arm RCT
    • CAPABLE: Community Aging in Place-Advancing Better Living for Elders
  • Nielsen et al. (2018) RCT
    • The client-centered program included home adaptations/modifications to promote AIP.
  • Stark et al. (2017)
    • SR focused on home modification interventions and the overall effectiveness of OTs in this area of practice.
  • Stark et al. (2018)
    • Practitioners were identified as effective, and interventions could be low cost.

I have listed some great articles that might jump your knowledge in this area. The first is a single-blind two-arm randomized control trial looking at the capable program. This article came out and was published in 2021. It discusses community aging in place and advancing better living for elders.

A study by Nielsen et al. (2018) was a randomized control trial that discusses a client-centered program including home adaptations and modifications to promote aging in place. This study emphasized how we as occupational therapists can view the AIP movement and truly help use our OT knowledge. Additionally, some individuals may have CAPS knowledge to promote aging in place for the home the person may already own.

There are two articles listed here by Stark et al., and both are amazing. One is a systematic review full of information and interventions to help you understand the overall effectiveness of occupational therapists in this practice area. In 2018, this study identified the OTs are effective and can provide aging-in-place recommendations at a low cost. 

Resources

Here are a few resources. The first one is from the NIA, the National Institute of Aging, which is affiliated with the National Institute of Health. The next one is the National Resource Center on Supportive Housing and Home Modifications. It is important to use this resource to see what is available in your state. Lastly, I have listed the CAPABLE resource from John Hopkins.

Questions and Answers

How would a COTA tap into this industry? Do we have to partner with an OT?

That's a great question. COTAs are able to get into this realm. A local company in my town employs two OTs and one COTA. They all have their CAPS certification. 

How is AIP and CAPS service reimbursed? And, who was the payer in your case study?

With the CAPS and AIP, it can be a very different payment arrangement. When working in a skilled nursing facility, I use my knowledge to complete a home assessment before discharge. It is just a benefit that I provide. When I am working independently, it is a fee for service, and I set my rate. It could also be consultative where I sit down as the CAPS professional in the drafting portion of home design. I have a case next Monday that a colleague has asked me to do. It is a complete home assessment and write-up for remodeling with an AIP focus. This will be a fee-for-service arrangement.

Is how do you find jobs using the skillset?

I think it depends on if you're looking at being a private contractor in the sense of what I was just referencing. You can use social media to put yourself out there. In my instance, I connected with a realtor friend and general contractors that I know from other experiences. I told them about my geriatric-focused background and my new venture if they wanted to send me referrals. 

What's the process and cost of obtaining CAPS?

I put in the reference to NAHB for you to search that out if you choose because I cannot speak to the cost now. I have had this certification for many years. 

Is it necessary to maintain an OT license if CAPS is certified?

I uphold my CAPS license because, as I referenced, I have two avenues of how I get my referrals. One is from the skilled nursing facility that sometimes they will call me to do PRN or home assessments because of my background, and the other is an independent contractor. I am not sure if it is mandated, but I think your referral source may recommend it.

Are most of the work done as a consultation?

I have gone through the consultative piece, but I have also gone in and done home assessments as I referenced. I have an excellent home assessment app that I found years ago that an OT created. I use it for my pre-assessment, and then I go back after the remodel for a post-assessment. It uses an OT lens to assess the environment and the client's performance rather than just consultative, but it could be both.

May we ask what your fee for service rate is or what the average rates are?

The rates are based on where you live and the demographics. I use a fee-for-service model, but I do pro bono because I work in an academic setting. I have a scholarship and a line of service based on the unique nature of the requirements set forth by my employer. However, I have known other individuals that charge anywhere from $100 to $500 per consultative assessment visit. 

Do insurances ever cover services?

I am not aware of insurances covering this service. Most of the clients that seek out this opportunity are willing to pay a fee for service. 

Have you had to go back into homes you have already modified to make changes?

I have clients who have had significant changes related to function call and ask if they can still use something. It is more of a check-in-type service versus a reassessment. I try to set people up with things that will serve them over time.

How do you get to be a consultant for SNFs for home assessments?

I am on their per diem list, and they know it is one of my specialties.

What are some examples of apps to use?

I use the Home for Life Design app, which I found years ago, that I referenced a few minutes ago. Other apps that I have used help with a basic design to give clients a visual of what you are recommending.

Some long-term care policies do provide funds for limited home modifications. They provide a set amount for the policyholder, but the amount is limited.

Thanks for sharing that information.

References

Center for Disease Control and Prevention. (2009). Healthy places terminology. Retrieved from https://www.cdc.gov/healthyplaces/terminology.htm

Cole, M. & Macdonald, K. (2015). Productive aging: An occupational perspective. Thorofare, NJ: SLACK INC

Deardorff, C. J., & Birdsong, C. (2003). Universal design: Clarifying a common vocabulary. Housing and Society, 30(2), 119-138.

Liu, M., Xue, Q., Gitlin, L. N., Wolff, J. L., Guralnik, J., Leff, B., & Szanton, S. L. (2021). Disability prevention program improves life‐space and falls efficacy: A randomized controlled trial. Journal of the American Geriatrics Society, 69(1), 85-90.

Mace, R. (1997). What is universal design? The Center for Universal Design at North Carolina State University, 19, p. 2004.

Nielsen, T. L., Andersen, N. T., Petersen, K. S., Polatajko, H., & Nielsen, C. V. (2018). Intensive client-centered occupational therapy in the home improves older adults’ occupational performance. Results from a Danish randomized controlled trial. Scandinavian Journal of Occupational Therapy, 26(5), 325-342.

Stark, S., Keglovits, M., Arbesman, M., & Lieberman, D. (2017). Effect of home modification interventions on the participation of community-dwelling adults with health conditions: A systematic review. American Journal of Occupational Therapy, 71, 7102290010

Stark, S., Somerville, E., Conte, J., Keglovits, M., Hu, Y.-L., Carpenter, C., Hollingsworth, H., & Yan, Y. (2018). Feasibility trial of tailored home modifications: Process outcomes. American Journal of Occupational Therapy, 72, 7201205020.

Wiseman, J., Stamper, D., Sheridan, E., Caterino, J., Quatman-Yates, C., & Quatman, C. (2021). Barriers to the initiation of home modifications for older adults for fall prevention. Geriatric Orthopaedic Surgery & Rehabilitation, 12, 1-5.

Citation

Story, S. (2021). Aging in place: An occupational therapy and CAPS perspective. OccupationalTherapy.com, Article 5468. Retrieved from http://OccupationalTherapy.com

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Sara Story, EdD, OTD, OTR/L, BCG, CAPS

Sara Story, EdD(c), OTD, OTR/L, BCG, CAPS is an occupational therapist and associate professor in the Auerbach School of Occupational Therapy at Spalding University. She is board-certified in gerontology through the American Occupational Therapy Association (AOTA) and Certified Aging in Place Specialist (CAPS) through the National Association of Home Builders (NAHB). Her areas of practice include gerontology and mental health with a research interest in aging in place, community mobility, and mental health services. Sara has published and delivered presentations at the regional, state, and national levels supporting her research and scholarship interests.
 
 



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