Home Adaptations: Entrances (Rehabilitation Therapy)

ALERT

Provide special consideration to patients who are at an increased risk for falls due to impaired cognition or vision or to decreased strength or balance.

OVERVIEW

The Occupational Therapy Practice Guidelines for Home Modifications defines home modifications as adaptations to environments that are intended to increase use, safety, security, and independence.^{undefined#ref5">5} Modifications may include, but are not limited to, the use of medical equipment or universally designed products; architectural modifications or major home renovations; and education of the patient regarding new strategies to use in the home environment.⁵

Therapeutic intervention that includes home modifications may prevent premature long-term care by supporting aging in the home,⁴ as well as improve the patient’s functional performance and reduce the risk of falls and physical demands on caregivers.⁵ Additionally, home adaptations may reduce costs while older adults age in the home.⁵

When considering home modifications, the patient’s physical function is one of the main factors for the therapist to keep in mind. The therapist must also take into consideration the patient’s perception of the home modifications, readiness to change the environment, and costs.³ The therapist must work with the patient or caregiver (or both) and have the patient’s consent before making any changes in the home.

Entrances are an important area for the therapist to focus on during a home safety assessment. Barriers at a home entrance can prevent out-of-home mobility for patients² and may contribute to falls and injuries.³ The therapist should also address entrances inside the home, as well as outside.

SUPPLIES

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EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Educate the patient and caregiver on home modification recommendations.
• Educate the patient and caregiver on the use and installation of adaptive equipment.
• Instruct the patient to report pain experienced during functional mobility.
• Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Explain the procedure and ensure that the patient agrees to treatment.
5. Assess the patient for pain.
6. Assess the patient’s strength, balance, and vision.
7. Review risk factors that predispose the patient to falls or accidents in the home.

   Take note of preexisting conditions such as visual or hearing impairment, neuromuscular dysfunction, fatigue or reduced energy, or postural hypotension.

8. Assess the patient’s thoughts and perceptions on home adaptations.
9. Partner with the patient and caregiver to conduct a safety assessment of the home’s entrances.
10. Have the patient complete functional mobility while entering and exiting the home, with assistance as needed. Observe and document the safety of the functional mobility, including any challenges the patient encounters.
11. Make specific entrance modification recommendations based on the patient’s needs and comfort.
    1. Advise the patient to keep the hallways clear for ease of passage in case of an emergency. Recommend that the patient remove any tripping hazards.
    2. Advise the patient to place locks where all members of the household can reach and use them. Recommend that the patient have an easy-to-grasp lock installed if needed.
    3. Advise the patient to have a lever handle installed on the front door if the patient has trouble opening the door.
    4. Advise the patient to have a side latch or chain installed on the door so that the patient can open it enough to speak with someone outside without fully unlocking or opening the door.
    5. Advise the patient to have the doorway widened to accommodate a walker or wheelchair as needed. Explain to the patient that the recommended width of the doorway is 81.5 cm (32 inches) at minimum (Figure 1).¹
    6. Advise the patient to have continuous handrails installed on both sides of the steps leading to the entrance. If the patent has any trouble with the steps or has an existing ramp, ensure that the steps or ramp are safe.
       1. Explain that handrails on the sides of the steps should be 86.5 to 96.5 cm (34 to 38 inches) above the walking surface (Figure 2) and extend a minimum of 30.5 cm (12 inches) horizontally along the landing (Figure 3).¹
       2. Explain that a ramp should have a running slope no steeper than 1:12, a width of at least 91.5 cm (36 inches), a rise of 76 cm (30 inches) maximum, and landings at the top and bottom.¹

          Ramps with a rise of more than 15 cm (6 inches) should have handrails.¹

       3. Explain that a ramp landing should be a minimum of 152.5 cm (60 inches) long (Figure 4).¹
       4. Explain that the handrails for a ramp should be 86.5 to 96.5 cm (34 to 38 inches) above the ground (Figure 2) and extend a minimum of 30.5 cm (12 inches) horizontally at the beginning and end of the ramp run (Figure 5).¹
    7. Advise the patient to have adequate lighting outside of the home at the entrance. Recommend that the patient have sensors installed that automatically turn the lights on at dusk and off at dawn and when motion is detected.
    8. Advise the patient to make the address number on the home visible from the street so that emergency responders can locate the home easily. Recommend that the patient improve lighting on the outside of the home, install address numbers that contrast with the house color, and display the address on the mailbox or fence if applicable.
    9. Advise the patient to have a no-trip doorway threshold and to make the exterior door threshold easy to see. Recommend that the patient add reflective tape if needed.
       1. Explain that threshold heights should be no more than 1.3 cm (½ inch).¹
       2. Explain that threshold heights that exceed 1.3 cm (½ inch) should be beveled.¹
    10. Advise the patient to make the outside entrance free of clutter to avoid tripping hazards.
    11. Advise the patient to keep exterior pathways free of loose bricks, uneven pavement, leaves, snow, or other tripping hazards.
12. Remove PPE and perform hand hygiene.
13. Document the procedure in the patient’s record.

MONITORING

1. Observe the patient for signs and symptoms of pain. If pain is suspected, report it to the authorized practitioner.
2. Observe the patient for signs and symptoms of orthostatic hypertension. If this condition is suspected, report it to the authorized practitioner.
3. Observe the patient’s functional mobility while entering and exiting the home. If the patient is unsafe, educate the patient and caregiver.

EXPECTED OUTCOMES

• Patient participates in home safety assessment of entrances.
• Patient understands and implements home safety modification recommendations.

UNEXPECTED OUTCOMES

• Patient and caregiver do not acknowledge risks identified from the home safety entrances assessment.
• Patient or caregiver fails to implement modifications agreed upon during evaluation and intervention.
• Patient suffers a fall or injury in the home.

DOCUMENTATION

• Education
• Patient’s progress toward goals
• Unexpected outcomes and related interventions
• Entrances safety assessment and recommendations
• Changes made within the environment
• Assessment of pain

OLDER ADULT CONSIDERATIONS

• Older adults are at greater risk for falls due to age-related physiologic changes.²
• Orthopedic conditions (e.g., arthritis, joint pain) and decreased vision, sensation, balance, and mobility affect older adults and their ability to complete functional mobility throughout the home.

REFERENCES

1. Department of Justice. (2010). 2010 ADA standards for accessible design. Retrieved May 16, 2023, from https://www.ada.gov/regs2010/2010ADAStandards/2010ADAStandards.pdf (classic reference)* (Level VII)
2. Lim, Y.M., Kim, H., Cha, Y.J. (2020). Effects of environmental modification on activities of daily living, social participation and quality of life in the older adults: A meta-analysis of randomized controlled trials. Disability and Rehabilitation. Assistive Technology, 15(2), 132-140. doi:10.1080/17483107.2018.1533595 (Level I)
3. Maggi, P. and others. (2018). Fall determinants and home modifications by occupational therapists to prevent falls: Facteurs déterminants des chutes et modifications du domicile effectuées par les ergothérapeutes pour prévenir les chutes. Canadian Journal of Occupational Therapy, 85(1), 79-87. doi:10.1177/0008417417714284 (Level III)
4. Naseri, C. and others. (2018). Reducing falls in older adults recently discharged from hospital: A systematic review and meta-analysis. Age and Ageing, 47(4), 512-519. doi:10.1093/ageing/afy043 (Level I)
5. Siebert, C., Smallfield, S., Stark, S. (2014). Occupational therapy process for home modifications. In Occupational therapy practice guidelines for home modifications (pp. 11-40). Bethesda, MD: AOTA Press. (classic reference)* (Level VII)

ADDITIONAL READINGS

Keall, M.D. and others. (2017). Cost-benefit analysis of fall injuries prevented by a programme of home modifications: A cluster randomised controlled trial. Injury Prevention, 23(1), 22-26. doi:10.1136/injuryprev-2015-041947

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports