Home Safety Evaluations for Healthcare Professionals

According to AARP, 87% of adults aged 65 and older and 70% of 50-64 desire to age in place (AARP, 2019). With an increasing number of older adults who want to remain in their homes for as long as possible, it is up to healthcare professionals to work with patients and families to ensure that their homes are as safe as possible in order to decrease the risk of falls and hospitalizations.

Various environmental assessments exist for older adults, including the In-Home Occupational Performance Evaluation (I-HOPE), Safety Assessment of Function and the Environment for Rehabilitation—Health Outcome Measurement and Evaluation (SAFER-HOME), Home Falls and Accidents Screening Tool (Home FAST), and the Westmead Home Safety Assessment. Using a standardized, valid assessment tool is advantageous for therapists completing comprehensive home assessments (AOTA, 2019).

Registered nurses and other healthcare providers such as physical therapists, occupational therapists, and discharge planners are responsible for creating comprehensive, timely home safety assessments. When safety concerns are identified, it is the responsibility of these healthcare providers to recommend corrective actions. This action may include recommendations to modify the home environment to ensure the patient is safe in their home. The safety needs may result from extrinsic factors of the environment, such as insufficient lighting or the need to install grab bars in the shower to decrease the risk of falls. Conversely, the safety concerns can also be related to intrinsic factors such as decreased safety awareness, insight, and judgment. Other considerations must include the patient's age, sensory and perceptual abilities, level of independence, and cognition. Nurses who provide home care must ensure that emergency phone numbers are readily accessible to the patient (RegisteredNursing.org, 2019).

Approximately one out of three older community-dwelling adults falls at least once a year. Falls represent the leading cause of injury-related deaths in older adults. Impaired hearing and vision, especially at night, contribute to an increased risk of falls. Older adults need up to three times more light than younger adults to see well. Altered depth perception may be another risk factor for falls in older adults. Any functional limitation which impairs mobility or participation in activities of daily living can also lead to an increased risk of falls. Including a focused geriatric assessment as part of a standard assessment can help to improve the quality of life and overall independence. Some options for fall risk assessment include:

• The Hendrich II fall risk model
• The Katz Index of Independence in Activities of Daily Living
• The Housing Enabler

These assessments include a comprehensive health history and physical assessment, including mental status and gait. After a home safety evaluation is completed, it is vital to implement patient-specific interventions to address the risk factors which are modifiable in order to decrease the risk of falls and enable the patient to remain safely in the home. Interventions may include installing nightlights to improve safety when traveling to the bathroom at night, teaching patients to wear shoes with non-skid soles, or removing throw rugs to decrease the risk of tripping when using a walker in the home (Edelman & Ficorelli, 2012).

Medication safety is another important area to assess in the home environment. It is vital to share tips with patients to keep them safe. It is helpful for patients to list all medications, including any over-the-counter products and dietary supplements, to share with all healthcare providers. Patients should read and then save the written information with all medications and store them in the same location. The medications should be taken exactly as prescribed, including taking the correct dosage at the correct time, and should never be skipped to save money. Patients should contact their healthcare provider or pharmacist if they are having trouble affording the medications they need, as there could be generic brands available or special programs to assist with covering the cost of certain medications. If required, memory aids may be helpful to remind patients to take medications on time.

Patients should be informed to notify their healthcare provider right away if they experience any issues with the medications or if the side effects seem to outweigh the benefit. Patients must know to avoid mixing alcohol and medication. All medications should be taken until they are completed or until the healthcare provider informs the patient that it is okay to stop. Patients should be told not to share their medications with others. Ensure the area where the patient is taking their medication is well lit. Be sure that patients check the expiration dates on medications and dispose of them properly. If there are children in the home, all medications must be stored out of sight and reach. Patients should also avoid taking medications in front of young children (Edelman & Ficorelli, 2012).

Many older adults are injured in or near their home every year in the US. It is estimated by the US Consumer Product Safety Commission (CPSC) that, on average, 1.4 million adults aged 65 or older are treated in emergency rooms each year for injuries associated with consumer products. The rate of injury is highest for adults 75 or older. One of the major causes of injuries to older adults is falls in or around their homes. Older adults are also at a greater risk of mortality due to house fires. Many injuries result from easily overlooked hazards but are easy to fix.

The US Consumer Product Safety Commission created a home safety checklist for older consumers to help prepare for emergencies and identify possible safety hazards in the home to prevent injuries to consumers or visitors to their homes. Their top 10 safety checklist for older consumers includes (CPSC 2019):

• Installing smoke and carbon monoxide detectors throughout the home
• Having an emergency escape plan with arrangements in place for assistance with escaping if needed
• Keeping a fire extinguisher in the kitchen in case of fire
• Ensuring there is proper lighting both in the home and outside of the home to prevent falls
• Make sure that walking surfaces are even, slip-resistant, free of clutter, and in good condition in order to decrease the risk of falls
• Keeping any smoking materials, candles, etc. away from any combustible items such as curtains or furniture and never leave fires unattended
• Having any appliance which runs on fuel inspected by a professional every year to ensure they are working correctly and not leaking carbon monoxide
• Installing ground fault circuit interrupters in potentially damp areas such as the kitchen or bathroom in order to protect against electrocution
• Ensuring that all medications, matches, and lighters are stored out of reach of children
• Setting the hot water heater to no more than 120° F to prevent burns

Smoke alarms and carbon monoxide alarms should be installed on every level of the home, including outside of sleeping areas. The alarms should be checked regularly to ensure they are still working properly. Approximately 2/3 of home fire deaths occur in houses without working smoke alarms. For hearing impaired patients, alarms with strobe lights should be installed to notify of smoke or carbon monoxide during the day, and an assistive device that vibrates the bed and pillow should be used at nighttime.

An emergency escape plan can help reduce the time required for a patient and their family to exit the home safely and improve chances of survival. When possible, two exits should be identified in every room, and patients should avoid escape routes requiring a ladder, increasing the risk of falls. It is important to ensure that the patient or family member can unlock and open all windows involved in the escape plan. The emergency escape plan should be practiced regularly. Emergency phone numbers, including police, fire department, local poison control center, doctor, and a trusted neighbor or family member, should be posted on or near all telephones. A telephone should be present in the bedroom if the patient is trapped in their bedroom by a fire. A telephone with large, lighted number keys should be used for patients with impaired vision. It is also helpful to keep telephones at a low height so that the patient can reach the phone if they have a fall or accident, which results in them being unable to stand. Another option would be to use a wearable medical alert device that includes a button that can be pushed to call for assistance (CPSC, 2019).

It is important to ensure that all walking surfaces are free of electrical cords, boxes, furniture, appliances, and any other objects that could be a tripping hazard, especially in an evacuation due to an emergency or fire. All flooring should be in good condition, flat and uniform, and slip-resistant or covered with slip-resistant carpeting, rugs, mats, or similar materials. Slip-resistant surfaces are especially important in potentially wet locations such as bathrooms, kitchens, and entryways. Any carpet in place should be low pile and in good condition. Any steps should have flat, even surfaces and be free of objects that could pose a tripping hazard. All stair treads should be in good condition and have slip-resistant surfaces, such as slip-resistant strips securely attached to the steps. All stairs should have sturdy, easy-to-grip handrails that run continuously along the full length of the stairs on both sides. Light switches should be located at both the top and bottom of the stairs.

Good lighting prevents falls as poorly lit or shadowed areas can hide slipping or tripping hazards. Indirect lighting or frosted bulbs can be utilized to decrease glare. All light bulbs should be the appropriate wattage and type for the lamp or light in which they are installed. If a light fixture does not identify the correct wattage, bulbs should not exceed 60 watts or 25 watts for bulbs with a miniature base, such as a candelabra. Compact fluorescent or other energy-efficient bulbs produce more light than incandescent bulbs (CPSC, 2019).

All electrical outlets located in potentially damp locations, such as the kitchen, bathroom, garage, near the utility tub or sink, and on the house's exterior, should have ground-fault circuit interrupters (GFCIs) installed to protect against electrical shock. GFCI receptacles can provide power even when they no longer provide shock protection. The GFCI receptacle should be tested monthly by plugging a nightlight or lamp into the receptacle and turning it on. When the TEST button is pressed on the GFCI receptacle, the RESET button should pop forward, and the light should go out. Pressing the RESET button should restore power to the outlet. Electrical outlets or switches should never be unusually warm or hot to the touch as that may indicate unsafe wiring conditions. These electrical outlets should stop being used immediately and be checked by an electrician as soon as possible. All electrical outlets and switches should have cover plates installed to expose no wiring. Any unused receptacles should have safety covers installed to prevent access by young children. All cords such as electrical or extension cords or telephone cords should be out of the walkway as they pose a tripping hazard. Cords should not be placed underneath furniture, rugs, or carpet or be pressed against the wall by furniture. Electrical cords should be in good working condition and free from any damage. The total wattage of all appliances plugged into an extension cord should not exceed the rated capacity of the extension cord. If the extension cord rating is exceeded, a higher-rated cord can be used, or some appliances should be unplugged. Standard 16-gauge extension cords can carry 1625 watts (CPSC, 2019).

A fire extinguisher should be located in the kitchen in case of fire. The National Fire Protection Association (NFPA) recommends that everyone remembers the acronym PASS to operate a fire extinguisher. This acronym stands for Pull the pin - hold the extinguisher with the nozzle pointing away from you and release the locking mechanism. Aim low - point the extinguisher at the base of the fire. Squeeze slowly and evenly. Sweep the nozzle from side to side. Fire extinguishers should be less than 10 years old. The extinguisher itself and the area around it should be free from dust, grease, and clutter, potentially catching fire. It is recommended to avoid wearing loose-fitting clothes with flowing or oversized sleeves while cooking.

It is also important that kitchen ventilation systems or range exhausts function properly. Indoor air pollutants and carbon monoxide can accumulate in a kitchen where gas or kerosene-fired appliances are used. Ventilation systems or open windows should be used to clear the air of vapors and smoke. The range or stove should never be used to heat the home. It is important to always stay within view of any food cooking on the stovetop. Cooking is the number one cause of home fires and injuries, especially unattended cooking. Electrical appliances and extension cords should be kept away from the sink and other water sources and away from hot surfaces such as the range. Electrical receptacles that supply countertop appliances, such as coffeemakers and toasters, should be protected by ground-fault circuit interrupters. A steady step stool with a handrail should be easily accessible for reaching high items, as standing on chairs, boxes, or other unsteady objects could result in falls (CPSC, 2019).

All chimneys should be professionally inspected and cleaned every year. Chimney openings should be clear of leaves and other debris that could clog them, as a clogged chimney can cause poisonous carbon monoxide to enter the home. Burning wood in a fireplace can cause creosote, a highly flammable substance, to build up inside the chimney. This material can ignite and result in a severe chimney fire. All portable space heaters and wood-burning heating equipment should be at least 3 feet from walls, furniture, curtains, rugs, and other flammable or combustible materials. All portable space heaters should be stable and located out of walkways. The surface of each fireplace should be fireproof. All wood-burning heating equipment should be installed on fireproof flooring or an approved non-combustible floor protector. Burning material can be ejected from an open fireplace. Fire-resistant hearthrugs, made of wool, fiberglass, or other synthetics, should be used to protect the area in front of a fireplace. Ashtrays, smoking materials, candles, hot plates, and other potential fire sources should be kept away from curtains, furniture, blankets, and other combustible items and should never be left unattended (CPSC, 2019).

All bathtubs and showers should be equipped with non-skid mats, abrasive strips, or surfaces that are not slippery and have at least one secure and easy-to-grip grab bar. The bathroom floor should be slip-resistant or covered with secure slip-resistant materials. Personal care items such as hair dryers, razors, curling irons, and other small electrical appliances should be unplugged when not in use and away from sinks, bathtubs, and other water sources. In the bedroom, a flashlight should be within reach of the bed in case there is a power outage and a telephone within reach of the bed in case of an emergency. Patients should make sure that their mattress meets the new federal flammability standard. Newer mattresses are more resistant to fires from open flames such as candles, lighters, and matches and will have tags to indicate that they meet the federal standard. Electrically-heated blankets should not be folded, covered by other objects, or tucked into the bed when in use. The power cord should not be pinched or crushed between the bed and a wall or the floor. Any object covering the blanket's heating elements or controls can cause overheating. The patient should not allow anything, including other blankets, comforters, and pets, on top of an electric blanket while it is in use. The heating pad should always be turned off before the patient sleeps as it can cause serious burns, even at relatively low settings (CPSC, 2019).

Medicare Part B will cover the cost of medically necessary durable medical equipment (DME) prescribed for home use by their doctor. Some DME items which are commonly recommended following home safety evaluations and may be covered under Medicare Part B include:

• Canes
• Commode chairs
• Hospital beds
• Patient lifts
• Walkers
• Wheelchairs
• Scooters

Medicare covers the cost of different kinds of DME in different ways. Depending on the type of DME and qualifying diagnosis, the patient may need to rent or buy the equipment. Medicare only provides DME coverage if the doctor and DME supplier enroll in Medicare. Patients must ask whether the DME supplier participates in Medicare before getting DME. If suppliers are enrolled in Medicare but are not "participating," they may not accept assignments, and there is no limit to the amount of money they can charge. DME must meet the following criteria: it must be durable, meaning it can withstand repeated use and has an expected lifetime of at least 3 years, it must be used for a medical reason in the home, and it is generally not useful to someone who is not sick or injured (Medicare.gov, 2019).

Medicare does not cover the cost of home modifications, such as wheelchair ramps or wider doors to improve wheelchair access, as modifications are not included under the DME benefit. Medicare does not cover assistive devices, such as telephones with large buttons for those with low vision or flashing doorbells for those who are hard of hearing. Some organizations can assist with finding low-cost products and services. AbleData is a federally funded database of assistive technology products and rehabilitation equipment. All states have an Assistive Technology Program which helps patients, their family members, and caregivers to identify and obtain the equipment they need to live safely and independently. The National Rehabilitation Information Center provides information on organizations and agencies to help people with disabilities (MedicareInteractive.org, 2019). Therapists, nurses, or other healthcare professionals can assist patients and their families by researching organizations that can help with financial coverage for needed home modifications. In some cases, they may also be able to help explain the medical necessity of requested items.

Home Assessments by Home for Life Design includes a complete home assessment developed based on 10 years of practice and research in aging-in-place. It is designed around four components of SPACE-ous living.

• Safe – to help prevent injury by using evidence-based best practices in home modifications.
• Personalized – to meet the needs of patients and their families based on their medical needs and the occupations most important to them.
• Accessible – to implement elements of Universal Design and remove physical barriers within the home to facilitate healthy and independent lifestyles.
• Cost-Effective – maintaining important aspects of the patient's home within their available budget. Their patient-centered, occupation-based approach to home modifications has been proven to help reduce falls, increase functional performance, and decrease the role of caregivers in the home.

The occupational therapists that deliver quality home assessments and home modification recommendations work to initiate the first steps in living at home for life. Allowing patients to age in a designated environment can ensure the best outcomes for continued safe living at home or aging. The Home Assessments by Home for Life Design help to advance the occupational therapy home assessment process from a list of hazards in the home to solutions to ensure a safe environment for the patient. It is quick and easy to use and can be used in any therapy setting. It is guided by the Person-Environment-Occupation model of practice which is central to best practice delivery in home modifications. The patient can identify the important occupations which they perform in their environment. At the same time, the healthcare professional can ensure that the environment supports engagement in those occupations by using the best product or design recommendations when indicated (Home for Life Design, 2019).

Home for Life Design has combined home health professionals' expertise and best practices with mobile technology to deliver first-to-market solutions to the aging-in-place market. Their Home Assessment Solution provides OTs, PTs, nurses, CAPS specialists, healthcare professionals, and rehab agencies with a mobile platform in which they can conduct ongoing patient home assessments and streamline data into a centralized reporting system. Some of the benefits include the ability to eliminate paper documentation, decrease patient re-admission rates, perform patient home assessments on mobile devices, capture home environments using videos and pictures, provide product recommendations for aging in place, create and send patient reports, as well as centralize patient reporting and assessment data (Home for Life Design, 2019b).

Mrs. Smith is an 87-year-old female who sustained a ground-level fall after tripping on a bathroom rug at 2 am. She lived at home alone and stayed on the bathroom floor until 8 am when her supportive son stopped by to check on her and found her. Her son tried to help her stand up; however, she could not put any weight on her right hip. The son called 911, and in the ED, she was found to have sustained a right intertrochanteric hip fracture. Mrs. Smith is now s/p IM nail fixation, and she is WBAT R LE. She has been at your skilled nursing facility for 4 weeks and is close to meeting all of her goals in therapy, so you schedule a home evaluation.

During the home evaluation, you find that Mrs. Smith lives in a one-story home with no steps to enter. The doorways are narrow as her house was built in 1952. She did not previously use any AD for mobility, so you bring along the rolling walker (RW) she has been using with success in rehab for the home evaluation. She can navigate her home well with the RW, but she does have to sidestep to get into some rooms due to the narrow doorways. You notice she still has to throw rugs throughout her kitchen and bathroom, so you encourage her son to remove them to avoid another fall. He removes the rugs and tells you he would gladly accept any additional recommendations you have. The RW does not fit inside the bathroom; however, Mrs. Smith can hold on to the long vanity to reach the toilet. She requires min A to transfer to standing from the low toilet. She requires mod A to step into her bathtub as there are no grab bars. Mrs. Smith seems fearful of falling again while she is in her bathroom. The bathroom was the only aspect of the home evaluation where she needed physical help for transfers as she does not own any DME. Following the home evaluation, you can provide the patient and her son with DME recommendations to improve her independence and safety once she returns home. If you had not completed the home evaluation, Mrs. Smith would have been at increased risk of falls and re-hospitalization as the fall hazards and needed DME would not have been identified.

In conclusion, it is vital that health care professionals involved with ensuring a safe home environment for patients, including occupational therapists, physical therapists, and nurses, are aware of the many factors which must be considered when conducting home safety assessments. Health care professionals must take into account the home environment and the patient's ability to function safely within the home when making recommendations.

Whenever possible, it is also important that the health care professional involved with the home safety assessment follow up with the patient regularly as the patient's needs and the environment will likely change over time. This assessment will allow the patient to request further assistance to ensure that they can safely age in place.

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• Home for Life Design. Home Assessment Solution for Individual Therapy Practitioners.Accessed August 4, 2019b. Visit Source.
• Medicare.gov. Durable medical equipment (DME) coverage.Accessed August 4, 2019. Visit Source.
• MedicareInteractive.org. Home modifications to continue living at home.Accessed August 4, 2019. Visit Source.
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• Rebuilding Together. History. https://rebuildingtogether.org/history Accessed August 4, 2019.
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