The purpose of this continuing education course is to provide healthcare providers with information regarding important factors to consider when conducting home safety evaluations in order to enable patients to safely age in place.
After completing this continuing education course, the participant will be able to meet the following objectives:
According to AARP, 87% of adults age 65 and older, and 70% of adults age 50-64 desire to age in place.1 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.
There are various environmental assessments which 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.2
Registered nurses, as well as 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 may include recommendations to modify the home environment in order to ensure the patient is safe in their home. The safety needs may be the result of extrinsic factors of the environment, such as insufficient lighting or the need to install grab bars in the shower to decrease 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 for the patient.3
The following is a list of some of the most commonly identified safety needs which will be assessed in the patients’ homes:
The adequacy of lighting is assessed to determine whether or not the lighting within the interior and exterior of the home is sufficient for patients to safely maneuver in the bathroom, bedroom, stairways, exits from the home and the driveway.
Foodborne illnesses pose a safety risk to patients, especially when the patient is immunocompromised or due to normal age-related changes such as a weakened immune system. The most common pathogenic microorganisms associated with foodborne illnesses are Escherichia coli and salmonella. Some preventive measures to ensure food safety include proper handwashing when handling food, as well as during meal preparation and disposing of any expired food products.3
Oxygen safety within the home environment includes the use of "No Smoking" signs, avoiding synthetic fibers and fabrics near the oxygen as they can create static electricity, and avoiding the use of flammable liquids like acetone near the source of oxygen.
The greatest risk factors associated with carbon monoxide poisoning are automobiles running in an enclosed area such as a garage and the absence of carbon monoxide alarms that detect high levels of carbon monoxide in the environment. The signs and symptoms of carbon monoxide poisoning include weakness, dull headache, shortness of breath, confusion, blurred vision, nausea, vomiting, dizziness, and loss of consciousness. People who are sleeping or unaware of these symptoms, for example due to cognitive impairments, are in the greatest danger for carbon monoxide poisoning.
Emergency alert systems including the appropriate number and placements of smoke alarms and a carbon monoxide alarm should be present in the patient’s home. Batteries for smoke alarms and carbon monoxide detectors should be changed at least every six months.
Household cleanliness and sanitation are assessed in order to protect the patient from commonly occurring infections, which can happen when the home is dusty, dirty, or infested with insects or vermin.
The home should be assessed for frayed wires, overloaded electrical sockets, and other hazards such as electrical items near water, the absence of smoke alarms, and the absence of a fire extinguisher. Electrical hazards must immediately be corrected when they are discovered.3
Emergency evacuation plans for patients and their family members are assessed, including how to respond in various situations such as tornadoes, hurricanes, flooding, and utility failures. Patients and their families should have an emergency evacuation shelter in place with electricity if lifesaving treatments are necessary.
Assistive devices such as raised toilet seats, grab bars, handrails, and tub transfer benches may be needed in order to improve patient’s safety, as well as decrease risk of falls. A fall alert system should also be considered for patients at increased risk of falls who live alone.
Other environmental safety hazards may include cluttered or congested areas, unsecured scatter rugs, and the presence of chemicals and poisons which could be accidentally consumed by adults with a cognitive impairment.3
Rebuilding Together is a premier nonprofit community revitalization organization originally founded in 1988 with the goal of helping people to safely age in place.4 They have national partnerships with Area Agencies on Aging, AARP, American Occupational Therapy Association, National Association of Home Builders, and National Council on Aging, among others. Rebuilding Together, in partnership with the Administration on Aging and the American Occupational Therapy Association created a comprehensive Safe at Home Checklist. The goal of the checklist is to identify home safety issues, potential fall hazards, and issues with accessibility. The checklist includes sections on exterior entrances and exits, interior door, stairs, and halls, bathroom, kitchen, living, dining, and bedroom, laundry, basement, telephone and door, storage space, windows, electric outlets and controls, as well as heat, light, ventilation, smoke, carbon monoxide, and water temperature control. Based on areas of potential issues identified in the first section of the checklist, the second section offers intervention options in order to enhance safety, prevent falls, and facilitate increased accessibility.5
Approximately one out of every three older community-dwelling adult 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 increased risk of falls. Older adults need up to three times more light than younger adults in order to see well. Altered depth perception may be another risk factor for falls in older adults. Any type of functional limitation which impairs mobility or participation in activities of daily living can also lead to 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:
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 risk of falls and enable the patient to remain safely in the home. Interventions may include installation of nightlights to improve safety when traveling to the bathroom at night, teaching patients to wear shoes with non-skid soles, or removing throw rugs in order to decrease risk of tripping when using a walker in the home.6
It is important to assess all fall risk factors, including intrinsic and extrinsic risk factors, which may impact a patient’s safety in the home.
Intrinsic fall risk factors may include:
Extrinsic factors may include:
Corrective actions should immediately be taken if extrinsic factors which lead to increased risk of falls are identified.6
Medication safety is another important area to assess in the home environment. It is vital to share tips with patients in order to keep them safe. It is helpful for patients to make a list of 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 which comes 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 in order 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 the 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. It is important that patients know to avoid mixing alcohol and medication. All medications should be taken until they are completed or until the healthcare provider informs the patient it is okay to stop. Patients should be told not to share their medications with others. Make sure 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, it is important that all medications are stored out of their sight and reach. Patients should also avoid taking medications in front of young children.6
In the U.S., many older adults are injured in or near their home every year. It is estimated by the U.S. 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 home. Older adults are also at a greater risk of mortality due to house fires. Many injuries result from hazards which are easily overlooked, but easy to fix.
The U.S. 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 in order to prevent injuries to consumers or visitors to their home. Their top 10 safety checklist for older consumers includes7:
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 on a regular basis to ensure they are still working properly. Approximately 2/3 of home fire deaths occur in houses without working smoke alarms. For patients who are hearing impaired, alarms with strobe lights should be installed to notify of smoke or carbon monoxide during the day and an assistive device which vibrates the bed and pillow should be used at nighttime.
An emergency escape plan can help to reduce the time required for a patient and their family to exit the home safely and can improve chances of survival. When possible, two exits should be identified from every room, and patients should avoid escape routes which require the use of a ladder, which could increase risk of falls. It is important to ensure that the patient or their family member can unlock and open all windows involved in the escape plan. The emergency escape plan should be practiced on a regular basis. 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 in the event that the patient is trapped in their bedroom by a fire. For patients with impaired vision, a telephone with large, lighted number keys should be used. 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 which includes a button which can be pushed to call for assistance.7
It is important to ensure that all walking surfaces are free of electrical cords, boxes, furniture, appliances, and any other objects which could be a tripping hazard, especially in the event of 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 which are 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 stairs.
Good lighting is an essential factor in preventing falls as poorly lit or shadowed areas can possibly 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.7
All electrical outlets located in potentially damp locations, such as the kitchen, bathroom, garage, near the utility tub or sink, and on the exterior of the house, 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 night-light 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 condition. 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 so that no wiring is exposed. 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.7
A fire extinguisher should be located in the kitchen in case of fire. To operate a fire extinguisher, the National Fire Protection Association (NFPA) recommends that everyone remembers the acronym PASS. This 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 which could potentially catch 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 are functioning properly. Indoor air pollutants and carbon monoxide can accumulate to unhealthy levels 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 home injuries, especially unattended cooking. Electrical appliances and extension cords should be kept away from the sink and other water sources, as well as 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.7
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 on 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.7
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 should be away from sinks, bathtubs, and other sources of water. In the bedroom, a flashlight should be within reach of the bed in case there is a power outage, as well as 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 by the bed, between the bed and a wall or the floor. Any object that covers 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 goes to sleep as it can cause serious burns, even at relatively low settings.7
Medicare Part B will cover the cost of medically necessary durable medical equipment (DME) when it is 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:
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 either rent or buy the equipment. Medicare only provides DME coverage if the doctor and DME supplier are both enrolled in Medicare. It is important that patients 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 assignment, 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.8
Medicare does not cover the cost for 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. There are organizations which 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 that can help people with disabilities.9 Therapists, nurses, or other healthcare professionals can assist patients and their families with researching organizations which can possibly help with financial coverage for needed home modifications. In some cases, they may also be able to help with providing an explanation regarding 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.
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 in place. 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 while the healthcare professional can ensure that the environment supports engagement in those occupations through the use of the best product or design recommendations when indicated.10
Home for Life Design has combined the expertise and best practices of home health professionals 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.11
Mrs. Smith is an 87-year-old female who sustained a ground-level fall after tripping on a bathroom rug at 2 am. She lives 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 is able to navigate through 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 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 is able to 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 in place. 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 are now able 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, as well as 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 on a regular basis as the needs of the patient and the environment will likely change over time. This will allow the patient to request further assistance if needed with ensuring that they can safely age in place.