Retrofits & Adaptations:

Improving Mobility in the Home

Adaptations for Townhomes and Row Houses

U.S. Department of Housing and Urban Development | Office of Policy Development and Research

DISCLAIMER

Neither Home Innovation, nor any person acting on its behalf, makes any warranty, express or implied, with respect to the use of any information, apparatus, method, or process disclosed in this publication or that such use may not infringe privately owned rights, or assumes any liabilities with respect to the use of, or for damages resulting from the use of, any information, apparatus, method, or process disclosed in this publication, or is responsible for statements made or opinions expressed by individual authors. The contents of this report are the views of the contractor and do not necessarily reflect the views or policies of the U.S. Department of Housing and Urban Development or the U.S. Government.

Retrofits & Adaptations:

Improving Mobility in the Home

Adaptations for Townhomes and Row Houses

Prepared for

U.S. Department of Housing and Urban Development

Office of Policy Development and Research

Prepared by

Home Innovation Research Labs

Upper Marlboro, MD

August 2022

ACKNOWLEDGMENTS

U.S. Department of Housing and Urban Development

Office of Policy Development and Research

Government Technical Representative: Jagruti D. Rekhi

University of Buffalo

Center for Inclusive Design and Environmental Access (IDeA)

Ed Steinfeld

Danise Levine

Subject Matter Experts

Richard Duncan

Helen Eltzeroth

Louis Tenebaum

Charlotte Wade

Interdisciplinary Advisory Group (IAG)

Thank you to the IAG members for their contributions to this important research: Deborah Adler

Donna Norris

Dan Bawden

Kevin Purcell

Jim Costello

Jon Pynoos

Gail Gibson Hunt

Jon Sanford

Glen Hedman

Diane Selvaggio

Katherine Inge

Sanford Steinberg

Sandy Markwood

Joanne Theunissen

Traci McClellan-Sorell

Debra Young

NAHB Remodelers Council and Design Committee

Tim Ellis

Alexandra Isham

All photos taken by a member of the Home Innovation Research Lab staff.

Visit the U.S. Department of Housing and Urban Development (HUD), Office of Policy Development and Research (PD&R) website— https://www.huduser.gov/portal/home.html—to find this report and other relevant resources, reports, guides, and ordinances sponsored by PD&R

to aid homeowners and property owners. Many reports are available in print here. As always, all reports are available as free downloads from HUD User.

FOREWORD

The Centers for Disease Control and Prevention (CDC) estimates that the number of adults 65

years or older will reach 80.8 million by 2040 and 94.7 million by 2060—when older adults will make up nearly 25 percent of the population. As people age, they are more likely to have or develop a mobility impairment. Moreover, the housing market has a significant shortage of units suitable for people with mobility challenges to remain safely in their homes. Solutions call for assistive technologies that are innovative yet affordable and readily available.

Evidence demonstrates that people have a strong desire to remain in their homes—and a strong desire to adapt their homes to meet their changing preferences and needs. However, remodeling to improve accessibility is often expensive, and residents and caregivers cited cost as the most important consideration. Likewise, floor plan constraints and local regulatory requirements can make retrofitting or adapting the property to meet the needs of residents impossible. For example, row houses often are built with little or no front yard, making ramps impossible to install and requiring more expensive solutions.

The main objective of the study, Retrofits & Adaptations: Improving Mobility in the Home, was to review and test home modifications for semidetached and nondetached residential buildings (townhomes and row houses) with narrow floorplans and functional areas spread among several levels, and often with elevated entrances. The researchers conducted focus groups and a literature review to understand the daily and long-term challenges of individuals aging in place.

Focus group discussions were conducted among three primary stakeholders—users, caregivers, and professionals—to understand better the needs and challenges of making a townhome or row house accessible. Focus group findings confirmed that older adults expected to age in place and a strong desire to do whatever is necessary to adapt their homes; however, they don’t want their homes to look like an institution. Professionals regarded safety for all home modifications and fall prevention as the primary concern.

The literature review and feedback from the focus group yielded three key takeaways: (1) The appearance of the assistive device is important and must fit with the character of the existing home; (2) assistive devices need a standard method of evaluation to increase consumers’ trust that the devices are safe to use; and (3) affordability is a primary consideration and a potential barrier to making modifications. Ten innovative product solutions were identified as potential solutions to the typical accessibility challenges found in townhomes and row houses such as lack of space, small rooms, narrow hallways, functional areas on multiple levels of the house, etc. The Interdisciplinary Advisory Group (IAG) narrowed the list down to four assistive technologies.

The four accessibility products tested improved users’ mobility within the house. Many of assistive devices, however, were manufactured outside the United States and are, therefore, less available, and more expensive. Efforts to provide residents with affordable devices are needed.

We hope this study generates interest in developing market-based solutions for expanding access to accessibility devices that can be installed in homes to allow residents to safely remain in their homes.

Solomon J. Greene

Principal Deputy Assistant Secretary for Policy Development and Research

U.S. Department of Housing and Urban Development

iii

TABLE OF CONTENTS

Executive Summary ....................................................................................................................... vi

Focus Group Findings: Assistive Devices May Help Individuals Age in Place ....................... vi

Improving Grants, Loans, and Decisionmaking Tools for Home Assessment ......................... vii

Improve Program Awareness, Funding Options, and Innovation in the United States ........... viii

Introduction ..................................................................................................................................... 1

Literature Review ....................................................................................................................... 1

Inventory of Existing Homes ...................................................................................................... 4

Methodology ................................................................................................................................... 7

Focus Groups .............................................................................................................................. 7

Selection of Devices ................................................................................................................... 9

Evaluation Protocol ................................................................................................................... 12

Evaluation of Devices That Improve Mobility ............................................................................. 13

Construction of Demonstration Platform and Doorway Mock-Up .......................................... 13

Findings and Observations........................................................................................................ 14

Data Analysis ............................................................................................................................ 14

StairSteady Evaluation .............................................................................................................. 16

AssiStep Evaluation .................................................................................................................. 18

FlexStep Evaluation .................................................................................................................. 21

All-Push Door Evaluation ......................................................................................................... 23

Cost-Benefit Analysis ................................................................................................................... 27

StairSteady Cost-Benefit Analysis............................................................................................ 27

AssiStep Cost-Benefit Analysis ................................................................................................ 28

FlexStep Cost-Benefit Analysis ................................................................................................ 29

All-Push Door Cost-Benefit Analysis ....................................................................................... 29

Challenges and Barriers ................................................................................................................ 31

Affordability ............................................................................................................................. 31

Accessibility Products and Availability .................................................................................... 32

Recommendations ......................................................................................................................... 35

Future Research ............................................................................................................................ 37

References ..................................................................................................................................... 38

Appendix A: Home Modification Literature Review ................................................................... 40

Appendix B: Focus Group Discussion and Exploration of Accessibility Needs and Challenges 70

Appendix C: Summary of Design Selection and Prototype Construction .................................. 133

Appendix D: Home Innovation Accessibility Evaluation Survey .............................................. 154

Appendix E: Installation Instructions for Accessibility Devices ................................................ 169

Appendix F: Evaluation of Assistive Devices by Users, Caregivers, and Professionals ............ 185

Appendix G: Cohort Response Distribution Graphs for Each Device ....................................... 216

iv

LIST OF EXHIBITS

Exhibit 1. Accessibility Features as a Percentage of Each Building Structure Type ..................... 4

Exhibit 2. Raised Entryway ............................................................................................................ 5

Exhibit 3. Raised Entryway ............................................................................................................ 5

Exhibit 4. Garage First Level .......................................................................................................... 5

Exhibit 5. Garage on First Floor (No Bedroom or Full Bathroom) ................................................ 5

Exhibit 6. Innovative Product Solutions for Accessibility Improvements in the Home ............... 10

Exhibit 7. IAG Product Ranking ................................................................................................... 10

Exhibit 8. Research Team Product Ranking ................................................................................. 10

Exhibit 9. StairSteady, AssiStep, and FlexStep ............................................................................ 13

Exhibit 10. All-Push Door ............................................................................................................ 13

Exhibit 11. Example of a Survey Question, Which Solicits a Specific Response ........................ 15

Exhibit 12. Example of Median Score for the FlexStep Device ................................................... 15

Exhibit 13. Cohort 1 (Users and Caregivers) Divided Response: Speed of the FlexStep ............ 16

Exhibit 14. Comparison of Cohorts 1 and 2: Physical Effort ....................................................... 17

Exhibit 15. Height of Handle ........................................................................................................ 18

Exhibit 16. Adjust to Be at 90° ..................................................................................................... 18

Exhibit 17. Handle Too Low ........................................................................................................ 18

Exhibit 18. Comparison of Cohorts 1 and 2: Had Problems with Device .................................... 19

Exhibit 19. Comparison of Cohorts 1 and 2: Others Would Have Problems with Device ........... 20

Exhibit 20. Correct Position of Handle ......................................................................................... 20

Exhibit 21. Upper and Lower Bars ............................................................................................... 20

Exhibit 22. Adjusting Handle and Disengaging the Track ........................................................... 21

Exhibit 23. Descending the Stairs ................................................................................................. 21

Exhibit 24. Comparison of Cohorts 1 and 2: Easy to Be Installed ............................................... 22

Exhibit 25. Stair Mode .................................................................................................................. 23

Exhibit 26. Lifting Mode .............................................................................................................. 23

Exhibit 27. Final Position ............................................................................................................. 23

Exhibit 28. Comparison of Cohorts 1 and 2: Mistakes Made and the Need to Redo Steps ......... 24

Exhibit 29. Comparison of Cohorts 1 and 2: Needed Assistance ................................................. 24

Exhibit 30. Outer Door Frame Operation ..................................................................................... 25

Exhibit 31. Inner Door Frame Operation ...................................................................................... 25

Exhibit 32. Cost Comparison—Willingness to Pay: StairSteady and Stair Lift ........................... 27

Exhibit 33. Cost Comparison—Willingness to Pay: AssiStep and Stair Lift ............................... 28

Exhibit 34. Cost Comparison—Willingness to Pay: FlexStep and Wheelchair Lift .................... 29

Exhibit A-1. Ramp Slope Recommendations

53

Exhibit A-2. Average 2018 Costs of Most Commonly Implemented Home Modifications in the

Western New York Region ........................................................................................................... 66

v

EXECUTIVE SUMMARY

The U.S. Department of Housing and Urban Development (HUD) has identified townhomes and row houses as needing innovative solutions to accommodate the growing population who experience physical, mental, or sensory challenges, which threaten their ability to remain safely and productively in their homes. Several programs exist that provide retrofits to existing homes, but in many cases, the cost of renovating townhomes and row houses can be prohibitive due to narrow hallways, multilevel stairs, and the lack of bedrooms and full baths on the first floor.

Home Innovation Research Labs (Home Innovation) and the Center for Inclusive Design and Environmental Access (IDeA) partnered to study innovative assistive devices that can improve accessibility without requiring major renovations to the home. The research was conducted using a mixed-methods approach, including data collected from focus groups and product evaluations.

The participants in the study included seniors, persons with disabilities, caregivers, and design professionals who specialize in accessibility.

Focus Group Findings: Assistive Devices May Help Individuals Age in Place Based on focus group findings and other industry data, most older adults are expected to age in place. Seniors in this study expressed a strong desire to do whatever is necessary to adapt their homes to meet their changing needs as they age. Similarly, focus group members strongly desired to remain in their homes. Both groups saw an inherent value associated with staying in their homes because it provides them with a sense of comfort, independence, and well-being. In addition, the findings from the focus group corroborate the key findings from the literature search, including that (1) the appearance of the assistive device is important and must fit with the character of the existing home; (2) assistive devices need a standard method of evaluation to increase trust on the part of the homeowner that the devices are safe to use; and (3) affordability is a primary consideration and a potential barrier to making modifications.

The research project’s primary goal was to identify low-cost, low-effort technological adaptions with aesthetically pleasing design modifications that can make existing townhomes and row houses more accessible to those individuals with mobility-related challenges. The initial literature review helped define the starting point for the authors’ investigation by highlighting the condition of existing housing and known challenges. Through a combination of stakeholder focus group discussions and the expertise of Home Innovation’s research team, the authors identified four promising devices to be installed in the laboratory for evaluation by people with disabilities, their caregivers, and accessibility professionals.

The four accessibility products that Home Innovation evaluated (StairSteady, AssiStep, FlexStep, and All-Push Door) successfully improved the user’s mobility, with each varying in associated cost. 1 The StairSteady assistive device costs less than a conventional stair lift product, whereas the AssiStep was similar in cost to a conventional stair lift product. The FlexStep was more expensive than a similarly sized wheelchair lift device but had the benefits of being able to convert into a flight of stairs and a much more participant-preferred appearance. The All-Push Door was comparable in cost to an automatic door opener; however, the installation cost increased if the door frame needed to be widened.

1 Accessibility products included two stair-climbing devices (StairSteady and AssiStep), one wheelchair lift device (FlexStep), and one door assist device (the All-Push Door).

vi

Remodeling to improve accessibility can be extremely expensive, especially in existing townhomes and row houses. During the focus group discussions, cost was cited as the most important consideration by most residents and caregivers. The general perception was that retrofits and modifications would be cost prohibitive, and some believed that implementing accessibility improvements would be difficult without financial assistance. Some participants noted that a major renovation, including an additional bedroom and full bathroom on the first floor, could increase the home’s resale value.

Improving Grants, Loans, and Decisionmaking Tools for Home Assessment

Ultimately, for residents of some townhomes and row houses, the best decision may be to move to a more accessible home. A retrofit or adaptation of the property may not be a good value proposition, especially if grants are used to subsidize construction. Grants are usually capped and may not cover the total cost of the needed improvements, resulting in a less-than-adequate solution. The renovations needed may be extremely expensive. For example, retrofitting a townhouse with accessible entry steps may require the installation of a FlexStep outside and an AssiStep inside. If the home also needs a new roof and furnace, however, investing funds in accessibility improvements without also doing the other repairs does not make sense. Floor plan constraints and local regulatory requirements can make it impossible to retrofit or adapt the property to meet residents’ needs. For example, row houses are often built with little or no front yard. Ramps will not fit, so a more expensive solution such as the FlexStep or a conventional lift may be needed to make the home minimally accessible. For some individuals, staying in one’s own home may be possible, but it could affect quality of life considerably. An AssiStep or StairSteady could provide access to a second-floor bathroom and bedroom, but stairs at the main entry may become a barrier to someone with a disability, and the resident may be unable to leave the home without assistance. Thus, if not enough money is available to renovate the home successfully, moving may be a better alternative, particularly if the home has significant value that could be tapped to relocate.

As part of home modification, an assessment of the value proposition for the homeowner could help decisionmaking concerning aging in place, the scope of improvements to implement, or whether relocation is more desirable. If the homeowner decides to relocate, assistance in finding an appropriate home may also be needed. In its existing programs, HUD could require that such an assessment be included as part of home modification services funded by the agency. To assist providers, HUD could fund the development of tools for evaluating strategies and making informed decisions. Individuals may resist moving for many reasons, even if it is in their best interest. In many cases, such decisions are made as a family, in consultation with adult offspring or other relatives. Such tools would help to clarify the benefits of each strategy and make the implications clear to all involved.

Many low-income residents do not have the money to pay for moving costs, security deposits, or the first month’s rent. That financial stress can be a barrier to relocation, even if the resident understands that it is the best option. In some localities, grants, and loans to cover such costs are available, but no source of funds is generally available for that purpose. HUD may be able to provide funding or assist with the development of a new funding stream in cooperation with other federal agencies, such as the U.S. Department of Health and Human Services (HHS), targeted toward low-income homeowners. For higher-income individuals, a revolving federal loan fund may be a means to maximize the impact of such a program by reaching the population who do not have the funds at hand but are capable of paying the loan back in installments. HUD

vii

could also consider providing incentives such as tax credits or subsidies for homeowners older than 65 to purchase new homes with basic accessibility features, such as ICC/ANSI A117.1

standard, Type C Visitable Dwelling Units. This incentive program could be implemented through a certification and labeling approach, such as that for the ENERGY STAR program for appliances, which may increase demand for accessible housing and subsequently encourage increased builder interest in this market segment.

Improve Program Awareness, Funding Options, and Innovation in the United States The focus group findings indicated that many residents are unaware of existing retrofit programs.

Increasing awareness was beyond the scope of this study, but additional outreach is needed.

Home Innovation proposes further research to study how HUD’s existing funding programs could include greater outreach and higher funding caps. According to HomeAdvisor (2022), the typical home renovation for accessibility can range from as little as $800 up to $19,000. A closer look at the cost data reveals that major accessibility renovations that include bathrooms and kitchens can be as much as an additional $40,000 to $60,000.

The funding for medical devices is generally covered by health insurance, Medicare, or Medicaid. Assistive devices that improve the accessibility of the home are typically not regarded as medical devices (although some motorized stair lifts may be paid for using health insurance, Medicare, and Medicaid), and government funding is harder to obtain for accessibility improvements in the home. HUD’s Older Adult Homes Modification Program can assist with the cost of improving accessibility in the home, but the grants typically cover only a portion of the total cost for minor renovations (if one considers the cost range reported by HomeAdvisor).

The assistive devices in this study were manufactured outside the United States. European countries and Canada have developed assistive devices that can be installed on stairs and doors at a much greater frequency than the United States. Most U.S. companies primarily focus on personal assistive devices, such as canes, walkers, wheelchairs, and braces or prosthetics for individuals with mobility-related issues. Personal assistive devices are generally regarded as medical devices, whereas assistive devices that are installed permanently in the house are generally considered home improvement products in the United States.

To spur more design innovation in the United States, HUD should consider creating an Innovation Competition for Accessibility Products for the Home, similar to HUD’s Affordable Housing Student Design and Planning Competition. 2 The competition may drive more innovation in the area of assistive devices permanently installed in the home. Doing so could lead to increased demand for the manufacturing and installation services of assistive devices for U.S. homes.

2 For more information, see https://www.huduser.gov/portal/challenge/home.html.

viii

INTRODUCTION

The United States has a large housing stock of semidetached and nondetached residential buildings (townhomes and row houses) with narrow floor plans, and functional areas are spread among several levels, often with elevated entrances. Those home configurations are particularly challenging when modifications are required to improve access, safety, and usability for elderly and people with disabilities. HUD has identified townhomes and row houses as needing innovative solutions for the growing population who experience physical, mental, or sensory challenges that threaten their ability to remain safely and productively in their homes.

For this project, Home Innovation Research Labs (Home Innovation) and the Center for Inclusive Design and Environmental Access (IDeA) of the School of Architecture and Planning at the State University of New York (SUNY) at Buffalo conducted research to (1) understand the typical pitfalls of retrofitting for accessibility in townhomes and row houses; (2) identify best practice solutions for overcoming barriers to adoption; and (3) develop construction guidance to support designers, remodelers, and homeowners in their decisionmaking and construction processes.

The scope of work included (1) a comprehensive literature search, (2) focus groups to identify problems and potential solutions, (3) selection of viable accessibility solutions or devices, (4) construction of accessibility solutions or devices for evaluation at Home Innovation, (5) in-person evaluation of accessibility solutions or devices, (6) quantitative and qualitative analysis of evaluation results, (7) a cost-benefit analysis of the selected accessibility solutions or devices, and (8) design guidance for determining if modifications are possible and what is required by homeowners to make the adaptions successful.

Literature Review

In general, people can respond to environmental barriers in their homes in one of four ways (Salomon, 2010):

• Adapt their behavior.

• Move to another home.

• Modify their existing home.

• Turn to institutional care or another supportive housing arrangement.

Adapting behavior can often lead to unsafe conditions; moving can be cost prohibitive or disruptive, especially to persons advanced in age; and institutional care is often the most expensive and least desirable option for homeowners older than age 65. This situation makes the implementation of home modifications an effective and popular option for a wide range of homeowners (Bayer and Harper, 2000).

Home modifications can be categorized by their features and benefits and range in scale from minor adaptations, which include the installation of additional lighting or the replacement of doorknobs with levers, to more significant interventions, such as widening doorways or installing ramps. Although home modifications are defined as any adaptation made to the home that serves to decrease environmental demands for the user, defining modifications through specific goals is often beneficial. Steinfeld and Maisel identified the primary goals of home modifications as—

• Accessibility to interior and exterior spaces in the home and on the property.

1

• Usability to reduce barriers in the environment (Slaug et al., 2011).

• Safety to reduce the risk of accidents and improve security and fire safety.

• Support for caregiving and health care.

• Support of social integration and engagement.

The literature review focused on strategies that become a permanent feature of the home and bolster or improve the occupant’s ability to perform activities of daily living (ADLs), which include independence when—

• Eating.

• Dressing.

• Walking or transferring from one place to another.

• Bathing.

• Using the bathroom for toileting.

• Maintaining continence.

This study excluded interventions that can provide significant benefits but are generally not permanent architectural changes to the home. Those less permanent adaptations could include the mitigation of clutter or the use of temporary assistive devices and equipment, such as a freestanding bath bench or a toilet seat riser.

Although existing research illustrates the effectiveness and benefits of home modifications (Steinfeld and Shea, 1993), public policy and private-sector practices continue to fall short of providing adequate services and financial resources (Pynoos and Nishita, 2003). Many factors have contributed to the gap between knowledge and practice, including limited published research using large and diverse samples, lack of clarity in the definition of home modifications, and lack of knowledge about current practices in the construction industry and their effectiveness. Research on this topic is complicated by great variations in housing stock and conditions; construction practices and costs; and disability type, severity, and individual preferences toward home alterations.

A home modification is defined as any adaptation made to the home environment that addresses the functional limitations of the occupants and promotes independence, comfort, and safety (Steinfeld and Maisel, 2012). Modifications are not limited to any single population, but the authors’ literature search focused on modifications for four primary populations: (1) people advanced in age; (2) individuals with decreased mobility; (3) persons with visual impairments; and (4) individuals with cognitive impairments. Those four populations are explicitly addressed because they constitute significant subpopulations, and the modifications prescribed for them likely benefit a much larger group. Important to note is that the needs of all occupants of the home must be considered when recommending modifications, including family members and guests. Appropriate interventions address the physical and emotional needs of the caregiver as well.

The literature on home modifications has evolved considerably since this topic was identified in the 1970s as an important aspect of adaptation to aging. Government policy and private-sector initiatives in housing for the older generation, however, have consistently favored new construction over investment in the existing housing stock. Likewise, research funding devoted to modifications to keep the aging population in their homes longer has not been a priority of the government or the private sector. The Home Modifications Action Coalition—a collaborative 2

effort of the American Association of Retired Persons (AARP), the American Society on Aging, academia, and service providers—highlighted the importance of those services through its Blueprint for Action (North Carolina State University: School of Design, 1997). Research on practices in the field demonstrates that the mechanisms for delivering home modification services, from financing to construction, are fragmented and uncoordinated. Not much has changed since that time, although now a heightened awareness of the problem exists among service providers, government agencies, and the remodeling industry.

One of the most important findings from the literature review was the disconnect between the expectations of older adults and persons with disabilities with the reality of their housing.

Although a large majority of older adults expect to age in place, research demonstrated that their living arrangements do not support that choice without major compromises to their quality of life. Consumers were unaware that they might need deliberate—or even major—interventions in their home environment to realize their aspirations for aging in place. The rising cost of alternatives to renovating one’s home, such as moving to a new, universally designed home or service-intensive facility, will likely create a greater demand for home modification design and construction services. A danger exists that the supply of needed services, financing, and expertise may not meet the demand. Even worse, the potential mismatch between expectations and actual outcomes could make older people dread engaging service providers, akin to avoiding a visit to the dentist until it is too late. This dilemma will add to the burden of healthcare providers, relatives, and friends and severely reduce aging homeowners’ quality of life.

Research and practice clearly identified the scope of usability-related home modifications and the most common solutions. The authors considered a wide range of interventions, yet each individual and home are different. The challenge was to identify the most strategic interventions to target for in-depth research. For instance, satisfactory, low-cost, and easily implemented modifications such as cueing for people with dementia, improving illumination, and installing grab bars already exist; innovation is unnecessary.

Thus, the focus of research in this project was on improving the effectiveness of some of the most expensive and hard-to-implement modifications related to accessing homes and maintaining the safety of people with disabilities and their caregivers. Initially, the authors thought the focus would be on overcoming inaccessible entries (such as by installing ramps and lifts); access to essential facilities (such as laundry and parking) on inaccessible floors; and bathroom access, particularly access to toilets and bathing arrangements in cramped bathrooms.

However, given the unique vertical design layout of townhomes and row houses, the authors’

focus shifted to mobility issues, stairs, and door entries.

A large percentage of townhomes and row houses have bedrooms and bathrooms on the second or third level, making vertical navigation a daily challenge for those individuals with mobility-related disabilities. Stair lifts, inclined stair platform lifts, and elevators are potential home modifications for individuals who cannot climb stairs but require access to multiple levels of a home (Steinfeld and Maisel, 2012).

With vertical mobility in mind, the authors evaluated innovative products that make stairways safer and easier to climb, including easier-to-grip railings and innovative devices such as the StairSteady and AssiStep. Initially, the authors thought that evaluating a new lift or elevator technology was outside the scope of this research due to budget, time, and engineering constraints. However, the authors identified a cost-effective option, the FlexStep, an innovative 3

lift product manufactured in Europe. In addition, the authors secured an easy-to-use door called the “All Push Door” from Taiwan, specifically designed for individuals who have difficulty pulling doors open. Appendix A has the Home Modification Literature Review report.

Inventory of Existing Homes

The U.S. Census Bureau and HUD (2021) published the 2019 American Housing Survey (AHS), which includes data concerning home accessibility. The AHS estimates that 48 million households (39 percent of the total households in the United States) have at least one person older than age 65, with a disability, or both. Approximately 35 percent of people who live alone have a disability, and 37 percent of those who live alone are age 65 or older. Approximately 42

percent of people who use a mobility device have a disability, and approximately 26 percent of people who use a mobility device are age 65 or older. The AHS estimates occupied housing units with accessibility features as a percentage of each structure type. Exhibit 1 includes a chart of accessibility features for (1) detached houses, (2) attached and semi-attached houses, (3) multifamily apartment buildings, and (4) manufactured or mobile homes. For each building structure type, the exhibit identifies the percentage with ramps, a step-free entryway, a bedroom on the first floor, and a full bathroom on the first floor.

Exhibit 1. Accessibility Features as a Percentage of Each Building Structure Type Source: U.S. Census Bureau

Attached and semi-attached houses (townhomes and row houses) are represented in exhibit 1 by the “One-unit building, attached to one or more buildings” bars. The research team attempted to categorize townhomes and row houses on the basis of the floor plan but could not identify a

“typical” design. The existing housing stock of attached and semi-attached houses have a wide variety of floor plans based on regional design differences and the age of the homes. Some design features, such as the prominence of garages and limited livable space on the ground level, are recent compared with other, older design features, such as grand stairs (or stoops) seen on 4

vintage brownstones. Both design features present a challenge for accessibility into the house when the occupant has a mobility-related disability or limitation.

The authors identified three design features—elevated entryways, garages occupying most of the ground level, and stairs to access multiple floors—that made accessibility challenging.

Exhibit 2. Raised Entryway

Exhibit 3. Raised Entryway

Exhibit 4. Garage First Level

Source: Home Innovation

Exhibit 5. Garage on First Floor (No Bedroom or Full

Exhibits 2 and 3 are older

Bathroom)

vintage row houses with raised

entryways. This design feature

may present a challenge when

considering accessibility,

especially when set-back space

in the front of the property is

limited. The space constraint

shown in exhibits 2 and 3 makes

installing a conventional ramp

impossible. In such cases, a stair

lift may need to be installed, or

the resident may need to relocate

if no retrofit solutions are viable.

Exhibit 4 illustrates a common

design feature of modern

townhouses: the garage occupies

most of the ground floor space.

The floor plan in exhibit 5 also

demonstrates this style of design.

Two key accessibility features—

a bedroom and a full bathroom

on the first floor—mentioned in

Source: Home Innovation

exhibit 1—are not included in the first floor plan shown in exhibit 5. Instead, the second floor 5

has three bedrooms and two full bathrooms, all accessible only by stairs. If a resident has a mobility-related disability, one of three options must be considered to ensure that the townhome is accessible. First, the homeowner may do a major renovation on the first floor by converting the great room into a bedroom and expanding the half-bathroom into a full bedroom. Second, the homeowner may install a stair assistive device from the garage to the first floor and add a second stair assistive device from the first floor to the second floor. Third, the homeowner—or resident with a disability—may move to a different house or assisted living facility. This study is focused on identifying and evaluating devices that make staying in the home viable in terms of affordability and improving mobility in the home.

6

METHODOLOGY

The primary goal of the authors’ research project was to identify low-cost, low-effort, and aesthetically pleasing design modifications that can make existing townhomes and row houses more accessible to older adults and persons with disabilities. The literature review helped define the starting point for the authors’ investigation by highlighting the condition of existing housing and known challenges. In conjunction with planned stakeholder focus group discussions and the expertise of Home Innovation’s research team, the authors identified devices to be installed in the laboratory for evaluation and consideration by persons with disabilities, elderly people, their caregivers, and accessibility professionals. 3

Focus Groups

As part of the preliminary research plan, focus group discussions were conducted among three primary stakeholders—users, caregivers, and professionals—to better understand the needs and challenges of making a townhome or row house accessible. Each focus group discussion lasted approximately 2 hours, and each group had 8 to 10 participants. 4 The sample sizes for the focus groups were small—nine users, 10 caregivers, and eight professionals—and the responses were qualitative; therefore, extrapolating the results to a larger population is not appropriate.

Nonetheless, the findings from the focus group corroborate the key findings from the literature search; for example, (1) the appearance of the assistive device is important and must fit with the character of the existing home; (2) assistive devices require a standard method of evaluation to increase trust on the part of the homeowner that the devices are safe to use; and (3) affordability is a primary consideration and a potential barrier to making modifications.

Caregivers in the focus groups were more likely to report challenges than the users or people with a disability. This difference was likely due to one or more of the following reasons. First, except for one caregiver, all other participating caregivers in the focus group were not assisting the users in the other focus group; for the most part, the caregivers were discussing a different group of people with disabilities, who may have had more limitations than the user cohort in this study. Second, caregivers and users may define challenges differently on the basis of their perspectives. The authors noted that caregivers tended to categorize an activity as challenging if any delay or difficulty was perceived. On the other hand, users resisted classifying an activity as a challenge as long as they could ultimately achieve the goal, despite delay or difficulty. Third, users may perceive the word challenge negatively and resist applying that word to themselves. In every category, the caregivers consistently rated the activity more difficult than did the users.

Caregivers and users prioritized challenges the same, even though the relative incidence of challenges for users was lower than caregivers reported.

Several areas of the home—such as bathrooms, stairs, laundry room, and entryway or entrances—were commonly cited as presenting some of the greatest challenges in terms of accomplishing daily activities and ease of use. Among caregivers and users, the fear of falling was a primary safety concern associated with the bathroom and stairs. Users thought that the stairs and bathrooms needed to be modified for them to remain in their homes long term, and caregivers stressed the importance of having good retrofit solutions for bathrooms and stairways, 3 Professionals included occupational therapists, physical therapists, architects, designers, remodelers, certified aging-in-place experts, Universal Design experts, and assistive device manufacturers.

4 The focus group participants were paid an honorarium of $150 (in the form of a gift card).

7

both interior and exterior. Caregivers thought that stairway solutions were the most important feature because they improved mobility inside the house and prevented the senior or person with a disability from feeling isolated or confined to one part of the house. In general, caregivers in the focus groups thought that mobility-facilitated social interaction kept the user engaged with family, friends, and life in general.

Professionals in the focus groups stated that residents who stayed in their homes rather than transitioning to assisted living or a nursing home facility saw greater benefits in terms of quality of life and added value to their home—if a major renovation expanded the function of the first floor. Most residents prefer to stay in their homes (Goyer, 2021), and professionals have seen an increased demand for aging-in-place solutions. 5 The benefits of aging in place have contributed to more people believing that home retrofits and modifications are a good investment.

Professionals regarded home renovations as an investment that may improve the resale value and marketability because it benefits older adults, people with disabilities, and multigenerational households. The cost of a major renovation, such as adding an accessible bathroom to the main level of an existing home, can range from $20,000 to $30,000. Some insurance companies offer long-term care policies with riders that fund home retrofits as an alternative to placing the family member in assisted living or a nursing home. Insurance companies recognize that an aging-in-place retrofit can be more cost effective and better for the patient’s health and well-being in the long run. However, that option depends on the person having a particular type of long-term care insurance (American Association for Long-Term Care Insurance, n.d.).

Remodelers, builders, and architects who participated in the research project claimed to encourage their clients to proactively plan for future needs when planning general remodels or designing new homes. 6 Some criticized the term aging in place because it emphasizes design for declining abilities. Those professionals have found that their clients were more accepting of solutions that highlight empowerment and the ability to improve one’s quality of life. Proactive planning involved considering design choices that can be easily modified in the future or implementing universal design (Center for Universal Design at NC State, n.d.) concepts for a new home. Client relations are an important aspect of home modification services. The professionals involved not only have to be knowledgeable about how to design for aging in place, but they need to present the idea to clients in ways that the client will value. This finding suggests that a valuable follow-up research study could examine how homebuilders, remodeling contractors, and their design consultants communicate the concept of design for aging in place to clients. Research questions could include the following:

• How many home builders, remodeling contractors, and their design consultants know enough to design for aging in place?

• Do they present the idea to clients?

• What language and approaches are most successful in getting clients to adopt aging-in-place practices?

The output could include revisions to the Certified Aging-in-Place Specialist (CAPS) curriculum or online courses that builders and remodelers could access to become more informed.

5 Aging in place refers to people remaining in their home without losing their quality of life as they age.

6 The remodelers, builders, and architects who participated in this study were accessibility specialists, hence they often recommended Universal Design and accessibility features to their clients.

8

Professionals generally ranked exterior access solutions as the most challenging to implement. In some situations, installing a ramp was not possible due to space limitations because ramps may not block the sidewalk or extend into a public area. As illustrated in exhibits 2 and 3, space limitations are common challenges for townhomes and row houses. An occupational therapist in the authors’ focus group confirmed this challenge, sharing that a client who lived in Baltimore needed a ramp or wheelchair lift to access the home, but the home’s entryway did not have space for a ramp, and the cost of a wheelchair lift was prohibitive—from $15,000 to $20,000); lack of a practical and affordable option for entry and exit ultimately forced the individual to move.

Professionals thought safety was a fundamental consideration for all home modifications. Fall prevention was the primary concern for older clients and persons with mobility-related disabilities. The professionals identified bathrooms, stairs, door thresholds, and floor material transitions as the areas with the highest probability of falls. Professionals thought that typical solutions—grab bars, handrails on stairs, improved lighting, and better entry doors with

“no-step” thresholds—were well known and straightforward to implement. Most professionals stated that they relied on device suppliers, or distributors, to keep them apprised of the best practices for remodeling for accessibility. Product availability, performance specifications, warranty, and installation requirements were essential for professionals to know when determining whether a product would be used on a remodeling project.

Professionals believed that aesthetics were very important to encouraging proactive planning with their clients. Although everyone valued safety and ease of use, professionals stated that their clients also wanted their homes to look and feel like “a home,” not a hospital or assisted-living facility. Architects, designers, and remodelers were keenly aware that if all devices were equal in terms of performance, clients preferred the best-looking device.

The focus group participants believed that affordability was the number-one barrier to retrofits and renovations. Despite available grant money, rebates, and other funding sources, homeowners often struggled to get needed financial assistance. In some cases, a resident may not qualify for a financial accessibility grant because of income or asset thresholds, lack of homeownership—

generally a requirement for many of the programs—or a complex application process. Even when funding is secured, it may not be enough to cover the total cost of the retrofit or renovation.

For townhomes and row houses, retrofits and renovations are complicated by narrow hallways, cramped stairways, and other space limitations. To address those constraints, professionals have proposed complex design solutions that include more expensive devices such as elevators or major renovations compared with a one-story house plan. Appendix B contains the Focus Group Discussion and Exploration of Accessibility Needs and Challenges report.

Selection of Devices

Using the results from the focus group discussions, Home Innovation and IDeA conducted several brainstorming sessions to identify innovative product solutions that could address the following accessibility challenges typically found in townhomes and row houses:

• Lack of space.

• Small rooms.

• Narrow hallways.

• Stairways, accessing functional areas on multiple levels of the house.

• Elevated exterior door entry.

9

• Shared walls between the houses (limits renovation options).

• Small lots with limited space between the house and the property line.

Home Innovation’s research team identified 10 innovative product solutions, listed in exhibit 6.

The Interdisciplinary Advisory Group (IAG) was asked to review the products and rank them on how many challenges they addressed. 7 The IAG also considered (1) safety, (2) functionality, (3) cost effectiveness, (4) aesthetics, and (5) the overall impact if the product were successfully installed.

Exhibit 6. Innovative Product Solutions for Accessibility Improvements in the Home Accessibility Solutions to Consider and Rank

All-Push Door

StairSteady

FlexStep

Vehicle Lift

Fixture Integrated Rails/Handholds

Adjustable Height Toilet

Toilet Riser/Step Combination

Movable Storage Wall

SuperPole

Turntable/Carousel

The IAG product ranking is listed in exhibit 7, and the research team’s ranking is listed in exhibit 8. The bold items in the exhibit represent the highest scoring items from exhibit 8 and their ranking by IAG Product ranking in exhibit 7.

Exhibit 7. IAG Product Ranking

Exhibit 8. Research Team Product Ranking

Ranking

Accessibility Solutions:

IAG

Ranking

Accessibility Solutions:

Research Team

4.4

SuperPole

4.9

All-Push Door

3.9

StairSteady

4.9

FlexStep

3.5

All-Push Door

4.4

StairSteady

3.4

Toilet Riser/Step Combination

3.9

Moveable Storage Wall

3.4

FlexStep

3.5

Fixture Integrated Rails/Handholds

3.1

Fixture Integrated Rails/Handholds

3.5

Vehicle Lift

2.5

Moveable Storage Wall

3.5

Turntable/Carousel

2.5

Turntable/Carousel

3.0

Toilet Riser/Step Combination

2.1

Vehicle Lift

2.3

Adjustable Height Toilet

1.8

Adjustable Height Toilet

1.6

SuperPole

The rankings were the average score from 1 to 5 of the members in the IAG and the research team members. When considering the 10 accessibility solutions, the research team ranked products high that addressed challenge areas from the focus group data: (1) stairways, (2) entryways, and (3) limited space. The IAG generally ranked products high that it thought were innovative, even if widely available (such as the SuperPole). The toilet retrofit devices were 7 The Interdisciplinary Advisory Group (16 subject matter experts) is identified in the acknowledgment section of this report. They represent a broad group of industry stakeholders and offered various recommendations during the evaluation of product solutions.

10

good products for improving accessibility in the bathroom but did not address the most challenging areas in townhomes or row houses. The remaining accessibility products ranked too low to be considered for evaluation.

The All-Push Door was selected for further study because it can be adapted to an exterior or interior door opening. The “push-only” concept was designed for people who may have issues pulling a door open due to cognitive impairment or physical limitations in their hands. The product also eliminates the need for someone in a wheelchair to turn around when entering a door from the pull direction. The product is manufactured in Taiwan and has limited availability in the United States, but the manufacturer wanted to have products available to meet anticipated future demand. In general, the All-Push Door must be sized to meet door specifications in the United States, and the manufacturer is aware of those requirements—especially for exterior doors, which must meet building codes, fire codes, and other voluntary product performance requirements.

The FlexStep was selected for further study because it converted from a lift to a staircase, which made it a potential solution when space is limited at a house’s main entrance. The product is also well suited for interior doors that enter the house from the garage, as illustrated in exhibits 4

and 5. The FlexStep received a high ranking because it has the potential to address stairs, entryways, and limited spaces; however, a preliminary review of the product’s cost revealed that it might be too high to be considered affordable. The product is manufactured in Europe but is readily available for purchase in the United States through distributors.

The StairSteady was selected for further study because the product offered a simple, relatively inexpensive assistive device for climbing stairs. Given the limited space in some older townhome and row house stairways, the StairSteady is compact in size and easy to install—but the user must have some upper body strength to use the manual device. The device was affordable, low maintenance, and compact enough to be concealed when not in use. Because the product can be painted any color, the authors believe it can easily match the surrounding decor of virtually any home, appealing to the aesthetic preferences of most user participants. The device is manufactured in Canada and must be special-ordered because there are no U.S. distributors that offer the product.

The Movable Storage Wall was selected for further study because it was considered useful when space limitations were present and storage was needed. The concept proved limited because the system required a partition wall with no utilities present to have a movable storage unit

“embedded” within an interior wall. Home Innovation built a mock-up Movable Storage Wall to illustrate the system’s functionality and discovered that although it could work for some existing floor plans, it was not space conserving. The authors eliminated the Movable Storage Wall from further consideration in this project.

Home Innovation identified an additional device to evaluate—the AssiStep—a manual stair assistive device for climbing stairs, similar to the StairSteady. The AssiStep has an adjustable handle and can be installed on stairways with limited space. The manual device is mounted on a track that requires very little upper body strength to move. The product is affordable, low-maintenance, and can be folded up when not in use. The device is manufactured in Europe and must be special-ordered because no U.S. distributors offer the product. Appendix C contains the Summary of Design Selection and Prototype Construction report.

11

In March 2020, Home Innovation installed the accessibility products in the testing and observation spaces in its laboratory facility to conduct in-person product evaluations in April 2020, but the COVID-19 pandemic delayed this key part of the research project. Although a limited product evaluation was conducted with select remodeling professionals in November 2020, Home Innovation continued to delay the comprehensive product evaluations with users, caregivers, and professionals until COVID-19 vaccines were readily available to all adults in June 2021.

Evaluation Protocol

In July 2021, Home Innovation recruited 51 participants—users, caregivers, and professionals—

to evaluate accessibility devices. The participants included users with mobility-related disabilities or limitations, caregivers of older adults or individuals with mobility-related disabilities or limitations, and professionals with expertise in accessible design, including physical and occupational therapists, architects, designers, and contractors who specialize in accessibility renovations.

The in-person evaluations were conducted in August 2021. Upon arriving at Home Innovation’s location in Upper Marlboro, Maryland, participants read and signed the permission and release documents, authorizing Home Innovation to conduct observational research with the participants as they evaluated accessibility devices. Home Innovation staff followed the Institutional Review Board (IRB) ethical guidelines to ensure a safe research experience and environment. 8

The participants were given a short orientation that included a review of the evaluation process and a demonstration of how to use each device. Then, the participants were instructed to evaluate each device and answer questions from the IRB-approved survey. Home Innovation staff documented the participant responses, which addressed the ease of use, installation, maintenance, aesthetics, need for the device, price willing to pay, and perceived advantages and disadvantages of each device. After completing the survey questions, the participants engaged in open-ended discussions with Home Innovation staff, which led to further insight into the participants’ experiences with the devices. In some cases, participants offered recommendations for how the devices could be improved. Appendix D contains the Home Innovation Accessibility Evaluation survey.

Home Innovation did not conduct performance testing on the accessibility devices and does not endorse or debunk any claims made by the manufacturer. Instead, Home Innovation captured the participants’ perceptions and comments through observational research. The data gathered cannot be reliably extrapolated to a larger population, and statistical analysis cannot be applied to the results to characterize a larger population accurately. Nonetheless, the results provided valuable insight into how best to select accessibility devices based on the needs of the user.

8 The IRB is an independent reviewer of research methods (including questionnaires and surveys) to ensure that they are ethical and protect the rights and welfare of human subjects involved in research.

12

EVALUATION OF DEVICES THAT IMPROVE MOBILITY

The objective of the in-person evaluation was to identify which devices help minimize or eliminate the accessibility challenges within typical townhomes or row houses. The participants evaluated four accessibility devices, which included two stair assist devices (StairSteady and AssiStep), one stair lift device (FlexStep), and one door entry device (All-Push Door).

Home Innovation recruited 15 users, 16 caregivers, and 20 professionals. Many of the caregivers had mobility issues; in fact, the authors observed several elderly caregivers with mild mobility-related limitations, though not as severe as those of the person they were assisting. As a result, the authors considered responses from users and caregivers together as one larger group called Cohort 1. The professionals were called Cohort 2.

For Cohort 1, the participants—users and caregivers—were required to have a mobility-related disability or care for someone with a mobility-related disability. In addition, Cohort 1 had to reside in or assist someone in a townhome or row house. For Cohort 2, the participants (professionals) had to have experience evaluating individuals with mobility-related disabilities or have design or installation experience—or both—with accessibility devices.

Construction of Demonstration Platform and Doorway Mock-Up

Home Innovation hired a contractor who specialized in installing accessibility devices—lifts, ramps, grab bars, etc.—to build the demonstration structure and doorway mock-up used during the in-person evaluations. The contractor was able to easily install the accessibility devices using the manufacturer’s instructions. None of the accessibility products evaluated are considered do-it-yourself devices. The manufacturers recommended using a remodeler or contractor to ensure that the devices are installed correctly. The StairSteady, AssiStep, and FlexStep devices were installed on the demonstration platform shown in exhibit 9. A separate doorway mock-up structure was built to install the All-Push Door shown in exhibit 10.

Exhibit 9. StairSteady, AssiStep, and FlexStep

Exhibit 10. All-Push Door

Source: Home Innovation

Source: Home Innovation

The StairSteady and AssiStep—shown on the right of exhibit 9—are assistive devices that aid the user in climbing stairs. When installing these devices, the contractor must know the height and stature of the person who will use them because the structural supports must be mounted at a 13

height that “fits” the biometric measurements of the user. Because 51 participants were of unknown height and stature, Home Innovation was unable to customize the installation of the StairSteady and AssiStep for each person in the study. As a result, the contractor installed both devices on the basis of the standard height of the railing used on the platform. That height corresponds to a person with an approximate height of 5 feet 5 inches. The StairSteady handle cannot be vertically adjusted once mounted and installed. The AssiStep handle can be vertically adjusted (within a 6-in. range) after being mounted, but doing so requires removing attachment screws and re-installing the handle. All 51 participants evaluated the StairSteady and AssiStep without adjusting them for biometric differences. Appendix E contains the Installation Instructions for Accessibility Devices. 9

Findings and Observations

In general, each participant evaluated the accessibility devices one at a time using the IRB-approved survey. Home Innovation staff typically started with the StairSteady and then proceeded to the AssiStep and FlexStep devices, all located on the demonstration platform (exhibit 9). After completing surveys for StairSteady, AssiStep, and FlexStep, administered by Home Innovation staff, the participants completed the All-Push Door evaluation (exhibit 10).

Overall, each participant required approximately 2 hours to evaluate all accessibility devices and provide additional comments. Each accessibility device required approximately 20–30 minutes to complete the evaluation. After completing the evaluations, each participant was asked open-ended questions to understand why specific responses were provided; this final step took an additional 20 minutes. Upon completing the open-ended discussion questions, all participants were paid a $150 honorarium for offering their insight and time for the study.

Data Analysis

Home Innovation compiled and analyzed the data from the 51 participant surveys. First, the authors considered how the data were useful to residents of townhomes and row houses that required retrofits and adaption for mobility. Second, the authors considered that manufacturers of accessibility devices could benefit from the data if they used them to improve existing devices or develop new devices.

In most cases, Home Innovation observed that the survey responses were similar for Cohort 1

and Cohort 2. As a result, the responses from both cohorts were combined and the data analyzed as one group—statistically, a case was made for doing this given the small number of participants in each cohort. An observational market research report was prepared, including general findings and perceptions from the participants concerning safety, ease of use, aesthetics, installation, and maintenance. Appendix F contains the Evaluation of Assistive Devices by Users, Caregivers, and Professionals report.

In a few cases, Home Innovation observed differences between the cohorts—the users and caregivers did not agree with the professionals—and the authors observed differences within the cohorts. To better understand those differences in perception and opinion, the authors revisited the recorded interviews to gain context for why certain questions were answered in a particular way. To explore those differences further, the authors reanalyzed the data and illustrated the 9 Instructional videos are also available at www.homeinnovation.com.

14

distribution of the answers instead of focusing on an average or median response among a cohort. This closer look at the data proved valuable when coupled with comments from the recorded interviews and provided insight into how the cohorts were similar but, equally important, why they were divided at times.

The survey questions are designed using declarative statements on a Likert scale to which the participant must respond by selecting one of five specific answers, as exhibit 11 illustrates. 10

Exhibit 11. Example of a Survey Question, Which Solicits a Specific Response Home Innovation assigned numerical values to each of the discrete responses—Strongly Disagree was “1,” Disagree was “2,” Neither was “3,” Agree was “4,” and Strongly Agree was

“5.” The numerical values were then calculated to determine a single median score, which was used to represent the collective response of a cohort to a specific question. Exhibit 12 illustrates an example of this with a red “X” at the point on the scale for the median score of 3.1, which is Cohort 1’s collective response to the declarative statement, “It takes more time to go up and down the stairs than it should,” for the FlexStep device.

Exhibit 12. Example of Median Score for the FlexStep Device

A single score simplifies the analysis when considering multiple participant responses, but a single score can also hide valuable information. When considering the mean score of 3.1 in exhibit 12, the reader may ask, “Did the participant reply ‘neither’ for virtually all responses, or did the score of 3.1 represent a divided cohort (with approximately one-half agreeing with the statement and one-half disagreeing with the statement)?”

In this report, the authors have included the distribution in responses using three categories on a single graph:

Disagree includes a count of both “Strongly Disagree” and “Disagree” responses. It means that the participant disagreed with the statement (some more than others).

Neutral includes a count of only “Neither” responses. It means that the participant could neither disagree nor agree with the statement. The participant could have responded this way for a variety of reasons, including (1) not having an opinion, (2) believing that the answer could vary depending on the circumstance, or (3) believing that the statement was not applicable.

10 The Likert scale assumes that the strength or intensity of an opinion or attitude can be measured on a continuum from “Strongly Agree” to “Strongly Disagree” (or other variations, such as frequency, quality, and likelihood). It was used in the Evaluation of Assistive Devices by Users, Caregivers, and Professionals report (appendix F).

15

Agree includes a count of both “Strongly Agree” and “Agree” responses. It means that the participant agreed with the statement (some more than others).

Exhibit 13 illustrates the responses using the three categories previously defined. Although the median score was 3.1, as illustrated in exhibit 12, a closer look at the distribution of responses shows a divided Cohort 1—some believing that it took more time than it should to go up and down the stairs, whereas others thought the time was reasonable. Many of the neutral respondents were of two minds—they understood that the FlexStep should move slowly for safety reasons but could see why people would be frustrated by the device taking so long to ascend or descend (four steps).

Exhibit 13. Cohort 1 (Users and Caregivers) Divided Response: Speed of the FlexStep Home Innovation provided cohort graphs, such as exhibit 13, for all questions for each accessibility device. The cohort graphs are presented together on a single graph such that the reader can compare the responses of Cohort 1 with those of Cohort 2. During the discussion that follows, the authors highlight certain questions that yielded a significant response difference and provide some context based on the comments provided by the participants. In cases in which the cohorts were in agreement, the authors summarize the findings and observations to indicate that result. Appendix G contains the Cohort Response Distribution Graphs for Each Device report.

StairSteady Evaluation

Professionals, users, and caregivers considered the StairSteady easy to install, clean, and match with any home decor—provided the device was painted. All participants thought the StairSteady required little maintenance because it did not have any mechanisms or motors—it is a manual device with a simple handle and rail. Both cohorts found the StairSteady instructions easy to understand, but most thought the device handle required some practice. During the evaluation, the handle did not glide smoothly and required maneuvering to move from one position to the next. As a result, most professionals, users, and caregivers “had problems using the device” and believed that others would have the same problems they encountered.

16

The professionals and the users and caregivers disagreed about the physical effort needed to use the StairSteady. Nearly all professionals thought that the upper body strength needed to maneuver the handle of the StairSteady would make the device difficult to use for most frail elderly users or any client recovering from a stroke (exhibit 14, orange bars). When answering this question, the physical and occupational therapists considered a wider range of potential users, not only those individuals with mobility-related disabilities or limitations. The users and caregivers were divided about the physical effort necessary to use the StairSteady (exhibit 14, blue bars). Some believed they could improve the ease of use with some practice; others thought the device was not positioned correctly for their body size and stature. The distribution of responses to the question of physical effort is illustrated in exhibit 14.

Exhibit 14. Comparison of Cohorts 1 and 2: Physical Effort

The participants for the in-person evaluation varied in size and stature. The StairSteady was installed according to the manufacturer’s instructions, but the device could not be adjusted for each participant and is not designed to be adjusted after it is installed. The in-person evaluations proved that the StairSteady has no “one-size-fits-all” installation. The device must be installed on the basis of the user’s physical measurements.

The users and caregivers who required little effort to use the device were simply fortunate enough to fit the installation of the StairSteady. If one was taller, the handle did not line up at 90°

with the person’s elbow, and the user was pushing the handle at an angle that kept it from moving smoothly. For a taller individual, the StairSteady installation was more difficult coming down the stairs than going up because a taller person’s center of gravity (COG) was typically over the handle, which made pushing the handle less safe.

17

Exhibit 15. Height of Handle

Exhibit 16. Adjust to Be at 90° Exhibit 17. Handle Too Low

Source: Home Innovation

Source: Home Innovation

Source: Home Innovation

Exhibit 15 illustrates that the handle is too low for this Home Innovation staff person (he is 6 ft.

2 in. tall). Exhibit 16 illustrates that the device should be raised so that the arm is at 90°. Exhibit 17 illustrates the difficulty and risk of going downstairs when the device is mounted too low for the individual. Although most of the participants were not 6 ft. 2 in. tall, the device was determined to be too low for many participants who tried to use it—an unavoidable outcome given the random nature of the recruiting of participants—and may partially explain some of the poor ratings received by the StairSteady.

Although the StairSteady is straightforward to install, it must be installed at the correct height for the user. One physical therapist regarded the StairSteady as a quasi-medical device that should be installed by a trained professional to ensure that the user knows how to use the device correctly. One professional thought that the device’s simplicity leads do-it-yourself installers to believe that they can install the device—only to mount it incorrectly.

Both cohorts were divided on whether an immediate need existed for the StairSteady or if a future need would arise. The professionals were less likely than the users and caregivers to believe that the device was needed. In some cases, users thought they did not need the StairSteady now because they could still navigate the stairs using a cane. Nonetheless, some professionals thought the device needed improvements before they would recommend it.

AssiStep Evaluation

The responses from the participants about the AssiStep are like the ones provided for the StairSteady device. Professionals, users, and caregivers considered the AssiStep easy to install and clean but not easy to match with any home decor, given the design of the device. Most participants believed that the AssiStep required little maintenance, even though the rail has a sophisticated metal track with special gears inside. In general, the users and caregivers liked the 18

appearance of the AssiStep more than did the professionals. 11 Both cohorts found the AssiStep instructions easy to understand, but most thought the device required some practice to use correctly. During the evaluation, most participants found going up the stairs very easy because of the special track on which the handle glides. However, an equal number of participants struggled with disengaging the handle from the track when going down the stairs. As a result, most professionals, users, and caregivers were divided about whether they “had problems using the device.” Exhibit 18 illustrates the difference in opinion within both cohorts and that professionals more often cited problems than did the users and caregivers.

Exhibit 18. Comparison of Cohorts 1 and 2: Had Problems with Device

When the professionals evaluated the AssiStep, they were not evaluating the device for personal use but were considering whether their clients or patients could use it. Nearly all professionals thought that others would have problems with the AssiStep even when they did not have difficulty using the device. However, the users or caregivers typically supposed, “If I can do it, anyone can,” or “If I had a problem, someone else will have a problem too.”

Exhibit 19 illustrates how the users and caregivers and the professionals thought about other potential users differently.

11 Because the AssiStep and StairSteady devices were side by side on the demonstration platform, the participants often compared the appearance and other functions of the two devices, likely because both the AssiStep and StairSteady devices were stair-climbing assistive devices.

19

Exhibit 19. Comparison of Cohorts 1 and 2: Others Would Have Problems with Device The AssiStep was installed according to the manufacturer’s instructions. The device’s handle can be adjusted vertically after it has been installed on the metal track. No handle adjustments were made for participants, and the handle position was not considered an issue. Instead, most participants were concerned with (1) how to disengage the handle when going downstairs and (2) how to fold the device away when it is not being used.

Exhibit 20. Correct Position of Handle

Exhibit 21. Upper and Lower Bars

Source: Home Innovation

Source: Home Innovation

A closer look at the AssiStep illustrates the adjustability of the handle in relation to the user. The participants could hold one of two locations (the upper bar or the lower bar) of the handle while allowing the standing user’s elbow to be at 90°. Exhibit 20 illustrates the correct standing position for the AssiStep, and exhibit 21 illustrates the handle’s two bar locations.

20

The AssiStep’s handle can be adjusted up and down, as shown in exhibit 22. When one is walking down the stairs, the device’s handle must be lifted to disengage the metal track, as shown in exhibit 23. The center of gravity for the Home Innovation staff person is not leaning over the handle. Nonetheless, some participants thought that lifting the handle could be difficult for some elderly users.

Exhibit 22. Adjusting Handle and Disengaging the Track

Exhibit 23. Descending the Stairs

Source: Home Innovation

Source: Home Innovation

Although the AssiStep was considered easy to install, it must be adjusted to the user’s height.

Most professionals expressed concerns about having to lift the handle on the device while descending the stairs; they believed that it could be difficult for an older person. The users and caregivers were less concerned, believing that, with practice, a person could safely disengage the handle from the track.

Both cohorts were divided on whether an immediate need existed for the AssiStep or if a future need was likely. The professionals were less likely to believe that the device was needed than were the users and caregivers. In some cases, users thought they did not need the AssiStep now because they could still navigate the stairs using a cane. Some professionals said that the device needed a mechanism to lock in an emergency—in case the handle was disengaged from the track—as an additional safety feature before they would recommend it.

FlexStep Evaluation

Professionals, users, and caregivers considered the FlexStep easy to clean and maintain, nice looking, and easy to match with any home decor. Both cohorts found the FlexStep instructions easy to understand but also thought the control buttons on the device required some practice to use correctly. During the evaluation, most participants had to try the control buttons several times to understand how to operate the FlexStep. As a result, most professionals, users, and caregivers “needed Resistance to use the FlexStep.” They believed that others would need formal training to remember what control buttons to push and what to do in a power outage. The FlexStep comes with a backup battery, but many participants were worried that power would go out and they would be trapped on an upper floor in the house if they depended solely on the FlexStep.

21

Both cohorts agreed that installing the FlexStep would not be easy. They assumed that the user would need to hire a professional to complete the installation and provide training to use the device correctly. Exhibit 24 illustrates how similar the responses were for the users and caregivers and the professionals.

Exhibit 24. Comparison of Cohorts 1 and 2: Easy to Be Installed

Both cohorts were concerned about maintenance and repair options for the FlexStep. Users and caregivers thought that finding general maintenance service for the device would be difficult. In addition, some respondents expressed concern about the cost of maintenance and repair. Many thought that if the purchase cost of the FlexStep was expensive, then maintenance and repair would likely be equally expensive. The manufacturer stated that authorized FlexStep dealers throughout the United States offer maintenance plans. Furthermore, the manufacturer stated that the FlexStep would not need annual maintenance; the company recommends maintenance every 5 years.

The users and caregivers complained about the noisy operation and warnings from the FlexStep.

When in operation, the device made multiple “beeping” noises and flashed lights. The manufacturer stated that many warning cues can be disabled, or the device’s volume can be turned down. The automatic sensors and safety features on the FlexStep were well received—the device is designed to prevent pets and objects from getting trapped under the stairs as it converts from stairs to a lift. Some additional features were recommended for individuals who are hearing impaired.

The FlexStep can accommodate individuals with a wide range of mobility-related disabilities, including users who have moderate mobility limitations and those who use wheelchairs.

Participants liked that multiple people of different sizes and statures could use the FlexStep without special configurations. Exhibit 25 illustrates the FlexStep in the default step mode, exhibit 26 illustrates the transition mode, and exhibit 27 illustrates the final lift position at the top of the landing.

22

Exhibit 25. Stair Mode

Exhibit 26. Lifting Mode

Exhibit 27. Final Position

Source: Home Innovation

Source: Home Innovation

Source: Home Innovation

Most users and caregivers who did not want the FlexStep thought it would not fit in their house due to the layout of their exterior or interior stairs—multiple levels in their townhome or row house, older narrow stairways—and they were concerned about the cost of major renovation to use the device. Many participants thought that the FlexStep would be almost impossible to integrate into interior floor spaces, but most thought that the FlexStep could work at entryways such as backyard doors or inside garages, where short flights of steps were common.

All-Push Door Evaluation

Professionals, users, and caregivers considered the All-Push Door easy to install and clean and would match any home decor. Most participants believed that the All-Push Door required little maintenance. Both cohorts found the instructions easy to understand but also thought the locking mechanism on the door should be easier to operate. Some participants thought that knowing whether the door was locked was difficult because of the two sets of locks. During the evaluation, most participants had to try out the locking sequence several times to understand how to operate the All-Push Door. As a result, most professionals “needed assistance to use the All-Push Door.” In addition, many professionals, users, and caregivers “made mistakes that required them to redo some steps.” The participants believed that others would need some practice to learn how to use the double set of locks; a few other participants recommended different locks for the All-Push Door.

Both cohorts disagreed about how much assistance was needed to operate the All-Push Door.

The users and caregivers appeared to make fewer mistakes operating the door than did the professionals. Exhibits 28 and 29 illustrate the differences in the number of mistakes made and in the need for assistance, respectively, comparing both cohorts.

23

Exhibit 28. Comparison of Cohorts 1 and 2: Mistakes Made and the Need to Redo Steps Exhibit 29. Comparison of Cohorts 1 and 2: Needed Assistance

As shown in exhibit 28, the users and caregivers were somewhat divided about how many mistakes were made that required them to redo steps during the operation of the All-Push Door.

24

However, most of the professionals stated they had to redo steps. The locking sequence was the step that required some clarification.

As shown in exhibit 29, most users and caregivers did not need much assistance to use the All-Push Door. They were able to figure out the function of the locking mechanism and were confident that with some practice, they could master all functional aspects of the All-Push Door.

Many professionals thought that the small locking mechanisms of the device could present a problem to those individuals with arthritis or other hand grasping issues. When the professionals considered the operation of the All-Push Door and whether their clients or patients could operate the device with ease, many thought that some elderly clients or patients could accidentally leave one of the multiple locks open. Exhibits 30 and 31 illustrate the operation of the All-Push Door.

Exhibit 30. Outer Door Frame Operation

Exhibit 31. Inner Door Frame Operation

Source: Home Innovation

Source: Home Innovation

The All-Push Door has a double-hinged mechanism that allows the door to be pushed from either direction to go through the doorway. In exhibit 30, the door is being pushed from the inside. In exhibit 31, the door is being pushed from the outside. The user of this door type does not have to pull the door open. The All-Push Door operates just like swinging doors in a restaurant.

The participants believed that the All-Push Door addresses the problem of having to back up when approaching a door that opens toward the person using an assistive device. Whether the individual is in a wheelchair, using a walker or cane, or simply having a mobility issue, being able to push the door open from either side of the doorway is of great benefit.

Although operating the door was not completely intuitive due to the double set of locks on the inner and outer frames of the door (the locks are best seen in exhibit 30, near the door handle), 25

the participants thought that it was a minor issue that could be overcome with some instruction and practice. The door was considered attractive, and it appears to be a standard door size.

The manufacturer claims that the door can be made available in many styles to fit almost any interior or exterior decor; other features such as peepholes, glass panes, and keypad entries instead of a lock and key can be easily added to the All-Push Door. The door is not widely available in the United States, but the manufacturer plans to distribute the product in the United States in the near future.

26

COST-BENEFIT ANALYSIS

When considering the costs and benefits of the accessibility devices in the study, Home Innovation focused on answering two key questions:

How does the cost of the accessibility device compare with the typical retrofit solution?

Does the device improve mobility within the home?

Home Innovation identified the cost range for typical retrofit solutions, whereas the product manufacturers in the study provided cost ranges for their accessibility devices. In addition, the survey asked participants to identify the price they were “willing to pay” for each accessibility device they evaluated. As a result, the cost analysis included a comparison of (1) the typical retrofit solution, (2) the innovative accessibility device, and (3) the price participants were willing to pay. Only some participants in the study answered the willingness-to-pay question.

StairSteady Cost-Benefit Analysis

Exhibit 32 illustrates the cost comparison for the StairSteady. The authors identified the amount of money that Cohorts 1 and 2 were willing to pay. They included the cost range for the typical retrofit solution: a stair lift device. The authors also provided the manufacturer’s price for the StairSteady.

Exhibit 32. Cost Comparison—Willingness to Pay: StairSteady and Stair Lift $15,000

Stair Lift

Cost

$2,000

StairSteady

Mfg. Cost

Mfg. = manufacturing. Pros = professionals.

The StairSteady was approximately $1,150, not including $500 for shipping the device from Canada. The StairSteady price was based on the straight length of the stairs, hardware, and the number of turns the rail must accommodate. When comparing the median price that the users and pros were “willing to pay” ($300 to $750) for 6 to 8 ft. of straight-run StairSteady product with what the manufacturer’s price was—without the cost of labor to install—the costs were similar.

If one considers the price for a stair lift traveling straight for 8 to 10 ft., the best price is approximately $2,000. The price range can easily go up to $15,000 if complexity is added to the stairs (Robinson-Walker and Millard, 2022).

27

The StairSteady costs less than a typical stair lift, and it can improve mobility in the home, but it has limitations. The StairSteady must be customized and installed for just one user. A stairlift can accommodate more than one user—provided the additional users do not exceed the chair’s weight limit. The StairSteady is a manual device; therefore, the user must have some upper body strength to use the handle. If users have a degenerative condition in which their mobility-related disability progresses, they may not be strong enough to use the StairSteady device in the future.

A stairlift can remain useful even as a user’s mobility-related limitations worsen.

AssiStep Cost-Benefit Analysis

Exhibit 33 illustrates the cost comparison for the AssiStep. The authors identified the amount of money that Cohorts 1 and 2 were willing to pay, including the cost range for the typical retrofit solution—a stair lift device. The authors also provided the manufacturer’s price for the AssiStep.

Exhibit 33. Cost Comparison—Willingness to Pay: AssiStep and Stair Lift

Mfg. = manufacturing. Pros = professionals.

The AssiStep was approximately $2,060, not including $680 for shipping the device from Norway. The AssiStep price was based on the straight length of the stairs, hardware, and the number of turns the rail must accommodate. When comparing the median price that the users and pros were “willing to pay” ($750) for 6 to 8 ft. of straight-run AssiStep product with what the manufacturer’s price was—without the cost of labor to install—the manufacturer’s price was twice as much as the willing-to-pay price. If one considers the price for a stair lift traveling straight for 8 to 10 ft., the best price is approximately $2,000. The price range can easily go up to $15,000 if complexity is added to the stairs (Robinson-Walker and Millard, 2022).

The AssiStep manufacturer stated that the cost range is virtually the same as a typical stair lift.

The AssiStep does have more functionality than the StairSteady device and can improve mobility within the home, but there are limitations. It must be customized and installed for one user (but can be adjusted to accommodate another user of similar stature). A stair lift can accommodate more than one user (provided the additional users do not exceed the chair’s weight limit). The AssiStep is a manual device, but the gear design of the track does not require much upper body strength to push the handle. However, if users have a degenerative condition in which their 28

mobility-related disability progresses, they may not be strong enough to use the AssiStep device in the future. A stair lift can remain useful even as a user’s mobility-related limitations worsen.

FlexStep Cost-Benefit Analysis

The cost comparison for the FlexStep is illustrated in exhibit 34. The authors identified the amount of money that Cohorts 1 and 2 were willing to pay and included the cost range for the typical retrofit solution—a wheelchair lift device. The authors also provided the manufacturer’s price for the FlexStep.

Exhibit 34. Cost Comparison—Willingness to Pay: FlexStep and Wheelchair Lift Mfg. = manufacturing. Pros = professionals.

The FlexStep was approximately $10,400, not including $640 for shipping the device from Norway. The FlexStep price was based on raising the user’s height by four steps (or approximately 3 ft.). When comparing the median price that the users and pros were “willing to pay” ($2,750 to $6,500) with what the manufacturer’s price was (without the cost of labor to install), the manufacturer’s price was twice as much as the willing-to-pay price. If one considers the price for a wheelchair lift raising the user approximately 3 ft., the best price is approximately $4,000 to $6,000. The price range can easily go up to $30,000 if additional stairs or a second story is included (HomeElevators.com, n.d.).

The FlexStep is more expensive than the typical wheelchair lift, but the FlexStep can serve as both a lift and traditional stairs, accommodating more user types in one building. It has more utility than a traditional wheelchair lift because it requires less space. The FlexStep is also more aesthetically appealing and less “institutional-looking” than a traditional wheelchair lift. Both products can remain useful as a user’s mobility-related limitations worsen.

All-Push Door Cost-Benefit Analysis

Exhibit 35 illustrates the cost comparison for the All-Push Door. The authors identified the amount of money that Cohorts 1 and 2 were willing to pay, including the cost range for the typical retrofit solution—a residential automatic door opener. The authors also provided the manufacturer’s price for the All-Push Door.

29

Exhibit 35. Cost Comparison—Willingness to Pay: All-Push Door and Door Opener Mfg. = manufacturing. Pros = professionals.

The All-Push Door was approximately $1,500—not including $2,265 for shipping the door from Taiwan. The All-Push Door price was based on a heavy-duty, 36-in.-wide door. When comparing the median price that the users and pros were “willing to pay” ($750–$1,150) for the door with the manufacturer’s price—without the cost of labor to install—the manufacturer’s price was 50 percent more than the willing-to-pay price. If one considers the price for an automatic door opener, the best price is approximately $850. The price can increase to $2,700 if more controllers are added (Gentleman Door Automation LLC, n.d.).

The manufacturer stated its intention to mass produce the All-Push Door in the United States to further reduce costs. The All-Push Door can improve mobility in the home by making entering and exiting the house easier. As a retrofit product, the All-Push Door may reduce the width of the door opening because the double-hinge frame requires more space than a standard door frame. The automatic door opener may be more cost effective and easier to retrofit if major modifications are made to the existing door framing.

30

CHALLENGES AND BARRIERS

The challenge for homeowners attempting to improve the accessibility and function of their townhome or row house starts with one question: “Where do I begin?” Based on the literature review, any home improvement for accessibility should bolster or improve the occupant’s ability to perform activities of daily living (ADLs). The needs of the occupants must be known to ensure the best remodeling outcome. In planning for a home modification, an individual with a disability or physical limitation should have an ADL assessment (Gaunt, 2022), which is typically done by a physician or occupational therapist. For ADL assessment, the occupational therapist visits the home and completes an OT Home Health Evaluation Checklist and Quality Measures assessment form (AOTA, n.d.). The occupational therapist evaluates the person’s physical capabilities in his or her home environment and identifies barriers to be addressed.

A barrier can be a physical condition of the home that prevents an individual with a disability from using the house safely. Retrofits or adaptations may be necessary to remove the barriers.

The occupational therapist can prescribe assistive devices and minor home modifications, but any major retrofits or renovations are typically done by a remodeler specializing in accessibility.

For example, mobility is one of the ADLs that are evaluated. If someone has a mobility-related disability and needs assistance walking or transferring from one place to another, the occupational therapist may prescribe an assistive device such as a cane or walker. The occupational therapist may note that the person would benefit from a ramp and a no-threshold doorway home modification, but those products are not medical devices that the doctor or occupational therapist can prescribe.

If a home retrofit or renovation is needed, the homeowner will need to hire a remodeler with expertise in accessible design. The homeowner would benefit from understanding some basic information about improving accessibility. AARP publishes an easy-to-use home assessment document titled, AARP HomeFit Guide, which highlights features every house should have and recommends improvements to make the house easier for older adults to use (AARP, 2021). The homeowner should consider consulting with a remodeler that specializes in accessibility, such as a universal design (UD) professional (NARI, n.d.) or a Certified Aging-in-Place Specialist (CAPS; NAHB, n.d.).

In some cases, the homeowner may benefit from engaging multiple experts on a team, including a physician, an occupational therapist, and a remodeler specializing in accessibility. A plan can be developed so that the improvements are prioritized and done in phases if financing the home improvements is cost prohibitive.

Affordability

Remodeling to improve accessibility is expensive, especially in existing townhomes and row houses. During the focus group discussions, most residents and caregivers cited cost as the most important consideration. A general perception existed that retrofits and modifications would be too expensive to afford, and some believed that implementing accessibility improvements would be difficult without financial assistance.

Participants noted a lack of resources and did not know where to find reliable information about accessibility for residential houses or government grants, rebates, and other incentives that could reduce the cost of remodeling. In general, greater awareness and understanding of available options are needed.

31

Several federal grants and loans are available for home improvements. The U.S. Department of Veterans Affairs (VA) offers four grant programs that include Specially Adapted Housing (SAH) Grants, Special Housing Adaptation (SHA) Grants, Temporary Residential Adaptation (TRA) Grants, and Home Improvements and Structural Alterations (HISA) Grants (VA, 2022). The requirements for each grant vary, and applicants must be veterans. The U.S. Department of Agriculture offers the Rural Housing Repair Loans and Grants program for seniors who live in rural areas of the United States (USDA, n.d.). The U.S. Department of the Interior, Bureau of Indian Affairs, offers the Housing Improvement Program (HIP) for members of Native American tribes (DOI/BIA, n.d.).

Several state grants and loans for home improvements are obtainable:

• The State of Maine offers the Home Accessibility and Repair Program for low-income people living with disabilities.

• The State of Illinois offers a Home Accessibility Program for people with disabilities.

• The State of Maryland offers an Accessible Homes for Seniors Program for people older than age 55. Many other state grant programs are accessible throughout the country.

Several private disability grants for home improvements are also available:

• The Travis Roy Foundation Grant is available to homeowners with spinal cord injuries.

• The Modest Needs Foundation offers Self-Sufficiency Grants to homeowners with lower incomes.

• Rebuilding Together offers volunteer no-cost home repairs and upgrades. For homeowners who do not qualify for any of those grants, other low-cost loan programs are available through the Federal Housing Administration (FHA) 203 (k) rehabilitation loan and the Federal National Mortgage Association (Fannie Mae) Home Style Renovation Mortgage.

In some cases, the cost of major renovations, retrofits, and remodeling projects may still be prohibitive because the grants are not large enough to cover the total cost of the project. One solution explored by this project was to identify more accessibility product options that are affordable and functional.

Accessibility Products and Availability

The four accessibility products evaluated by Home Innovation successfully improved the user’s mobility. The StairSteady assistive device costs less than a conventional stair lift product, and the AssiStep was similar in cost to a conventional stair lift product. The FlexStep was more expensive than a similarly sized wheelchair lift device but could also convert into a flight of stairs and had superior aesthetics—preferred by users of accessibility devices. The All-Push Door was comparable in cost to an automatic door opener but could easily exceed that range if installation requires a major door frame modification.

The assistive devices in this study were manufactured outside the United States. European countries and Canada have developed assistive devices that install on stairs and doors at a much greater frequency than the United States. Those devices were considered against other devices and selected by the research team in consultation with the technical advisory group. Because the assistive devices were manufactured outside the United States, their availability was limited, and there were added costs associated with shipping. Most products in this study must be purchased 32

directly through the manufacturer’s website, and then the buyer must wait several weeks for the product to arrive. Purchasers of the StairSteady, AssiStep, and All-Push Door must hire a remodeler to install those products. The manufacturer of the FlexStep has distributors in the United States, so the product can be readily found, and the distributor will complete the installation, provide maintenance, and offers warranty services. The manufacturer of the All-Push Door is interested in manufacturing the product in the United States; that interest may lead to lower costs and wider availability in the long term. If the other product manufacturers do the same, these accessibility products could be widely used; but for now, all have limited availability.

In other countries, particularly the Nordic countries, national health services—financed through mandatory long-term care insurance—will pay for these assistive devices. This arrangement increases demand, establishes a built-in market, and provides a mechanism to market the products through the professionals who provide the services. In the United States, developing innovative products such as these devices is much riskier because manufacturers need significant capital to reach the market. That financial reality is an important finding of the research and suggests that HUD develop a program to help designers and manufacturers develop innovative products or facilitate the introduction of such products into the U.S. market.

One of the barriers to introducing products from other countries into the U.S. market is compliance with codes and standards. The FlexStep complies with ASTM A18.1 Safety Standard for Platform Lifts and Stairway Chairlifts; therefore, the product can be used in accessibility applications in which an ASTM A18.1 product is specified (American Society of Mechanical Engineers, 2021). The AssiStep complies with the requirements of a low-risk medical device in Europe, and the manufacturer is considering applying for a similar designation in the United States. Gaining that designation will be challenging because the StairSteady and AssiStep products are regarded as home remodeling or improvement products in the United States; no similar devices are listed in Medicare’s Durable Medical Equipment directory (U.S. Centers for Medicare and Medicaid Services, n.d.). The U.S. Food and Drug Administration recognizes certain stair lifts as a Physical Medicine Therapeutic Device (under Part 890, Subpart F—Section 890.5150—Powered Patient Transport). 12 HUD could be influential in working with industry to develop standards for products that do not fit in the FDA’s domain of medical equipment or in the domain of existing standards for building products such as ASTM A18.1. The Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) is the International Organization for Standardization (ISO)-designated organization in the United States for the development of standards in the field of assistive technology. HUD could work with RESNA to identify which additional standards are needed and coordinate with ISO standards committees so that standards approved by ISO could be simultaneously approved in the United States.

In rare cases, persons with disabilities can get certain devices paid for by Medicare or Medicaid if they can prove that a device is medically necessary for their safety or welfare in the home.

Typically, the user of the device has a waiver to receive care in the home instead of moving to a nursing facility. In general, a physician must make a case for certain devices and complete a Certificate of Medical Necessity form CMS-849—this form is explicitly for seat lift mechanisms (U.S. Centers for Medicare and Medicaid Services, 2019). Getting approval for the waiver may 12 “Physical Medicine Therapeutic Devices,” 21 CFR Part 890.5150. March 4, 2013.

https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr=890.5150.

33

take a long time. HUD could coordinate with the Centers for Medicare and Medicaid Services to establish a list of approved devices that do not require the waiver process. This procedure would make devices such as the ones tested in this project easier to fund through an established and well-funded federal program. It would also eliminate the cost of such devices to HUD’s home modification program so that those grants could also be applied to brick-and-mortar retrofits and adaptations rather than only the cost of devices. Such a program could be tied to the standards initiative proposed previously.

34

RECOMMENDATIONS

Residents in the study expressed a strong willingness to adapt their homes to meet their needs.

Improving a home’s functionality to accommodate the needs of individuals with disabilities or limitations was of primary importance to both the users and the caregivers. An inherent value is associated with staying in one’s home; it provides a sense of independence and well-being.

Although aspects of existing townhomes and row houses presented a challenge, the residents wanted to stay in their homes.

The accessibility devices evaluated in this study offer some new options, but in terms of performance, they are not “game changers.” The StairSteady is the most affordable option but is a manual device that can only be used by individuals with some remaining upper body strength.

If the person suffers from a degenerative disease or osteoarthritis, walking up and down stairs using a manual device may cause the person’s joints to deteriorate faster. The AssiStep is also a manual device for stairs, but it is somewhat easier to use, requiring less upper body strength. The price of the AssiStep is only slightly less than a conventional stair lift device; it is marketed as a rehabilitation device, suggesting that the user may get some exercise or other physical benefits through using the device. The FlexStep is innovative because it can transform from a lift to a flight of stairs. The price is about 30 percent more than a traditional chair lift, but the innovation may be worth that premium—it eliminates the need to have a lift and a separate set of stairs. The All-Push Door, a manual door that can be “pushed open” in both directions, is comparable in price to an automatic door opener device.

For some townhomes and row houses, the best decision is for the homeowner to move because (1) a major retrofit or adaptation of the property, such as adding a bedroom or full bathroom on the first floor, cannot be done cost effectively; and (2) the floor plan constraints and local building code requirements may make retrofitting or adapting the property impossible. Many residents may want to move but may also believe that they have no good alternatives because of the stigma associated with assisted living, nursing homes, and certain types of senior housing options (Zimmerman et al., 2016). If the property value is depressed, the homeowner may be unable to move or retrofit the property due to a lack of equity. Another challenge is a lack of affordable, accessible housing and long waiting lists when housing does exist.

Home Innovation recommends the following activities for HUD to implement:

• In collaboration with occupational therapists, develop better assessment tools that prioritize retrofits and adaptations so they can be done incrementally, as funding becomes available. For example, a full home assessment may identify five areas that need retrofits: those areas should be prioritized so that the most important improvements are made in sequence (from most to least important). An assessment tool could help residents and service providers understand the value proposition for implementing renovations or, as an alternative, relocating to a more accessible dwelling.

• In collaboration with HHS, consider working with the Centers for Medicare & Medicaid Services to approve the purchase of home accessibility products that meet safety and usability requirements. This activity can be coupled with a new product-testing and certification program to provide guidance for product manufacturers and give consumers more confidence in the safety and usability of such products.

35

• Partner with RESNA, the ISO-designated standards organization in the United States for assistive technology, to coordinate with ISO standards committees so that products that meet ISO standards are also approved in the United States. This collaboration should include funding RESNA to develop new standards for products such as the StairSteady and AssiStep, the All-Push Door, and others that should not be treated like prosthetic devices. 13 This partnership could facilitate importing products that have been developed and opening new markets for U.S. manufacturers.

• Study the impact of relocation costs on decisions to move when home modifications are not a good value proposition for the household. This research could also determine whether existing HUD programs, such as the Community Development Block Grant program and the Older Adult Home Modification Program, can be used to provide relocation expense grants or whether a new program might be needed.

HUD should partner with RESNA and the Assistive Technology Industry Association (ATIA) to create an innovation competition focused on developing better devices for accessibility. The first competition can focus on the type of products that most effectively overcome barriers in existing townhomes and row houses. The participants in the competition could be university graduate students or seasoned industry subject matter experts.

HUD should evaluate the existing program with the American Institute of Architects to determine whether it effectively promotes professional education on design for aging in place.

The assessment should include criteria such as the adoption of the program by a broad range of architecture schools, the knowledge about aging in place represented in the winning entries in previous years, and the inclusion of innovative ideas. The evaluation could also engage faculty at architecture schools who have not adopted the program to find out why and obtain their opinions on what could be improved to make the program more effective.

Home Innovation will disseminate consumer-friendly information gathered during this research project. The authors believe that this type of outreach is critical given that many participants stated they did not know where to go for reliable accessibility information. The authors will share their findings and tips with advocacy organizations such as AARP, NAHB, and the National Association of Area Agencies on Aging.

13 The manufacturer of the FlexStep has already gone through the process of having their product recognized by the FDA under lift device requirements.

36

FUTURE RESEARCH

The four innovative products described in this study show that many opportunities exist for innovation. They also demonstrate the economic value of government support for home modification services. Such support can create a market for innovation, improve product quality, and reduce the cost of retrofits and adaptations. Spending caps and the available funding are much higher there because the governments’ national healthcare programs bear the cost of home care and other assistance. Furthermore, home modification services in those countries routinely involve professional physical therapists and designers. That arrangement creates an infrastructure to assess homes adequately, make informed recommendations to households, and develop the most effective solution for each household.

Home Innovation and the IDeA Center recommend that HUD support future research to study European approaches to home modifications. That research should include the economics of product development and best practices in service delivery. The study could also identify European products that could be imported to the United States and assess potential barriers perceived by European companies. Exceptional European researchers who study home modifications could collaborate with U.S. colleagues.

All the research on preferences for housing in old age has demonstrated that older people want to age in place. However, the cost of home modifications is clearly a major barrier for homeowners.

The desire to age in place may be an artifact of the lack of incentives to relocate. The lack of incentives plus the psychic and economic cost of relocation could be fueling the desire to age in place, even when, objectively, it may not make sense. The authors know of no study that explored the reasons why older people do not relocate rather than remain in place, especially when their housing is not amendable to supporting independence.

The focus group finding suggests that a valuable followup research study could examine how home builders, remodeling contractors, and their design consultants communicate the concept of design for aging in place to clients. Research questions could include—

• How many home builders, remodeling contractors, and their design consultants know enough to design for aging in place?

• Do they present the idea to clients?

• What language and approaches are most successful in getting clients to adopt aging-in-place practices?

The output could include revisions to the CAPS curriculum and online courses that builders and remodelers could access to become more informed.

According to the Census Bureau, a house is considered accessible when it has a step-free entrance or ramp, a bedroom on the first floor, and a full bathroom on the first floor. Although the Fair Housing Act requires a range of accessibility features in new construction of dwelling units, many types of housing are exempt from these requirements. HUD may consider incentivizing accessible features in new townhomes and row houses that are otherwise exempt from the design and construction requirements of the Fair Housing Act. By adding more universal design features to new housing, the need for accessible modifications in the future may be avoided.

37

REFERENCES

AARP. 2021. AARP HomeFit Guide. https://www.aarp.org/content/dam/aarp/livable-

communities/housing/2020/homefit/AARP%20HomeFit%20Guide-singles-062022.pdf.

American Association for Long-Term Care Insurance (AALTCI). n.d. Long-Term Care Insurance Information Resource Center. https://www.aaltci.org/long-term-care-

insurance/resource-center/.

American Occupational Therapy Association, Inc. (AOTA). n.d. “OT Home Health Evaluation Checklist & Quality Measures.” https://www.aota.org/practice/domain-and-process/-

/media/2fed2d479efd4bfcb1d5a40287b9a884.ashx.

American Society of Mechanical Engineers. 2021. “A18.1-2020 Safety Standard for Platform Lifts and Stairway Chairlifts.” https://www.asme.org/codes-standards/find-codes-standards/a18-

1-safety-standard-platform-lifts-stairway-chairlifts.

Bayer, Ada-Helen, and Leon Harper. 2000. Fixing to Stay: A National Survey of Housing and Home Modifications Issues. Washington, DC: AARP.

https://www.aarp.org/content/dam/aarp/research/surveys_statistics/general/fixing-to-stay.pdf

Center for Universal Design at NC State. n.d. The Principles of Universal Design.

https://www.udinstitute.org/_files/ugd/634d48_3139cce3918548a58619252b8a6401d9.pdf.

Gaunt, Angelike. 2022. Activities of Daily Living Checklists for Seniors. A Place for Mom.

https://www.aplaceformom.com/caregiver-resources/articles/adls-iadls.

Gentleman Door Automation LLC. n.d. “Easy Gentleman Air Powered Door Opener (Interior Doors).”

https://www.gentlemandoorautomation.com/store/p7/Easy_Gentleman_Air_Powered_Door_Ope

ner_%28Interior_Doors%29.html.

Goyer, Amy. 2021. Resources, Gadgets and Tools to Care for an Older Adult at Home.

Washington, DC: AARP. https://www.aarp.org/caregiving/home-care/info-2021/tips-for-aging-

independently.html.

HomeAdvisor (Reviewed by Ezra Laniado, expert contributor). 2022. “How Much Does It Cost To Remodel For Disability Accommodation?” Remodel for Disability Accessibility.

https://www.homeadvisor.com/cost/environmental-safety/remodel-for-disability-

accommodation/.

HomeElevators.com. n.d. Wheelchair Lifts. https://homeelevators.com/wheelchair-

lifts/#:~:text=Price%20of%20a%20wheelchair%20lift%20The%20cost%20of,over%20%2430%

2C000%20depending%20on%20what%20type%20you%20need.

National Association of Home Builders (NAHB). n.d. “Professionals with Home Building Designation: CAPS.” Washington, DC. https://www.nahb.org/nahb-community/nahb-

directories/professionals-with-home-building-designations-

directory#sort=%40lastname%20ascending&f:Designation=[CAPS].

National Association of the Remodeling Industry (NARI). n.d. “Universal Design Certified Professional (UDCP).” https://www.nari.org/certification-accreditation/certification/universal-

design-certified-professional.

38

North Carolina State University: School of Design. 1997. A Blueprint for Action: A Resource for Promoting Home Modifications. Prepared for the U.S. Department of Housing and Urban Development, Office of Policy Development and Research. Washington, DC: HUD.

https://www.huduser.gov/portal/publications/destech/blueprin.html.

Pynoos, Jon, and Christy M. Nishita. 2003. “The Cost and Financing of Home Modifications in the United States,” Journal of Disability Policy Studies 14 (2): 68–73.

https://doi.org/10.1177/10442073030140020201.

Robinson-Walker, Dawnielle, and Elizabeth Millard. 2022. “Best Stair Lifts of 2022,” Forbes Health. https://www.forbes.com/health/healthy-aging/best-stair-lifts/.

Salomon, Emily. 2010. Fact Sheet: Home Modifications to Promote Independent Living.

Washington, DC: AARP Public Policy Institute. https://assets.aarp.org/rgcenter/ppi/liv-

com/fs168-home-modifications.pdf.

Slaug, Björn, Oliver Schilling, Susanne Iwarsson, and Gunilla Carlsson. 2011. “Defining Profiles of Functional Limitations in Groups of Older Persons: How and Why?” Journal of Aging and Health 23 (3): 578–604. https://doi.org/10.1177/0898264310390681.

Steinfeld, Edward, and Jordana Maisel. 2012. Universal Design: Creating Inclusive Environments. Hoboken, NJ: John Wiley & Sons.

Steinfeld, Edward, and Scott Shea. 1993. “Enabling Home Environments: Identifying Barriers to Independence,” Technology and Disability 2 (4): 69–79. https://www.deepdyve.com/lp/ios-

press/enabling-home-environmentsidentifying-barriers-to-independence-eIOtJoXXCW.

U.S. Census Bureau and U.S. Department of Housing and Urban Development. 2021. “2019

Home Accessibility,” 2019 American Housing Survey.

https://www.census.gov/library/visualizations/2021/demo/2019-home-accessibility.html.

U.S. Centers for Medicare and Medicaid Services. 2019. “Certificate of Medical Necessity Form CMS-849—Seat Lift Mechanisms.” https://www.cms.gov/medicare/cms-forms/cms-

forms/downloads/cms849.pdf.

———. n.d. Durable Medical Equipment (DME) Coverage.

https://www.medicare.gov/coverage/durable-medical-equipment-dme-coverage.

U.S. Department of Agriculture (USDA). n.d. “Rural Housing: Housing Repair Loans and Grants.” https://www.benefits.gov/benefit/402.

U.S. Department of the Interior, Bureau of Indian Affairs (DOI/BIA). n.d. “Housing Improvement Program.” https://www.bia.gov/bia/ois/dhs/housing-improvement-program.

U.S. Department of Veterans Affairs (VA). 2022. “Disability Housing Grants for Veterans.”

https://www.va.gov/housing-assistance/disability-housing-grants/.

Zimmerman, Sheryl, Debra Dobbs, Erin G. Roth, Susan Goldman, Amanda D. Peeples, and Brandy Wallace. 2016. “Promoting and Protecting Against Stigma in Assisted Living and Nursing Homes,” The Gerontologist 56 (3): 535–47.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4873761/.

39

APPENDIX A:

HOME MODIFICATION LITERATURE REVIEW

40

Home Modification Literature Review

Prepared for

U.S. Department of Housing and Urban Development

Office of Policy Development and Research

HUD FR-6000-N-29

Research, Prototype Testing, and Evaluation

of Accessible Design Retrofits

for Semi-Detached and Nondetached Houses

Prepared by

Center for Inclusive Design and Environmental Access

School of Architecture and Planning

State University of New York at Buffalo

and

Home Innovation Research Labs

March 2018

41

Table of Contents

Preface........................................................................................................................................... 43

Introduction ................................................................................................................................... 45

Inclusion and Exclusion Criteria ................................................................................................... 46

Description and Scope of Home Modifications ............................................................................ 47

Characteristics of Target Populations ........................................................................................... 48

Aging............................................................................................................................................. 48

Decreased Mobility ....................................................................................................................... 49

Cognitive Impairments.................................................................................................................. 49

Visual Impairment ........................................................................................................................ 50

Beyond Codes and Standards........................................................................................................ 51

Design ........................................................................................................................................... 52

Entrances and Exits ....................................................................................................................... 52

Bathrooms ..................................................................................................................................... 53

Kitchens ........................................................................................................................................ 54

Doorways and Hallways ............................................................................................................... 55

Stairs ............................................................................................................................................. 56

Effectiveness ................................................................................................................................. 57

Perceptions and Motivations ......................................................................................................... 57

Outcomes ...................................................................................................................................... 58

Certification Programs .................................................................................................................. 59

Discussion ..................................................................................................................................... 59

Key Findings ................................................................................................................................. 59

Identified Gaps .............................................................................................................................. 61

Conclusion .................................................................................................................................... 62

References ..................................................................................................................................... 63

Credentialing ................................................................................................................................. 67

Popular Home Modification Products and Suppliers.................................................................... 69

42

Preface

This literature review is part of a 3-year research project funded by the U. S. Department of Housing and Urban Development (HUD). HUD has identified a housing typology—townhomes and row houses—in need of innovative solutions for the growing population who experience physical, mental, or sensory challenges that threaten their ability to remain safely and productively in their homes. Such homes are characterized by narrow floor plans and functionality spread among several levels, often with elevated entrances. Those home configurations are particularly challenging when modifications are required to improve access, safety, and usability for elderly residents and residents with disabilities. The United States has a large housing stock of semi-detached and nondetached residential buildings that fits this description. Home Innovation Research Labs (Home Innovation) and the Center for Inclusive Design and Environmental Access (IDeA) of the School of Architecture and Planning at the State University of New York (SUNY) at Buffalo have undertaken a 3-year research project to (1) study the typical pitfalls of retrofitting for accessibility in townhomes and row houses; (2) identify best practice solutions for overcoming barriers to adoption; and (3) develop construction guidance to support designers, remodelers, and homeowners in their decisionmaking and construction processes. This literature review helps to define the starting point for the investigation, including current best practices and known challenges. In conjunction with planned stakeholder focus group discussions and the expertise of the research team, the literature review will inform the development of prototype solutions to be mocked up in the laboratory for evaluation and optimization. The primary deliverable is an inventory—a plan book—of specific and coordinated accessibility modifications to meet budget, construction, and geometry constraints unique to the target housing types.

43

Introduction

People can respond in four ways to environmental barriers in their homes (AARP, 2010):

• Adapt their behavior.

• Move to another home.

• Modify their existing home.

• Turn to institutional care or another supportive housing arrangement.

Adapting behavior can often lead to unsafe conditions, moving can be cost prohibitive or disruptive, especially to those persons advanced in age, and institutional care is often the most expensive and least desirable option for homeowners older than age 65. This situation makes the implementation of home modifications an effective and popular option for a wide range of homeowners (AARP, 2000).

In recent years, designers and builders have become more conscious of the varying physical and cognitive abilities of their residential end users and the impact the built environment has on the health, safety, and well-being of such consumers. Although this has led to improvements in new construction of multifamily and government-subsidized building projects, the majority of existing and new residences nationwide are not equipped to support independence for people who have functional limitations and disabilities (AARP, 2000; Kochera, 2002). Home modification, as defined by Gitlin (1998), is a process that includes evaluation, identification, and implementation of adaptations to permanent physical features of the home environment to reduce the difficulty of living independently by making tasks easier, reducing the risk of accidents, and supporting independent living and social integration (Pynoos, 1993; Gitlin, 1998; Fänge and Iwarsson, 2005). When designed and implemented properly, those modifications will not only benefit the resident for whom the adaptation was intended but should also serve to improve the overall functionality and safety for all occupants. Functionality is often measured by the resident’s ability to complete activities of daily living (ADLs), which include independence when—

• Eating.

• Dressing.

• Walking or transferring from one place to another.

• Bathing.

• Using the bathroom for toileting.

• Maintaining continence.

According to a 2010 U.S. Census Bureau report, 19 percent of the population reported having a disability, with more than half of those reporting their disability as severe (Brault, 2012). This number is expected to grow due to the aging of Americans and the direct relationship between aging and disability rates. By 2030, all baby boomers will be older than age 65, and by 2060, people in this age group will make up one quarter of the population (He et al., 2005). Severe disability rates increase to one in four after the age of 65. An aging housing stock and the increasing cost of institutional long-term care create a significant need for accessible housing (Brault, 2012; Lankford, 2016)—a strong argument for implementation of home modifications.

This literature review aims to identify relevant research related to home modifications such that public organizations, policymakers, and design professionals can be effective decisionmakers when developing home modification policy and implementing residential accessibility features.

45

The ultimate goal of home modifications within this context is to allow people to safely remain in their homes while reducing caregiver burden. Solutions in this area have the advantage of serving a much broader cohort of four distinct—but related—populations: rehabilitation, visibility, disability, and aging.

Inclusion and Exclusion Criteria

This review includes peer-reviewed literature and nonpeer-reviewed literature, including trade journals, to ensure that all key publication sources were addressed. Reference materials were screened based on several inclusion criteria:

• Accessible design retrofits of semi-detached and nondetached residential buildings.

• Solutions for accessibility in houses of the target typology.

• Grey literature materials that were readily available online or in the IDeA Center library.

Materials were excluded if they met any of the following criteria: (1) resources were not printed in English; (2) research published in peer-reviewed journals and conference proceedings before 1998 (20 years); (3) books published before 2008 (10 years); (4) trade publications published before 2013 (5 years); (5) literature referencing federal, state, and local home modification policy; (6) product information (catalogs and databases) produced by vendors; (7) research related specifically to fall epidemiology and prevention; and (8) publications focused on meeting accessibility, such as the Americans with Disabilities Act (ADA), guidelines. Seminal sources cited within this document that fall outside of the previous exclusion criteria were intentionally included due to their sustained relevance.

A database search for research and grey literature was conducted between December 9, 2017, and February 12, 2018 using the following keywords: home modification, environmental modification, disability retrofit, housing adaptation, environmental intervention, and remodeling. It also included filters related to (1) participants (i.e., disabilities, impairments, aging-in-place, older adults, and elderly) and (2) housing type (i.e. single-family, townhouse, and row house). Major works cited in the relevant papers were also reviewed. The focus was on actual modifications in residential buildings; the term “accessibility” was considered as a secondary search term only. In the primary sense, “accessibility” often leads to strategies that are

“100 percent” solutions. Instead, this research concentrated on interventions homeowners and designers implement that greatly increase accessibility in a home but which may not qualify as an accessible feature under ADA guidelines.

The search included the following five databases: Avery, Education Resources Information Center (ERIC), MedlinePlus SAGE, and PubMed Health. Grey literature was sought using databases, search engines, and websites of organizations involved in the home modifications industry. They included Google, USC Leonard Davis School of Gerontology, Home Modification Information Clearinghouse, National Association of Home Builders (NAHB), National Resource Center on Supportive Housing and Home Modifications (NRCSHHM), American Association of Retired Persons (AARP), United Spinal Association, and American Occupational Therapy Association (AOTA). This literature review aims to provide a wide range of home modification strategies and does not focus on a single question; therefore, a systematic review methodology was not used. Searches were supplemented by reviewing the references cited within the selected articles to find any other relevant papers.

Universal Design

46

Universal design (UD) is a term first coined by Ronald L. Mace (architect, product designer, and educator) who described the concept of “products and environments … usable by all people, to the greatest extent possible, without the need for adaptation or specialized design.” 14 It has been further defined as a process that enables and empowers a diverse population by improving human performance, health and wellness, and social participation (Steinfeld, Maisel, and Levine, 2012). Universally designed home modifications benefit a wider range of users than interventions focused on the specific needs of one household and can maintain or improve the value of a home. For the purposes of this literature review, the recommendations and research cited will not focus on UD. This is not to minimize the benefits of UD but rather to acknowledge that home modifications often are very specific interventions that benefit only one household, and perhaps only one occupant.

Description and Scope of Home Modifications

Home modifications can be categorized by their features and benefits, and range in scale from minor adaptations, which include the installation of additional lighting or the replacement of doorknobs with levers, to more significant interventions such as widening doorways or installing ramps. Although home modifications are defined as any adaptation made to the home that serves to decrease environmental demands on the user, it is often beneficial to define modifications through specific goals. Levine and Steinfeld (2012, 1981) identify the primary goals of home modifications as—

• Accessibility to interior and exterior spaces in the home and on the property.

• Usability, to reduce barriers in the environment (Slaug et al., 2011).

• Safety, to reduce the risk of accidents and improve security and fire safety.

• Support for caregiving and healthcare.

• Support of social integration and engagement.

This literature review focuses on strategies that become a permanent feature of the home and bolster or improve the occupant’s ability to perform ADLs, and standard tasks that indicate a high degree of self-sufficiency. This study specifically excludes less-permanent adaptations such as the mitigation of clutter or the provision of assistive devices and equipment such as a freestanding bath bench or a toilet seat riser—interventions that can provide significant benefits but are generally not a permanent architectural change.

Although existing research illustrates the effectiveness and benefits of home modifications (Steinfeld and Shea, 1993; Fänge and Iwarsson, 2005), public policy and private sector practices continue to fall short of providing adequate services and financial resources (Pynoos and Nishita, 2003). Many factors have contributed to this gap between knowledge and practice, including limited published research using large and diverse samples, lack of clarity in the definition of home modifications, and lack of knowledge about current practices in the construction industry and their effectiveness. Research on this topic is complicated by great variations in housing stock and conditions; in construction practices and costs; and in disability type, severity, and individual preferences toward home alterations.

14 https://projects.ncsu.edu/ncsu/design/cud/about_us/usronmace.htm.

47

In a home services context, it is important to understand that the need for home modifications is only one possible deficiency faced by individuals in their existing housing. Other needs include addressing deferred maintenance, repairs to equipment, and improving fire safety and home security. Services that address needs such as these are not always included in research relating to this topic, yet occupants cannot attain independence and autonomy in homes that are unsafe and unhealthy. Although this review will not go into detail regarding these services and supplemental conditions, policymakers and practitioners should be aware that successful implementation of home modifications will require that residents and their caregivers have access to home maintenance services that address the following (Community Research Applications, Steinfeld et al., 1977): Emergency repairs such as for severe roof leaks or plumbing breaks.

Weatherization strategies to provide safety during extreme temperatures and weather events.

Security modifications for windows and doors, increased surveillance, and lighting.

Fire safety improvements such as fire-rated doors, fire extinguishers, and smoke detectors.

Removal of clutter and access to handyman services.

Characteristics of Target Populations

For the purpose of this report, home modification is defined as any adaptation made to the home environment that addresses the functional limitations of the occupants and promotes independence, comfort, and safety (Levine, 2012). Modifications are not limited to any single population, but this report addresses modifications for four primary populations: (1) those advanced in age, (2) those with decreased mobility, (3) those with visual impairments, and (4) those with cognitive impairments. Accommodating aging in place will be the primary focus.

Those four populations are explicitly addressed because they constitute significant subpopulations and because the modifications prescribed for them are likely to benefit a much larger group. It is important to note that the needs of all occupants of the home must be considered when recommending modifications, including family members and guests.

Appropriate interventions address the physical and emotional needs of the caregiver as well.

Aging

When making home modifications to support aging in place, useful features should address typical issues older adults encounter such as decreases in functional mobility, balance, strength, and sensory sensitivity. AARP conducted a 2012 survey of 2,250 Americans older than age 60

regarding their current and future housing situations and found that more than 90 percent of respondents planned to stay in their homes for as long as possible. Of this population, 85 percent felt confident that they would be able to do so without making significant modifications to their homes (AARP, 2012). This finding is problematic because the vast majority of the housing stock in the United States will not accommodate the limitations in function associated with aging. Data from research conducted by the Census Bureau indicate that one in three adults older than age 65

has trouble using some feature of their home (U.S. Census Bureau, 2016). Census information also indicates that one in five individuals older than age 65 is reported to have a disability, with this number increasing to one in four beyond the age of 85 (Brault, 2012). Lack of accessibility can leave residents confined to small spaces within their homes, which limits their activity, curtails their participation in the community and family life, requires them to depend on others for basic needs, and by extension limits their overall quality of life (Pynoos, Caraviello et al., 2009).

Promotion of independence and autonomy while aging in place can improve overall physical, psychological, and emotional health and well-being and can reduce instances of premature 48

institutionalization and the resulting increased healthcare costs for residents and their families (Pynoos, Caraviello, and Cicero, 2009). Furthermore, studies have indicated that older people generally spend more time overall in their homes than younger people do, especially if they are retired from work, making it a place of greater significance (Tanner, Tilse, and de Jonge, 2008).

Tanner, Tilse, and de Jonge (2008) conducted a study on the delivery and effectiveness of accessibility modifications and found that residents reported improved function, comfort, and ease of access around the home after modifications were complete (Tanner, Tilse, and de Jonge, 2008). The limited negative feedback in one study was evidently related to the homeowner not having been involved in the modification design and installation process, highlighting the importance of the resident’s participation throughout the process. This reinforces the importance of independence and autonomy when managing one’s home and making large changes (Tanner, Tilse, and de Jonge, 2008). It also identifies dissatisfaction resulting from potential disruption to daily patterns. Home modifications can provide security, safety, and comfort while also supporting social relationships (Mathieson, Kronenfeld, and Keith, 2002). Modifications implemented before the user’s health has significantly declined will generally be more effective and cause less stress in the short and long term, as compared to waiting until conditions are dire.

Decreased Mobility

Perhaps the most well-known modifications for those with decreased mobility are highly visible features such as ramps, lifts, widened doorways, and automatic doors. Decreased mobility can be the result of aging, disease, accident, or injury. The percentage of individuals in the United States who have difficulty with ambulation (walking or climbing stairs) is 0.6 percent, 5.1 percent, and 22.6 percent for ages 5–17, 18–64, and 64 and older, respectively (Kraus, 2017), again pointing to the appropriateness of such modifications later in life. HUD-sponsored research analyzed data from the 2011 American Housing Survey (Bo’sher et al., 2015) on the accessibility of the current housing stock for people with mobility impairments. The results show that most U.S. homes are not fully accessible. Only about one third have features that are potentially modifiable, and less than 1 percent of all units are equipped with the features needed for a wheelchair user to live independently. Only 0.13 percent of owner-occupied homes are equipped for independent living by wheelchair users.

Home modifications that help to accommodate those with mobility impairments include (Levine 2012)—

• Installing nonslip floor materials.

• Increasing overall lighting levels.

• Creating step-free entries (implementation of ramps, vertical lifts, elevators).

• Installing handrails.

• Widening doorways and hallways to accommodate mobility aids (e.g., wheelchair, walker, scooter, cane).

Cognitive Impairments

Individuals with a wide range of conditions can suffer from cognitive impairments such as stroke, Parkinson’s disease, traumatic brain injury, developmental disabilities, and dementia due to Alzheimer’s disease and other causes. Those conditions can lead to difficulty remembering, concentrating, or making decisions. Although the prevalence of all types of disabilities increases with age, cognitive impairment shows the least variation between age groups and accounts for 49

4.8 percent of the population aged 5 to 64 in the United States and 9.0 percent for those aged 65

and older (Kraus, 2017). This increase after age 65 is in large part a result of dementia.

Modifications that support independence for those with cognitive impairments most commonly relate to simplified informational cueing and the removal of elements in the home that may cause risk of injury.

More than 4 million Americans suffer from dementia. This number will increase significantly in the coming years due to the aging population (Marquardt et al., 2011). It is estimated that 73

percent of dementia patients are cared for in their homes, highlighting the demand for appropriate housing (Wimo et al., 2013). Dementia is the leading chronic disease that contributes to disability and the need for care (Wimo et al., 2013). The majority of dementia patients receive informal, at-home treatment, so home modifications would provide much-needed aid to caregivers as well (Wimo, Winblad, and Jonsson, 2007).

Home modifications designed to reduce the agitation and confusion of those suffering from dementia and other cognitive disabilities provide helpful cues by using features of the home to aid residents in orienting themselves and understanding their surroundings (Calkins, 2001).

Examples include—

• Highly visible environmental controls.

• Increased light levels.

• Illumination that minimizes shadows.

• Increased visibility of railings and stairs.

• Avoidance of patterns on flooring and walls.

Marquardt et al. (2011) and others have reported that dementia caregivers most frequently requested modification of bathrooms, followed by the implementation of kitchen safety features.

They also reported that several of the respondents often used furniture for balance as they navigated their homes, highlighting the benefit that additional railings and grab bars can offer (Marquardt et al., 2011). As disorientation and confusion are synonymous with this disease, implementing the previous strategies in a way that minimizes changes from the original home design is vital to supporting this population’s independence. For example, modifications should be integrated into the existing floor plan and color scheme to avoid a drastic visual change (Belchior, 2005). Additional modifications that help to accommodate those with cognitive impairments are—

• Installing grab bars in bathrooms and handrails along primary paths of travel.

• Installing nonslip flooring.

• Removing any high-gloss materials that cause glare and distract users from finding their way.

• Implementing a combination of visual, audio, and tactile cues as a means of communicating environmental information.

• Implementing safety features such as locking mechanisms that may help to keep residents safely within a space.

Visual Impairment

Low vision can occur as a result of birth defect, injury, disease, or age. Although severity varies, it is defined as vision that cannot be corrected by eyeglasses, contact lenses, medication, or 50

surgery (National Institute of Building Science, 2015). A lack of visual clarity can cause functional limitations and reduce the ability to navigate the built environment safely.

Modifications for this population include (National Institute of Building Science, 2015)—

• Increasing overall illumination and task lighting.

• Increasing the color contrast between elements such as walls and light switch plates.

• Decreasing glare.

• Decreasing or reducing tripping hazards.

• Increasing tactile and auditory cues.

Beyond Codes and Standards

Many recommendations for design of home modifications are based on existing standards and guidelines for accessible design. For example, guidelines for home modifications recommend that a wheelchair turning space be 60 inches in diameter, which is derived from accessibility standards, but there is better information available. Human factors and ergonomics (HFE) is a multidisciplinary field of research and application that seeks to increase human performance by improving the fit between human abilities and environmental demands. HFE includes research from rehabilitation science and engineering, psychology, biomedical sciences, and design. HFE

knowledge is often applied in the design of products and devices to improve safety, reduce effort, and minimize errors in use. It is less common for HFE knowledge to be applied in the design of the built environment, but some requirements in building standards are based on HFE

principles, including safety and accessibility standards.

One major topic in HFE research is anthropometry—the science of measuring body sizes and abilities such as range of motion and maneuvering a wheelchair. Modern accessibility standards and guidelines are based on anthropometric data generated from anthropometric research completed more than 40 years ago from 1974 to 1978 (Steinfeld et al., 2010). Accessibility for people who use wheeled mobility devices is a critical part of anthropometry research because the space needs of users of these devices are usually greater than other individuals. Since that time, both the bodies of Americans and the design of wheeled mobility devices have significantly changed (Steinfeld et al., 2010). New data exist that can be used to ensure that wheeled mobility users can be better accommodated (Steinfeld et al., 2010). Some criteria in the ICC/ANSI A117.1 Standard, which is the consensus standard on accessibility in the United States referenced by building codes, were revised in 2017 to reflect that research but are not yet referenced by the International Building Code or state and local codes. New tools are being developed to help designers apply the research findings that will be useful for home modification design for wheeled mobility users (D’Souza et al., 2017).

Because a significant percentage of home modifications are concerned with accommodating wheeled mobility device users, a good understanding of the space requirements of a user and his or her device is vital to a successful modification. Through their research of the anthropometry of wheeled mobility devices, Steinfeld et al. (2010) found that a significant proportion of wheelchair users would not be accommodated by the current U.S. accessibility standards for clear floor space, knee and toe clearances, and wheelchair turning space. For example, the research demonstrated that a better guideline for a wheelchair turning space is 68 rather than 60

inches. Those data illustrate the importance of designing each home modification to the specific 51

end user’s needs, as even designing to national standards will at times fail to enable a user to meet the functional goal of completing ADLs.

Anthropometry is just one area of research in HFE studies. Other research evidence and design principles from this field can be applied to home modification design. Much of that knowledge has not been incorporated into existing standards and guidelines for accessible design or home modifications. Examples of applications include design of cueing for people with dementia, reducing risk of falls on stairs, improving usability and safety of fixtures and equipment, and improving illumination. Steinfeld and Maisel (2012) provide an overview of the potential applications of HFE knowledge that can improve the existing standards and guidelines.

It is important to note that different individuals may have different needs. Although the larger wheelchair users and those who use power chairs may require 68 inches to turn around, a smaller person using a small chair who has good upper body abilities may be accommodated with a much smaller turning area. HFE practitioners and researchers have developed clinical methods and principles that can be used to create the best fit for an individual with the lowest investment of resources. For example, biomechanics is an important area of HFE research that studies lifting, among other issues. Knowledge from this area of research can be applied to select equipment and furniture when arranging a bedroom or bathroom to reduce the risk of injury to both individuals and caregivers (Salvendy, 2012).

Design

When designing home modifications to decrease environmental barriers impacting activities of daily living, the main issues to consider are—

• Safety when using entrances and exits independently.

• Sufficient clearance through doorways and hallways to ensure general safety and accommodate mobility devices.

• Safety when using stairs.

• Independent and safe bathing and use of the toilet.

• Independent and safe transfers into and out of bed.

• Safety and full facility in the kitchen.

• The ability to turn doorknobs and control all home hardware.

Although not always possible without major renovations, homes that provide a kitchen, full bath, bedroom, and laundry on one level that are accessible without the use of steps greatly increase a home’s accessibility for residents and visitors alike. When focusing specifically on townhomes and row houses—often defined by long, narrow floor plans—designers may need to consider widening paths of circulation and borrowing space from neighboring rooms.

Entrances and Exits

Access into and out of a home is vital to the independence and safety of residents, specifically in the housing typology the authors are focused on—townhomes and row houses—as the floor plan often includes narrow, stepped entrances. Some minor modifications that can help to make entryways safer include (Steinfeld and White, 2010)—

• Increasing illumination to both the interior and exterior of the entryway.

• Replacing doorknobs with easy-to-operate lever handles.

• Installing overhangs for protection from rain and snow.

52

• Installing sturdy, easy-grip, multiple-height railings that extend beyond the first and last steps.

• Adding nonslip surfaces on steps and landings.

Stepless, nonslip entries should be implemented to provide greater access to those with limitations of mobility, vision, or balance. Because the entrance level of many homes is positioned above grade, ramps or lifts are often installed. Ramps can be constructed of wood, metal, concrete, or composite material (Levine, 2012). Although modular, lightweight aluminum ramps are a good option for temporary use, permanent ramps consisting of durable, nonslip materials should be implemented for long-term use (Levine, 2012). The U.S. Access Board recommends that ramps have a maximum 1:12 slope, with a maximum cross slope of 1:48, a minimum unobstructed, flat, 5-foot square landing at the top and bottom of the ramp, a minimum ramp width of 36 inches, and edge protection and handrails for any rise greater than 6 inches.

(U.S. Department of Justice, 2010). If enough space is available, a shallower slope is preferable than the maximum slope. Although accessibility standards do not apply to private residences constructed without public funding, it is valuable to reference those standards when designing residential ramps for individuals with mobility impairments. Exhibit A-1 illustrates the appropriate slope for accessibility and UD standards.

Exhibit A-1. Ramp Slope Recommendations

Note: The diagram illustrates the maximum slope (1:12) and straight run length (72 in. or less) required by the ADA and the maximum slope (1:15) and straight run length (greater than 72 in.) required to meet Universal Design recommendations of ramps .

Source: University at Buffalo Center for Inclusive Design and Environmental Access Homeowners are often deterred from installing ramps due to their utilitarian and clinical appearance. Planners should consider side, rear, or garage entrances when architecturally appropriate designs are prohibitively expensive or dimensionally impossible at the front entrance (Levine, 2012). When space for a ramp is not available, platform lifts can be installed within a much smaller footprint. Although there are additional mechanical and safety considerations related to a lift, it is a reliable and functional option (Levine, 2012).

Bathrooms

The personal nature of tasks performed in bathrooms, combined with an increased risk of slips and falls that can result in injury, mean that bathrooms frequently need modification. Gitlin, Miller, and Boyce (1999) conducted a pre- and post-analysis by an OT of bathroom 53

modifications for 34 people along with a telephone survey of an additional 75 people who had also received bathroom modifications. When asked about their home’s usability, respondents complained most of difficulty bathing and performing tub and toilet transfers (Gitlin, Miller, and Boyce, 1999). Despite a wide range of functional disabilities, all respondents reported that easier, more confident shower and toileting tasks were supported by the following design solutions (Gitlin, Miller, and Boyce, 1999; Levine 2012):

• Textured grab bars and/or handholds in the shower and beside the toilet.

• Raised toilets with elongated seats.

• Nonslip surfaces on the bathroom floor and in the shower and tub.

• Roll-in, barrier-free showers.

• Temperature-balancing shower and faucet controls.

In addition to increased safety and independence, resident privacy was improved because such modifications helped to reduce the amount of assistance required when performing those tasks (Gitlin, Miller, and Boyce, 1999). Other modifications that increase the functional and safe use of bathrooms include (Levine, 2012)—

• Increasing the overall illumination levels.

• Providing unobstructed, clear floor space of at least 5 feet x 5 feet when mobility aids such as wheelchairs are being used.

• Replacing faucet knobs with levers.

• Installing countertop surfaces with rounded edges.

• Installing countertop and floor surfaces that limit glare from overhead lighting.

• Removing base cabinets to provide wheelchair users knee and toe clearance beneath a vanity.

• Adding structural reinforcement to walls to support grab bars.

• Providing a handheld shower head with offset controls to minimize reaching and bending.

• Installing a walk-in bathtub.

In addition to assistive devices such as shower seats, those modifications can greatly decrease risk of injury and improve independence.

Kitchens

Kitchens can be dangerous for anyone, but particularly for those with functional limitations, cognitive disabilities, and decreased sensory perceptions. When planning for modifications within kitchens, designers should first consider space planning and identify how the space is used by the residents, i.e., how many people will be using the space, who is the primary user, and what activities are most often performed in the space (Peterson, 1998; The Internet Stroke Center, 2018). Identified by Pynoos (1993), the “kitchen triangle” refers to the recommended triangular path of travel between the sink, stove, and refrigerator. (USC Leonard Davis School of Gerontology, 2018). For safety and efficiency, those areas should be arranged to accommodate linear or triangular travel between these steps, should not cut through an island or peninsula by more than 12 inches, and should be located adjacent to a heat-resistant workspace surface (USC

Leonard Davis School of Gerontology, 2018). Work aisles should have a width of at least 42 inches, or 48 inches for more than one user, with perpendicular walkways providing ample 54

turn space—a minimum of 60 inches, but preferably sized to meet the individual needs of the resident (VGM Live at Home, 2018).

As with bathrooms, base cabinets in the kitchen can be removed to accommodate knee and toe clearance for wheelchair users, and adjustable height countertops or multiple height countertops provide comfortable work spaces for a variety of users (Levine, 2012). Lever handles on sink faucets provide easier control with decreased strength and dexterity, whereas shallow sink designs can provide increased knee clearance for a seated user (Levine, 2012). Additional modifications that decrease environmental demands and hazards include (Levine, 2012; USC

Leonard Davis School of Gerontology, 2018)—

• Installing pull-down shelving and pull-out, pantry-style cabinets.

• Replacing drawer and cabinet knobs with handles.

• Increasing room and task (surface) lighting.

• Providing accessible appliances such as:

• Side-by-side refrigerators or freezers.

• Appliances mounted at heights customized for the user.

• Ovens, microwaves, and dishwashers that provide large-format, front-mounted controls to limit bending and reaching across hot surfaces.

• Counter space or slide out platforms adjacent to appliances for easy food transfer.

• Installing nonslip flooring.

• Installing flooring and surface finishes that limit glare.

Doorways and Hallways

One of the most commonly implemented structural home modifications is the widening of doorways. Many homes do not provide circulation space that can easily accommodate mobility devices such as walkers, wheelchairs, or scooters. To adequately support the use of those devices, doorways should ideally have a clear width of at least 32 inches (for 34-inch doors), whereas hallways should be 42 inches wide. (Levine, 2012; VGM Live at Home, 2018). If increasing the width of a doorway is not possible, offset hinges can add 2 inches of additional clearance to most doorways by allowing the entire door panel to swing clear of the opening (Levine, 2012). For some users this slight increase will be sufficient. Doorknobs can be replaced with levers, which magnify force with a one-way action that does not require grip strength.

Navigation and access can be improved by removing latches, locks, or other operating devices that require a person to exert a significant amount of strength or dexterity (Levine, 2012).

Marquardt et al. (2011) found that more than 28 percent of individuals with dementia and functional limitations reported holding on tightly to furniture and walls when navigating through and between rooms, indicating that users would benefit from support devices in more spaces than just bathrooms and stairways, such as kitchens and halls (Marquardt, 2011). The installation of threshold ramps, where a raised threshold either is needed due to a floor material change or is required due to a change in level, eliminates abrupt level changes, which decreases tripping hazards and improves navigation with mobility devices (Levine, 2012). Ramps can be added to address an elevation change between neighboring rooms, but care must be taken to avoid introducing an entirely new tripping hazard with the ramp’s placement. As mentioned previously, increased light levels and implementation of lighting controls at each entrance improve visibility and orientation, highlighting trip or bump hazards.

55

Stairs

A large percentage of homes have bedrooms and bathrooms located on the second level, making vertical circulation a daily challenge for those with functional disabilities. Stair lifts, inclined stair platform lifts, and elevators are potential home modifications for individuals who lack the ability to climb stairs but require access to multiple levels of a home (Levine, 2012).

Stair lifts are mechanical assistive devices that are installed in stairways and consist of a seat that moves the user along a track mounted to the wall or stair nosing that follows the length of the stairway (Levine, 2012). The seat rotates at the top and bottom landings to allow user access.

Stair lifts are generally the most affordable option for this type of assistance (Levine, 2012). The structure, width, and geometry of the stairway are issues to consider with this modification, because stairways often lack the structural capacity to support these lifts, are too narrow, or have a curved or switchback orientation that requires customization (Levine, 2012). An additional issue is the need for multiple mobility devices to accommodate the user at each level. Stair lifts also require the user or caregiver to have appropriate strength and balance for transferring to and from the device, particularly when doing so at the top of the stairs (Levine, 2012).

An inclined stair platform lift consists of a platform traveling on a rail, which moves along the pathway of the stairs (Levine, 2012). The open platform allows users either to remain in their mobility device, while it is secured to the platform, or to simply stand. This may be preferred over the stair lift because it does not require users to transfer from a mobility device at each level but can also pose fall hazards if the platform has no rail or if the user lacks functional control of the device (Levine, 2012). This type of modification fills the entire width of the stair, making it undesirable for some situations.

Elevators offer accessibility superior to each of the previous devices, but costs for residential elevators are often prohibitive, starting around $20,000 per lift (Levine, 2012). It can also be difficult to meet space requirements on each floor to accommodate the shaft, typically taking up the same amount of space on each floor as a half bath, approximately 4 feet x 6 feet (Levine, 2012). Residential elevators are available in a wide variety of sizes and configurations to provide optimal usability for diverse needs. Issues to consider when purchasing and installing a residential elevator are (Levine, 2012)—

• Cab size should accommodate the needs (and potential needs) of everyone in the house and may need to accommodate two adults if the user is not capable of entering, exiting, and operating the controls of the elevator without assistance.

• Door configuration should increase accessibility and ease of entering and exiting.

• Door type should be selected to provide the largest clear opening possible and may be automatic or manual, as need dictates.

• Accessible controls for the individuals using the elevator.

• Selection of safety features such as an accessible emergency control or battery-powered telephone that can be used in the event of an emergency or power failure, or an emergency call button.

Additional modifications to consider for stairs without the implementation of a lift device include—

• Increasing illumination at the top and bottom of a stairway.

• Installing handrails on both sides of a stairway, extending past the top and bottom steps.

56

• Implementing high-contrast nosing for treads to accentuate the edge of each step.

• Installing nonslip materials on stair treads.

• Removal of thick carpeting that can negatively alter the stair geometry and create overly rounded nosings.

• Ensuring that the tread and riser dimensions meet building standards (recommended: 7-inch riser height with 11-inch tread depth).

Effectiveness

Although this literature review primarily focuses on the functional value of modifications made to permanent physical features of the home, additional characteristics must be considered, such as—

• Cost (materials and installation price, and impact on the home’s value).

• Available funding (insurance, grants, Medicare).

• Service delivery (local designers and contractors who are knowledgeable and competent in the field of home modifications).

• Durability (long-lasting, robust materials that are easy to clean and maintain).

• Appearance (colors and styles that complement the existing aesthetic).

• Means of prescription (design recommendations from a physical or an occupational therapist).

In addition, the impacts of home modifications as they relate to personal, physical, and social dimensions, and the impacts on caregivers, should be addressed.

The majority of home modification research is based on data collected through interviews and surveys. Although this information provides direct user input, the available research shows gaps in reliable quantitative measurements. A solution to this gap in research may be the further development of the Housing Enabler, which is a tool that was developed for occupational therapists, a group often responsible for prescribing home modifications. The tool is designed to assess the accessibility of housing by documenting functional limitations and environmental barriers for use in the calculation of an accessibility score (Iwarsson, 2016). Iwarsson and her colleagues have completed extensive research on the reliability and effectiveness of the tool, although it has not been used extensively in the United States. Gitlin (2003) found that gaps in research are also attributed to a lack of data from diverse racial and ethnic groups, housing conditions, and socioeconomic level.

Perceptions and Motivations

Home modifications are implemented for a variety of reasons, but one primary purpose is to increase safety. Aplin, de Jonge, and Gustafsson (2015) found that modifications typically resulted in an increased sense of safety, a reduced level of anxiety, and a decreased rate of injuries and falls for people with a broad range of impairments (Stark et al., 2009; Stark et al., 2017). Regardless of functionality and safety, the appearance of home modifications, specifically those visible from the exterior of the home, can have a positive or negative impact on a respondent’s subjective evaluation of the modification. This effect occurs when homeowners associate the appearance of their home with their identity (Aplin, de Jonge, and Gustafsson, 2015). For example, a visible ramp leading to the front entrance of a home can be stigmatizing, and users may resist this public announcement of their disability. Similarly, Aplin found that if a 57

modification installed within the privacy of the home was designed in a way that made the resident feel “disabled” or as if he or she was “in the hospital,” the resident would rate the modification as less effective (Aplin, de Jonge, and Gustafsson, 2015). Conversely, the participants in the same study who reported low concern about the appearance of the modifications tended to rate the modifications as more effective (Aplin, de Jonge, and Gustafsson, 2015), which highlights the importance of the homeowners’ preferences. Therefore, for maximum user satisfaction and perceived effectiveness, contractors and designers should consult with homeowners, prior to any home modification installation, to understand what visual elements are of primary importance and to respect the resident’s sense of personal control in the process.

Outcomes

Regaining or maintaining independence within the home is highly valued for residents and caregivers alike. Studies have shown that home modifications often yield outcomes that reduce the amount of assistance needed from spouses and caregivers when completing ADLs. Effective home modifications also reduce the level of difficulty and can sometimes completely restore the resident’s ability to participate in everyday life tasks and valued activities such as socializing, cooking, and gardening (Petersson et al., 2009; Aplin, de Jonge, and Gustafsson, 2015).

Additional studies have shown that home modifications for persons with dementia led to slower declines in patients’ ability to perform ADLs, whereas the spouses or other caregivers of those individuals reported reduced upset and enhanced self-efficacy in managing behaviors (Gitlin et al., 2001). Furthermore, Petersson et al. (2009) found that implementation of prescribed home modifications helped recipients to continue to live in their homes and to take part in social activities in spite of decreases in functional abilities (Petersson et al., 2009). Although independence is often cited as a primary goal for persons with functional limitations, it also provides additional benefits of improved health and well-being through increased activity and social participation.

Negative outcomes of home modifications often result from poor service delivery such as ineffective prescriptions from healthcare professionals, long lead times for installation, unacceptable levels of disruption, poor communication with the homeowner, poor workmanship, and little to no followup or training as to how to properly operate or use modifications (Aplin, de Jonge, and Gustafsson, 2015; Stark et al., 2017). Petersson et al. (2009) found that modification lead time had an impact on the perceived effectiveness of modifications. Survey respondents reported that their difficulty performing ADLs increased with each month that the modification was delayed, meaning that the benefits delivered by modification can be completely obviated if homeowners are left to wait for longer than 1 year (Petersson et al., 2009). This was an unexpected result that has major implications and further highlights the important role that service delivery has in the home modification process.

In surveys, a typical report from a satisfied modification recipient describes a positive experience with the builder, noting that the builder was clean and respectful of the recipient’s home and took care to include the recipient in the process by listening to his or her requests (Aplin, de Jonge, and Gustafsson, 2015). In this same study, the most satisfied respondents were part of a program in which their occupational therapists were also in constant contact with the builder, and instead of using multiple subcontractors, the single builder was responsible for all modifications (Aplin, de Jonge, and Gustafsson, 2015). An additional factor related to positive experiences was client involvement in decisionmaking (Aplin, de Jonge, and Gustafsson, 2015). This factor needs to be 58

considered at the earliest phase of the home modification process. Occupational therapists, physical therapists, and other qualified design specialists should not simply be prescribing modifications but instead should engage in an open, responsive negotiation (Iwarsson, 2014).

Those professionals must understand not only their patients’ functional limitations but also their priorities and values. Research has shown that standard environmental modification practices work effectively, but the relationship of humans to their environments and the meaning of

“home” are complex; including the end user throughout the design process will yield improved usability and effectiveness of modifications.

Certification Programs

One solution to problematic service delivery is the improved standardization and completion of training and credentialing programs. Programs such as the Certified Aging-in-Place Specialist (CAPS) provide participants with technical, business management, and customer service skills training to better close gaps that are often present between care coordinators or prescribers, such as occupational therapists, and the individuals responsible for construction and design of modifications. Appendix B contains a list of certification programs.

Discussion

Key Findings

The literature on home modifications has evolved considerably since this topic was identified as an important aspect of adaptation to aging in the 1970s. Government policy and private sector initiatives in housing for the older generation, however, have consistently favored new construction versus investment in the existing housing stock. Likewise, research funding devoted to the topic of modifications with the goal of keeping the aging population in their homes longer has not been a priority of the government or the private sector. The Home Modifications Action Coalition, a collaborative effort of AARP, the American Society on Aging, academics, and service providers, highlighted the importance of those services through its Blueprint for Action in 1997 (Duncan et al., 1997). Research on practices in the field demonstrates that the mechanisms in place for delivery of home modification services, from financing to construction, are fragmented and uncoordinated. Not much has changed since that time, although there is a heightened awareness of the problem among service providers, government agencies, and the remodeling industry.

As the population ages rapidly, the demand for home modifications will increase. Local community agencies such as Area Agencies on Aging and other nonprofits have demonstrated service models that work. Researchers have demonstrated that home modifications are effective, providing significant benefits for older residents. The private sector has also responded to the growing need by developing training programs for contractors, equity conversion instruments such as reverse annuity mortgages, and provisions in long-term care insurance to cover the cost of modifications. However, there is still a gap between demand and the availability of resources and expertise. Many unanswered questions and unexplored areas in research also still exist.

One of the most important findings from this literature review was the disconnect between the expectations of older Americans and the reality of their housing. Although a large majority of older Americans expect to age in place, research demonstrates that their living arrangements do not support this choice without some major compromises to their quality of life. Consumers are not aware that they may need deliberate, or even major, interventions in their home environment 59

to realize their aspirations for aging in place. The rising cost of alternatives to renovating one’s home, such as moving to a new, universally designed home or service-intensive facility, will likely create a greater demand for home modification design and construction services. A danger exists that the supply of needed services, financing, and expertise may simply not meet the demand. Even worse, the potential mismatch between expectations and actual outcomes could make older people dread engaging service providers, akin to avoiding a visit to the dentist until it is too late. This complication will add to the burden of healthcare providers, relatives, and friends, and it will severely reduce aging homeowners’ quality of life.

A definition of home modifications emerged in the literature; it is “a process that includes evaluation, identification, and implementation of adaptations to permanent physical features of the home environment to reduce the difficulty of living independently by making tasks easier, reducing the risk of accidents, and supporting independent living and social integration” (Fänge and Iwarsson, 2005; Gitlin, 1998; Pynoos, 1993). This definition provides a comprehensive view of home modifications, useful for development of policy and service programs. It is particularly valuable for educating construction professionals who may erroneously view their service as just another application of a standard approach to home improvements with a few twists thrown in (e.g., ramps and roll-in showers), not recognizing the need for evaluation, integration, and anticipation. The definition does not adequately take into consideration the perspectives of consumers who may not believe that their homes have any major barriers to living independently. They may resign themselves to the belief that certain inconveniences are an unavoidable part of aging. Thus, they may resist engaging in a complicated intervention without a good understanding of the potential benefits for themselves, their ability to control the process, and the ultimate costs of a project. They may think that home modifications are for people with more serious limitations.

One set of research findings that should be particularly compelling to the building industry is the discovery that when homeowners actively value the appearance of their home, they perceive the modification’s effectiveness in proportion to its visual appeal. Clearly, appearance must be addressed in developing modification strategies that will be acceptable to consumers. Research questions include: How do consumers define “intrusive”? What materials and styles are favored over others? What tradeoffs on usability and safety are acceptable to achieve a positive emotional response? Are homeowners concerned that modifications could affect the resale value of their homes?

Research and practice clearly identify the scope of usability-related home modifications and the most common solutions. There is a wide range of interventions, yet each individual and home is different, which presents a challenge for the future tasks of this project, which will complete focused R&D on innovative approaches. The challenge will be to identify the most strategic interventions to target for indepth research. For instance, satisfactory, low-cost, and easily implemented modifications such as cueing for people with dementia, improving illumination, and installing grab bars already exist; innovation is not necessary.

Thus, the focus of R&D in this project will be on improving the effectiveness of some of the most expensive and hard-to-implement modifications related to access of essential facilities and maintaining the safety of residents and caregivers. These goals clearly are related to overcoming inaccessible entries (e.g., ramps and lifts); access to essential facilities on inaccessible floors (e.g., laundry and parking); and bathroom access, particularly access to toilets and bathing 60

arrangements in cramped bathrooms. Improving kitchen cabinet accessibility and usability is less of a safety concern, but it can also be very valuable for maintaining independence.

With regard to attached single-family housing, which is the focus of this research, some of these topics can be investigated by research at the “drawing table” rather than in the laboratory. For example, access to inaccessible floors does not necessarily mean providing lifts or elevators.

Design explorations on the reconfiguration of spaces to move essential facilities to an accessible floor could be accomplished using computer-aided drafting and graphic visualization techniques.

Consumer acceptance can be effectively evaluated using such methods.

Testing innovative products that make stairways safer and easier to climb, including easier-to-grip railings and innovative devices such as the StairSteady, is certainly possible. Even though the development of new lift and elevator technologies is outside the scope of this research due to budget, time, and engineering constraints, it may be possible to study innovative applications of technologies available in other sectors but not currently in use in the home market. For example, federal, state, and local regulations prohibit the use of vehicle lifts in housing. However, vehicle lifts are much less expensive, can be installed without foundations, and are engineered for many more cycles of use than porch lifts. They could be evaluated for use in housing, leading to product improvements specific to building installations and potential changes in regulations that would ultimately allow for their use.

Finally, this project will identify counterexamples: existing conditions that indicate a positive outcome is unlikely or not cost-effective, given standard accessible modification design options and typically acceptable budgets.

Identified Gaps

There are some important gaps in the literature that are beyond the scope of this research but that should be addressed by others.

Research on outcomes has explored the impact of providing people with individualized modifications based on a professional assessment, but it has not explored the impact of less-than-ideal modifications. Understanding of the relative impact of a graduated set of interventions would be particularly valuable for policymakers and third-party payers.

Many reference works speculate that the need for accessible residential modification is severely underreported (Duncan et al., 1997). Comprehensive, nationwide surveys to corroborate this expectation and identify nuances related to geography, demography, etc. would be useful. Such research can also identify the extent of latent demand that could be addressed through better public education and marketing of services.

Industry lacks detailed understanding of the limitations of accessibility standards in application to personalized home adaptations. Do current standards intended for public spaces and accessible hotel rooms make sense for home modifications? Evidence indicates that full-bore ADA standards such as those developed for toilet height and grab bars may not be effective for older people with less severe limitations (Sanford, 1995). Departure from those standards may pose liability risks for service providers and safety hazards for clients.

More research is needed on the perceptions of older people toward home modifications and service providers. How prevalent is the belief that home modifications could reduce the value of a home? What level of trust do older homeowners have in service providers, including social 61

service agencies and for-profit builders? What can improve perceptions of the process and the providers, e.g., certification of builders, public education, etc.?

The home remodeling industry has initiated programs to improve education of builders on home modifications such as NAHB’s CAPS program. However, no studies to date have evaluated the effectiveness of such efforts. Do builders with the CAPS certificate actually offer better services and improved outcomes? Do they get more business than other builders with the same experience? Research that demonstrates the value of certification could improve consumer trust and potentially increase interest in obtaining more education.

Steinfeld and Shea (1993) found that many elderly households need a comprehensive approach to addressing their housing needs. The current fragmented service delivery system provides narrowly focused funding (e.g., funding can only be used for ADL- related improvements) that may be irrelevant for many households that have other critical housing-related needs such as deferred maintenance and high energy bills. Corroboration of this finding by a larger study would imply that funding for home modification services should be part of a broader scope of service delivery that can meet several needs at once.

Finally, further research is needed to understand how to help older people and people with disabilities identify their own needs and make the proactive decision to modify their homes before they have an accident, curtail their quality of life, or reluctantly relocate. Steinfeld and Shea (1993) found that a simple assessment can be helpful to motivate individuals to make minor improvements but not those that are more difficult or costly. That research used an expensive professional assessment, but it was before the days of self-help apps and websites. Perhaps digitally based tools could be effective in enabling self-assessments and providing access to resources to help with implementation.

Conclusion

This literature review confirms the operating assumptions of many experts in the field while adding valuable scope and detail. The fundamental desire of the majority of aging occupants or occupants with disabilities is to stay in their own homes for as long as possible. The high cost of institutional care and the intrinsic value of personal independence make this an appropriate societal goal as well. Numerous studies confirm, though, that typical residential housing includes barriers to the ability of aging occupants or occupants with disabilities to complete the basic activities of daily living. Several viable modifications appear to exist for most architectural conditions that present safety or accessibility issues to that population. The challenge seems to be a combination of evaluating, designing, and installing those solutions in a cost-effective, attractive, and durable manner that meets the client’s goals and expectations for independence and control. The target house typology—single-family attached and semi-attached houses—will present constraints to the design team in solving the identified problems but offer opportunities to identify approaches that can provide solutions in the most challenging situations.

62

References

AARP. 2000. Fixing to Stay: A National Survey of Housing and Home Modification Issues.

Washington, DC: AARP.

AARP. 2010. Home Modifications to Promote Independent Living: Fact Sheet. Washington, DC: AARP.

AARP. 2012. The United States of Aging Survey.

Aplin, T., D. de Jonge, and L. Gustafsson. 2013. “Understanding the Dimensions of Home that Impact on Home Modification Decision Making,” Australian Occupational Therapy Journal 60

(2): 101–109.

Aplin, T., D. de Jonge, and L. Gustafsson. 2015. “Understanding Home Modifications Impact on Clients and their Family’s Experience of Home: A Qualitative Study,” Australian Occupational Therapy Journal 62 (2): 123–131.

Belchior, P. 2005. “Home Modifications and Universal Design,” In International Handbook of Occupational Therapy Interventions, edited by Ingrid Soderback, 177–187.

Bo’sher, L. et al. 2015. Accessibility of America’s Housing Stock: Analysis of the 2011 American Housing Survey (AHS). U.S. Department of Housing and Urban Development Office of Policy Development and Research.

Brault, M. W. 2012. Americans With Disabilities: 2010. Washington, DC: U.S. Census Bureau.

Calkins, M. P. 2001. “The Physical and Social Environment of the Person with Alzheimer’s Disease,” Aging & Mental Health 5 (sup1): 74–78.

Community Research Applications, E. Steinfeld, M. B. Holmes, D. Holmes, and United States Administration on Aging. 1977. Planning Handbook: Residential Repair and Renovation Services Guide for State and Area Agencies on Aging. New York, NY: Community Research Applications.

D’Souza, C. et al. 2017. “Effects of Transit Bus Interior Configuration on Performance of Wheeled Mobility Users During Simulated Boarding and Disembarking,” Applied Ergonomics 62: 94–106.

Duncan, R. et al. 1997. A Blueprint for Action: A Resource for Promoting Home Modifications.

Raleigh, NC: North Carolina State University.

Fänge, A., and S. Iwarsson. 2005. “Changes in Accessibility and Usability in Housing: An Exploration of the Housing Adaptation Process,” Occupational Therapy International 12 (1): 44–59.

Fänge, A., and S. Iwarsson. 2005. “Changes in ADL Dependence and Aspects of Usability Following Housing Adaptation—A Longitudinal Perspective,” American Journal of Occupational Therapy 59 (3): 296–304.

Gitlin, L. N. 1998. “Testing Home Modification Interventions: Issues of Theory, Measurement, Design, and Implementation.” In Annual Review of Gerontology and Geriatrics, edited by R.

Schulz and G. Maddox, 190–246. New York, NY: Springer Publishing Company.

63

Gitlin, L. N. 2003. “Conducting Research on Home Environments: Lessons Learned and New Directions,” The Gerontologist 43 (5): 628-637.

Gitlin, L. N. et al. 2001. “A Randomized, Controlled Trial of a Home Environmental Intervention,” The Gerontologist 41 (1): 4-14.

Gitlin, L. N., K. Swenson Miller, and A. Boyce. 1999. “Bathroom Modifications for Frail Elderly Renters: Outcomes of a Community-Based Program,” Technology & Disability 10 (3): 141.

He, W. et al. 2005. “65+ in the United States: 2005.” U.S. Census Bureau Current Population Reports, from https://www.census.gov/library/publications/2005/demo/p23-209.html

Iwarsson, S. 2014. “Housing Adaptations and Home Modifications.” In International Handbook of Occupational Therapy Interventions, edited by Soderback Ingrid, 177–187.

Iwarsson, S. 2016. “The Housing Enabler: An Objective Tool for Assessing Accessibility,”

British Journal of Occupational Therapy 62 (11): 491–497.

Kochera, A. 2002. Accessibility and Visitability Features in Single-Family Homes: A Review of State and Local Activity. Washington, DC: AARP Public Policy Institute.

Kraus, L. E. 2017. 2016 Disability Statistics Annual Report. Durham, NH: University of New Hampshire.

Lankford, K. 2016. “Options for Dealing with Rising Long-Term-Care Insurance Premiums,”

Kiplinger Financial Magazine.

Levine, D. 2012. “Home Modifications.” In Univeral Design: Creating Inclusive Environments, edited by Edward Steinfeld and Jordana Maisel. Hoboken, NJ: John Wiley & Sons.

Marquardt, G. et al. 2011. “A Descriptive Study of Home Modifications for People with Dementia and Barriers to Implementation,” Journal of Housing for the Elderly 25 (3): 258–273.

Mathieson, K. M., J. J. Kronenfeld, and V. M. Keith. 2002. “Maintaining Functional Independence in Elderly Adults: The Roles of Health Status and Financial Resources in Predicting Home Modifications and Use of Mobility Equipment,” The Gerontologist 42 (1): 24–31.

National Institute of Building Science. 2015. “Design Guidelines for the Visual Environment.”

In Low Vision Design Program. National Institute of Building Science.

Peterson, M. J. 1998. Universal Kitchen and Bathroom Planning: Design that Adapts to People.

New York, NY: McGraw-Hill.

Petersson, I. et al. 2009. “Longitudinal Changes in Everyday Life After Home Modifications for People Aging with Disabilities,” Scandinavian Journal of Occupational Therapy 16 (2): 78–87.

Pynoos, J. 1993. “Toward a National Policy on Home Modification,” Technology and Disability 2 (4): 1–8.

Pynoos, J., R. Caraviello, and C. Cicero. 2009. “Lifelong Housing: The Anchor in Aging-Friendly Communities,” Generations 33 (2): 26–32.

Pynoos, J., and C. M. Nishita. 2003. “The Cost and Financing of Home Modifications in the United States,” Journal of Disability Policy Studies 14 (2): 68–73.

Salvendy, G. 2012. Handbook of Human Factors and Ergonomics. 4th ed. Hoboken, NY: Wiley.

64

Slaug, B. et al. 2011. “Defining Profiles of Functional Limitations in Groups of Older Persons: How and Why?” Journal of Aging and Health 23 (3): 578.

Stark, S. et al. 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 (2): 7102290010p7102290011-7102290010p7102290011.

Stark, S. et al. 2009. “Client-Centered Home Modifications Improve Daily Activity Performance of Older Adults,” Canadian Journal of Occupational Therapy 76 Spec No: 235–45.

Steinfeld, E. et al. 2010. “Anthropometry and Standards for Wheeled Mobility: An International Comparison,” Assistive Technology 22 (1): 51–67.

Steinfeld, E., J. Maisel, and D. Levine. 2012. Universal Design: Creating Inclusive Environments. Hoboken, NJ: John Wiley & Sons, Inc.

Steinfeld, E. et al. 2010. Anthropometry of Wheeled Mobility Project. School of Architecture and Planning, University at Buffalo: Center for Inclusive Design and Environmental Access.

Steinfeld, E., and S. Shea. 1993. “Enabling Home Environments: Identifying Barriers to Independence,” Technology and Disability 2 (4): 69–79.

Steinfeld, E., and J. White. 2010. Inclusive Housing: A Pattern Book. New York, NY: W.W.

Norton & Company, Inc.

Tanner, B., C. Tilse, and D. de Jonge. 2008. “Restoring and Sustaining Home: The Impact of Home Modifications on the Meaning of Home for Older People,” Journal of Housing For the Elderly 22 (3): 195–215.

The Internet Stroke Center. 2018. Kitchen Modifications.

U.S. Census Bureau. 2016. Aging Accessible Homes. Edited by graphic-aging-in-place.

census.gov: U.S. Census Bureau.

U.S. Department of Justice. 2010. ADA Standards for Accessible Design.

USC Leonard Davis School of Gerontology. 2018. Do-Able Homes: Kitchen.

VGM Live at Home. 2018. “Home Modifications.”

Wimo, A. et al. 2013. “The Worldwide Economic Impact of Dementia 2010,” Alzheimers & Dementia 9 (1): 1–11 e3.

Wimo, A., B. Winblad, and L. Jonsson. 2007. “An Estimate of the Total Worldwide Societal Costs of Dementia in 2005,” Alzheimers & Dementia 3 (2): 81–91.

65

Exhibit A-2. Average 2018 Costs of Most Commonly Implemented Home Modifications in the Western New York Region

Modification (installation included)

Range of Costs

Widen doorway to 36 in. (interior)

$1,400–$1,800

Widen doorway to 36 in. (exterior)

$2,100–$2,400

Installation of offset hinges

$90

Installation of lever handles

$50–$60

Installation of grab bars

$90–$400

Custom tiled roll-in-shower (excluding demolition)

$5,800–$6,400

Prefabricated fiberglass roll-in shower (excluding demolition)

$1,000 or less

Vertically adjustable and removable shower head

$200

Nonslip floor tiles (including all associated materials)

$35–$40 per sq. ft.

Wall-hung sink

$600 on average

Raised toilet

$380 on average

Wooden ramp with handrails, straight run (20 ft long total)

$5,000 on average

Wooden ramp with handrails, turns with landing (20 ft long total)

$7,000 on average

Vertical platform lift (exterior installation, would include a concrete pad) $8,400–$12,800

Stair lift (straight run)

$7,000–$9,000

Residential elevator

$18,000–$26,000

Source: Data from Amico Home Improvement

66

Credentialing

(Note: All websites were accessed on March 7, 2019.)

Abilities OT Online Seminars in Accessibility

Abilities OT and Accessibility Services

Program description (from website: https://www.aotss.com/online-seminars/)

A dynamic learning experience is combined with personal email communication with mentors who are national experts. Learners receive access to the Abilities OT Services & Seminars (AOTSS) Accessibility Consultants Network (ACN) containing lessons, conference call lectures, discussion board, networking, and extensive links to resources. Training will focus on promoting safety and independent living services for pediatric through geriatric populations and will encompass a wide range of physical and cognitive disabilities. Participants learn from the comfort of their own environment using their own timeframe and earn continuing education credits. College credits are also available.

Certified Aging-in-Place Specialist (CAPS)

National Association of Home Builders

Program description (from website:

https://www.nahb.org/Education%20and%20Events/Education/Designations/Certified%20Aging

-in-Place%20Specialist%20CAPS)

Certification requires the successful completion of three courses:

Marketing and Communicating with the Aging-in-Place Client (CAPS I)

https://www.nahb.org/education-and-events/education/course-overviews/marketing-and-communicating-with-the-aging-in-place-client-caps-i

Design Concepts for Livable Homes and Aging-in-Place (CAPS II)

https://www.nahb.org/education-and-events/education/course-overviews/design-concepts-for-livable-homes-and-aging-in-place-caps-ii

Details and Solutions for Livable Homes and Aging-in-Place (CAPS III)

https://www.nahb.org/education-and-events/education/course-overviews/details-and-solutions-for-livable-homes-and-aging-in-place-caps-iii

The CAPS designation program teaches the technical, business management, and customer service skills essential to competing in the fastest growing segment of the residential remodeling industry: home modifications for the aging in place.

Executive Certificate in Home Modification Program

https://homemods.org/echm/

67

USC Leonard Davis School of Gerontology

Program description (from website: https://homemods.org/online-courses/)

This program is designed for professionals who work directly or indirectly in the field of supportive home environments. Students include remodelers and contractors, planners, personnel of organizations representing the elderly and people with disabilities, occupational and physical therapists, policymakers, and others interested in starting their own home modification business.

The courses connect professionals from around the country who learn from each other and experts in the field.

Home Modifications Practitioner Certificate Program (VGM Group)

The VGM Group

Program description (from website: https://www.vgm.com/pages/home-modification)

The courses are valuable to individuals who provide any type of home evaluation, design, or construction service for seniors or people with disabilities, such as occupational therapists, physical therapists, nurses, home healthcare workers, case managers/social workers, builders and remodelers, architects, and interior designers.

NARI Universal Design Certified Professional (UDCP)

https://www.nari.org/certification-accreditation/certification/universal-design-certified-professional

National Association of the Remodeling Industry

Program description

(from website: https://www.nari.org/industry/development/certification/universal-design-

certified-professional-udcp/)

This certificate is intended for remodeling professionals interested in becoming experts in Universal Design practices. Courses focus on topics such as conducting client needs assessments; Universal Design applications used in residential remodeling; construction techniques used to implement Universal Design to a remodeling project; plumbing and electrical systems unique to Universal Design; and differences between model building codes and ones described in the Americans with Disabilities Act.

IDEA 107: Universal Design and Home Modifications

Center for Inclusive Design and Environmental Access

Program description (from website: https://www.udeducation.org/allcourses/)

This course examines the role that home modifications play in improving the fit between people and their homes. It describes the primary goals of home modifications and policies and methods of home assessment. In addition, it discusses several common home modifications and case studies to exemplify both good and bad home modifications.

68

Popular Home Modification Products and Suppliers

• 800Wheelchair.com

• AbleData: Assistive Technology Product Guide

• Access Able Designs, Inc.

• Access Lifts & Ramps

• AlumiRamp, Inc.

• AmeriGlide

• Amramp®

• Arjo

• Bruno®

• CleanCut™

• Drive DeVilbiss Healthcare

• Easy Climber®

• ELDERLUXE®

• EZ-ACCESS®

• Grab Bar Specialists©

• #GRABDASHBAR©

• Great Grabz®

• Handi-Ramp®

• Mor-Medical InternationalTM

• Open Sesame Door Systems, Inc.

• Prairie View Industries, Inc.

• Prism Medical, Inc.

• Roll-A-Ramp®

• SafePath ProductsTM

• Savaria®

• Silver Spring®

• StairSteady

• SureHands®

• TubcuT

69

APPENDIX B:

FOCUS GROUP DISCUSSION AND EXPLORATION OF

ACCESSIBILITY NEEDS AND CHALLENGES

70

Focus Group Discussion and Exploration of

Accessibility Needs and Challenges

Qualitative Research

Key Points Summary

71

72

73

Introduction,

Challenges

Exploration of

warm-up, purpose

Home

experienced/

solutions,

of discussion

concerns

consideration

factors

Challenges, unmet

needs

74

75

Gender

Age,

years

76

77

Situation of Person Providing Care To

Gender Current home stairs Assistive Devices

Personal Task Challenges

78

79

80

81

Executive Summary

Overall Key Findings

Results from qualitative research provide DIRECTIONAL insights and cannot be reliably projected to a larger audience.

82

83

84

85

86

87

Summary of Key Findings

Residents and Caregivers

Participant comments in red are paraphrased.

Results from qualitative research provide DIRECTIONAL insights and cannot be reliably projected to a larger audience.

88

89

90

91

92

93

94

95

96

97

98

99

100

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

117

118

119

120

121

122

123

124

125

126

127

128

Key takeaways from all three focus

groups:

• Affordability is the top need;

functionality is a close second.

• Spatial constraints are a major

difficulty, especially for bathrooms and

entries.

• Plumbing coordination--especially drain

location

2.0

1.S

1.0

o.s

0.0

8 Professional Respondents, 1 = Highest Priority

■

Affordibility

■

Functional use

■

Ease of Installation

Aesthetics

Range and average (x) are shown.

129

130

131

132

APPENDIX C:

SUMMARY OF DESIGN SELECTION AND PROTOTYPE

CONSTRUCTION

133

134

135

136

137

138

139

140

141

3.0 Toilet Riser/Step Combination

2.3 Adjustable-Height Toilet

1.6 SuperPole

142

143

144

145

146

147

148

149

150

151

152

4.4 StairSteady

3.9 Moveable Storage Wall

3.0 Toilet Riser/Step Combination

2.3 Adjustable-Height Toilet

1.6 SuperPole

153

APPENDIX D:

HOME INNOVATION

ACCESSIBILITY EVALUATION SURVEY

154

SURVEY: HOME INNOVATION ACCESSIBILITY EVALUATION

The authors thank users very much for coming to the lab recently and helping them to evaluate the StairSteady, FlexStep, All-Push Door, and AssiStep. The input was very helpful. Home Innovation’s research of these accessibility devices is sponsored by the U.S. Department of Housing and Urban Development (HUD). It is intended to gather user opinions of each device and does NOT include any sales or marketing activities.

Now the authors request that participants complete a short survey about their experiences with each of these three products. For the following sets of questions, respondents should check the response that best reflects how they felt about each accessibility device. Participants will also be able to type in their own descriptions

155

StairSteady

156

1. Please indicate range of agreement or disagreement with each of the following aspects of the StairSteady.

Strongly

Strongly

Disagree Disagree Neither

Agree

Agree

It is easy to understand how to use the

StairSteady.











It takes more time to go up and down the stairs

than it should.











The StairSteady requires little physical effort to

use it.











Needed assistance to use the StairSteady











When using it, sometimes made mistakes that

required redoing some steps











Using the StairSteady raised concerns about

personal safety











Any additional comments about previous answers can be added here:

2. Please indicate range of agreement or disagreement with each of the following aspects of the StairSteady.

Strongly

Strongly

Disagree Disagree Neither

Agree

Agree

Using the StairSteady could draw unwanted

attention to the user.











The StairSteady seems like it’s easy to install for

use.











The StairSteady seems like it’s easy to clean and

maintain.











The StairSteady wouldn’t get in the way of

others using the area around it.











The StairSteady looks nice.











The StairSteady could be made to match one’s

home décor.











Any additional comments about previous answers can be added here:

157

3. POSSIBLE USE OF THE StairSteady: Please indicate range of agreement or disagreement with each of the following questions.

Strongly

Strongly

Disagree Disagree Neither

Agree

Agree

Had problems using the StairSteady











Think others would have problems using the

StairSteady











Would like to have this product in home now











Would like to have this product in home in the

future











Any additional comments about previous answers?

4. If you needed it, how much would you pay for the STAIRSTEADY?

 $100–$500

 $501–$1,000

 $1,000–$1,500

 $1,500–$2,000

 $2,001 or more

Any comments about the price?

5. What are the ADVANTAGES of using the STAIRSTEADY?

6. What are the DISADVANTAGES of using the STAIRSTEADY?

158

FlexStep

159

7. Please indicate range of agreement or disagreement with each of the following aspects of the FlexStep.

Strongly

Strongly

Disagree Disagree Neither

Agree

Agree

It is easy to understand how to use the

FlexStep.











It takes more time to go up and down when

using the FlexStep than it should.











The FlexStep requires little physical effort to use

it.











Needed assistance to use the FlexStep











When using it, sometimes made mistakes that

required redoing some steps











Using the FlexStep raised concerns about

personal safety











Any additional comments about previous answers can be added here:

8. Please indicate range of agreement or disagreement with each of the following aspects of the FlexStep.

Strongly

Strongly

Disagree Disagree Neither

Agree

Agree

Using the FlexStep could draw unwanted

attention to me.











The FlexStep seems like it’s easy to install for

use.











The FlexStep seems like it’s easy to clean and

maintain.











The FlexStep wouldn’t get in the way of others

using the area.











The FlexStep looks nice.











The FlexStep could be made to match one’s

home décor.











Any additional comments about previous answers can be added here:

160

9. POSSIBLE USE OF THE FlexStep: Please indicate range of agreement or disagreement with each of the following questions.

Strongly

Strongly

Disagree Disagree Neither

Agree

Agree

Had problems using the FlexStep











Think others would have problems using the

FlexStep











Would like to have this product in home now











Would like to have this product in home in the

future











Any additional comments about previous answers?

10. If you needed it, home much would you pay for the FlexStep?

 $5,000–$10,000

 $10,001–$15,000

 $15,501–$20,000

 $20,001–$25,000

 $25,001 or more

Comments about the price?

11. What are the ADVANTAGES of using the FlexStep?

12. What are the DISADVANTAGES of using the FlexStep?

161

All-Push Door

162

13. Please indicate range of agreement or disagreement with each of the following aspects of the All-Push Door.

Strongly

Strongly

Disagree Disagree Neither

Agree

Agree

It is easy to understand how to use the All-Push

Door.











It takes more time to go through the door than

it should.











It requires little physical effort to use the All-

Push Door.











Needed assistance to use the All-Push Door











When using it, sometimes made mistakes that

required redoing some steps











Using the All-Push Door raised concerns about

personal safety











Any additional comments about previous answers can be added here:

14. Please indicate range of agreement or disagreement with each of the following aspects of the All-Push Door.

Strongly

Strongly

Disagree Disagree Neither

Agree

Agree

Using the All-Push Door could draw unwanted

attention to the user.











The All-Push Door seems like it’s easy to install

for use.











The All-Push Door seems like it’s easy to clean

and maintain.











The All-Push Door wouldn’t get in the way of

others using the area.











The All-Push Door looks nice.











The All-Push Door could be made to match

one’s home décor.











Any additional comments about previous answers can be added here:

163

15. POSSIBLE USE OF THE All-Push-Door: Please indicate range of agreement or disagreement with each of the following questions.

Strongly

Strongly

Disagree Disagree Neither

Agree

Agree

Had problems using the All-Push Door











Think others would have problems using the All-

Push Door











Would like to have the All-Push Door in home

now











Would like to have the All-Push Door in home in

the future











Any additional comments about previous answers?

16. If you needed it, how much would you pay for the All-Push Door?

 $100–$500

 $501–$1000

 $1,001–$1,500

 $1,501–$2,000

 $2,001 or more

Comments about the price?

17. What are the ADVANTAGES of using the All-Push Door?

18. What are the DISADVANTAGES of using the All-Push Door?

164

AssiStep

165

19. Please indicate range of agreement or disagreement with each of the following aspects of the AssiStep.

Strongly

Strongly

Disagree Disagree Neither

Agree

Agree

It is easy to understand how to use the

AssiStep.











It takes more time to go up and down the stairs

than it should.











The AssiStep requires little physical effort to use

it.











Needed assistance to use the AssiStep











When using it, sometimes made mistakes that

required redoing some steps











Using the AssiStep raised concerns about

personal safety











Any additional comments about previous answers can be added here:

20. Please indicate range of agreement or disagreement with each of the following aspects of the AssiStep.

Strongly

Strongly

Disagree Disagree Neither

Agree

Agree

Using the AssiStep could draw unwanted

attention to the user.











The AssiStep seems like it’s easy to install for

use.











The AssiStep seems like it’s easy to clean and

maintain.











The AssiStep wouldn’t get in the way of others

using the area.











The AssiStep looks nice.











The AssiStep could be made to match one’s

home décor.











Any additional comments about previous answers can be added here:

166

POSSIBLE USE OF THE AssiStep: Please indicate range of agreement or disagreement with each of the following questions.

Strongly

Strongly

Disagree Disagree Neither

Agree

Agree

Had problems using the AssiStep











Think others would have problems using the

AssiStep











Would like to have the AssiStep in home now











Would like to have the AssiStep in home in the

future











Any additional comments about previous answers?

21. If you needed it, how much would you pay for the AssiStep?

 $100–$500

 $501–$1,000

 $1,001–$1,500

 $1,501–$2,000

 $2,001 or more

Comments about the price?

22. What are the ADVANTAGES of using the AssiStep?

23. What are the DISADVANTAGES of using the AssiStep?

167

SURVEY: HOME INNOVATION ACCESSIBILITY EVALUATION

THANKS VERY MUCH!!!

The authors want to thank everyone very much for all the help and information they provided.

For any questions about this survey, or about one’s participation, please call: Ed Hudson

Director, Market Research Division

John Peavey

Director, Building Science Division

Home Innovation Research Labs

1-800-638-8556

168

APPENDIX E:

INSTALLATION INSTRUCTIONS

FOR ACCESSIBILITY DEVICES

169

ADAPTING USER’S HOME

INSTALLATION STEPS

STAIRSTEADY

STEP 1

Measure key dimensions of stairway

This information must be provided to the

manufacturer. It will be used to precut the

StairSteady components.

STEP 2

Measure user’s key dimensions

This biometric information will be used to

custom-mount the StairSteady at the correct

height for the user.

170

ADAPTING USER’S HOME

INSTALLATION STEPS

STAIRSTEADY

STEP 3

Add structural support to mount the StairSteady

The railing on the authors’ test platform required

additional structural support to install the

StairSteady assistive device.

STEP 4

Install the StairSteady rail

This StairSteady rail must be level and installed

at the height of the user’s biometric

measurements.

171

ADAPTING USER’S HOME

INSTALLATION STEPS

STAIRSTEADY

STEP 5

Add StairSteady handle

The StairSteady handle provides support to the

user as the person walks up and down the stairs.

STEP 6

Use the StairSteady assist device

The user can test the StairSteady assist device to

ensure that it has been installed correctly and

works well.

172

ADAPTING USER’S HOME

INSTALLATION STEPS

FLEXSTEP

STEP 1

Unpack the FlexStep

The FlexStep is fully assembled and shipped in a

crate; but it must be hardwired in order to

operate. The wiring includes power, a motor, a

safety guard, and controls.

STEP 2

Prepare the FlexStep for installation

The FlexStep must be wired to operate the

safety guard, motor, and controls.

173

ADAPTING USER’S HOME

INSTALLATION STEPS

FLEXSTEP

STEP 3

Wire the supports for the safety guard

The safety guard must be wired to the

FlexStep along with the controls that operate

the device.

STEP 4

Install the safety guard

The safety guard must be synchronized with

the FlexStep. The motor and controls must

also be connected to operate the FlexStep.

174

ADAPTING USER’S HOME

INSTALLATION STEPS

FLEXSTEP

STEP 5

The FlexStep in the default mode

When the FlexStep is not in use as a lift, the

device’s default position is as a conventional flight

of stairs.

STEP 6

The FlexStep in lift mode

When the FlexStep is used as a lift, the device

engages the safety guard and an anti-roll guard on

the lift to prevent a wheelchair from rolling off the

lift.

175

ADAPTING USER’S HOME

INSTALLATION STEPS

FLEXSTEP

STEP 7

Use the FlexStep

The user can test the FlexStep to ensure that it has

been installed correctly and works well.

176

ADAPTING USER’S HOME

INSTALLATION STEPS

ASSISTEP

STEP 1

Measure key dimensions of stairway

This information must be provided to the

manufacturer. It will be used to precut the AssiStep

components.

STEP 2

Measure user’s key dimensions

This biometric information will be used to

custom-mount the AssiStep at the correct

height for the user. The AssiStep can be

adjusted vertically after it is installed.

177

ADAPTING USER’S HOME

INSTALLATION STEPS

ASSISTEP

STEP 3

Add structural support to mount AssiStep

The railing on the authors’ test platform required

additional structural support to install the AssiStep

device.

STEP 4

Install the AssiStep rail system

The AssiStep has a double-track rail system

that allows the support handle to be adjusted

vertically to fit multiple users with different

biometrics.

178

ADAPTING USER’S HOME

INSTALLATION STEPS

ASSISTEP

STEP 5

Install the AssiStep rail system

The double-track rail system allows the user to

quickly release or lock the handle while providing

support to the user as the person walks up and

down the stairs.

STEP 6

Install the AssiStep handle

The AssiStep handle engages both the bottom and

top rail system. It can be adjusted vertically, and

the user can use the upper or lower support.

179

ADAPTING USER’S HOME

INSTALLATION STEPS

ASSISTEP

STEP 7

Use the AssiStep device

The user can test the AssiStep device to ensure

that it has been installed correctly and works well.

180

ADAPTING USER’S HOME

INSTALLATION STEPS

ALL-PUSH DOOR

STEP 1

Measure the door opening

The door opening must be measured to

determine if it is wide enough and level to install

the All-Push Door. Modifications may be

necessary if the opening is too narrow or if the

wall jambs and threshold are not level.

STEP 2

Unpack the All-Push Door

The All-Push Door is provided as a prehung

door that is installed into the door opening.

181

ADAPTING USER’S HOME

INSTALLATION STEPS

ALL PUSH DOOR

STEP 3

Fit and adjust the All-Push Door

Place the All-Push Door into the opening, make

adjustments to the clips, and ensure the All-Push

Door is level before completing the installation.

STEP 4

Secure All-Push Door with clips

Use screws to install the clips of the All-Push

Door to the door header and wall jambs. The

clips are evenly spaced to anchor the door

securely.

182

ADAPTING USER’S HOME

INSTALLATION STEPS

ALL PUSH DOOR

STEP 5

Anchor the hinges of the All-Push Door

The All-Push Door hinges must be screwed into

the wall jamb to complete the door

installation.

STEP 6

Install the trim to finish

Cover the clips and the rough edge of the door

opening with a trim material.

183

ADAPTING USER’S HOME

INSTALLATION STEPS

ALL-PUSH DOOR

STEP 7

Use the All-Push Door

The user can test the All-Push Door to ensure

that it has been installed correctly and works

well.

184

APPENDIX F:

EVALUATION OF ASSISTIVE DEVICES

BY USERS, CAREGIVERS, AND PROFESSIONALS

185

186

187

188

189

190

191

192

193

194

3.8

2.1

195

3.7

3.5 3.6

3.1

2.7

2.8

2.6

2.5 2.6

2.1

1.8

196

197

198

199

200

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

APPENDIX G:

COHORT RESPONSE DISTRIBUTION GRAPHS

FOR EACH DEVICE

216

STAIRSTEADY

It is easy to understand how to use the StairSteady

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

It takes more time to go up and down the stairs than it

should

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

217

STAIRSTEADY

The StairSteady requires little physical effort to use it

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

I needed assistance to use the StairSteady

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

218

STAIRSTEADY

When I used it, I sometimes made mistakes that required

me to redo some steps

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

For me, using the StairSteady made me worry a little bit

for my safety

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

219

STAIRSTEADY

Using the StairSteady could draw unwanted attention to

me

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

The StairSteady seems like its easy to be installed for use

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

220

STAIRSTEADY

The StairSteady seems like it's easy to clean and maintain

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

The StairSteady wouldn't get in the way of others using

the area around it

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

221

STAIRSTEADY

The StairSteady looks nice

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

The StairSteady could be made to match my home décor

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

222

STAIRSTEADY

I had problems using the StairSteady

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

I think others would have problems using the StairSteady

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

223

STAIRSTEADY

I would like to have this product in my home now

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

I would like to have this product in my home in the future

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

224

ASSISTEP

It is easy to understand how to use the AssiStep

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

It takes more time to go up and down the stairs than it

should

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

225

ASSISTEP

The AssiStep requires little physical effort to use it

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

I needed assistance to use the AssiStep

50%

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

226

ASSISTEP

When I used it, I sometimes made mistakes that required

me to redo some steps

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

For me, using the AssiStep made me worry a little bit for

my safety

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

227

ASSISTEP

Using the AssiStep could draw unwanted attention to me

50%

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

The AssiStep seems like its easy to be installed for use

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

228

ASSISTEP

The AssiStep seems like it's easy to clean and maintain

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

-10%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

The AssiStep wouldn't get in the way of others using the

area around it

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

229

ASSISTEP

The AssiStep looks nice

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

The AssiStep could be made to match my home décor

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

230

ASSISTEP

I had problems using the AssiStep

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

I think others would have problems using the AssiStep

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

231

ASSISTEP

I would like to have this product in my home now

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

I would like to have this product in my home in the future

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

232

ALL-PUSH DOOR

It is easy to understand how to use the FlexStep

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

It takes more time to go up and down the stairs than it should

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

233

ALL-PUSH DOOR

The FlexStep requires little physical effort to use it

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

I needed assistance to use the FlexStep

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

234

ALL-PUSH DOOR

When I used it, I sometimes made mistakes that required

me to redo some steps

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

For me, using the FlexStep made me worry a little bit for

my safety

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

235

ALL-PUSH DOOR

Using the FlexStep could draw unwanted attention to me

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

The FlexStep seems like its easy to be installed for use

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

236

ALL-PUSH DOOR

The FlexStep seems like it's easy to clean and maintain

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

The FlexStep wouldn't get in the way of others using the

area around it

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

237

ALL-PUSH DOOR

The FlexStep looks nice

120%

100%

80%

60%

40%

20%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

The FlexStep could be made to match my home décor

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

238

ALL-PUSH DOOR

I had problems using the FlexStep

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

I think others would have problems using the FlexStep

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

239

ALL-PUSH DOOR

I would like to have this product in my home now

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

I would like to have this product in my home in the future

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

240

ALL-PUSH DOOR

It is easy to understand how to use the All-Push Door

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

It takes more time to go through the door than it should

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

241

ALL-PUSH DOOR

The All-Push Door requires little physical effort to use it

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

I needed assistance to use the All-Push Door

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

242

ALL-PUSH DOOR

When I used it, I sometimes made mistakes that required

me to redo some steps

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

For me, using the All-Push Door made me worry a little

bit for my safety

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

243

ALL-PUSH DOOR

Using the All-Push Door could draw unwanted attention

to me

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

The All-Push Door seems like its easy to be installed for

use

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

244

ALL-PUSH DOOR

The All-Push Door seems like it's easy to clean and

maintain

120%

100%

80%

60%

40%

20%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

The All-Push Door wouldn't get in the way of others using

the area around it

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

245

ALL-PUSH DOOR

The All-Push Door looks nice

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

The All-Push Door could be made to match my home

décor

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

246

ALL-PUSH DOOR

I had problems using the All-Push Door

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

I think others would have problems using the All-Push

Door

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

247

ALL-PUSH DOOR

I would like to have this product in my home now

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

I would like to have this product in my home in the future

80%

70%

60%

50%

40%

30%

20%

10%

0%

Disagree

Neutral

Agree

User

Pros

Poly. (User)

Poly. (Pros)

S

“Poly” is an abbreviation for the polynomial curve used to fit the data represented as a dotted-line graph.

“Pros” is an abbreviation for the professional cohort.

248

U.S. Department of Housing and Urban Development

Office of Policy Development and Research

Washington, DC 20410-6000

June 2024

Document Outline

Retrofits & Adaptations: Improving Mobility in the Home ADAPTATIONS FOR TOWNHOMES AND ROW HOUSES

DISCLAIMER

ACKNOWLEDGMENTS

U.S. Department of Housing and Urban Development Office of Policy Development and Research

University of Buffalo Center for Inclusive Design and Environmental Access (IDeA)

Subject Matter Experts

Interdisciplinary Advisory Group (IAG)

NAHB Remodelers Council and Design Committee

FOREWORD

TABLE OF CONTENTS

LIST OF EXHIBITS

EXECUTIVE SUMMARY

Focus Group Findings: Assistive Devices May Help Individuals Age in Place

Improving Grants, Loans, and Decisionmaking Tools for Home Assessment

Improve Program Awareness, Funding Options, and Innovation in the United States

INTRODUCTION

Literature Review

Inventory of Existing Homes

METHODOLOGY

Focus Groups

Selection of Devices

Evaluation Protocol

EVALUATION OF DEVICES THAT IMPROVE MOBILITY

Construction of Demonstration Platform and Doorway Mock-Up

Findings and Observations

Data Analysis

StairSteady Evaluation

AssiStep Evaluation

FlexStep Evaluation

All-Push Door Evaluation

COST-BENEFIT ANALYSIS

StairSteady Cost-Benefit Analysis

AssiStep Cost-Benefit Analysis

FlexStep Cost-Benefit Analysis

All-Push Door Cost-Benefit Analysis

CHALLENGES AND BARRIERS

Affordability

Accessibility Products and Availability

RECOMMENDATIONS

FUTURE RESEARCH

REFERENCES

APPENDIX A: HOME MODIFICATION LITERATURE REVIEW

Table of Contents

Preface

Introduction

Inclusion and Exclusion Criteria

Universal Design

Description and Scope of Home Modifications

Characteristics of Target Populations

Aging

Decreased Mobility

Cognitive Impairments

Visual Impairment

Beyond Codes and Standards

Design

Entrances and Exits

Bathrooms

Kitchens

Doorways and Hallways

Stairs

Effectiveness

Perceptions and Motivations

Outcomes

Certification Programs

Discussion

Key Findings

Identified Gaps

Conclusion

References

Credentialing

Abilities OT Online Seminars in Accessibility

Certified Aging-in-Place Specialist (CAPS)

Executive Certificate in Home Modification Program

Home Modifications Practitioner Certificate Program (VGM Group)

NARI Universal Design Certified Professional (UDCP)

IDEA 107: Universal Design and Home Modifications

Popular Home Modification Products and Suppliers

APPENDIX B: FOCUS GROUP DISCUSSION AND EXPLORATION OF ACCESSIBILITY NEEDS AND CHALLENGES

Background

Qualitative Research Objectives and Methodology

MARKET RESEARCH OBJECTIVES

METHODOLOGY

Discussion Structure

RESIDENTS

CAREGIVERS

PROFESSIONALS

Sample Summary

RESIDENTS

CAREGIVERS

PROFESSIONALS

Respondent Profiles -RESIDENTS

Respondent Profiles -PROFESSIONALS

Respondent Profiles -CAREGIVERS

Respondent Profiles and Recruitment Summary Details

RESIDENTS

CAREGIVERS

CONTRACTORS

Challenges Summary, in Order -Residents and Caregivers

Discussion of results:

Solutions Summary -Modification Professionals

Most Typical Solutions

Stair Accommodation Capability

Training or Credentials

Discussion of results:

Executive Summary

Executive Summary-Overview

Executive Summary-Key Locations

Executive Summary -Priorities

Executive Summary-Modification Investment Decisions

Executive Summary-Barriers to Action

Summary of Key Findings

Residents and Caregivers

PROFESSIONALS

APPENDIX C: SUMMARY OF DESIGN SELECTION AND PROTOTYPE CONSTRUCTION

Home Innovation Research Labs and SUNY /DeA Center present: Task 5 -Design Leading to Task 6 -Prototype Construction

The Team:

Methodology-Investigative Approach:

Takeaways from precursor research-Literature Review

Takeaways from precursor research-Focus Groups

Takeaways from precursor research-Site Observation

Next Steps: Construction, Evaluation, Optimization

Design Team Brainstorming; IAT and Team QC

1st (tied) All-Push Door

1st (tied) FlexStep

3rd StairSteady

4th Moveable Storage Wall

Potential 2nd round

Lowest-ranked Prototypes

Final lab research choices remain the same

APPENDIX D: HOME INNOVATION ACCESSIBILITY EVALUATION SURVEY

SURVEY: HOME INNOVATION ACCESSIBILITY EVALUATION

StairSteady

FlexStep

All-Push Door

AssiStep

APPENDIX E: INSTALLATION INSTRUCTIONS FOR ACCESSIBILITY DEVICES

ADAPTING USER’S HOME INSTALLATION STEPS STAIRSTEADY

STEP 1

STEP 2

STEP 3

STEP 4

STEP 5

STEP 6

ADAPTING USER’S HOME INSTALLATION STEPS FLEXSTEP

STEP 1

STEP 2

STEP 3

STEP 4

STEP 5

STEP 6

STEP 7

ADAPTING USER’S HOME INSTALLATION STEPS ASSISTEP

STEP 1

STEP 2

STEP 3

STEP 4

STEP 5

STEP 6

STEP 7

ADAPTING USER’S HOME INSTALLATION STEPS ALL-PUSH DOOR

STEP 1

STEP 2

STEP 3

STEP 4

STEP 5

STEP 6

STEP 7

APPENDIX F: EVALUATION OF ASSISTIVE DEVICES BY USERS, CAREGIVERS, AND PROFESSIONALS

Introduction -Mobility Assistive Devices Evaluated in this Phase

Research Methodology

Questionnaire Design

Safety Questions

Ease of Use Questions

Appearance Questions

Installation and Maintenance Questions

Desirability of Devices: Do Users Want It in Their Homes?

Concerns and Limitations When Using the Devices

All-Push Door Ratings

Summary of Survey Findings and Feedback Responses from Interviews for the All-Push Door

FlexStep Ratings

Summary of Survey Findings and Feedback Responses from Interviews for the FlexStep

AssiStep Ratings

Summary of Survey Findings and Feedback Responses from Interviews for the AssiStep

StairSteady Ratings

Summary of Survey Findings and Feedback Responses from Interviews for the StairSteady

General Findings from Post-Survey Discussions: Safety

General Findings from Post-Survey Discussions: Ease of Use

General Findings from Post-Survey Discussions: Appearance

General Findings from Post-Survey Discussions: Installation and Maintenance

Conclusions

APPENDIX G: COHORT RESPONSE DISTRIBUTION GRAPHS FOR EACH DEVICE

STAIRSTEADY

ASSISTEP

FLEXSTEP

ALL-PUSH DOOR