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Background Home visits prior to inpatient rehabilitation facility (IRF) discharge allow occupational therapists to observe functional abilities among patients with stroke and address barriers that impact daily activities at home. However, home visits prior to IRF discharge are not standard practice due to barriers of time and cost constraints. We explored whether an access visit (visiting the home without the patient) could serve as an alternative to a home visit (with the patient) to anticipate functional abilities at home. Methods We used baseline data from a randomized controlled trial that occurred before and during the COVID-19 pandemic, which caused predischarge home visits to be modified to access visits without the participant. Participants had suffered a stroke and were treated in an IRF, aged ≥ 50, with plans to discharge home. International Classification of Functioning, Disability, and Health (ICF) qualifier scores were compared between participants’ home/access visits and IRF discharge. ICF scores were compared between predischarge home visits and IRF discharge and between access visits and IRF discharge using Wilcoxon signed-rank tests. Differences in ICF scores between home/access and IRF discharge were compared between home and access visits using linear regression models. Results Among 99 participants (58% men, average 67 years old, 60% Black), 57 received a home visit and 42 received an access visit. Both groups had significantly worse ICF scores at the home/access visit compared to IRF discharge for most activities. Differences in scores between home visit and IRF were significantly greater than between access and IRF for bathing, upper and lower body dressing, bed/chair transfer, walking, and navigating stairs. The largest differences between home and access visits were for walking (β = 1.05 95% CI 0.46 to 1.64) and going up and down stairs (β = 0.87 95% CI 0.25 to 1.49). Conclusions Participants with stroke had greater difficulty performing daily activities in both home and access visits than at the IRF, but observed differences were greater for home visits than access visits. While access visits may be beneficial to anticipate functional abilities in the home when home visits cannot occur, visiting the home to directly observe patients’ performance is ideal. Trial registration Registered on 3/26/2018 at clinicaltrials.gov, NCT03485820.

OBJECTIVE. We describe the development and preliminary psychometric properties of an assessment to quantify the magnitude of an environmental barrier’s influence on occupational performance. METHOD. The assessment was developed and then piloted on a group of 77 older adults before and after an occupational therapy intervention focused on environmental barrier removal. Refinements were made to the assessment before it was evaluated for interrater reliability in a sample of 10 older adults using 2 raters. RESULTS. The In-Home Occupational Performance Evaluation (I–HOPE) is a performance-based measure that evaluates 44 activities in the home. The 4 subscales of Activity Participation, Client’s Rating of Performance, Client’s Satisfaction With Performance, and Severity of Environmental Barriers are sensitive to change in the environment. The subscales’ internal consistency from .77 to .85, and intraclass correlation coefficients ranged from .99 to 1.0. CONCLUSION. This preliminary study suggests that the I–HOPE is a psychometrically sound instrument that can be used to examine person–environment fit in the home.

Home modifications provided by occupational therapists (OTs) are effective in improving daily activity performance and reducing fall risk among community-dwelling older adults. However, the prevalence of home modification is low. One reason is the lack of a centralized database of OTs who provide home modifications. This study aimed to develop and test the usability of a mobile app directory of OTs who provide home modifications in the United States. In phase 1, a prototype was developed by identifying OTs who provide home modifications through keyword Web searches. Referral information was confirmed by phone or email. In phase 2, community-dwelling older adults aged older than 65 years and OTs currently working in the United States were purposefully recruited to participate in a single usability test of the mobile app, Home Modifications for Aging and Disability Directory of Referrals (Home Maddirs). Participants completed the System Usability Scale (SUS) and semistructured interview questions. Interview data were coded, and themes were derived using a grounded theory approach. In phase 1, referral information for 101 OTs across 49 states was confirmed. In phase 2, 6 OTs (mean clinical experience 4.3 years, SD 1.6 years) and 6 older adults (mean age 72.8 years, SD 5.0 years) participated. The mean SUS score for OTs was 91.7 (SD 8.0; out of 100), indicating good usability. The mean SUS score for older adults was 71.7 (SD 27.1), indicating considerable variability in usability. In addition, the SUS scores indicated that the app is acceptable to OTs and may be acceptable to some older adults. For OTs, self-reported barriers to acceptability and usability included the need for more information on the scope of referral services. For older adults, barriers included high cognitive load, lack of operational skills, and the need to accommodate sensory changes. For both groups, facilitators of acceptability and usability included perceived usefulness, social support, and multiple options to access information. Home Maddirs demonstrates good preliminary acceptability and usability to OTs. Older adults' perceptions regarding acceptability and usability varied considerably, partly based on prior experience using mobile apps. Results will be used to make improvements to this promising new tool for increasing older adults' access to home modifications.

Background Falls remain the leading cause of injury, long-term disability, premature institutionalization, and injury-related mortality in the older adult population. Home modifications, when delivered by occupational therapists, can reduce falls among high-risk community-dwelling older adults by 39%. However, home-modification implementation is not standard practice in the United States. The goal of the H ome H a zard R emoval P rogram (HARP) study is to implement an evidence-based home modification intervention for older adults designed to reduce the incidence of falls through an aging services network. Methods We will conduct a hybrid effectiveness/implementation trial of 300 older adults at risk for a fall who are randomized and followed for 12 months. Participants who are randomized to treatment will receive the home modification intervention provided by an occupational therapist in addition to usual care, defined as continued services from the area agency on aging. We will compare the effectiveness of the program and usual care using survival analysis with the time to the first fall over 12 months as the primary outcome of interest. Secondary outcomes include daily activity performance, fall self-efficacy, and health-related quality of life. Fidelity, dose, adherence, safety, cost, and health care utilization will also be examined in the implementation component of this study. Discussion This intervention targets an underserved, difficult to reach population of older adults. The tailored approach of the study intervention is a strength in improving adherence, as each recommendation is individualized to be acceptable to the participant. The effectiveness/implementation design of the study allows for rapid dissemination of results and implementation of the intervention in a United States social services agency. Trial registration Clinicaltrials.gov identifier: NCT02392013 . Retrospectively registered on March 5, 2015.

Background Remaining at home is a high priority for many older adults, but the capacity to “age in place” often is threatened by environmental barriers. Purpose To describe a client-centred occupational therapy home modification intervention program and examine the impact of the intervention on daily activity performance over time. Methods Using a competence-environmental press framework, a client-centred home modification program for older adults was implemented. In this quasi-experimental, single group prospective study, participants' subjective ratings of daily activity performance were evaluated before and after the intervention (baseline/post/post). Findings After home modification, participants' perception of their daily activity performance at home improved significantly and was maintained 2 years post-modification. Implications Home modification may benefit older adults attempting to age in place.

Date Presented 4/16/2015 Home modifications improve daily activity performance and could potentially affect other important health outcomes, including community participation for older adults with chronic conditions.

Home modification interventions have the potential to provide support to informal caregivers; however, the impact of these interventions on caregivers is understudied, and adequate assessments are lacking. This study describes the development and preliminary psychometric properties of a performance-based assessment that identifies environmental barriers to performance of daily caregiving activities. An existing assessment of person–environment fit was modified using key informant interviews and was administered to 31 informal caregivers. The In–Home Occupational Performance Evaluation for Providing Assistance demonstrated reliability across raters, good internal consistency for all subscales, and convergent validity with existing measures. This assessment has the potential to guide home modification interventions and measure the impact on informal caregiving in the home.

Falls are the leading preventable cause of morbidity, mortality, and premature institutionalization for community-dwelling older adults. To test the effectiveness of a behavioral intervention on fall risk among older adults receiving services from an Area Agency on Aging. This randomized clinical trial examined a home hazard removal intervention in the community using a race- and sex-stratified randomization design. Older adults receiving services from the Area Agency on Aging in urban St Louis, Missouri, were assigned to a home hazard removal intervention delivered over 2 weeks with a 6-month booster or usual care control. Eligible participants were adults aged 65 years or older who did not have dementia, were at high risk for falling, and resided in the community. Enrollment occurred from January 2015 to September 2016; 12-month follow-up occurred from February 2016 to October 2017. Data were analyzed from February 2019 to July 2021. The intervention was a home hazard removal program delivered by an occupational therapist in the home that included a comprehensive clinical assessment and a tailored hazard removal plan. Usual care control consisted of annual assessments and community referral. The primary outcome was the hazard of a fall over 12 months. Prespecified secondary outcomes included the rate of falls over 12 months, daily activity performance, falls self-efficacy, and self-reported quality of life. A total of 310 participants (mean [SD] age, 75 [7.4] years; 229 [74%] women; 161 Black participants [52%]) were randomized, with 155 participants assigned to the intervention and 155 participants assigned to usual care. Retention was 127 participants (82%) in the intervention group and 126 participants (81%) in the control group. There was no difference for our primary outcome of fall hazard (hazard ratio, 0.90; 95% CI, 0.66-1.27). There was a 38% reduction in the rate of falling in the intervention group compared with the control group (relative risk, 0.62; 95% CI, 0.40-0.95; P = .03). At 12 months, the rate of falls per person-year was 1.5 (95% CI, 1.32-1.75) in the intervention group and 2.3 (95% CI, 2.08-2.60) in the control group. There was no difference in daily activity performance (adjusted difference, -0.20; 95% CI, -0.95 to 0.55; P = .60), falls self-efficacy (adjusted difference, -0.12; 95% CI, -1.25 to 1.01; P = .84), or quality of life (adjusted difference, 0.84; 95% CI, -0.95 to 2.64; P = .35). This randomized clinical trial found that a brief home hazard removal program did not reduce the hazard of falls among community-dwelling older adults at high risk for falling. The intervention was effective in achieving a reduced rate of falls, a prespecified secondary outcome. This effectiveness study has the potential for delivery through the national aging services network. ClinicalTrials.gov Identifier: NCT02392013.

Date Presented 4/7/2016 We aimed to determine the effectiveness of home modifications in reducing falls and maintaining independence in ADLs for older adults. Those who received treatment experienced a decrease in falls at 6 months and an improvement in daily activity performance that was maintained at 12 months. Primary Author and Speaker: Susan Stark Contributing Authors and Additional Speakers: Marian Keglovits, Emily Somerville

Date Presented 4/16/2015 The In-Home Occupational Performance Evaluation for Providing Assistance is a reliable and valid tool to measure caregiver support, self-efficacy, and barriers in the environment. Researchers and clinicians can use this tool to guide and assess home modification interventions to support caregivers.