U.S. Department of Health and Human Services

Home Modifications: Use, Cost, and Interactions with Functioning Among Near-Elderly and Older Adults

Executive Summary

Vicki A. Freedman, Ph.D.
University of Medicine and Dentistry of New Jersey, School of Public Health

Emily M. Agree, Ph.D.
Johns Hopkins University, Bloomberg School of Public Health

October 10, 2008

This report was prepared under contract #HHS-100-03-0011 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Urban Institute. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officers, Hakan Aykan and William Marton, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Their e-mail addresses are: Hakan.Aykan@hhs.gov and William.Marton@hhs.gov.

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.

Background. Recent studies suggest a potentially large role for assistive home features in the daily lives of older adults. Yet surprisingly little current and generalizable information has been available to policy makers to allow them to investigate who has assistive home features, who has added these features and at what cost, who actually uses such features, and who potentially needs such features but has not put them into place. The 2005 Pilot Study of Technology and Aging was funded by the Assistant Secretary for Planning and Evaluation in cooperation with the National Center for Health Statistics and the National Institute on Aging to develop measures of the home environment and assistive technology use for national health and aging surveys (Freedman, Agree, & Cornman 2005; Freedman, Agree, & Landsberg 2006; Freedman, Agree, & Cornman 2006b). A subset of these items was included in the 2006 Health and Retirement Study (HRS) as an experimental module. In this report we analyze the 2006 HRS Home Modification Module (N=1,512) to describe the range of assistive home features for near-elderly and older adults (born 1953 or earlier; ages 52 and older in 2006).

Research Questions. Four questions are addressed:

1. To what extent do near-elderly and older adults live in homes with assistive features and to what extent have they added and do they use such features (alone and in combination with personal care)?

2. What is the distribution of out-of-pocket costs for adding assistive features and to what extent do insurance and government programs contribute?

3. How does the existence, addition, and use of assistive home features vary for demographic groups? Are these differences accounted for by differences in economic or health-related factors?

4. To what extent are near-elderly and older adults at risk for home modifications--that is, what percentage of near-elderly and older adults have low functioning, yet do not have relevant assistive home features--and what is the demographic and socioeconomic makeup of this group?

Data and Methods. Respondents to the 2006 HRS Home Modifications Module were asked about ten assistive home features: ramps at the entrance, handrails at the entrance (asked if the respondent has to step up or down to get into home), an emergency call system, grab bars in the shower or tub area, a seat for the shower or tub, grab bars around the toilet, a raised or modified toilet seat, a stair glide or chair lift to go up or down stairs (asked if the respondent has living space on more than one floor), handrails in the stairways (if the respondent has living space on more than one floor), and handrails in the hallways. For each feature, the respondent was asked about its existence (whether the home has the feature), addition (whether it was there when the respondent moved in or added), and use in the last 30 days (first by the respondent and then by others in the household). For persons who added features to the home, information on out-of-pocket costs was obtained through a series of bracketed questions. Respondents were first asked if they paid more than $500, about $500, or less than $500 for all the features added; then a follow-up question asked about either $100/$1000 depending on the previous answer. Respondents were also asked if any payments were made by insurance or government programs.

We developed summary measures to indicate the existence, addition, and use of any of nine assistive home features (excluding stair railings, which are nearly universal among respondents with living space on more than one floor). We also created a six-category indicator of amount spent out-of-pocket on assistive home features: don't know, $0, $1-100, $101-500, $501-1000, and >$1000. A final outcome identifies individuals at risk for a housing modification (i.e., those who currently have low functioning, yet do not have relevant assistive home features). Low functioning was defined as having either mild deficits indicated by only a behavioral change (e.g., fear of falling, holding onto walls when walking) or moderate to severe deficits reflected in difficulty or help with bathing, toileting, or walking across a room or use of a mobility device.

Results. In 2006 two-thirds of the population ages 52 and older had one or more assistive home features, about one-third added at least one of these features, and 40% used at least one feature in the last 30 days. The most common assistive home features included railings at the home entrance (36.2%), followed by grab bars in shower/tub (30.3%) and a seat for the shower/tub (27.3%). Among those who added features, roughly 9% reported no out-of-pocket payments, one-third <$100, another third >=$100 to <$500, 10% >=$500 to <$1000 and the remaining 10% >=$1000. Only 6% of respondents who added features could not report an amount in broad brackets. A very low percentage--about 6%--reported that insurance or government programs paid some of the cost.

In logistic regression models that included demographic, economic, health, and housing-related factors, significant predictors (direction of association by outcome shown parenthetically) included: age (+existence, +addition, +use), having another adult in the household (-use), home ownership (+addition), Medicare DI (+existence, +addition, +use), and long-term care insurance (+existence). Few health-related factors predicted the existence or addition of assistive home features; however, respondents with high blood pressure, diabetes, cancer, and lower body limitations were more likely to use such features.

One in four near-elderly and older adults are at risk for a home modification, that is, have a lower body limitation and an unmodified barrier at the entry to their home, inside their home, or in the bathroom (either shower/bath area or toilet area). Persons at risk for a modification were more likely to be older, widowed, non-Hispanic Black, with less than a high school education, to rent their homes, to have Medicare, Medicare DI, and Medicaid coverage and less likely to have employer-provided coverage, and more likely to be in the lowest income and asset quartiles. They have a higher risk of reporting chronic conditions, upper and lower body limitations and fair/poor memory, vision and hearing. In logistic regression models, those receiving Medicare DI remained at elevated risk for a home modification after controlling for other economic and health-related factors.

Implications. Findings offer policy makers several new insights into the role of assistive home features in the daily lives of near-elderly and older adults. Five points are particularly noteworthy. First, assistive home features among near-elderly and older adults are more prevalent than previously suggested by national survey data. Second, we found that the existence, addition, and use of assistive home features varies considerably across demographic groups, but these effects do not persist once other demographic, economic and health-related factors were considered. Nevertheless, one consistent and strong finding--that home owners are significantly more likely to add assistive features to their home, compared to those who rent, even after controlling for demographic, economic, health, and housing-related factors--may require further investigation. Third, as many as one in four near-elderly and older adults have a lower body impairment and an unmodified barrier in their home and therefore may be considered at risk for a home modification. Thus, public policies that encourage extension of home modifications to those in greatest need have the potential to improve the functioning of older adults even more and potential reduce their reliance on personal care. Fourth, despite the finding that Medicare DI beneficiaries are more likely to have, add, and use assistive home features, we also found that these beneficiaries have an increased likelihood of being at risk for a home modification, even after controlling for demographic, health, and economic factors. This finding in turn suggests that the DI program may serve as a useful vehicle for identifying and targeting individuals at risk. Given that most home modifications are relatively inexpensive, it may be fruitful to investigate in future research the reasons (other than cost) why Medicare DI beneficiaries do not have home modifications on par with other individuals. Finally, it is not currently possible to track over time the contribution of assistive home features to disability trends or to monitor the size of the population at risk for assistive home features. Incorporating these measures into ongoing national health surveys would allow tracking these potentially important public health indicators.