Home Modification Information Needs of

Occupational Therapists Practicing in NSW

Authored by
Fiona Cowell, Catherine Bridge, & Stephanie Mathews

1st ed. July 2007

ISBN: 1 86487 771 5

www.homemods.info
Authored by Fiona Cowell, Catherine Bridge, & Stephanie Mathews for the Home Modification Information
Clearinghouse, City Futures Research Centre, UNSW Australia.

Publication History
1st edition Home Modification Information Needs of Occupational Therapists Practicing
in NSW by Fiona Cowell, Catherine Bridge, & Stephanie Mathews, Month July 2007.
Reprinted May 2007

Contribution of Authors
This is the number edition of the Occasional Paper: Title, replacing the original
publication of the same name, authored by Fiona Cowell, Catherine Bridge, &
Stephanie Mathews, July 20072007 for the Home Modification Information
Clearinghouse, University of Sydney.

Acknowledgements
This material has been published by the Home Modification Information Clearinghouse
within the City Futures Research Centre, Faculty of the Built Environment, UNSW
Australia (University of New South Wales).
This material was reprinted with funding from the Australian Department of Social
Services (DSS), and Ageing, Disability & Home Care (ADHC), a part of the NSW
Department of Family and Community Services (FACS).
This work is based on Fiona Cowell’s honours thesis, completed under the supervision
of Catherine Bridge, and with the support from an internal grant from the School of
Occupation and Leisure Sciences. Stephanie Mathews translated it to this format. The
authors gratefully acknowledge funding from The Home and Community Care program,
a joint Commonwealth and NSW Department of Ageing, Disability and Home Care
(DADHC) program, to support the original production of this document.

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Liability Statement
The Home Modification Information Clearinghouse team gives no warranty that the
information or data supplied contain no errors. However, all care and diligence has
been used in processing, analysing and extracting the information. The Home
Modification Information Clearinghouse will not be liable for any loss or damage
suffered upon the direct or indirect use of the information supplied in this document.

Reproduction of material
Any table or material published in this Occasional Paper may be reproduced and
published without further license, provided that due acknowledgement is made of this
source. The preferred acknowledgment style is:
Fiona Cowell, Catherine Bridge, & Stephanie Mathews (2014) Home Modification
Information Needs of Occupational Therapists Practicing in NSW, 2nd printing.
Sydney: Home Modification Information Clearinghouse, University of New South
Wales. (May) [online]. Available from www.homemods.info

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Authored by Fiona Cowell, Catherine Bridge, & Stephanie Mathews for the Home Modification Information
Clearinghouse, City Futures Research Centre, UNSW Australia.

Contents
Publication History 2

Introduction 6

1.1 Project Aims 6

1.2 Background 6

2. Methodology 11

2.1 Phase 1: Exploration 11

2.1 Phase 2: Data Collection 12

2.1.1 Sampling Frame 12
2.1.2 Interview Process 13
2.1.3 Interview Schedule 14
2.1.4 Theoretical Sensitivity 15
2.2 Phase 3: Dissemination 16

3.Thematic analysis 16

3.1 Spatial requirements 16

3.1.1 Client-Specific Measurements 17
3.1.2 Australian Standards 17
3.1.3 Scaled Drawings 18
3.1.4 Carer requirements 18

3.2 Requirements for community inclusion 20

3.2.1 Requirements for meeting standards of care 20
3.2.2 Disability access components 23

3.3 Funding policy 23

3.4 Building and land regulation 25

3.5 Natural environment 25

3.6 Built environment 25

3.7 Other Education 26

3.7.1 Assessment Process 28
3.7.2 Understaffing 29
3.7.3 Client Collaboration 30
3.7.4 Communication with Home Modification Services 30

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4. Summary of findings 32

4.1 Specific Information Needs 32

4.2 Collaboration with Clients and Carers 33

4.3 Modification Installation 33

4.3.1 Communication with Service Providers 33
4.3.2 Staffing 34
4.3.3 Assessment Process 35
4.3.4 Filling the Information Gap 35

References 37

APPENDIX A: Invitation to participate 41

APPENDIX B: Ethical consent 42

APPENDIX C: Interview Framework 43

Figures
Figure 1. Knowledge needs identified by NSW occupational therapists
circa 1994 11
Figure 2. Sources of Product Information used by Participants 19

Tables
Table 1. Home Assessment Components 9
Table 2. List of topic areas, definitions and examples of topic areas 13

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Introduction
This research examined the home modification information needs of occupational
therapists in New South Wales. Increasing numbers of people with disabilities and a
growing trend toward making it possible for people with disabilities to remain in their
homes have created a growing need for home modification services. Occupational
therapists typically are responsible for determining what home modifications are
appropriate. Indeed, government funding for home modifications is only available after
an occupational therapist has made recommendations. Identifying therapists’ home
modification information needs is important so that the gaps in their knowledge may be
filled. All participants in this study were occupational therapists practicing in New South
Wales who devoted at least part of their practice to home modification.

1.1 Project Aims

This research sought information about the home modification needs of occupational
therapists in New South Wales. “Information” includes facts told or heard or discovered
(Hawkins, 1988), and “need” is the discrepancy or gap between current practice and
best practice (Witkin & Altschuld, 1995).
This project aimed to gain information from practicing occupational therapists that
would guide dissemination of information about home modification. Specifically, we
aimed to:
 determine what home modification information occupational therapists need;
 learn how occupational therapists acquire information; and
 learn how occupational therapists’ home modification knowledge affects the
services they provide

1.2 Background
With increasing numbers of people with disabilities and rising costs of institutional care,
home modification is an important alternative that permits many people with disabilities
to remain in their own homes and function with a maximum degree of independence
(Mann, Ottenbacher, Fraas, Tomit, & Granger, 1999; Stark, 2004). Occupational
therapists play a key role in designing modifications and accessing home modification
services, yet therapists may not have all of the information they need to provide the
best home modification service. Therapists have identified several areas in which they
believed they needed additional information (Bridge, 1994). The present study
examines in greater depth the home modification information needs of occupational
therapists, using the topic areas and interview techniques that Bridge and Martindale
(2002) used to assess the home modification information needs of the Home
Modification & Maintenance Service of New South Wales.
Due to demographic, economic and social change, there is a growing trend toward a
community focus on health and a greater push to make it possible for older adults and
people with disabilities to remain in their own homes and age in place (Wylde, 1998).

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The incidence of reported disability in the Australian population increased from 13.2
percent in 1981 to 19.3 percent in 1998 (Davis, Beer, Gligora, & Thorn, 2004).
Technological and medical advances have resulted in longer life-spans, with some
people acquiring disabilities as they age and those with pre-existing disabilities living
longer (Commonwealth Department of Family and Community Services, 2004). Due to
the high cost of residential care, premature transition to residential care is not a viable
long-term solution. National policy reflects the interest in enabling people to continue to
live in their own homes. The National Strategy for an Ageing Australia (Commonwealth
Department of Health and Ageing, 2001) and the Commonwealth
Disability Strategy (Commonwealth Department of Family and Community Services,
2004) recognised that older people and people with disabilities want to stay active,
independent, and connected to the community. The Disability Services Act (1986) and
the Disability Discrimination Act (1992) promote the autonomy of people with
disabilities. The Home and Community Care Act (1985) established a variety of
services for people with disabilities and frail aged people to enable them to remain in
their own homes.
Home modifications change the home environment to allow individuals to function with
maximum independence (Law, Cooper, Strong, Stewart, Rigby, & Letts, 1997).
Common modifications include hobless showers for easy access, grab rails in the
shower and toilet, access ramps, wider doorways, increased lighting, removal of mats
to prevent falls, and assistive devices such as wheelchairs and shower chairs. The
goals of home modifications are to make tasks easier, facilitate care giving, increase
people’s independence, improve safety, reduce the need for personal care services,
and enable people to live in the place of their choice (Pynoos, Sanford & Rosenfelt,
2002; Hawkins & Stewart, 2002).
Home modifications also serve an injury-prevention function, which can contribute to a
client’s independence and defer costly institutionalisation. Fall prevention is of
particular concern for older adults and people with disabilities because the risk of life-
threatening injury and the risk of function loss are significant (Cumming, Thomas,
Szonyi, Salkeld, O’Neil, Westbury, & Frampton, 1999; Smith & Widiatmoko, 1998;
Tinetti & Speechly, 1989). For example, about 50% of older adults who sustain a hip
fracture will never regain their pre-fall level of functioning; this often results in costly
long-term institutionalisation (Tinetti & Speechly, 1989). Decreasing the risk of injury
and subsequent hospital admissions by installing home modifications can reduce the
overall cost of care (Gibson, Angus, Braddock, Fortune, Johnstone, Maddein, &
Mason, 2001; Mann, et al., 1999). Preventive home modifications also can increase the
level of safety people feel when performing daily tasks (Bridge, 1996). That feeling of
safety increases confidence in performing tasks that clients previously avoided
(Rogers, Holm & Stone, 1997).
Although a homeowner could make any modifications at his or her own expense, the
Home and Community Care, Veterans Affairs and Department of Housing Home
Modification Programs may subsidise or provide in full the cost of home modifications.
These programs, however, require that the modifications be implemented in

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accordance with an occupational therapist’s recommendations (Home and Community

Care Program, 1998; NSW Department of Housing, 2002). The Home Modification and
Maintenance division of Home and Community Care funds and installs home
modifications for the Home and Community Care population. No one can be excluded
from the service due to inability to pay (Home and Community Care Program, 1998).
There are three levels of Home and Community Care Home Modification services:
 Level 1 – Home modifications < $5,000
 Level 2 – Between $5,000 - $20,000
 Level 3 - > $20,000
Although State and Commonwealth funded, each Home Modification and Maintenance
service is managed independently. The mandate of the New South Wales Department
of Housing is to provide safe, decent and affordable housing for people on low incomes
(NSW Department of Housing Home Page). If it is economically viable to do so, the
Department will modify housing free of charge to suit people with disabilities or older
adults (NSW Department of Housing, 2002). Department of Housing approval of
modifications depends on the long-term value of the property, the cost of alternative
approaches, the cost/benefit of relocating the tenant, and the priorities competing for
funds (NSW Department of Housing, 2002).
Given the high cost of many modifications, occupational therapists must be able to
justify clearly and describe precisely the recommended modifications. The cost of
common modifications, such as bathroom renovations or access ramps, may exceed
$5,000, and sound justification is required before Department of Housing or Home and
Community Care will approve funding. Clear justification is no less important if the
client is to finance all or part of the modification. Similarly, the therapist must be able to
specify the modification clearly so the trades people can properly install the therapist’s
designs. To adequately describe and justify recommended modifications, the
occupational therapist must have the information necessary to design modifications for
each particular client and the basic knowledge to guide information collection and
modification design.
The accuracy and completeness of the information the occupational therapist obtains
at each stage of the assessment process affects the suitability of the recommended
modifications and the efficiency of the home modification process. Accurate and
complete client referral data can help therapists to properly determine the urgency with
which the client needs to be seen and the issues to be addressed during a home visit
(Bridge, 1996). As stated by Rogers, Holm & Stone (1997), the home assessment may
involve face-to-face interviews, a detailed examination of the home environment,
observation of the client performing tasks, or a combination of all three (see Table 1).
Based on those observations, the therapist will recommend environmental changes to
maximise the client’s independence, safety, and participation in light of the client’s
needs and wants (Pynoos, Tabbarah, Angelelli, & Demiere, 1998).

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Table 1. Home Assessment Components

Data-Gathering Purpose
Method

Interview Provide overall profile of the client’s abilities

Understand client’s priorities in relation to task performance
Target tasks requiring further in-depth evaluation

Observation of task Assess the performance of components of tasks identified

performance as being difficult for the client to perform
Identify possible intervention strategies
Ascertain whether a change in the environment would
enable ease of task performance

Examination of the home Assess for environmental hazards

environment Suitability of environment for client
Understanding of culture and values of client
Assess structural and maintenance issues

If the therapist obtains complete and accurate information from the referral and the
home assessment, and has a solid knowledge basis from which to analyse that
information, he or she should be able to recommend and justify effective home
modifications for the client.
There are instruments to help therapists collect pertinent home assessment data, but it
is not clear that therapists are using the most valid and reliable instruments. Home
assessment frameworks are structured guidelines that help therapists identify client
needs and evaluate the home environment (Bridge & Martindale, 2002). Assessment
frameworks generally come in the form of checklists that prompt the therapist to
explore all areas of the client’s physical environment and to consider the client’s social
and cultural perspective (Mitchell & Unsworth, 2004). A framework can help the
therapist to problem-solve in a consistent and reliable way (Bridge & Martindale, 2002).
1
Although several standardised assessment tools are available, therapists more
commonly use self-designed assessment instruments (Clemson, Roland, & Cumming,
1992; Corcoran & Gitlin, 1997). Because self-designed assessment instruments are not
standardised or tested, their reliability and validity is open to question (Cooper, Cohen,
& Hasselkus, 1991; Mitchell & Unsworth, 2004).
Even with an ideal home assessment framework, collaboration with the client in the
decision-making process is pivotal to the success of home modifications (Law, Cooper,
Strong, Stewart, Rigby, & Letts, 1997; Stark, 2004). Client motivation to learn and
maintain a skill is higher when the client determines the goals and controls the way
they are performed (Barnes, 1991). Collaboration permits the therapist to work with the
client to establish goals that are realistic and meaningful to the client (Law, Cooper,

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Clearinghouse, City Futures Research Centre, UNSW Australia.

Strong, Stewart, Rigby, & Letts, 1997; Law, Polatajko, Pollock, McColl, Carswell, &
Baptiste, 1994). The occupational therapist also should seek input from family
members, carers, and other professionals who work closely with the client (Ford &
Tonkin, 1994).
A therapist’s basic knowledge and experience can affect his or her ability to collect
necessary information and formulate appropriate recommendations. Table 2 sets out
the relevant competencies documented by Ford & Tonkin (1994) expected of
Occupational Therapists within the first few years of commencing Occupational
Therapy practice.

Home Modification competencies relevant to

Occupational Therapists

1.4 Respects the individuality and worth of each client within their
environment

1.5 Establishes and maintains collaborative working arrangements

with other disciplines

2.2 Assesses the occupational environment(s) of the individual or

group

3.3 Prescribes specialised adaptive equipment and techniques

3.5 Provides consultation regarding modification to the workplace,

home and leisure environments

3.12 Understands the role of the client’s caregiver

3.13 Utilises available community resources and facilities

In 1988 the NSW Occupational Therapy Association expressed concern that the
undergraduate course did not prepare graduates to advise clients about environmental
modifications (Bridge, 1996). To investigate occupational therapists’ perceptions of
their need for home modification information, In 1994, Bridge surveyed 29 occupational
therapists and asked them to identify their home modification knowledge needs the
results of this survey are displayed in Figure 1.

____________________
1 The Westmead Home Safety Inventory (Clemson, 1997) and the Safety Assessment of Function and the Environment for Rehabilitation
(SAFER) (Oliver, Blathwayt, Brackley, & Tamaki, 1993) are examples of standardised home assessment frameworks.

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Building on the information that Bridge (1994) acquired, the present study sought to
gather more specific information about therapists’ home modification knowledge needs.
In the present study, therapists were interviewed about knowledge they gained through
formal education and about their information needs in ten basic categories:
requirements for meeting standards of care, spatial requirements, carer requirements,
funding policies and options, building and land laws, product requirements, disability
access components, natural environment, built environment, and requirements for
community inclusion.

8% 8%

10% 8%
Resources available
Building technology

8% Working with stakeholders

10% Clinical Reasoning

Specific options available
Applications of standards
Optimisation
17% Post occupancy evaluation
14%
Structural Considerations

17%

Figure 1. Knowledge needs identified by NSW occupational therapists circa 1994

2. Methodology
A three-phased needs assessment model (Witkin & Altschuld, 1995) was used to
identify the information that participating therapists need regarding home modification.
In Phase 1, six occupational therapists were observed in order to explore the needs of
therapists involved in home modifications and to provide a better understanding of
behaviours in context (Grbich, 1999; Emerson, 1981; Bogdewic, 1992). In Phase 2,
nine therapists practicing in the area of home modifications across urban and rural New
South Wales were interviewed. In Phase 3, the results were disseminated.

2.1 Phase 1: Exploration

Eighteen visits by six different occupational therapists were observed over a 3-week
period comprising two weeks in two different urban settings and one week in one rural
area. The purposes of the observations were to:
1. gain knowledge of occupational therapy roles and responsibilities in the area of
home modifications for a range of client groups;

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2. gain practical experience in home modifications;

3. observe and record occupational therapy interaction with clients, builders, home
modification service providers, and co-workers; and
4. examine and document current practices to allow for comparison with in-depth
interview transcripts and current literature.
Participating therapists ranged in experience with home modifications from 2 to 30
years. One of the therapists had trained overseas; some had practiced in other areas,
such as mental health, before taking community positions and focusing on home
modifications.
The observer could not take notes during home visits; however, notes were made
immediately after each visit and expanded when recorded on computer at the end of
each day. The notes were then coded according to the interview topic areas to allow for
comparison to current literature and the in-depth interview results.

2.1 Phase 2: Data Collection

2.1.1 Sampling Frame
It was estimated that a sample of 8 to 10 participants for Phase 2 would provide
sufficient information to identify key issues affecting the home modification
occupational therapy practice (Llewellyn, Sullivan, & Minichiello, 1999). Interview
participants were recruited using a purposeful random sampling method (Llewellyn, et
al., 1999). Five rural and five urban occupational therapy departments were selected at
random from 281 public and 162 private New South Wales hospitals listed in the
Australian Yellow Pages on-line. One therapist was invited to participate from each
department. If no occupational therapist was employed, or if the therapist or
department declined participation, another hospital was selected at random until the
sample was complete. A number of private occupational therapy companies also were
contacted, but all declined to participate.
Five female2 occupational therapists practicing in urban areas and four female
occupational therapists practicing in rural areas across New South Wales participated
in Phase 2. Participants had between 1 and 35 years’ experience in home
modifications and worked with a range of client groups including general hospital,
spinal cord units, disability services, specific home modification services, and paediatric
services. To be included in the study participants were required to:
 have completed an undergraduate occupational therapy degree;
 currently practice as an occupational therapist in New South Wales; and
 provide home modification services in their current employment

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2.1.2 Interview Process

Therapists interested in participating in the study were sent an information package
containing a letter of invitation explaining the study (Appendix A), an interview consent
form (Appendix B), and an interview framework that outlined the topic areas to be
discussed and examples of information within each topic area (Appendix C).
Table 3 lists, defines, and provides examples of each interview topic area. Interview
times were scheduled through follow up telephone calls.
Table 2. List of topic areas, definitions and examples of topic areas

Topic Area Definition Explanatory examples

Spatial ‘Of, relating to, involving, or having the Anthropometric

requirements nature of spatial measurements, turning
space, front and rear

data pertaining access

to the needs of people with disabilities’

Carer ‘Individual who attends or assists an Parent, spouse, home care

requirements individual to carry out daily self-care attendant, community
activities’ nurse

Product ‘Information on building products that Walls, tiles, doors, vanities

requirements are bought or sold commercially’

Requirements ‘Information strategies used to involve Ageing in place policy,

for community clients in the community’ community services,
inclusion respite care

Requirements ‘Established procedure to be followed Occupational Health &

for meeting in carrying out a given home Safety, duty of care,
standards of modification’ documentation
care

Disability access ‘Products fabricated especially for use Grab rails, chair raisers,
components by people with disabilities’ slip-resistant paint, hand-
held showers

Funding policy ‘All decisions, policies, and sums of Home and Community
money or resources set aside for a Care funding, Department
specific purpose’ of Housing

Building and ‘Principles and laws designed to Building Code of Australia,

land regulation control and influence building NSW Home Building Act
construction’

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Topic Area Definition Explanatory examples

Natural ‘Natural environment surrounding Terrain, air, weather,

environment client’s home’ location

Built ‘Basic soundness of housing Maintenance of house and

environment structures’ structure

Education ‘Knowledge gained through formal Undergraduate degree,

study’ post-graduate study,
courses

2.1.3 Interview Schedule

A semi-structured interview framework was used to elicit information about home
modification knowledge needs (Kaufman, 1994). Each interview consisted of three
phases: introduction, semi-structured section, and conclusion. The introduction
included nonessential questions to develop rapport (Berg, 1989). The semi-structured
portion of the interview comprised the 11 pre-determined topic areas described in
Table 3 (Bridge & Martindale, 2002). The conclusion stage of the interviews provided
an opportunity to summarise and clarify issues discussed throughout the interview and
to tell participants how the data would be used and when the transcript would be
provided for endorsement.
During the interviews, participants were invited to give their perspectives on each topic.
When necessary, the interviewer used pre-determined open-ended questions to gain
more specific information and to clarify meaning. See Table 4. The interviewer also
used probing questions to elicit further information after participants’ initial statements
(Berg, 1989). Examples of probing questions include “What does that involve?”, “How
do you cope with that?” and “What do you do in those instances?”

Topic Area Example of open ended question

Spatial requirements What do you look for when assessing a client?

Carer requirements How do you consider carers when prescribing

home mods?

Product requirements How do you find out about new products?

Requirements for How do clients find out about your service?

community inclusion

Requirements for meeting Do you follow any standard guidelines when

standards of care prescribing home modifications?

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Topic Area Example of open ended question

Disability access What do you consider to be access barriers?

components

Funding policy What funding options do you access for clients?

Building and land regulation What is the process for obtaining council approval
for home modifications in your area?

Natural environment What do you assess differently in urban/rural

areas?

Built environment What are the processes you follow if you are
unsure about the suitability of the structure for
home modifications?

Education How have you further developed your home

modification skills?

All interviews were recorded on audiotape (Witkin & Altschud, 1995), and the
interviewer took notes. Tape transcripts were sent to participants, who were given the
opportunity to alter the transcripts (Minichiello, Fulton, & Sullivan, 1999).
After the participants returned the transcript and any changes were incorporated, the
transcripts were coded for analysis. Each of the 11 topic areas was divided into themes
and sub-themes, and each theme and sub-theme was assigned an alphabetical code.
Each transcript was then coded according to its themes and sub-themes. Finally,
quotations from the transcripts were grouped in a separate document by theme or sub-
theme to create a quotation bank. The quotation bank was used during the analysis to
determine the relationships between participants’ responses and to identify the
emerging premises of the interview data. The results of the interview analysis were
compared with information obtained from the literature and participant observations.

2.1.4 Theoretical Sensitivity

Although the interview framework was shown to be effective in other studies
(Cruickshank & Bridge, 2004; Bridge & Martindale, 2002), a pilot interview was
necessary to determine its suitability for obtaining information from occupational
therapists. The pilot interview was carried out with a therapist who met the study
criteria and who had extensive knowledge and training in the area of home
modifications. Although no changes were necessary to the semi-structured interview
guide, the pilot did highlight the need for more open-ended questions, prompts, and
probes. Relevant changes were made to questioning before proceeding with the
interviews.

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2.2 Phase 3: Dissemination

During the final stage of the research, each participant received a copy of the thesis
and information about the Home Modification and Maintenance Information
Clearinghouse website, and each was invited to provide feedback.

3.Thematic analysis
The results of this study indicate that occupational therapists require more information
about 8 of the 10 topic areas: spatial requirements, carer requirements, requirements
for meeting standards of care, disability access components, funding policies and
options, building and land regulation, natural environment, and requirements for
community inclusion. Therapists knew of many sources of product information, but time
constraints limited their use of some sources. All participants acknowledged the
importance of involving building professionals to assess structural integrity and to help
plan major modifications, and they used various techniques to accomplish that
consultation. Participating therapists commented on changes in education and
supervision that might help to close the gap between information they have and
information they need to provide the best possible home modification service. Finally,
participants discussed the impact of staffing on services and the importance of
communication with various home modification service providers.

3.1 Spatial requirements

Spatial requirements include anthropometric measurements, such as range of motion
and reach capabilities, and environmental measurements, such as the necessary
turning space in the home for a wheelchair. The Australian Standards for Accessibility
provide useful guidance for the therapist who is assessing spatial requirements, but
they are based on a generic template, and do not apply to private homes (Bridge,
1996). Sometimes the Standards may not be appropriate for a private home because
of structural limitations (e.g., the bathroom is too small) or because they do not meet
the client’s individual requirements. Even then, however, the Standards can guide the
clinical reasoning process, allowing the therapist to assess the reasons why the
modifications cannot be designed to Standard specifications and to rationally develop
alternatives.
The results indicate that therapists require information about the importance of
individual anthropometric measurements, the Australian Standards, and the importance
of providing scaled drawings to service providers and tradespeople. Although client
collaboration should be a key component of the assessment process, the results
indicate that therapists may not always involve clients in decision-making. Finally, the
results suggest that the assessment process, from referral through home assessment,
could be modified to enhance consistency and objectivity.

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Clearinghouse, City Futures Research Centre, UNSW Australia.

3.1.1 Client-Specific Measurements

All therapists participating in this study discussed the need to take spatial
measurements of the home when recommending modifications, but only a few
mentioned individual client measurements. Many participants acknowledged that it is
not always possible to have the client present during a home assessment; some were
able to compensate for the client’s absence by taking individual setting.
Three participants who specialised in paediatrics emphasised some of the differences
between assessing children and adults for home modifications. Paediatric therapists
need to plan modifications that children can use immediately and in their teenage and
adult years. For example, if the child uses a wheelchair, modifications should
accommodate the size of the chair and the turning space that can be expected when
the child reaches adulthood.
“It involves quite a bit of creative playing around to meet the Australian Standards
but we really try to meet them because it’s a long-term plan for these families. So
even though you might be doing the modification when they are seven, you have
to keep in mind that they are probably still going to be using it when they are 50.”
(6)

3.1.2 Australian Standards

Therapists varied in their use of the Australian Building Standards. Therapists with
more clinical experience stated that they used the Standards regularly as a guide to
practice.
We use the Australian Standards all the time; we have all the copies you could
possibly have, the latest standards, particularly things like waterproofing,
electricity, and all those types of things.” (2)

In contrast, over half of the therapists, including two new graduates, discussed their
difficulties in interpreting the Standards.
Therapists accustomed to working with the Standards recognised that it may not
always be possible or appropriate to modify a private home to comply with the
Standards because of structural limitations:
“Many times I’ve had to modify places and they don’t and they never will be to AS
because of the structural limitations, like you just have a bathroom that is way too
small.” (1)

Even though the Standards don’t typically apply to private homes, several participants
discussed the importance of documenting their clinical reasoning processes when
recommending modifications that depart from the Standards:
We don’t do things necessarily to the Standard because we’re working in a
private home and not a public building; but as long as we have the clinical reason
that explains why we’ve done it to that standard, then that’s fine.” (2)

A few therapists expressed concern that builders, both those connected with the Home
Modification and Maintenance Service and private contractors, did not always follow

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Clearinghouse, City Futures Research Centre, UNSW Australia.

the Australian Standards or the occupational therapist’s recommendations. For

example:
Our builders do, but lots of other builders don’t. Lots of other builders haven’t
heard of the access standards and so on. They might have heard of the
waterproofing and the electricity, but some of them aren’t working to that either.

3.1.3 Scaled Drawings

Response was divided regarding the responsibility to provide scaled drawings for
proposed modifications. Home Modification and Maintenance Services in New South
Wales expect occupational therapists to provide all spatial data, including drawings
(Bridge & Martindale, 2002). While all participants reported that they faxed a report,
complete with diagrams, to the Home Modification and Maintenance Service, there
were significant differences in the level of detail provided in the diagrams. As one
therapist pointed out:
If it was straightforward, so just a few rails and things, we would do the home
visit, come back and write up our report and draw our scaled diagrams. (5) For
minor modifications we might even tend to do it without even a ruler and do a
quick sketch and that’s acceptable. (3)

3.1.4 Carer requirements

Information from carers also is essential to the formation of effective home modification
recommendations, and involving carers in the decision-making process may increase
the likelihood that the modifications will be approved. The carer has a unique
perspective on the client’s needs and abilities and may be able to provide useful
information about proposed modifications. Moreover, one goal of home modification is
to make it easier for carers to provide care (Pynoos, et al., 2002), and their input can
help meet that goal. Finally, carers may control decision-making or finances for the
client (Luker & Chalmers, 1989), and carers who have been involved in the
assessment process may be more likely to approve recommended modifications.
Interview results indicate that occupational therapists obtain carer information, but
therapists not working in paediatrics do not routinely involve carers in the decision-
making process. Paediatric therapists must include the child’s parents or guardians
because they will make the decisions regarding home modifications. All three
participating paediatric therapists included the family in the decision-making process.
Two paediatric therapists did this by using cut-outs that the family could move around
an area to determine which lay-out would best fit the family and the child with the
disability. Other practices included taking families to the Independent Living Centre
NSW where there is a bathroom and kitchen display or showing them pictures of
completed modifications from brochures or the Internet. Therapists reported a wide
range of responses from carers to their proposed home modifications.

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3.1.5 Product requirements

Therapists need to be familiar with available products in order to design effective and
desirable solutions for their clients. One of the major reasons clients refuse to
implement home modifications is that they do not want their home to look ‘disabled’
(Taira, 1984; Mann, Hurren, Tomita & Karuza, 1993). A therapist who has current and
comprehensive product information may be able to allay those concerns. Moreover,
Home Modification and Maintenance Services routinely rely on the occupational
therapist to provide updated product information and to specify where to obtain special
order products.
Participants were aware of many sources of product information, but may need more
time to stay up to date. Occupational therapists use a variety of sources to obtain
information about available building products (see Figure 3).

60

50

40

30

20

10

Figure 2. Sources of Product Information used by Participants

One of the most common sources of product information for occupational therapists is
the Independent Living Centre (ILC) NSW. Therapists mentioned using the ILC
catalogue, ILC staff and the ILC website to source and price products. Occupational
therapists also received brochures by mail from local and national equipment
companies. In contrast, only two therapists mentioned having regular contact with sales
representatives who provided information about new products.
Interestingly, most therapists also discussed receiving input from clients or family
members who had sourced new products. The Internet is a valuable resource for
product information, and over half of the participants participated in list serves.
Therapists most commonly mentioned the University of Queensland home modification
list serve. Only two participants received information from their local Home Modification
and Maintenance Service and builders, and these therapists had developed a positive

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working relationship with the coordinators and builders of the Home Modification and
Maintenance Service. Due to time constraints, attendance at disability expos usually
was limited to once every couple of years.

3.2 Requirements for community inclusion

Community services can complement home modifications to maximise client
independence (Trickey, Maltais, Gosselin & Robitalle, 1990). Most community councils
offer a range of services for older adults and people with disabilities, such as meals on
wheels, transport services, neighbour aid programs, household cleaning assistance,
and garden maintenance assistance. Home nursing and respite services often are
available to carers (Australian Institute of Health & Welfare, 2004; Opacich, 1997). A
therapist who is familiar with available services will be better able to provide
comprehensive services to his or her client.
The results indicate that therapists appear to need more information about the nature
and importance of community services. Only half of the therapists interviewed
discussed the need to educate clients about available services.

3.2.1 Requirements for meeting standards of care

Most legal cases against health professionals are based on the claim that the
professional breached his or her duty of care. Health professionals have a duty to
exercise reasonable care to avoid foreseeable risks (Creyke & Weeks, 1985). To
prevail in a case against a health professional, the claimant must show that the
professional’s breach of duty caused injury or loss. Standards of care help to define
what care is reasonable and what risk is foreseeable. Occupational therapy standards
of care include, for example, the basic competencies expected of new graduates, the
occupational therapy code of ethics, documentation requirements, and occupational
health and safety considerations. Sound basic knowledge, effective information-
gathering skills, and good clinical reasoning are essential to the exercise of reasonable
care to avoid foreseeable risks. When a client is injured because a therapist prescribed
an unsuitable modification, failed to prescribe a needed modification, or failed to train
the client to use a modification, the client may sue the therapist for compensation.
While professional liability insurance can protect an occupational therapist’s financial
resources against such claims (Creyke & Weeks,1985), prevention of such claims is
better for all concerned.
The results indicate that most participants took a proactive approach to assessments in
that they considered modifications for injury prevention and modifications that would
accommodate a client’s changing needs. Injury prevention often arose in the context of
elderly clients or clients with progressive illnesses:
“If they were elderly and they had had a fall and they had other medical
problems then you might think that they’re not getting any younger and it might
be beneficial for you to have an extra rail there and it saves you having to do it
later.” (5)

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A few therapists outlined the special difficulties that arise in discussing modifications for
clients whose function is going to decline as a result of their illness. For example:
“Sometimes families have difficulty in coping with that because I suppose the
reality of it is that [they] see someone who is . . . able to walk, [and wonder] why
are you talking about wheelchair access.” (7)

Therapists noted that discussing the need for modifications while the client is still
functioning independently can prepare the client and his or her family to deal with loss
of function by making them aware of modifications, equipment and services that are
available. In addition, major home modifications involve structural changes to the
house and require time to plan for financially and to install.
Conversely, several therapists mentioned difficulties experienced when the client
perceived a need for modifications that the therapist determined were not necessary
For example:
“We find as far as things like ramps go we have often told people that it’s not
appropriate and they will go and demand that it happens anyway.” (5)

“In most cases they don't actually need a ramp. They are actually asking because
someone has said you should have a ramp instead of steps. But they are actually
quite mobile and are quite able to manage steps.” (3)

A therapist’s duty to provide reasonable care to avoid foreseeable risk often presents
challenges when a therapist is confronted with a client who is reluctant to follow
recommendations. Participants identified many ways to help clients make informed
choices about home modifications. While most understood the importance of
documentation when a client declined to follow recommendations, therapists may need
more information about what their duty of care requires when a client ultimately decides
not to implement recommended home modifications.
Participants identified various reasons that clients refuse or are reluctant to implement
recommended home modifications. Cost was a major factor in clients’ refusal or
reluctance to install home modifications. Clients also refused modifications because
they perceived a stigma attached to home modifications; others thought that home
modifications were unappealing and could make the home look like a hospital; some
feared that modifications would devalue the home. For therapists working in
paediatrics, the most common reason for refusal of modifications was that parents or
guardians found it difficult to emotionally acknowledge their child’s disability.
As cost is a major reason for client reluctance, it is not surprising that clients may agree
to the modification, but want to have a friend install it or to substitute a generic item for
a costly specialised assistive device. All participants recognised the right of clients to
install modifications themselves or to hire non-professionals at their own expense. All
participants emphasised that improper installation can pose a safety risk for clients.
One therapist outlined her concern:

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“They try and substitute by saying ‘I’ll put the rail in myself or I’ll get the garden
chair from out the back and use that’ instead of getting a shower chair. We try
and negotiate that with them but often they take the recommendations and say
‘we’ll organise it’ and that concerns me ” (5)

Participants stressed the importance of insuring that clients made informed choices
about professional installation and specialised assistive devices. Therapists advised
that, in order to protect themselves from legal action, they should inform the client of
the potential safety problems with lay installation or generic devices, provide
information on the Home Modification and Maintenance Service, and document
discussion in client files.
There were many ways in which therapists dealt with clients’ reluctance to install home
modifications. Most therapists mentioned the need to involve the client in the decision-
making process; however, the ways in which therapists did this differed significantly.
Three involved clients in the drawing up of plans. Others provided opportunities for
clients to view modifications by showing photos of completed modifications from the
Internet or from previous clients or by taking clients to view completed modifications in
other settings:
“One thing we have done is taken clients out to visit ex-clients so they can have a
look because some of our clients have an image that a wheelchair-accessible
home looks different but are quite surprised when they visit [another] client’s
home.” (8)

Most therapists noted the importance of patience with reluctant clients. Clients and
families who are initially reluctant may come to accept the need for modifications after
they have had time to think it over. Another noted that some clients will install the
minimum modifications and, when they have experienced a number of functional
benefits, they are then willing to have the other modifications installed.
“I’ll have somebody who has found the rail so wonderful and they’ve since been
able to think and contemplate what I’ve talked to them about weeks prior and
thought that would be good to then have a rail in the shower”(9)

The responding therapists differed in their perceptions of their duty of care in the face
of clients’ ultimate refusal to follow recommendations. Occupational therapists could
benefit from additional information about this challenging situation. Most participants
stated that, from a legal standpoint, it was sufficient to document recommendations and
the client’s refusal in the client’s file:
“As long as you document exactly what happened and if you are making a
recommendation and they are saying no, then you write your recommendation
and state that patient refused the service and there is much else you can do.” (4)

One therapist, however, went a step further and stated that she believed that she had a
professional responsibility to make the client as safe as possible in performing the
activity that the client wanted to do. She gave the example of a terminally-ill client who
continued to use the bath even though the therapist had advised the client not to do so

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for safety reasons. The therapist sought legal advice regarding her duty of care and
explained
“I do the right thing by advising her the safest measure, she makes the decision not to
do that and I would tell her my reasons of course and then look at other options…but
ultimately if someone is going to refuse then I consider then what is the safest way to
do what she wants to do”. (1)

3.2.2 Disability access components

Therapists should be familiar with the functions of products made especially for people
with disabilities, include clients in the decision-making process, and train clients how to
use devices in the settings in which they will be used. These may be items installed in
the home (such as grab rails and visual signalling devices) or assistive devices (such
as wheelchairs, walkers, and shower chairs). Such products can be critical components
in restoring occupational performance and preventing further functional decline. The
major purpose of assistive devices is to minimise the mismatch between the client’s
ability and the demands of his or her environment (Trefler & Hobson, 1997). The most
common reasons for non-use of such aids are the unsuitability of the aid, client
rejection of the aid due to associated stigma, and client claims that the device is too
complicated (Haworth & Hopkins, 1980). Research has shown that training by the
occupational therapist increases the client’s use of the device. In many cases,
therapists train clients to use prescribed devices in the hospital; however, clients often
have difficulty adapting the hospital-based training to their home environments (Trefler
& Hobson, 1997). At least some training should occur in the setting in which the client
will use the device. A knowledgeable therapist will be able to work with the client to
prescribe appropriate products and properly instruct the client in their use.
The results suggest that occupational therapists need more information about disability
access components, particularly the importance of trialling devices in the client’s home.
One participant explained:
If trialled in the home, the same wheelchair may still have been the most suitable;
however, the necessary home modifications could have begun immediately. Because
that did not happen, the client had to wait one year for the wheelchair, three months for
a visit from the community occupational therapist and an additional eight months for the
home modifications to be completed. The prescribing therapist’s lack of knowledge
about the client’s home environment resulted in poor clinical reasoning and significant
delays for the client.

3.3 Funding policy

A good understanding of funding policies and options is essential to a complete home
modification practice. While subsidies are available through the Home and Community
Care program, non-uniform fee policies across New South Wales make it difficult to
advise clients about Home and Community Care funding policies and options (Bridge &
Martindale, 2002). To fully advise clients about the cost of home modifications,
therapists need to understand a variety of funding and payment options.

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Although participants identified cost as a major consideration for clients deciding

whether to install the recommended home modifications, some participants lacked
even basic knowledge about funding policies and options. Most participants knew of
the different Home and Community Care home modification levels and their funding
caps; a few, however, lacked even this basic information. Only about half the therapists
interviewed had a good understanding of the financial contribution required by clients
who were receiving modifications through the Home Modification and Maintenance
Service. These were therapists who experienced good relationships with their local
Home Modification and Maintenance Service. Some clients may be able to afford their
share of the cost if they are allowed time to pay, but only about half of the participants
mentioned the option of allowing clients to pay for modifications, interest free, over two
years. In general, therapists with more experience in the area of home modifications
had an in-depth knowledge of funding options.
Therapists also should be aware of alternative sources of financial assistance. For
example, only two participants mentioned contingency funding from the State
Government. One therapist described this process:
“If we have to fund it then it goes to the management committee to ask for
funding and the management committee would then approve that. If we didn’t
have the money we would ask for contingency funding from the State
Government. At the end of the year there is often money that is not used by other
services that goes back into the pool.” (2)

Other alternate funding sources participants mentioned included trust funds,

community care packages, Legacy, and the Department of Veterans Affairs. Some
therapists also mentioned community organisations such as Rotary or Lions Club, but
reported that it is often difficult to secure funding from these organisations. There
appears to be more community funding available for children than for adults. Paediatric
therapists reported higher levels of cooperation from local charities than did therapists
working with adult clients.
“We’ve got quite a good area of local charities that are more than willing to help
kids. … The local Lions Club and those types of things will provide assistance
with funding for these types of things and they have been happy to provide it.” (6)

Because cost is a key cause of client reluctance to implement home modifications,

therapists need to understand funding policies and alternatives. While the results
indicate some therapists are well-equipped with such knowledge, others need much
more information to effectively advise clients.

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3.4 Building and land regulation

The Building Code of Australia (BCA) and the New South Wales Home Building Act
(Bridge & Martindale, 2002) contain information relevant to a home modification
practice. Although the BCA applies only to public buildings, it contains many
accommodations with which builders are familiar and that may provide useful guidance
for private home modifications. Examples include access accommodations (e.g.,
ramps, door openings, and landings for wheelchair access) and circulation
accommodations (e.g., turning space, lifts, tactile indicators, and audible and visual
signalling devices). The New South Wales Home Building Act (1989) may apply to
many home modifications. It requires a written contract for any work over $1,000
performed by a builder or tradesperson. The contract must include, among other
things, a sufficient description of the work to which the contract relates and any plans
and specifications for the work (New South Wales Home Building Act of 1989, Section
7). While occupational therapists are not legal advisers, they can help clients by
informing them that a written contract is or may be required. The contract requirement
also highlights the importance of clear and precise written specifications, as the
therapist’s written specifications may be incorporated into the contract.
The results indicate that therapists require more information about building and land
regulation. When asked about this topic, most therapists expressed frustration because
major modifications were not always installed according to the therapists’
recommendations. None of the therapists, however, mentioned that the Home Building
Act’s contract requirement.

3.5 Natural environment

The natural environment includes terrain, air quality, weather and location of the client’s
home (Cruickshank, 2003). It influences the types of modifications recommended, the
materials used to construct those modifications, and whether assistive devices can be
used outside (Bridge & Martindale, 2002). For example, due to limited space in an
urban area, a chair lift rather than a ramp may be necessary to provide wheelchair
access. To provide effective home modification recommendations, an occupational
therapist should understand the implications of the natural environment at a client’s
home.
The results suggest that occupational therapists gain knowledge about the importance
of the natural environment by experience. Experienced participants mentioned that
they considered the natural environment when formulating recommendations for home
modifications, but newly graduated therapists did not discuss natural environment
during the interview.

3.6 Built environment

The basic soundness and structure of the client’s home are important because they
may make it impossible to install certain modifications. Therapists are not trained to
evaluate the structure of a building, but may undertake a joint home assessment with

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the Home Modification and Maintenance Service, Department of Housing technical

officer, or builder/tradesperson. Experienced building professionals can evaluate the
structural soundness of a property and determine whether spatial or structural
limitations affect the kinds of modifications that are possible.
Many common modifications are major. Bathroom modifications were most commonly
recommended by most of the participants. Major bathroom modifications usually
involved replacing the existing bathroom with an accessible design, often requiring
removal of the wall between the toilet and bath areas. Minor bathroom modifications
included handheld showers; grab rails by the toilet or in the shower or bath; and slip-
resistant coating on tiles. Access into and out of the home was the second most
commonly prescribed modification. Access modifications ranged from handrails to
ramps or lifts.
All participants recognised that major modifications require collaboration between the
builder and the occupational therapist to determine how to meet the client’s needs
within the structural limitations of the home. For most therapists, consultation with the
builder occurred on site, which allowed the client to be involved in the discussion. The
primary purpose of such consultation was to determine the structural soundness of the
property and to determine if the recommended modifications were suitable for the
home. For example:
“If it’s a major mod like kitchen, bathroom, converting the garage to a self-
contained unit I will usually bring in one of the builders, tradespeople to help me
identify any structural issues that I’m not aware of…” (9) “I will go with the builder
and look at what the recommended drawings are and have the input of the
builder as to whether it is possible or not possible.” (7)

While all therapists consulted with builders before recommending major modifications,
the consultation process varied. The most common practice was for the therapist to
conduct an initial assessment to determine the client’s functional needs. Following that
initial assessment, the therapist would meet with the builder at the client’s home to
discuss how to structurally implement the home modifications. The therapist then
provided a report, including scaled diagrams, to the relevant home modification service.
One participant obtained information from clients before the first home visit and, if
major modifications were required, arranged to meet with the builder on site at the time
of the first home visit. Another department faxed reports to the Home Modification and
Maintenance Service or Department of Housing with the invitation to meet with the
builder if required. Three participants mentioned that they regularly attached digital
photos to the report to further clarify issues raised.

3.7 Other Education

The participants’ comments about their education and their assessment of new
graduates’ information needs provide insights about training and supervision that may
be helpful to educators and policy makers interested in closing the gap between
needed and acquired information. Participants’ comments confirmed the New South

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Wales Occupational Therapy Association’s concern that occupational therapists are not
as prepared as they should be to advise clients about home modifications.
Therapists who supervised occupational therapy students on placement observed:
“I think every single one of them, and I know I certainly did when I was a student,
felt that I didn’t have enough knowledge on that area.” (8)

“That’s where our training needs to be as that we are able to make educated
decisions and following the decision-making process which has some analytical
base. I can see that in the students that come through and have pracs here and it
is not coming through automatically.” (3)

One therapist saw a need for more education about theory:

“I think there needs to be more training at the theory level as to understanding
why you are recommending a rail versus. a shower chair or what the whole
mechanical advantage of having a rail next to the toilet is for example.” (5)

Others emphasised the need for more practical skills training. For example:
“Most students on a one-to-one basis is very good for teaching home
modifications because we are doing a lot of home visits and you get to do hands
on because you can't really stand back and watch a home modifications
occupational therapist. You feel obliged to hold the other end of the tape
measure.” (2)

The most common reason participants gave for their difficulty using the Australian
Standards was that they did not learn to interpret and apply the Standards while at
university:
“We would just be busy writing down that frame and writing down exactly what
the whole standard is about instead of learning how to interpret what that meant
and how you apply that to home modifications.” (4)

Several participants viewed supervised practice as one way to improve understanding

and performance with the Standards. For example:
“You can have the basic information and they can know about Australian
Standards but they’d have to start applying them and using them and working
with a client. I think they need that in a supervised environment.” (1)

The most common methods participants used to acquire more information about home
modifications were completing short courses in home modifications offered by the ILC,
reading publications and journals, attending in-service presentations, discussing home
modifications with builders, and receiving support from other therapists. Two therapists
had completed the Graduate Diploma in Home Modifications offered by University of
Sydney.
Given the many areas in which occupational therapists need additional information and
experience, supervision is very important, particularly for recent graduates. All
participating therapists recognised the need for supervision. For example, one
commented:

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“You are making recommendations not only for today but for 5 or 10 years down
the track and that is hard to do. I think that having a good supervisor who has
already had that experience can help guide a new therapist.” (1)

Unfortunately, participants did not always have ready access to an experienced

supervisor. One of the new graduates involved in the study had accepted a position as
a sole therapist in a rural area, someone from outside her area agreed to supervise her
and she then reported experiencing difficulties when complex decisions had to be
made quickly and her supervisor was unavailable.

3.7.1 Assessment Process

Although practicing therapists acknowledge the importance of conducting home
assessments, there is no consensus on how these assessment information is used to
prioritise caseloads; telephone interviews may help streamline the assessment
process; and practicing therapists need more information about standardised home
assessment frameworks and the risks of using untested frameworks.
Referrals, which typically may come from any source, are used to prioritise clients.
Common referral sources include the client (self-referral), doctors, nurses, hospitals,
special care units, Home and Community Care, and other service providers. One
therapist, however, stated that her department requires a referral letter from a doctor or
specialist:
“We have just recently changed our service policy at the hospital that outpatients
now have to have a GP or a specialist referral to access the OT service. Just
purely from a waiting list and a priority point of view” (5)

Telephone, fax or letters were the tools typical used for making referrals. One
participant discussed her department’s involvement in a State Government initiated
electronic referral program:
“We did participate in the electronic referral project. We didn’t find that very good
because of the way that the system operated you couldn’t actually include a lot of
useful information in the referral…We are very happy with our referral process
and we haven’t had any problems with the old-fashioned methods.” (3)

After the department has prioritised referrals, the next step usually was a face-to-face
interview with the client. One therapist, however, conducted telephone interviews
before the initial home visit to gain extra information about the client’s situation and to
discuss expectations for the occupational therapy visit. This enabled the therapist to
prepare for the home visit and bring necessary equipment, possibly eliminating the
need for a further visit.
“Basically we conduct the initial interview over the phone because what we found
is that actually having a little bit more information before going out we can see if
there are any other issues and maybe bring out some equipment and things like
that.” (9)

For all participating therapists, the home visit began with a face-to face interview with
the client about his or her situation and functional ability. Most therapists also

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Authored by Fiona Cowell, Catherine Bridge, & Stephanie Mathews for the Home Modification Information
Clearinghouse, City Futures Research Centre, UNSW Australia.

discussed the need to observe the client performing activities because the functional
level clients described often differed from the functional level observed.
“They'll often say `oh no, I'm all right' or `I do this or that' and then when you get
them to show you and they actually can't’. They haven't realised how bad they
were or that they could have improved their situation very quickly.” (3)

Some participants were aware of standardised assessment frameworks, but chose not
to use them; others, including a new graduate, were not even aware that standardised
frameworks existed. All participants used self-designed assessment frameworks or
frameworks designed by the area health service. A few therapists stated that their
forms covered all aspects of the client home.
“We developed the home assessment form so it will make things a lot easier
especially in regards to documentation. It’s also good for people who are
relatively new to OT practice to give an idea of the sorts of things that you should
be looking at in terms of home mods. Before we just played it by ear by going in
there and having a look”.

It appeared that most therapists used their frameworks as general guides and relied on
their own knowledge to determine what to look for and to make extensive notes.
For example:
“We have a standard home assessment form which looks at the access, all the
bedrooms, the kitchen, dining room, the bathrooms, of course, and the laundry.
They are very general so you can slot in the information that you want but it
doesn’t give you any prompting of what you should actually be looking for.” (4)

3.7.2 Understaffing
Lack of funding has resulted in extensive waiting lists for the majority of NSW
occupational therapy practices in both rural and urban areas. Most departments were
able to see urgent clients within a week or two of receiving the referral, but non-urgent
clients often had to wait more than 3 or 4 months. One therapist expressed the
frustration of not being able to see clients immediately for home assessment:
“Waiting lists are always hard because you find that if it’s too long by the time you
get there, the person has either died or become so much worse and are so
devastated at having had to wait all that time and it becomes really difficult.” (3)

Lack of staff places an increased strain on already limited services in rural areas. In a
rural practice, travelling to and from client appointments takes up a considerable
portion of a therapist’s time and may decrease the number of clients he or she can see.
Travel time is increased for a therapist when positions are vacant in nearby areas and
he or she must help to cover that neighbouring area:
“It (staff shortages) only becomes a difficulty if a particular area has a position
vacant, which happened in **** for about 12-18 months. There were no
services there so we were finding it really hard to get people assessed...
So we would often go to **** which was an hour away which caused a strain
on our services.” (5)

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Authored by Fiona Cowell, Catherine Bridge, & Stephanie Mathews for the Home Modification Information
Clearinghouse, City Futures Research Centre, UNSW Australia.

Therapists also noted that delay is compounded because the wait for modification
installation after the assessment is completed can be 6-8 months. For some
participants, the push from management to decrease waiting list times without funding
to employ more therapists resulted in ethical problems:
“I know some of the other therapists I work with prefer to spend less time on each
person and get through more on the waiting list and expect the person to nominate the
areas of difficulty. I've found that you can't rely on people to do that.” (3)

3.7.3 Client Collaboration

It does not appear that participating therapists always involved their clients fully in the
decision-making process. A number of therapists talked about the importance of
communicating and involving the client in the clinical reasoning process. One therapist
gave an example of the situation often encountered when installing access ramps:
“It's common that people don't like the idea of a 1 in 14 ramp or a 1 in 16 ramp,
who just want their mate to do a nice little short thing that's about a 1 in 5
gradient but once you explain the safety… it's very unusual for people to say; no I
want my brother-in-law to put in this itsy bitsy little one.” (2)

In practice, however, therapists did not always involve clients in formulating

recommendations. For example, participating therapists who were unable to take the
client on home assessments did not mention discussing recommendations with the
client either before or after the home assessment.

3.7.4 Communication with Home Modification Services

There were varying levels of communication with home modification service providers.
None of the participants mentioned consumer organisations as information resources.
Therapists may be aware of the importance of these organisations, but the interview
topic areas did not specifically invite comments about them.
All participants who worked with Department of Housing expressed concern about poor
follow up and lack of communication that often resulted in sub-standard modifications.
The following comment illustrates the importance of follow up during and after
installation:
“What I usually find is that I’ve sent this report and all these drawings and I walk
in and the rail is set diagonally in the shower up to the ceiling or something like
that and what’s happened and the contractor has just walked in according to the
client and the client has said they like the diagonal rail and I’ll have it here thanks,
and put it in and left and Department Of Housing hasn’t followed it up” (8)

A few therapists expressed concern about inconsistency within Department of Housing

regarding the allocation of resources:
“I don’t see it as an equitable service as an outsider looking in. I’ve had some
clients who get everything done and it’s done quite timely and then I’ve had other
clients who have never heard from them and maybe it’s been a year later and
they have been asked to look at it.” (3)

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Authored by Fiona Cowell, Catherine Bridge, & Stephanie Mathews for the Home Modification Information
Clearinghouse, City Futures Research Centre, UNSW Australia.

Occupational therapy departments that have been proactive in initiating communication

with Department of Housing have improved communication and expedited home
modification installation. One participant’s department initiated a monthly meeting with
its local Department of Housing office:
“What we do there is log it in a book and each month we have a meeting with
Department of Housing just to find out where everyone is and what status the job
is at and if they need more information or if they need a joint home visit we can
organise it then.” (4)

One participant illustrated how sensitivity to Department of Housing’s decision-making

process also can expedite home modifications. Rather than submitting plans and
having the Department of Housing reject them on the basis of limited funding, one
participant arranged to meet with the Department of Housing’s Technical Officer on site
before submitting plans to determine the feasibility of modifications and whether
Department of Housing would provide funding.
Occupational therapists’ relationships with Home Modification and Maintenance
Services appeared to be more positive than those with the Department of Housing.
Therapists who worked with their local Home Modification and Maintenance Service on
a regular basis reported having a good understanding of the role that each played in
the provision of home modifications. Respect for each party’s specialty resulted in a
good working relationship.
Therapists offering specialised services often worked with a range of Home
Modification and Maintenance Services, which made it difficult to develop a relationship
with a particular Home Modification and Maintenance Service. These therapists were
often confused about Home Modification and Maintenance processes because each
service provider had a different policy:
“They seem to operate quite independently of each other and every area has a
different referral form and a different method of processing the application and a
different attitude towards managing the client so that can be a bit frustrating.” (8)

Therapists identified some areas where communication could be improved, such as

notification from the Home Modification and Maintenance Services when modifications
have been completed. Occupational therapists need to know when modifications are
completed to insure that the client has received the promised service and to provide
any necessary training. Most participants contacted the client periodically to assess the
progress of modifications; with limited time and high caseloads, however, clients could
be overlooked. Improved communication would allow therapists to monitor more
reliably and efficiently the progress of home modifications and insure that clients are
promptly trained to use the modifications.

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Authored by Fiona Cowell, Catherine Bridge, & Stephanie Mathews for the Home Modification Information
Clearinghouse, City Futures Research Centre, UNSW Australia.

4. Summary of findings
The demand for home modification services has grown in the last decade due to
demographic, social, and economic changes. New South Wales occupational therapy
services have not kept pace with the demand, placing time constraints on already busy
occupational therapists. The results of this study indicate that occupational therapists
recognise the importance of home modifications and work hard to conscientiously meet
their clients’ needs. Many have good working relationships with home modification
service providers and have developed innovative ways to promote effective and timely
communication. Some participants have devised creative ways to involve clients and
their families in making decisions about home modifications. The findings also highlight
ways in which services could be improved. The findings of this research confirmed and
reiterated themes of the home modification literature:
 occupational therapists need additional specific home modification information;
 many occupational therapists do not involve clients and carers sufficiently in the
decision-making process;
 occupational therapists are concerned for the safety of clients because
tradespeople do not always implement home modification as prescribed by the
therapist;
 the establishment of good communication processes between occupational
therapists and home modification professionals can improve service efficiency and
quality;
 time constraints affect service; and
 the assessment process could be improved.
Simple procedural changes could improve the assessment process. Changes in
undergraduate education, better supervision, continuing education and better staffing
could improve the situation for clients and therapists.

4.1 Specific Information Needs

The results highlight several areas where therapist knowledge could be improved: the
use of the Australian Standards for accessibility, the importance of individual client
measurements, the use of standardised assessment frameworks, duty of care when
the client declines modifications, funding policies and options, prescribing assistive
devices, the role of community services, the impact of natural environment on home
modifications, and building and land regulation. All of these topics are included to some
extent in the undergraduate course, but for some topics, the necessary knowledge and
the ability to apply it appears to be acquired with experience. Supervision by or
collaboration with a more experienced occupational therapist, continued education, and
consultation with local Home Modification and Maintenance Service directors may help
practicing therapists increase their competence.

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Authored by Fiona Cowell, Catherine Bridge, & Stephanie Mathews for the Home Modification Information
Clearinghouse, City Futures Research Centre, UNSW Australia.

4.2 Collaboration with Clients and Carers

The results confirmed earlier findings that occupational therapists are taught the
importance of client collaboration, but do not always involve clients in the decision-
making process (Brown & Bowen, 1998). The nature of home modification underscores
the importance of client involvement: home modifications not only change the look of a
client’s most personal space, but they are designed to increase client comfort and
safety in completing routine and often highly personal tasks, such as bathing or
toileting. Earlier research suggests that clients are more likely to use modifications if
they participated in decision-making. Established procedures that gather assessment
information from clients and involve clients in decision making could promote regular
client collaboration.
Similarly, many participants did not report involving carers in decision-making. Carers
are often in positions of control (Luker & Chalmers, 1989), and involving the carer in
decision-making could decrease the carer’s resistance to recommendations. Separate
forms or questions for carers may promote involving carers in decision making.

4.3 Modification Installation

Better information and improved communication can help alleviate problems with
noncompliant installations. For major modifications in NSW, the Home Building Act’s
contract requirement could increase compliance because the contract must include
specifications for the work. That requirement may encourage therapists to be more
precise in their descriptions and encourage tradespeople to seek clarification if the
specifications are not clear. The contract also could provide a remedy when
modifications do not conform to the specifications. Improved relationships and
communication with builders, tradespeople, Home Modification and Maintenance
Services, and Department of Housing also could increase the likelihood that
installations would comply with recommendations. Understaffing, however, makes it
difficult for occupational therapists to have time to develop those relationships and
organise regular communication and follow up.

4.3.1 Communication with Service Providers

The results suggest that proactively establishing communication with funding agencies,
builders, and tradespeople can encourage timely problem solving dialog and promote
follow up to ensure compliance with recommendations. Therapists’ time constraints
and inconsistent policies across Home Modification and Maintenance
Services in NSW make it difficult for some occupational therapists to develop
relationships and engage in regular communication with service providers.

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Authored by Fiona Cowell, Catherine Bridge, & Stephanie Mathews for the Home Modification Information
Clearinghouse, City Futures Research Centre, UNSW Australia.

4.3.2 Staffing
Increased caseloads impact client service in more ways than one. In the present study,
staff shortages presented particular problems in rural areas. These results are
consistent with numerous studies that have reported difficulties in filling rural
occupational therapy positions (Millsteed, 2000; Bridge, & Martindale, 2002). Clients
may have to wait as long as four months, and the length of delay continues to increase
(Harries & Gilhooly, 2003; Mitchell & Unsworth, 2004). Because neither Home and
Community Care nor Department of Housing will approve funding for modifications
without an occupational therapist’s recommendations, the entire home modification
process is delayed when occupational therapy departments are short-staffed. If the
case is urgent, Home Modification and Maintenance Services must contact a private
occupational therapist, which can increase the cost of individual jobs by as much as
$60-$200 (Bridge & Martindale, 2002). As funding is limited, the increased cost for
urgent cases can reduce the number of clients that the Service is able to assist. Clients
waiting for home modifications may be unable to perform basic functional tasks and
risk injury. Some clients, such as those with recent spinal cord injury, cannot even
return home until the home is wheelchair accessible. Pressure on therapists to do
‘quantity’ work may mean that therapists spend less time on the assessment process,
which could result in inaccurate assessments. Higher workloads also mean that
therapists have less time to spend staying up-to-date on funding policies and options,
products, assessment techniques, and the law. Overworked therapists don’t have time
to cultivate good relationships that could expedite the home modification process.
Inaccurate assessments and delayed home modifications will have a far greater impact
on the financial resources of the health system than employing more therapists to meet
the increasing demand for services (Kraskowsky & Finlayson, 2001).
Therapists are hesitant to accept positions in rural areas because of limited resources,
reduced access to continued educational opportunities, distances of work-related
travel, insufficient support, and feelings of isolation (Welch, McKenna & Bock, 1992;
Podsakoff, MacKenzie, Podsakoff, & Lee, 2003; Millsteed, 2000). State and territory
governments have implemented some initiatives to encourage more allied health
professionals to accept positions in rural Australia (e.g., scholarships, a state-advisor
for allied health services, and increased funding), but rural health services are still
losing allied health positions (National Rural Health Alliance, 2004). Additional efforts
that focus on the reasons therapists decline rural positions may be necessary to avert
the shortage.

Occasional Paper: Home Modification Information Needs of Occupational Therapists Practicing in NSW 34
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Authored by Fiona Cowell, Catherine Bridge, & Stephanie Mathews for the Home Modification Information
Clearinghouse, City Futures Research Centre, UNSW Australia.

4.3.3 Assessment Process

Referral procedures that insure the consistent collection of relevant and accurate
referral data may help assure proper prioritisation and more efficient service. The
results from this study are consistent with those of other studies, showing that the
referral base for occupational therapy services is broadening (Luker & Chalmers,
1989). More referral sources may mean increased variability in the quality and quantity
of referral data. Because clients are prioritised on the basis of referral information,
consistency is important to fairness. Procedures to promote the consistent collection of
complete and accurate referral data may improve the fairness and efficiency of home
modification services.
Telephone interviews could streamline the assessment process. Gathering basic
information prior to the home visit permits the therapist to focus the home visit
specifically on the everyday difficulties experienced by the client, rather than using the
first session to gain basic information that could have been acquired over the telephone
(Korner-Bitensky & Wood-Dauphinee, 1995). A telephone interview also may increase
the efficiency of the process because the therapist will be more likely to have
everything he or she needs at the time of the home visit and avoid the need to return.
The phone interview could even signal the need to have a builder accompany the
therapist to the home assessment. The phone interview also can be used to provide
the client with information about the roles and responsibilities of the therapist and
services available, which may facilitate better rapport and more meaningful
communication during the home visit.

4.3.4 Filling the Information Gap

There are several possible ways to fill the gap between information therapists have and
information therapists need about home modifications.
More problem based learning opportunities may enhance students’ competence in
home modification. Several participants identified a need for more practical educational
opportunities in home modification. Problem-based learning has helped
undergraduates to develop better clinical reasoning skills and to better apply their new
knowledge (Hammel, Royeen, Bagatell, Chandler, Jenson, Loveland & Stone, 1999).
Supervision and professional support also can provide an expanded knowledge base
and facilitate clinical reasoning and effective practice. One third of rural therapists are
new graduates when they begin their positions, and the majority of the rural therapists
work as sole practitioners (Podsakoff, MacKenzie, Podsakoff, & Lee, 2003). One
possible solution would be for Area Health Departments to appoint an area advisor for
home modification services. The benefits could far outweigh the cost. Prescription of
inappropriate home modifications and assistive devices are costly mistakes that might
be avoided with proper supervision.

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Authored by Fiona Cowell, Catherine Bridge, & Stephanie Mathews for the Home Modification Information
Clearinghouse, City Futures Research Centre, UNSW Australia.

Continued education and graduate training can expand therapists’ basic knowledge
and educate them about current issues and new developments in home modification.
To insure that practicing therapists receive timely and useful information, the
information needs of occupational therapists should guide continued education
program development.
The Home Modification Information Clearinghouse website can provide some of the
home modification information required by occupational therapists. Results of this study
indicate that the majority of therapists have access to the internet and that this is a
quick way for time-pressed therapists to obtain home modification information.

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Clearinghouse, City Futures Research Centre, UNSW Australia.

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Authored by Fiona Cowell, Catherine Bridge, & Stephanie Mathews for the Home Modification Information
Clearinghouse, City Futures Research Centre, UNSW Australia.

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Occasional Paper: Home Modification Information Needs of Occupational Therapists Practicing in NSW 40
nd
July 2007; 2 printing., May 2014
ISBN: 1 86487 771 5 www.homemods.info
Authored by Fiona Cowell, Catherine Bridge, & Stephanie Mathews for the Home Modification Information
Clearinghouse, City Futures Research Centre, UNSW Australia.

APPENDIX A: Invitation to participate

Dear
The Ageing, Disability and Home Care Department of NSW and the University of Sydney would
like to invite you to a discuss your information needs and priorities as a part of the preliminary
work being undertaken to establish a Home Maintenance Modification and Information Clearing
House.
Older people and people with disabilities and their carers are living in homes that are
inappropriate for their needs. Not only is this a large problem today, it is also a problem that is
increasing as the number of older households and households of people with mobility
restrictions increase in NSW.
The collation of interview findings from a range of service providers, industry and consumer
advocates will be used to inform the design and contents of an information clearing house. This
collaborative action based approach is we believe the best means to ensure that stakeholders
needs are appropriately identified and prioritised.
As a key stakeholder you may wish to contribute. Consequently, we want to explore your
perspectives on a number of issues concerning Home Modification and Maintenance
information needs, policies and services. We would like to conduct the interview via telephone
and expect it to take approximately 60 minutes of your time. Following notification of your
interest in this project we will contact so that a visit or telephone interview can be arranged at a
time most convenient to you. With your written consent, we will audiotape the interview so that
you can later verify the key themes and priorities that emerge.
If you are interested in contributing to this important project we would ask that you complete the
attached forms, and reply in writing to Mrs Fiona Cowell at the address given below. If you have
any queries regarding the project, please do not hesitate to contact Dr Catherine Bridge or Dr
Peter Phibbs (the Chief Project Investigators)
We look forward to your response and contribution to this exciting project.
Yours faithfully
Fiona Cowell
Co-Investigator

Occasional Paper: Home Modification Information Needs of Occupational Therapists Practicing in NSW 41
nd
July 2007; 2 printing., May 2014
ISBN: 1 86487 771 5 www.homemods.info
Authored by Fiona Cowell, Catherine Bridge, & Stephanie Mathews for the Home Modification Information
Clearinghouse, City Futures Research Centre, UNSW Australia.

APPENDIX B: Ethical consent

Consent Form

Please take as much time as you wish to consider participating in this study before you sign.

Feel free to contact the project investigator (details below) to ask any questions on aspects of

this study that are not clear.

In no way should you feel obliged to participate in this study.

I _______________________________________ have read and understood the

Name (please print)

‘Subject Information Statement’ and letter inviting me to participate in the above research
project, and have chosen to participate in the study.
I am aware of what is involved in the study and understand that I may withdraw at any time.

I agree/disagree to the interview being audiotaped (Please indicate your preference by crossing
out the response that is not applicable).
I also understand that for the purposes of this study my identity will remain confidential.

My signature indicates that I have received a copy and agreed to this consent form.

________________________________________________ ___/___/____
(Signature of participant) (Date)

________________________________________________ ___/___/____
(Signature of witness) (Date)

Occasional Paper: Home Modification Information Needs of Occupational Therapists Practicing in NSW 42
nd
July 2007; 2 printing., May 2014
ISBN: 1 86487 771 5 www.homemods.info
Authored by Fiona Cowell, Catherine Bridge, & Stephanie Mathews for the Home Modification Information
Clearinghouse, City Futures Research Centre, UNSW Australia.

APPENDIX C: Interview Framework

Issue: Lack of knowledge about information needs on a regional and service
level basis.
Purpose: To inform action to develop a web based clearing house and to
determine the priorities and topic areas for information to be cleared.
Background: How are information trends impacting on Home Modification services?
 What knowledge/Information is most crucial to you? Why
 Could you rank or prioritise this? Why or why not?
 What areas of information do you want/need to know more about? Why?
 How do you obtain information at present? Why?
 What specialist information has been developed that you are aware of? How helpful
is this to you and your service
 Spatial requirements (i.e. how is knowledge about dimensions such as width length,
height etc. gathered/examined? To what extent is this knowledge/information
related to information about walkers, wheelchairs, scooters, ambulance trolleys,
canes, traymobiles etc.)
 Carer requirements (i.e. how is data about needs of other users
considered/factored in? To what extent is this related to knowledge/information
about occupational health and safety regulations, public liability etc.)
 Product requirements (i.e. how is data about products gathered? To what extent is
this contained in policy and procedure manuals, independent living centre
equipment data base, building supply catalogues etc.)
 Requirements for community inclusion (i.e. how is information made available to
consumers? To what extent is information available in other languages, accessible
formats etc.)
 Requirements for meeting standards of care (i.e. how is information about policy
and procedures documented and obtained? To what extent are manuals, how to
guidelines etc. available?)
 Disability access components (i.e. how is data about fabrication and installation of
ramps, lifts, doors, floor treatments, sanitary facilities, thermostatic mixer valves etc.
obtained?)
 Funding policy (i.e. how is information about funding gained? To what extent is
assistance for purchasing or loan of equipment etc. considered?)
 Building and Land Regulation (i.e. how is information about building and land
regulation obtained? To what extent are access standards, human rights and equal
opportunity guidelines, building approval guidelines etc. considered?)
 Natural environment (i.e. How is information about the natural environment related
to the home modification under consideration? To what extent are issues such as
terrain, altitude, weather and air quality, light, sound etc. considered?)
 Built environment (i.e. how is information about the property considered? To what
extent is structural stability, age, health etc. considered?)
 Other (i.e. what other information might service providers have to keep and or
maintain? For instance, to what extent are occupational health and safety
regulations etc. expected?)

Occasional Paper: Home Modification Information Needs of Occupational Therapists Practicing in NSW 43
nd
July 2007; 2 printing., May 2014
ISBN: 1 86487 771 5 www.homemods.info