A reader asked about the considerations involved in making home modifications for people with disabilities and medical needs and allowing them to age in place vs placing them in an outside facility. *
That’s an excellent question, and one for which there is no set answer – and it’s usually not an easy or obvious answer in any given situation, either. The very first considerations are also definitely not about the physical modifications themselves, but about what the client needs in order to remain safe and to manage whatever care they need, although if the needed changes cannot be made for one reason or another, that certainly needs to be known early on in the decision making process.
Assuming the medical condition allows a choice, it’s really got to be an individual decision in every case, taking many issues into account, starting with the client’s medical needs, what they are able to do for themselves, how that would be impacted with home modifications if they are needed and made, what services they need and can afford, whether or not they have help from family and/or friends that they can rely on, what insurance, Medicare, medical assistance, VA benefits, etc. will pay for, what future needs are anticipated, etc. – and then comparing all of that with the costs and services available in an outside facility, including looking at long term ramifications of each option.
This evaluation has to include these analyses with each of the different facilities they are considering, as they vary extensively in every possible way.
One of the biggest issues, of course, is the psychological and emotional impact of one choice vs another. Most people want to stay at home if they can, and that almost always outweighs any other consideration initially. If money is tight, though, as it is for most people, compromises may have to be made, or decisions that would otherwise not be desired.
The needs and comfort of other residents of the home may also need to be considered, if there are any, and those of caregivers. For some people, this will not be an issue, but for others it might.
What, for example, will a healthy spouse who is still able to get around just fine do for a living room if the only space in their small house where his wife’s hospital bed will fit is the current living room, and the bed and her medical supplies take up the whole room? Or what will the children or grandchildren that live there or visit frequently do? How will she get to the bathroom if the only one is upstairs, if indeed she is able to walk and toilet on her own at all, but can’t manage stairs? How will she bathe? How will her privacy be protected if she’s in a public space like the living room – especially if it faces the street and front door? Will other residents be able to navigate the single bathroom once it’s full of the disabled/elderly person’s access paraphernalia?
These answers could be very different depending on the particular home, its location, size, what the family can afford, the specific needs, etc. – and the solutions that would be viable for one client might not be for another with similar needs, both in terms of what home modifications can be made, or the choice of doing them vs moving the client to a facility.
Of course, from a design and construction point of view, it’s critical to evaluate early on whether or not a given residence can, in fact, be modified sufficiently for the client’s particular needs and preferences – and at a price they can afford. Many homes simply cannot be modified in a viable way at all for one reason or another, or maybe not without really extraordinary expense and/or total aesthetic destruction or other issues.
Even when it’s possible to do the modifications, and the client can afford it, if major changes are to be made, they can take a tremendous amount of time, just like any other remodeling project.
At times, people may also have to settle for changes that are far less aesthetically desirable or less than ideally functional than they would prefer just because of time constraints and product availability.
Some people will absolutely have to move somewhere else no matter what if they have a sudden need for an accessible home, and the job can’t be done in the time available before insurance quits paying for a hospital stay, for example – and that somewhere else may well need to be an extended care facility of some sort, possibly at their own expense. And if the modifications can’t be made for one reason or another, and moving to a new house is not an option, the patient will end up in a facility of some sort if they have nowhere else to go. Or they will end up totally housebound, perhaps even confined to a single room or even bedridden, depending on their condition and the house, none of which are very attractive options.
This is a big part of why it makes much more sense to plan ahead and to make universal design changes including moving to a new home if necessary while one is still healthy, to prepare in advance, so as to not get caught in a time squeeze when and if an actual need comes up. Major remodeling is stressful enough at the best of times without adding illness and urgency on top of it.
If a person facing such possibilities is elderly, or on disability, Medicare or medical assistance might pay for a long term care facility, but if they have been released to go home, that is highly unlikely. If they are younger and/or previously healthy, even those safety nets won’t exist. If the care needed is not medical but personal only, then no insurance or assistance program other than a really good independent long term care insurance policy will pay for it anywhere.
On the flip side, insurance, Medicare, etc. will often pay for inpatient care but not care at home, if ongoing medical care of any sort is needed, so the decision may well be made for the client just by that alone.
Again, this is all a very individual thing, and without a professional evaluation of a particular residence and client’s needs, it may not be at all obvious what can – or cannot – be done with the home, and at what price, if in fact remaining at home is even an option in light of these and a number of other possible considerations.
Once a person sits down to do these evaluations and comparisons, from a financial and logistical point of view, the results can actually be quite surprising. For some people, doing whatever it takes to remain at home is the best choice, for any or all of a number of reasons. For others, it will be to move to a new home and to make whatever changes there might be necessary – or move into a facility.
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* A “facility” could include anything from an independent living house or apartment within a continuing care retirement community (CCRC), assisted living, personal care home, or skilled nursing, depending on the individual’s needs, what they can afford, and availability.
Independent living is actually still living in one’s own home or apartment, except that it’s physically located in and part of the CCRC (or similar facility). They make it easier for people to remain more independent for longer than they might be able to in their own separate homes, though.
There are a great number of other benefits included in the price of such a residency option, including meals available onsite, various activities onsite such as lectures and classes, transportation to doctors, grocery stores, banks, etc. (which can be critical if one can no longer drive), oftentimes minor medical care, physical therapy if needed, and many other possible ones including laundry and basic housecleaning service, dry cleaning pick up and delivery, onsite maintenance and assistance with even things like changing lightbulbs, and some even have swimming pools and other recreational facilities and assistance designing a fitness plan. They can be quite luxurious at prices that may actually be well below local market rates for a comparable separate home or apartment – and are already designed and built to be fully accessible. Some modifications may still be necessary; for example, we still needed to add grab bars in my father’s bathroom, but sometimes those will be paid for by the facility as they were in our particular situation where Dad lived.
