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Chapter 6: Assessing Need & Getting Help for Home Modification or Equipment

Introduction

In recent years, people with disabilities and their friends, families, and service providers have helped communities realize that home is usually the best place for their citizens with disabilities to live. In the process, they have learned that home living can be much less expensive than institutional care. But most importantly, they have learned that living in one's own home increases the quality of one's life.

The federal government has passed legislation to help ensure affordable, accessible, community housing for people with disabilities, as well as the accessibility of public buildings. The National Affordable Housing Act of 1990 (PL 101-625) provides for subsidized housing programs for people with disabilities. The Fair Housing Amendments Act of 1988 (24 CFR Part 100) includes guidelines for accessible restrooms, parking, entryways, and more, and the Architectural and Transportation Barriers Compliance Board publication (36 CFR 1191) contains data on barrier-free environments.

In many cases, homes need to be modified to allow people with disabilities to live independently, safely, and with dignity. Independence and safety are crucial - but dignity is equally important. For instance, taking a door off its hinges to make a bathroom or bedroom wheelchair-accessible quickly solves the immediate problem, but ignores the dignity of the person. For almost every situation exists a cost-effective solution available that provides both accessibility and dignity.

Solutions to problems of accessibility and safety need not be very expensive and the ideas presented here are generally low-cost. As a rule, it costs more to modify an existing home than to include modifications in the building process of a new home. But, whether one is buying an existing home, building a new home, or modifying a rental property, modifications and assistive devices can be purchased outright through Medicaid programs or through deferred, interest-free loans for home modifications.

This chapter discusses strategies for consumers and families to use in assessing and modifying homes to meet their needs. People who live in public or private rental housing should, of course, contact the property manager to determine whether and under what conditions modifications can be made. If the public housing is federally subsidized, an individual has certain rights under the Fair Housing Act.

Thinking About Needed Modifications

The following considerations are important in thinking about and choosing housing for persons with physical disabilities. One should carefully examine the issues and problems that will need to be taken care of in any home one is looking at. Unresolved issues and problems often lead to regrets about the housing chosen and/or future expense. If there are important problems that need to be addressed in the home being considered, it's important to make sure there is a plan to make and pay for the needed modifications before committing to a lease or mortgage. Some of the areas of the home and related issues/potential problems that might be particularly important to persons with disabilities are identified in the following pages. Of course, these considerations aren't exhaustive nor does every consideration apply in every situation.

Outdoors

Make sure walkways are clear and wide enough to accommodate wheelchairs, walkers or other mobility aids that may be used or needed.
Make sure any needed ramp is at a manageable angle.
Doors should be at least 32 inches wide (for wheelchair users).
Check to see if sliding glass doors have thresholds that are low enough for easy and safe crossing.
Make sure railings are installed on both sides of the front steps.
If needed or helpful have a lever door handle rather than a doorknob on the entry doors.
It may be important to have a single-action deadbolt lock on the inside of the front door.
Examine the walkway/porch front entryway area to see if it's well lighted.
Make sure that the mailbox is in a location that makes it easy to retrieve mail or that an agreement is made to move it.

Garage and Parking

Find out if the garage is wide enough to accommodate a wheelchair exiting from a van, or if the person will have to get out of the van outdoors.
Make sure the garage entrance is high enough for a van.
Check to see if there is an automatic garage door opener.
Garage lights, hangers for gardening and other tools, and other things to which an individual needs access should be hung in such a way that they are easily reachable.
Determine whether the parking lot has convenient handicapped spaces.

Indoors - General

Make sure that switches and thermostats are located so that they can be easily accessed (usually within 44 inches of the floor).
Make sure electrical outlets can be reached (preferably placed at least 27 inches from the floor to minimize bending).
Make sure that carpeting allows easy navigation with a wheelchair or walker. It should be securely fastened to the floor. (People may want to determine whether these are hardwood floors so that carpets might be removed.)
Examine the stairs to see that both the rail and bannister have a sturdy hand grip and that the carpeting on steps is in good repair and tightly secured to the steps.
It's recommended that ceiling lights be replaced with wall lights to make it easier to replace light bulbs. Find out if ceiling lights can be changed with a light-bulb changer (available at most hardware stores).
Make sure any doors to stairs close completely.
Make sure that light bulbs been replaced with long-life bulbs.
Check if floor and table lamps have switches that are activated by touch or sound.
Smoke detectors should be installed low enough to allow ease in changing batteries. Ideally they should be electric or arrangements should be made to insure active smoke detectors.
Locate an acceptable location to mount a rechargeable flashlight in case of a power failure.
Check to see if doors have lever handles instead of round doorknobs.
Interior doorways should be at least 32 inches wide. If not, see if doors can be mounted with swing-clear hinges. This will eliminate the need to tear out doorjambs to widen the doorways.
For many people personal security devices are advisable for each room of the house. Such devices alert help if someone falls or needs emergency assistance. There are a number of these devices on the market and they often are reimbursable under the funding sources described on page 56 and in Chapter 5. (They can save government agencies a lot of money if they reduce the amount of direct supervision needed by an individual.) Some of these devices, when activated, make a phone call to a central location that can dispatch help. Others are programmed to ring the home phone at prearranged times during the day; if the phone is not answered, emergency personnel are sent to the house. It's also possible to establish alerting systems directed to apartment staff, neighbors, and others.

Kitchen

The kitchen is usually one of the most "lived-in" rooms in a house. Cooking, eating, cleaning, and entertaining can be made easier by housing modifications and assistive devices. Safety is also an issue in the kitchen because of the potential for burns, spills, and fires. For these reasons, it's important to inspect several features in the kitchen, including:

Check whether shelves roll out to minimize bending and providing access to the items in the rear.
Check that there is adequate storage space, given one's likely schedule of shopping.
It's often helpful to have a shelf with cutouts that can hold bowls securely for one-handed stirring or that is placed at a level convenient to a person who is seated.
Lighting should be adequate and directed over any modified work areas.
Make sure that can openers, vegetable peelers, and other kitchen utensils have easy-grip handles. Find out if they can be purchased and mounted.
The sink should be easily accessible. Some sinks have sloped fronts so that dishes can be slid into them. In addition, long-handled lever faucets and spray nozzles simplify dishwashing.
The refrigerator is often more convenient if it has a side-by-side refrigerator-freezer setup or a freezer on the bottom for easy access.
Make sure burner controls are mounted on the front of the stove, to eliminate the risk of burns from reaching over a heating element.
Check to see that fire extinguishers are easily reached, lightweight and easy to use.
Find out if dishwashers, microwaves, washers and driers have or require modifications (e.g., Braille or tactile labels, or customized knob turners, special on/off switches).
Besides these fairly major modifications, there are many inexpensive "tricks of the trade" that allow easier maneuvering in the kitchen:
A small mirror mounted over the range allows seated cooks to see into the pans on back burners.
Unbreakable glass pots let seated cooks see how the food is cooking.
Clamps (like clothespins) can be attached to burner knobs, making turning easier, or used to secure pots on a range to help with one-handed stirring.
An old-fashioned potato masher or slotted spoon can be used to turn knobs on a clothes dryer.
Tongs can help get cans or boxes off cabinet and refrigerator shelves.
Oven rack push-pulls can help cooks in wheelchairs or who have limited reach.
A cart can be used to minimize carrying.

Bathroom

The bathroom often presents some of the greatest challenges for people with physical disabilities. These challenges include preventing falls and eliminating the hazards of using electrical appliances around water, maintaining privacy and dignity while attending to problems of accessibility and safety, and making necessary modifications in efficient and cost-effective ways. Among the areas that should be checked in the bathroom are:

Make sure the bathroom is located in an easily accessible area of the home.
Check if the entry door is adequate. If the doorway is too narrow, sliding doors may have to be added to provide needed space or the wall of the adjoining closet may have to be knocked out to create a new doorway. Find out who must approve this, what it costs and who would pay.
Examine the shower to see if a commode or shower chair will fit.
Make sure a sturdy seat is installed in the shower.
Grab bars should be installed around the toilet and tub and should be well positioned.
Try out the faucet hardware to see if it's easy to operate, with easy to-turn knobs or levers.
Check the wet surfaces to find out if they have anti-slip material.
Make sure that a wheelchair can pull up to the sink.
Take a look at the location of mirrors and outlets to see if they are at usable levels and positions.
Inspect the linen closet or cabinet for accessible and adequate storage space. (You may want to consider installing extra shelves or organizers.)
Make sure the electrical outlets are located away from the sink and bathtub, to minimize the risk of electric shock.
Find out if there is either a telephone or emergency alert device in the bathroom or whether one can be installed.

Living Rooms and Bedrooms

Living rooms, bedrooms, and other rooms without plumbing are fairly easy to make accessible. Some of the major considerations have already been mentioned: wall switches, thermostats, electrical outlets, carpeting, and so forth. Many considerations regarding the adequacy of living and sleeping environments have to do with devices more than specific modifications. Many of the devices that can greatly increase a person's independence in their own homes are ones that are readily available on the open market. Among the issues to consider are:

Living Rooms

Check the windows to see if they are easy to open. (Windows that tilt out at the base make opening easy, and help keep out rain.)
It's helpful to have remote controls on the TV, VCR, radio, CD, etc.
Make sure there is a cordless phone or a speaker phone installed. (This can be an important safety as well as communications device for people with mobility impairments.)
Inspect the placement of phone jacks and phones to confirm that they are installed throughout the house for safety and security.
Remote control devices to allow control of appliances and lights from another room are often desirable. (For instance, these devices can be used to turn lights on before entering a room.)
Find out if there is an intercom at the front door. Another useful device is a wireless doorbell, which can be carried from room to room to ensure that ringing is heard.
Make sure that the switches on lights are easy to find, reach, and control.

Bedrooms

Check the height of the bed to see if it's the right height for a minimally assisted wheelchair-to-bed transfer.
Make sure that lamps near the bed can be turned on by touching the lamp base or another easy way.
Open the closet door and see if lights turn on automatically when the door is opened.
Clothing rod heights should be easily adjustable.
It's helpful to have curtains of the easy gliding type, rather than curtain rods and drawstrings.
Make sure there is a phone next to the bed.

There are many commercially available products designed to aid people with disabilities in the routines of daily living. The STAR Program in Minnesota was developed to help Minnesotans identify such products that meet their specific needs. The Metropolitan Center on Independent Living (MCIL) can also provide assistance in suggesting devices that can meet individual needs. (See Chapter 9 for contact information for these agencies.)

Sources of Financial Support

Minnesota has a number of programs that can assist people with developmental disabilities to obtain the home modifications and assistive devices they need to live in their own homes. These include the following programs:

Home and Community-Based Services (HCBS) Waiver

This program was described in Chapter 5. It should be noted here that home modifications and assistive technologies may be purchased through the program, including architectural items, communication aids/emergency warning devices, and mobility aids.

Community Alternative Care (CAC) Waiver

This program is available to people under age sixty-five who are eligible for Medical Assistance, regardless of parental or spousal income. They also must be residents of inpatient hospitals or at risk of such placement, but would prefer community-based care. Medical Assistance will provide services to support the person's preference.

Besides regular Medical Assistance services, the services available under this waiver include case management, respite care, minor home adaptations, family counseling and training, extended foster care services, home-maker services and extended coverage for health services, medical supplies and equipment, prescribed drugs, and transportation. The types of assistive technology that can be funded under this waiver include:

Ambulation aids
Seating/positioning aids
Prosthetics and orthotics
Sensory aids
Communication aids
Architectural items
Environmental controls
Bed aids
Aids for daily living
Mobility aids

Community Alternatives for Disabled Individuals (CADI) Waiver

This program provides medical and related services - which can include assistive technology - to children and adults with disabilities who reside in their homes but require the level of care provided in a nursing home. To be eligible, a person must be under age sixty-five and must prefer home or community care. Besides regular Medical Assistance services, this program provides case management, home and vehicle adaptations, adaptive equipment, homemaker services, respite services, family counseling and training and adult day care. The types of assistive technology that can be funded under this waiver include:

Ambulation aids
Seating/positioning aids
Prosthetics and orthotics
Sensory aids
Communication aids
Architectural items
Environmental controls
Bed aids
Aids for daily living
Transportation aids
Mobility aids

Traumatic Brain Injury (TBI) Waiver

Since November 1998, local agencies may review and authorize home and vehicle adaptations and modification requests for TBI waiver recipients, as well as for HCBS, CADI, and CAC waiver recipients.

Family Support Grant Program

The Family Support Grant Program provides cash grants (maximum $250 per month) to eligible families for the purchase of services and items, which can include assistive technology, necessary to maintain children (0-22 years) with developmental disabilities in the family home. In 2000, families with annual incomes below $73,446 were eligible for this program. This is a state-funded program administered at the county level.

Medical Assistance for Assistive Technology

Medical Assistance (MA) funding is available for both assistive technology devices and assistive technology services. Basically, MA funds equipment, devices, and other health services that are "medically necessary." Examples include:

Augmentative communication devices.
Assessment for augmentative communication.
Bath lifts, bath tub chairs and seats.
Canes, crutches, and walkers.
Oxygen and oxygen supplies.
Seating and positioning devices.
Wheelchairs, both manual and motorized.

MA also covers medical equipment rental and maintenance/repair of recipient-owned equipment.

Assistive technology devices and services must receive prior authorization by MA before they are provided. In Minnesota, the request for prior authorization must show that the device or service meets all six of the following criteria:

Must be medically necessary as determined by prevailing medical community standards;
Must be appropriate and effective to the medical needs of the recipient;
Must be timely, considering the nature and state of the recipient's medical condition;
Must be furnished by a provider with appropriate credentials;
Must be the least expensive, appropriate alternative health services available; and
Must represent an effective and appropriate use of program funds.

The MHFA Rehabilitation Loan, Fix-Up Fund (Accessibility) Loan, and Access Home Fund Programs

These programs, administered by the Minnesota Housing Finance Agency, are described in Chapter 5.

Working with the System

People who plan to apply for Medical Assistance to acquire assistive technology devices and services or home modifications should be well informed about Medical Assistance's policies and procedures. By law each state agency that applies for Medical Assistance funds must keep copies of its policies and guidelines in every agency office, and these policies must be available to read or copy during office hours. One should bear in mind that physical modifications to homes are available through the waiver programs, but not the general Medical Assistance program.

If possible, one should meet with a representative from the county agency in which he or she applies for Medical Assistance. It's a good idea to establish a personal rapport with the people who make assessments and decisions about funding. Knowing the specific assistance individuals need (e.g., a modification such as a ramp or widened door; a service such as evaluation; or equipment such as a wheelchair or an augmentative communication device) will also be helpful.

If your doctor recommends a particular service or piece of equipment, he or she will then refer you to an approved provider. The provider contacts Medical Assistance for authorization to purchase the modification, equipment or service. This prior authorization must be received before the recipient gets most devices and services.

It's important to remember that Medical Assistance requires devices and services that are "necessary." Because medical necessity can be open to interpretation - especially when it comes to assistive technology devices and services - you should be prepared to pursue your case for some time. Obtaining prior approval can take months and can sometimes be a difficult process.

If Medical Assistance denies a request for assistive technology, the denial shouldn't be considered an end to the search for funding. Individuals who want to appeal a denial should contact the state Department of Human Services in writing to schedule an appeal. For further assistance, disability legal services offices can help; the phone number of the state office appears in Chapter 9. An important tool in an appeal will be a complete set of records including all correspondence and phone conversations.

People are their own strongest advocates in an appeals process because they know better than anyone else what their needs and resources are. Federal law supports the individual's right to achieve his or her maximum potential through increased independence, productivity, and integration into the community.

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A Guidebook on Consumer Controlled Housing for Minnesotans with Developmental Disabilities, a joint publication of Arc Minnesota and the Research and Training Center on Community Living, Institute on Community Integration (UAP), University of Minnesota.