Overcoming Inertia to Jumpstart Home Modifications for Aging in Place

Abstract

Three quarters of older adults in the United States would prefer to age in place, but our current housing stock is not suited for older adults with mobility issues and chronic disease. Modifying one’s current home, prior to onset of advanced aging, can prevent falls and illnesses common in late life. Confusion on how to motivate older adults to remodel remains, but there are bright spots in policy regarding home modifications. This article details home modification programs and policy going forward to solve this challenge.

Key Words:

home modification, aging in place, remodeling, incentives, public policy


Three-quarters of adults ages 45 and older want to remain in their home of choice as long as possible (AARP Bulletin, 2018), or “age in place,” defined by the Centers for Disease Control and Prevention (CDC) as “the ability to live in one’s own home and community safely, independently, and comfortably, regardless of age, income, or ability level” (CDC, 2020). Federal and state long-term services and supports policies increasingly emphasize the financing and delivery of home-based care and technology, such as remote monitoring and in-home apparatus like pill-minders and smart speakers, to support aging in place. Growing evidence reveals that aging in place costs less than do the alternatives.

Aging in place signifies a confluence of consumer desire, technology, and policy innovation—and potential cost-savings. It can effect better health outcomes (Bryant, 2019) and support older adults’ dignity. Many factors contribute to successful aging in place, but home modification is critical to shaping a supportive physical environment. Even so, it has not garnered enough attention, which raises questions of what challenges need to be overcome and what programs and policies can make home modification processes more accessible?

The Need for Updated Homes

The need to update homes is an unintended consequence of extended longevity. Americans are living longer than they have in the past and mobility declines with age. Because our housing stock was designed before this boost in longevity, it is not suited to older residents, yet it is the only housing available to most older Americans, who will have to age in place.

There are 100 million homes in the United States. Because the housing industry only builds about 1 million new homes in a good year, there is not enough time to build new housing for all aging Americans. Instead, remodeling existing housing stock should become an important part of aging policy.

Most U.S. housing does not support extended longevity

The postwar housing boom established many design elements that remain typical today, including designs for young families, of which there are fewer. In 1965, life expectancy was age 71, which, due to medical advances by 2000 was age 76, and now is approximately age 79. Anyone now who lives to age 65 will probably live to age 85. Because declining mobility begins in earnest as people reach their late 70s, many homes no longer support this demographic, which needs a range of accessibility features.

This need is underscored by “The Forgotten Middle” (Pearson et al., 2019) a report from Health Affairs which concludes that for those in middle-income brackets, 54 percent of people older than age 75 will not by 2029 have enough money to pay for their housing and care. Middle-income needs are growing: 60 percent will have mobility limitations and 20 percent will have high healthcare and functional needs. Currently, 66.5 percent of all bankruptcies are tied to medical issues (Konish, 2019). Without a policy to encourage home updates, middle-income families risk enduring a medical incident that pushes them into the very low-income category. This study makes it clear that the potential benefits of age-friendly housing span the income spectrum.

‘Anyone now who lives to age 65 will probably live to age 85.’
Messaging has not motivated people to update homes

Many people don’t consider modifying their homes until they confront a medical situation. This is largely because communications around home modifications tend to occur too late, often linking to chronic health issues or hospital discharge. Home modifications are then seen as a health solution, rather than as a proactive, forward-thinking policy.

Often, updates are recommended to people with progressive and chronic illness such as multiple sclerosis, Parkinson’s disease, Chronic Obstructive Pulmonary Disease, Amyotrophic Lateral Sclerosis, or following a medical event such as stroke or heart attack or complications from diabetes.

Or home modifications are recommended as part of hospital discharge, which is a significant problem because the remodeling process and the discharge-planning regimen do not mesh. Discharge planning is a quick process at the end of treatment. Remodeling takes time. Designing good solutions is iterative, and unless drawings, permitting, procurement, and scheduling are performed in an orderly process, the results may be chaos, poor problem-solving, and low-quality construction.

Instead, home modifications could prevent illness and injuries resulting from falls, which are a huge expense and the source of a high percentage of morbidity and disability among older adults (National Council on Aging, 2020). Associating home modification with chronic conditions or discharge plans eliminates proactive benefits such as falls prevention. It is preferable to consider such modification as part of mainstream remodeling so that residents can take advantage of preventive benefits before mobility issues occur. Also modifications can be viewed as investment opportunities, creating jobs in the construction industry, and connected to smart-home infrastructure policy that responds to the shift in the country’s demographics. Home modifications can be positioned as part of the retirement planning process, rather than as an aspect of healthcare.

A consortium of aging organizations hired The Frameworks Institute to study attitudes toward older adults and how to change messaging to be more effective (Lindland et al., 2017). The researchers uncovered deeply rooted skepticism throughout the general population regarding the idea that individuals could control the course of their aging experience. People tend to assume that whatever happens—good or bad—is a matter of luck or genetics.

This mindset creates a paradox: the more professionals in the field of aging urge folks to take action, the less likely consumers are to trust such professionals, because they are making recommendations contrary to consumers’ sense of what is possible. Though not specifically studied, this effect likely holds true with home modification recommendations as well. Importantly, Frameworks also concluded that many older adults champion the values of fairness and equity. So, housing communications positioned to provide for the welfare of “the aging population,” as opposed to individuals about their own interests, should reap greater support.

‘Home modifications could prevent illness and injuries resulting from falls.’

Market demand for home updates is extremely low

Because 80 percent of older Americans own their own homes, and spend about $130 billion per year on home remodeling (Joint Center for Housing Studies of Harvard University, 2019), this demographic is a logical group to educate about updating homes for aging in place. Many people older than age 60 say they are remodeling to age in place, yet they are not taking the necessary steps to do so (Will, 2015). (For a description of the most useful accessibility features, see sidebar below.)

This confusion over how to motivate remodeling for aging in place remains despite major efforts by AARP and other organization in the aging sector to educate consumers. The media covers the topic frequently. AARP and other organizations have published numerous books, booklets, and articles about universal design, accessibility, “design for all,” inclusivity, “visitability,” and the like. In 1991 AARP produced one of the first pamphlets, The Do-Able Renewable Home: Making Your Home Fit Your Needs, (Salmen, 1991) explaining the basics of remodeling for aging in place, including no-step entries, grab bars, curbless showers, roll under sinks, wider doorways and hallways, lever door handles, and other features.

In addition, many printed and online assessment tools are available for homeowners or professionals to evaluate homes and develop action plans. With the expectation that remodeling for aging in place would be a growing and important market, the National Association of Home Builders, the remodeling industry, and other organizations have developed education and training programs for contractors, designers, and health professionals such as occupational therapists. The concept of universal design (defined as “design that accommodates the widest spectrum of needs possible without special adaptation”) has for decades been in the curriculum for architects, industrial designers, and interior designers (Pilarski and Rath, 2013).

Unfortunately, none of these efforts has increased demand.

Public Policy to Encourage Home Updates

Ideally, public policy is a response to a shared, recognized need. In the aging field this takes many policy and programmatic forms. Older adult programs are run by agencies at all levels of government. Nonprofits also run programs, sometimes receiving government funding in addition to individual or foundation contributions. Other policy strategies influence private investment by individuals and businesses such as Medicare Advantage plans or Medicare-funded home care agencies. Affordable housing is another example of public-private partnerships. A similar range of approaches should be employed to encourage more housing updates. 

Home modification program examples

There are some bright spots in policy regarding home modifications. The physical environment finally has been recognized as a “social determinant of health.” Such factors are gaining attention from policy makers and the business world because of the important role they play in keeping the population in good health and reducing healthcare costs. What follows are a sampling of home modification programs:

  • Medicaid Waiver programs pay for some home modifications. As of January 1, 2020, CMS allows Medicare Advantage plans to provide supplemental benefits for chronically ill subscribers to cover “structural improvements to the home.” Non-medical interventions are covered because of their health benefits.
  • The Department of Veterans Affairs offers home modification programs. They are restricted to individuals who have disabilities or a proven medical need, age is not qualifying in and of itself.
  • State and local governments have a variety of different programs to promote home modifications for people with disabilities and-or those who are aging in place. Some are loans, sometimes forgivable. Others are grants such as Safe at Home (Department of Aging and Community Living, 2020). Most contain health or income eligibility criteria.
  • A number of cities and states have “visitability” ordinances or regulations that require or reward basic accessibility features in new or remodeled single-family residences. Some require visitability for projects with government funding, others offer incentives by expediting permit review and-or waiving fees, or offer property or other tax credits (e.g., Montgomery County, Maryland; Freehold Borough, New Jersey; Austin, Texas, Atlanta, Georgia, Birmingham, Alabama) (Guzman, Viveiros, and Salomon, 2017). These programs are laboratories to find best practices.
  • The Community Aging in Place Advancing Better Living for Elders (CAPABLE) study conducted by the Johns Hopkins School of Nursing is a shining example of cost savings demonstrated by home improvements (Szanton, 2017). Approximately $1,300 per person was spent on patient-requested home improvements to high-risk Medicaid patients. For the demonstration research, medical costs for homes that had been improved were compared to homes without improvements. The net savings in medical costs for the full program, including case management and occupational therapy, was nearly tenfold.
  • At the federal level, a bill for a $30,000 income tax credit has been introduced in Congress several times, but there has been little movement (Senior Accessible Housing Act, 2016, and Senior Accessible Housing Act, 2017). Though the potential upside on such a bill is high, the finances of a tax credit that covers the full cost of home modifications for a large segment of the population is probably a non-starter. 

Where Do We Go from Here?

Because homeownership rates among older citizens are high, policy that encourages individual investment in home updates is likely an effective strategy. Policy and programming from other sectors for models about how to encourage home modifications hold lessons for the aging sector.

For example, individual private investment into the purchase of hybrid cars and solar collectors has grown rapidly with incentives. The car or solar array is not paid for outright, but its cost is reduced through incentives. The purchaser must come up with the money to make the investment in order to take advantage of incentive tax credits. And it works! These programs have been very successful at kick-starting private individual investment.

How might this work for home modifications? The low hanging fruit, so to speak, are individuals who are already remodeling their homes. They could be encouraged to include aging-in-place features if it saves money on a project they had already planned to do, such as a bath remodel. These modifications are a one-time capital expenditure, more similar to solar collectors or a hybrid car than to smoking cessation or weight loss, which require long-term behavior change.

One place to find the money to fund the incentive is by allowing tax-free withdrawals from retirement savings plans, such as 401(k)s, IRAs, TSPs (Thrift Savings Plan), or the required minimum distribution from any of these. Many Americans have these accounts. It is their money, already planned for use in retirement. Using it for remodeling shifts it from liquid savings to enhance real estate assets. The net effect will be to improve the home as a tool for aging. Medicare savings from reduced falls and rehab stays will balance the reduced tax revenue.

This is a multi-step strategy. Following the example of CAPABLE, the initial incentive program could function as a demonstration project to test the validity of cost savings resulting from home modifications. The program would provide health-cost data collected from households using the incentives, in comparison to houses without improvements. If the return on investment (ROI) is as expected, future funding mechanisms for people with too little or no retirement savings could come from socially responsible investment, social impact bonds, community reinvestment, or block grant–type funding, as well as means-tested subsidies. Air bags were adopted in similar, multiple stages. They were first introduced as an option in luxury cars only. Once the safety value was established, they were quickly encouraged by insurance companies and then required by law.

What’s more, if the designs are attractive, these upper-middle-income projects could start a trend toward this type of remodeling. If residents who initiate the remodeling live in the home for long enough, they, their parents, or friends will use the benefit. If they move, the next resident will reap the benefits.

Incentives that encourage private spending are a more economical approach than entitlements and large tax credits. Whether incentives are provided by a private business or by the government, the ROI to the incentive payer is higher because they are paying a smaller percentage of the total cost. This is the same thinking behind tax credits for solar panels and hybrid cars. The incentive payer’s interest is reduced carbon input in one case and reduced health costs in the other. Just as with global warming, every U.S. citizen is impacted by healthcare costs for older Americans.

‘Incentives that encourage private spending are a more economical approach than entitlements and large tax credits.’

As the Frameworks study points out, “fairness” is a value that appeals to large segments of the population (Lindland et al., 2017). Two benefits follow from this finding and the fact that older citizens are reliable voters. One is that their support for this topic will form a solid core of grassroots effort, alerting legislators of its importance. The second is that supporting home-modification incentives brings elders closer to making decisions for their own homes without arousing personal fears or needing to be told to do the “right thing.” Fairness means that every American should share in the possibility of an updated home. Incentives should be needs-blind to the age and health of the consumer. This will maximize the proactive benefits of home modifications.

Conclusion

Home modifications could be the missing link to solve the problem of aging economically and with dignity. Important considerations such as paid leave for caregivers, telemedicine, exercise to maintain balance and general health, and transportation, are not separate issues. Investment in housing updates is a common-sense means to ensure an effective platform for delivering healthcare and other support services in the home, while reducing health costs for families, individuals, and the healthcare system. At the same time, aging in place supports self-sufficiency and self-reliance, while fulfilling the desires of older American consumers.


Louis Tenenbaum is the founder of HomesRenewed, a coalition of business, consumers, and nonprofits, driving policy and investment to increase the number of age-friendly homes. Tenenbaum began in the early 1990s, to focus his remodeling company on aging in place, and is author of “Aging in Place 2.0.” Susan Kimmel, M.Arch, J.D., is co-founder and vice president at HomesRenewed and a registered architect, with residential, hospital, and institutional experience as well as more than twenty years experience as a regulatory attorney.  


References

AARP Bulletin, 2018. “Most Retirees Prefer to Stay Put.” tinyurl.com/y6ddsecb. Retrieved March 26, 2020.

Bryant, B. 2019. “Humana CEO: Home-Based Care Key to ‘Great Health Care System.’ ” Home Healthcare News. tinyurl.com/teztjd4. Retrieved March 25, 2020.

Department of Aging and Community Living. 2020. Safe at Home. tinyurl.com/tn97pan. Retrieved March 26, 2020.

Guzman S., Viveiros J., Salomon, E. 2017. “Expanding Implementation of Universal Design and Visitability Features in the Housing Stock.” Insight on the Issues, No. 121. AARP Public Policy Institute. tinyurl.com/yx22g6fk. Retrieved March 24, 2020.

H.R. 5254, 114th Congress (2015–2016) Senior Accessible Housing Act.

H.R.1780, 115th Congress (2017–2018) Senior Accessible Housing Act.

Joint Center for Housing Studies of Harvard University. 2019. Improving America’s Housing 2019. tinyurl.com/vcmwbzx. Retrieved March 24, 2020.

Konish, L. 2019. “This Is the Real Reason most Americans File for Bankruptcy.” CNBC. tinyurl.com/y3gzp5q4. Retrieved March 26, 2020.

Lindland, E., et al. 2017. Gauging Aging: Mapping the Gaps between Expert and Public Understandings of Aging in America. tinyurl.com/vqxc2j4. Retrieved March 25, 2020.

National Council on Aging. “Falls Prevention Facts.” tinyurl.com/hazavmb. Retrieved March 25, 2020.

Pearson, C., et al. 2019. “The Forgotten Middle: Many Middle-Income Seniors Will Have Insufficient Resources for Housing and Health Care.” Health Affairs (38) 5. tinyurl.com/rzut23h.. Retrieved March 25, 2020.

Pilarski, C. and Rath, J. 2013. “Universal Design: Moving Beyond Accessibility Accommodations to a More Inclusive Environment for Everyone.” Spotlight on Disability Newsletter. tinyurl.com/w8tppsb. Retrieved March 25, 2020.

Salmen, J. P. S. 1991. The Do-Able Renewable Home: Making Your Home Fit Your Needs. Washington, DC: AARP. tinyurl.com/yb8wb7n4. Retrieved May 27, 2020.

Szanton, S. L., et al. 2017. “Medicaid Cost Savings of a Preventive Home Visit Program for Disabled Older Adults.” Journal of the American Geriatrics Society. tinyurl.com/w9v7nm2. Retrieved March 25, 2020.

U.S. Centers for Disease Control and Prevention. 2020 “Healthy Places.” tinyurl.com/rq8hjl8. Reviewed March 25, 2020.

Will, A. 2015. Aging in Place: Implications for Remodeling. Joint Center for Housing Studies Harvard University. tinyurl.com/rmxgq3x. Retrieved April 7, 2020.

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