White Paper: The Impact of Home Modifications and Occupational Therapy on Aging in Place with Models for Better Scalability

Introduction

Aging in place, the ability for older adults to live independently and safely in their own homes, is a widely desired outcome, with approximately 90% of older adults expressing this preference. However, a significant gap exists, as only about 40% of U.S. homes are adequately prepared for the accessibility needs of an aging population ². This challenge is prevalent globally, with residential environments posing a major barrier to successful aging in place². Falls are a frequent and severe concern for older adults, often leading to physical injuries, psychological consequences like fear of falling (FoF), disability, and a loss of independence, all of which profoundly impact one's quality of life (QoL)³. This paper explores the critical role of fear of falling, the demonstrable impact of home modifications and occupational therapy interventions, and the importance of cost-effective, scalable solutions in supporting older adults to age in place with improved health outcomes and enhanced quality of life.

The Interplay of Fear of Falling and Quality of Life

Fear of falling (FoF) is a significant concern for older adults, affecting a wide range of individuals, from 3% to 92% of community-dwelling elderly fallers³. Notably, FoF can exist even in more than 50% of individuals with no prior fall experience³.

• FoF is strongly associated with a diminished quality of life (QoL), affecting physical and cognitive functions and often leading to activity restriction³. This restriction can initiate a "downward spiral of inactivity, de-conditioning, loss of confidence, and further increased fall risk^3”.
• A consistent association has been observed between lower levels of FoF and higher perceived QoL³. Studies indicate a linear relationship where increased FoF correlates with poorer QoL scores³.
• FoF acts as an independent predictor for QoL, with this relationship often stronger for the physical components of QoL than for mental components³. Physical function, general health perceptions, bodily pain status, vitality, physical role functioning, and physical mobility are particularly affected by FoF³.
• The association between FoF and QoL appears to be largely independent of the specific measurement instruments used³. Common tools include the Falls Efficacy Scale (FES) and its variations for FoF, and the SF-36 or WHOQOL-BREF for QoL⁵. The WHOQOL-BREF categorizes QoL into four domains: physical, psychological, social, and environmental⁵.

Given the significant impact of FoF on QoL, interventions targeting FoF are crucial for improving the well-being of older adults³.

Innovations in Home Modification and Occupational Therapy

Home modifications are a critical intervention strategy to address physical and cognitive function declines that increasingly impact independence and safety in residential environments². These modifications encompass structural changes, assistive devices, and even furniture rearrangement².

• Adaptive equipment and virtual occupational therapy (OT) assessments have demonstrated success in improving health outcomes for older adults. The AskSAMIE Community Grant Project, for example, successfully reduced fear of falling, decreased re-hospitalization rates, and improved quality of life for grantees through virtual OT evaluations and the provision of $1,500 worth of adaptive equipment and services.
  
• The preliminary data from this project showed a decrease in the number of grantees with a fear of falling, with 53% reporting some fear in pre-surveys and only 5% reporting any fear of falling in the 6-month survey. Re-hospitalization rates decreased significantly from 35% to 8% after interventions, with 100% of post-equipment installation hospital visits being for acute reasons n(like the flu), not chronic condition exacerbations. Overall, 67% of older adults reported an increase in their quality of life.
  
• The Home Hazard Removal Program (HARP), a randomized clinical trial in the U.S., found that a brief home hazard removal intervention, delivered by an occupational therapist, led to a 38% reduction in the rate of falling among community-dwelling older adults at high risk (4). Similarly AskSAMIE’s Community Grant Project demonstrated a significant decrease in FoF with OT led provision of equipment and services.
  
• In another model example, The Community Aging in Place—Advancing Better Living for Elders (CAPABLE) program employs an interdisciplinary team, typically consisting of an occupational therapist, a registered nurse, and a handy worker, working collaboratively with the participant¹. The Colorado CAPABLE pilot demonstrated statistically significant improvements in Activities of Daily Living (ADLs) by 24% and Instrumental Activities of Daily Living (IADLs) by 21%¹.  Additionally, participants reported a statistically significant increase in their confidence in not falling and a reduction in pain scores¹.
  

A systematic review of home modifications for aging in place indicates that these interventions are effective in fall prevention, functional independence, and cost savings². The most common and impactful modifications include mobility and accessibility improvements, and bathroom safety enhancements such as grab bars and non-slip mats².

Cost-Effectiveness and Scalability

One of the key advantages of modern home modification and OT interventions is their potential for cost-effectiveness compared to traditional approaches.

• The AskSAMIE project proved its innovation by improving health outcomes at a lower price point ($1500) compared to existing OT-led home modification programs like CAPABLE, which range from $3000 - $7,000 per person. Due to its success, AskSAMIE plans to increase the spending allotment per grantee to $2,000 to accommodate inflation and enhance accessibility of SAMIE the AI tool by allowing it to be accessed by phone or text in addition to a web browser.
  
• The HARP intervention, costing a mean of $765.83 per participant, showed a potential 111% Return on Investment (ROI) through declines in health care utilization⁴. This suggests that such programs are potentially cost-effective for high-risk populations⁴.
  
• The average total cost per member for the Colorado CAPABLE pilot was $2,976, with over 85% of members incurring less than $3,500 in costs. This cost is considered lower than previous CAPABLE studies when adjusted for inflation¹. Previous CAPABLE studies have estimated significant reductions in Medicare expenditures and lower probabilities of using inpatient, outpatient, and specialist services, leading to substantial cost-savings over time¹.
  

These programs are designed for scalability and repeatability, often leveraging technology. The CAPABLE model, for instance, emphasizes an "entrepreneurial" delivery of services, allowing teams to quickly adapt to changing circumstances and ensuring timely follow-through on recommendations¹.

Discussion

However, the challenge is that neither HARP nor CAPABLE have become standard of practice for communities. While the programs have been implemented in multiple cities across the country, they are not even in every major city, despite the problems with aging in place being evident cost to coast. Despite both programs being well researched, evidence based and cost effective they haven’t achieved mass adoption. Our hypothesis is that it is due to program length for participants, cost per participant and limited access to OT’s to participate in the program.

Our model’s design focuses on being able to move quickly to engage, assess and serve the client while providing highly customized recommendations using SAMIE and validating that with a virtual OT assessment. This decreases the time needed for participation, decreases costs for modifications and improves access to OT’s.

Conclusion

The evidence strongly supports the effectiveness of targeted home modifications combined with occupational therapy interventions in addressing the complex needs of older adults, particularly in reducing falls, alleviating fear of falling, and enhancing overall quality of life. AskSAMIE’s model is innovative as it adds technology to decrease time and costs while creating significant improvements in cost driving health outcomes.

Doing so creates a cost-effective and scalable solution that can be integrated into existing healthcare and aging services networks. Critically, this interventions emphasize a participant-directed, interdisciplinary approach, fostering independence and building sustainable skills. While challenges exist, particularly in outreach to diverse populations and addressing complex co-morbidities, the proven benefits and outcomes underscore the importance of continuing to develop and implement AskSAMIE’s technology into programs that support older adults in living safely and independently in their homes as they age.

References

1. Boffy-Ramirez, E., Dougherty, Y., & Versen, E. (2024). Colorado Community Aging in Place–Advancing Better Living for Elders (CAPABLE) evaluation: Final report. (Report No. 23-10B). Denver, CO: Colorado Evaluation and Action Lab at the University of Denver.

2. Cha, S.-M. (2025). A systematic review of home modifications for aging in place in older adults. Healthcare, 13(7), 752.

3. Schoene, D., Heller, C., Aung, Y. N., Sieber, C. C., Kemmler, W., & Freiberger, E. (2019). A systematic review on the influence of fear of falling on quality of life in older people: Is there a role for falls? Clinical Interventions in Aging, 14, 701–719.

4. Stark, S., Keglovits, M., Somerville, E., Hu, Y. L., Barker, A., Sykora, D., & Yan, Y. (2021). Home hazard removal to reduce falls among community-dwelling older adults: A randomized clinical trial. JAMA Network Open, 4(8), e2122044.

5. World Health Organization. (2004). The World Health Organization Quality of Life (WHOQOL) -BREF.