Accessible Home Modification Failure (and Thrive for Life’s Correction): A Case Study

We encountered a client where there was an accessibility home modification failure. This is what we found, how we addressed it, and how we approach home modification projects to ensure positive outcomes for our clients.
Accessible Home Modification Failure
Introduction
A client with a high-level C4 spinal cord injury can present with a variety of symptoms including paralysis of arms, hands, trunk, and legs and as well as the inability to breathe on their own, regulate blood pressure properly, or control bowel and bladder movements.
 
This client and her family hired a contractor to build a roll-in shower that could accommodate her bathing and toileting needs at a wheelchair level.
Home Modification Failure
The contractor the family and healthcare insurer hired built an ADA-compliant 60"x30" roll-in shower, but the shower failed in two major aspects:
 
(1) The shower failed to meet the client's individual needs. Even though the shower was ADA-compliant, it was not long enough for her to recline in while sitting in her wheelchair. That meant that she could not elevate her legs after her bowel and bladder program, which she needed to do in order to reduce vasovagal responses and prevent dizziness and fainting. Because she did not have room to recline in the shower stall, she was forced to rotate her chair when elevating her legs so that her legs protruded out of the shower stall into the bathroom.
 
(2) The shower failed to drain properly. Water flowed out of the shower, into the bathroom and bedroom rather than down the shower drain. The family feared water damage and began screening for mold in the walls. They felt it was causing respiratory problems and did not want to use that bathroom.
 
The client and her family were furious and ready to sue for damages. One of the biggest challenges was that the contractor did not have a medical background; he was not familiar with her injury or positional needs during her bathing routine. Neither the contractor nor the family thought to consult with her medical team to ensure the shower design would support her needs to recline and ensure that her legs were elevated to fit the new shower.
Thrive for Life's Assessment and Solution
When we arrived to evaluate the situation, we tried to build rapport and suggested small mitigating actions, such as using a squeegee to push the water toward the drain after each shower or bathing her diagonally. However, the family was not interested in those kinds of solutions. What worked for this individual was being reclined after her bowel and bladder program, and she just did not fit in the shower as built.
 
We had to address the mold concerns by having a company come out to evaluate the space, and then go back to construction to remodel the entire space to fit her in the reclined position.
 
In the end, the bathroom had to be remodeled twice—a messy and expensive ordeal. Upon completion of this project, the client's health plan acknowledged that this was an unfortunate situation and the added expense would never have happened had they hired an experienced accessibility home modification company in the first place.
 
From the health plan service perspective, we had to communicate from the service coordination level to the administrative level to the director of the health plan. That was a waste of their time as well as the administrative teams at the highest level of the health plan. However, in the process of correcting this issue, we established rapport and trust with the health plan which has resulted in their choosing our company for subsequent projects.
 
This solution resulted in benefits for multiple parties in a variety of aspects:
1. The client's and family's quality of life improved because the water and mold concerns were resolved.
2. Caregivers were saved from having to take the extra steps required for turning the wheelchair to recline the client.
3. The caregiver's risk of falls was lessened because we removed the standing water issues at the bathroom floor.
 
The healthcare teams realized they could trust us to be directors and planners for this project. They trusted us to manage projects before, during, and after construction. They felt reassured that the final result of future projects would be a positive outcome for their members.
Thrive for Life's Assessment Process
On the clinical side, our assessment process helps to justify our recommendations based on our expertise. We assess the needs of both clients and their caregivers. There are nuances involved in putting together a plan or project for a family that includes clients and caregivers.
 
As Occupational Therapists, we understand our clients' diagnoses and all the ramifications for care when someone has a complex diagnosis list. We approach their home modification needs in a comprehensive way and identify all the areas that need to be addressed. Contractors without occupational therapy training will miss many of the nuances of care, quality of life, and safety.
 
Our comprehensive home modification process involves seven phases: processing a new referral, assessment, design (specifications and finishes), bid procurement, permitting, construction, and post-occupancy evaluation.
Seven Project Phases
Processing New Referral
In this phase, we are gathering information and identifying key points of information such as the client's medical history, barriers at the home, homeowner address and phone number, and coordination of a site visit.
Assessment
Initial assessment begins with understanding their medical diagnosis and completing a comprehensive review of the client and the environment with their caregiver and key decision-makers present or available (e.g. homeowner). In the aforementioned case, it was understanding the C4 diagnosis in general as well as this patient's individual capabilities and needs. We reviewed her medical history and her activities of daily living routine with her and her caregivers.
Design
The design phase involves understanding the existing home environment in order to design a solution that fits the needs of our clients and their caregivers. We schedule a designer or draftsman for a site visit to draw up initial plans and write up a Letter of Medical Necessity if needed. We get any physician signatures necessary to expedite permitting. We finish plans, go over them with the client for agreement, and follow up with the insurance company or payer source.
 
In this case, the bathroom needed to be remodeled in order to fit a reclined wheelchair inside a zero-threshold shower stall, as well as the room to easily turn the wheelchair inside the bathroom.
Permitting
We went to the local permit office with the draftsman to discuss the project and see what paperwork we needed to submit for the permits we needed to have. In this case, the family owned the home, but we were also working with the state-run healthcare plan and needed to also follow their requirements.
 
Permit processes and requirements vary by location, so this is a very important step. The best way to learn is to go to the permitting office and ask. Building relationships with the people in those offices will help you as an OT make your way through the system and get things done. If you need something expedited, an established trust relationship will smooth that path for you and your client. Knowing building codes and timelines in your area is part of the value you bring to your home modification client. They often lack the time and resources to learn these often-complicated rules and regulations. The more you know, the more valuable you are to your client.
Contractor Bids
We began with vetting contractors. This involved investigating their online reviews, looking them up in the Better Business Bureau, and confirming their licenses, reference, and insurance. We asked several contractors to come to the house to see the true scope of the project so that the bid they returned would be an accurate and complete one.
 
In this case, we interviewed them one at a time. We asked them a lot of questions and got to know them, but still had to do follow up with them to receive their bids. We then took those bids, insurance information, references, and previous projects as a packet to the health plan so they could choose which contractor they would like to work with.
 
Finding the right contractor to complete the project is vital. In this case, the contractor who installed the bathroom incorrectly in the first place for the client was likely the lowest bid of the three, which is why the health plan chose them. Health plans speak in terms of being good stewards of taxpayer money, which by itself is a worthy goal. However, understanding the nuances of a situation and making a wise decision (rather than just the least expensive one) is the better path.
 
This situation is an example of that.
 
Making a choice based only on one set of financial standards both hurt the client and cost more money in the end (because they had to pay for the original remodel as well as the repair).
Relative cost is an important point for clients and health plans to understand. Accessible home modifications are expensive. In this case, the repair of the original bathroom remodel was more than $30,000. However, this client was in her twenties and so the repaired bathroom will remain functional for her for many years.
 
It is important to look at these solutions in relative terms. If a client with complex medical needs is faced with the choice of completing a $100,000 project or going to a care home, which one is the best choice? At first glance, health plans might choose the care home. However, in our area of Hawaii, care homes can cost $10,000 per month. If the client were able to complete a $100,000 project to stay in the home, they would only have to stay for 11 months in order for that project to be less expensive than the care home.
 
In either case, the quality of life enjoyed by the client is often higher when they can stay at home rather than go to an institutional care home.
Construction
The construction process is pretty straightforward if you have chosen a good contractor. Sometimes the best contractor is not the least expensive one. Some contractors will deliver a lower bid initially but adds change orders later. To avoid that, it is important to be as clear and detailed as possible during the bid process. It may be more difficult to choose a higher-cost contractor in the beginning, but if that contractor has accounted for variables or contingencies inside the bid, it can cover any issues that come up without financial surprises or change orders.
 
We set the scope of work with clear expectations for the contractor from the start, down to the specific hours they will be on-site working. We do weekly site visits to check in on construction and take photos of the progress. Site visits are vitally important to catch any issues during the construction phase when they are likely easier to correct. We have had some contractors put thresholds on shower entrances because they did not understand the need wheelchairs have for a curbless surface.
 
Misunderstandings about a caregiver's ability to lift or maneuver a wheelchair over a threshold are not uncommon. To avoid any confusion, we put up large drawings on the wall at the site so the scope of works is posted and clear as to what the expectations are for the project.
 
We communicate as clearly as possible with the contractor about expectations. What if the client has only one bathroom? We have been known to add a temporary toilet and shower on the property for our client to use during the construction phase as well as make certain that the contractor has a portable toilet installed on-site for them to use. If there will be a lot of debris and dust from the project, we place air purifiers in the home to cut down on dust. We also have had some clients move out of the home, to hotel rooms, during construction if the process will be too disruptive for their care. We also make sure that we have professional cleaners come in after the work is completed so that when we leave and the client resumes life in the space, everything is clean and ready.
Post Occupancy Evaluation
When the work is completed, we make sure that family members and their caregivers have been provided the owners' manuals and warranty statements and are trained in how to use any equipment that has been installed. We have them demonstrate the use of modifications, reviewing care routines with them to ensure the safety of our clients and their caregivers.
 
Finally, we close out our cases with a client satisfaction survey.
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