University at Buffalo Machiko R. Tomita, Ph.D. William C. Mann, Ph.D., OTR/L Linda F. Fraas, MA, OTR/L Bin-Min Tsai, MS,

1. Effectiveness of Assistive Devices and Home Modifications in Maintaining Independence and Containing Health Care Costs for the American Home-Based Black Frail Elderly University at Buffalo Machiko R. Tomita, Ph.D. William C. Mann, Ph.D., OTR/L Linda F. Fraas, MA, OTR/L Bin-Min Tsai, MS, OTR/L

2. Introduction • While Americans as a group are healthier and living longer, not all Americans are benefiting equally. The gains have been greater for Whites than for Blacks, producing a larger health disparity (US Department of Health and Human Services, 2000) Blacks have higher rates of chronic disease, risk indicators (i.e., hypertension), and functional impairments than Whites (Lewis, 1989).

3. Purpose of the study • While the advantages of using assistive devices have been reported, Black elders use fewer assistive devices than White elders(Macken, 1986; Tomita, Mann, Fraas, & Burns, 1997; Silverman, Musa, Kirsch, & Siminoff, 1999; Carrasquillo, Lantigua, & Shea, 2000). • The present study of home-based Black frail elders provided assistive devices and minor home modifications to determine their impact on functional status health care costs.

4. Black elders regard assistive devices as a symbol of disability (Brooks, 1991) and have more personal assistance available. • Tomita, et al., (1997) reported a relationship between self-reported pain and home environmental problems among Black elders.

5. Major Research Question • Does provision of appropriate assistive devices and minor home modifications for conditions that are impeding daily tasks help in maintaining functional status and in reducing health care cost over one year?

6. Specific Research Questions • Do Black frail elders accept and use appropriate (to their functional limitations) assistive devices and home modifications provided to them? • Do assistive devices and minor home modifications promote and/or maintain functional status over one year for Black frail elders? • Do assistive devices and minor home modifications reduce health care costs for Black frail elders over one year?

7. Methods:Study Participants • Using a purposive sampling method, 50 home-based Black elderly with physical impairments, but without cognitive impairments, were recruited in the Western New York area. • Study participants were randomly assigned to a treatment (n=25) group and a control group (n=25 to 24).

8. Methods:Study Design • A randomized control trial, with pre and post test design R O X O R O O

9. Methods:Procedure • An occupational therapist (OT) or a nurse trained for research, blind to participants’ group assignments, visited 50 study participants’ homes. • They interviewed and assessed the participants twice, taking an average 2.5 hours initially and again one year later.

10. Intervention • The 25 treatment group participants received a total of 417 assistive devices that addressed physical impairments, four devices for hearing impairments, 40 devices for vision impairments, 6 devices for safety and 54 minor home modifications. • Among minor home modifications: 11 were installing stair railings, 7 were repairing of stairs and towel bars, 6 were securing power strips, 4 were for creating storage pantry and cabinet, 3 for reversing the direction of opening of the refrigerator door, 3 for adding levers to kitchen or bath cabinet doors or drawers, 3 for adding sliding baskets to lower cabinets, 3 for adding bed stabilizing blocks, etc .

11. The participants received a mean of 18.7 devices, ranging from 12 to 30 and a mean of 2.2 home modifications. The mean intervention cost including assistive devices (AD), material for home modifications (HM), labor, and training was $879.86 (SD = $487.99) for the treatment group. Some participants paid for AD and HM in the amount of, on average, $4.20 (SD = $17.30).

12. Instruments • Functional Independence Measure (FIM)(Center for Functional Assessment Research/Uniform Data System for Medical Rehabilitation, 1994), • IADL scale, developed by Duke University Center for Study of Aging and Human Development(Fillenbaum, 1988), • Physical Disability Scale of the Sickness Impact Profile (SIP)(Gilson, Gilson, Bergner, Bobbit, Kressel, Pollard, & Vesselago,1975) • Functional Status Index(Jette, 1980). • Mini Mental Status Exam (MMSE)(Folstein, Folstein, & McHugh,1975).

13. Data Analysis • Each group was further divided into two groups: Low Disability (LD) and High Disability (HD), totaling four groups. The division was made based on the mean score of the physical disability levels, 30.12%. In the treatment group, LD consists of 12 elders and HD, 13. In the control group, LD consists of 15 elders and HD, 9.

14. Results:Acceptance of the Intervention • In an experimental study, a low rate of acceptance of intervention and intentional or unintentional compensatory behaviors to lack of intervention affect the outcomes. Among 25 treatment group participants, only two participants accepted less than half of the recommenced interventions: one person was offered 19 devices, but used two and the other was offered 23 devices, but used eight. No one in the control group acquired more than four assistive devices by themselves.

15. Results:Effectiveness of Intervention on Physical Functional Status Over One Year

16. Results:Effectiveness of Intervention on Cognitive Functional Status Over One Year

17. Results:Effectiveness of Intervention on Pain Status Over One Year

18. Reasons of unexpected outcomes for changes in physical function • We found that despite random assignment of study participants to a treatment and a control group, the two groups were initially non-equivalent in seemingly important health variables. The treatment group participants had experienced more sick days, had greater severity of musculoskeletal disorders, greater pain, and more home environmental problems, but used and were satisfied with fewer assistive devices than the control group participants.

19. Results:Total Home Health Care Cost in One Year

20. Results:Total Health Care Cost in One Year

21. Discussion • The effectiveness of assistive technology and home modification interventions is multi-dimensional. • The intervention led to pain reduction for both disability levels and this result was congruent with a previous randomized trail of the effectiveness of home modifications and assistive technology service provisions(Mann, et al., 1999)

22. Discussion • The intervention appears to help maintaining cognitive function, as the control group declined in both MMSE and FIM cognition, again paralleling results from a previous trial (Mann et al., 1999). • The intervention was also effective in improving ADL functions (FIM Motor) for elders with low severity of disability, but was limited in maintaining IADL functions among elders with high severity of disability. These results were comparable with Agree’s study in 1999.

23. Discussion • However, the intervention was not so effective in maintaining IADL functions among elders at risk with high severity of disability and many sick days. When people lose functional ability, it is manifested by losing IADL capability prior to diminishing ADL abilities. When the rate of deterioration surpasses the effectiveness of assistive device use, physical functional status will decrease, beginning with IADL functions.

24. Discussion • The intervention was very effective in reducing home health care cost (4 to 17 times less for the treatment group) but that was not the case for institutional cost (1.3 times more for the treatment group). • The home health care cost containment was successful for elders with both levels of disability. It may be because the intervention targeted independence in home living.

25. Discussion • Finally, this study reinforced the findings of past studies attributing lack of accessibility and opportunity to receive the services of health care professionals to Black elders having more disability than White elders. In this study, the acceptance of recommended interventions by Black frail elderly was 96%. This suggests that, given the opportunity, Black elders will utilize assistive devices and home modifications but they may not actively seek the services associated with these interventions.