Independence Through Home Modification
When an employee sustains a significant injury which requires inpatient care and rehabilitation, going home is often the first major goal of recovery. But the comforts of home may not be so comforting if the person requires a wheelchair or other assistive devices to get around. On today’s Inside Workers’ Comp, we talk with Nicole Usher of Apricus who explains how home modifications can make an injured employee’s house home sweet home again.
Tom Kerr (TK): So let’s start with the basics. What is the purpose of home modifications in a workers’ comp case?
Nicole Usher (NU): So, the purpose of home modifications, in general, is really support the health and safety of injured employees when returning back into the home setting and also empowering them to live their daily lives to the fullest potential.
TK: And when would home modifications be needed for a workers’ comp case?
NU: Each case is unique, and it really depends on the needs and ability of the patient. The clinical care team that’s overseeing the patient’s care will start to engage as the patient starts to transition back home. And it really depends on the level of support that’s in the home, what type of injury has occurred, but the care team, typically, will initiate that process.
TK: And what types of modifications are often considered for injured employees to be able to return home safely?
NU: So, the most common that we see can be as simple as installing a ramp. If the entryway has a threshold — even one to three inches— can be an obstacle for patients in a wheelchair.
So, we assess the entryways, the door frames if the injured employee is in a wheelchair. Also, grab bars for stability in the restroom area especially, so the injured employee can have that normal function while back at home and support him or herself. If there are stairs in the home, a stairlift could be required.
TK: What point in the recovery process, typically, are home modifications considered?
NU: So, in that recovery process, the team will start to evaluate the patients’ gait, can he or she support themselves? Is there going to be additional support systems needed in the home while walking, standing? If they’re going to be permanently in a wheelchair or in a wheelchair the majority of the time, that’s when the specialist will start to consider home modifications.
TK: Who is involved in determining what modifications are best for the injured employee?
NU: So, we typically start with an occupational therapist. We use licensed and registered occupational therapists who go out and perform the home assessment for the patient. The OTs really look at the patients’ abilities, what they can do on their own, and their ability to maneuver in their home if they’re in a wheelchair, per se.
They look at the ADA regulations, making sure that there’s ways in and out of the home, if the doors are wide enough to support the patient in a wheelchair, and any type of additional support needs. Are they able to transfer themselves from the bed to a chair, or are they mobile and don’t need support there?
So they’ll evaluate the home, the abilities of the patient, and come up with an assessment that tells everyone involved exactly what is required in the home to make it safe for the patient.
We, typically, will take that evaluation and use what’s called a CAPS‑certified designer or contractor, that is a Certified Aging‑in‑Place Specialist. They work with designing adaptations. They understand, if you are in a wheelchair, how high do the cabinets need to be, do we need pull‑down cabinets?
Depending on the skills and ability of the patient, the needs, do they have people in the home that will be supporting them 24/7 or are they completely independent? Those kinds of things. It’s a collaborative effort.
And then, the most important people to consider are the patient or their support person at home.You want to make sure that they’re comfortable with the designs that you come up with. So we do tend to engage the patient or a family member, the caregiver in the home.
TK: So, obviously with home modifications, there's a lot of people involved, a lot of moving parts. So, can you walk us through the process?
NU: So, as you mentioned, there’s a lot of moving parts, there’s a lot of people involved. So if we get an adjuster that needs help or support with a home modification, the referral will come to us. And it will come to us maybe from a nurse, or an evaluation, or it can come from the adjuster.
The moment we get it, we start to really identify the injured employee’s needs. We have CAPS‑certified employees, so we would dedicate a team that handles home modifications. It would be assigned to one of those care coordinators. And then we discuss the goals with the adjuster and with the injured employee: what are we hoping to achieve with a home modification? Because realistic expectations are important to assure a positive outcome.
They perform onsite visits. We will go out with our vendors. We typically get three quotes from three separate contractors. They will typically have similar designs based on the needs of the patient and what’s medically necessary. But they will all have a different outlook on how to achieve the home modification and what’s required. We then evaluate those bids and pass those off to the claims adjuster to make a decision.
If there’s additional questions, concerns, we can address those. We can ask follow‑up questions to each of our contractors. And, at that point, a contractor’s selected. So that’s the start, right? That’s laying the foundation. We call that our pre‑bid process. And, when doing that, it’s really important to understand, the goals of the client, the goals of the patient, and moving forward with selecting the appropriate contractor for the job.
TK: Are there advantages to having a case manager on board when it comes to making home modifications?
NU: There are, especially depending on the severity of the case. It’s critical that we can have somebody who really knows the patient, understands the intricacies of what we’re dealing with, because that allows us to avoid potential miscommunications. It allows us to get another vantage point on bringing this to fruition.
So we do like to have a case manager. And from a case manager standpoint, they may not understand construction, right? So, they may need the partners and the expertise that Apricus brings to the table and the network of licensed and insured contractors that can come in.
And we handle all of the communication with those contractors. So, it really alleviates some of that administrative burden or any gaps in knowledge around the construction process for the case manager.
So you really team together to make sure that they’re getting the clinical aspects of what’s required for the patient, and that we’re considering the design that will help them and empower the patient to really become as independent as possible when returning back to their life as close as possible to what they had prior to their injury.
TK: And the injured employee is the focus of these home modifications but, oftentimes, the injured employee has a family or roommates who are also going to be impacted by these modifications. So how do you work with the family to make them more comfortable with the process?
NU: This is a great question. And I think this is an opportunity for us to really engage the team. This an important portion of our process that’s just dedicated to those family engagements, making sure that we are considering the home environment and that caregiver who is spending the most time with the patient, and supporting them through a transitional phase back to the home. So the goals for the injured employee also consist of the goals of their caregivers and those that that are closely tied to the care of the patient.
So having an opportunity with the group as a whole allows us to understand the caregiver. It could be a wife, a son, a daughter, a close relative. We also address whether the home we’re modifying is the injured employee’s home, the caregiver’s home, or if it’s a rental, because something that we would do for a renter may not be the same that we would do for a homeowner, or if it’s the injured employee’s sister’s home, right? So we really want to be careful and consider the needs and the wants of those people who will be supporting the injured employee because home modifications can be life‑altering, not just for the patient but for their homelife as well, for everyone involved. So we, have those goal‑setting sessions, and really lay out the fact that we’re trying to get absolutely what’s medically necessary, but with consideration of what’s needed.
And if we can achieve both of those things without impact to the client or to the budget, that’s what we want to try to achieve. That’s where we’re going to get the best results. We have to get them to a point where they’re comfortable. We don’t want to overdo something or not enough. And it really impacts the person who owns a home or is in their homes, because then that can be really an entire project which is also costly.
So making sure that you get buy‑in upfront and then setting realistic expectations, definitely helps, but invite them into the conversation.
TK: So, if the injured employee has a landlord or homeowner's association do you run into certain restrictions on making modifications? Or do you have the ADA on your side so you can make a home more accessible?
NU: So, yes, we have ADA on our side, but we’re also very cognizant if the injured employee is not an owner, we have to get the buy‑in from the owner of the property. We can’t make changes without them knowing. There are also alternatives to making permanent structural changes. We can do temporary structures if it’s a ramp, if it is grab bars, those kinds of things. Or, we can arrange to have it, in the contract, when we’re working with the contractor that a modification be removed by a professional and brought back to pre‑modification stages.
So, it can present some obstacles, but we’ve dealt with every scenario you can think of. We do work closely with the homeowners to ensure that we do get their buy‑in, that we get their sign‑off on any project before we begin if that’s not the injured worker really making sure that we follow the necessary guidelines. And the contractors who work for us, always know the zoning requirements. We’ll work with the homeowners association if that’s what’s required.
Typically, when it comes to ramps and other modifications, we don’t have a problem because the ADA does say that you need accessibility, right? You need to be safe in the event of an emergency. So those, typically, work in our favor. And it’s not too much. But there are times where we’ve had to maybe paint or stain a ramp to match the exteriors of other buildings. If they have a deck, we may have to just make sure that it meets, the guidelines of the HOA. Things like that.
TK: What about smart homes or the implementation of smart technology? Are you incorporating its use to make homes more accessible?
NU: I think it really depends on the injury because we have had patients who are quadriplegic but still very in tune with what they want, how they want to get around. So we’ve added devices like a lift in the ceiling that are controlled by the patient himself. He will always have a caregiver, but he really wants to be independent, right?
So, having the ability for smart technology, I think is key, and offers the injured employee another sense of freedom if it’s right for them. It’s use has been progressive over the last several years, so I do think that it’s important to always be evaluating the technologies and the equipment that’s available.
TK: When the modifications are done prior to the injured worker coming home, is your job done? Or do you often have to revise or adapt things in the person's home before you can finally say, “OK, we’ve made the home accessible enough to meet the injured employee’s needs?”
NU: That’s a great question, Tom. So, we actually have, as a part of our closing process, the injured employee come to their home prior to moving in or taking possession to evaluate everything, in case those modifications are needed. But we’re not done until they sign off on the work. The injured employee has to say “everything is good. I can use the stairlift, the grab bars were installed properly and I feel comfortable with them.”
Even after we get that sign‑off, we guarantee our work. We’ll follow and tell them to give us a call back if needed and we will get somebody out to either change the direction of a cabinet door or something that will help in their overall functionality of the space.
TK: Do you receive feedback from the case manager or someone involved in the case about how a home modification changes the employee’s psyche?
NU: Absolutely. So, this is something that we take pride in, and it’s not something that you’re always going to hear or somebody is going to tell you outright … that the employee is struggling with this.
But as we engage, we listen for those things or we will ask their case manager or their clinical care teams, “is there anything we should know that might be preventing them from reaching their potential mentally or emotionally?” But we try to listen out for that.
And I think including the injured employee’s input into the modification development process or asking them questions about it really empowers them to build their future. I think that can be extremely empowering for them. We’ve had instances when we’re doing it these very large modifications, where they feel empowered. They feel a sense of relief of accomplishment for being engaged and involved.
And, obviously, that’s a fine line. We have to engage them to a point where they can feel empowered to move forward, but also ensuring we’re walking the line of medical necessity. So, we want them to make decisions where they can, but knowing what decisions we can put in front of them and incorporate them into the process is critical.
And through the CHAMP certification, which is the comp certification for home modification, accessibility, and disability, they train on understanding the behavioral health and emotional element of the process. Because that’s something that I don’t think people talk about enough, and having staff trained to hone in on that really makes a difference. So, I think that’s a critical part of what we do and how we can help and engage either the case manager or the adjuster at right times of the process.
TK: Can you give me an example of a home modification that made a significant difference in an injured employee’s recovery?
NU: Absolutely. It was about a year ago. We were in the middle of COVID lockdown, but we had a patient who was catastrophically injured and had gone through rehab. He was renting his home prior to his injury and, as a part of his settlement, he was awarded a home to permanently modify.
He was probably mid-to-late 30s, had two small children that he took care of independently prior to the injury. So, we needed to find a home we could modify where he could still be the primary caregiver.
Getting him back home with his children was critical. And this patient was overjoyed even though he had this catastrophic injury, um, was able to come back, still take care of his children. He was progressing overall prior to getting out of rehab. He wasn’t sure what he was going to do. So, mentally, we actually had our adjuster that came back and said this is night and day from the patient that we were seeing.
He is very pleased with the home, pleased with his life balance now. He still needs a lot of support, but he is able to do things more independently. We found him the right home, with the right modifications, making sure that he could still cook dinner for his children, and it made all the difference in his overall health and well‑being.
And that makes all the difference.
TK: Thanks, Nicole. And we’ll be back with another Inside Workers’ Comp soon. Until then, thanks for listening.