Valuing Home Modifications: Insights and Implications for Occupational Therapists.

Occupational therapists (OTs) specializing in home modifications are increasingly required to demonstrate both the value and value for money (VFM) of their recommendations, especially when working within funding frameworks. However, as highlighted by recent research, the definitions and practical application of these concepts remain ambiguous, leading to significant variability in practice and decision-making. This blog explores the findings of Bitner, Gillett, and Foster’s 2022 study on the street-level policy work of Australian OTs in home modification, situates these findings within the broader literature, and offers practical considerations for OTs navigating this complex landscape.

Understanding Value and Value for Money in Home Modifications

Key Findings from the Study

The 2022 qualitative study interviewed 20 experienced Australian OTs engaged in home modification work. The research found that:

• OTs are often required by funders to assess and justify the value and VFM of home modifications, but there is little consensus or formal guidance on how to do so.
• In the absence of robust frameworks, OTs employ a range of individual strategies, including:
  • Using reductions in formal and informal care needs as metrics
  • Opting for the cheapest available solutions
  • Comparing costs across different modification options
• OTs occupy a unique position, mediating between the sometimes conflicting values of clients, funders, and other stakeholders. This “value alignment” work is often invisible but crucial for achieving solutions that are broadly acceptable.

The study conceptualizes OTs as “street-level policy agents,” highlighting their role in interpreting, enacting, and sometimes challenging policy in daily practice as they navigate the competing demands of stakeholders.

Analysis in Context: Comparing with Other Studies

Cost-Effectiveness and Impact

Several studies have demonstrated that OT-led home modifications are both cost-effective and impactful, particularly for older adults and those with disabilities:

• A U.S.-based study employing a two-visit OT home modification model for low-income older adults found significant improvements in occupational performance and satisfaction. The mean modification cost was $10,396.65, substantially less than annual health care or paid caregiving costs, which ranged from $22,763 to $154,478.
• These findings support the assertion that home modifications not only improve quality of life and independence but also offer substantial savings to health and social care systems.

Methodological Challenges and Value Alignment

• The Australian study’s finding that OTs use ad hoc methods to establish value and VFM is echoed in international literature, which notes a lack of standardized outcome measures and frameworks for evaluating home modifications.
• Studies also emphasize the importance of client-centered approaches and the need to balance economic considerations with personal and social factors—such as safety, autonomy, and caregiver burden.

Policy and Practice Implications

• The lack of clear, consistent guidance on VFM can place OTs in difficult positions, forcing them to act as intermediaries between clients’ needs and funders’ requirements.
• Collaborative and transparent approaches involving all stakeholders—clients, families, funders, and professionals—are viewed positively and may improve value alignment and satisfaction with outcomes.

Practical Considerations for Occupational Therapists

1. Advocate for Clearer Frameworks

• OTs should engage in policy discussions and advocate for the development of standardized, transparent frameworks for assessing value and VFM in home modifications.
• Participation in professional networks and research initiatives can help drive the creation and adoption of such frameworks.

2. Document and Communicate Value

• Clearly document the rationale behind recommendations, including both economic and non-economic benefits (e.g., reduced care needs, improved safety, enhanced independence).
• Use client-centered outcome measures (such as the Canadian Occupational Performance Measure) to capture changes in performance and satisfaction.

3. Facilitate Stakeholder Alignment

• Proactively facilitate conversations between clients, families, and funders to surface and reconcile differing values and expectations.
• Where possible, promote collaborative decision-making processes that make value judgments explicit and transparent.

4. Leverage Evidence

• Draw on existing research demonstrating the cost-effectiveness and impact of OT-led home modifications to support funding applications and policy advocacy.

Conclusion

The work of OTs in home modification sits at the intersection of clinical expertise, client advocacy, and policy implementation. As “street-level policy agents,” OTs must navigate the complex terrain of value and VFM, often without clear guidance. By advocating for clearer frameworks, documenting value, facilitating stakeholder alignment, and leveraging evidence, OTs can continue to deliver impactful, cost-effective solutions that support aging in place and participation in daily life.

REFERENCES:

Bitner, G., Gillett, C., & Foster, M. (2022). Valuing home modifications: The street-level policy work of occupational therapists in Australian home modification practice. Australian Journal of Occupational Therapy, 70(1):61-72, https://doi.org/10.1111/1440-1630.12836

Grasso, A. Y., Murphy, A., & Abbott-Gaffney, C. (2023). The Impact of a Two-Visit Occupational Therapy Home Modification Model on Low-Income Older Adults. The Open Journal of Occupational Therapy, 11(1),
1-9. https://doi.org/10.15453/2168-6408.2047