November is Alzheimer’s Awareness Month. Occupational therapists (OTs) are uniquely positioned to help persons with dementia and their caregivers navigate the complex challenges of maintaining safety and independence at home. As dementia progresses, risks of accidents, confusion, and decreased function grow. To address these concerns systematically, evidence-based assessment tools are essential. The Home Environment Assessment Protocol-Revised (HEAP-R), grounded in recent research and professional consensus, stands out as a practical and psychometrically sound instrument for guiding home modifications for this vulnerable population (Struckmeyer, 2019; Struckmeyer et al., 2021).
What is the HEAP-R?
The HEAP-R is an updated, streamlined assessment tool specifically designed for occupational therapists to evaluate the home environments of persons with dementia (PWD) and support their caregivers (Struckmeyer, 2019; Struckmeyer et al., 2021). Unlike generic checklists, the HEAP-R focuses on five domains shown to impact safety and well-being:
- Hazards (trip, slip, fall, burn, poison, etc.)
- Adaptations (environmental supports, aids, or devices)
- Visual Cues (signage, labels, markings)
- Clutter (organization and environmental flow)
- Comfort (lighting, noise, ergonomics)
Each domain is scored consistently with clear definitions and examples, making HEAP-R accessible for clinicians across settings (Struckmeyer, 2019).
Why Use the HEAP-R When Working with Dementia?
1. Evidence-Based and Psychometrically Valid
Linda Struckmeyer’s doctoral thesis and related studies demonstrate strong content validity and concurrent validity for HEAP-R, especially in identifying hazards, adaptations, clutter, and comfort in PWD’s homes (Struckmeyer, 2019; Struckmeyer et al., 2021). Content validity exceeded .98, and domain correlation coefficients ranged from .74 to .95, establishing the tool’s reliability and clinical relevance (Struckmeyer, 2019; Struckmeyer et al., 2021).
2. Person-Environment Fit
The person-environment fit is a core OT concept: optimal outcomes occur when the environment adapts to a person’s evolving capabilities (Gitlin et al., 2002; Struckmeyer & Pickens, 2016). HEAP-R’s focus on environmental modifications supports aging in place, reduces caregiver burden, and improves functional outcomes (Struckmeyer & Pickens, 2016; NIH, 2011).
3. Guidance for Home Modification
HEAP-R goes beyond hazard identification, offering a nuanced snapshot that directs intervention. Research shows that caregivers often react to adverse events, rather than proactively adjusting the environment; the HEAP-R provides a roadmap, enabling OTs to recommend modifications before injuries or crises occur (Struckmeyer, 2019; Struckmeyer et al., 2021).
4. Facilitating Communication with Caregivers
Caregiver engagement is critical in dementia home care (Struckmeyer & Pickens, 2016). HEAP-R includes caregiver interviews and observations, aligning intervention with family values, routines, and concerns. The tool’s structured format also aids in documenting needs for payers and service coordinators (Struckmeyer & Pickens, 2016).
5. Holistic, Multidimensional Assessment
Research supports OTs’ use of holistic, multidimensional assessments to balance safety and quality of life (NIH, 2011; Clark & Czaja, 2017). By scoring hazards and adaptations alongside comfort and clutter, HEAP-R keeps person-centered care at the forefront.
What the Evidence Shows
HEAP-R’s concurrent validity is high, correlating well with established home safety protocols. While early iterations revealed mixed inter-rater reliability, especially for subjective domains like visual cues, further guidance and video training for raters are improving consistency (Struckmeyer, 2019). Real-world studies confirm strong domain correlations and clinical acceptance among OTs (Struckmeyer et al., 2021; Gitlin et al., 2002).
Single case studies reveal that the decision to implement home modifications is influenced more by adverse events than by professional input—highlighting how proactive, structured use of HEAP-R can redirect this pattern toward prevention (Struckmeyer, 2019).
Potential limitations include the need for further training and experience to ensure rating consistency, especially for new practitioners. However, available resources and growing professional familiarity are closing this gap (Struckmeyer et al., 2021).
Clinical Implementation and Program Value
For OTs in home health, geriatric, or memory care settings, HEAP-R serves as both a clinical tool and a communication bridge. It can document needs, justify service delivery, monitor intervention effectiveness, and empower caregivers with practical recommendations. OTs can integrate HEAP-R scoring into routine assessments, home modification programs, and interdisciplinary care planning (Struckmeyer, 2019; Struckmeyer & Pickens, 2016).
Conclusion
For occupational therapists specializing in home modifications, the Home Environment Assessment Protocol-Revised (HEAP-R) offers a powerful, evidence-based framework to evaluate and enhance safety for persons living with dementia. Its multidimensional approach enables OTs to systematically identify hazards, recommend targeted adaptations, and collaborate more effectively with caregivers—all while supporting aging in place and promoting meaningful daily activity. By applying the HEAP-R in your practice, you can deliver measurable outcomes, justify interventions, and elevate your professional value in home-based care.
Ready to master the HEAP-R and expand your impact? Register for specialized training and resources offered by The Home Accessibility Therapist—gain the skills and confidence to lead best practices in home safety, dementia care, and accessibility. Visit our training page or message for more details about upcoming workshops and certification opportunities.
Empower your clinical practice with the HEAP-R and join a community of therapists leading change in home modifications for dementia care.
References:
Clark, P. A., & Czaja, S. J. (2017). Aging and home safety: An individual and environmental issue. Journal of Aging and Health, 29(2), 233-245.
Gitlin, L. N., Schinfeld, S., Winter, L., Corcoran, M., Boyce, A., & Hauck, W. W. (2002). Evaluating home environments of persons with dementia: Interrater reliability and validity of the Home Environmental Assessment Protocol (HEAP). Disability and Rehabilitation, 24(1-3), 59-71. https://doi.org/10.1080/09638280110085753
National Institutes of Health. (2011). The role of the occupational therapist in the management of Alzheimer’s disease and dementia. NIH News in Health, 6(4).
Struckmeyer, L. R. (2019). Aging in place with dementia: A single case study. Journal of Psychiatry and Cognitive Behavior, 3(1), 1-8. https://doi.org/10.29011/2574-7762.000054
Struckmeyer, L. R., & Pickens, N. D. (2016). Home modifications for people with Alzheimer’s disease: A scoping review. American Journal of Occupational Therapy, 70(1), 7001270020p1-9. https://doi.org/10.5014/ajot.2015.016089
Struckmeyer, L. R., Morgan Daniel, J., Ahrentzen, S., & Ellison, C. (2021). Home modification assessments for accessibility and aesthetics: A rapid review. Journal of Interior Design, 46(2), 43-60.
Struckmeyer, L. R., Pickens, N. D., Mulligan, S., & DiGangi, B. (2020). Home Environmental Assessment Protocol-Revised initial psychometrics: A pilot study. OTJR: Occupation, Participation and Health, 40(2), 90-97. https://doi.org/10.1177/1539449220912186
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