Why clients say no!

What Your Clients Are Really Telling You About Home Safety Assessments

Before You Read: Have We Been Here Before?

We have previously addressed the issue of clients following through on recommendations made by occupational therapists as part of a home assessment. (https://thehomeaccessibilitytherapist.blog/?s=adherence) This post takes a different, and arguably more fundamental, angle: Why do clients refuse the assessment in the first place? A 2025 qualitative study by Lee and colleagues in JMIR Human Factors goes upstream — looking at the emotional, aesthetic, and logistical barriers that prevent older adults from ever getting to the point where adherence is even possible. The territory is related, but the lens is new. Where the adherence blog asks “How do we get clients to install the grab bar?” this one asks “Why won’t they let us through the door?”

The Problem Is Bigger Than We Think

Falls remain the leading cause of injury-related death among adults aged 65 and older, with the age-adjusted fall death rate increasing 21% between 2018 and 2024 — reaching 78.4 deaths per 100,000 older adults. Emergency departments record nearly 3 million visits for older adults due to falls annually. The financial burden is staggering: fatal and nonfatal falls cost an estimated $80 billion in 2020, the bulk paid for by Medicare (CDC, 2026; Lee et al., 2025).

Home safety assessments conducted by occupational therapists are one of the most powerful tools in the prevention arsenal — reducing fall risk by up to 36% and decreasing serious injuries, including hip fractures. A landmark randomized controlled trial involving 842 households demonstrated a 26% decrease in fall injuries through a standardized home modification package. Yet despite this compelling evidence, adoption of home safety assessments remains stubbornly low. Some insurers have even discontinued home safety assessment benefits due to underuse by older adult policyholders — a troubling feedback loop where low demand erodes coverage, further shrinking access (Lee et al., 2025).

The mismatch between what the evidence says and what clients actually do is where Lee et al.’s 2025 study begins.

About the Research: A Human-Centered Design Approach

This explanatory qualitative study by Lee et al. (2025), conducted in the San Francisco Bay Area between February and June 2021, used the “inspiration” phase of human-centered design (HCD) — a methodology rooted in engineering, psychology, anthropology, and design that involves stakeholders in identifying barriers and generating solutions.

Who Was Interviewed (n=28):

3 community-dwelling older adults
4 geriatricians
6 therapists (physical, occupational, and mental health)
2 product managers
8 researchers in older adult health
5 leaders of older adult care programs/communities

Method: Semi-structured interviews (30–60 minutes each), analyzed through reflexive thematic analysis. Seven follow-up interviews were also conducted. Interview notes — rather than full transcripts — were analyzed to protect participant confidentiality.

Three key insight statements emerged from the analysis, each paired with a “design opportunity” — an actionable direction for solution development.

The Three Insights: What Your Clients Are Really Experiencing

Insight 1: Home Modifications Threaten Identity, Not Just Comfort

The first insight reframes what OTs often interpret as simple resistance. Older adults in this study weren’t just being stubborn about grab bars — they were protecting a deeply held sense of who they are. One participant described an all-consuming fear of falling after her first fall, with “a repeating mantra in my head throughout the day saying ‘above all, don’t fall.’” Yet paradoxically, this same fear didn’t translate into accepting help. A geriatrician in the study observed that “patients are reminded of their mortality when an occupational therapist comes to the home to visit” (Lee et al., 2025).

This fear of aging — not the fear of falling — is the barrier. One older adult who had grab bars placed throughout her home linked their gray, institutional appearance directly to a hospital stay she associated with trauma. She hadn’t rejected safety; she had rejected what the safety solution represented. This aligns with broader research showing that 62% of older adults have a deep emotional attachment to their home and 83% report feeling safer there than anywhere else, which means that any modification perceived as hospitalizing that space triggers powerful psychological resistance (Landgraf, 2024, Lee et al., 2025).

The design opportunity identified: Return a sense of control and autonomy. This means active participation in the redesign process, customizable solutions (e.g., wood-finished grab bars instead of chrome), positive framing that emphasizes enhanced independence rather than decline, and fostering a “growth mindset” toward aging.

Practice implication: Before recommending a single modification, ask the client: “What does your home mean to you?” and “What would make this feel like yours rather than a hospital room?” Aesthetic co-design is not a luxury — it is a clinical strategy.

Insight 2: Privacy and Dignity Override Safety Logic

The second insight surfaced something that may be uncomfortable for clinicians to hear: older adults are often fully aware of their fall risk, have been told by family members to make changes, and have consciously chosen not to. One interviewee noted: “My kids have been telling me for months to install a grab bar in my shower, but I just don’t like the way it looks in my home.” Another described their home as a “personal haven” — a refuge from the preferences of others (Lee et al., 2025).

A fall prevention center leader in the study was blunt: “They don’t want to change, and this term [home modifications] isn’t enough to conquer their fear of change.” (Lee et al., 2025). This resistance persisted even after a first fall had occurred, suggesting that the emotional stakes of a home visit — privacy invasion, loss of control, confrontation with aging — can outweigh even the lived experience of a fall.

Research on older adults and autonomy consistently supports this: exclusion from decision-making increases resistance to modifications, while involving older adults in these decisions reduces emotional distress and increases acceptance. Personalized care approaches that prioritize individual preferences significantly improve intervention acceptance and perceived autonomy (Lee et al., 2025).

The design opportunity identified: Reframe the assessment itself. Rather than a “home safety assessment,” consider framing the process as designing a “forever home” — a personalized space that supports the life the client wants to live. Connect clients with trusted contractors for both safety and preferred renovations together. Provide educational resources about aging that address dignity, not just risk (Lee et al., 2025).

Practice implication: The language of “safety” may actually be counterproductive for certain clients. Pilot terminology like “home optimization,” “designing your independence,” or “home aging audit” and gauge the response. The content of the assessment doesn’t change — but its emotional framing does.

Insight 3: Access Is the Invisible Barrier

The third insight shifts from psychology to infrastructure. The study documented a significant and growing mismatch between supply and demand for occupational therapy home safety services — a gap exacerbated, but not caused, by the COVID-19 pandemic. Rural OT coverage was already sparse before the pandemic: one interviewee described a home assessment requiring “an occupational therapist on a 2-hour commute each way to see this person, which can take up the majority of their day just assessing one home.” (Lee et al., 2025)

When the pandemic hit, community organizations halted in-person assessments with no clear alternative. Ashby Village in California — a community-based organization using trained volunteers — suspended home assessments in March 2020 and had no resumption plan at the time of the 2022 interview. Even after restrictions lifted, older adult hesitation about strangers in their homes remained. One participant put it plainly: “If I can’t even feel safe inviting family into my home, why would I invite a complete stranger in?” (Lee et al., 2025).

This intersects with technology. The pandemic accelerated exploration of remote assessment alternatives, and research supports telehealth home safety assessments as both feasible and valid. The PATH (Protocol for Administering Telehealth Home Safety Assessments) protocol has demonstrated validity as a structured approach to synchronous telehealth home assessments, increasing access to underserved individuals while addressing rising healthcare costs and practitioner shortages. An earlier blog has explored how virtual assessments are reshaping the OT role — particularly through the expanded participation of family caregivers in the remote assessment process (thehomeaccessibilitytherapist, 2025; McBride et al., 2023).

The design opportunity identified: Technology-enabled access — online photo submission tools reviewed by licensed OTs, computer vision for automated hazard detection, and personalized recommendations based on demographic data and design preferences (Lee et al., 2025).

Practice implication: Advocate actively for telehealth reimbursement parity and develop structured protocols for remote assessments in your practice. The barrier for rural and underserved clients is not clinical competence — it is access infrastructure.

Strengths and Limitations: Reading This Study Critically

OTs are evidence-based practitioners, which means approaching research with both appreciation and appropriate scrutiny.

Strengths:

The HCD methodology is well-suited to identifying nuanced, emotionally layered barriers that survey data would miss
Multi-stakeholder sampling (older adults, clinicians, researchers, program leaders) provides a richer picture than single-population studies
The study’s three-step thematic analysis included consensus-building and peer debriefing to reduce individual researcher bias
Published in JMIR Human Factors (2025) — peer-reviewed and open access

Limitations:

Only 3 of 28 participants were older adults themselves — the primary population of interest. This is the most significant limitation, acknowledged by the authors. Clinician and researcher perspectives, while valuable, are not the same as lived experience.
All participants were recruited from the San Francisco Bay Area, limiting generalizability. Attitudes toward aging, healthcare access, and technology adoption vary substantially across regions, cultures, and socioeconomic strata
Interview notes rather than full transcripts were analyzed, which may have missed subtle themes or nuances in participant responses
The study represents the inspiration phase only of the HCD process — design opportunities were generated by the research team, not co-created with older adults. These solutions require validation through participatory design before clinical implementation
The small sample makes it impossible to quantify the relative prevalence of each barrier — is aesthetic concern more common than privacy concern? The study cannot tell us

Bottom line: This study is best used as a hypothesis generator, not a clinical protocol. Its value is in expanding the clinical imagination — prompting OTs to ask different questions and listen differently. It should be read alongside quantitative literature and the practitioner’s own clinical experience.

From Research to Practice: Five Action Steps

Translating the Lee et al. findings into day-to-day practice doesn’t require a redesign of your assessment protocol. It requires a shift in how you enter a client’s space — literally and figuratively.

Lead with the client’s story, not the hazard list. Begin your assessment by asking about the client’s relationship to their home: memories associated with it, features they love, things they would never change. This data shapes every recommendation that follows — and signals respect before you ever identify a risk.
Offer aesthetic options at the point of recommendation. Carry product catalogs or phone photos showing grab bars in brushed nickel, matte black, or wood finish. Show non-slip flooring that looks like hardwood. Normalize the idea that safety products can be designed, not just installed.
Reframe the purpose of the visit. Experiment with your intake language. Instead of “home safety evaluation,” try “home independence consultation” or “home optimization visit.” Subtle language shifts can reduce the psychological defensiveness that limits engagement.
Develop a remote assessment option. Whether or not telehealth reimbursement is available in your current setting, building a structured video-based protocol expands your reach and provides a lower-barrier entry point for clients resistant to in-person visits.
Bring clients into the design process. Present two or three modification options with tradeoffs (cost, aesthetics, effectiveness) rather than a single “correct” answer. Decision-making agency is not a nicety — it is a documented facilitator of adherence and a clinical tool for overcoming the independence-safety conflict this study describes (thehomeaccessibilitytherapist, 2024; Lee et al., 2025).

The Bigger Picture

There is a quiet crisis embedded in the data: OTs are providing evidence-based services that reduce fall risk by up to 36%, and older adults are declining them. The CDC reports that falls kill more than 38,000 older adults annually and the death rate is still rising. AARP’s 2024 survey found that 75% of adults over 50 want to remain in their homes — yet only 10% of U.S. homes have the accessibility features needed to support that goal (Binette, 2025; Lee et al., 2025; CDC, 2026; Vespa et al., 2020).

This gap is not primarily a clinical problem. It is a design, communication, and trust problem. Lee et al.’s study, limited as it is in scope, identifies the terrain. The occupational therapy profession — with its foundational emphasis on client-centered care, occupation-based reasoning, and environmental analysis — is uniquely positioned to close it. Not by doing better assessments, but by doing assessments differently.

The checklist matters. But what happens before the clipboard comes out matters more.

References

Binette, J., (2025). Building for the future: Creating homes and communities for aging well. 2024 home and community preferences survey. https://www.aarp.org/research/topics/community/info-2024/home-community-preferences.html

Centers for Disease Control and Prevention (CDC). (2026). Older adult falls data. https://www.cdc.gov/falls/data-research/index.html

Cumming, R. G., Thomas, M., Szonyi, G., et al. (1999). Home visits by an occupational therapist for assessment and modification of environmental hazards: A randomized trial of falls prevention. Journal of the American Geriatrics Society, 47(12), 1397–1402. https://doi.org/10.1111/j.1532-5415.1999.tb01556.x

Florence, C. S., Bergen, G., Atherly, A., et al. (2018). Medical costs of fatal and nonfatal falls in older adults. Journal of the American Geriatrics Society, 66(4), 693–698. https://doi.org/10.1111/jgs.15304

Gillespie, L. D., Robertson, M. C., Gillespie, W. J., et al. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2012(9), CD007146. https://doi.org/10.1002/14651858.CD007146.pub3

Haddad, Y. K., Miller, G. F., Kakara, R., et al. (2024). Healthcare spending for non-fatal falls among older adults, USA. Injury Prevention, 30(4), 272–276. https://doi.org/10.1136/ip-2023-045023

Keall, M. D., Pierse, N., Howden-Chapman, P., et al. (2015). Home modifications to reduce injuries from falls in the Home Injury Prevention Intervention (HIPI) study: A cluster-randomised controlled trial. Lancet, 385(9964), 231–238. https://doi.org/10.1016/S0140-6736(14)61006-0

Landgraf, B. (2024, February 7th). Aging in Place Statistics. Carex Blogs. Retrieved from: https://carex.com/blogs/resources/aging-in-place-statistics

Lee, J. J., Patel, D., Gadgil, M., Langness, S., von Hippel, C. D., & Sammann, A. (2025). Understanding barriers to home safety assessment adoption in older adults: Qualitative human-centered design study. JMIR Human Factors, 12, e66854. https://doi.org/10.2196/66854

McBride, C., Story, S., & Cason, J. (2023). Development and Validation of the Protocol for Administering Telehealth Home (PATH) Assessments. International journal of telerehabilitation, 15(1), e6545. https://doi.org/10.5195/ijt.2023.6545

Romero, S., Lee, M. J., Simic, I., et al. (2018). Development and validation of a remote home safety protocol. Disability and Rehabilitation: Assistive Technology, 13(2), 166–172. https://doi.org/10.1080/17483107.2017.1300345

The Home Accessibility Therapist. (2024, November 24). Improving adherence to occupational therapy home modifications [Blog post]. https://thehomeaccessibilitytherapist.blog/?s=adherence

The Home Accessibility Therapist. (2025, July 24). Family engagement in virtual home assessments: Expanding roles for occupational therapists [Blog post]. https://thehomeaccessibilitytherapist.blog/2025/07/24/family-engagement-in-virtual-home-assessments-expanding-roles-for-occupational-therapists/

Vespa, J., Engelberg, J., & He, W. (2020) Old Housing, New Needs: Are
U.S. Homes Ready for an Aging Population? U.S. Census Bureau,
U.S. Government Printing Office, Washington, DC. Retrieved from: https://www.census.gov/content/dam/Census/library/publications/2020/demo/p23-217.pdf