Improving home modification evaluation practice: stakeholder perspectives on important home modification outcomes within the Australian context

Abstract

BackgroundHome modifications are a commonly provided intervention to address environmental barriers in the home. In Australia, modifications are delivered by aged care and disability services, which have undergone reforms in the last decade emphasising consumer-directed care. Older people and people with a disability now have more choice and control over what services they receive and who provides these services in their home. The services that provide home modifications in these systems aim to achieve person-centred practice and are required to demonstrate that they are enhancing person-centred outcomes. However, outcomes are rarely evaluated in practice and, if evaluations are done, the approach is often inconsistent or lacking a formal or standardised process and measures. Consequently, the quality, consistency and adequacy of services to meet the needs of consumers remains unclear. While there is a growing body of literature examining home modification outcomes, there is a paucity of research exploring consumer’s perspectives of important home modification outcomes, and outcome measurement tools, which limits person-centred home modification evaluation practice.Given the consumer-directed care focus of the aged and disability sectors and the need for providers to demonstrate person-centred outcomes, an important first step in developing person-centred practice for outcome evaluation is to understand consumer perspectives on outcomes of importance. This information can guide the selection of appropriate tools for evaluation practice. Along with consumer perspectives, service provider perspectives on important home modification outcomes are also important, to understand whether current practice aligns with consumers’ perspectives and the aged and disability care sectors’ focus on person-centred outcomes.Aims This research had two main aims:1) To understand the perspectives of older people and people with a disability on their valued outcomes of home modifications. 2) To understand the perspectives of occupational therapists and managers of home modification services on important home modification outcomes for older people and people with a disability.MethodThe thesis involved two qualitative studies to address the research aims. An interpretive description approach was used to examine important home modification outcomes from the perspectives of older people and people with a disability who had received major home modifications (Study 1), and occupational therapists and managers of services providing home modifications (Study 2) in Queensland, Australia. In the first study, 20 older people and people with a disability aged 24–93 years of age were individually interviewed. The second study involved six managers who were individually interviewed and nine therapists who attended one of two focus groups. Thematic analysis was used to theme the data gained from all interviews and focus groups.Results Two major themes emerged in the findings from the first study on the views of older people and people with a disability of important home modification outcomes: (1) life before and during modifications – “it was all hard”, and (2) life after modifications – “to have a life”. Peoples’ prior experience of home, the circumstance relating to needing modifications, the time required to plan the modifications, the perceived value of the modifications, and the home modification process and funding influenced perceptions of outcomes. Valued home modification outcomes included those that enable people to experience emotional and physical health and safety, to do what they want, to maintain the image of the home, and to plan for the future. The findings indicate that the important home modification outcomes reported are not separate and distinct from one another but overlap, each influencing the other, reflecting participants’ complex experience of their major home modifications.In the second study, five themes emerged describing occupational therapy and manager views of important home modification outcomes. These were: (1) providing people with independence and freedom, and supporting care; (2) allowing people to be safe and healthy; (3) allowing people to remain at home; (4) being included in all aspects of home and community life; and (5) maintaining the look, condition, and value of the home. Themes (1), (2) and (3) reflect the more important outcomes described by participants. Themes (4) and (5) were not described as often or as highly valued.Clients, occupational therapists and managers differed, in part, in their perceptions of important home modification outcomes. Modification outcomes most valued by therapists and managers were not expressed with the same depth or emphasis as clients’ views. The breadth and depth of responses relating to the importance of outcomes differed between less experienced and more experienced therapists and managers, with more experienced therapists and managers discussing a broader range of outcomes. External factors such as funding and service delivery requirements influenced their views.Conclusion This research examined a range of stakeholders’ perspectives to understand which outcomes of home modifications they view as most important. The findings provide important information to inform home modification service providers and policymakers about the outcomes of importance to consumers that should be utilised in person-centred evaluation practice. ​​​​​​​