Modification makes the home environment accessible, usable, safe, and secure. Home modifications are intended to maximize independence in the home as well as outside the home to improve the accessibility and safety of the home. When thinking about adapting a home to a person's special needs, it is important to consider all areas of the home, both inside and outside.

IMPROVEMENTS ON THE INSIDE

One of the first areas in the home that people need modifications in, besides for mobility and general ambulation, is the bathroom. The bathroom presents a great risk for falls, and there also are barriers to accessibility. People often have trouble getting in and out of the tub or on and off the toilet. Easily installed aids that can reduce difficulty in the bathroom include raised toilet seats, tub chairs, grab bars, handheld showers, and toilet rails.

Solutions for bathtubs and showers are to install grab bars on the wall that supports the faucet and on the rear wall to improve safety. Generally, a short bar (12 inches) vertical on the wall as you enter the tub or shower and a right angle grab bar on a far wall are recommended. Shower/bath chairs inside the bathing area also are recommended to reduce fatigue.

Getting in and out of the bathtub poses a big challenge for some people. One solution is to use a transfer bench, which is positioned to have one leg outside the tub and the other inside the tub. The person first sits on the bench outside the tub and then carefully swings each leg over into the tub. Then, grab bars can be used to lower oneself to the desired level to reach the water.

Standing up from the toilet is also a challenging task to a person with ambulatory constraints. Increasing the seat to floor height of the toilet can markedly improve the ability to get up and down from the toilet. For wheelchair users, the height of the toilet should equal that of the wheelchair to allow for a level lateral transfer. The more traditional raised toilet seats have a variety of options, including armrests, adjustable height, and different seat surfaces.

Modifications in the kitchen should focus on accessibility and space. Ample clearance in front of appliances is one of the most important considerations for people using wheelchairs. The height of cabinets and counters should be individualized according to the needs of the person. Lever-type faucet handles can be used if hand function is impaired.

OUTDOOR OPTIONS

As mobility becomes increasingly limited, the structure of the home may be modified, including widening doors, adding entrance ramps, or even removing walls.

Easy access to the home is an important concern. Most homes have a set of steps leading up to a porch, deck, or landing at the door. These steps can become obstacles for persons who are frail; have problems with balance or vision; or use wheelchairs, walkers, or canes. Solutions include installing a sloping walkway, ramp, outside lift, or door openers; and providing handrails on both sides of steps.

There are additional recommendations for wheelchair/scooter users. For example, there should be at least 2 inches of clearance on each side of the chair going through doorways. Door-width space can be gained by changing the direction that a door swings open, using a reverse hinge to mount the door, or having a carpenter widen the doorway.

Additional tips for doorway improvements include:

• Make sure the doorway is wide enough. A good rule of thumb is to create a doorway that provides 32 inches of clear space. This also will accommodate wheelchair users.
• Use lever handles for your doors to eliminate the need to twist to grab the doorknob. With lever handles, simply pressing down on the flat surface of these handles opens the door.
• Install a remote-controlled door opener that opens and closes a door automatically. Open Sesame, San Leandro, Calif, offers remote-controlled systems, which can be mounted on wheelchairs, that opens, unlocks, locks, and closes doors.
• Leave an open space just inside and outside of your front door. The area should measure at least 5 feet x 5 feet. This space is useful to people who use a cane, walker, or wheelchair. It gives them plenty of room to move up to and through the front door. Leave 2 feet of open floor space on the side of the door where the lock and lever handle are. That way, someone in a wheelchair can reach the door handle.
• Build an overhang above the door. Once you are out of the rain or snow, you can take your time opening the door. A roof also keeps ice and snow from building up outside the front door.
• Build an outside shelf near the door. Put your packages on the shelf before you start fishing for your keys.

In addition to modifications to doorways, increasing accessibility in approaching the house is also important. Ramps offer an optimal solution. Ramps aren't just for wheelchairs anymore—anyone who uses a walker, uses a cane, or has balance issues can benefit from using a ramp instead of climbing stairs.

Ramps are made from a variety of materials, including wood, concrete, asphalt, or metal. "Straight-shot" ramps make no turns. "L-shaped" ramps make a 90º turn. "Switchback" ramps make a 180º turn. AlumiRamp, Quincy, Mich, offers four lines of aluminum modular ramp systems that can be configured to fit different locations as needed, as well as a full line of portable mini ramps.

It is important to construct a ramp with a gentle slope. The higher your ramp is, the longer it needs to be. It is recommended that the ratio for an external ramp be 20 inches of length for every 1 inch of height.

Landings are an important part of every ramp. Ideally, there should be a landing every time the ramp changes direction. Recommended dimensions for landings are 60 inches long and 60 inches wide—landings should be at least as wide as the ramp. There should be one landing at the top of the ramp and one at the bottom. The top landing will keep a person from rolling or falling backward when the door to the house is opened. The bottom landing will let the person move safely from the ramp to level ground.

Keep in mind that you'll use a ramp in all kinds of weather—sun, rain, and snow. Make sure it is safe no matter what the season.

The following ramp accessories can add to the safety of the ramp:

• Mount guardrails along the side of the ramp. Put them about 18 inches from the ramp floor. This rail will help keep people and wheelchairs safely on the ramp.
• Install edging along the floor of the ramp so no one will slide off. The edging should be 2 inches high.
• Put handrails on both sides of the ramp. Handrails should extend at least 12 inches beyond the ramp at both ends. Handi-Ramp®, Libertyville, Ill, offers handrails and railing systems that can be purchased separately or in conjunction with the company's aluminum, galvanized steel, and concrete ramps for outside the house.

When making any of these modifications to the home, it is important to keep in mind that the needs of the person evolve over time. A thorough evaluation of the patient's current lifestyle and future expectations are necessary to make changes that improve accessibility in the present, as well as allow for additional alterations in the future.

Michelle Clark, OTR/L, is an occupational therapist at Pinnacle Physical Therapy in San Antonio. For more information, contact .