This month we meet the winners from the National Healthy Housing Awards.
DFG Return on Investment
There is a growing evidence based for the continued investment in home adaptations and the disabled facilities grants.
This page pulls together some of the key reports, both from the UK and from around the world.
If you think there’s anything we have missed, please get in touch.
The Social Value of aids and adaptations
A report commissioned by Foundations Independent Living Trust sets out the social value of home adaptations.
This research explores the stories of the people helped by Home Improvement Agencies to find, fund, and use adaptations to their homes. Enabling them to stay in the homes they love, in the areas and near to the people they know is hugely valuable at human level. However it is all the more essential when accessible properties are not being constructed quickly enough to meet the needs of a growing older and disabled population, nor is it economically sensible to construct afresh when needs can be met at lower cost in the houses which are already built and occupied.
Those stories show five key needs being met, time and time again. Through these we see families, couples and individuals maintaining their independence and mobility, finding new solutions for everyday living that make tasks around the house simpler and less of a burden. In some cases we can see significant changes in life course: a downward spiral of incapacity turned around, or a debilitating accident, otherwise just a matter of time before it happened, now avoided.
Those changes, little or great, are experienced by people at five levels. They are given knowledge and information about how to adapt their homes, and their ways of living, to make them more comfortable and suited to their needs. They are guided to the financial assistance necessary to fund the adaptations, or are helped to find cost-effective solutions if they are not eligible for grant support. They see improvements in mobility, wider physical health and wellbeing. These all have a significant effect on independence and self-respect, and enable people to maintain greater degrees of purpose and identity. Last but not least, they find themselves less fearful, less isolated, and feel safer.
The financial benefits emerge from our exploration of blended case studies presented as four personas with their individual storylines. Even with an evaluation of just some of the cost benefits, and a restriction of the evaluation period to one over which outcomes can be reasonably predicted, cost benefits are felt which all show strong improvements. Some of these are enjoyed by the person themselves, but many fall to the public services that support them should their needs escalate.
Whichever way you look at it, home adaptations bring real value.
Listen to their stories
Foundations Study: Linking DFG and Social Care Data
A Freedom of Information Request was issued to all local authorities with responsibilities for Social Care in August 2015. The intention was to discover:
- whether local authorities can link the data collected by their respective housing and social care departments;
- how many people who apply for a DFG also receive domiciliary care; and
- what impact a DFG funded adaptation may have on the age that people are admitted into residential care and how long they stay there.
The text of Freedom of Information Request is included at Appendix A of this report. It was submitted to all 152 local authorities in England with responsibility for Social Services.
As of 9 October 2015, 133 responses had been received. The breakdown is summarised in the table below:
For those authorities who could not complete the exercise the reason given in the vast majority of cases is that social care records are kept on a separate system to DFG applications and there is no easy way of linking the two datasets. In these cases it appears that social care departments do not generally record assessments carried out by Occupational Therapists in a structured manner within social care records; indeed many responses referred to paper based record keeping. This will make it extremely difficult for local authorities to monitor the outcomes of DFG as part of the Better Care Fund.
The majority of the fully completed returns were from single tier authorities, however this only equates to 12% of all single tier authorities. Full returns were made by 11% of County Councils.
One of the stated requirements of the BCF is data sharing between Health and Social Care based on the use of NHS Number, it would seem logical to extend this to Housing and DFGs in particular.
Recommendation 1: The NHS Number is recorded for all DFG Applications.
DFG and Home Care
The DFG funds home adaptations for people with disabilities, so it may be assumed that most applicants also receive domiciliary or home care services from the local authority. However, this survey found that only 16% of people applying for a DFG also received domiciliary care.
For those in receipt of domiciliary care, the survey showed a slight fall in the number of hours they needed one year after the DFG work had been completed – falling from an average of 15.7 to 14.7 hours per week. While this research shows a weak correlation between DFG funding and formal domiciliary care, it may be the informal carers that actually benefit from investment in adaptations. For instance, a level access shower may allow a disabled person to shower unaided where previously a carer had shoulder and back pain from lifting them into a bath.
According to the Office for National Statistics unpaid carers for the sick, disabled and increasingly elderly in England and Wales had grown by 600,000 since 2001 to reach approximately 5.8 million in 2011. With The Care Act 20142 “putting carers on an equal legal footing to those they care for and putting their needs at the centre of the legislation” it will be important to better understand the benefit of adaptations for carers.
Recommendation 2: Research is undertaken to understand the benefit of adaptations for informal carers.
DFG and Residential Care
This survey asked local authorities to return the average age of people who had been placed in residential or nursing care according to whether or not they had previously received a DFG, and the average age at which they died. The results are summarised in the table below:
|Average Age||Had a DFG||Not had a DFG|
|Moved into residential or nursing care||80||76|
For people who have had to move into residential care, those who had previously received a DFG on average moved just before their 80th birthday and stayed there for 2 years. Those people who hadn’t applied for a DFG moved when they were 76 and stayed in residential care for another 6 years.
With a residential care place costing around £29,000 per year, compared to an average DFG costing less than £7,000 as a one-off, this research highlights the major impact that adaptations can have for social care budgets as part of the Better Care Fund. With over £1.4bn spent on DFGs over the last five years it could also go some way to explaining why the number of care homes reduced for the first time ever in 2014.
Further research will be required to validate these results, but the indications are that adaptations should be fully considered as part of a preventative strategy alongside extra care housing, reablement or telecare services.
Recommendation 3: Adaptations are key part of a wider preventative strategies alongside extra care housing, reablement and telecare services.
- 1A. Over the last 5 years what percentage of people that your social services department referred (or were consulted upon) for a Disabled Facilities Grant were in receipt of a domiciliary care package at the point of referral?
- 1B. For those people in receipt of a domiciliary care package – what was the average number of hours of care at the point of referral? hours
- 1C. For those people in receipt of a domiciliary care package – what was the average number of hours of care one year after the Disabled Facilities Grant had been completed? hours
- 2. Over the last 5 years what has was the average age of people placed in residential or nursing care for:
- 2A. People who had previously received a Disabled Facilities Grant years
- 2B. People with has NOT previously received a Disabled Facilities Grant years
- 3. Over the last 5 years what has was the average age of people who died in residential or nursing care for:
- 3A. People who had previously received a Disabled Facilities Grant years
- 3B. People with has NOT previously received a Disabled Facilities Grant
UK Based Evidence
This section features research projects and evidence on the cost effectiveness of home adaptations from the UK.
Bathing adaptations in the homes of older adults (BATH-OUT)
Northumbria University, 2018.
Housing adaptations have been identified as an important environmental and prevention intervention for older adults, which may improve health and quality of life. The onset of disability in bathing can act as a warning for further disability in other activities and may therefore be a judicious time-point for intervention. The aim of this study was to determine the feasibility of conducting a Randomised Controlled Trial (RCT) of bathing adaptations, to evaluate whether they improve older adults’ perceived health status and quality of life, prevent further functional deterioration, and reduce the use of other health and social care resources. This study was conducted in preparation for a powered RCT.
This is the first RCT of housing adaptations in the UK. We demonstrated the feasibility of using a waiting list control, subject to minor alterations to the timescales for privately owned properties. A powered trial would evaluate the impact on older adults’ quality of life and investigate the impact of waiting times on functional outcomes and health and care resource use.
The cost-benefit to the NHS
arising from preventative
In 2014 a ‘Bletchley Day’ workshop organised by Care & Repair England, was tasked with considering ways to demonstrate the investment value of home adaptations and modifications through the production of better evidence. Previous health cost benefit assessments of home adaptations have largely examined these for individual household scenarios. BRE Trust agreed to fund the research, which attempts to model the cost-benefit of some common preventative home interventions on a larger scale using national data sources. It is important to stress from the outset that this research was not designed to demonstrate the economic benefits to the state of Disabled Facilities Grants (DFGs) at the national level.
Unlike previous research into home adaptations, the main aim of this BRE research project was to consider the cost-benefits of preventative home interventions by reducing the need for NHS treatment and reducing the subsequent need for reactive home adaptations in as many cases as possible. The NHS treatment and adaptations relate to households with known health problems and who are living in homes with serious hazards assessed through the Housing Health and Safety Rating System (HHSRS). This reduction in the need for home adaptations that result from a preventable health problem allows the DFG budget to provide help to those households where preventative action is not applicable. The cost-benefits of DFG-funded adaptations to the NHS and social care, particularly when compared to the cost of residential care (highlighted in the literature review in the Appendix) continue wherever such adaptations are carried out.
The role of home adaptations in improving later life
Centre for Ageing Better, 2017
Living in a suitable home is crucially important to a good later life. Good housing and age friendly environments help people to stay warm, safe and healthy, close to those who make up their social circle, and enable them to do the things that are important to them.
The majority of older people in England live in mainstream housing, but that housing often has small room sizes, steep internal stairs, baths rather than showers and steps outside. As people get older these become increasingly difficult to manage, with increasing long-term conditions and disabilities impacting on day-to-day activities within the home. Very little attractive, affordable housing has been built in the right locations to enable people to move to properties that are more accessible.
Adapting the home can increase the usability of the home environment and enable the majority of people to maintain their independence for as long as possible. This could potentially reduce the risk of falls and other accidents, relieve pressures on accident and emergency services, speed hospital discharge and reduce the need for residential care.
Better Outcomes, Lower Costs
Office for Disability Issues, 2007.
With the current demographic changes in society, any policy with the power to reduce the costs of health and social care for older and disabled people and enable resources to serve more people must be of interest to Government. If the policy also produces improved quality of life outcomes, it will be all the more welcome.
The Audit Commission and other bodies have asserted that increased investment in housing adaptations and equipment would bring significant savings to the National Health Service and to social services budgets, but funding and structures, compounded by the lack of clear evidence, have created barriers to such investment.
To tackle one part of this problem, this report has gathered the evidence together through a search of the international literature, in the disciplines of medicine, housing studies, ageing studies, economics, health-economics and occupational therapy, and through use of case studies from the grey literature.
The evidence is not complete, and more work is needed to disaggregate the ‘multi-factorial interventions’ that are known to be effective but not fully understood. Despite this, there are already findings that the provision of housing adaptations and equipment for disabled people produce savings to health and social care budgets in four major ways.
Disabled Children and the Cost Effectiveness of Home Adaptations & Disabled Facilities Grant
School of Law Leeds University and Cerebra June. 2017.
English Housing Survey – Home adaptations report.
The Ministry of Housing, Communities and
Local Government, 2019-20.
The English Housing Survey (EHS) is a national survey of people’s housing circumstances and the condition and energy efficiency of housing in England. It is one of the longest standing government surveys and was first run in 1967. This report provides the findings from the 2019-20 survey on home adaptations.
Home adaptations, which can range from simple grab rails and ramps to accessible shower rooms and stair lifts, can make homes safer and promote independent living for the people who require them.
Chapter 1 of this report investigates the circumstances of households that had a person/s with a long-standing physical or mental health condition that required them to need adaptations in their home. It examines whether these households had the adaptations they required and whether their home was suitable for their needs. Chapter 2 describes the types of adaptations needed inside and outside the home. Chapter 3 looks at those households that did not have the adaptations they needed. The fourth and final chapter explores the characteristics of households that wanted to move to more suitable accommodation.
Home modifications and disability outcomes: A longitudinal study of older adults living in England
School of Social Sciences, University of Manchester. 2022.
This section features research projects and evidence on the cost effectiveness of home modifications from across the world.
How Home Modifications Reduce Care Needs of Older People and People with Disability
University of Technology Sydney, 2019.
The extent to which housing design can minimise levels of community caregiving has remained largely unmeasured. This paper reports the potential for home modifications to reduce caregiving in the peoples’ homes, particularly older people and people with a disability. It contributes to new knowledge in understanding how housing can play a role in community caregiving and acknowledges the role of the built environment in managing care levels in ageing societies.
This paper analyses self-reported care data from 157 Australian community care recipients (average age: 72 years) who had received home modifications within the past 6 months. A before/after comparison of care provided revealed that home modifications reduced hours of care provided by 42% per week. More detailed analysis revealed that the positive association of home modifications with care reduction is stronger with informal care (46% reduction) followed by formal care (16% reduction). These results suggest the role that home modifications, and housing design in general, play in reducing care needs in a community setting.
Cost Effectiveness of a Home-Based Intervention That Helps
Functionally Vulnerable Older Adults Age in Place at Home
Journal of Ageing Research, 2012.
Evaluating cost effectiveness of interventions for aging in place is essential for adoption in service settings. We present the cost effectiveness of Advancing Better Living for Elders (ABLE), previously shown in a randomized trial to reduce functional difficulties and mortality in 319 community-dwelling elders. ABLE involved occupational and physical therapy sessions and home modifications to address client-identified functional difficulties, performance goals, and home safety.
Incremental cost-effectiveness ratio (ICER), expressed as additional cost to bring about one additional year of life, was calculated. Two models were then developed to account for potential cost differences in implementing ABLE. Probabilistic sensitivity analyses were conducted to account for variations in model parameters.
Home modifications to prevent home fall injuries in houses
with Māori occupants
Lancet Public Health, 2021.
As with many Indigenous populations internationally, Māori in New Zealand suffer health inequity. We aimed to assess the rate of fall injuries at home with and without home modifications in houses with Māori occupants.
We did a single-blind randomised controlled trial in the Wellington and Taranaki regions of New Zealand and enrolled owner-occupied households with at least one Māori occupant. Only households who stated they intended to live at that address for the subsequent 3 years were eligible for participation. We randomly assigned (1:1) households to either the intervention group, who received home modiﬁcations (handrails for outside steps and internal stairs, grab rails for bathrooms, outside lighting, repairs to window catches, high-visibility and slip-resistant edging for outside steps, fixing of lifted edges of carpets and mats, non-slip bath mats, and slip-resistant surfacing for outside areas such as decks) immediately, or the control group, who received the modifications 3 years later. Data on home injuries were obtained from the Accident Compensation Corporation and coded by study team members, who were masked to study group allocation. The primary outcome was the rate of medically treated fall injuries at home per household per year, analysed according to intention to treat.
Making it safe to age in place
At no (net) cost to the government
HomesRenewed Resource Center, 2022.
The existing quantity of housing dedicated for older adults is not sufficient to meet the needs of this growing population. And even as the Centers for Medicare and Medicaid Services reimbursement structures are shifting from traditional inpatient and outpatient settings to care in the home, it is a commonplace that most homes were not designed or built to support the needs of aging residents or the provision of healthcare. It is time for America’s 100 million existing houses to be made as safe and accessible as possible for aging in place. Falls cost over $50 billion a year in medical expenses. This paper distills current knowledge regarding healthcare cost reductions from home modifications, and then calculates the cost efficiency to society and to the federal government of providing government subsidies for home modifications for older adults at the ages of 50, 65 and 75. Cost sharing among insurers, government and the beneficiary is one way to achieve the positive social returns.