A Blueprint for Independence
How providers can customize their home access services to serve the unique needs of patients using mobility devices.
- By David Kopf
- May 01, 2014
As providers work to open doors on new revenue sources, one business opportunity that is looking increasingly attractive is home access. Providing home access lets providers leverage many of these existing patient and referral partner relationships, while providing a much-needed service that is free of Medicare interference.
Home access is attractive because it offers providers a migration path for building their business. HME businesses can start off by offering simple items related to their expertise, and then build from there. For instance, a provider serving senior patients could start by offering bath safety products, and then move into other areas of the home, such as the kitchen or stairs to provide additional solutions.
And, most importantly, there is considerable market potential for home access services. Multiple patient groups benefit from home access, and one of those groups in particular is mobility patients. Patients in wheelchairs and other mobility devices have home access needs that can differ greatly from the home access needs of, say, bariatric or senior patients.
The First Hurdle
The biggest home access barrier for mobility patients starts with the front door. They must have a method for entering a home, and when the front door is off the ground — as most front doors are — that means home access providers need to look at installing one of two solutions: a ramp, or a vertical platform lift.
Where ramp installations are concerned, there must be a foot of ramp for every inch of rise between the ground and the 5-foot-by-5-foot platform that is placed in front of the entryway the platform provides a level spot for the patient to open and close the door. That said, the landscape where the ramp will go needs to be assessed as well. If the ground slopes away from the house, then the ramp will actually need to be longer.
A patient’s mobility capabilities might be more compatible with one device or another. For instance, a manual wheelchair user might find having to roll up a gradually inclining 50-foot ramp a challenge. And, if the patient is a manual wheelchair user, regular landings must be factored into the ramp’s design so that the patient have the ability to rest if he or she gets tired going up the ramp. This is also a safety factor, as well, as landings help prevent the possibility of gravity taking over and a manual wheelchair user accidentally rolling down the ramp with no control.
Additionally aesthetics are an important consideration, as well. We are talking about a patient’s home, and he or she might not like how a large, aluminum ramp might look in the front yard. Similarly, a homeowners association might have rules governing the look and placement of home access devices, and obtaining approval for a ramp or VPL might be required. And, if the patient is renting, then the landlord will need to approve, as well.
Often deciding which one to use comes down to a question of space. The area must be large enough to accommodate a ramp if need be, and if there isn’t enough space, then a VPL might be the right choice.
“The biggest concern I always find is the having the room available,” says Rick Pearce, VPL sales manager for Mac’s Lift Gates Inc., which manufactures in vertical platform lifts for the home access market. “People just don’t have room for a ramp when you get into mobile homes and little tight communities.”
Installing a ramp can wind up taking up the entire carport, or not fitting at all Pearce says. That can lead to cutting corners, which is a concern.
“What happens is that [patients] get somebody who wants to help them out that builds a ramp that is not safe for anybody,” Pearce says. “They want to preserve a portion of their carport, so they don’t build to one foot of ramp for every inch of height.
“If you have someone in their 20s, who is very active, in a light chair, then they probably have the strength to navigate a ramp like that,” he continues. “But grandpa pushing grandma up that ramp could put a tremendous task upon them. When you don’t build that ramp to code to accommodate them, it’s just that more dangerous.”
Pearce says it is very common to see out-of-spec ramps designed at “completely unsafe” angles, particularly in mobile home parks.
“It’s a matter of practicality,” he explains. “They [patients] have to get in maybe once a month for a doctor’s visit, and it’s much more cost effective — in their mind it’s better to take that risk once a month and save money, but it’s really not.”
Getting a Lift
In situations where a ramp is not possible, installing a lift is the right option, but there is a choice that needs to be made: platform or a stairlift. Clearly, stairs leading into the home represent a challenge to mobility patients, and perhaps one of the simplest solutions is a stairlift. For patients that can transfer from their chair to a stairlift this can be a viable solution, and they can be installed both indoors and out.
“We have a lot of patients in mobility devices that can transfer; they can take one or two steps,” says Bill Page, product manager for the Accessibility Division of Bruno Independent Living Aids. “Then a stairlift is a good option.”
But if the patient cannot transfer and needs access while he or she remains in a mobility device, then the next product level would be a platform lift. These devices can travel vertical or along an inclined path, but the key is hat the patient stays in the mobility device and is carried by the platform.
For a vertical lift, all that’s needed is a four foot-by-four foot concrete pad for the foundation of the lift. This saves considerable space.
Inside the Home
Once inside the home, patients often still need to get from one floor to the next, says Dean Davis, president of Sheridan Surgical Inc., a full line DME provider in Buffalo, N.Y. that providers home access services. Here again, platform and stair lifts come into play, but it goes beyond that.
“Staircases are always a concern,” he says. “… Many times people might have their only bathing facility on the second floor.
“So for them to use their home, they need to either overcome the staircase, or possibly put on an expensive addition,” Davis continues. “People want to use their whole house, they way they always have.”
Just like getting inside the house, now the question is whether the patient can transfer in and out of a stairlift. Presuming her or she can’t, then it gets back to a question of an incline lift or a vertical lift. Incline lifts not only require the use of the stair but need room for a landing for the platform, both upstairs and down. That can be a space consideration, says Jim Quinly, general manager for Accessibility Products at Harmar.
“That platform has to clear the lower step and come flush with the ground level,” he explains. “Sometimes at the bottom of the stairs you don’t have enough room.”
In that case the strategy then becomes looking for a way to install a vertical platform lift within the home, Quinly says. That could be made possible via closets or corridors that line up between floors, or what is called a three-wall bump out. This is where an addition is made to the house to accommodate the stairlift; it’s almost like an elevator shaft.
Building Skills and Knowledge
Probably the first place to get training is through the manufacturers of the various pieces of home access equipment. Most offer — and sometimes require — training on the installation and maintenance of their products. That kind of knowledge can go a long way, according to Davis.
“All of our installation technicians are factory trained,” he says. “There is ongoing training with our senior installers, but it starts with the manufacturers’ training. … Furthermore, I prefer to have a sales person that is a former installer. The advantage to that is that the expectations being set are realistic. … They’re not going to make any claims that the installer cannot fulfill.”
“We highly recommend that all of our dealers and their technicians come to us and go to our school,” Quinly says. “We hold a technical training school on install and technical service every month.
“The other thing providers need to understand is the code,” he says. “There are things lift they can do, but that might not be applicable to the local code that has jurisdiction.”
This means providers might have to have proper license within their jurisdiction to install these devices. It depends on the area, so providers should look at state elevator code, and to reach out to whatever local authorities issue building permits to know what’s required.
And, in some cases such as Harmar, manufacturers will offer on-staff expertise that is familiar with various building codes to help guide providers.
Beyond equipment installation, other considerations such as electrical, remodeling and construction. This is where matters become a little trickier. Does the provider get a contractor’s license? Do they need electrical certification? All these questions start coming into play because building codes are involved.
Davis says for his company’s part, they call in the licensed sources to ensure all work is done correct.
“If it’s out of our scope, we will subcontract,” he says. “We will subcontract electricity; any type of hook-up that needs to be installed is installed by a licensed electrician. If we are in need of a concrete pad, we will subcontract the concrete pad.”
To find good partners, Quinly suggests getting in touch with the local Home Builders Association and the local Remodelers Council.
“That’s a great pool of subcontract labor; be it the electricians you’ll need, carpenters, finish, trim men, architects,” he says. “That’s a great way to network. … It also lets all the local subcontractors know that you’re a specialist in this kind of product that they can now go to when they have a customer.”
After factory training, there are education and certification options available to the industry. First off the VGM Group’s Accessible Home Improvement of America (AHIA; www.accesshomeamerica.com) offers a Certified Environmental Access Consultant (CEAC) certification, which demonstrates that holders of that certification are formally educated through a standardized curriculum and are credible providers of home access services.
CEAC certification proves that the provider understands the various home access options and services that are available; understandings their patients’ home access needs; and are aware of everything entailed in providing and installing those services and solutions. CEAC certification is available to other professions and specialists, such as independent living specialists, occupational therapists, physical therapists, remodeling contractors and builders, interior designers, engineers, rehabilitation specialists, case managers, public health nurses and assistive technology specialists. This creates a common level of skills and understanding.
And, of course, involvement in the AHIA and possessing CEAC credentials puts the provider in a nationwide network of professionals from various backgrounds providing home access and independent living services and providers to patients. This gives providers a deep pool of referral resources and potential partnerships, as well. So, with the CEAC credential, providers can show other professionals serving patients, such as claims adjusters, grant administrators, case managers, risk managers, health care professionals, federal and state social service directors, and professional organizations that they are qualified in helping a patient with their home access needs.
CEAC certification entails different levels. Levels one through five help consumers and other home access and health professionals more easily gauge a provider’s skill and knowledge level in home access and establish minimum standards for providers of this service. Most HME businesses that are providing access solutions such as portable ramps, bath safety products and aids to daily living would fall under a basic level one. Here’s a more
- Level 1 — Threshold and suitcase ramps, basic assistive transfer devices, bath safety, and multiple aids to daily living products.
- Level 2 — Designated to a provider who has obtained a CEAC designation and provides products requiring simple installation, such as simple portable ramps with handrails, standing poles, bedrails, portable patient lifts, trapezes, and bath and tub lifts. Included are all products that require operational training and simple technical instructions.
- Level 3 — Includes light remodeling requiring CEAC designation and the knowledge and capability to align with applicable local building codes and license requirements. Level 3 providers provide an assessment of need and provision of products and equipment. They are manufacturer trained for more complicated modular ramps, grab bars, and bridge lifts. This includes ramps with platforms and turns, grab bars, and handrails.
- Level 4 — Designates CEAC and CAPS certifications to comply with all applicable local building codes and license requirements. Providers will give the client an assessment and have obtained manufacturer training. Level 4 providers offer sales and installation of stair lifts, vertical platform lifts, and ceiling lifts. Also included are roll-in showers, walk-in tubs, vertical/incline platform lifts, and wall- and ceiling-mounted track lifts.
- Level 5 — Designates CEAC, CAPS, certified/licensed healthcare professional, licensed contractor or remodeler. Projects at this level are considered quite involved and a team approach is recommended. Level 5 providers comply with any applicable building codes and license requirements along with involving the licensed trades, such as plumbers and electricians. Typical projects would be complete bathroom modifications or renovations, such as roll-in showers, walk-in tubs, widening doors, kitchen modifications, additions and elevators.
CEAC certification is not the only program available. The NAHB National Association of Homebuilders (NAHB; nahb.org) provides home access training and certification via its Certified Aging-in-Place Specialist (CAPS) designation. As can be evidenced by the name this designation is particularly useful for providers interested in serving home access solutions up to seniors. With the growing population of older Americans, and the steady influx of Baby Boomers hitting retirement age, the rapid increase of adults needing safe access to their homes is pronounced and growing. The CAPS program gives providers an overview of the equipment and fixtures that can make life safer and easier for seniors living at home, and also offerings technical insights on how to properly install these items. More in-depth knowledge on more complex solutions is available through an NAHB course called Universal Design that shows how to install devices such as elevators, and movable sinks and cabinets.
Once training and expertise is on-staff, Davis says that capability needs to available so that providers can help patients at any time. Things can break down and providers need to plan and prepare ahead of that.
“It is machinery,” he says. “Twenty-four-hour service is hugely important to these customers. You can’t have equipment go down on a Saturday afternoon and not take care of it on Monday morning. … You need to be a reliable provider.”
A key part in providing any solution is truly understanding the patient’s condition, Sheridan’s Davis notes.
“A key to home access is understanding your customer, and their diagnosis and the potential progression of their diagnosis,” he says. “We’re trying to provide service that is going to be long lasting. “If someone has wheeled mobility in their future, a stairlift might be an answer for today, but it might be limited in the future,” he continues. “They might need something that can not only handle them, but their mobility device, as well.”
So, when a provider visits a patient’s home and reviews his or her situation, it is important to weight all of the available options in order to make an informed decision with the customer.
“You’re working for today,” he says, “but you’re hopefully making a suggestion that will work for a good long time.”
This article originally appeared in the May 2014 issue of HME Business.