Products & Technology

Rethinking Aging in Place

Aging in placeYou might not realize it, but there’s a good chance you’re an aging in place provider. That might seem a bit “off,” but it’s true. Many providers in the post-acute care space have very specific ideas on what aging in place means, and those ideas typically fixate on home access. When they think “aging in place,” they think about ramps, lifts and other, more access-oriented items.

But given the market opportunity, that’s not the way providers should be thinking about aging in place. America’s getting older. There were 37.3 million Americans aged 65 years or older in 2006, according to the Department of Health and Human Services Administration on Aging (AOA). The AOA projected that by 2030, the AOA says there will be about 71.5 million Americans aged 65 years or older. At 78 million people, the Baby Boom is retiring at the rate of 8,000 people a day.

As providers already know, the majority of this large population wants to keep living in their homes as they age, and they will need the products and services to help them do that.

And those products go far beyond stair lifts and threshold ramps. If anything, providers need to look at aging in place as a continuum of products. It’s not just access. It’s not just safety. Aging in place means all the products that can help seniors continue living independently.

Ultimately, what aging in place needs is a rethink. Moreover, providers must start believing that they are part of this overall trend.

“We need to get educated on what it takes to help someone live safe at home,” says Jim Greatorex, president of The VGM Group Inc.’s Accessible Home Improvement of America (AHIA) division. “Everybody is an individual. You need to look at their specific needs and build a plan around their home that they can afford, and not only help them now, but five years from now.”

Providers need to be able to look at their clients’ entire aging in place situation, and create the solutions that will make that possible, Greatorex explains. He adds that he does not think that the industry, as whole, is ready to do that in a uniform way, and is working to create some kind of certification that can create a consistent approach industry-wide.

“The industry, as a whole, has to work to certify people, and to create the education that can do that,” he says. “That’s where we think we need to start the process. We’ll do it with a non-profit involved that is non-biased and doesn’t have an agenda, and that can bring all these people that do have agendas, even myself, into the fold so that we can work together with manufacturers, providers, clinical people, and consumers to make standards that we can live by.

“It’s for the good of the industry,” he adds. “There are going to be more government dollars thrown at this, because it’s going to be the least expensive alternative in many situations.”

In the meantime, providers that work with seniors work to redefine and reimagine what aging in place actually means, and ponder the variety of HME offerings that help clients live independently. Here are some key categories that will make up that spectrum of offerings:

Ramps

Let’s start with an obvious aging in place category: ramps. For any senior that has mobility issues that require assistance entering the home, ramps are a key product consideration. Simply put, ramps make home access possible.

But the key “hump” for a provider that serves seniors to get over when considering adding ramps to their product mix isn’t a learning curve, but rather a comfort curve, according to Bob Heffernan, president of ramp manufacturer Access4U.

“I’ve met a number of people who have a store or a local business providing wheelchairs, walkers, mobility devices of one sort or another, but are ‘intimidated,’ I think is the right word, by bigger ramps,” Heffernan says.

His advice is that if investing in all the tools and equipment and construction knowledge is not a provider’s cup of tea, that’s fine. But that provider still can get in the ramp game, and should.

“What does seem to work is partnering with a local handyman or construction company that might already be doing some accessibility work,” Heffernan advises.

Specifically, he suggests a provider go with a smaller construction firm that has the tools, truck, license and knowledge, and then the provider can play to its strengths in terms of understanding the senior’s access needs.

“I’ve paired a couple of people with, two people that work together,” Heffernan explains. “One [the provider] finds the need and the other goes out and does the assessment and installation. ... He has the background on accessibility from his other work.”

Providers should understand the typical installations costs. A starting ballpark estimate for a typical “front of the house” ramp to the door is about $120 a foot or so, according to Heffernan. Twists and turns that necessitate additional platforms will increase the cost of a job.

In terms of the space a ramp consumes, ADA guidelines require one inch of rise per 12 inches of ramp, which puts a ramp’s incline at 4.9 degrees. That said, local codes can be more accommodating, though it might be best to stick with the original ADA rules.

“The ADA law has been widely adopted, but it is also true that frequently local codes,” Heffernan notes. “So one will allow one inch of rise per eight inches of ramp. Typically, you don’t want to go any steeper than that. I think the people that did the original ADA guideline work did an excellent job. You typically don’t want to go more than one to eight, even on a residence where someone has a power chair.

“Just for a visual, think of a guy who might be a double amputee,” he continues. “He has most of his weight up in his chest and so on. He heads down and his body’s going to want to tip forward and so on. A sudden stop or anything like that, and you don’t want him falling out forward. … You want to err on the side of caution and safety.”

And Heffernan says he suspects most providers probably understand the safety factors that will vary based on patient assessment, and likely to watch for in patients and they know the ADA guidelines intuitively.

“They’ve been taught that and they know what to look for,” he says. “What they don’t know sometimes is construction kinds of things, which leads me back to my original thought of partnering with some small local accessibility company that you can work with.”

Getting back to that partnership element, Heffernan advises a team approach out of the gate to really develop an approach to the jobs and to ensure the partnership is smooth and equitable.

You’ve got to do a couple of projects together to be successful, but the first three or four times, they should both go on the evaluation visit,” he says. “Ahen after that, maybe only one of them can go, once they’re both on the same page. What I’ve done with people is say, ‘You both have costs on that. Split it down the middle in the beginning.’ Just find a working partnership ... it takes a little time to learn to work together.”

Standing Aids

Still, many seniors have no trouble entering their homes; they simply need a little help safely negotiating around them. And that little bit of help can prevent big problems. Among older adults, falls are the leading cause of injury deaths, and are also the most common cause of non-fatal injuries and hospital admissions for trauma, according to the Centers for Disease Control. Most fractures among older adults are caused by falls. For instance, in 2005, 15,800 people 65 and older died from injuries related to unintentional falls; approximately 1.8 million people 65 and older were treated in emergency departments for non-fatal injuries from falls. Startling statistics indeed.

Standing aids are a critical element in a provider’s aging in place product lineup because they help prevent injuries from falls.

“Most people don’t really start educating themselves about aging in place until after there’s an accident,” says Wade Olsen, chief strategy officer for Stander Inc., which manufactures various standing aids.

Olsen says a typical aging in place scenario might see the family of a senior that is struggling to stay in her home try to ensure she has the resources she needs in order to be remain home and live independently. They will typically start doing some Googling and quickly encounter a good bit of sticker shock in the process.

“I don’t know if you’ve done this, but most of the searches online about aging in place will take you to contractors’ websites talking about the need to widen doors and hallways and revamp that kitchen and bathroom,” Olsen explains. “And you’re suddenly looking at a $70,000 to $100,000 price tag.”

The alternative scenario to that is an assisted living center that can cost thousands of dollars every month. Essentially, the family is looking at “the nuclear option” no matter how they look at it, as Olsen points out. And that’s particularly frustrating if the senior currently only needs a little bit of help to live independently.

“There are a few stability and mobility products that can help add years of independence onto seniors’ lives with just a couple of hundred dollars,” Olsen explains. “Really, the types of products that we sell are pretty critical because a lot of times when they first start having issues with independence, they may not need to do the full home remodel. The products that we develop are ones that blend into the home and add this level of stability and mobility that will often, with many people, get them through year, years’ worth of independence without having to make drastic changes.”

So what are the key considerations when providing standing aids? It starts with offering a rich lineup. Olsen advises it starts with differentiation. Providers must offer the kinds of unique, non-commodity items client’s won’t find in a big box retailer. Also, providers want to offer plenty of options in that regard. Olsen notes that studies have shown that HME customers are more likely to buy when they have between three and six items from which to choose. That makese sense given that no two HME clients’ circumstances are going to be the same. Think about it: not every person trying to get out of a chair is going to have the same problems. They’ll be different heights, suffer from differing physical limitations — heck, they’re all going to have different chairs. So choice is key.

Also, providers should provide products that differ enough in terms of features and cost that the provider can serve up a range of “good, better, best” selection to its customers. According to Olsen, customers are more likely to trust a standing aid’s price if they can compare its function and price to other product options. Moreover, those clients that prioritize product quality will gravitate toward the “best”-option product thanks to the provider’s price range. Also, because the provider is offering unique items and in a range that highlights both features and price, it will further differentiate itself from the general retailers offering commodity items.

Above everything, providers must keep in mind is that these retail sales items are real life-savers not just in terms of living independence, but financial independence. They have an opportunity to really make an important difference in their clients’ lives, so they should not be afraid to sell the customer everything he or she needs or wants.

“We’ve done an analysis on it and the average home remodel is 70,000 for aging in place at home,” Olsen says. “That’s the average remodel. If you go through and get a cocktail of product, not just ours but all of them — like toilet seat risers and lift chairs, things that we don’t sell — a regular DME store might be able to write up a ticket around $4,000 to $5,000 and pretty much solve that person’s needs for a long time.

“What they forget is that they’re a hero. In that moment, $4,000 is a lifesaving number to these people,” he continues. “One of the pitfalls is just hesitancy or feeling like what they’re offering, with their expertise, what they’re offering isn’t worth the price tag. It’s not only worth the price tag, they’re a hero in the eyes of that customer walking in the door.”

Lift Chairs

In the same vein as standing aids, lift chairs help seniors safely get in and out of chairs by raising and lowering. To get in the chair, the senior uses a control wand or similar input to have the chair raise up. As it raises, the chair tilts forward. The senior then leans against the chair cushion, and then commands the chair to lower to a seated position. To get up, the senior raises the chair up to the point where he or she is standing. Essentially the chair provides not only safety, but convenient safety to a senior that might have trouble getting in and out of a chair even with a standing aid.

The key thing for providers to understand from an aging in place context is that lift chairs are changing in dramatic ways. Because seniors are living much more actively and independently these days, lift chairs are quickly going from a need to a want, says Micah Swick, director of sales for Pride Mobility Products Corp.

“We’re taking a fresh look at lift chairs and a fresh approach to this category and one of the things that I think is important we talk about because people are healthier today than they were,” he says. “I mean, 70 today is not what 70 was 10 years ago or 20 years ago.

“Lift chairs used to be a need,” he continues. “It was ‘Oh, jeez, Mom can’t get up any more and I can’t lift her. I can’t get her out of the chair, so we have to go get a lift chair.’ Those days are not gone, but we’re not in that era anymore. … Eventually, everybody gets to that place. But let’s make it exciting. Let’s make it comfortable.”

So, Swick companies such as Pride are starting to focus on how to make lift chairs the type of product that seniors simply want to buy, regardless of whether or not they officially require one.

“We’re doing things like offering pocketed coils seating that provides this unprecedented comfort in the seat,” Swick explains. “We’re making the chairs bigger because Americans are not just living longer and living better but they’re larger.

“We’re providing a fashionable piece of furniture that is using the latest style in fabrics, in colors, in comfort that hasn’t existed in the category before,” he says. “Forget the fact it’s a lift chair, we all have furniture in our home. We all need some place to sit, so let’s provide some place that’s really comfortable and really enjoyable; some place you really want to be, with features that you really appreciate.”

That approach also means trying to think outside the box about the sorts of things the chair can do. For instance, how many times have you been sitting in a chair and your smart phone or tablet is just about to run out of juice. Walking upstairs or across the house to fetch a charger can be a pain in the neck. For a senior who has difficulty getting up and down and walking through the home, that pain in the neck is far worse.

“We also offer a USB charging port in our hand control on all of our chairs,” says Renae Storie, director of strategic accounts for Pride. “While someone is resting in their chair, they don’t need to find a plug for their smartphone or their iPad or Kindle or whatever device that they’re using. They can charge it directly through the hand control of the lift chair.”

And the features will keep coming in this category. The dynamics of a retail marketplace for lift chairs demand it. Swick notes that features Pride will be launching include power headrests, power lumbar support, new heat technology, and other enhancements to make them more comfortable and desirable.

“We’re trying to look at this in a very retail-minded approach,” he says. “Who is our customer and how can we best serve them? How can we make products that they both enjoy and want and meet their needs whether they’re today’s needs or tomorrow’s needs?”

That is the same approach providers should be taking to the categories of lift chairs. Hearkening back to Olsen’s points about offering feature and price ranges, providers must ensure they are able to provide their customers with the kind of options that will enhancing their aging in place.

Bath Safety

Seniors and the bathroom don’t make for a good combination. We already know that the bathroom is the most dangerous room in the house. More than 80 percent of home accidents occur in the bathroom, according to the National Safety Council. A 2008 study from the Centers for Disease Control and Prevention said that every year about 235,000 people over the age of 15 visit emergency rooms because of injuries suffered in the bathroom. Of the injured more than 33 percent were caused while bathing or showering; and more than 14 percent occurred while using the toilet.

Moreover, injury rates increased with age, especially those that occurred on or near the toilet. The proportion of injuries in or around the tub or shower was highest among persons aged 15 years to 24 years (84.5 percent) and lowest among persons aged 85 or older (38.9 percent), whereas the proportion of injuries that happened on or near the toilet was lowest among persons aged 15 years to 24 years (7 percent) and highest among persons aged 85 and older (51.7 percent).

Injuries associated with getting into and out of the tub or shower occurred among persons of all ages, suggesting that adding grab bars both inside and outside the tub or shower might help prevent bathroom injuries to all household residents. Overall, approximately 14 percent of injuries were associated with standing up from, sitting down on, or using the toilet, but among persons aged 65 years and older, the proportion ranged from 19 percent to 37 percent. The CDC said that preventing falls and subsequent injuries in this vulnerable older population is critical. Persons with postural hypotension can reduce symptoms by standing up slowly; installing grab bars near the toilet would provide an additional measure of safety.

So, if providers want to enter the aging in place category, bath safety is an almost mandatory category to stock. Bearing that in mind the DME industry has an extensive inventory of bath safety products.

And, like standing aids, bath safety products don’t have to cost a lot to make big differences for aging in place customers. Bath safety items represent a key retail sales category for HME providers, given that many bath safety items fall below the $200 price mark. Moreover, those devices that are more expensive are typical going to be DME that the patient specifically needs and will buy. So where to begin?

For starters, grab bars are critical. They should be strategically located in and around the bathing area, as well as around the toilet. This has two benefits: it ensures that the patient is supported and kept safe from a fall, but it also helps the patient gently lower and raise himself or herself while bathing or using the toilet. In terms of the toilet, ideally the patient would use a raised toilet so that he or she does not have far to travel when rising or lowering. Commode lifts are another option in this case.

For the bathing area, the ideal situation would be to have a bathing stool or bench that the senior can use in conjunction with a handheld shower to protect against falls. Along with the aforementioned grab bars, the shower floor should be lined with non-slip material or strips. In general it also is a good idea to avoid having bathmats or other items on the floor that could cause a fall. Also, another bathing option could be a bath lift, which raises and lowers the client into the tub.

Also, ensure that the bathroom is brightly lit and that there is a bright enough night light to help the patient negotiate the bathroom at night, when poor vision could otherwise contribute to a fall. If possible, situate a chair or stool in the bathroom that the senior can use while grooming themselves or applying makeup, and ensure there are nearby grab bars, as well. Lights and stools are simple, non-DME products providers can stock that pay major bath safety dividends.

But providing bath safety can go much deeper. If the senior has mobility limitations, other products can come into play. Typical modifications include replacing the bathtub or existing shower stall with a roll-in shower stall. That can mean knocking out just the tub, or possibly expanding the bathroom itself. Another option might be to remove the lip of a shower stall and replace the shower stall frame.

If the bathroom requires deeper renovation to ensure safety and access for the aging in place client, the scenario can get trickier. A complete bathroom remodel can range between $15,000 and $30,000, but there are less expensive options, such as removing cupboards or installing pedestal or hanging sinks. Other modifications include moving the toilet and removing the tub and installing a roll-in shower, which requires a change in drainage system and other plumbing modifications.

Naturally, most HME providers do not staff certified and licensed plumbers or electricians, and tearing out a bathroom, expanding it and putting in all new fixtures sounds like a challenging task better suited for a building contractor. Extrapolating from Heffernan’s point about partnering for ramp installs, there are professionals with whom providers can align to provide turnkey services to patients in need of heavy-duty bath safety help.

Fortunately, the National Association of Home Builders offers a Certified Aging in Place Specialist (CAPS) designation for builders who specialize in these types of modifications. Moreover that designation is geared toward ensuring that the contractor works to understand and match the solution to the patient need and organize the work in such a way as to minimize disruption. Also, the VGM Group’s Accessible Home Improvement of America offers its Certified Environmental Access Consultant (CEAC) certification. The Level 5 CEAC certification is for certified/licensed healthcare professionals and licensed contractors and remodelers, and ensures those professionals understand major remodels and will comply with any applicable local building codes and license requirements.

Mobility

Scooters and Group 2 power chairs play an important role in aging in place scenarios because they help clients get around their homes, as well as outside. Whether due to medical necessity or because they tire easily, many seniors need assistance getting around. Given that there is a wide variety of both funded and retail product, providers are in a place to offer their senior clients many solutions, notes Pride’s Swick.

“Regardless of where they’re at today, or where providers are focusing their attention, there’s an opportunity and the need to expand the breadth of the product,” he says. “Every business has to go out, should be going out there trying to find new areas of opportunities. New categories.”

Given the profit margin on mobility solutions, as well as the large number of clients that could benefit from them, standard power mobility is an upsell providers can’t afford to ignore.

“If I have a customer coming into my building and I’m selling them product X, and I could also sell them product Y, then I have the opportunity to get twice the business, or maybe five times the business, depending on the price point of that product, that I’m currently enjoying,” Swick explains.

However, the key with scooters is to put the priority on quality and features. Quality has been an issue for scooters in the recent past, as funding pressures created a “race to the bottom” when it comes to product quality. Given the Baby Boom’s purchase power, Swick says that was the wrong course to take. Many seniors can afford devices that offer both high quality and lots of features.

“Retail is a fashion business,” he explains. “Consumers spend money on what they want, not what they need. Let’s give them something they can be excited about having, so it can make them feel young again and more fashionable, more stylish.”

Certain features are obviously important in aging in place scenarios. Mobility devices need to work both in and out of the home. Tires shouldn’t leave scuff marks. The scooter should be able to maneuver through doorways and safely negotiate household obstacles.

“We try to make sure that all of our products are very maneuverable in the home,” Prides Storie notes. “Keeping in mind we want to have good foot room, and good overall size of the scooter. But it also needs to keep a very tight turning radius so that you can move around your home very easily, and get from the bathroom to the bedroom in those cases without any difficulty.

“The other thing is, a majority of our scooters break down very easily,” she continues, highlighting that many users travel with their mobility devices. “If it’s something that you’re transporting from a home to a facility, or a facility to your children’s home, it can easily be taken apart and transported in vehicles, or on one of our vehicle lifts. You can simply bring the battery pack in and just charge directly off that, so you don’t even have to bring in the whole unit if you’re storing it somewhere.”

This need to provide lots of options and high-quality product creates a conundrum for providers: inventory. Mobility devices are expensive and providers cannot tie up huge amounts of overhead in stock that is waiting for a client to buy it. Fortunately, vendors are responding to this.

“Companies like ours, we stock all of this product for them,” Swick says. “Really, all they have to do is have one in their showroom. They don’t need warehouses. They don’t need stock and inventory. …You’ve got to get one product on your floor, and then use that product to sell off our inventory. We’re going to ship it either to you, or directly to your consumer, in the matter of just a few hours.”

Oxygen

Let’s switch gears and look at a category that at first glance might seem far afield from aging in place, but is more closely aligned with the care segment than one might initially think: oxygen. Oxygen services can help senior patients live in their homes, and portable oxygen in specific can help them live independently in their homes for a lot longer than they might otherwise be able to do.

“The problem is the disease our products help manage is incurable and it’s progressive, and it just continues to get worse,” says George Coppola, director of marketing for oxygen equipment maker CAIRE Inc., a Chart Industries Company. “We have a full range of products that progress with that patient through the disease state. As they age and as they get worse we can move them from one product to another.

Conditions such as Chronic Obstructive Pulmonary Disorder (COPD) can hit anywhere from age 45 on up, and given that COPD and related conditions are seeing increased diagnosis. These patients — even at retirement age — are not ready to sit in their homes. They want to get out and live their lives and portable oxygen can help make that possible.

“Let’s say you have this tightness of breath and you’re up there in age but you’re in walking club,” Coppola says. “Your tightness of breath is preventing you from going out and spending time with those people and doing the walking and getting the exercise that you really need and want. What a POC does, is a POC will allow you to do that by giving you the oxygen you need as you do those activities. It helps you maintain your quality of life.

It’s important to be cognizant that oxygen can represent a major learning curve. A generalist HME provider or a mobility provider recognizing oxygen’s relevance in the aging in place continuum probably already understands that respiratory services represent a much larger degree of onboard expertise needed in comparison to offering, say, standing aids or bath safety items. For a provider that is interested in branching out into this sector they could try entering a referral relationship with another provider, or perhaps adding the services through acquisition, or organically gaining the expertise.

For providers looking to organically adding oxygen services, Coppola says it starts with gaining Respiratory Therapist on staff, not only to have the relevant care competency, but to ensure the provider is working in accordance with state-level licensure or certification requirements. It’s like building a whole new business.

“They [providers] need to have the right capabilities and they need to understand the needs of that segment,” Coppola says. “And they have to make sure that their business has the infrastructure to support those needs.”

And of course the provider will need to work with its Accrediting Organization to have the right accreditation. Also, the provider will want to work with its vendor to ensure its technicians are properly trained.

“We offer service schools,” Coppola says. “For our service school, [the provider] would bring its technicians into our facility and we would show them how to fix a product should it break. We also offer product training, technical training.”

Bottom line is that oxygen does help patients remain independent, so it should sit on the aging in place continuum, but it is a complex offering that should not be undertaken lightly. Care, forethought and proper planning are mandatory — even when growing by acquisition — in approaching and serving this category.

This article originally appeared in the April 2017 issue of HME Business.

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