Home Modification by an Occupational Therapist: Preventing Falls by Changing the Environment, Assessed at Home

When an older person falls at home, the most common thing family members say is to remind them to “be more careful”. High-quality research data show, however, that the approach that can actually be measured and does reduce falls is not asking the older person to be more careful. It is removing the hazards in the environment that cause falls, that is, treating the environment itself as an intervention that can be changed. It also matters a great deal who carries out the assessment and prescribes the changes, because the final effect can differ widely. Based on the latest research evidence, this article looks at how well home modification works in preventing falls, why risk stratification is needed beforehand to pick out the high-risk people, and why having a full set of assistive devices does not mean safety. What matters is that the devices are matched precisely.

How the home environment relates to preventing falls in older people

Putting a fall down simply to the older person being “not careful” underestimates how serious the problem is and misses the intervention that really works. A wet and slippery bathroom, high thresholds, a dim corridor and stairs without a handrail are all real hazards in the environment, and they can be removed by modification. Once the focus moves from “blaming the older person” to “improving the environment”, fall prevention is no longer a vague word of advice. It becomes a treatment plan with evidence behind it and an effect that can be measured.

The latest Cochrane systematic review pooled data from 22 randomised controlled trials with 8,463 community-dwelling older people, and confirmed that improving the home environment and removing fall hazards lowers the overall fall rate by about 26% (RaR 0.74). Among older people at higher risk of falling, the certainty of this evidence is high, and the fall rate can be reduced by about 38% (RaR 0.62, 95% CI 0.56–0.70), equal to 702 fewer falls per 1,000 people per year (Clemson, 2023). This shows that improving the home environment is in itself a fall prevention method whose effect can be measured.

Research on how well home modification prevents falls

Is home modification effective? Several large systematic reviews have already given a clear answer. Taken together, the results show that the size of the effect depends heavily on whether the right people are targeted and the right assessment method is used.

The latest high-certainty evidenceThe 2023 Cochrane review showed that environmental interventions lower the overall fall rate by about 26% (RaR 0.74). In older people at high risk of falls this is high-certainty evidence, with the fall rate reduced by about 38% (RaR 0.62), whereas in the general low-risk population that was not screened there was no clear benefit (RaR 1.05) (Clemson, 2023).

Consistent conclusion of a large reviewA Cochrane review covering 159 RCTs and 79,193 older people found that home safety assessment and modification reduce the rate of falls (RR 0.81, 95% CI 0.68–0.97) and the risk of falling (RR 0.88). It stated clearly that such interventions are more effective in high-risk people (including people with severe visual impairment) and work better “when delivered by an occupational therapist” (Gillespie, 2012).

What effective modifications have in commonA meta-analysis of 10 RCTs with 1,960 older people showed that home hazard modification reduces falls overall by about 7% (RR 0.93, 95% CI 0.87–1.00). It also found that effective interventions share these features: comprehensive, focused, matching the environment to the person, and with enough follow-up (Lektip, 2023).

All three pieces of evidence point to the same conclusion. General “home safety tips” have limited effect. What does work to prevent falls is a modification plan that targets high-risk people, is designed to suit the individual by a professional, and is followed up continuously.

Effect of home modification in older people at different fall risk

The most common misunderstanding about home modification is to treat it as a standard prescription that benefits everyone who follows it. In fact, the same modification plan can give very different results in people at different levels of risk.

Older people at high risk of falls

Who: people who have fallen in the past year, have just left hospital, have severe visual impairment, or have reduced balance or leg strength
Home environment modification reduced the fall rate by about 38% (RaR 0.62, 95% CI 0.56–0.70, high-certainty evidence) (Clemson, 2023)
In older people with severe visual impairment, falls related to environmental hazards fell by about 60% after an occupational therapy home safety intervention (IRR 0.40, 95% CI 0.21–0.74) (La Grow, 2006)
Equal to 702 fewer falls per 1,000 people per year (Clemson, 2023)

Low-risk people who have not been screened

Who: ordinary older people who have not been assessed and whose own fall risk is not high
The same kind of environmental modification showed no clear benefit in this group (RaR 1.05) (Clemson, 2023)
Modifying blindly costs money and does not necessarily bring a real gain in safety
Conclusion: what matters is to screen and stratify first, and find the people who are truly at high risk and the hazardous environmental factors

Occupational therapist (OT) home assessment compared with modifying it yourself

Many families think that fall prevention just means buying a few grab rails and non-slip mats from a hardware shop and fitting them at home. Research shows a key finding, though: even when the same equipment is fitted in the same places, the fall-prevention effect differs markedly depending on who carries out the assessment and prescribes the changes.

A three-arm randomised controlled trial (238 people aged over 70 who had fallen in the past year) showed that home environment assessment and modification prescribed by an occupational therapist significantly reduced falls (IRR 0.54, 95% CI 0.36–0.83, P=.005), while the same kind of intervention delivered by trained assessors who were not occupational therapists had no significant effect (IRR 0.78, P=.34). The Cochrane review also notes that home safety interventions work better “when delivered by an occupational therapist”.

Pighills, 2011; Gillespie, 2012

In other words, who carries out the assessment and prescribes the changes is itself part of the treatment effect. The value of the occupational therapist does not lie in knowing where a grab rail can be fitted. It lies in taking the older person's physical function, the real daily movement routes, the limits of the home and the likely future course of the condition into account together, and in finding and changing the spots in the environment most likely to cause an accident. This is why a home visit by an occupational therapist cannot be replaced by ordinary modification work.

Four steps of the home assessment

What an occupational therapist does on a home visit is far more than walking round to see what looks dangerous. It is a structured clinical assessment and intervention process. The systematic review by the American Occupational Therapy Association (AOTA) found “strong evidence” that home modification interventions improve functional performance in people with different health conditions, and the large majority of the studies involved were led by occupational therapists (Stark, 2017). The home visit process is made up of the four steps below.

1
Functional assessment
The therapist first assesses the older person's mobility, balance, eyesight, cognitive function and self-care ability, to judge whether the person belongs to the high fall risk group (Clemson, 2023).
2
Environmental assessment
The therapist measures the space in the home where the older person actually lives and looks for environmental problems that can cause accidents, such as a wet and slippery bathroom, thresholds that are too high, a dim corridor and stairs without a handrail.
3
Drawing up the plan
The therapist takes the older person's abilities, the home environment and the needs of daily activities into account together, and tailors the modifications to the person. The therapist also decides the type, position and height of the assistive devices, and does not apply a standard list blindly.
4
Follow-up training
After the modification is done, the therapist teaches the older person and the family how to use the new fittings correctly and follows up on how they are used. If the older person's physical function changes later, the therapist also adjusts the plan in good time (Stark, 2017).

Key points of fall prevention modification in each area of the home

Home modification does not mean putting equal effort into every room. Each area has its own specific hazards, and the changes are matched to them. The main points for each area of the home are listed below, but the exact dimensions and specifications still have to be set by the occupational therapist to suit the actual user (Gillespie, 2012).

BathroomThis is the place with the highest risk of accidents at home. Common changes include fitting grab rails at the toilet and in the shower, laying non-slip mats or non-slip floor tiles, providing a shower chair, using a hand-held shower, and using a raised toilet seat.

BedroomFor difficulty getting in and out of bed, the bed height can be adjusted to knee level, a bed rail can be fitted, and a motion-sensor night light can be installed to light the way to the toilet at night.

Living room and kitchenFor difficulty sitting down, standing up and everyday tasks, chairs with armrests can be used, rugs and clutter on the floor removed, cables tidied away, frequently used items kept within easy reach, and non-slip mats laid on the floor.

Passages and stairsTo keep entering, leaving and going up and down safe, make sure corridors and passages are wide enough, fix or remove thresholds, fit handrails on both sides of the stairs, stick non-slip strips on the steps, and keep the lighting bright.

Modifying the bathroom to prevent falls

Bathroom floors easily become wet and slippery, the space for movement is small, and toileting and bathing involve frequent sitting and standing transfers, so the bathroom has always been a high-incidence place for older people to fall at home. The home safety modifications supported by Cochrane evidence deal with these high-risk points one by one (Gillespie, 2012).

Grab rails—Fit L-shaped and vertical grab rails beside the toilet and in the shower. The occupational therapist (OT) decides the exact position and height after measuring the older person's height and ability to move.
Non-slip surfaces—Lay suction-type non-slip mats or non-slip floor tiles, which deal directly with the wet and slippery floor, the thing most likely to cause a fall.
Bathing equipment—Provide a shower chair to be used with a hand-held shower, so that the older person can wash seated and is less likely to slip because of unsteady standing.
Lighting—Add a night light, so that the older person does not fall because of poor visibility when getting up to use the toilet at night.

Modifying the bedroom, living room, kitchen, passages and stairs

Besides the bathroom, other corners of the home also hide fall hazards. Only by improving the hazards in these areas one by one can the older person move safely in every part of the home (Clemson, 2023).

Bedroom and living room

Adjust the bed height to knee level and fit a bed rail
Fit motion-sensor night lights beside the bed and in the corridor, and make sure the light switches are easy to reach
Use chairs of suitable height with armrests, so the older person can push on them to stand up and sit down
Remove rugs and clutter on the floor, and fix or tidy away cables

Kitchen, passages and stairs

Keep frequently used items at a height that is easy to reach, and lay non-slip mats on the floor
Make sure passages are wide enough for a walking frame or wheelchair to pass smoothly
Fix or remove thresholds, and clear obstacles from the passages
Fit handrails on both sides of the stairs, stick non-slip strips on the steps, and make sure the lighting is bright

Assessing and matching assistive devices

Many families, once they find that an older person has difficulty moving, rush to search online for shower chairs, grab rails, walking frames and other equipment. Research data show, however, that the value of an assistive device does not lie in how many are bought. It lies in whether the device really matches the user's physical function, the actual space at home and the future course of the condition.

Effect of well-matched assistive devices

Assessing the older person's physical function and the home environment systematically first, and then providing assistive devices and modifying the environment, clearly slowed the decline in function (FIM) and also slowed the worsening of pain (Mann, 1999)
By contrast, the control group of older people who did not receive this assessment and modification needed more residential care and had clearly higher spending on visiting nurses or case managers (Mann, 1999)
The AOTA systematic review also states that there is “strong evidence” that home modification effectively improves performance of daily function (Stark, 2017)
This shows that when assistive devices and environmental modifications are matched accurately, they not only help older people keep their self-care ability but also reduce the cost of residential care in the long term

Problems when assistive devices are matched badly

If devices are bought without considering the older person's physical function, the space at home and the course of the condition, it is easy to buy the wrong item or use it wrongly, and in the end it is left unused
If the older person has no proper training in how to use it, an unsuitable device can even bring new accident risks
Research found that one year after home modification recommendations were put in place, only about half of the modified items were still in use (Cumming, 1999)
For assistive devices to really work, accurate matching beforehand and follow-up afterwards are both needed

Principles for choosing and providing assistive devices

For assistive devices and home modification to really help an older person, three things must be considered together when providing them: the user, the actual environment and change over time. These are the core principles that occupational therapists follow when choosing and providing equipment (Lektip, 2023; Mann, 1999).

Principles for providing assistive devices and home modification

Centre on the person: choose equipment according to the older person's own physical function, habits and acceptance, and choose simple, easy-to-use types where possible
Fit the environment: confirm there is room at home to put the equipment and that it works with the existing furniture; also assess beforehand whether it can be installed, and check whether a rented flat has restrictions on alterations
Anticipate the course of the condition: consider how the condition may develop and what will be needed later, to avoid equipment that stops being suitable after a short time and has to be replaced
Match the environment and the person: consider the older person's ability, the home environment and daily activities together, and not just a single problem
Training in use: after the equipment is installed, teach the older person how to operate it correctly and make sure they really know how to use it
Continuing follow-up: check regularly how the equipment is actually used, and adjust the plan in good time as the older person's physical function changes

Continued use and regular follow-up after modification

Many people mistakenly think that once home modification is installed, the job is done for good. In reality, the fall-prevention benefit of modification often fades over time, and the older person's physical function and condition also keep changing. Without follow-up, the fall-prevention effect of the modification gradually weakens without anyone noticing.

A randomised controlled trial of 530 older people discharged from hospital found that the fall-prevention effect of an occupational therapist's (OT) home assessment and modification was clearly effective only in the group who had fallen in the past year (relative risk 0.64, 95% CI 0.50–0.83). The study also found a practical problem: at 12 months after the modification, only about 50% of the recommended home modification items were still installed and in use (Cumming, 1999). This shows that follow-up after modification, and whether the older person keeps using the changes, are as important as the modification work itself.

For this reason an occupational therapist does not finish once the equipment is installed. The therapist keeps following up on how the older person uses it, guides the correct way to operate it, and adjusts the plan flexibly as the older person's physical condition changes, so that the home modification continues to protect the older person's safety in the days ahead.

Key points

Falls cannot be prevented just by reminding older people to “be more careful”. The living environment has to be improved. Research shows that after home environment modification, the fall rate in older people at high risk of falls can be reduced by about 38% (Clemson, 2023).
How well home modification works depends heavily on the older person's own fall risk. The fall-prevention effect is clearest in high-risk older people who have fallen before, have just left hospital or have visual impairment, while there is almost no difference in low-risk groups that have not been screened (Clemson, 2023; La Grow, 2006).
Who carries out the assessment directly affects the fall-prevention effect. Even for the same modification items, assessment and prescription by an occupational therapist is needed to reach a clear fall-prevention effect (Pighills, 2011).
More assistive devices does not mean more safety. They need to be chosen to suit the older person's abilities, the home environment and the course of the condition, with follow-up afterwards. Otherwise about half of the modification items are given up after a year (Mann, 1999; Cumming, 1999).
After the modification is done, whether the older person keeps using it and whether there is regular follow-up are the key to preventing falls in the long term. An occupational therapist therefore needs to review it regularly and adjust the plan as needed (Cumming, 1999; Stark, 2017).

Frequently asked questions

Can home modification really reduce falls in older people? How large is the effect?

There is solid evidence for it. The latest Cochrane systematic review in 2023 (22 randomised controlled trials, 8,463 older people) found that targeted modification of the home environment lowers the overall fall rate by about 26%. In older people at high risk of falls this is high-certainty evidence, and the fall rate can be reduced by about 38%. The same review also points out that for low-risk older people who have not been screened, the effect of modification is not clear. The key to preventing falls is therefore to assess first, find the older people who are truly at high risk and the environmental factors involved, and then make the changes, and not to start work blindly.

Is there a difference between buying grab rails and non-slip mats online and fitting them myself, and having an occupational therapist visit?

The difference is large. A three-arm randomised controlled trial showed that when the same kind of home modification was prescribed by an occupational therapist it significantly reduced falls (the fall rate fell by about half), but when it was handled by trained assessors who were not occupational therapists it did not reach a significant effect. The Cochrane review likewise states that home safety interventions work better “when delivered by an occupational therapist”. The reason is that an occupational therapist matches the older person's physical function and daily movement routes to the actual home space, and does not judge by eye where one more grab rail is missing.

Which older people most need a home modification assessment?

Research shows that people at high risk of falls benefit the most. They include people who have fallen in the past year, who have just come out of hospital, who have severe visual impairment, or who have declining balance or leg strength. A classic study found that the fall-prevention effect of home modification was significant only in the subgroup of people who had fallen before. A study in older people with severe visual impairment showed that falls related to environmental hazards could be reduced by about 60%. If an older person at home belongs to these high-risk groups, a home assessment should be arranged first.

Is it safer to buy a full set of assistive devices?

No. The real value of an assistive device lies in matching it to the person, the environment and the future course of the condition, and it must come with proper training in how to use it and follow-up. Otherwise the wrong item is easily bought or used wrongly, and it ends up as unused clutter. One study found that only about half of the home modification recommendations were still in use after one year. By contrast, systematic assessment by an occupational therapist before devices are provided and the environment is modified has been shown to slow functional decline and to reduce long-term medical and care costs from residential care.

Is the job finished once the modification is done? Is a follow-up check needed?

A follow-up is definitely needed. Research shows that older people's adherence to home modification recommendations falls over time, and after 12 months only about half of the items are still in place and in use. An older person's physical function and condition also change with time. After the modification is done, the occupational therapist therefore continues to follow up on how it is used, teaches the correct way to operate it, and adjusts the plan in good time as the older person's physical condition changes, so that the fall-prevention effect lasts.

Why is the bathroom the focus of modification? What should be changed first?

Bathroom floors are often wet and slippery and the space is narrow, and toileting and bathing involve repeated sitting and standing transfers, so the bathroom has always been a black spot for falls at home. The home safety modifications supported by Cochrane evidence mainly concern fitting suitable grab rails at the toilet and in the shower area, laying non-slip mats and non-slip floor tiles, providing a shower chair and a hand-held shower, and adding lighting for night-time. The exact positions and heights of the equipment should be set by the occupational therapist to suit the user's height and ability to move.

Home modification for fall prevention often has to be combined with other rehabilitation and care services, so that an older person can stay in the familiar home with confidence. You may also like to read more about occupational therapy for activities of daily living and how it helps older people improve their self-care ability, care worker services and how they give close personal care in daily routines, and the main points of choosing stroke rehabilitation equipment.