Team Approach

For motor vehicle accident (MVA) clients, an essential aspect of achieving an independent lifestyle is a safe and functional home environment that facilitates maximum mobility. While this might seem obvious, depending on a client’s specific post-accident condition, the barriers to independence in their home can be anything but obvious. In most cases, it is necessary to structurally modify the home to remove any barriers that impede mobility and safety – and to add structural enhancements to promote mobility and safety. But in Ontario, how best to meet the Statutory Accident Benefits Schedule (SABS) requirements that home modifications and associated costs be “reasonable and necessary”? The answer is teamwork.

As the Statutory Accident Benefits Schedule Section 16, sub-sections 16.3(i), 16.4 (b) and 16.4(c) stipulates that “an assessment must be completed upon the catastrophically-impaired client’s home in order to establish a quantum value for home modifications. The extent of the home modifications, as well as the associated costs to complete the modifications must be reasonable and necessary.

There’s no going it alone

To effectively assess potential modifications to the pre-accident home requires a long-term view of what is necessary to meet a client’s and their family’s present and future needs. Whether these modifications can be achieved by renovating the existing home, or by investigating alternative housing options is a central issue. However, in all cases, the difference between assessing home modifications versus other types of assessments is that it requires a team approach because it requires diverse skill sets. The expertise required to provide a client with a comprehensive assessment doesn’t exist in just one type of professional-it requires the combined skills of an occupational therapist and a housing expert.

One professional’s assessment (occupational therapist) without the other professional’s assessment (housing expert) can result in recommendations that are not “reasonable and necessary” – plus there is the potential for significant liability issues. Working in isolation, each professional is not qualified to provide the type of recommendations required to ensure that a client’s specific housing needs are effectively addressed and in keeping with SABS requirements.

A Home Modifications Assessment of the pre-accident or existing residence identifies the adaptive modifications that should be considered, as well as the associated costing to complete the same. The resulting Home Modifications Report is the basis for making the decision regarding whether to renovate the pre-accident/existing home or, alternatively, to explore other housing options. 

The occupational therapist

Before it’s possible for a client’s home modification needs to be determined, first an occupational therapist (OT) must assess the client’s physical and cognitive abilities and limitations. The OT scope of practice enables them to determine a client’s post-accident functional status:

• An OT is qualified to assess a client to determine what is “necessary” from a functional abilities perspective.

• An OT is not qualified to recommend specific home modifications or associated costing. OT’s are only qualified to provide general recommendations regarding accessibility.

OTs are not qualified to assess structural limitations of a client’s home because they are not trained in architectural design and construction principles (i.e., feasibility of structural modifications, cost estimates, etc.). In addition, OTs are not trained in design standards or building code requirements. If an OT provides structural recommendations, the recommendations are not necessarily “reasonable and necessary” and there is also liability risk.

Overall, the OT, while weighing in on recommendations from a functional perspective, should defer all design and costing to the housing expert.

Do:
It is within the OT scope of practice to comment that, for example, “If provided with an appropriate bathroom design, Mr. X will have the functional ability to independently conduct his daily self-care routine.” 

Don’t:
It is outside the OT scope of practice to recommend specific structural details like “To maximize Mr. X’s functional abilities within the bathroom, consideration should be given to the construction of a second story addition off the home’s rear elevation.”

The housing expert

Based on the OT’s functional assessment, which provides a clear understanding of what a can and can’t do, the housing expert can now determine what structural modifications are necessary to maximize function and limit the “can’t do” aspects of a client’s post-accident functional status:

• The housing expert is qualified to assess the structural aspects a client’s post-accident home to determine what is “reasonable” from a design, construction, and cost perspective based on the OT’s functional assessment.

• The housing expert is not qualified to assess a client’s functional ability.

Using the OT functional assessment as the foundation, the housing expert – trained in barrier-free design – now assesses to what degree the structural aspects of the home impede or enhance a client’s functional status. Where the pre-residence structure now poses barriers post-accident, it is up to the housing expert to provide detailed architectural solutions to overcoming these barriers through recommendations that focus on structurally modifying the residence.

Do:
It is within the housing expert scope of practice to recommend structural specifications and associated costing, for example, “Based on the functional information provided it appears that Mr. X would benefit from the inclusion of a fully accessible en-suite bathroom. The proposed bathroom design would include a wheel-in shower enclosure, an open access vanity with off-set covered plumbing and a height-adjusted raised toilet.”

Don’t:
It is outside the housing expert scope of practice to comment on functional abilities like “Mr. X was observed to experience cognitive fatigue and appears to have deficits that affect his tolerance and ability to perform certain activities.”

No part to play on the team: unqualified professionals

To provide a client with the best assessment possible-plus ensure a defensible report and avoid liability risk-assemble a team with these two distinct skill sets:

• Check that the OT is registered with the College of Occupational Therapists of Ontario (COTO). As COTO describes, “registration with the College qualifies occupational therapists to use the title ‘Occupational Therapists’ or ‘O.T.’, and the designation ‘OT Reg. (Ont.)’. Registration indicates to the public that their occupational therapist has met entry-to-practice requirements, and meets the College’s standards of practice and quality assurance requirements. In addition, it provides the public with a means of recourse, should they receive occupational therapy treatment they feel does not meet professional standards.” (http://www.coto.org/registration/default.asp)

• Housing expert: look for certification as a registered architect or construction engineering professional specialized in barrier-free design and cost estimating. This not only ensures that the housing expert is qualified regarding accessible design, but also that they carry the right type of liability insurance.

Don’t settle for one without the other

Combined skills is the only way to meeting SABS requirements. The team approach ensures that home modifications and associated costs are “reasonable and necessary.” And ultimately, teamwork ensures that a client maximizes post-accident abilities in a safe and accessible living environment – while avoiding p
otential liability risks. 

David Borthwick is the president of Accessible Solutions Inc. (ASI): specialists in barrier-free home assessments, design, and construction management for insurers with MVA clients who have suffered mobility and/or cognitive impairments.