Over half of the barriers that were identified as high priorities by the participants themselves were not resolved at the end of the study period. While, in one sense, it is encouraging to find out that households that have older people with disabilities will take action to remedy problems, a higher level of resolution would be desirable. What can be done to increase the rate of action? Our findings indicate that technical assistance and referral services alone are not sufficient to help improve the rate of action. A different type of intervention is needed.
The results show that there are three major reasons why the older people in our sample did not take action on a recommendation for a home modification. The first is that the economic cost of implementation was perceived as being outside their means. The second was that the physical and psychic energy required to implement the recommendation was perceived to be beyond their capacity. Third, implementation required a realistic assessment of self, specifically the belief that a change in the environment can make a difference in one's quality of life. Such a reassessment was not acceptable in many cases. Two additional but, still important reasons are that the ability to make the change was out of the control of the respondent and that the barrier was not perceived to be important enough yet to demand action.
Previous demonstration studies on this topic have not only provided assessments but also either offered to make modifications free of charge or provided cash grants (see for example Trickey et. al.). These studies reported higher implementation rates. Our findings confirm that the availability of financial assistance is the most important incentive for insuring action. It is important to note, however, that the previous studies did not compare the rate of implementation prior to and after the service intervention. Our findings indicate that this should be an important methodological component of intervention studies.
The research has several implications for improving the delivery of home modification services to support aging in place. First, more attractive financing mechanisms need to be developed. A funding program that could address all the implications of aging in place together and provide a menu of health care, social service and shelter options would increase flexibility in the use of existing funds and thereby address the diverse needs of households. Second, service providers should reduce the stress of implementing home modifications by providing "one stop shopping" for all related services and maintaining high quality and reliability standards that will promote trust and security. Third, ways to reduce the cost of service delivery are needed. Fourth, case managers and outreach personnel need to address the issue of lack of control with strategies to encourage landlords and families to fulfill their obligations. Fifth, educational programs are needed to improve the awareness of aging in place and the advantages of home modifications for the older consumer. Sixth, there is a need to develop low cost, "hassle free" and age appropriate solutions to the common barriers to aging in place.