- Email: [email protected]
Home Planning for the Severely Disabled
Home Planning for the Severely Disabled CAROL R. SMITH, M.A.*
In planning a rehabilitation program for the severely disabled patient, one must be concerned with what will happen when he returns home. If the person is dependent on a wheelchair, there is a likelihood that he may not even be able to get into his house. Considering the great cost in skill, effort, and money spent in many months of intensive rehabilitation, it is a tremendous economic and human waste to return the patient to an environment in which he cannot live independently. Needless to say, all physical disabilities complicate living, but it is the wheelchair that encounters the most restrictive problems in the home. As might be expected, the most frequent architectural barriers are entranceways, bathrooms, the kitchen, and stairways to bedrooms located on an upper floor. As the results of a homemaker training research program over the past 8 years at the Institute of Rehabilitation Medicine, a home planning service has now evolved to assist in the final step of bringing rehabilitation to a productive conclusion, and practical procedures for turning common barriers into functional architectural facilities have been identified to make it possible for the person in a wheelchair to continue to manage independently after leaving the less structurally complicated rehabilitation center. As with all severely disabled people, in planning for the homemaker, two sets of facts need to be worked out: first, physical limitations of the patient as related to ability to handle a wheelchair, and, second, the problems of the job to be done as related to the space in which to do it. In addition, there are the peripheral but important considerations of finances, family relations, and living patterns.
KITCHEN PLANNING: THE BEGINNING OF THE SERVICE Because homemaking is a major vocation and the problems of the Woman trying to cook from a wheelchair are so obvious, the kitchen was 'Home Economics Consultant, Institute of Rehabilitation Medicine, New York, New York :Medical Clinics of North America - Vo!. 53, No. 3, May, 1969
703
704
CAROL
FLEXIBLE SHOWER MIRRO
MIRR
ARM
R.
FLEXIBLE ARM
SMITH
HOWER
OPEN UNDER NO CURB
E~VATION
PLAN
A
ELEVATION
~--9'-0' - - - - I
1-1
PLAN
B
1--:-::.---:--- 9 ' - 0 " - - - - - 1
6" \
~ ~,
DOOR TO SWING •• ,OU:
)
FLOO~
PLAN B
Figure 1. Small wheelchair bathrooms: a 4'6" x 9'0" area converted into a small bathroom for independent use. Plan A, To be used from a wheelchair by transferring to the toilet and to the shower bench. Plan B, To be used with a shower-commode chair that wheels directly into the shower and over the toilet.
the natural first area to attract specialized attention for study and analysis of obstacles. To begin with, a standard wheelchair measures approximately 4 feet from the front of the footrest to the back of the wheels and is 26 inches wide; standard arms are 29 112 inches high. Hence, the low counter required for working in a sitting position should be about 31 inches high and the space below should be left open to provide comfortable leg room. Obviously, this is a change in pattern from the standard kitchen. The second requirement for the cook in a wheelchair is to reduce her need to move the chair to carry items back and forth. Toward this end, the kitchen sink and cooking top should be within easy reach of each other, and there should be a continuous connecting counter on which pots and utensils can be slid rather than carried between these two areas where most of the heavy work of cooking is done. On the basis of these principles, the ideal wheelchair kitchen should be V-shaped, a dead-end wraparound kitchen, wherein the homemaker can maintain herself in one key position. The following are its basic specifications: 1 The sink and cooktop are located within comfortable reach of each other in a continuous worktop (31 inches high and open underneath for knee and leg room). One other worktop or pull-out board about 27 inches high is provided for easy cutting, mixing, and chopping. A wall oven, preferably side-opening, has a pull-out board located directly below it to facilitate handling of hot and heavy pans to and from the oven. A refrigerator has its door so hinged that it can be approached in the wheelchair, with a counter top next to the open side for loading and unloading, and
705
HOME PLANNING FOR THE SEVERELY DISABLED
with freezer storage located at the bottom of the unit with an easy-opening door. Ample and easily accessible storage spaces are built for frequently used items.
WHEELCHAIR BATHROOMS: SMALLER, NOT LARGER The bathroom, commonly the most difficult barrier for all disabled patients, was the next logical area for study. Research in bathroom planning has shown that, as with the kitchen, the same two sets of facts constitute the elements which must be correlated to effectively plan a functional arrangement for independent use by the disabled. This planning should always be done in close cooperation with the rehabilitation therapist who is training the patient in performance of his activities of daily living. Further, since bathrooms and bedrooms are usually located off a hallway, the dimensions of the hall passageway and of the doorways are important in planning to determine whether they are accessible to a wheelchair. Three different basic wheelchair bathroom designs have now been developed and in actual practice seem to solve most common housing situations. The small wheelchair bathrooms (plans A and B) are very
ELEVATION OF TOILET WALL
ELEVATION OF SINK WALL
SHOWER CURTAIN ROD
ROLL-IN- 5 HOWER NO CURB - LEVEL FLOOR
I------~ 9'-0 ..-----1 FLOOR
PLAN
ELEVATION OF TUB So SHOWER WALL
Figure 2. Family bathroom planned to accommodate the disabled. Designed to be used independently from a wheelchair by transferring to the toilet and to the shower bench, or with a shower-commode chair. The sink is directly in front of the door, to be easily used, and is purposely located to be accessible while the user is seated on the toilet. For the rest of the family, there is a tub with a standard shower. For the disabled, there is a roll-in shower with flexible shower arm, and for those who can safely use the tub, it has been located with ample room for an end approach.
706
CAROL
I--
1 -' -
;- I ---'- :-; :-
=
THERF~~~~JiC
/
MIRRO
~CONTROL
/
~I-
I~
ELEVATION OF TOILET WALL
- . T1 t :r II : d- :-
i
SMITH
J
-
'~T
R.
~
"
-L.OUTLET
~ OPEN
I
UNOER
ELEVATION OF SHOWER 8 SINK WALL
-5'-S'~ r--30'~
ROLL-INj SHOWER
'0 T
on
Figure 3. Minimum bedroom-bathroom plan for the severely disabled. A 5' 10" x 5'6" area with a roll-in shower and toilet to be used independently with a shower-commode chair. Because of limited floor space the wash bowl has been placed out in the bedroom.
o I
j
T
BED
-~~~.1:::J
ll-~'------II '_S" ----~--II FLOOR
PLAN
practical plans which make use of "borrowed" space taken from the bedroom, an existing lavatory or an adjoining room. The family bathroom (plan C) is a solution for the severely disabled in a one-bathroom house. The minimum bedroom-bathroom (plan D) is useful when it is totally impractical to adapt the existing house and there is no alternative but to add a new room for the patient. The predominating features of these designs are: A wash bowl placed in a counter top easily accessible from the wheelchair. The toilet positioned properly for transfers. A shower without a curb, with a stable seat, and located to permit easy transfers. A door hinged as a safety precaution to open out from the bathroom. Drawers for storage installed on nylon rollers rather than the usual style of bathroom cabinets.
If the patient is physically unable to perform transfers safely, then a shower-commode chair which rolls over the toilet and directly into the shower should be considered for toileting and showering. Showercommode chairs of sturdy construction with good brakes are now available that can be safely and independently used by the severely disabled.
HOME PLANNING FOR THE SEVERELY DISABLED
707
To plan a bathroom simply on the basis of spaciousness with ample area for easy maneuverability of a wheelchair is a waste of floor space that people can ill afford. The important principle is the placement of standard equipment in compact relationships that are accessible to the particular patient. As a result, many homes can be adapted without necessitating extensive renovations to the entire house. Though less of a problem, bedrooms also must be planned and rearranged to permit optimal independence in dressing and bed activities. House entrance obstacles such as steps and porches may present serious problems by restricting mobility. The conventional entrance ramp is seldom a practical solution because of small lots, defacement of property, and difficulty of use in bad weather. Small electric outdoor wheelchair lifts frequently provide the simplest answer.
THE SERVICE IN TERMS OF THE PATIENT Home planning evaluation is initiated as soon as a patient's functional level can be predicted medically and as early as possible in the hope that home changes will be completed by the time the patient is discharged. Informal consultations with the patient and his family are frequent during all of the planning stages, so that the new arrangements will also be practical for the rest of the family. The home planning consultant works closely with the physical and occupational therapists who know how the patient functions. Also, since the social importance of being independent in daily living and its implications for the entire family are now well recognized, the social worker plays an essential part in helping the family to adjust to the necessary changes and stresses the importance of letting the patient manage for himself when he returns home. The Mechanics of the Service Because homes vary so widely, it is essential to evaluate each patient's housing individually, and, when possible, a home visit is made to get an accurate picture of the patient's total housing situation and to evaluate the feasibility for changes. On such a visit, one begins by first taking an over-all look at the plot and house plan, carefully noting the whole house in relationship to the driveway and garage. Someone should be available who knows the house and can identify the locations of plumbing lines and bearing walls, which need to be considered before planning any structural changes. The fastest and most reliable method of getting the dimensions is to have two people, one measuring with a steel rule and the other recording the dimensions in the form of a rough sketch on a pad OP/4 inch grid graph paper held on a clipboard. The overall length and width of each specific area are recorded first, and then the locations of the doors, windows, and furnishings. Doorways are always measured from the inside of the frame to the nearest part of the door standing in its open position, which is the narrowest part of the opening. Using approximately one grid square to a foot, the parts of the area can be kept in relatively true proportions to
708
CAROL
R.
SMITH
the whole. From this diagram with its dimensions, an area of the home can be simulated at the hospital. Here the patient practices to determine whether he will be able to function in his wheelchair at home. When it is not possible to make a home visit, one may establish a working pattern for planning by long distance with the family. A freehand sketch is made on graph paper from the patient's description of his home, as he remembers it. During this consultation, it is helpful to keep a steel rule handy so that when the question of sizes and shapes come up, it can be used to help in estimating approximate dimensions. From this description, a simple drawing is made and a letter is sent to the family asking for accurate measurements and details and for correction of any mistakes. If perchance the family is planning a new home or an extension to their existing one, suggestions are planned directly on the architect's or contractor's working drawings. The final· recommendations, a scale drawing with specifications to implement the changes, must be simple and clear so that prints can be used by the family or sponsoring agency to receive bids and select a contractor for the work.
A WORD ABOUT FINANCING If finances are no worry, then there is no problem in carrying through with the necessary changes. When only limited funds are available, suggested changes must be planned within the scope of the budget. Where there are no funds and the patient can qualify for assistance under the public program of vocational rehabilitation, the necessary changes may be financed by the state rehabilitation agency. In addition to counseling, diagnostic, and physical restorative services, disabled clients of such an agency are eligible for the training, tools, equipment, and "other goods and services necessary to render a handicapped individual fit to engage in a remunerative occupation." Because homemaking is classified as a remunerative occupation, homemakers are thus eligible for these services, including home changes if these make the difference between being employable and being unemployable.
HOME PLANNING FOR MRS. D.: AN EXAMPLE CASE At the onset of illness, Mrs. D. was a 44 year old wife and mother of two teenage boys. She became a quadriplegic secondary to a cervical spinal abscess. The following suggestions were based on a homemakinghomeplanning evaluation, a home visit, and frequent consultations with both Mr. and Mrs. D. The drawings show the changes recommended for Mrs. D.'s kitchen and for a downstairs bedroom with bath which would make her independent in daily living and let her resume her homemaking activities. THE KITCHEN (Figure 4). On the home visit, it was determined that the rear entrance to the kitchen could be made easily accessible to a wheelchair if a wheelchair lift were installed beside the existing back porch.
709
HOME PLANNING FOR THE SEVERELY DISABLED
In the kitchen itself, none of the existing cupboards, counters, and equipment would be accessible to Mrs. D., so a new "wheelchair kitchen" (31 inches high and open under the counter for leg room) was planned for convenience and the maximum conservation of her limited energy. A comfortable space was also provided for eating in the kitchen. This new plan includes the following features, which have proved to be the most practical for a chair-bound homemaker: The sink with a single-lever faucet and cooking top with front control panel are located in the continuous counter so that they can both be reached from one sitting position and pots and pans can be slid back and forth rather than lifted and carried between sink and range. A pull-out board is provided 28 inches above the floor with a hole to secure a mixing bowl for the most comfortable use at this work space. A wall oven has a side opening door and pull-out board below to facilitate use from a wheelchair. An electric dishwasher (recommended in this case because it saves so much energy) is 36 inches high and installed to the left of the continuous counter. The refrigerator has a freezing compartment at the bottom of the box, easily accessible from a wheelchair.
j
OPEN
UNDER~-'L
.,.-_-"k24"1'~~'~~i;~;--1 SINK WALL
ADAPTED
~r::--'2;;;5'"~+-;--;;2-:;4"·--r-:-9-;:;,~1-t5--'.2;:::4:;r"-1-f'---..JI ELEVATION OF COOK TOP WALL
ENTRY
O[J CLOSET
r9
~~ 30.---lr-----'=========------~ t
DINING ROOM
~R
~
30" --k-- 30"--1
ELEVATION OF REF. WALL
FLOOR PLAN Figure 4.
[
Proposed kitchen changes for Mrs. D.
710
CAROL
tr 12" DEEP SH ELF /"'"
SMITH
BOOK SHELVES
TIllI1
T T '-,.
R.
I;:
DOOR TO
MIRRO
/; '==
~
T>
LIVING ROOM
~
1---30" + 36"-j ELEVATION OF INSIDE WAL~ ~o
/
~~
LlVING/RO O INSIDE
~12
'i----
WALL
C)
I
OPEN PORCH
I ...
-I
ISI-O"
FLOOR
~I
G--:
SHOWER
DRAIN TRQUGH ==- 1
0
I
-0)
J
PLAN
D 1 2 " I
1---36"- -+-36" -t- 4-1 ELEVATION OF OU1SIDE WALL plan for Mrs, D, (a), Move open porch wall as shown, -bath bedroom Figure 5, Proposed sink-van ity top 31 inches high; Cb), Install toilet and flexible shower arm in partition ; make and raise floor to level of add shelves, drawers, and closet. Cc), Provide electric panel heating living room floor.
controls at the The combin ation washer- dryer is front loading and has the laundry can be done front so that it is easy to use from a chair, and a comple te without any lifting of wet and heavy clothes.
The Three structu ral change s were require d for this installa tion. were kitchen and existin g partitio n and cupboa rds betwee n the pantry feet to the remove d, the door to the back apartm ent was moved about 3 were lines supply and waste ing plumb the corner of the kitchen , and . window the of front in wall outside moved to the
HOME PLANNING FOR THE SEVERELY DISABLED
711
THE BEDROOM AND BATH (Figure 5). With an additional 7 feet taken from the adjoining front entrance porch, the existing small enclosed porch was converted into a practical unit planned for independent living. Before these changes were made, Mrs. D. was sleeping on this porch because it was impossible for her to get upstairs. The open view through the front yard and trees to the street made it a pleasant place, but the cramped room was not winterized, and there were no bathroom facilities. The plan shows a simple but very comfortable arrangement with shelf space around the bed and easily accessible clothes storage cabinets taking up a minimum of floor space. The washbowl and dressing table shelf with drawers facilitate self-care. The toilet compartment is designed to be used with a shower-commode chair and is planned with a flexible shower arm and special floor drain so that Mrs. D. can use the same space as a shower stall while in a sitting position. (The plumbing waste and supply lines for the upstairs bathroom are conveniently located to tie into the new installation.) To winterize the space, a new floor with insulation below, about 2 inches thick, brings the finished floor level with that of the adjoining living room, and electric panel heating units are installed in the front window wall. Other structural changes were moving the partition over on the front porch and relocating the entrance. It was felt that with these changes in the house, Mrs. D. would be able to manage without the services of a homemaker-health aid and resume her own homemaker position in the household. She thus qualified for assistance as a homemaker under the Division of Vocational Rehabilitation in the State of New York, and these home changes were sponsored in part by this agency.
REFERENCE 1. Wheeler, V. H.: Planning Kitchens for Handicapped Homemakers. Rehabilitation Mono-
graph XXVII. New York, Institute of Rehabilitation Medicine, 1965.
400 East 34th Street New York, New York 10016
In planning a rehabilitation program for the severely disabled patient, one must be concerned with what will happen when he returns home. If the person is dependent on a wheelchair, there is a likelihood that he may not even be able to get into his house. Considering the great cost in skill, effort, and money spent in many months of intensive rehabilitation, it is a tremendous economic and human waste to return the patient to an environment in which he cannot live independently. Needless to say, all physical disabilities complicate living, but it is the wheelchair that encounters the most restrictive problems in the home. As might be expected, the most frequent architectural barriers are entranceways, bathrooms, the kitchen, and stairways to bedrooms located on an upper floor. As the results of a homemaker training research program over the past 8 years at the Institute of Rehabilitation Medicine, a home planning service has now evolved to assist in the final step of bringing rehabilitation to a productive conclusion, and practical procedures for turning common barriers into functional architectural facilities have been identified to make it possible for the person in a wheelchair to continue to manage independently after leaving the less structurally complicated rehabilitation center. As with all severely disabled people, in planning for the homemaker, two sets of facts need to be worked out: first, physical limitations of the patient as related to ability to handle a wheelchair, and, second, the problems of the job to be done as related to the space in which to do it. In addition, there are the peripheral but important considerations of finances, family relations, and living patterns.
KITCHEN PLANNING: THE BEGINNING OF THE SERVICE Because homemaking is a major vocation and the problems of the Woman trying to cook from a wheelchair are so obvious, the kitchen was 'Home Economics Consultant, Institute of Rehabilitation Medicine, New York, New York :Medical Clinics of North America - Vo!. 53, No. 3, May, 1969
703
704
CAROL
FLEXIBLE SHOWER MIRRO
MIRR
ARM
R.
FLEXIBLE ARM
SMITH
HOWER
OPEN UNDER NO CURB
E~VATION
PLAN
A
ELEVATION
~--9'-0' - - - - I
1-1
PLAN
B
1--:-::.---:--- 9 ' - 0 " - - - - - 1
6" \
~ ~,
DOOR TO SWING •• ,OU:
)
FLOO~
PLAN B
Figure 1. Small wheelchair bathrooms: a 4'6" x 9'0" area converted into a small bathroom for independent use. Plan A, To be used from a wheelchair by transferring to the toilet and to the shower bench. Plan B, To be used with a shower-commode chair that wheels directly into the shower and over the toilet.
the natural first area to attract specialized attention for study and analysis of obstacles. To begin with, a standard wheelchair measures approximately 4 feet from the front of the footrest to the back of the wheels and is 26 inches wide; standard arms are 29 112 inches high. Hence, the low counter required for working in a sitting position should be about 31 inches high and the space below should be left open to provide comfortable leg room. Obviously, this is a change in pattern from the standard kitchen. The second requirement for the cook in a wheelchair is to reduce her need to move the chair to carry items back and forth. Toward this end, the kitchen sink and cooking top should be within easy reach of each other, and there should be a continuous connecting counter on which pots and utensils can be slid rather than carried between these two areas where most of the heavy work of cooking is done. On the basis of these principles, the ideal wheelchair kitchen should be V-shaped, a dead-end wraparound kitchen, wherein the homemaker can maintain herself in one key position. The following are its basic specifications: 1 The sink and cooktop are located within comfortable reach of each other in a continuous worktop (31 inches high and open underneath for knee and leg room). One other worktop or pull-out board about 27 inches high is provided for easy cutting, mixing, and chopping. A wall oven, preferably side-opening, has a pull-out board located directly below it to facilitate handling of hot and heavy pans to and from the oven. A refrigerator has its door so hinged that it can be approached in the wheelchair, with a counter top next to the open side for loading and unloading, and
705
HOME PLANNING FOR THE SEVERELY DISABLED
with freezer storage located at the bottom of the unit with an easy-opening door. Ample and easily accessible storage spaces are built for frequently used items.
WHEELCHAIR BATHROOMS: SMALLER, NOT LARGER The bathroom, commonly the most difficult barrier for all disabled patients, was the next logical area for study. Research in bathroom planning has shown that, as with the kitchen, the same two sets of facts constitute the elements which must be correlated to effectively plan a functional arrangement for independent use by the disabled. This planning should always be done in close cooperation with the rehabilitation therapist who is training the patient in performance of his activities of daily living. Further, since bathrooms and bedrooms are usually located off a hallway, the dimensions of the hall passageway and of the doorways are important in planning to determine whether they are accessible to a wheelchair. Three different basic wheelchair bathroom designs have now been developed and in actual practice seem to solve most common housing situations. The small wheelchair bathrooms (plans A and B) are very
ELEVATION OF TOILET WALL
ELEVATION OF SINK WALL
SHOWER CURTAIN ROD
ROLL-IN- 5 HOWER NO CURB - LEVEL FLOOR
I------~ 9'-0 ..-----1 FLOOR
PLAN
ELEVATION OF TUB So SHOWER WALL
Figure 2. Family bathroom planned to accommodate the disabled. Designed to be used independently from a wheelchair by transferring to the toilet and to the shower bench, or with a shower-commode chair. The sink is directly in front of the door, to be easily used, and is purposely located to be accessible while the user is seated on the toilet. For the rest of the family, there is a tub with a standard shower. For the disabled, there is a roll-in shower with flexible shower arm, and for those who can safely use the tub, it has been located with ample room for an end approach.
706
CAROL
I--
1 -' -
;- I ---'- :-; :-
=
THERF~~~~JiC
/
MIRRO
~CONTROL
/
~I-
I~
ELEVATION OF TOILET WALL
- . T1 t :r II : d- :-
i
SMITH
J
-
'~T
R.
~
"
-L.OUTLET
~ OPEN
I
UNOER
ELEVATION OF SHOWER 8 SINK WALL
-5'-S'~ r--30'~
ROLL-INj SHOWER
'0 T
on
Figure 3. Minimum bedroom-bathroom plan for the severely disabled. A 5' 10" x 5'6" area with a roll-in shower and toilet to be used independently with a shower-commode chair. Because of limited floor space the wash bowl has been placed out in the bedroom.
o I
j
T
BED
-~~~.1:::J
ll-~'------II '_S" ----~--II FLOOR
PLAN
practical plans which make use of "borrowed" space taken from the bedroom, an existing lavatory or an adjoining room. The family bathroom (plan C) is a solution for the severely disabled in a one-bathroom house. The minimum bedroom-bathroom (plan D) is useful when it is totally impractical to adapt the existing house and there is no alternative but to add a new room for the patient. The predominating features of these designs are: A wash bowl placed in a counter top easily accessible from the wheelchair. The toilet positioned properly for transfers. A shower without a curb, with a stable seat, and located to permit easy transfers. A door hinged as a safety precaution to open out from the bathroom. Drawers for storage installed on nylon rollers rather than the usual style of bathroom cabinets.
If the patient is physically unable to perform transfers safely, then a shower-commode chair which rolls over the toilet and directly into the shower should be considered for toileting and showering. Showercommode chairs of sturdy construction with good brakes are now available that can be safely and independently used by the severely disabled.
HOME PLANNING FOR THE SEVERELY DISABLED
707
To plan a bathroom simply on the basis of spaciousness with ample area for easy maneuverability of a wheelchair is a waste of floor space that people can ill afford. The important principle is the placement of standard equipment in compact relationships that are accessible to the particular patient. As a result, many homes can be adapted without necessitating extensive renovations to the entire house. Though less of a problem, bedrooms also must be planned and rearranged to permit optimal independence in dressing and bed activities. House entrance obstacles such as steps and porches may present serious problems by restricting mobility. The conventional entrance ramp is seldom a practical solution because of small lots, defacement of property, and difficulty of use in bad weather. Small electric outdoor wheelchair lifts frequently provide the simplest answer.
THE SERVICE IN TERMS OF THE PATIENT Home planning evaluation is initiated as soon as a patient's functional level can be predicted medically and as early as possible in the hope that home changes will be completed by the time the patient is discharged. Informal consultations with the patient and his family are frequent during all of the planning stages, so that the new arrangements will also be practical for the rest of the family. The home planning consultant works closely with the physical and occupational therapists who know how the patient functions. Also, since the social importance of being independent in daily living and its implications for the entire family are now well recognized, the social worker plays an essential part in helping the family to adjust to the necessary changes and stresses the importance of letting the patient manage for himself when he returns home. The Mechanics of the Service Because homes vary so widely, it is essential to evaluate each patient's housing individually, and, when possible, a home visit is made to get an accurate picture of the patient's total housing situation and to evaluate the feasibility for changes. On such a visit, one begins by first taking an over-all look at the plot and house plan, carefully noting the whole house in relationship to the driveway and garage. Someone should be available who knows the house and can identify the locations of plumbing lines and bearing walls, which need to be considered before planning any structural changes. The fastest and most reliable method of getting the dimensions is to have two people, one measuring with a steel rule and the other recording the dimensions in the form of a rough sketch on a pad OP/4 inch grid graph paper held on a clipboard. The overall length and width of each specific area are recorded first, and then the locations of the doors, windows, and furnishings. Doorways are always measured from the inside of the frame to the nearest part of the door standing in its open position, which is the narrowest part of the opening. Using approximately one grid square to a foot, the parts of the area can be kept in relatively true proportions to
708
CAROL
R.
SMITH
the whole. From this diagram with its dimensions, an area of the home can be simulated at the hospital. Here the patient practices to determine whether he will be able to function in his wheelchair at home. When it is not possible to make a home visit, one may establish a working pattern for planning by long distance with the family. A freehand sketch is made on graph paper from the patient's description of his home, as he remembers it. During this consultation, it is helpful to keep a steel rule handy so that when the question of sizes and shapes come up, it can be used to help in estimating approximate dimensions. From this description, a simple drawing is made and a letter is sent to the family asking for accurate measurements and details and for correction of any mistakes. If perchance the family is planning a new home or an extension to their existing one, suggestions are planned directly on the architect's or contractor's working drawings. The final· recommendations, a scale drawing with specifications to implement the changes, must be simple and clear so that prints can be used by the family or sponsoring agency to receive bids and select a contractor for the work.
A WORD ABOUT FINANCING If finances are no worry, then there is no problem in carrying through with the necessary changes. When only limited funds are available, suggested changes must be planned within the scope of the budget. Where there are no funds and the patient can qualify for assistance under the public program of vocational rehabilitation, the necessary changes may be financed by the state rehabilitation agency. In addition to counseling, diagnostic, and physical restorative services, disabled clients of such an agency are eligible for the training, tools, equipment, and "other goods and services necessary to render a handicapped individual fit to engage in a remunerative occupation." Because homemaking is classified as a remunerative occupation, homemakers are thus eligible for these services, including home changes if these make the difference between being employable and being unemployable.
HOME PLANNING FOR MRS. D.: AN EXAMPLE CASE At the onset of illness, Mrs. D. was a 44 year old wife and mother of two teenage boys. She became a quadriplegic secondary to a cervical spinal abscess. The following suggestions were based on a homemakinghomeplanning evaluation, a home visit, and frequent consultations with both Mr. and Mrs. D. The drawings show the changes recommended for Mrs. D.'s kitchen and for a downstairs bedroom with bath which would make her independent in daily living and let her resume her homemaking activities. THE KITCHEN (Figure 4). On the home visit, it was determined that the rear entrance to the kitchen could be made easily accessible to a wheelchair if a wheelchair lift were installed beside the existing back porch.
709
HOME PLANNING FOR THE SEVERELY DISABLED
In the kitchen itself, none of the existing cupboards, counters, and equipment would be accessible to Mrs. D., so a new "wheelchair kitchen" (31 inches high and open under the counter for leg room) was planned for convenience and the maximum conservation of her limited energy. A comfortable space was also provided for eating in the kitchen. This new plan includes the following features, which have proved to be the most practical for a chair-bound homemaker: The sink with a single-lever faucet and cooking top with front control panel are located in the continuous counter so that they can both be reached from one sitting position and pots and pans can be slid back and forth rather than lifted and carried between sink and range. A pull-out board is provided 28 inches above the floor with a hole to secure a mixing bowl for the most comfortable use at this work space. A wall oven has a side opening door and pull-out board below to facilitate use from a wheelchair. An electric dishwasher (recommended in this case because it saves so much energy) is 36 inches high and installed to the left of the continuous counter. The refrigerator has a freezing compartment at the bottom of the box, easily accessible from a wheelchair.
j
OPEN
UNDER~-'L
.,.-_-"k24"1'~~'~~i;~;--1 SINK WALL
ADAPTED
~r::--'2;;;5'"~+-;--;;2-:;4"·--r-:-9-;:;,~1-t5--'.2;:::4:;r"-1-f'---..JI ELEVATION OF COOK TOP WALL
ENTRY
O[J CLOSET
r9
~~ 30.---lr-----'=========------~ t
DINING ROOM
~R
~
30" --k-- 30"--1
ELEVATION OF REF. WALL
FLOOR PLAN Figure 4.
[
Proposed kitchen changes for Mrs. D.
710
CAROL
tr 12" DEEP SH ELF /"'"
SMITH
BOOK SHELVES
TIllI1
T T '-,.
R.
I;:
DOOR TO
MIRRO
/; '==
~
T>
LIVING ROOM
~
1---30" + 36"-j ELEVATION OF INSIDE WAL~ ~o
/
~~
LlVING/RO O INSIDE
~12
'i----
WALL
C)
I
OPEN PORCH
I ...
-I
ISI-O"
FLOOR
~I
G--:
SHOWER
DRAIN TRQUGH ==- 1
0
I
-0)
J
PLAN
D 1 2 " I
1---36"- -+-36" -t- 4-1 ELEVATION OF OU1SIDE WALL plan for Mrs, D, (a), Move open porch wall as shown, -bath bedroom Figure 5, Proposed sink-van ity top 31 inches high; Cb), Install toilet and flexible shower arm in partition ; make and raise floor to level of add shelves, drawers, and closet. Cc), Provide electric panel heating living room floor.
controls at the The combin ation washer- dryer is front loading and has the laundry can be done front so that it is easy to use from a chair, and a comple te without any lifting of wet and heavy clothes.
The Three structu ral change s were require d for this installa tion. were kitchen and existin g partitio n and cupboa rds betwee n the pantry feet to the remove d, the door to the back apartm ent was moved about 3 were lines supply and waste ing plumb the corner of the kitchen , and . window the of front in wall outside moved to the
HOME PLANNING FOR THE SEVERELY DISABLED
711
THE BEDROOM AND BATH (Figure 5). With an additional 7 feet taken from the adjoining front entrance porch, the existing small enclosed porch was converted into a practical unit planned for independent living. Before these changes were made, Mrs. D. was sleeping on this porch because it was impossible for her to get upstairs. The open view through the front yard and trees to the street made it a pleasant place, but the cramped room was not winterized, and there were no bathroom facilities. The plan shows a simple but very comfortable arrangement with shelf space around the bed and easily accessible clothes storage cabinets taking up a minimum of floor space. The washbowl and dressing table shelf with drawers facilitate self-care. The toilet compartment is designed to be used with a shower-commode chair and is planned with a flexible shower arm and special floor drain so that Mrs. D. can use the same space as a shower stall while in a sitting position. (The plumbing waste and supply lines for the upstairs bathroom are conveniently located to tie into the new installation.) To winterize the space, a new floor with insulation below, about 2 inches thick, brings the finished floor level with that of the adjoining living room, and electric panel heating units are installed in the front window wall. Other structural changes were moving the partition over on the front porch and relocating the entrance. It was felt that with these changes in the house, Mrs. D. would be able to manage without the services of a homemaker-health aid and resume her own homemaker position in the household. She thus qualified for assistance as a homemaker under the Division of Vocational Rehabilitation in the State of New York, and these home changes were sponsored in part by this agency.
REFERENCE 1. Wheeler, V. H.: Planning Kitchens for Handicapped Homemakers. Rehabilitation Mono-
graph XXVII. New York, Institute of Rehabilitation Medicine, 1965.
400 East 34th Street New York, New York 10016