HME Today – Home Modification: A Conversation with Louis Tenenbaum, CAPS.

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The terms aging in place and universal design are tossed around, but what do they really mean? We asked Louis Tenenbaum (, a carpenter, contractor, consultant, and Certified Aging-in-Place Specialist (CAPS), for his take on the risks, rewards, and obligations of home modification. For more information, Tenenbaum has a monthly blog, which can be accessed at

Greg Thompson, editor of HME Today: What should providers know before they jump into the home modification business?

Louis Tenenbaum, CAPS: Get excited about this, but don’t think you know it all right away. So many people are hearing about this stuff, but you must slow down. Examine whether you have the resources to start something for which you don’t have experience. Understand the margins and the liabilities. I have seen dealers who take on this kind of work””and they get the work, but are broke 16 months later. They have blown the money from their company, because they did not understand the margins and liabilities. It is not drop off, delivery, and hook up, which a DME may be comfortable with. The contracting business is risky with different types of skills and long-term liability. It’s a call-back business. You do something and you think you have it covered. You hired a guy who said he knew what he was doing. Two months later, you’ve got damage on a part of the house that you didn’t even know you were touching””and you have to come up with the cash to resolve it.

Tools and Tactics


It’s a call-back business. It is not drop off, delivery, and hook up.
Universal design is about making things work for the largest part of the population, which now includes people with different abilities.
Think of universal design as equal accessibility to the best parts of the building, not just the minimum parts.
Recognize that you need to offer 24-hour service, or close to it.
Thompson: Why are home modifications gaining so much attention these days?

Tenenbaum: In the past, a small percentage of the population had a disability. Before the Second World War, people with spinal cord injuries, MS, and polio did not often survive. Now the people with these conditions are surviving, and if you want to include them, you need to move toward universal design. Universal design is about making things that work for the largest part of the population, which now includes people with different abilities.

Thompson: Is the Americans with Disabilities Act (ADA) responsible for sparking these innovations?

Tenenbaum: When you start to rethink for universal design, know that it is not about the ADA. The ADA is a civil rights ordinance that is about making sure people are included prescriptively. Universal design is a much bigger picture that is about the spirit of it. Think of universal design as equal accessibility to the best parts of the building, not just the minimum parts. For example, if you go through the lobby of a big building and it has an escalator that goes up through the lobby, that’s a dramatic thing. Part of the pleasure of the building is the drama you enjoy from that escalator. ADA says you have to have an elevator somewhere to get people up there. But if disabled people don’t get to enjoy the drama of the building, you may have met the prescription with that elevator around the corner or in the back, but you did not meet the spirit. A glass-enclosed elevator could approximate the drama of the building.

Thompson: What is aging in place?

Tenenbaum: Aging in place is a whole system of housing and care that gives people what they desire, instead of a needs-based system. People want to stay in their own home. They want to be independent. Right now, if you have a problem with your health, we shift you to assisted living because that’s a health care solution that happens to include a housing component. Aging in place keeps people in their own homes using a bunch of things including design, assistive technology, DME, and services””which might be someone to help you up off the toilet, or a better toilet with more room, and a walker or a grab bar nearby. People are now adopting the phrase without really knowing the scale of the shift.

Thompson: How can providers learn to assess the home and work as part of the health care team?

Tenenbaum: Start learning the language of the people you are going to be working with. The word “assessment” has a general meaning, and that is probably the general meaning that contractors use””figure out the situation the way it is right now. But assessment in the medical world is a term having to do with gathering information and putting it into a context that includes a prescription. You get a lot of occupational therapists who want to provide information, and have it attended to by a contractor who really doesn’t have a basis to understand and use the information. In much the same way, a contractor has lots of words””such as specifications, designs, joists, sash, and jamb. These are words that mean a lot to contractors, but not much to other people. When we enter a transdisciplinary world, we have to speak carefully, listen carefully, and confirm that communication has actually happened. The biggest way a contractor gets into trouble with clients is when he has different expectations than the client.

Thompson: Where does the communication usually go wrong?

Tenenbaum: When a health care professional writes a report with all this important information, the contractor glosses over it because it’s overly medical. We ultimately have a limited range of solutions. And the more universal those solutions are, the more they provide flexible opportunities for the client to meld their individual needs to the environment, the better. We want it generalized in a better way, so the client can bring his specificity to it.
Louis Tenenbaum
I would rather create a shower that anyone can use, than create a shower that is specific to a particular client. My client is going to change, get older. The house may have another person living in it in 10 to 20 years. Wouldn’t it be great if that bathroom was still valuable? When you think universally, you are trying to create the most flexible situation, rather than the most client-specific situation.

Thompson: What are the biggest risks of getting into this business?

Tenenbaum: There are issues of control, risk, and reputation. The more control, the greater your risk. If you are the contractor, you are the one who is going to take that risk financially. And you also have the chance for profit. Do you want to risk your reputation? Or do you want to distance yourself from the work that you are not as familiar with? Those are big issues, because it’s a risky business. You can’t just start selling this stuff, because you have to have that staffing. If you’re going to learn it, the typical installer of lift equipment understands the mechanics and the electronics.

To find more articles, visit our free archives section. In the archives, you’ll find a knowledge database including articles such as: March 2008 Retail Therapy By Ann H. Carlson

Thompson: What should a provider look for in a lift?

Tenenbaum: Most lifts are pretty good. I look for a dealer/installer program that combines the best warranty and service. Once you enter into this, you must recognize that you need to have 24-hour service, or nearly that. One of the dealers in this area gives a maintenance contract and that’s a good idea. This dealer has a three-level maintenance contract. He has two checks a year for everyone. Then there is the 24-hour call, the 72-hour call, or the 1-week call. For the dealer/installer, you have to stock parts for everything that you sell.

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