Introduction
Nearly all older Canadians say they would prefer to age in their own homes and communities, a finding that anchors the National Research Council's Aging in Place Challenge program (NRC). The home is also where most falls among older people occur (University of Sydney).
Falls are the leading cause of injury-related hospitalizations and injury deaths among Canadians aged 65 and older (Public Health Agency of Canada). PHAC's earlier Seniors' Falls in Canada: Second Report estimated that 20% to 30% of older Canadians fall each year (PHAC). In fiscal 2023/24 there were 81,599 fall-related hospitalizations among adults 65 and older outside Quebec, a crude rate of 14.1 per 1,000. These count hospital stays, not unique individuals (Yao et al., 2024).
Home modification can reduce environmental barriers and hazards without asking the person to change. Renovators bring expertise in building. Occupational therapists bring expertise in how a person's abilities and daily activities fit their surroundings. Written from the perspective of an aging-in-place service provider, this commentary argues for bringing that clinical expertise in earlier, sets out what the research does and does not show, and proposes how renovators, clinicians, homeowners, and government can work together. I have not identified published Ontario-wide data measuring how often occupational therapists participate in aging-in-place renovations. This commentary therefore makes a case for collaboration without estimating the size of that practice gap.
What the evidence shows
A renovator assesses a building. An occupational therapist assesses a person in a building: their mobility, transfers, balance, vision, routines, and how these may change. The question is when that second perspective adds value, and the research gives a qualified answer.
A major synthesis is the 2023 Cochrane review by Clemson and colleagues, which searched the literature through January 2021. Across several types of environmental intervention, it included 22 studies and 8,463 participants. In the pooled analysis of home fall-hazard reduction (12 studies, 5,293 participants), these interventions probably reduced the rate of falls (rate ratio 0.74, 95% CI 0.61 to 0.91, moderate certainty). Among people at higher risk, such as those who have fallen in the past year, been recently hospitalized, or need support with daily activities, the evidence is high certainty (rate ratio 0.62, 95% CI 0.56 to 0.70; 9 studies, 1,513 participants). Among people not selected for fall risk, the review found no evidence of a reduction (rate ratio 1.05, 95% CI 0.96 to 1.16) (Clemson et al., 2023). These are relative reductions in the rate of falls, not in the share of people who fall.
The review also separates hazard-reduction programs from renovations intended to enable daily activities, and found no eligible trials measuring falls for the latter. The evidence therefore supports targeted fall-hazard reduction. It does not establish the effect of every accessibility renovation.
Evidence on who should deliver the intervention is mixed. These programs are often delivered by OTs, who match a person's capacity and fall risk to the hazards in their home (University of Sydney). Occupational Therapy Australia, summarizing the review, reports a larger observed effect when OTs delivered the intervention (OT Australia). Even so, evidence that OT-delivered interventions outperform those delivered by other trained personnel is less conclusive than the evidence for targeting higher-risk people. In the UK, the 2025 NICE falls guideline recommends considering having home hazard assessment and intervention carried out by an occupational therapist (NICE NG249); this is UK guidance, not Ontario policy.
Two trials illustrate the uncertainty. In a three-arm pilot trial of 238 adults aged 70 and older with a recent fall, the OT arm had fewer falls than controls at 12 months (incidence rate ratio 0.54), while the arm assessed by trained non-OT assessors did not differ significantly from controls (0.78). Falls were a secondary outcome, and these reported comparisons with controls do not, by themselves, establish a statistically significant difference between the two intervention arms (Pighills et al., 2011). The larger UK OTIS trial, with 1,331 participants at higher risk, found no reduction in falls from a single OT-delivered home assessment and modification visit (adjusted incidence rate ratio 1.17, 95% CI 0.99 to 1.38) (Cockayne et al., 2021).
Builders deliver measurable benefit too. In New Zealand's HIPI trial, low-cost modifications such as stair handrails, bathroom grab rails, outdoor lighting, and slip-resistant surfaces, installed by qualified builders, were associated with an estimated 26% reduction in medically treated fall injuries at home (adjusted rate ratio 0.74). The households studied were not limited to older adults, and the trial did not compare builder-only work with OT and builder collaboration (Keall et al., 2015; Keall et al., 2018).
Read together, the evidence supports targeting: hazard reduction helps most where risk is highest. It does not show that every renovation needs an OT, or that collaboration guarantees better outcomes. The case for earlier OT involvement is a practice argument, and it is strongest where the evidence is strongest: for people who have fallen, been hospitalized, need help with daily activities, or face questions about transfers and equipment.
Possible barriers to collaboration
The four barriers below are offered as plausible explanations drawn from program rules, published research, and practice, not as proven causes.
1. Access to publicly funded OT is organized around assessed care needs. In Ontario, OT is publicly funded during hospital and rehabilitation stays. At home, it is available through Ontario Health atHome to people who meet eligibility criteria after assessment, and otherwise through workplace or auto insurance, Veterans Affairs, employer benefits, or private payment (College of Occupational Therapists of Ontario; Ontario Health atHome). Anyone can ask about access, and people should ask early. But because public service is organized around current care needs, a person planning a renovation before any need arises may have to pay privately for clinical advice.
2. Clinical recommendation and construction are arranged separately. Ontario's Home and Vehicle Modification Program illustrates the pattern. For construction, an OT must complete an assessment letter or a Verification of Disability Form that sets out the recommendation and what has been trialed, and the applicant separately obtains two contractor quotes (March of Dimes Canada, 2025 information package). Nothing in that process requires the OT and the builder to work through the design together. In the UK, researchers found that OT-led home modification lacked a defined design and construction process, and developed a protocol in response (Russell, Ormerod and Newton, 2018).
3. Each discipline holds part of the knowledge. Renovators are trained in building, not in clinical assessment or in how conditions such as arthritis, Parkinson's disease, or low vision progress. The gap can run the other way too: the Canadian Association of Occupational Therapists describes home modification as requiring knowledge and training that OTs are unlikely to receive in entry-level education (CAOT continuing education workshop, citing Meyer and Proganc, 2022). A shared vocabulary and working relationships can help collaboration.
4. Planning is often delayed. Many people put off planning for changing needs. In the Bloomberg feature that prompted this piece, Rodney Harrell of the AARP Public Policy Institute uses the term "Peter Pan syndrome" for the sense that other people will need support with age, but not oneself. He describes decisions being made after a fall, a hospital stay, or a loss (Locke, The Seniors Against Senior Housing, Bloomberg, 2026). Surveys point to practical barriers as well, including cost and not knowing whom to contact, discussed in the government section below. A homeowner who frames a renovation purely as a style project is unlikely to seek clinical input, and clinical needs may remain outside the renovation brief unless someone raises them.
What should be done
The evidence does not support sending an OT to every renovation. It supports a tiered approach: sound building practice for everyone, and clinical input where a person's risk, transfers, equipment, or changing abilities raise questions the builder cannot answer. The practices below are proposed guidance, not validated screening rules or regulatory requirements.
For renovators
Asking how a space will be used, and by whom, is good design practice. The aim is to gather the functional information a design needs while leaving clinical interpretation to qualified professionals.
For occupational therapists
OTs hold the clinical judgment a renovation may need. That judgment only helps the client if it carries through from assessment to construction.
For homeowners and families
Planning before anything forces the decision keeps the choices in your hands.
For government
Government holds the levers no renovator or clinician can pull alone: who can get clinical advice, when, and at what cost.
Ontario's Home and Vehicle Modification Program shows where clarity is needed. For construction, an OT must complete an assessment letter or a Verification of Disability Form setting out the recommendation and what has been trialed (March of Dimes Canada, 2025 information package). The ministry's program page states that funding may be used for an assessment completed after application, and for design and professional fees for approved work (Government of Ontario). March of Dimes' public "What We Fund" page lists eligible devices and modifications but does not address assessment costs (March of Dimes Canada). Reading these public materials together, I could not establish whether the initial OT documentation required to submit an application would be paid for, by whom, and at what stage. The administrator should make that distinction explicit. The program also states that funding is not guaranteed, and applicants must first make reasonable efforts to access other available public or private funding, excluding charitable organizations (March of Dimes Canada, program application).
This uncertainty may discourage an applicant. A household with limited income, facing an unclear upfront cost for an uncertain outcome, may reasonably decide not to start. I have not identified data showing how often this happens. It is a question the ministry and program administrator are best placed to answer, and to resolve.
Awareness is a second barrier. A 2014 survey by British Columbia's Office of the Seniors Advocate found that awareness of support programs was lowest among people over 75 and those with lower incomes (BC Office of the Seniors Advocate, March 2015). A 2025 report by Newfoundland and Labrador's Seniors' Advocate, based on a non-representative survey that included adults aged 55 to 64, found that 27% of respondents had adjusted their homes to accommodate changing abilities. In a separate question, 80% identified cost as a barrier older adults face in preparing to age at home; in another, 52% disagreed that they knew whom to contact or where to go for help adapting their home (Seniors' Advocate NL, 2025). In a national survey conducted in 2020 and published in 2021, 55% of Canadians identified paying for home modification as a challenge of aging in place (March of Dimes Canada). None of these measures current awareness of Ontario programs specifically, but together they suggest that information, not only money, stands in the way.
Six steps would make the path clearer:
Conclusion
A well-built renovation that does not consider how a person's abilities may change can leave them needing further work sooner than expected. The research supports targeted home fall-hazard reduction, most clearly for people at higher risk. It is less certain about who should deliver it.
Despite uncertainty about comparative delivery models, I believe earlier collaboration is a practical way to coordinate clinical recommendations and construction: renovators who ask the right functional questions and know when to suggest clinical input, OTs whose recommendations carry through to construction, and public programs whose rules people can understand before they spend money.
As someone who works every day to help people stay in the homes they love, I believe each of us can start with one change in our own practice.
To the occupational therapists reading this: what single change would make you more likely to collaborate with a renovator on a client's home?
Program and web pages cited were accessed October 5, 2026.