A Reference Guide for Occupational Therapists
Achieving a meaningful existence depends greatly upon a person’s ability to access his or her environment. In fact, Mary Reilly (1962), proposed the philosophy behind occupational therapy practice that focused on the need for people to master their environment. In many cases, a wheelchair is necessary for a person to effectively function in his or her surroundings. The absence of a customized seating and mobility system can potentially put clients at risk for medical, psychological and social complications. The problem is many health care professionals are not well-informed about the process for obtaining the appropriate wheelchair for a client. Therefore, the purpose of this article is to educate occupational therapists on the process of obtaining customized wheelchairs to improve their client’s quality of life.
Understanding the Significance
In 2016, 2.2 million people were using a wheelchair in the United States (CDC, 2016). Common diagnoses warranting the need for customized wheelchairs in the adult population are spinal cord injuries, cerebral vascular accidents, traumatic brain injuries, and multiple sclerosis (CDC, 2016). These conditions and the limitations they impose create a potential disconnect between the person and his or her ability to engage in the environment. Prescribing the appropriate wheelchair is an integral intervention necessary for a client to participate in meaningful occupation. It may be clear how the wheels of a chair can help someone navigate their surroundings, but the optimally-configured seating system is equally important. For example, getting to the dining table may be the first challenge presented during a meal. However, proper positioning for safe swallowing, adequate respirations, and maximum independence in the feeding task yields positive quality of life. Fortunately, for individuals with seating, positioning, and mobility needs there are many options available and a well-designed process for obtaining this equipment.
Custom Wheelchair Procurement Process
Occupational therapists are experts in assisting clients in reaching maximum independence in activities of daily living. An important part of occupational therapy practice includes recommending appropriate seating and mobility equipment. Collaboration with an Assistive Technology Practitioner (ATP) is required by the Center of Medicare and Medicaid Services to provide funding for customized seating systems (U.S. CMS, 2018). The Rehabilitation Society of North America is the governing body for ATP services and their guidelines will be referred to in this article (RESNA, 2011). Customized wheelchairs address vital components such as posture, skin integrity, respiratory function, mobility-related activities of daily living, comfort, and activity tolerance. Prescribing the proper customized wheelchair system will help individuals participate in their environment safely and effectively which contributes to their best quality of life.
Needs Assessment. The first step in the process for procuring the appropriate wheelchair is to identify a client’s needs. A wheelchair evaluation is necessary when a client has a change in condition warranting the initial need for a wheelchair or when the current system is no longer meeting the client’s needs. If the client is expected to require the use of a specialized wheelchair for more than six months, the occupational therapist (OT) contacts an ATP with a referral to perform an assessment with the prescription from a physician. The OT and ATP collaborate with the client during a formal wheelchair evaluation which examines body structure, bodily functions, activities, participation, environment and current technology (RESNA, 2011). The client’s goals are the basis upon which the customized wheelchair is designed. Information is gathered in the areas of anatomical alignment, postural control, sitting balance, skin integrity, vision, cognition, individual measurements, speech and language as well as neuromuscular, cardiovascular, respiratory, digestive and urinary systems (TMHP, n.d.). After the evaluation is completed, the equipment recommendation and selection phase will begin.
The therapist and ATP choose the base of the chair along with seating and positioning products from a diverse group of manufacturing companies. Manual and power options must be determined from the assessment findings which include technology for interfacing and managing the completed device. Frame categories include folding, rigid, tilt in space, power assist, and power mobility. Assistive technology such as sip and puff, alternate drive control, and augmentative communication may be used for drivability and positioning options. When possible, it is beneficial to provide the client with demonstration equipment to trial its efficacy especially when more intelligent technology is being considered (RESNA, 2011).
Funding and Procurement. RESNA (2011) lists funding and procurement as the next step of designing a customized wheelchair system, although it is common practice for the providing company to address this section prior to the evaluation. Investigating funding sources immediately following a referral provides clients with their financial options at the beginning of the process. Eligibility for customized wheelchair equipment is confirmed through payer sources such as Medicare, Medicaid, private insurance, Veterans Affairs, and private pay. Once coverage is identified, the ATP obtains quotes from each manufacturer needed to build the system. These pricing quotes and other documents are compiled and submitted to the funding source for pre-authorization to order the equipment. The required documents for approval differ for every funding source. Official forms are located at the Center of Medicare and Medicaid Services website such as the formal wheelchair evaluation, certification of medical necessity, product description and justification, and approved billing codes for all items recommended (U.S. CMS, 2018). Each packet must have signatures from the patient or caregiver/representative, OT, ATP, and physician. Once pre-authorization has been procured the client’s equipment can be ordered.
The ATP confirms the receipt of all items ordered then assembles the custom wheelchair according to the specifications from the evaluation. If specialty power controls have been selected, an initial set up of the patient-specific electronic parameters is also completed.
Delivery and Adjustments. The ATP delivers the customized wheelchair to the client with the OT present and performs the client-centered fitting and training procedure. All adjustments are made to achieve the planned results including seating, mobility, and mechanical components. Thorough training on the proper use of the system is provided to the client and caregivers to ensure the optimization of function, comfort, and safety. The extent of the delivery visit varies depending on the complexity of the device.
Once the chair has been delivered the distributing company is able to bill the funding source for the provision of services and equipment. The provider is required to follow-up on the equipment for all necessary maintenance and repairs for the client’s lifetime or as long as he or she uses the wheelchair. Typically, every five years there is potential to procure a new customized wheelchair depending on the funding source. In the case there is a significant change in medical condition within those five years, the client may be eligible for a re-assessment earlier. Funding sources do not reimburse for mistakes. However, the providing company is required to deliver the appropriate equipment even if the products ordered initially are deemed unsuitable. All equipment trialed on a client is essentially non-refundable.
Outcome Measures. The last step in the process for providing customized wheelchairs is to measure outcomes. To verify the efficacy of customized wheelchair provisions, RESNA recommends a baseline measurement of function and patient satisfaction be obtained before and after the final delivery of any system (RESNA, 2011). There are several standardized tests available to collect this data. An example of an outcomes measurement tool is the Wheelchair Outcomes Measure (WhOM) developed in 2007 by Mortenson, Miller, and Miller-Pogar. The WhOM is a client-centered assessment tool based on the World Health Organization’s international classification of function, health, and disability (WHO, 2018). Collecting data related to the effectiveness of customized wheelchair intervention supports improvement in the quality of patient care.
Adhering to specific guidelines for wheelchair procurement and prescription is necessary to provide clients with the best quality of care in the timeliest manner possible. Table 1 serves as a quick reference to the process for customized wheelchair provision and is intended to be useful in practice as a check off list to ensure all steps are completed. Conducting further research in the field of assistive technology will be useful for helping those in need of customized wheelchairs. Occupational therapy as a profession currently includes customized wheelchair seating, positioning, and mobility in its scope of practice (AOTA, 2010). OTs play a vital role in the procurement of assistive technology services and can act as a catalyst for improving a client’s quality of life.
Table 1. Wheelchair Provision Process
|Wheelchair Evaluation Inc. Baseline Patient Satisfaction Assessment|
|Equipment Recommendations and Selection|
|Delivery, Fitting, and Training|
|Patient Satisfaction Assessment-Outcome Measurement|
Note: This table was created by the author utilizing information from RESNA, 2011.
- American Occupational Therapy Association. (2010). American Journal of Occupational Therapy, 64, S70-S77. doi:10.5014/ajot.2010.64S70
- Center for Disease Control. (2016). How many people use assistive devices? National Institute of Health and Human Development. Retrieved from: https://www.nichd.nih.gov/health/topics/rehabtech/conditioninfo
- Mortenson, W. B., Miller, W. C., & Miller-Pogar, J. (2007). Measuring wheelchair intervention outcomes: Development of the Wheelchair Outcome Measure. Disability and Rehabilitation: Assistive Technology,2(5), 275-285. doi:10.1080/17483100701475863
- Reilly, M. (1962). Occupational therapy can be one of the greatest ideas of 20th century medicine. 1961 Eleanor Clarke Slagle Lecture. American Journal of Occupational Therapy, 16, 1-9.
- RESNA Wheelchair Service Provision Guide. (2011). Retrieved from https://www.resna.org/sites/default/files/legacy/resources/position-papers/RESNAWheelchairServiceProvisionGuide.pdf
- US Center for Medicare and Medicaid Services. (2018). Manual wheelchairs & power mobility devices. Retrieved from http://www.medicare.gov/coverage/manual-wheelchairs-power-mobility-devices
- Wheelchair/Scooter/Stroller Seating Assessment Form – TMHP. (n.d.). Retrieved from http://www.tmhp.com/Provider_Forms/PA_Forms/F00098_CCP-HHS_Wheelchair_Seating_Assessment_Form.pdf
- World Health Organization (WHO) (2018). International Classification of Functioning, Disability and Health. Retrieved from http://www.who.int/classifications/icf/en/