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Greer N, Brasure M, Wilt TJ. Wheeled Mobility (Wheelchair) Service Delivery [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Jan. (Comparative Effectiveness Technical Briefs, No. 9.)

Cover of Wheeled Mobility (Wheelchair) Service Delivery

Wheeled Mobility (Wheelchair) Service Delivery [Internet].

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Description and Context of Wheeled Mobility Service Delivery

Wheeled mobility service delivery is the process by which mobility impaired individuals are matched to wheeled mobility devices and provided services. This process has been described by a number of experts from the point of identification of a need for wheeled mobility to the point of replacement. These sources provide background, education, and guidance to the topic of wheeled mobility service delivery.

Our guiding questions were developed to direct our search of the literature and to focus our discussions with our key informants. Based on the information we gathered about the wheeled mobility service delivery process and how it occurs in practice, our findings for Guiding Question 1 (Technology) are presented under the heading (below) “Available guidance for the service delivery process.” Our findings for Guiding Question 2 (Context) are presented under the headings “Description of third party payers and current policies,” “Current practice of wheeled mobility service delivery,” and “Wheeled mobility service delivery elements.”

Available guidance for the service delivery process. The “Technology” (Guiding Question 1) being reviewed in this Technical Brief is the wheeled mobility service delivery process. The process has been outlined, in various levels of detail, by providers, organizations representing patients, payers, suppliers, researchers, and health care agencies. Some of the models presented are from the broader area of Assistive Technology (AT) while others are specific to wheeled mobility service delivery. While there are many common elements among these descriptions or models, there are also differences. The service delivery process for individuals with complex rehabilitation needs will differ from the process for an individual needing a wheeled mobility device for short-term use. How the wheeled mobility device will be paid for (Medicare, private insurance, out-of-pocket, etc.) may also influence the service delivery process as different payers have different requirements. With the exception of adherence to the steps required to obtain reimbursement, no service delivery process is mandated. Furthermore, no evidence exists to say that one source of guidance is superior to another or which steps are essential in obtaining an appropriate match between an individual and wheeled mobility system. The guidance described below represents individual or consensus expert opinion. Table 1 provides an overview of these sources. More detail is presented in Appendix D.

Table 1. Recommended elements of wheeled mobility service delivery.

Table 1

Recommended elements of wheeled mobility service delivery.

Once a patient is referred, the patient evaluation takes place. There is overall agreement that identifying the individual’s goals and needs, assessing various aspects of their ability (including physical, cognitive, and functional), and assessing the environment in which they will use the wheeled mobility device are important elements of the patient evaluation. With regard to equipment selection and delivery, equipment trials, offering users the opportunity to try out the proposed equipment assembled to meet their needs, are not consistently recommended. This may be, in part, because in some settings the equipment is not available, and in some reimbursement systems equipment trials are not covered. Furthermore, an equipment trial may be difficult due to the high degree of customization that is often required in complex rehabilitation cases. After the equipment is delivered, there is agreement on the need to train the individual and, if necessary, family members or caregivers, on the use of the equipment. A formal followup phase was recommended by many but, perhaps because followup is not reimbursed separately from the overall pricing of the product, it was not included in all of the delivery systems. Outcome assessment, one approach to determining the appropriateness of the equipment (e.g., usage, user satisfaction), was less frequently recommended.

The American Medical Association’s 1996 “Guidelines for the Use of Assistive Technology: Evaluation, Referral, Prescription” described the role of the primary care physician in meeting the needs of individuals with disabilities.17 These guidelines were developed by the Assistive Technology Advisory Panel with input from focus groups of consumers and allied health professionals. The primary care provider may be the person who initially identifies the individual’s need for assistive technology. An interdisciplinary team of physicians, therapists, rehabilitation engineers/technologists, durable medical equipment (DME) suppliers, social workers, vocational counselors, and caregivers/family members will likely be needed for more in-depth assessment, prescription, and training. Respect for the individual and caregiver goals, needs, and preferences, continual assessment of the status and goals, monitoring to ensure that the AT prescribed matches what was delivered, and documentation of goals, intervention provided, and outcomes achieved are elements of the rehabilitation processes that also pertain to service delivery.

The Paralyzed Veterans of America prepared a guide to eligibility for wheelchairs within the Veterans Affairs system.18 The steps to obtaining a wheelchair were also presented (Table 1). Clinical practice recommendations for patient evaluation included consideration of medical diagnoses, prognosis, functional abilities, limitations, goals, and ambitions.19

Cooper described an iterative process20 (Table 1) for AT service delivery in which outcomes are assessed and compared to goals. He suggested that the individuals’ perspective, objectives, and goals will evolve and should be regularly assessed. Given that inadequate training is a potential factor in predicting equipment abandonment, training for individuals prior to or at delivery and for rehabilitation professionals to keep abreast of new products was also recommended.

In a series of online lectures developed to provide an overview of the wheelchair mobility and seating evaluation process, Schmeler and Buning described a nine-step process for service delivery21 (Table 1). The screening step should focus on the needs and goals of the individual. Fitting, delivery, and training often involve the supplier, so selection of the right supplier is critical. Followup is especially important for individuals with progressive conditions.

Minkel outlined five steps for AT service (Table 1).22 A team approach was recommended with the individual AT user, payer, practitioner (physician, therapist, teacher, and counselor), supplier, and rehabilitation engineer included in the decisionmaking process.

In 2004 the Clinician Task Force of the Coalition to Modernize Medicare Coverage of Mobility Products 23 developed recommendations for wheeled mobility device coverage and presented the recommendations to the Centers for Medicare and Medicaid Services (CMS) Interagency Work Group. The goal was to “provide CMS with an objective and consistent process by which medical necessity may be determined and documented.” The Task Force addressed all steps in the service delivery process (Table 1) with particular emphasis on patient evaluation. They identified three levels of patient complexity—basic (requiring basic manual mobility devices with limited adjustability and simple seating support; typically recovering from a temporary medical condition or recuperating after a surgical intervention), intermediate (requiring a mobility device to meet typical daily functions or for independent mobility but with intact or good sitting balance and therefore simple or no seating and positioning needs), and complex (requiring extensive seating and positioning needs in addition to mobility assistance often as a result of neurological disease)—with a more in-depth evaluation required as complexity increased.

Cook and Polgar addressed AT delivery in their guide for clinicians and individuals. They described six steps24 (Table 1) and emphasized a collaborative and consumer-centered approach. Identifying needs and goals during the initial evaluation was believed critical as it would provide the basis for assessing the effectiveness of the final outcome, justifying the purchase to payers, and guiding the rest of the evaluation.

Guidelines from the WHO outlined eight steps in wheelchair service delivery (Table 1). The overall focus of the guidelines was on provision of manual wheelchairs in “less resourced settings.” The individual’s physical, environmental, and lifestyle needs should be considered. The guidelines further described “good practice” for each of the service delivery steps.

The perspective of the clinician was described by Taylor and Furumasu in the Industry Profile on Wheeled Mobility.25 Their focus was on the seating and mobility evaluation, but they outlined the overall process, as well (Table 1). They emphasized the need to evaluate seating first because postural stability, upper extremity function, and head control are factors in controlling and/or propelling a mobility device. They identified the primary individual needs as comfort, independence, and the ability to be mobile. The role of the supplier was also addressed. The supplier, ideally credentialed by RESNA and certified by the National Registry of Rehabilitation Technology Suppliers (NRRTS), is involved in equipment trials and selection of devices and features. They may also follow up with the individual in their home.

Batavia presented a nine-step approach to wheeled mobility service delivery26 (Table 1). Key steps included early identification of the funding source, as this might limit equipment options, selection of a knowledgeable, reputable supplier (certified, Medicare enrolled, experienced, available in emergency situations, convenient location for service, carry wide variety of products), and training (for individual and family/caregiver).

In addition to the overall process descriptions, providers have contributed suggestions for service delivery focused on specific populations. These include children,25,27,28 bariatric patients,29 patients with neurological or musculoskeletal conditions,30–33 and older adults.34,35

Descriptions of the AT or, more specifically, wheeled mobility, service delivery process have also been presented in the published literature. Di Marco et al.36 reported that, after a literature review identified no published standards of practice for wheelchair prescription, staff occupational therapists developed clinical guidelines for wheelchair selection, a maintenance education package, and a followup plan. Their focus was on three outcomes: abandonment of the wheelchair, satisfaction, and posture and comfort. They identified factors that influenced these outcomes and that should be addressed in the delivery process based on their experience with 128 patients over a 2-year period of implementing the guidelines. These factors included lack of active involvement of the individual in the prescription process, lack of training of professionals involved in the process, changes in the needs of the individual between prescription and delivery, poor device performance, and unsatisfactory design features and poor fit. Measurement tools, while not validated, were identified for assessment of service delivery from user (satisfaction, comfort, posture, management skills, maintenance knowledge), technology (stability, durability, need for repair/modification), and process (provision of education, followup, waiting time between prescription and delivery) perspectives.

Ripat and Booth interviewed six providers, seven funders, and five individual users to identify the components of ideal AT service delivery.37 Three themes emerged. First, the user of AT is a unique individual within his or her environment. The user must be the focus of all decisionmaking, and individuals should not be classified on the basis of their diagnosis, age, or the type of equipment they require. As part of the service delivery, it is important to identify the individual’s priorities, current and future abilities and needs, and the resources available to the individual (financial, human, and environmental). The second theme related to allocation of equipment in a fair and equitable manner. The individuals’ “needs” should be identified and their “wants” should be considered. It is important to match the AT to the individual within their context. Finally, given the complexity and rapid development of AT devices and services, AT should be considered to be broader than just a device with a single purpose. The device impacts the individual’s safety, health, comfort, socialization, quality of life, and self-esteem. Beyond the cost of the equipment, costs of training and maintaining equipment in the individual’s environment should be considered.

The most comprehensive process description was presented by Eggers et al.38 The focus of the work was on individuals with spinal cord injury being evaluated for a primary replacement chair. In addition to the seven-component model for overall service delivery (Table 1), sub-models were developed for each component. Service delivery may be influenced by individual user factors, provider factors, supplier factors, payer factors, and system factors.

Numerous authoritative and comprehensive descriptions of the wheeled mobility service delivery process exist. These sources can offer education or guidance to providers and other stakeholders. However, conversations with key informants provided little assurance that these models are fully utilized in actual practice.

Description of third-party payers and current policies. For all wheeled mobility users, an important element of the “Context” (Guiding Question 2d) in which wheeled mobility service delivery occurs relates to the payer. There are a variety of funding sources for wheeled mobility devices (including Medicare, Medicaid, Veterans Affairs, worker’s compensation, vocational rehabilitation, and private insurance), each with different service delivery processes. Although payers do not specify the steps in the delivery process, third-party payer coverage policies determine the equipment, features, and services that are reimbursed for enrollees.

Medicare is a major source of reimbursement for wheeled mobility. CMS last modified the Medicare National Coverage Determinations Manual in 2005.39 The current coverage is based on mobility-related activities of daily living—activities such as toileting, feeding, dressing, grooming, and bathing.

Mobility assistive equipment (MAE) is one aspect of the DME benefit category. DME is defined as equipment that (1) can withstand repeated use, (2) is primarily and customarily used to serve a medical purpose, (3) generally is not useful to an individual in the absence of an illness or injury, and (4) is appropriate for use in the home.40

Prescription guidelines were included in the CMS 2005 Decision Memo for Mobility Assistive Equipment.40 The guidelines were derived, in part, from the work of the Interagency Wheelchair Work Group, physicians, therapists, researchers, and policy specialists with practical experience with mobility device utilization issues.41 The CMS guideline development group also reviewed the evidence presented in an unpublished technology assessment on the topic. The resulting guidelines identify assessment of the individual’s physical, cognitive, and emotional limitations and abilities, their willingness to use MAE on a regular basis, and their typical home environment as important for appropriate prescription. A series of questions, in the form of an algorithm, direct the clinician in identifying the appropriate MAE.

A second element of the review of policies related to MAE was the 2006 final rule on power mobility device regulation and payment.42 This document specified the responsibilities of physicians and other treating practitioners as well as suppliers. Specifically, the physicians’ or other treating practitioners’ responsibilities include (1) a face-to-face examination of the individual, (2) a written prescription submitted to a supplier within 45 days of the examination, (3) supporting documentation outlining the need for the power mobility device in the home, submitted to the supplier within 45 days of the examination, and (4) billing and payment for the face-to-face examination and for the work and resources required to compile the supporting documentation. The supplier, having received the prescription and supporting documentation, must identify the specific type of power mobility device to fill the prescription.

A third phase of the CMS initiative is development and implementation of quality standards for suppliers of DME.43 The standards pertain to Business Service and General Product-Specific Service and specify supplier qualifications and specific responsibilities related to intake, record keeping, product trials, delivery and set up, and training and instruction.

Another major payer is Medicaid. Each state establishes its own coverage policies but many follow the CMS policy. As with CMS, the focus is not on the wheeled mobility service delivery steps but rather on the qualifications of the prescriber and the documentation of need for a particular device.

A third major payer for wheeled mobility is the VA. Information from the Paralyzed Veterans of America and the Veterans Benefit Department outlines the VA policies.18 Veterans who meet eligibility for prosthetic service and have a disability that requires the use of a wheelchair may receive a wheelchair and a backup chair. Power mobility devices may be used to access medical care and for tasks of daily living in the home and community.19 Repairs and replacement chairs (based on whether the chair meets the patient’s requirements or the estimated costs of repairing the chair) are also provided.

Other elements of the “Context” (Guiding Question 2 a, b, c, e, and f) are addressed in the “Current practice of wheeled mobility service delivery” and “Wheeled mobility service delivery elements” sections below.

Current practice of wheeled mobility service delivery. The actual practice of wheeled mobility service delivery was a topic of discussion with a number of our key informants. In practice, the process of wheeled mobility service delivery begins with the recognition of mobility limitations and action taken to address these limitations. At their own recognition or that of a provider or family member, an individual enters the wheeled mobility service delivery process. Entry to the process may be via a rehabilitation department after an injury or stroke, through a provider referral based on a progressive condition, through a supplier storefront, or through an advertisement. We have focused this report on individuals who have complex needs and who will therefore likely work with a team of specialists to obtain appropriate wheeled mobility equipment. We further describe the process for an individual working with a third party payer. For these individuals, a physician referral is required by many payers. We recognize that individuals may obtain wheeled mobility devices in other ways (e.g., out-of-pocket/retail, VA, vocational rehabilitation).

As summarized from input from providers, suppliers, consumers, and payers on our key informant panel, once the need for wheeled mobility is recognized (potentially by a physician, therapist, family member, or other) and the individual finds his or her way into the process, an assessment is conducted. Ideally, a physical therapist (PT) or an occupational therapist (OT) specializing in seating and mobility performs the assessment. A physician may also be involved. Both current and future needs and abilities should be considered. The assessment process can vary in intensity based upon the complexity of the individual’s medical condition and functional needs. A rehabilitation technology supplier is typically involved in the assessment to assist the therapist in identifying the appropriate equipment. While the individuals and their care teams are knowledgeable about the individuals’ goals and their physical condition and functional needs, the supplier has the expertise in selecting the technology that can match the identified physical and functional needs. Although ideally the assessors are unaware of the patient’s funding source and are focused on maximizing the patient’s functional ability, consideration must be given to what will be reimbursed. Equipment options (given funding limitations) and potential sources of additional funding should be reviewed with the patient. Once the assessment is complete, a prescription and a seating and mobility system recommendation in the form of a letter of medical necessity is written by the physician and forwarded by the supplier to the third party payer.

Occasionally, the supplier will provide trial equipment so the patient has a chance to try it out before committing to the purchase. Ideally, a home assessment or a home trial will be included in the service delivery process in an effort to design a system that will work well in the individuals’ home. Work environments (as appropriate) and transportation needs should also be addressed.

Once the third-party payer authorizes payment, the supplier can order the equipment. Seating and mobility systems for complex needs often require parts from several manufacturers. The supplier assembles the system that he/she designed and ordered and delivers the system to the patient. Ideally, with the therapist present, a fitting and any necessary adjustments or programming are completed at delivery. Based on our conversations with key informants, there is little followup after the delivery. Although many outcome assessment tools have been developed to assess patient satisfaction and functional ability when using a wheeled mobility device, our key informants reported that outcomes were rarely formally assessed.

Wheeled mobility service delivery elements. Theoretically, many elements of the wheeled mobility service delivery process can affect the quality of the match between the individual and the wheeled mobility device.

Access to high quality providers. Identifying high-quality providers and suppliers and having access to those providers and suppliers is an important component in achieving appropriate wheeled mobility service delivery. Certification for providers and suppliers is an objective way to identify those with more training in seating and mobility. Asking providers and suppliers about their years of experience, in particular, experience with the condition of interest to the individual, is another approach, although more subjective, recommended by key informants and others.26,36,44 In rural areas there are likely fewer certified and experienced providers and suppliers. Little is known about other factors that might limit access to high-quality providers.

Provider type and qualifications. The provider is another element that clearly influences wheeled mobility service delivery. Ideally, there would be a team of trained professionals involved in service delivery, including a physician, a PT or an OT, a certified rehabilitation technology supplier, and a rehabilitation technician. It is generally accepted that that PTs and OTs have the training necessary to perform seating and mobility evaluations. However, from conversations with key informants we have learned that most PT and OT education and licensure programs spend little time providing training on these skills. The providers that we talked to emphasized that their seating and mobility skills were learned and enhanced through continuing education opportunities (e.g., seating workshops, product in-services) and through their work experience. Professional certification is offered through RESNA. Their Assistive Technology Professional (ATP) certification is focused on broad-based knowledge of assistive technology. RESNA has also developed a specialty certification, Seating and Mobility Specialist (SMS), focused on seating and mobility assessment, funding resources, implementation of the intervention, outcome assessment and followup.45 Suppliers are credentialed through the NRRTS. The Certified Rehabilitation Technology Supplier (CRTS) is a Registered Rehabilitation Technology Supplier (RRTS) with at least 4 years of full-time experience in seating and wheeled mobility provision.46

Setting. Key informants recommended that patients be seen in a hospital seating clinic. The clinic will likely be staffed with PTs, OTs, rehabilitation engineers or technicians, and others.

Steps in the service delivery process. Many of the commonly performed or recommended steps in the service delivery process have obvious links to the quality of matching individual and device and the resulting outcome. Training and patient education have been identified as important factors in reducing accidents,47 preserving limb function,48 and increasing use of the wheeled mobility device.49,50 Involving the individual in the prescription process may reduce the risk that the device will be abandoned.12,13,36 Active followup has been found to reduce accidents51 and allow for adjustments to improve fit.36

The ultimate goal of the process is to obtain a good match between the individual and the device. A good match will reduce nonuse or inappropriate use of seating and mobility equipment and features.49 As described above, several factors can be expected to influence how well this process works. The next section of this report, Evidence Map of Wheeled Mobility Service Delivery, describes available evidence applicable to support these expectations.

Evidence Map of Wheeled Mobility Service Delivery

Evidence. Searching the bibliographic databases for studies about the process of wheeled mobility service delivery yielded 2,106 titles (1,761 from MEDLINE, 303 from CINAHL, and 42 from ERIC). Of these, 18 primary studies qualified for inclusion. Hand searching yielded another 6 studies for inclusion, for a total of 24 studies. A reference flow diagram appears in Figure 1. An evidence map is presented in Table 2. As previously mentioned, evidence for Technical Briefs is not synthesized because their purpose is to describe the populations, interventions, comparators, and outcomes that have been studied and because of the relatively low quality of the available evidence on these emerging topics.

Figure 1 is a reference flow diagram for published, peer-reviewed studies about the wheeled mobility service delivery process. The literature search identified 2,169 references. A review of the titles and abstracts (if available) resulted in the exclusion of 2,151 references and the inclusion of 18 references. An additional 6 references were identified by hand-searching resulting in a total of 24 references included.

Figure 1

Reference flow diagram.

Table 2. Summary of studies on wheeled mobility service delivery.

Table 2

Summary of studies on wheeled mobility service delivery.

Study design/size. Included studies were published from 1986 to March 2011, with the majority of the studies published during the last 3 years. We read each study, and highlights are discussed in this text. Study designs for this limited body of research varied widely and included 1 randomized controlled trial, 1 quasi-randomized controlled trial, 1 controlled trial, 1 case-control study, 3 retrospective cohort studies, 16 cross-sectional studies, and 1 case series. More recent publications used higher quality study designs with a quasi-randomized trial published in 2005, a randomized controlled trial published in 2007, and a controlled trial published in 2010.

Sample sizes ranged from three to 318 and included individuals of all ages, with most studies focused on adults. Four studies included children; two focused exclusively on children.

Indication/patient inclusion criteria. Many types of consumers were represented in these studies, including individuals with spinal cord injuries, multiple sclerosis, spina bifida, cerebral palsy, rheumatoid arthritis, osteoarthritis, and stroke. Ten of these studies included a consumer population with similar diagnoses; three studies addressed individuals with spinal cord injuries, and one study each addressed individuals with spina bifida, rheumatoid arthritis or osteoarthritis of the knee, stroke, muscular dystrophy, amyotrophic lateral sclerosis, cerebral palsy, and neuromuscular disorders (broadly classified). Often the group of individuals in a particular study experienced mobility limitations related to the same condition, such as spinal cord injuries. However, wheeled mobility service delivery studies also occasionally addressed groups of individuals as wheelchair users from a particular service delivery clinic or geographic area. These studies provided a broader representation of individuals in terms of disease and conditions as may be the case in practice. Most of the included research was conducted on localized practices of wheeled mobility service delivery and took place in the United States, the United Kingdom, Canada, Sweden, Holland, the Netherlands, and Australia.

Elements of service delivery. The study purposes of these studies were primarily exploratory. Batavia and Hammer52 and Ward et al.53 set out to identify factors important to individuals when considering wheeled mobility options. McDonald54 and Telfer et al.55 assessed children’s caregivers’ and parents’ opinions about the wheeled mobility used by their child. Beaumont-White and Ham,56 Karmarker et al.,57 Pimentel,58 and Wressle and Samuelsson59 sought to understand user satisfaction with wheeled mobility device and service delivery. Their studies addressed service delivery within a particular service or regional area to describe user satisfaction and/or identify opportunities for improvement. White and Lemmer60 address similar questions with a more comprehensive data collection strategy.

Outcomes assessed. Most of these studies addressed consumer satisfaction with wheeled mobility and related services in some way. Seventeen addressed satisfaction with the equipment and ten addressed satisfaction with aspects of wheeled mobility service delivery.

Five of the studies we identified involved comparisons of one approach to wheeled mobility service delivery to another. Barlow et al.61 and Schein et al.62 compared in-person assessments with those done via telerehabilitation. These studies were both completed relatively recently, possibly indicating a trend towards more research on this topic. The other three comparison studies compared different treatment approaches, either different types of treatment or different approaches to assessment. Hoenig et al.63 compared an intervention including a multifactorial team approach to service delivery to usual care where a physical or occupational therapy assistant, PT, or OT provided a standard wheelchair at discharge. In a second study, Hoenig et al.64 compared the provision of a motorized scooter to adults with osteoarthritis or rheumatoid arthritis of the knee to usual care. While the primary purpose of the study was not to make a comparison, Dicianno, et al.65 compared outcomes between patients having assessments performed at specialized AT clinics to those that did not.

Samuelsson et al.66 analyzed outcomes in response to a seating clinic visit concerning a particular problem the individual was experiencing related to their wheelchair. Kittel et al.13 explored individuals’ reasons for abandoning their equipment.

Table 2 summarizes the elements of wheeled mobility service delivery and the outcomes addressed in the included studies. While 14 studies examined some aspect of the wheeled mobility service delivery process overall, other studies addressed particular elements of the process. Several authors explored opinions and views of consumers, and others aimed to identify aspects of service delivery important to outcomes. Elements of service delivery studied included access, setting, provider, patient education, device selection, device delivery, wheelchair user training followup, and maintenance and repairs. The outcomes analyzed in these studies included mobility, device usage, goal achievement, and satisfaction with the device and service provided.

Issues related to service delivery. Five studies reported patient dissatisfaction with various aspects of service delivery. Included were issues with wait times for appointments and equipment, provider training, patient involvement in the process, and equipment repair.

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