Over the last month or so, I have been reading and hearing from therapists that cost is often the initial factor that they think about when prescribing mid to high-cost assistive technology (AT). Honestly, this breaks by heart a little. It breaks my heart to think that therapists are missing a large piece of their clinical reasoning to get to the end point. Don’t get me wrong – I am aware of the balls that prescribing therapists are juggling – from billable hours, funding criteria, report writing, working across multiple clinical groups/ diagnosis, limited approved therapy hours and the list goes on. Despite all this, when cost is the first factor which is considered, it may decrease the initial time required during the initial assessment and even the report writing, but it often creates more difficulties down the track, as ultimately the client is being fitted to the equipment, not the equipment to the client.
Dr. Per Udden, the founder of Permobil, started the company with the believe that “Every person with a disability has the right to have his or her needs compensated as far as possible by the aids with the same technical standard as those we all use in our everyday lives.”
With this is mind, how do we ensure that we prescribe the best piece of AT for our clients, whilst ensuring the equipment is reasonable and necessary? Ultimately, this comes down to the initial assessment and goal prioritisation. The RESNA Wheelchair Service Provision Guide provides a detailed outline of the entire wheelchair prescription process and goes into considerable detail on the assessment process. The guideline outlines that the assessment should be thorough and include:
- Interview and History
- Physical Status
- Environment
- Functional Level and Lifestyle considerations
- Current equipment
Personally, to ensure that cost is not the initial factor which guides equipment prescription, I reach for the International Classification of Functioning, Disability and Health (ICF). I find the ICF model very practical and easy to use as it does not focus on a person’s disability, instead it focuses on their level of health (or function). This model oozes the mindset of an Occupational Therapist as it ensures that the person remains at the centre of the experience. It is the person that matters. Not their diagnosis. Two people with the same exact diagnosis will both have very different goals and different equipment needs. To assist in setting and prioritising goals the ICF looks at each life domain and can be fluid. If your client’s life or circumstances change, these changes can be reflected.
Lets look at each domain briefly:
Health Condition: Disorder/disease/diagnosis
Body Structures: This refers to the anatomical parts of the body. Specifically, when prescribing wheelchairs and seating I consider manual muscle testing, the MAT Ax, tone, spasticity, bladder and bowel function, vision, cognition, sensation, proprioception etc.
Activity: refers to how the person executes a task. Think about the bread and butter of Occupational Therapy here – Activities of Daily Living. How do they perform these tasks and why do they want to perform these tasks? Don’t forget to consider the tasks they are not doing here. Could the new AT assist them return to them or decrease informal care?
Participation: The involvement of life. What is important to the person in their life. Dig deep – is it work, school, sport, outings with their family, church? Investigate also what the person is not doing and why they are not doing it. It is perhaps the current AT limiting the person participating in their life? I know that I do not settle, neither should our clients.
Environmental Factors: The physical, social and attitudinal environments which the person lives. What is their home environment, where do they go or want to go outdoors, what is their work/school like, transport, terrains and the list goes on.
Personal Factors: who is the client, what do they believe and what is important to them? In a world where we get to prescribe AT based on function and participation and not under a medical model, understanding your participant will assist in ensuring that the equipment fits the person.
An in-depth overview of the ICF can be found here if you want to read up on it further: ICF Beginner's Guide: Towards a Common Language for Functioning, Disability and Health (who.int)
Through applying the ICF model and using this to guide your practice, you can establish and prioritise your client's wheelchair and seating goals. These goals then assist to determine the wheelchair and seating parameters. What are the non-negotiables of the wheelchair? Where does it have to go? What is the smallest space it needs to turn in? Or how far does it need to go for your client to get to work or what sport does your client want to play at lunch?
Spending the time to assess and understand your client, their goals, and what they want to do and where they want to go assists us to clearly outline the wheelchair and seating parameters. Having clear parameters will enable you and your client make compromises if needed and be clear on what the wheelchair will and will not do. – Even with the developments of technology, the unicorn chair does not yet exist.
Ensuring that you and your client are clear on the goals, equipment parameters and the priorities – will enable you to clearly justify and prescribe the most appropriate equipment and ensure that it is reasonable and necessary. It will be easy to justify as you and your client will be clear on goals, participation and outcomes. Yes – there is no doubt that doing an in-depth assessment, and taking the time to understand your client, their level of function and goals takes up more time. Doing this though, means that you don’t initially think about costs. I can assure you however, that the wheelchair and seating system that you do prescribe will be the most cost-effective long term option, as it will enable your client to participate in their life and achieve their goals. Don’t get me wrong – I don’t want us to prescribe equipment as though we have blank cheques, – however let’s make sure that what we do prescribe enables our clients to achieve their goals now and into the future. Let's aim for each wheelchair to be ideal for as long as possible for everyone.
So, when do you consider cost? I always stop and pause throughout the trial period. Are these goals appropriate? Is this the most reasonable piece of equipment? Is it the most cost effective both now and in regards to maintenance and servicing? It is the most cost-effective piece of equipment long term? By considering cost towards the end of our intervention, and not the start – this should enable you to prescribe the most cost effective and reasonable and necessary wheelchair and seating. Not only should it be the b=most cost effective, but it should end up being the most ideal piece of equipment to enable your client to achieve their goals.
If you are not sure where to start, please feel free to reach out to any the clinical services team to have a discussion education.au@permobil.com.
Resources:
RSENA Wheelchair Service Provision Guide: WC SVC PROVISION GUIDE - FINAL 6-1-11 (pitt.edu)
ICF Beginners Guide: ICF Beginner's Guide: Towards a Common Language for Functioning, Disability and Health (who.int)
Tilly Brook
Clinical Services Specialist
Permobil APAC
Tilly Brook graduated from the University of Adelaide in 2008 with a Bachelor of Health Science followed by a Masters of Occupational Therapy (Hons) in 2010 from the University of Sydney. Tilly worked within rehabilitation, working primarily with adults with a brain injury until 2015 when she moved to Singapore. In Singapore, she worked with children and adults at the Cerebral Palsy Alliance School (CPAS). In 2017 Tilly’s clinical knowledge continued as she worked with Mobility Solutions in Auckland, New Zealand. On her return to Australia, Tilly assisted in the development of the Clinical Hub Team at Sunrise Medical where her passion and experience for mentoring and educating therapists grew. Tilly Joined Permobil in January 2022 and is driven to grow therapists, enabling them to be the best therapist they can be.