FOOTWEAR PRESCRIBERS’ ONLINE WORKSHOP Rehabilitation Appliances Program (RAP) 2011

THE WORKSHOP The aim of the workshop is to: provide you with a better understanding of the Department’s requirements relating to prescribing and supplying medical grade footwear.

Rehabilitation Appliances Program (RAP) The aim of RAP is to keep veterans in their own homes as long as possible and Provides equipment or appliances for self help and rehabilitation

RAP Program provides: Aids to daily living eg mobility aids, home modifications Treatment aids eg continence products, oxygen Medical Grade Footwear (since July 2000)

Spending of public money DVA, RAP can lawfully utilise public money in the provision of aids or appliances to eligible beneficiaries under the provisions of: Section 90 of the Veterans’ Entitlements Act and Treatment Principles Part 11 The link below offers in depth material – Federal Register of Legislative Instruments (Frli): http://australia.gov.au/topics/law-and-justice/legislation

Who is Eligible Gold Card Holders - full range of treatment (footwear supplied where clinically necessary) White Card Holders - full range of treatment for accepted disabilities (footwear supplied where clinically necessary for accepted disability) ** White card holders need prior approval before podiatry and footwear treatment

The Cards GOLD card holders assessed on basis of clinical need The TPI Gold Card looks the same but references Totally & Permanently Incapacitated http://factsheets.dva.gov.au/factsheets/ http://factsheets.dva.gov.au/factsheets/ Gold Card http://factsheets.dva.gov.au/factsheets/

No eligibility for RAP items Pharmaceuticals ONLY WHITE card holders assessed on basis of clinical need related to an accepted disability (AD) http://factsheets.dva.gov.au/factsheets/ No eligibility for RAP items Pharmaceuticals ONLY FACT SHEETS WHITE CARD http://factsheets.dva.gov.au/factsheets/ ORANGE CARD http://factsheets.dva.gov.au/factsheets/

MEDICAL GRADE FOOTWEAR (MGF) MGF Review An initial review undertaken in 2004/05 The review included the definition of what constitutes MGF Footwear clinically prescribed for the purpose of correcting, alleviating or replacing deficiencies or deformities in gait, feet or lower limbs. As part of this review the MGF Register of suitable footwear was compiled

MEDICAL GRADE FOOTWEAR Review of MGF Register (an accepted list of footwear which meet specific criteria, and referred to as medical grade) undertaken in 2010 Some shoes removed due to their not being considered clinically appropriate Suppliers of MGF are selected from an open tender process, last completed 2010.

MEDICAL GRADE FOOTWEAR Definition: Footwear clinically prescribed for the purpose of correcting, alleviating or replacing deficiencies or deformities in gait, feet or lower limbs. MGF is prescribed when readily available everyday footwear cannot be used or modified for this purpose.

Medical Grade Footwear Ready-made Depth/Width Ready-made has specific features that accommodate foot abnormalities. Listed on Register of DVA Approved Ready-Made Depth/Width Medical Grade Footwear. Determined by a technical advisory panel according to specific technical criteria. Custom Made Manufactured to individual specifications.

Examples of Technical criteria Examples of technical criteria for ready-made Depth/Width footwear include a defined: Min Depth 6.0mm added evenly along the last. Inside back heights a min. of 67.0mm for size 7 women’s shoes and 72.0mm for size 9 men’s shoes, with a 2.0mm difference in back height between each size. Min Width should be avail in 3 width fittings with a minimum width sizing of a standard EE forefoot. Design should allow for easy donning and doffing. The shoe should be lace up, velcro or buckle closure and able to be modified in this respect. Quality and thickness of materials used for soles, in uppers, linings and torsional stability.

Examples of Ready-made Depth/Width Brands Drew Barefoot Freedom Apex Ambulator OAPL Essential Doc Cobbler Drew Gadean PW Minor Luttgens Oceana JJJ’s Mt Emey Walkon

Custom-made Footwear Made from lasts or casts built to replicate the feet. Specifically designed to accommodate gross deformity and/or biomechanical anomalies.

WEBSITE LINKS MGF National Register and Fee Schedules http://www.dva.gov.au/service_providers/dental_allied/podiatry/Pages/index.aspx RAP Schedule & Forms http://www.dva.gov.au/service_providers/rap/Pages/index.aspx

Non-medical grade footwear stock or off the shelf walking shoes slip-on shoes/boots/court shoes runners/joggers “reef style” or “orthopaedic moulded” sandals

Podiatry Advisors Are available for you to discuss MGF issues, treatment concerns etc DVA Health Provider Line 1300 550 457 (metro) 1800 550 457 (regional) Press Option 1 for RAP (aids and appliances & medical grade footwear)

Procedures for assessing lower limb management Podiatrists must assess the client by the following order of interventions, as clinically appropriate. Consider the use of: more appropriate stock footwear; corrective insoles; modifications to stock footwear; ready-made footwear; or When no other clinically suitable option remains the prescription of :- custom footwear

Key to Success 1 Thorough assessment of the client’s foot type and shape is the first step to prescribing adequate treatment interventions orthoses or footwear.

Assessment Guidelines step 1 full examination of foot bony abnormalities/exostoses toe positions oedema the ‘at risk’ foot unusual skin conditions step 2 gait structural weakness abnormal function condition of footwear in use

Assessment Guidelines cont. step 3 adjunct therapies - padding and strapping digital devices eg. OKW; silipos products (gel padding/ inserts) - internal shoe: Simple Insoles Moulded Inlays Functional Orthoses - external shoe: Shoe modifications AFO’s; Callipers / T-straps - systemic: Medications; Surgical stockings

What Do I Want To Achieve when considering Footwear ? Key to Success 2 What Do I Want To Achieve when considering Footwear ? To facilitate correction, support or gait assistance ? To facilitate stability ?; and / or Accommodating abnormal foot structures ?

Is the existing footwear suitable for the clinical condition ? Key to Success 3 Is the existing footwear suitable for the clinical condition ? Existing footwear can be improved with shoe modifications without need for MGF Where necessary clients should be advised to purchase more appropriate footwear Readily available footwear is an acceptable choice if it has adequate depth, width, and stability.

MGF can be prescribed when: Appropriate treatment and appliance therapy have been tried and failed Where appropriate, shoe modifications to the veteran’s own footwear have been tried and failed There is significant clinical need and the deformity or condition cannot be managed without the use of ready-made or custom MGF

Key to Success 4 What footwear and/or appliances are available to accommodate this clinical condition ? As the MGF prescriber it is your responsibility to keep abreast of the types of footwear available on the DVA MGF Register and any changes occurring within the industry. When prescribing MGF you should have an indication of what type of shoe will be most suitable for your client and what additional appliance/s would be beneficial. Local suppliers are keen to work with Podiatrists to share information about the range and styles available to match to patient foot type and need. DVA Pod Advisers may also be contacted for help with suggestions of suitable choices/styles to suit the clinical need.

BASIC FOOTWEAR COMPONENTS Back Quarter - quarters are the back sections of the upper which support and help control the hind-foot Heel Counters - extended medially and/or laterally Insoles - cut from last shape and determines the shape of the shoe, waist support and flexibility Linings - material used to contact the foot for the purpose of absorbing perspiration, reducing heel slip, durability Lug Length - the top opening of the shoe which runs down the dorsum of the midfoot (the laces area). The length is usually a standard proportion of the shoe. May be extended down the toebox. E.g used commonly for high insteps or forefoot amputations

BASIC FOOTWEAR COMPONENTS cont.. Outsole - base of shoe which contacts the ground – durable Shank - reinforces the mid section of the shoe – critical ! Toe Puffs - can be walled or extend onto the dorsum over the digits Tongue - may be padded or stitched down Vamp - The material section of the shoe which covers the top part of the foot

Deciding Ready-made or Custom There are many factors which affect this decision. For example clinical conditions need to be stable before prescribing custom footwear and MGF, e.g. presence of oedema. It is essential to have an up to date medical history including medications. The following shoe features should also be considered: Counter Lug Length Modifications

CUSTOM OR READY-MADE Custom is generally required when: Toe box needs to be 30 mm or higher Forefoot width is in excess of 3 fittings wider than hind-foot Equinus foot shape Rocker bottom foot Severe adducted or abducted forefoot Excessive Oedema Severe Rheumatoid deformities Other deformities which cannot be accommodated in depth/width footwear e.g Marked asymetry between feet

SUMMARY Key to success 1: Thorough assessment of the client’s foot type and shape is the first step to prescribing adequate footwear. Key to success 2: What Do I Want To Achieve With Footwear? Key to success 3: Is the existing footwear suitable for the clinical condition? Key to success 4: What footwear and/or appliances are available to accommodate this clinical condition?

Referral MGF Flowchart Veterans can be referred by the LMO to either Medical Specialists or Podiatrists for MGF assessment. The process is the same. Veteran LMO Podiatrist Specialist Supplier DVA – RAP section for approvals Modifications & repairs over $100 require approval

New Patients Referral from LMO Confirm MGF History – Ask the Veteran - Do they have/ have they had footwear previously issued through the Department ? Ask DVA if unclear

MGF Prescription Forms D0688 D0688 Forms are now available on the DVA website in pdf format for downloading go to: http://clientforms.dva.gov.au/clientforms/ Forms can also be ordered as follows: Online – http://www.dva.gov.au/service_providers/Pages/Forms.aspx; or Telephone: 1800 155 355; or Fax: 1800 671 670; or Post: DVA Distribution, PO Box 251, Woden, ACT 2606

The MGF Prescription Form – D0688 There are 2 forms required to be filled out in the process of prescribing MGF for eligible veterans. D0688 - Medical Grade Footwear Prescription (for the prescriber) D9009 - MGF Footwear Supply (completed by the supplier) Please note that the two pads of forms are companion items, ie when one is ordered, the other is automatically provided with it.

Footwear Prescription Clinical justification Subjective symptoms Objective assessment include deformities Other therapies considered Current footwear/modifications tried Appropriate stock shoes attempted

Filling in the Prescription Form D0688 NOTE: the Guidelines for Prescribers on the cover page of the prescription pad ! Succinctly: Delays can be avoided by filling in the D0688 form completely, including all relevant: clinical information and footwear details information regarding modifications/repairs list clearly any special instructions NB. When insufficient details are provided a request for additional information, will be made to the Prescriber.

Prior Approval Process Approvals / Rejections If all criteria are met: Approved If minimal criteria are met/provided: Rejected MGF will not be provided for the sole purpose of accommodating orthoses.

Footwear Supply DVA has contracts with suppliers of MGF. Some provide only ready-made depth/width, others only custom-made, others provide both types of MGF. Suppliers include: Orthotists Commercial Shoe Stores MGF Specialists

The Podiatrist prescribing the MGF is the case manager... Acquittals The Podiatrist prescribing the MGF is the case manager... Acquittal - is the formal “sign off” that the footwear is as prescribed by the case manager and suitable for the purpose for which it has been requested. Acquittal maintains the warranty. Acquittals are to be recorded on the D0688 or in patient’s clinical notes and comments made as necessary.

Process of Acquittal Clinicians are strongly encouraged to provide the information below at time of acquittal. Comments can include but are not limited to: Acquittal dates and information Acquittals should be done within 1-2 months of footwear being supplied Problems at acquittal are the responsibility of the prescriber to liaise with supplier to adequately resolve in a timely manner Prescriber must review - all footwear issued Modifications to footwear must be reviewed Excessive wear and quality issues should be referred to DVA offices rather than condemn and replace Unsatisfactory supplies MUST be addressed

How Many? - Shoes 2 prs Day/Dress shoes at any one time 1 pr Recreational shoes - where MGF need to be modified to comply with a sporting club regulation. Must provide club letter confirming financial membership & playing status 1 pr Work shoes if required by an employer, in addition to day shoes - may need confirmation from employer e.g. SAFETY SHOES 1 extra pr day shoes for rural and remote residents (defined as >100km from a suitable Prescriber)

Replacing Footwear “CONDEMN” FOOTWEAR when no longer repairable or clinically suitable When condemning footwear and requesting replacement shoes, write details on script e.g. date approved, make, style, size, or colour. Early condemning of footwear please write on prescription the reasons. Should only be a change in clinical circumstances not where a patient changes their mind Punch holes in the tongue or mark an X in permanent marker (this identifies that MGF have been condemned and repairs will not be paid by DVA) If high risk client - discard unsafe footwear

Repairs and Modifications DVA pays for repairs to current DVA footwear - script given to client Routine repairs may be done by the original supplier without need for prescription Contracted suppliers are required to manage any warranty needs e.g repairs (generally 12mths) An exception; unless extreme access issues exist in visiting or sending shoes to the contracted supplier. Prescriber to keep adequate notes. After warranty has passed - Local repairers are able to repair - send invoice into the Department with copy of script.

How Many? Modifications to non DVA footwear Clinically required - e.g heel collars, sole raises, stretching etc. to non DVA footwear Limit of 3 self purchased pairs of footwear can be modified in any one year Needs a prescription form completed Contracted suppliers are required to manage any warranty needs e.g modifications (generally 12mths) After warranty has passed - Local repairers are able to modify - send invoice into the Department with copy of script.

How Many? - Orthoses/ Insoles Etc 1pr Customised - to move from shoe to shoe Where a clinical need exists (e.g. issues with manual dexterity) another pair of orthoses may be requested Where different shoe style makes transfer of orthosis difficult the orthosis could be mildly modified to adapt to the different shoe or shoes Veteran could purchase appropriate footwear to accommodate the orthosis To replace an orthosis: Replace by surrendering old one to podiatrist or supplier Provider supplying orthosis/es then clearly states this on prescription form

Prescription of Stock Footwear Requested through Rehabilitation Appliances Program (RAP) Prescription form on website www.dva.gov.au – DVA Forms Form D0992 this is not the same form as when requesting MGF Stock - AJ07 or Temporary - AJ06 Issued as essential part of a leg appliance e.g. amputee Modification/s to self purchased footwear may be required to accommodate a calliper Temporary footwear (AJ06) also available - cast boots/shoes e.g. “DARCO” Guideline for the prescription of Pullman slippers; extreme oedema, current ulceration and subsequent leg and foot bandaging

Warranties Newly manufactured MGF - 12 months (workmanship, materials, fitting) Repairs/modifications - 3 months As a quality assurance measure – The Department may request the Prescriber returns those shoes that have failed to last an acceptable amount of time.

Home Visits for Suppliers Needs prior approval from the Department to be able to claim travel Requested on the Prescription Form by the Prescriber outlining the clinical reasons why the veteran cannot be transported to supplier Considered only where it is clear the client is medically confined to home A general rule of thumb – 1 (one) home visit for MGF and 2 (two) visits for custom MGF when requested by the podiatrist

Transport to Podiatry treatment Beneficiaries can claim reimbursement for travel costs for medical treatment to the closest practical provider - taxis or mileage (incl. to contracted footwear supplier or orthotist appt.) Service provider to sign travel form (available from the DVA’s Transport section) Booked Car with Driver (BCWD) scheme was made available to all beneficiaries over the age of 80 in 2006. See online DVA FACTS HSV125

MEDICAL GRADE FOOTWEAR (MGF) COMPLICATIONS & DIFFICULTIES What to do when: Footwear provided is not suitable the Veteran should: NOT sign the voucher if presented by the Supplier; Contact the Prescriber to discuss with Supplier and organise modifications. Footwear provided is not suitable the Prescriber should: NOT acquit the footwear; Advise supplier ASAP; Discuss and organise modifications. The veteran changes their mind: Veteran has financial responsibility for costs. There are problems with the supplier; Contact DVA RAP if unable to resolve.

MEDICAL GRADE FOOTWEAR (MGF) WHAT IF? Suppliers nearest contracted supplier is too far away liaise with supplier to work out possible solution - eg foot tracings; girth measurements and let DVA know of issues nearest supplier cannot supply most suitable MGF register shoes other suppliers can be contacted Maintain adequate records to support this approach

MEDICAL GRADE FOOTWEAR (MGF) WHAT IF? Prescribers do not complete the D0688 correctly form will be returned with request for more details are unsure as to the most appropriate shoe be specific in description of MGF characteristics discuss with a DVA Podiatry Adviser assess the beneficiary as not meeting clinical criteria explain to veteran and do not complete D0688 or send completed D0688 directly to DVA and attach a note indicating assessment that stock footwear is suitable keep precise clinical notes in case a review is requested

MEDICAL GRADE FOOTWEAR (MGF) MGF SUPPLIER LOCATIONS Contracted MGF suppliers are located throughout each State Please see the link below to locate the closest contracted supplier List of suppliers NOTE: Names and locations as listed are correct at time of publication.

MEDICAL GRADE FOOTWEAR (MGF) CONTACT NUMBERS DVA Health Provider Line 1300 550 457 (metro) 1800 550 457 (regional) Press Option 1 for RAP (aids and appliances & medical grade footwear) Option 3 for Medical & Allied Health (podiatry treatment)

MEDICAL GRADE FOOTWEAR (MGF) Thank you This completes the on line workshop Should you have further questions about MGF or the content of this presentation please contact DVA Health Provider Line 1300 550 457 (metro) 1800 550 457 (regional) Option 1 for RAP (aids and appliances & medical grade footwear)