1. Custom Durable Medical Equipment Stephanie Harrington, PT, MPT, ATP Meredith Ford, PT, DPT, C/NDT

2. 2 Objectives  Identify and evaluate for when DME is required  Recognize custom durable medical products in the field  Understand recent advances in custom DME  Discuss related insurance nuances

3. 3 Wheelchairs  Patient mobilization limitations  Does the patient have strength, endurance, range of motion or muscle tone limitations?  Does the patient have the capacity to independently propel themselves?  Does patient have cognitive ability and safety awareness in order to control a power chair?  Type of transfer – How to get in and out  Can the patient ambulate with assistance or by self?  Is a sliding board required for transfer?  Frame transportation  What type of vehicle does the patient have?  Is there an installed lift system?  Account for growth in pediatric cases  Insurance requirement for 20% growth in seat width and depth  Required to account for approximately 3-5 years of equipment use Considerations for Pediatric Care

4. 4 Wheelchairs  Tilt in Space Chairs  Accommodate tone abnormalities, posture deformities (scoliosis), weakness, respiratory and cardiac impairments -Freedom® NXT, Quickie® Iris  Upright Manual Chairs  Use when patient has good sitting balance, self propulsion, possible backup for a power chair  Folding chairs -Quickie® 2  Rigid chairs – lighter and more energy efficient -TiLite® Aero Z, KI Little Wave Clik Manual Products

5. 5 Wheelchairs  Accessories for Manual Chairs  Smart Drive -Easy on and off -Compatible with folding and rigid frames -Must trial prior to ordering -11 Pound drive  Emotion Wheels -Compatible with folding and rigid frames -Drive on wheels – 20 pounds/wheel Power Assist Products

6. 6 Wheelchairs  Wheel Type  Front wheel drive – indoor and outdoor use  Mid wheel drive – use in tight or confined spaces  Rear wheel drive – used in a variety of environments  Drive Type  If there is a functionally controlled movement, the patient can drive.  Hand, head array, Sip n Puff, Micropilot Power Products  Power Seat Functions  Power tilt indication - Does the patient have the ability to perform a pressure relief by themselves?  Power seat elevator indication – Can the patient perform a level transfer by themselves?  Power recline indication – Does the patient struggle with prolonged upright sitting?  Power elevating leg indication – Is the patient unable to lift legs or has risk of swelling?  Power stand indication – Is the patient a client for standing and can perform an independent level transfer?

7. 7 Seating Considerations for pediatric care  Variety of seating options for postural deficits  Cushions - Pressure relief, patient positioning, ease of use (ROHO®)  Sport backs – Mild postural deficits, weakness or tone abnormalities (Jay® 3™)  Solid seating – Moderate postural deficits, ability for customization (Freedom Seating System)  Custom molded – Most severe postural deficits: scoliosis, pelvic obliquities, Gibbus deformities (Contour-U)  Seating options on stroller are typically ‘off the shelf’  Wheel chair seating is more readily customized  Insurance will not pay for seating system changes within 6 months of equipment delivery

8. 8 Strollers Considerations for pediatric care  Tilt in Space and/or Recline  Consider when tone abnormalities, weakness, posture deformities, respiratory or cardiac deficit, or endurance impairments are present.  Is there a need for medical equipment transportation? Most products are capable for transport.  Zippie® Voyage™, Kimba® Neo  Upright  Typically used when patient is unsafe in wheelchair – behavioral issues, cannot physically or is not cognitively aware to propel wheelchair.  Convaid EZ Rider

9. 9  Imperative that there is an evaluation of the home environment – Q&A  Discussion at time of evaluation to assess: -Is the patient in own bath area or sharing with others? -Layout and type of bath/shower equipment?  Patient capabilities  Is the patient capable of independent transfers?  Does patient demonstrate good head and trunk control and sitting balance?  Bath Equipment  Rifton® Bath Chair  Drive Tub Transfer Bench  TubBuddy™ Transfer System  Toilet Equipment  Rifton® HTS  Columbia™ Medical Commode Chair Bath and Toilet Considerations for pediatric care

10. 10 Beds Considerations for pediatric care  Hospital Bed  Does the patient require head and foot elevations due to a medical condition? -Respiratory or cardiac deficit, impaired oral-motor function, seizures  Allows for head and foot articulation and/or bed height adjustment  Enclosed Safety Bed  Use indicated when patient is at risk to themselves or others.  Lack of cognitive or safety awareness to stay in bed – climb, scoot, roll out of bed.  Combination Hospital/Enclosed Options

11. 11 Car Seats Considerations for pediatric care  Patient Limitations  Consider postural limitations in seat selection  Commercial restraint has been out grown  Impaired safety awareness – patient able to unbuckle self  Weight requirements dictate equipment selection  Vehicle Requirements and Accessibility  Year of manufacture and installed safety equipment  Seat requires proper securing – top tether and seat belt  All adaptive car seats/beds/booster seats must be installed by a technician certified in car seat installation

12. 12 Car Seats Considerations for pediatric care  Weight Requirements  The Hope Car Bed ™ by EZ Tether – 4.5-35 lbs  Traveler Plus Car Seat by Snug Seat – 22-105 lbs  Recaro PerformanceSport – 20-120 lbs  The Roosevelt™ Car Seat by EZ Tether – 35-115 lbs  Spirit™ Car Seat by Columbia™ – 25-130 lbs  The Churchill™ Backless Booster by EZ Tether- 65-175 lbs  E-Z-On® Vests by EZ On Products – 20-168 lbs  The Jefferson ™ Car Seat by Merritt Mfg. – 7.5 – 40 lbs

13. 13 Standers, Gait Trainers, Walkers Considerations for pediatric care  All accessories require insurance justification  Must have growth built into system  Recommend trial prior to ordering  Insurance denies simultaneous Stander and Gait Trainer at same time  Insurance will not allow for changes or replacement within 6 months of equipment delivery

14. 14 Standers, Gait Trainers Commercial Products  Standers  Supine – Rifton®, Squiggles, Superstand, Zing™  Prone – Rifton® Prone, Lecky ProneStander, Jenx  Sit-to-Stand – Bantam™, Evolve™  Gait Trainers  Rifton® Pacer  KidWalk  Up n Free™  Grillo

15. 15 Other Equipment Considerations for pediatric care  Collars  Provide support for anterior neck muscle control  Adaptive to multiple equipment platforms  Adaptive tricycles  Not usually an insurance covered expense – charity and supplemental funding needed  Feeding, positioning, activity chairs

16. 16 Insurance Considerations Medicaid Nuances I  Custom manual and power wheelchairs/adaptive strollers  Requires PT or OT present with the Assistive Technology Practitioner (ATP) at the time of any new custom evaluation or major modification  Requires the same ATP to be present at time of equipment delivery  No payment for changes to current or new equipment until 6 months post equipment purchase  Eligibility for seat elevator on a custom power wheelchair  Must be able to preform level transfers or be able to perform level to unleveled surfaces with the use of a seat elevator  Adaptive car seats and booster seats  Pays based on medical or functional need  Not based on weight or height limits  Must be installed by vendor provided certified technician

17. 17 Insurance Considerations Medicaid Nuances II  Adaptive strollers  Must be age appropriate  Must have growth options  Must have firm seating system  Standers and Gait trainers  Requires justification for each accessory  Power beds  Patient must be able to independently physically transfer high-low function as well as operate remote  Head and foot articulation  Must be medical justification for this feature -Seizures, cardiac, respiratory, oral motor justifications

18. 18 Insurance Considerations Private Key Points  Therapist Presence  PT/OT not required for custom manual wheelchair or stroller evaluation  PT/OT must be present for Group 3 or higher custom power wheelchair evaluation  Insurance Coverage  Transit options and trays are typically not covered  May not cover bath/potty, car seat, and stander plan dependent coverage

19. 19 Insurance Considerations Alternate Funding Sources  Medicaid Waiver Program (MDCP and CLASS)  Must have Medicaid denial first  MDCP – Family must call to get 3 quotes for item requested  Texas Department of Assistive and Rehabilitative Services (DARS)  Charity Program  Texas ELKS  Junior League

20. 20 Durable Medical Equipment Stephanie Harrington, PT, MPT, ATP Meredith Ford, PT, DPT, C/NDT Questions?