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July 2005

By Michelle L. Lange, OTR, ABDA, ATP

Determining and justifying power wheelchairs requires thorough reporting.

I was on the phone with yet another insurance company. The person on the other end of the phone had a copy of my evaluation report in her hand, in which I had recommended a power wheelchair for a client. “So tell me,” she said, “can this person really drive? She doesn’t look like she can.” We usually attach pictures to the end of our reports showing the client in their current system and in our seating simulator. I guess this client didn’t “look like she could drive.”

As irritating as a phone conversation like this can be, these are certainly valid questions. Why should anyone pay thousands, often tens of thousands, of dollars for a power wheelchair? Or, at least, pay without some assurance that this person will really use the recommended equipment. The report needs to be comprehensive and evaluate actual driving with the recommended access method to justify this equipment.

Any evaluation begins with determining goals for the report and for the recommended equipment. The clinician goals are to 1) determine if the client is an appropriate candidate for a power mobility base; 2) determine the most appropriate power wheelchair and components, actuators, and access method; 3) justify the recommended equipment adequately to obtain funding; and 4) provide adequate support/training for a successful outcome. The client and caregiver goals are important to discuss and sometimes differ. The client may want a really fast chair. But mom may want something totally different—unscuffed walls.

The evaluation needs to be comprehensive to justify funding a power wheelchair. Factors to be evaluated include:

Current mobility skills including any form of independent mobility, ie, crawling;
Current mobility equipment including crutches, walkers, gait trainers, and manual and power wheelchair bases;
Related factors, such as transfers, seat to floor height requirements, and accessibility to transportation and environments;
Proper seating and positioning;
The need for power actuators, such as tilt, recline, seat lift, and elevating legrests;
The need to interface other assistive technology through the drive control, such as power actuators, communication devices, computers, and/or electronic aids to daily living;
Medical issues, including level of alertness and seizures;
Cognitive issues;
Access method;
Future needs.

EVALUATION REPORT
The evaluation report template that we use at Assistive Technology Partners includes all of this information; however, we still frequently encounter confusion at best and denials at worst. So, we came up with a power wheelchair criteria checklist. We attach this to any report in which we recommend a first power wheelchair for a client. Eventually, we revised this checklist to indicate indoor skills and made an additional checklist for outdoor driving skills. Many drivers are very proficient indoors, yet require close supervision outdoors where a different skill set is required. We have found many advantages to these criteria.

First, the checklist is brief and easy to read, compared to our reports, which tend to be lengthy and more narrative in style. Second, it clearly demonstrates that we have comprehensively evaluated a number of critical factors before recommending a power wheelchair. Third, it is more objective. Sometimes, an evaluation indicates that a client does not have adequate skills to use a power wheelchair functionally. This can be very emotional for the client and caregivers. The checklist allows the evaluator to objectively go through each skill with the team. If mobility training is recommended to develop the skills required to recommend a power wheelchair, the trainer can see just what skills are lacking and develop a treatment plan. If the criteria indicate that a power wheelchair is appropriate, the criteria are fairly objective and defined, which has decreased confusion among our funding sources.

When we first began using this tool, we were concerned that the criteria may appear to rule out a power wheelchair for a client who is actually appropriate for this recommendation. In the 5 years we have been using this tool, we have not yet encountered this situation.

POWER WHEELCHAIR CRITERIA—INDOOR
The following are criteria developed by Assistive Technology Partners to help determine if a client is appropriate for a power wheelchair. If a client is able to demonstrate the following criteria during an initial assessment and/or during any other subsequent training sessions, a power wheelchair is deemed appropriate. If the client meets only some of these criteria, training guidelines will be provided to the family/caregivers to help develop these skills. Assistive Technology Partners may then follow up by phone call or reevaluation to determine if all criteria are met following training. Our intention is to provide as appropriate a recommendation as possible for the client.

Once a client has demonstrated competence in these areas, indoor driving is considered appropriate. Outside driving requires further skills. Please refer to the Power Wheelchair Criteria—Outdoor checklist for more information.

POWER WHEELCHAIR CRITERIA—OUTDOOR
The following are criteria developed by Assistive Technology Partners to help determine if a client is appropriate for driving a power wheelchair outdoors. These criteria are assessed after a client has demonstrated competence driving indoors.

If a client is able to demonstrate the following criteria during an initial assessment and/or during any other subsequent training sessions, driving a power wheelchair outdoors is deemed appropriate. If the client meets only some of these criteria, training guidelines will be provided to the family/caregivers to help develop these skills. Assistive Technology Partners may then follow up by phone call or reevaluation to determine if all criteria are met following training. Our intention is to provide as appropriate a recommendation as possible for the client.

The checklist allows the evaluator to objectively go through each skill with the team. If mobility training is recommended to develop the skills required to recommend a power wheelchair, the trainer can see just what skills are lacking and develop a treatment plan.

Justifying power wheelchairs can be challenging. We frequently request funding for very expensive systems, due to the complex needs of a client. Custom seating, power actuators, alternative access methods, and electronics to support interfacing all add significantly to the cost. These criteria have been a successful tool in our clinic. I hope they may be of use in your clinic, as well.

Michelle L. Lange, OTR, ABDA, ATP, works at Assistive Technology Partners, University of Colorado at Denver Health Sciences Center. She evaluates children and adults in the areas of positioning, mobility, access to communication devices and computers, and electronic aids to daily living.

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