By Carol Daus
Therapists at the Austin State School in Texas discuss their team approach, funding dilemmas, the improvement of products, and their positive outcomes. With so many different products on the marketplace, selecting the appropriate ambulatory aids for patients is never a simple process. But the task becomes even more difficult when individuals with mental retardation or other severe mental illnesses are in need of mobility equipment. Physical and occupational therapists at Austin State School in Texas are experts in helping this population find the right equipment, since the facility typically has more than 160 residents who are wheelchair dependent and use other ambulatory aids such as walkers. “We have about 450 residents who stay here at the hospital, but we also have roughly 100 individuals from throughout Texas who have equipment needs and visit us periodically,” says Karen Hardwick, PhD, OTR, FAOTA, director of habilitation therapies. A Team Approach Austin State School uses a multidisciplinary team when determining equipment needs for patients. In addition to a physical therapist and occupational therapist, the team includes the patient’s physician, family members or caregivers, and case managers. “We look at a variety of factors—everything from their age, weight, diagnosis, circulatory assessment, dysphasia evaluation, motivation, certain behaviors, and their living environment,” notes Hardwick. Only until this multifactorial assessment is completed does a patient receive a referral to the school’s assistive equipment clinic. Although the cost of an ambulatory aid is certainly an issue, the rehab team will usually take this into consideration after the other factors have been evaluated. For residents, equipment is paid for out of the school’s general budget. However, if the person is covered under Medicare or has private insurance, the school will tap into those additional resources, particularly if an expensive system is needed. For the most part, the school receives very few denials for ambulatory aids from insurers. “I think it is because we are so inclusive in our evaluation process,” notes Christy Yeager, PT, director of physical therapy services. “We are also used to working with the different insurers, so we know what it takes to get preapprovals before we start to walk down a path of futility,” says Yeager. Hardwick adds that it does not make sense to ask for equipment that will most likely be denied. “If the chance of getting an approval is 80%, we will go for it, but if it is a 50% chance, we usually do not,” she says. In some instances, before asking for an expensive piece of equipment, they test a similar product from their inventory to see if it is suitable. “Recently, I thought an electric wheelchair would be perfect for one of our residents, but I knew there was some question as to whether the person’s skills would emerge from using it,” says Yeager. “We modified one of our chairs to see if this person could develop such a level of function, but we actually learned that these skills were not developing as a result of the wheelchair, so we did not pursue this course of action.” As Yeager notes, it is not always immediately clear to the therapists and the physician which type of equipment is best suited for certain individuals. Frequently, the prescription the physician has written needs to be modified after the therapists meet with the patient and their family members and learn more specifics about their needs. The family members and caregivers also play a determining role in which type of equipment is selected. Not only are they usually responsible for the payment, they also understand the client’s needs in terms of lifestyle and personality. “We usually treat a family member or caregiver as an end user,” says Hardwick. “It is true the client has to be functional and comfortable, but in many instances a family member is the primary user, since they have to hold, lift, and help operate the equipment.” From the family member, important information can be derived about whether the equipment needs to be transported, how accessible the house is (if the client does not reside in the hospital), and whether an adapted bathroom is available in the home. Sometimes the equipment that is best suited for the client’s functional needs is not well suited for the caregiver’s home environment. Better Products Therapists such as Hardwick and Yeager, who work extensively with clients in need of ambulatory aids, are quick to point out that manufacturers are finally beginning to respond to the numerous suggestions made by therapists to improve their products. One of the biggest changes has been that wheelchairs are now smaller and lighter. “Manufacturers are designing their equipment so that the client stands out instead of all the metal from the chair,” says Hardwick. Even when therapists at Austin State School make their own seating systems, they try to use the smallest components available to support a person. Yeager adds that because the composite materials used in making wheelchairs are now lighter, the average chair weighs between 25 and 30 pounds, compared to 50 pounds in the past. Another recent development is that equipment is more adjustable, which is important to therapists at Austin State School since many of the clients are admitted as children and stay through adulthood, requiring chairs to be adjusted over the years. Manufacturers now allow adjustments to be made to the width and height of the chair without charging the client an additional fee. “Even if the client gains weight, they do not have to automatically get another wheelchair,” says Yeager. It also used to be difficult to get chairs low enough for a person to foot propel, but now there are more options available for people who have better function with their feet than their arms. Hardwick also points out that cosmetic improvements in ambulatory aids have helped make family members feel better about the equipment. “A lot of our clients have problems that result in physical manifestations, causing them to look different, so we are extremely sensitive to trying to make our patients look as attractive as possible,” says Hardwick. “Over time, we have seen how the appearance of an ambulatory aid definitely has an impact on the individual’s care.” Facing Challenges One of the big challenges for supplying severely complex patients, such as those at Austin State School, is that seating systems and other ambulatory aids frequently need to utilize high-tech features that automate functions. “Some of our cases are so complicated that many therapists have difficulty working with them, and yet we are expecting someone with a high school education to follow a specific positioning program that, if not followed correctly, can result in the client’s death,” says Hardwick. The key, says Hardwick, is to utilize automation as much as possible. “It may be difficult for our staff to carry out 19 programs on 19 different people, but with an automated system, they can press a button to automatically turn a patient multiple times within an hour,” she says. The hospital also maintains quality standards by using a physical nutritional management program, a comprehensive 24-hour program that requires staff to make regular checks on equipment, along with other routine evaluations of patients’ medical status. Pictures and detailed explanations concerning how to utilize the equipment and take care of the client are shared with the staff. This highly reinforced quality control program is the primary reason the hospital has maintained such good outcomes. The facility’s record for individuals experiencing problems with decubitus ulcer is less than 1%, which is well below what most residential facilities experience. The staff also pays close attention to those residents who have a gastroesophageal reflex or aspiration problems since they are prone to choking. Twelve residential clients also have problems with gastric emptying so the therapists have made modifications to the chairs, allowing them to be physically placed in positions to facilitate that function. Hardwick points out that given the physical and mental limitations of many of the residents, much of the equipment is electrified so that the client as well as the caregiver does not have to operate it manually. “The more complex the person’s condition and the less well trained your staff is, the more you will need technology to keep the residents healthy and mobile,” says Hardwick. About 100 of Austin State School’s residents also use other ambulatory aids in addition to their wheelchairs. The most frequently used piece of equipment is the walker. According to Yeager, in the past therapists would have to modify standard walkers by creating a platform on top for people with arm deformities. Once manufacturers began to hear about these modified walkers, they started making their own, which has made things easier for therapists. Yeager adds that other developments in walkers are the power-assist or pelvic support walkers, which prevent individuals from falling if they have problems standing. There are even power-assisted “ambulators” for adults, which resemble large baby walkers. Priced at about $5,000, these expensive ambulatory aids are typically not funded by Medicare unless it is the patient’s primary method of getting around. “It is important to identify what their primary mode of mobility is and once that is addressed, there may be ways to get additional, more expensive, ambulatory aids,” says Yeager. She adds that another positive change has been the replacement of the simple, $99 aluminum walker that never worked very well. “The manufacturers then started to add wheels and casters, but people were having trouble because they lost control of the walkers,” she says. Now walkers come equipped with kick step stools and retractable wheels for stability. “In some ways, they have become mini-mobile work spaces, complete with seats, trays, and baskets to hold items.” The reason many of these improvements have been made to ambulatory aids is that the aging population has brought attention to the needs of the elderly. Not only are people living longer, Baby Boomers are becoming aware of these products as they take care of aging parents. “We Baby Boomers are so powerful in terms of numbers and savvy—we will not let inadequate equipment slow us down,” says Hardwick. “This will definitely keep manufacturers on their toes when designing better and less expensive ambulatory aids.” Carol Daus is a contributing writer for Rehab Management.
