Occupational therapy programs tables of content
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- Bu səhifədəki naviqasiya:
- WHAT ARE SOME OF THE MORE TYPICAL KINDS OF POSITIONING PROBLEMS AND POTENTIAL SOLUTIONS
- Problem Possible Solutions
- HOW DO I DOCUMENT POSITIONING/SEATING INTERVENTIONS GENERAL CONSIDERATIONS
- DISCHARGE PLANNING AND FOLLOW-UP
- HOW DOES REIMBURSEMENT FOR WHEELCHAIRS AND SEATING SYSTEM COMPONENTS WORK GENERAL REQUIREMENTS FOR DURABLE MEDICAL EQUIPMENT FUNDING
- SOURCES OF REIMBURSEMENT
CUSHIONS - All wheelchair seats should be equipped with cushions when using for more than transport purposes. Cushions that are combined with a solid-seat insert are generally best. Some basic types include: FOAM CUSHIONS Foam for cushions exist in a wide range of thicknesses, density, and buoyancy. Consult your vendor for more details on the properties of specific foams. In general, high density foam is best for prolonged sitting. Gel-based or air-based cushions - are more expensive that may offer better pressure relieving systems for patients with special needs or recurrent skin breakdown. Note that these cushions tend to require a higher degree of maintenance and may present with greater complexity for fitting properly. Note: Cushions do not offer a firm base to sit on unless combined with a solid insert. Solid seat and cushion combinations are usually the best option.
Refers to the leg attachments that elevate and support the lower leg. Even when lowered completely, most leg rests require the patient to be able to achieve less than 90 degrees of knee flexion and require sufficient hamstring length to allow pelvis to be in anterior tilt. An optional calf pad can be raised or lowered to support the lower leg, and can be purchased in extra-large sizes. “Swing-away” option is particularly helpful in transfers. A soft strap wrapped around and secured behind the calves can limit excessive knee flexion, prevent foot drag, and promote stable positioning of the lower leg against the calf pad. The patient must be able to remove the strap if it is not to be considered a restraint. Note that calf pads may not be needed for all patients. Calf pads can potentially increase flexor muscle tone of the lower extremities, and can be associated with skin breakdown with patients who tend to push against the calf pad due to flexor spasticity. 4 FOOTRESTS Refers to the non-elevating supports for the feet. Proper use of the footrest requires 90 degrees or more flexion at the knee. Adjusting the entire leg attachment tot he correct height is essential to assist the pelvis into a stable position. The foot rest should support the foot at a height where the thigh is parallel to the seat bottom. Comes with option for folding or extra large plates to accommodate large feet, or when increase extensor muscle tone is problematic, and are also available with adjustable angles. Additional soft (i.e., Velfoam) straps properly placed can assist with keeping foo/feet on the footrests. The patient must be able to remove the strap if it is not considered a restraint. 5 ARM RESTS Commercially available options include desk-style arms, and adjustable-height, removable, or swivel up-down features. In nursing home settings, many are standard length, non-removable and non-adjustable. This requires that the patients be able to stand in order to transfer. In some cases creative padding is needed to protect patients with fragile skin. 6 SEAT BELTS Seat belts are generally attached to the rear screw of seat bottom for the best stability and angle. Seat belts should be positioned at a 45 degree angle just above or below the hip joint. The patient should be able to remove the seat belt if it is not to be considered to be a restraint. 7 LAP TRAYS/ARM SUPPORTS Often used to support hypotonic or hypertonic upper extremities. Can assist in trunk alignment, prevent muscle shortening or scoliosis from developing. Are available in a variety of styles and materials, including: Acrylic/clear Lip or Rim edges Half-lap trays Fold-up styles Economy styles that attach with velcro Styles with wells for cups. 8 TRUNK SUPPORTS Lateral supports need to be positioned high enough to provide support but low enough to avoid impingement upon axilla or create excessive pressure areas. A general rule of thumb is that if you use a lateral support on one side, provide a support on the opposite side even if initially you think it’s not required. More than one point of contact is usually required for supportive correction. Proper support provided through the seat may eliminate the need for lateral supports. 9 HIP GUIDES/HIP BLOCKS Used to maintain the pelvis in a neutral position (side to side). Often used bilaterally to take up extra width in wheelchairs to stabilize the pelvis. Usually extend along the thigh to approximately 2-3 inches before knee. Can assist with excess abduction and can prevent some “windsweeping”. Often the easiest and most economical type are towels firmly folded or rolled and duct-taped to prevent unraveling.
Intended to encourage knee separation and femur alignment with hip/pelvis. They are not intended to prevent patients from sliding forward. Must be used sparingly and cautiously. They should be as small as possible and placed as distal as possible. Be careful to monitor skin for pressure areas. Can often be replaced by a supportive firm seat surface and/or small towel roll under center front of cushion. 11 HEAD SUPPORTS Evaluating the thoracic area is critical when making adjustments to cervical area. Finding appropriate contact point for pressure on head and neck and achieving satisfactory alignment that continues over time is extremely difficult and requires skill. Frequent monitoring and trial and error are usually necessary. Some prefabricated headrests are available. May require a solid back insert for attaching to the wheelchair. Some “temporary” headrest systems attach to the armrests of the wheelchair and do not require a solid back. May be able to eliminate need for head supports with good trunk and pelvis positioning. Allows patient to “balance” instead of “lift” head. 12 HANDRIMS A variety of different handrims are available depending on patient hand and arm function. Some variations include rubber coating for extra-traction, and spokes or knobs for easier grasping. Clinicians can also purchase kits or foam to increase the width of the grip.
Brake extensions may be required by patients with limited UE movement, visual deficits or hemipareses. Brakes can also be located in the rear of the wheelchair to increase safety of disoriented patients. Note that rear-mounted brakes could be considered a restraint if the resident can not physically reach back to release them. 14 DRIVE OPTIONS One arm drive–2 handrims on non-hemi side; very difficult to coordinate propulsion when cognitive and/or perceptual deficits are present. Ratchet or pump handle–requires only one arm to propel and steer. This wheelchair works well for many patients with hemipareses, however, it is expensive. Other options include Electric Chairs or Scooters–Hand Control, Sip’n Puff, Head Control. These options are very expensive . Obtaining reimbursement may be very difficult. 15 WHEEL OPTIONS Some patients may require smaller diameter wheels to bring them lower to the ground for better propulsion. Vendor input is needed to ensure integrity of chair is not compromised. Wheels can be moved forward to shift the center of gravity of chair forward for patient with double LE amputees who do not wear prostheses. 16 ANTI-TIPPING OPTIONS Chairs can be constructed to shift the center of gravity backward or forward. This is especially helpful for patients whose center of gravity is shifted forward or backward significantly. Patients in lower-extremity casts, with LE amputations, and those who tend to tip themselves forward or backward are examples. WHAT ARE SOME OF THE MORE TYPICAL KINDS OF POSITIONING PROBLEMS AND POTENTIAL SOLUTIONS? The following sections will present positioning problems that are primarily stemming from the patient or from the chair. Problems with the PATIENT: (adapted from Hallenborg, S. “Wheelchair Needs of the Disabled Adult.” In O. Jackson-Klykken, Ed. Therapeutic Considerations for the Elderly. New York: Churchill Livingstone, 19887.).
HOW DO I DOCUMENT POSITIONING/SEATING INTERVENTIONS? GENERAL CONSIDERATIONS Documentation should contain specific rationale for wheelchair positioning, including: Wheelchair positioning evaluation. Document key results on the EPOT. Keep a copy of that evaluation worksheet in the “soft” file. Factors indicating need for wheelchair positioning evaluation at that time. Prior level of function. Rehabilitation potential related to wheelchair positioning goals; including positive prognostic indicators. Specific functional outcomes. Incorporate documentation of skilled intervention and terminology. Patient-specific examples of treatment goals include: “Through improved postural control, the patient will sit upright in wheelchair for 30 minutes, to feed self independently for one meal a day.” “Through improved wheelchair positioning, the patient will safely and effectively mobilize his wheelchair with minimal assistance to complete grooming tasks.” “Following caregiver training, patient will set upright with stand by assistance for 20 minutes to complete grooming activity with moderate assistance.” Through improved positioning and maintenance of appropriate posture in bed, patient will have no areas of skin breakdown in the sacral area. Through improved position in wheelchair, patient will be able to be transported safely by staff. Following caregiver training, patient will transfer from bed to chair with moderate assist to be positioned appropriately for participation in activities. Follow caregiver training and improved trunk stability, patient will be able to maintain sitting for _____sec./min. To allow caregiver time to prepare for transfer bed to chair. Through improved trunk mobility and strength, patient will safely perform transfer with supervision. With properly fitted wheelchair, patient will be able to mobilize self throughout facility with supervision using both Les for propulsion. Through improved positioning, patient will have decreased flexor muscle tone in right LE allowing appropriate weight-bearing for stand-pivot transfer with minimal assistance. Document specific training to caregivers. In weekly summary, document that training was provided and identify the caregivers trained. Provide written communication for follow through by caregivers. Diagnosis Coding Examples for Rehab/Treatment Diagnoses may include: Malaise & Fatigue, 780.7 Abnormal Posture 781.9 Abnormal Involuntary Movements, 781.0 Muscular Incoordination, 781.3 Disorder of Muscle, Ligament, and Fascia, 728.9 Low Back Pain, 724.2 Vertigo, equilibrium disturbance, 780.4 Contracture of joint, 718.4 * * must add fifth digit to identify area of body
Compare baseline status to current status. Consider discharge if: Patient has reached maximum potential with goals at this time; AND Training has been completed; AND Discharge status has been documented and communicated to staff and family. Determine follow-up/screen date Discharge order obtained from physician. Complete discharge documentation, include written instructions given to patient and/or caregivers, the date the equipment was given, type of device provided, how the resident responded to use of the equipment, and how the equipment contributed to achieving the resident’s rehabilitation goals. Patient should be monitored informally as needed. Do not keep the patient on caseload for monitoring, as it is a non-skilled service. Follow-up screenings are to be documented. Patients should be re-screened for further positioning intervention within 3 months. Restorative Aides or other nursing personnel should be instructed to notify appropriate rehab staff member if patient’s status changes. HOW DOES REIMBURSEMENT FOR WHEELCHAIRS AND SEATING SYSTEM COMPONENTS WORK? GENERAL REQUIREMENTS FOR DURABLE MEDICAL EQUIPMENT FUNDING A. To receive payment from insurance companies, the following requirements are usually necessary: The client’s condition must be a result of an illness or accident. The equipment must be prescribed by a physician and certified as a medical necessity. For an insurance company to consider payment: The equipment must be a covered charge. The equipment must be medically necessary. The client must be covered by the medical insurance on date of service. Some policies may require insurance coverage on date of prescription. Benefits have not been exhausted. The equipment must be a therapeutic and/or prosthetic device which replaces a limb, organ or non-functioning body part, must be curative or improve the condition and/or function of the client. Equipment must be able to be used repeatedly (durable) and is non-expendable (wheelchair, hospital bed, communication prostheses, etc.) The client must be able to use the equipment, although training may be required. Training requirements must be documented in the physician’s note when equipment is prescribed.
When dealing with insurance companies, always: Obtain complete client insurance information prior to contacting them. Client’s name Client’s address Client’s phone number Insurer’s name Insurer’s address Insurer’s phone number Insurer’s employer Policy Number Group Number I.D. Number Obtain other funding information. Secondary insurance - same information as #1. (Important as coordination of benefits clause may be included. Do not take coordination of benefits for granted because it is not always a part of the policy benefits.) Medicaid, Medicare, Children’s Medical Programs, etc. Verify current information every time a claim is filed. Client or authorized person must sign the release of medical information and the payment authorization on the claim form. Be specific when giving the client’s name, identification, diagnosis, service date, services performed and costs. Sign, date, give your provider number, and your federal tax identification number on all claim forms, as indicated. Complete all blanks on any form as accurately as possible, indicating n/a in sections that do not apply. Claim forms are submitted for actual services provided only. It is illegal as well as unethical to submit claim until services have been provided. A tickler or follow-up files should be maintained on claims for quick reference and follow-up. Keep well informed by reading booklets and information on insurance, Medicaid, Medicare, Campus bulletins, etc. Attend workshops offered in your area since changes occur regularly. SOURCES OF REIMBURSEMENT Medicare Definition of Durable Medical Equipment (DME): “Durable medical equipment” is equipment which (1) can withstand repeated use, (2) is primarily and customarily used to serve a medical purpose, (3) is generally not useful to a person in the absence of illness or injury, and (4) is appropriate for use in the home. Most wheelchairs and positioning devices are considered to meet the Medicare definition of DME. Reimbursement under Part A The reasonable cost of DME can be recouped by a facility with Medicare certification during the cost settlement process. This process can occur annually, semi-annually or more frequently. Reimbursement at cost settlement means that the facility must budget for the purchase of the DME needs of its residents. Direct reimbursement to the facility through Part A is not available. The nursing facility recoups its costs in the form of adjustments to the per diem rate structure. Reimbursement under Part B In general, Part B denies specific coverage for DME for nursing facility residents who are not in a part of the facility that meets the definition of home, are not going to use the DME in a home, and/or who do not occupy a Medicare-certified bed. Part B reimbursement is more complicated and is dependent upon several critical variables:
The DME must be reasonable and necessary for the diagnosis of treatment of an illness or injury, or to improve the functioning of a malformed body member. A Certificate of Medical Necessity and physician’s prescription are required. The supporting documentation must state the patient’s diagnosis, prognosis, the reason the equipment is required and the physician’s estimate of duration of need.
DME Reimbursement is made on the bases of a fee schedule which establishes “maximum” allowables. DME Reimbursement under Part B is subject to a 20% co-insurance payment by covered beneficiaries. Medicare-certified nursing facilities that opt to purchase DME that will be used for Part A and B patient’s in certified beds have an opportunity to build these costs into the rate justification for its Part A per diem charges.
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