In September and in November, I wrote articles that related to seating and mobility assessments. The September article was on Best Practices in Seating and Mobility Assessments. The November article, More on Seating and Mobility Assessments, took a closer look at the content of assessments. Let’s finish the trilogy on assessments by looking at the overall process of wheelchair provision, of which assessment is only one step, by taking a broader look at all the steps that go into providing an appropriate wheelchair for an individual.
The Rehabilitation Engineering & Assistive Technology Society of North America (RESNA) Wheelchair Services Provision Guide outlines 8 steps in the provision of a wheelchair. These steps are: referral; assessment; equipment recommendation and selection; funding and procurement; product preparation; fitting, training and delivery; follow-up, maintenance and repair; and outcome measurement.1 The steps are generic and applicable across different funding programs.
The referral begins the process of wheelchair provision and an identification of need commences the referral process. The identification of need, whether temporary or permanent and the level of complexity, will help to stream an individual to different providers within the service delivery system. The RESNA guide notes that both a therapist and a vendor should be involved when working with an individual who requires a wheelchair on a long-terms basis, defined as more than 6 months, as the therapist and vendor bring complementary skills and knowledge to the wheelchair provision process.
The next step in wheelchair provision is the assessment. Please refer to More on Seating and Mobility Assessments for details regarding the assessment.
Equipment recommendation and selection follows the assessment. The seating and mobility goals that are established as a result of the assessment are used to identify products that have the features and capabilities required to meet the identified goals. Information regarding possible product options should be shared with the client and/or caregiver for informed decision-making.1 All possible options should be addressed, including those for which provincial funding may not exist, to allow the client to be fully informed as to products available that may meet identified goals and to allow the client to make decisions in light of any funding restrictions. During the discussion, all potential sources for funding should be explored to assist the client in obtaining optimal equipment.
Whenever possible, it is important for a client to trial the seating and wheelchair prior to its prescription to determine how well the seating and mobility system meets the client’s needs in the client’s environment. In some cases, trial of certain seating or equipment may not be possible. In these situations, it is important to simulate the positioning or configure the wheelchair as close as possible to what is being considered for prescription. Prior to a wheelchair trial, some education may be required for wheelchair skills or for safe operation of a power wheelchair.1
Documentation is an important part of the equipment recommendation and selection step. The use of outcome measures allows for an objective comparison of technologies and a systematic evaluation of how well the products meet a client’s needs and goals. Outcome measures may include “pain scales, respiratory function measures, functional performance measures, user satisfaction measures, and quality-of-life measures. Functional performance measures include, but are not limited to, distance propelled in a fixed time, stroke/push propulsion, and accuracy.”1 (p. 9). Documentation should include what products were trialed but did not meet the client’s needs, as well as the products that were considered but ruled out and the reason(s) for this.1
Funding and procurement begins with an understanding of the criteria for the funding source and following all policies and procedures that are required. Exclusions or restrictions to funding should be discussed with the client and any changes to funding expectations should be immediately reviewed with the client.1
Procurement involves ordering the wheelchair and/or seating system and ensuring that upon delivery, the equipment is as specified.
If the components of the seating and mobility system originate from different manufacturers, the next step in wheelchair provision is product preparation. During this step, the wheelchair and its accessories and the seating and positioning components will be set up in accordance with the recommended specifications, based on the assessment and trial of equipment.
The next step in wheelchair provision involves fitting, training, and delivery. With the client and team members present, the wheelchair and the seating are adjusted for the client for optimal fit, function, comfort and safety.1 Sometimes, incremental changes to seating and mobility are required to allow an individual to become accustomed to the changes.
Training is an important part in this step to ensure the client will be safe using the prescribed equipment. While some training is provided at the time of equipment trial, once the client’s own wheelchair and seating is delivered, it is important that skills for the safe and functional use of the equipment are reviewed. Care and maintenance of the equipment also should be reviewed. Proper set up of the seating system should be shown and its effect on skin integrity, posture and function should be discussed. Lastly, anything specific to the client’s lifestyle, such as transporting the wheelchair or occupant safety restraints while remaining seated in a motor vehicle, should be reviewed.1 (For more information on Wheelchair Tiedowns and Occupant Restraint Systems and Standards, please refer to a previous Clinical Corner article.
Delivery includes ensuring that the client has been provided with all the required documentation, including the Owner’s Manuals for the wheelchair and seating.
Follow-up, maintenance and repair is the next step identified in the RESNA guide. Follow-up is an important step to ensure that the wheelchair continues to meet the client’s needs, particularly if there are any changes to the person’s medical condition, functional status, weight, or environment. Follow-up is an ongoing process that can be initiated by the client, a caregiver, or a member of the wheelchair provision team.1
Maintenance and repair is important to ensure the optimal, safe functioning of the wheelchair. The client should inspect the equipment often and have any problems addressed before any issues become emergencies.1
The final step in wheelchair provision is outcome measurement. Outcome measurement has already been discussed with respect to equipment recommendation and selection as outcome measures are required throughout the process. At a minimum, outcome measures taken at the beginning and end of the service provide a comparison from baseline.
The steps in the RESNA Wheelchair Service Provision Guide provide a broad framework for the various funding models across the country. Following these steps helps to ensure that clients receive optimal seating and mobility equipment and appropriate training and that the equipment continues to work well for the client beyond the initial delivery of the equipment.
- (2011). RESNA Wheelchair Service Provision Guide. Retrieved from http://www.resna.org/sites/default/files/legacy/resources/position-papers/RESNAWheelchairServiceProvisionGuide.pdf.