Feature Series

COVID-19's Wide Reach

How the pandemic has impacted CRT... & what to expect next

COVID-19 graphicIn late January, the Centers for Disease Control (CDC) began reporting that the number of COVID-19 cases in the United States was dropping. The Public Health Agency of Canada reported a similar downward trend in that country.

If your response was more a weary sigh than jubilation… you’re not alone. It is clear that COVID will continue to cast a long and wide shadow, even if the virus fades relatively soon.

Complex Rehab Technology (CRT) stakeholders have taken blows from all sides. Clinicians, suppliers, and service technicians were deemed essential workers early in the pandemic — but that meant exposure to higher-risk environments, such as hospitals overrun with COVID patients. Lockdowns separated occupational and physical therapists and CRT suppliers from clients in skilled nursing centers and other facilities. Manufacturers paid more for raw materials; manufacturers and suppliers faced skyrocketing shipping costs. And the industry had to buy massive amounts of masks, gloves, and disinfecting wipes, while being unable to pass these costs on to consumers or funding sources due to existing, pre-pandemic allowables.

SUPPLY CHAINS & SHIPPING WOES

From the metals that make wheelchair frames to the computer chips that enable power chairs to move, materials and components shortages have led to delivery delays. Even when a seating system or a wheelchair is ready to go, shipping slowdowns cause further delays.

Compounding the issue: shortages and delays greatly vary.

Darrell Mullen is an RRTS for Tango Medical in Moncton, New Brunswick, Canada.

“For delivery dates, for instance, we have one manufacturer [whose] timelines on their product were extended by months,” Mullen said. “So we would have pretty much the whole chair in, but there were certain components on that prescription that we didn’t even have an ETA on. There’s a point when we have to go with something else. So then the prescription has changed.

“One of the things becoming a major concern is batteries for power wheelchairs. Apparently, there’s a shortage of the plastic that they use on those batteries, and we’re having open-ended back orders. We don’t sell hot dogs and pool tables. The products that we have, it’s very difficult for people to do without.”

NRRTS President Gerry Dickerson, ATP/CRTS, works for National Seating & Mobility (NSM) and said that while he’s aware of supply chain problems, he hasn’t personally experienced much difficulty so far. “Everybody’s market is different; you can have huge regional differences, let alone huge national differences,” he said. “With NSM’s management ability and everybody pulling together, we’ve just been able to pull from resources to get things done so people can get moving. NSM’s supply chain management group did enough predicting. They were completely on top of stuff that made our lives in the field that much easier. When we do get into a problem — maybe it is a battery or a joystick — the word goes out: ‘Anybody have this?’ And we get so many responses that we typically get things resolved.”

Cathy Carver, PT, ATP/SMS, is a member of the Clinician Task Force (CTF) and was CTF’s Executive Director when the pandemic began in 2020.

“I think the frustrating part is not having a direct line of communication to what the supply chain issues are,” she said. “I’ll have one supplier say, ‘Oh, we can’t get this part,’ or ‘So-and-so has stopped shipping this.’ But if I ask the very next supplier I’m working with, they don’t know that or have not heard of those issues. So as the clinician, trying to figure out what product is going to be best and available for my consumer, I have two different messages.”

Carver suggested that bulletins from manufacturers could help: “Invacare sent out a blast e-mail a few months ago, which I so appreciated. It went out to suppliers and to clinicians across the country about what their current situation was.

“As a clinician, I would love those updates straight from the manufacturer that lets us know about supply chain issues, like if they are low on batteries or a certain switch or cushion cover. One [manufacturer] cannot provide a certain type of switch box right now. That doesn’t keep us from still doing their chairs. We can still do power functions through other ways, they just don’t have that switch box. So that’s good to know as a clinician.”

CRT’s process — in which a clinician works with many suppliers, who work with many manufacturers and sales reps — complicates the issue, Carver added. “I think each supplier has different people they communicate with at the manufacturers to get updates, and it’s not always the same from the independent to the regional to the national suppliers. As a clinician, you’re in a difficult spot. You have to trust what they’re saying, but if you run it by someone else, you don’t get the same message.”

Mullen now asks reps about supply issues: “A lot of times, [the problem is] the shipping of the raw material. Some manufacturers are experiencing trouble with certain foam compositions because they’re not able to get the chemical to make the foam. These are questions we’ve never [had to ask] before.

“When manufacturer reps come to my door, I always ask them: ‘What’s your supply like? Tell me what you’re finding shortages on.’ A big part of my role, almost like an agent representing my client, is being able to get them the product they need. If item A is similar to item B, but it’s an onshore manufacturer vs. an overseas manufacturer, as long as that onshore manufacturer is able to get the raw product, I’m probably going to be able to get it more reliably.”

Mullen factors that information into his equipment recommendation process: “We use a lot of sheets of ABS for making custom wheelchair components, and I tried to get some and learned there’s a shortage,” he said as an example. “My supplier will give me two sheets, and he doesn’t know when he’ll get more. When we’re bringing out assessment equipment, we’re trying to build our assessment equipment with product we’re going to be realistically able to provide to the client.

“With our company, every Monday morning we have a start-up meeting for the week. Our shipping receiver gives us a heads-up on what he’s seen in terms of back orders. We used to have one binder of purchase orders open. For the last six months, we have three binders. These purchase orders are remaining open longer, and that’s changed the rates of our billing, too.”

Those delivery delays cause other issues: “Some clients’ conditions change, or they pass away and that sale is no longer available. The manufacturer wants to get paid because part of the prescription is at my door. The wheelchair is here; that’s the most expensive part. But the cushion, a lesser part of the invoice, is holding up the whole thing. In the meantime, we’ve had to pay the manufacturer for the wheelchair. It makes it harder to keep the lights on.”

HOW COVID HAS CHANGED CLIENTS

COVID has impacted all of healthcare, but even when hospital admissions return to more normal levels, COVID’s impact on CRT clients will remain.

“We’re going to have that 18-month window where people stopped getting their colonoscopies, bladder scans, bone-density scans, therapies, getting their medicines refilled,” Carver said. “Things like that are setbacks and will take time to catch up.

“From a wheelchair and seating perspective, I think the progression or the worsening of things is probably postural. If you could not walk or push a manual chair prior to the pandemic, you still cannot, but now you might need a different back or cushion because your trunk weakened, you gained or lost weight, you now can’t do a pressure relief. So we need to modify your seating or go to the next type of chair. But I think a lot of it is more postural changes that we could have probably stayed on top of had they been able to continue with therapies.”

“The lack of [occupational and physical] therapy has caused significant issues, whether it’s scoliosis or contractures or what we call ‘COVID 25,’ the 25 lbs. that they’ve gained sitting at home, ordering DoorDash,” Dickerson said. “When everything works right, good, skilled ATPs/CRTS’s generally can accommodate for much of the weight gain within parameters. But contractures and some of the more orthopaedic involvement — there are things you can’t account for.”

Dickerson added that weight gain has been significant for some clients. “Somebody who was 265 lbs. and is now 300 lbs., we’re completely outside of the parameters. I can’t tell you how many there were that were complete blowouts with changes, and we had to start all over again. But I can tell you of countless hours of wrenches and screws and hardware to make adjustments and changes to get the system that we originally prescribed to fit the person that we were seeing on delivery.”

Mullen said, “Anecdotally, I believe there are significant impacts. A child did not get in front of that professional for therapy when they should, and there are a whole bunch of reasons that might be. If anybody who is supposed to be at that appointment has [COVID] symptoms, then the whole thing gets canceled and rescheduled. We’ve never seen the rate of canceling and rescheduling that we’re seeing over the last two years.

“It’s not uncommon for people with compromised health situations to frequently cancel appointments. But the rate that we’re seeing the last two years is beyond anything. An OT I work with might have a child, and there was a [COVID] case in the child’s classroom. So now the parents have to isolate and stay home and take care of that child, so now that appointment’s canceled. The child that needs the treatment is fine, but nonetheless, the appointment is canceled, and they don’t get that treatment.”

Could COVID cause current CRT users to need more complex equipment? Or could the virus require previously able-bodied people to need CRT?

“Actually, I’ve seen both,” Carver said. “I have seen a healthy young 60s gentleman, not overweight, no health problems — got COVID and had a horrible long course of it. Went through long acute care, ICU, came through inpatient rehab and discharged to home in Complex Rehab. Just totally shut his strength down.”

She described people “doing fine in Group 2 — got COVID and the recovery was super slow and it affected their ability to do transfers and to shift their weight and to go to the restroom.”

Documenting the need for new equipment isn’t easy under current policies. “I think if they got that Group 2 [power chair] a year or two ago, and now they got COVID, I am not aware that Medicare is recognizing long-haul COVID as one of those diagnoses that lets you move someone to a Group 3, because it’s not a neurological condition,” Carver said.

“And that is a difficult hurdle when someone presents with Group 3 needs: high risk for skin breakdown, can’t do a pressure relief, spasms, maybe bowel and bladder issues, respiratory issues, all those things that would make you totally qualify someone for power tilt, power recline, and maybe even that edema in their lower extremities. But they don’t have the diagnosis. You can’t get all that added to a Group 2 [chair].

“What would be helpful, big picture, is if CMS [Centers for Medicare & Medicaid Services] and all our other insurance companies would allow us to justify what people need based on their level of function instead of these diagnoses.”

Carver added that the need to justify new equipment for people whose conditions have changed will continue.

“We’re going to probably be doing that for the next two or three years for people that got their chairs right before the pandemic and then got impacted by it,” she said. “I know some nurses that got COVID from working, especially one who is now waiting on a liver transplant.

“So we may be taking care of our own with CRT, our own healthcare providers who get it because they’re working in it and don’t bounce back. It affects organs, and this young man, this nurse who was 26 years old, is on dialysis from it all.”

HOW COVID HAS HURT MENTAL HEALTH

The prolonged pandemic has taken a health toll on all of CRT.

“We have people coming into clinic who haven’t spoken to anybody else outside their immediate family or PCAs [personal care assistants], and they just want somebody to talk to,” Dickerson said. “We sometimes spend a good portion of clinic helping somebody to work through their fears or their issues of now they developed overeating or they’re drinking too much.”

Mullen suggested that mental health could also impact how people respond to perceived setbacks, such as now needing to use mobility equipment.

“I don’t have any evidence to that effect,” he said, when asked if he’s seen clients who caught COVID and now need more complex equipment. “But yes, it would only stand to reason when we have people whose conditions are being exacerbated. The effects of their condition would normally present with minor symptoms, and now that has changed to more significant [due to COVID].

“If I were selling insurance that covers this type of equipment, I would be concerned about my risk and my payables because I think it is going to have an overall impact on the percentage of people that are going to require this type of equipment that wouldn’t have normally otherwise. Especially if they were on the cusp: It’s going to tip a certain percentage toward needing it where they wouldn’t have otherwise needed it.

“I think another contributing factor is the mental health of that person. If you’re experiencing physical challenges, if that person is feeling upbeat and positive, they may be a little more apt to get up and do that therapy; their glass is half full. Versus there’s so much going on, and depression sets in — people can give up. I think that’s a factor as well: ‘I need this chair now, so I give up.’ I think COVID in so many ways has impacted mental health.”

“Fear is enormous,” Dickerson said, of the factors that can prevent clients from getting to clinic on time. “It’s transportation issues, and then fear, or an inability to get a physician’s scrip to get into clinic. The prescription expired; now they need a new one. And the cycle continues.

“The mental health implications of this have yet to make themselves as evident as they should be. People are damaged from this.”

WHERE WE GO FROM HERE

The pandemic has created no shortage of problems, but there is at least one significant upside for CRT.

“The beauty of telehealth,” Dickerson said. “It burst onto the scene, and it still is in its infancy; it hasn’t seen its complete evolution yet, but the advent of telehealth is just spectacular.

“We’ve all done [telehealth appointments] here and there; I’ve done it for years with a couple of snowbird consumers between the Northeast and Florida. The number of times we were able to FaceTime and resolve a problem in 10 minutes was just remarkable.”

Dickerson said “most” clients find getting to clinic challenging.

“If you add the component of the disability and how impactful that disability is, then time and distance,” he said. “Can you imagine living in a bit of a rural area, and now with the minimization of clinics, because clinics are dying, you have to drive two hours on the highway to get to the outskirts of Manhattan? And then to go 100 blocks is another two hours to have your evaluation? And you have to do that three or four times? Just think about the burden of that.

“What did this person go through to get [to clinic] today? And there should be no reason that you shouldn’t have, with guidance, a robust telehealth operation. Telehealth in repair and service. However, if it’s not paid for, it’s going to be too resource-consuming, then nobody’s going to do it. We should be infinitely more radically aggressive in promoting the promise of assistive technology and what people with skill and compassion can accomplish for somebody with a disability.”

“What I see as a clinician as a plus of telehealth is being able to ensure good outcomes,” Carver said. “Now that we know we can do telehealth and we’ve had enough practice with it, when my supplier says, ‘Hey, Mrs. Smith’s chair is in, it’s ready for delivery’ — but she is weak, she has difficulty with transportation, she may have the beginning of a wound — I can say, ‘Let’s just set that up by telehealth.’

“[Using telehealth] to see a person in their home, I can more specifically address their needs such as turns, speed settings, or raising the seat-to-floor height so they can transfer to their toilet a little bit easier. I wouldn’t have known that if we were here [in clinic].” (The Clinician Task Force has developed a telehealth document/decision tree: tinyurl.com/CTFtelehealthtree.)

Carver agreed that a significant number of consumers will always find it difficult to attend clinic in person. “And they were there pre-pandemic, and if I could step on the top of the mountains, I would apologize to those people, that we were not as tuned in as we should have been to their difficulties of getting to us.”

Mullen is concerned about how circumstances now could cause lasting changes. “A child has a progressing condition with their spine, and the spine surgery is postponed because they’re only allowing one parent to be admitted with the child at a time, and the family’s realized it takes two parents to provide for that child in the hospital, so they’re postponing it,” he said. “That spine is continuing to curve, putting pressure on digestive and respiration systems. Those delays are having lifelong impacts on children. An intervention very early on could have a huge impact and a different rate of progression for the rest of that child’s life.

“How do we protect children and promote long-term gains? What can we do for that child to increase the chances of them having a better outcome long term, when they’re 20 years old?”

On the business side, Mullen acknowledges that basic expenses are outpacing funding that was established well before the pandemic: “Even getting a van to deliver equipment is being impacted. The price we pay to get vehicles bought or repaired and on the road — when you’re running 30 vehicles on the road, the increase we’re seeing in terms of cost is quite a kick. All of these factors really start to add up.

“Our cost of doing business is going up, but revenues coming in are slow to catch up, and our provincial funding agencies have maximums on what they’ll pay. Now I’m touching it or going over it in certain situations. So now that’s adding another delay because we have to fight for more money, and they have to amend their budgets to allow for that. That client is waiting longer again to get the [equipment]. And sometimes what we quoted a while ago — what the manufacturer is charging us has changed. But we have to honor our old quote.”

To expedite deliveries — and prevent some delay-related expenses — Mullen said, “I was highly influenced by my grandmother, who during the second World War had seen rations on things. I almost wonder: Should priority not be given to certain commodities? What’s more urgent? My grandmother couldn’t get nylons to wear because nylon was used for other things during the war. They couldn’t get tires for the car because that rubber was used elsewhere. If things get much worse, we need to start looking at prioritizing how raw materials are used, potentially.”

Dickerson said he has clients in a holding pattern: “We’ve seen a few people — we’re kind of tempering to see what happens a little bit — with manual wheelchairs as original prescriptions that are now considering whether they need a power mobility option because they just don’t have the endurance. Is that COVID related? Yes, globally. But it could just be from a sedentary lifestyle for 22 months.

“It’s probably everything. It’s hard to separate it out. They’re still able to do certain things, and they still can’t get over the psychological shock of going from a 15-lb. ultralight to a 400-lb. power wheelchair. They’re not sure they want to make that commitment yet, or they want to see: Does [their new condition] resolve in another three or four months? Everybody I’ve seen has identified the issue and is going to remain status quo until they cannot remain status quo anymore.”

And as CRT professionals continue to take care of clients, Carver emphasized that the industry needs to practice self-care as well. “We’re all focused on our end users that are dealing with the pandemic,” she said. “But I think we also should acknowledge that all of our various disciplines of healthcare are carrying their own weight coming into the clinic.

“They’ve got family members they’re worried about. They have their own children they’re worried about: going to school, all the things going on, and then they have to come ready to work with those folks. So just an acknowledgment of the stress that people feel.”

Current events, Carver said, have changed her approach in clinic. “I’ve begun to practice getting better at checking on people emotionally. Now each patient that comes in, we get to know each other a little bit and I’ll say, ‘So how are you doing with all the stresses and strains of this pandemic?’ Some will say, ‘Well, you know, day by day.’ Or, ‘I’m doing okay.’ Or, ‘Man, it’s really hard, you know?’ And I say, ‘If it gets too hard, please talk to your doctor about getting some support, talking to a counselor, getting some material about how to handle different things.’

“If people become emotional, I go a little further and just encourage them: ‘If you are having thoughts like I don’t think I can handle this anymore, this is too big for me, I wish I were not here, then you have to promise me you will speak up before you do anything,’ and I make them promise me.”

Carver admits this is new for her… just as this new world is requiring new processes from everyone. “I would’ve never done that pre-pandemic or at least been uncomfortable,” she said. “I think every discipline of healthcare is going to need to get comfortable talking to people about their emotional and mental places as we ebb and flow through things so that we can catch people at stages that they can get the help they need.”

This article originally appeared in the Jan/Feb 2022 issue of Mobility Management.

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