ATP Series

"We Don't Pay for Comfort"

Clients Want a "Comfortable" Seating System; Payors Fund What Is Medically Necessary. Can Both Sides Win?

Comfortable Seating SystemComfort has some similarities to — and sometimes a direct bearing on — happiness. Comfort can be tough to precisely define; it can be difficult to put into words exactly what we need, and in what quantities, to be comfortable at any specific time. In fact it’s oft en much easier to pinpoint when we aren’t comfortable than to describe how we feel when we are.

Such is the challenge for clinicians and ATPs striving to build wheelchair seating systems for clients who count on them as their primary sources of independent mobility. Because they spend hours every day in their wheelchairs, “comfort” is understandably high on clients’ lists of priorities. And yet, describing what they need to be and stay comfortable can be difficult to do — even more so if the client is non verbal or has difficulty with language.

Complicating the situation further: funding sources that zero in on medically necessary equipment to the exclusion of all else.

Is there a way to bring both sides together?

Defining & Understanding Comfort

Step one in the process might be trying to more precisely define what can be thought of as a subjective term.

“The concepts of comfort and discomfort have been around since the mid-1700s, yet the definition and the actual description of these two concepts are always open for debate,” says Kay E. Koch, OTR/L, ATP, rehab clinical education manager for Invacare Corp.

“At its most basic level,” says Julie Piriano, PT, ATP/SMS, director of rehab industry affairs for Quantum Rehab, “comfort is acknowledged when the physical needs and well being of the individual are met. For a wheelchair rider who utilizes postural support components, ‘comfort’ is a critical component for them to be able to sit in and use their mobility device throughout the day and perform or participate in their activities of daily living (ADLs). While they may be able to sit without discomfort in the sense that an able-bodied person would describe being comfortable, the type of ‘comfort’ individuals with disabilities and chronic medical conditions require is a very different use of the word.”

“Clients often describe comfort in the context of relieving discomfort,” says Tricia Garven, MPT, ATP, clinical applications manager for ROHO Inc. “They’ll say things like, ‘I have less back/neck/shoulder pain,’ or ‘My butt isn’t as sore.’ Clients also may say something is more comfortable if they can sit for longer periods, or do more activities without pain or fatigue. Comfort is such a subjective feeling that it’s often hard to qualify.”

And while these descriptions are understandable, says Lois Brown, MPT, ATP/SMS, there can be risks involved when clients aren’t able to precisely define what makes them comfortable or uncomfortable. “During an equipment trial, you often hear a patient describe the wheelchair seat or back as comfortable,” she notes. “We do the same when we are shopping for living room furniture or a mattress. When the patient comes to clinic in their existing chair and they describe what they like/don’t like about their chair, you more often hear them describe their seating in terms of pain or fatigue in relation to feeling positioned well in their wheelchair. The disconnect there is the time oft en during trial is very short, and we know that over a course of a day, a week, a month or years, they experience changes in their posture, or muscle weakness that affects their ‘comfort.’”

How Do Clinicians & ATPs Aim for Comfort?

Clinicians and ATPs are then tasked with understanding how a client interprets “comfort” and balancing that call with their own professional goals.

“As a clinician, the goal is to create a seating system that meets the clients’ specific seating needs (skin protection, positioning, etc.) and is comfortable, too,” Garven says. “Often times, when the seating needs are being met — posture, support and skin protection — comfort is a nice side effect.”

“We have basic subjective measures to assess comfort, such as directly asking a person about how comfortable they are or observing movements, reactions or actions, such as moving away from something uncomfortable like the edge of a lateral,” Koch says. “There are also a few objective measures that we can use, like pressure mapping systems to document pressure redistribution to assist with describing why someone is comfortable or uncomfortable in their system. As clinicians, we are assessing multiple things, including the body’s tone, range of motion, function, support and comfort. We look at how the components of the seating system integrate the goals of not only the client, but the team. If the system is not comfortable, utilization and acceptance of the system may not occur.”

Clinicians also attempt to foresee how today’s positioning might impact the client tomorrow, Brown says.

“Comfort may be the total time they are able to tolerate sitting in the chair without having to transfer to another surface such as a bed or other sit surface,” she points out. “Comfort may be an immediate sense of liking the support surface, but that of course depends on sensation. Comfort can mean they feel the seating system provides good postural support, and they do not have to constantly reposition themselves. Comfort can mean that as a result of a ‘slumped’ posterior pelvic tilt posture, they do not have actual back and neck pain associated with trying to maintain their head in an upright position. “In the background we are always striving to stave off secondary decline of postures, such as minimizing a kyphosis or scoliosis to maintain good respiration.”

Translating “Comfort” to Funding Sources

The next hurdle: making the case for “comfort” — i.e., clinically efficacious seating & positioning equipment — to funding sources.

“‘Comfort’ is considered much too subjective of a target — vague& not medically defined,” says Stephanie Tanguay, OTR, ATP, clinical education specialist for Motion Concepts. “It seems that the use of the word ‘comfort’ is almost a sure-fire way to have a denial or a request for additional documentation. Because we cannot qualify ‘comfort,’ we need to speak in terms that are quantitative.”

That can mean giving payors detailed, clinically based explanations.

“Feelings of discomfort are mainly associated with physical factors like pain or fatigue or postural instability,” Koch says. “Translating that to the physical characteristics of the seating system’s shape or materials utilized, combined with the activities of daily living that need to be accomplished or other goals for the client in their seating system, can help justify components. Tying in how the seating system interfaces with forces secondary to gravity and the effects of these forces on tone, circulation, respiration, skin and body temperature regulation can also enhance the justification.”

“As part of the seating and wheeled mobility evaluation process, clinicians identify what body system or systems are responsible for or contributing to the mobility challenges, work collaboratively with the supplier ATP to develop solutions and then explain the recommendations to third-party payors,” Piriano says. “As such, ‘comfort’ may mean the postural stability that allows one person to reach and function outside their base of support to carry out their ADLs without fear of losing their balance, while it may mean the ability to take a deep breath and speak to direct those same activities for another.

“The sense of ‘comfort’ an individual has when they can sit and enjoy a meal is immeasurable, regardless of whether the recommended mobility device and postural support components allow them to independently get to the table and feed themselves or be supported and positioned in a manner that allows them to chew and swallow their food safely.”

Longevity certainly counts when trying to objectively define a subjective feeling such as comfort. A consumer may not effusively express how comfortable her seating system is, but her willingness to stay in the wheelchair for longer periods and her high functional level while in that chair can be a great testament to its overall success.

“If a consumer has limited tolerance for staying in their chair due to fatigue or discomfort, documenting their ability to sit on a different cushion surface for longer periods of time may be helpful,” Tanguay says.

The down side?

“Unfortunately, determining what product(s) have the maximum benefit can take a period of time that is not realistic,” she notes. “I think pressure mapping has also been used to determine the most appropriate cushioning, and that data might not indicate what the consumer would perceive as the most comfortable surface, even if it is the product which provides them with the best pressure distribution. Some consumers or their caregivers have a perception about product thickness equating to comfort: the thicker a cushion or a back support is, the more comfortable it must be. That is most certainly not true in many circumstances.”

While it may not be possible to test every possible seating product, Garven points out that having a range of choices can be helpful to the seating team.

“The good news is there are a wide variety of products available to meet different seating/comfort needs,” she says. “ When the clients qualify for a certain type of coded product — cushions or backrests, for example — they qualify for many options, not just one make/model. Ideally, the clinician or ATP involved will identify what products will meet the client’s clinical seating and positioning needs, and then trial these options to settle on the most comfortable choice. In this situation, it’s a win-win. The seating needs are met, and comfort is also an end result.”

An End to Equipment Abandonment

While funding sources may outwardly seem less than empathetic regarding the comfort of their beneficiaries, all stakeholders should be concerned about the ultimate price of discomfort: the abandonment of costly technology.

“Although comfort is not technically a reason for payors to pay, it is quite important,” Garven says. “Comfort, or in this case, discomfort, can be a reflection of compliance with the recommended seating system. If someone isn’t comfortable, they most likely won’t continue to use the equipment… especially when they have other, often older or worn-out options, which may be a differently configured wheelchair, or just different seating components. This may put the client in an unsafe situation without them even realizing it because they are using older equipment that is likely not functioning properly anymore.”

“When funding challenges put up barriers to achieving this level of success,” Piriano says, “it is essential for consumers, clinicians and supplier ATPs to understand and articulate the concept that ‘comfort’ is not the absence of discomfort. It is the ability to maximize physical and psychological independence.

“For example, powered mobility provides individuals with 360 degrees of movement in a two-dimensional plane, but we live in a three-dimensional world. While some payors view power adjustable seat height technology as ‘not reasonable and necessary’ because it is for comfort and convenience, ask a power wheelchair rider how comfortable they are cooking on a stove top, or how convenient it is to get anything out of the freezer.”

She adds, “When we understand how empowering utilization of available technologies is, we can grasp the true meaning of ‘comfort,’ understand success in the provision of seating and wheeled mobility technologies, and make a difference in the daily lives of individuals with disabilities.”

Payors who initially show little interest in a consumer’s comfort might also consider, as Koch points out, that providing a successful seating system from the beginning can be much more efficient for everyone than having to repeatedly tweak a system down the road because the consumer, caregiver or clinician isn’t happy with it.

“Comfort plays a role in a client’s seating system and is one of multiple factors that should be addressed in the evaluation and trial of equipment along with pressure redistribution, postural support and stability,” she says. “There are other peripheral factors to comfort, which may include the aesthetics of the system, how the client feels peers or others perceive the system, and the psychosocial aspects of body image. These factors are highly individualized, but also play a role. In my opinion, preventing discomfort is easier than fixing discomfort.”

This article originally appeared in the September 2014 issue of Mobility Management.

In Support of Upper-Extremity Positioning