My background is acute rehab for over 25 years, so when I started to
work in geriatrics in a long-term care setting, I knew the pace would
be slower and the patient population would be drastically different.
I anticipated having to do my homework regarding geriatrics and
evidenced-based practice, and to learn how to work within a different
payor system.

What I was not prepared for was the isolation I quickly encountered
regarding DME and, specifically, wheeled mobility.

A Different Paradigm

In acute rehab, sales reps were always stopping by to offer their
services, and manufacturer reps were frequent visitors to introduce
a new product or to leave a “long-term trial” product. I had the cell
numbers of the local suppliers as well as local manufacturer reps, and
they would always answer quickly when called. I wouldn’t hesitate
to call late in the day to ask a question or to follow up on a status. I
could quickly get a piece to trial equipment for an upcoming appointment.
Naively, I thought this was the way the business worked
everywhere.

Now here I am in a long-term care setting. I ask about the local
suppliers who cover this facility, and I am given one name. Really,
just one? For the next couple of months, I didn’t see any other sales
reps or a single manufacturer rep in the therapy area. Not even the
one supplier I was told covered the facility.

I asked my supervisor about this, and he didn’t even understand
why I was asking to see a supplier. There was no need to see a
supplier, since when seating equipment was needed, the therapist
either looked in a closet for something or got something from a
catalog without even trialing the product.

The residents want to self-propel to get to activities, visit other
residents, go to the gift shop, go to meals and especially just be independent
in their room. The Catch-22 here is that these residents are
too medically or cognitively compromised to live at home, but the
long-term setting is a significantly larger environment to negotiate
than home. Our wheeled mobility solutions need to meet these additional
considerations for long distances.

Starting a Paradigm Shift

Fortunately, I am in a facility that values therapy’s input. The
facility is truly dedicated to providing the best care possible for our
residents. When we discussed seating & positioning with administration, I had full support to get what the resident needed… with
justification. While I appreciate now that this may not be the norm in
long-term care, I would like to share what we do in my setting.

The first step is simply education. I don’t mean just “how to assess
seating” education. Therapists can go to courses and learn how to
identify the problems, but as important as problem-identification is to
get educated on products available.

I contacted manufacturers for in-services and invited nurse
managers, social services and wound care specialists. Now we invite
maintenance as well, since they will need to service the products
in house, and their buy-in to new equipment is essential. I started
with wheelchairs and education on axle placement, seat height, and
standard vs. recliners vs. tilt, as well as the proper measurements.
Then we progressed with seating & positioning products for the
wheelchairs.

Having some demo product to use, I now could trial equipment
instead of ordering blindly from a catalog. The manufacturers started
bringing new suppliers into the facility, and soon I was getting calls
to schedule appointments with other vendors.

This provided the opportunity for competition and better pricing
for the facility, as well as more resources for the therapists to get
trial equipment or scheduling appointments for seating evaluations
with suppliers for suggestions on products that may meet resident
needs. Nursing was referring more residents to therapy, as they were
seeing our success with proper positioning… and not just requesting
residents be placed in geri recliners. Even better, we were getting requests to evaluate for alternate mobility for residents who had been
in geri recliners with the goal of using wheelchairs or tilt chairs.

I contacted the manufacturer rep and asked him to help us with
pressure mapping for proper product selection. We routinely utilize
pressure mapping to assist with justification and product selection.

Providing education and resources to access products was the
first step. Therapists needed to know what was out there and then be
given “permission” to go after it! If we don’t have the contact information
for a local manufacturer’s rep, I call the large freestanding
acute rehab center in the city and ask the seating specialists for the
information.

Reaching Out, Making Connections

The next step was how to provide optimal seating and mobility in a
cost-effective manner in the long-term care setting.

We have worked with social services to reach out to the ALS
Foundation, the MS Society, and the Muscular Dystrophy Association
for equipment needs for the appropriate residents. We have contacted
our manufacturer reps and suppliers to inquire about buying one
of their demos at a discount, if it will meet the resident’s needs. We
work closely with the maintenance department to adjust and maintain
the chairs. We have purchased different sizes of wheels and
casters to interchange on frames as needed, instead of buying new
wheelchairs. We have a supply of pushrims to use, if we want to trial
projections on a chair. We make sure that when a resident no longer
needs the equipment, it is safely stored so we can access it again when
needed.

When we do request a new seating system for a resident, we can
justify the equipment and often have trialed equipment (or close to the equipment requested) and documented the success of the system.
We may provide information from the pressure mapping sessions to
help with justification.

Administration, realizing there is not just one product for
everyone, is supportive of our efforts to control costs and to provide
optimal seating for the resident to enhance comfort and function.

When Mobility Management asked how seating & positioning is
different for the senior population, I understood the question was
about the unique considerations of co-morbidities, caregiver ease of
use, disease progression/change of status concerns, and payor limitations,
as well as power vs. manual considerations.

However, in my setting of long-term care, I ask: Why can’t seniors be
treated the same as community-based adults, with access to the resources
available for evaluation, product trial and selection?