COMFORTABLE SEATING: SHUTTERSTOCK.COM/YAKOBCHUK VIACHESLAV
In the history of wheelchair seating, assessing a
client’s home environment has been conducted
by different professionals.
Cindi Petito, OTR/L, MBA, ATP, CAPS,
CEAC, CLIPP, a seating veteran who has specialized in
home accessibility, recalls when clinicians often
completed home assessments prior to hospital
discharge: “When I used to work in-patient with brain
injury and spinal cord injury [clients], back in the
early 2000s, we did the home assessments,” she
recalled. “That’s how I learned and entered this
practice area [home accessibility] initially.”
But as funding sources cut fee schedule reimbursement
rates and implemented new coverage criteria for
therapy services, including hospitals paying clinicians
to do home assessments, those visits began shifting to
the supplier. “In 2005-06, when Medicare implemented
new coverage criteria for CRT stating that a
home assessment had to be completed, that’s where
the shift solidified [to the supplier],” Petito said. (She’s
hearing more payors are once again starting to pay
therapists to assess patients’ homes before discharge,
especially in workers’ compensation cases.)
Regardless of who on the seating team visits the
client’s home, Petito said a quality assessment can
yield valuable information.
“A home assessment is a vital component of the
wheeled mobility process because it ensures individuals
can function inside and outside their home and carry
out activities of daily living with use of the chair,” she
noted. “Without a home assessment as part of the
wheeled mobility process, there is the risk of providing
an inappropriate wheelchair that will end up sitting in a
closet or garage.
“In general, a comprehensive home assessment is a
way to capture the entire picture of what’s happening
in the home and community. It can provide additional
justification, supporting the need for the equipment
outside of the standard Medicare criteria. A comprehensive
home assessment can also identify additional
equipment needs. It helps clinicians and ATP
[suppliers] see beyond the wheelchair.
“Directly related to the wheelchair mobility process,
a comprehensive home assessment helps to ensure
clinicians and ATPs are assessing every aspect of that
individual’s daily routine life and maximizing
individuals’ ability to use the wheelchair to its full
capabilities — not just in a few performance areas.”
The Value of the In-Person Visit
Regardless of who does the assessment, Petito said an actual home visit is
much more useful than static photos.
“It would be great if the ATP [supplier] is in the home, and the clinician
can Zoom in to see the home,” she said. “Or if the clinician can complete the
evaluation in the home in person and the hospital can bill for that visit, then
the [supplier] is the one telehealthing in — either way, I think that’s the best scenario.
“You should have a reliable person in the home who’s operating
the measuring tape and measuring the environment
accurately. One good example is how people measure doorways:
Some people measure outside frame to outside frame; some
people measure the inside frame. But the inside frame is not
really the true wheeled space because you still have to take into
account the inside corner of the door that takes up space inside
the frame — when the door is fully open, it’s still taking up an
inch to 2″ of space. That 1″ to 2” doesn’t seem like much, but it
makes a big difference with somebody using a mobility device,
whether it’s a walker or a manual chair or power chair.”
An in-home visit, Petito said, is just more revealing: “You don’t
get to see potential barriers with pictures and a report.
Measuring the environment — and measuring it accurately — is
just as important as measuring somebody for a chair.”
When the real-life environment isn’t fully considered — when,
for example, wheelchair training takes place in the open spaces
of a clinic — clients can have trouble once they get home.
“Most clinicians in our industry work in clinics,” Petito said.
“They’re training clients in a controlled environment, and they’re
measuring for the wheelchair in that same controlled environment.
Once [clients] are discharged home, it can be a totally
different ballgame. The perception that I have being a wheelchair/seating clinician in the home is very different. There have
been times when somebody’s discharged to home with a new
chair, and they’re having complications related to unforeseen
barriers. In a few situations, I’ve had to call the seating clinic
therapist to let them know I’m going to recommend changes to
the chair because of barriers in the home environment.”
In the past, Petito has arranged loaner wheelchairs for clients
to test in their homes: “Being able to complete trials in the home
is even one step beyond completing the home assessment: If we
have the ability to perform a trial of a chair we think might work
in the home, that yields the best outcome. But I know for hospital
clinics and ATP [suppliers], getting that kind of time and
availability is difficult.”
Choosing Home Assessment Priorities
Petito listed her top three assessment priorities:
- Ensuring wheel configuration, turning radius, overall width/depth of the base and seating system are conducive to use in
the home. “Measuring rooms’ floor space and doorways are just
a few key factors,” she said. - Examining floor-to-seat height for transfers to all sitting
surfaces in the home, school, work, and community (i.e., bed, toilet, shower chair, vehicle). - Considering the client’s reach ranges, which are often overlooked
or forgotten. “For example, a home assessment is
completed for an individual who’s still in in-patient rehab:
Kitchen accessibility recommendations that include lower/upper kitchen cabinets cannot be made until reach ranges are
measured from the permanent wheelchair — or at least from a
loaner chair with a similar configuration. The same issues
occur in the bathroom: The reach range from the wheelchair to
the sink and water controls is an important factor in the
configuration of the chair. If the client is tall with a long seat
depth, their footrest and toes may hit the wall under the sink,
preventing the person from getting close enough to safely
reach.”
Home Assessments of the Future
Petito is a fan of the telehealth option that gained traction during
the pandemic. “Telehealth home assessments are far more
reliable, and provide more valuable information, than a family
member providing photos of their home or filling out a self-assessment
form for the clinic,” she said. “Telehealth assessments
allow the seating clinic to see the home and gather important
information about a person’s environmental and caregiver
demands — which helps the clinician and ATP make informed
decisions about wheelchair configuration and performance.”
Another significant impact to home assessments and equipment
choices could come if the Centers for Medicare & Medicaid
Services agrees to fund power seat elevation.
“If seating elevation was covered, that would be helpful in
multiple areas of the home — primarily the kitchen, reaching the
upper cabinets and pantries, the standard microwave-above-the-stove
issue,” Petito said. “Being able to access clothes closets.
Everyone knows seat elevation helps with transfers. But all the
other tasks in their home and their community need to be
assessed, like reaching shelves in a grocery store. Seat elevation
can reduce the amount of modification somebody would have to
make in their home, which is usually an out-of-pocket expense
that many people cannot afford.
“Their reach ranges would be more safe. If you think about
somebody with poor trunk control, if they have reach outside of
their base of support or functional support, [seat elevation] is
improving their functional reach.”
Incremental differences can significantly impact a client’s
ability to perform daily activities, Petito added, thus expanding
their independence. “It’s these little things you don’t think
about,” she said, “until they happen.”
