Lisa U. Pascual, MDClinical Professor

UCSF Department of Orthopaedic SurgeryOrthopaedic Trauma Institute

Zuckerberg San Francisco General

Walkers, Canes and More:Prescribing Rehab-RelatedDurable Medical Equipment

Medical Care of Vulnerable and Underserved PopulationsFebruary 23, 2017

DisclosuresNone

Objectives• Become familiar with commonly prescribed

DME that may help improve a patient’s functional status

• Learn how to order and where to order these devices

• Become familiar with which devices may/may not be covered by insurance

What is durable medical equipment (DME)?

• Any equipment that provides therapeutic benefits to a patient because of certain medical conditions and/or illness

Where can DME be dispensed?

• CPD (aka Central Supply) at ZSFG (Ground Floor Bldg. 5)

• Orthotics and Prosthetics (aka O & P) (Bldg. 9, 1st Floor)

• Direct home delivery by a vendor

Who else can help procure DME?

• Health at Home• ZSFG outpatient social worker• Laguna Honda Hospital

Who else can help to procure DME?

• Depending on eligibility, Social Services at ZSFG may be able to obtain DME that is paid for by the Medically Indigent Adult (MIA) fund

• Health at Home and Laguna Honda utilize community vendors that deliver equipment to the home

• Health at Home may utilize ReCares equipment recyclers (no guarantee if equipment will be available)

How do I order DME?

• Outpatient Order Form• Available at ZSFG clinics and community clinics• May be used at CPD and O & P

How do I order DME?

• O & P Prescription Form• Available at 3M Clinic • Has also been sent to

other clinics (and can be sent to other clinics electronically)

• A similar form will soon be available on eReferral (hopefully within the next month)

How do I order DME?

• Orthotic and Prosthetic Prescription Form• Available at O & P and 3M Clinic• If not available, utilize the Outpatient Order

Form• Include the diagnosis • Include the justification for the device

CPD Process

• Patient presents form/Rx at CPD window• The Rx is good for 30 days after the last patient

encounter• CPD will look on the LCR to determine when

the patient’s last encounter was• If > 30 days, the patient will be sent to the

1st floor (Building 5) to Eligibility• CPD does not fit devices or instruct on use; pts

are often directed to PT for assistance

ZSFG Outpatient SW process• The outpatient SW may be called if the patient is being seen in

clinic and needs equipment urgently• SW may help facilitate obtaining these items thru CPD • If not urgent, and the pt has a PCP, then SW refers the pt to their

PCP for all DME requests• PCP would write an Rx for the DME and pass it on to the

DME coordinator (e.g. Behavioral Assistance)

ZSFG Outpatient SW process• If urgent, and the pt does not have a PCP, SW may:

• Help to order the following thru a vendor for home delivery:• Hospital beds• Bathroom equipment• Toileting equipment (urinals, bedpans, incontinent

supplies, diapers, etc.) and• Help to obtain access to primary care

• If the pt is homeless (no address) and the DME is not stocked at ZSFG:• The pt may pick the DME up directly from the DME provider

(e.g. Sincere Care), or• The DME may be delivered to SW where the pt can then pick

it up at a later date

Commonly Prescribed Rehabilitation-Related DME

Single Point Canes

• Where: May be obtained at CPD• To fit: hand piece should be at level

of wrist crease with elbow bent 15-20 degrees

Quad Canes• Where: May be ordered through outpatient

SW• Not commonly ordered for outpatients unless

they are for replacement of a lost or damaged cane (usually PT is involved if the pt is using this type of cane)

• Comes in a wide based or small based model

• Provides a wider base of support than single point cane

• More cumbersome, quad piece may not fit on certain stairs

• To fit: hand piece should be at level of wrist crease with elbow bent 15-20 degrees

Using a Cane

• Cane should be held in the hand opposite the side of the impaired limb (on the “good side”)

• Level surfaces: impaired leg and cane advance together followed by good leg

• Stairs:• Going up: Good leg up � cane up �

impaired leg up• Going down: Cane � impaired leg down � good leg down

Crutches (Axillary)• Usually for short term use• Where: CPD at ZSFG• Sizes: Small, Regular, Tall• Details:

• To fit: • Hand piece should be level at the wrist

crease (elbow should be bent approx 30 degrees)

• Axilla should NOT rest on the top piece (2-3 inches distance below the axilla)

• Pt may drop by PT to see if there is staff available to fit

Crutches (Forearm)

• Often for longer term crutch use• Initially harder to learn, better for posture,

alternative terrains, different gait style• Also known as Lofstrand or Canadian

crutches• Where: Outpatient SW may help to

procure; these are not available at CPD• Sizes: Small, Regular, Tall

Crutches (Forearm)• To fit:

• Hand piece should be level at the wrist crease (elbow should be bent approx 30 degrees)

• The opening of the cuff piece should face forward

• Position the cuff 1-2 inches below the elbow

Using Crutches

• Swing To Gait:• Move crutches forward• Shift weight onto crutches to move body forward

(swing) landing on the good leg to meet where the crutches are positioned

• Stairs:• Going up: Good leg up (keeping impaired leg

bent) � crutches up • Going down: Crutches down � hop down with

good leg

Walkers• Types:

• Basic• Front Wheeled• Rollator

• How to Fit:• Hand piece should be level with

wrist crease (elbow at 15-20 degrees of flexion)

• Worn tips may be obtained at CPD • Tennis balls (cut open) are sometimes

used when the wheels are worn/broken

Walkers• How to obtain:

• These need to be ordered through a medical vendor

• Outpatient SW may help to procure• An order form/ Rx is needed• Health at Home and Laguna

Honda may order these through a vendor if the patient is actively being followed by their service

Basic WalkerBasic walker: no wheels•Advantages:

• Offers most stability when weight applied, therefore, best for pts who need to put significant weight on the walker

• Good for use on indoor, level surfaces

• Can be folded •Disadvantages:

• Walker must be picked up every 2 steps to advance

Front Wheeled Walker

Front wheeled walker: two wheels in front• Advantages:

• More ease of mobility indoors and outdoors

• Can be folded • Disadvantages:

• Less stable than basic walker

Rollator WalkerRollator walker: four wheels• Advantages:

• More ease of mobility indoors and outdoors

• For patients who need walker for balance but not for significant weightbearing

• May be equipped with brakes, seat and basket

• Disadvantages:• Less stable than other walkers• May not fit thru tight spaces or

doorways

Knee Scooters• How to obtain:

• Outpatient SW may help to procure

• Requires complete prescription + Knee Scooter Authorization Form (available on 3M)

• Rental maximum of 3 months

• Delivered to home

Controlled Ankle Movement (CAM) BootAKA Walking boot or Bledsoe boot

• Often used post op• Indication must be

related to a ligamentous avulsion, fx or high ankle sprain to be covered (should be stated in Rx)

• How to obtain: Need order form/RX

• Where to obtain: O & P

Wrist Splint

• Often used for carpal tunnel syndrome

• OT’s may facilitate obtaining (as long as has order/Rx) if pt is seen while in 3M Clinic or OT clinic

• How to obtain: Need order form/RX

• Where to obtain: O & P

Elbow Brace

• May be use to fix position or limit range of motion

• OT’s may facilitate obtaining (as long as has order/Rx) if pt is seen while in 3M Clinic or OT clinic

• How to obtain: Need order form/RX

• Where to obtain: O & P

Knee Brace• Has rigid medial and lateral

rigid stays for support• Used to protect knee from a

recent injury, future injury or to provide support

• How to obtain: Need order form/RX

• Where to obtain: O & P• Off the shelf knees sleeves

are not provided as they not covered by insurance

Hinged Knee Brace (adjustable)• Used to manage range of motion

requiring a fixed position or to limit movement. May be used:• Post op• To prevent further or future injury• To provide more rigid support

• Has joints where range of motion can be dialed in

• How to obtain: Need order form/RX • Where to obtain: O & P, CPD

• O & P will help to fit and instruct on donning

Knee Immobilizer• Often prescribed after surgery for

short term use• Has been used to maintain hip

precautions as makes internal rotation, adduction and hip flexion difficult

• How to obtain: Need order form/RX • Where to obtain: O & P, CPD

• O & P will help to fit and instruct on donning

Ankle Brace• Commonly used for ankle

sprains• May be applied to provide

arch support (e.g. in lieu or a shoe insert orthosis)

• How to obtain: Need order form/RX

• Where to obtain: O & P• (off the shelf ankle sleeves

and shoe inserts are not provided as they are not covered by insurance)

Cast shoes

• Commonly used to accommodate casts, bulky dressings

• Order form/RX • Where to obtain: CPD

Cervical Orthoses (Rigid)

• Type often determined by surgeon

• Pads may be removed to be washed with water

• How to obtain: Need order form/RX

• Where to obtain: O & P, CPD • O & P will fit the

collar and instruct on use

Aspen Collar

Miami J Collar

Cervical Orthoses

• Philadelphia collars are often use when bathing as they can be wiped dry

• How to obtain: Need order form/RX

• Where to obtain: O & P, CPD • O & P will fit the collar

and instruct on use• Soft collars are available at

CPDPhiladelphia Collar Soft Collar

Back Brace (Lumbosacral Orthosis) • How to obtain: Need order

form/RX • Where to obtain: O & P

Maternity Support • 2nd most commonly prescribed brace

in O & P• How to obtain: Need order form/RX • Where to obtain: O & P

Off the Shelf Ankle Foot Orthoses• Primarily used for uncomplicated

foot drop• May refer to Functional Limb Service

Clinic (3M) using an eReferral to Physiatry for more complicated foot drop issues:• Pt with spasticity• Pt with concomitant plantar

flexion or knee weakness• Pt with medial/lateral stability

• How to obtain: Need order form/RX • Where to obtain: O & P

““““Noodle””””AFO

Leaf Spring AFO

Helmets

• Primarily for patients s/p craniectomies (generally not craniotomies)

• How to obtain: Need order form/RX • Where to obtain: O & P, CPD

Diabetic Shoes• Provides pressure relief to the toes (wide

toe box) • Requires a diagnosis of diabetes with h/o

foot ulcer (which is sometimes problematic if a patient has foot ulcers due to non-diabetic reasons), foot deformity, previous amputation or peripheral neuropathy

• How to obtain: Need order form/RX • Where to obtain: O & P• (O & P can help to modify shoes to

provide pressure relief or for specific positioning needs)

Rocker Bottom Shoes• Provides comfort for loss of joint ROM in

the foot or ankle (e.g. d/t arthritis)• These shoes are NOT provided by O & P• O & P can modify a pts existing shoes,

but this is not covered by insurance (approx $100)

• How to obtain: Need order form/RX • Where to obtain: O & P• (O & P can help to modify shoes to

provide pressure relief or for specific positioning needs) Skeechers $42

Heel Lifts

• For use in patients with leg length descrepencies• e.g. polio or neuromuscular disorders

• O & P stocks ½” lifts• These are not covered by insurance• Cost: approx $28• How to obtain: Need order form/RX • Where to obtain: O & P• (for pts who need shoe buildups: $100)

Compression Stockings• Edema prevention• Vascular disorders• Measuring guide available• Rep is available to supply Rx pads and

inservice• How to obtain: Fill out an Rx form• Where to obtain: CPD (rec. ordering 2 pairs)

Standard Wheelchairs

• If needed urgently, outpatient SW may help to procure

• Will need order/Rx

Custom Wheelchairs

• Custom wheelchairs are usually appropriate for pts who will be long term wheelchair users

• OT’s (most common) or PT’s must evaluate the pt to provide the specifications of the wheelchair (e.g. dimensions, cushion type, accessories, wheelchair model, etc)

Custom Wheelchairs• The MD may:

• Refer the patient to OT at LH for evaluation, who will then forward it to a vendor

• Refer the patient directly to a vendor, where an OT or PT must then evaluate the patient

• The MD will ultimately sign off on the custom wheelchair prescription provided by the OT or PT

Power Wheelchairs and Scooters(AKA Power Mobility Devices or PMD)

• Not all primary wheelchair users are appropriate for power wheelchairs or scooters

• Certain diagnoses are not appropriate for PMDs (e.g. scooters are not appropriate for patients with trunk control issues)

• Medicare (and most insurances follow Medicare guidelines) have specific criteria that must be met to justify purchase of a power wheelchair.

Power Wheelchairs and ScootersThe criteria refers to the need for the device to be used in the home:“Does the beneficiary have sufficient upper extremity function to propel a manual wheelchair in the home to participate in MRADLs (mobility-related ADLs) during a typical day?”Read: Will the patient be using the power wheelchair in the home to perform ADLs?This requirement often excludes pts who do not need a power wheelchair/scooter within the home, and only need it for outdoors.

Custom Wheelchair Repair and Replacements• Repairs: The patient should return to the vendor that provided

them with the wheelchair.• Replacement:

• Custom wheelchairs may be replaced at 5 years provided that there are significant issues impacting the functioning of the current wheelchair

• Wheelchairs may be replaced or modified earlier than 5 years if the patient’s functional needs have changed and that the current wheelchair no longer meets the patient’s needs

Custom Wheelchair Repair and Replacements• Additional mobility devices:

• Typically, only one mobility device can be ordered (e.g. FWW only, no wheelchair)

• However, certain vendors may provide both a walking device and a wheelchair

Obtaining Custom Wheelchairs as an Inpatient• In general, vendors do not provide/deliver custom

wheelchairs to inpatients • Insurances (e.g. Medi-cal) requires documentation of plans for

discharge to the community and an address before authorization of a custom wheelchair

• Some vendors may provide a loaner chair while a patient awaits their custom chair (generally only when a custom chair has been approved)

Things to Remember(will be much appreciated by the staff and patient!)• OT does not have the funds nor the available storage capacity to

stock DME – please do not send the patient to OT to pick up supplies or equipment• If you would like OT to see evaluate the pt to determine the

need for DME, please submit an OT eReferral• Before sending a pt to CPD, please check to see if they carry the

desire DME• Make sure that the patient obtains the DME within 30 days of the

visit• When filling out the order form or prescription, please include the

diagnosis and justification (especially for high ticket items!). If possible, document the need for the equipment in the progress note.

Important Numbers

• CPD: Bldg. 5, Ground Floor, 415-206-3065• Orthotics and Prosthetics: Bldg. 9, 1st Floor, 415-206-4387• ZSFG Outpatient Social Worker: Bldg. 5, 1C12

• Currently: Richard Nyhagen, 415-206-5821• Health at Home: Laguna Honda, F5, 415-759-4760• Laguna Honda Occupational Therapy:

• Currently: Carolina Ong, OT Supervisor, 415-682-5714• For complex bracing issues: eReferral to Physiatry at ZSFG

• Appts will then be scheduled in the Functional Limb Service Clinic on 3M• Compression Garment Rxs and inservices: myrada.benjamin@bcnmedical.com

Thank You