Over the last few years, the only thing more elusive than adequate funding for rehabilitation products and services has been an objective and comprehensive definition of rehab. Many profess to know what it is — and what it isn't.
One person's rehab is another's consumer power. There seems to be a pervasive attitude that “high-end” rehab is intrinsically better than all the rest. Many people dislike the service delivery model used by providers of non-rehab mobility services and mistakenly denigrate the value of these products and services to clients.
Given the funding environment on both the federal and state levels, these issues have polarized the industry and profession, and rightly so.
To be sure that we are all speaking the same language, here are two definitions of rehab. The first was adopted by the American Association for Homecare's Rehab and Assistive Technology Council, and reads as follows:
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“Rehab technology services are defined as the application of enabling technology systems designed to meet the needs of a specific person experiencing any permanent or long-term loss or abnormality of physical or anatomical structure or function.
“[They] are provided through a process that determines the appropriate array of products and services, the selection of which is based on the consumer's input, present and future needs, and his [or] her optimal levels of function. This decision-making process is crucial to the provision of rehab technology services, and is facilitated by a knowledgeable team of allied health care professionals (e.g., occupational therapists, physical therapists, orthotists, rehabilitation technology suppliers, etc.).
“These services, prescribed by a physician, primarily address, but are not necessarily limited to, wheeled mobility, seating and alternative positioning, ambulation support and equipment, environmental controls and other equipment and services that assist the person in performing their activities of daily living.
“Rehabilitation technology services facilitate and/or enhance access and independence, thereby improving the person's quality of life.
“Rehabilitation technology services are provided by a rehabilitation technology supplier (RTS) working for a rehab technology company (RTC). The process of providing rehabilitation technology services includes, at a minimum, the RTS, working closely with other allied health professionals to:
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complete a comprehensive evaluation of the consumer's needs and requirements;
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specify and select appropriate technology and products that are intended to address the enhancement and protection of skin and skeletal integrity and respiratory function, and to support activities of daily living and the consumer's desired quality of life;
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assemble, fit, adjust and deliver the selected technology to the consumer; and,
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provide all necessary short- and long-term follow-up, training, re-evaluation, re-adjustments and service.
“With a combination of academic preparation, work experience, continuing education and commitment to a professional code of ethics and credentialing, rehabilitation technology suppliers are uniquely qualified to determine, select, provide and service the appropriate rehab products and services for the people who rely on them. Because these products and services are provided as part of a professional health care process, it is crucial that they be adequately reimbursed.”
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The second description defines rehab technology products and process and was developed by industry and profession leaders. It is based on three factors: a description of the products and technology being provided, the diagnosis/prognosis of the client and the evaluation and assessment process used. This description primarily addresses the provision of seated positioning and wheeled mobility products, which make up the largest sector of the rehab market, and it requires a few definitions of its own.
First, “mobility equipment” includes any manual wheelchair, power wheelchair or scooter that a client purchases, or has purchased on his or her behalf, and that is prescribed by the client's treating physician. “Mobility systems” are manual or power mobility equipment that include seated positioning components, powered seating options or manual tilt, alternative (non-joystick) drive controls, multi-adjustable frame, or specialized components.
Next, a “physical evaluation” is a face-to-face determination and documentation of the physiological and functional factors that impact the selection of appropriate mobility equipment for a specific client. A “technology assessment” is the face-to-face process and documentation of matching the pathology, history and prognosis of the client to the appropriate mobility equipment or system.
Rehab products include mobility systems, as defined above, and any mobility equipment provided to a client who is under age 21; has a primary diagnosis that results from childhood or adult onset injury or trauma, or which is progressive or neuromuscular in nature; requires adaptive seating or positioning equipment; or has a diagnosis that indicates a need for other assistive technology, such as speech-generating devices or environmental controls. The provision process includes a face-to-face physical evaluation by a physician or other qualified allied health professional and an in-person technology assessment prior to equipment prescription.
Defining the Relationship
Rehab and durable medical equipment are important parts of the health care process for people with disabilities and physical impairment. They are, however, not the same, regardless of the fact that most funding agencies currently do not make a distinction.
In the operating models of DME and non-rehab mobility providers, physicians and allied health professionals are adjuncts to the process, only important in that their signatures are required on requisite paperwork. Also in the DME operating models, direct appeals to clients through advertising and Internet-based marketing may arouse the “mobility need” in consumers who may not have known that they had a need. This is capitalism at work, but it is not rehab.
Rehab, on the other hand, is based on a referral model, in which a client with a disability is seen by a physician or therapist who identifies the physical impairments that limit the client's physiologic function and refers the client to an RTS. If a client visits an RTS first, he or she is almost always referred back to a physician or therapist. Advertising to the consumer is not necessary. No rehab client wakes up one morning and says, “Today I need a wheelchair and seating system.”
The rehab supplier's relationship with the client is akin to a surgical patient's relation with an anesthesiologist. The physician, or in the case of rehab, the therapist, chooses the most qualified professional to provide services to his or her clients. After all, the provision of wheelchairs and seating systems is an extension of the medical interventions and the therapeutic process. Unfortunately, this referral autonomy has been eroded by preferred provider contracts and other constraints on client choice.
Unreasonable? Definitely!
Can rehab survive the mess caused by Operation Wheeler Dealer and funding cuts on the state level? Absolutely. Why? Because it has to. The difference between dependence and independence for children and adults hangs in the balance. Rehab is not overwhelmed by fraudulent and abusive practices. Rehab is represented by registered and certified professionals. Rehab not only talks about policing itself but takes steps to implement fraud and abuse safeguards.
How will rehab survive? By continuing to meet the physiologic and functional needs of its client and separating its fate from the fate of DME. This entails, among other activities, carving rehab products and services out of all competitive bidding legislation and proposing consumer protection legislation on the state level that requires qualified suppliers to provide rehab equipment.
Will this approach divide and fractionalize the industry? Probably. Can it assure the future of rehab products and services for people with severe postural and mobility impairments? Most definitely!
George Bernard Shaw said, “Reasonable people adapt themselves to the world. Unreasonable people attempt to adapt the world to themselves. All progress, therefore, depends on unreasonable people.”
Rehab cannot accept the status quo. Rehab people have a story to tell. Their cause is just, but their message often gets scrambled. If you are a rehab supplier, be unreasonable. Your colleagues and your clients need you to be.
Simon Margolis, CO, ATS/P, is vice president of clinical and professional development for National Seating & Mobility, Chattanooga, Tenn., and president of the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). He may be reached at smargolis@resna.org or by phone at 703/524-6686.
