ESTABLISHING CRITERIA FOR A
SEATING
AND MOBILITY ASSESSMENT
WAITLIST
Margaret McCuaig, MA, OT & Elizabeth Sebesta, OT
The wheelchair priority list was developed in the Rehabilitation Services Department of a multi level care facility of 225 seniors, staffed with 1.2 occupational therapists (OT) and 2 rehabilitation assistants, as a way of managing a substantial and ongoing wait list for seating and mobility assessment and prescription. The tool is a ‘work in progress’ and was designed in response to requests for seating originating from residents, family members and friends, staff and outside agencies. In an effort to manage the burgeoning number of requests in an organized and equitable manner, criteria and a system of quantifying the criteria were developed to help guide decision making. The initial tool was trialed and modified several times before the numerical data appeared to match our clinical impression of the needs of the residents. It is important to note that this tool was intended primarily to assist in addressing a waiting list, and was not intended to replace clinical reasoning related to crisis intervention.
Our first challenge in approaching the daunting number of resident assessments for seating and mobility systems was to decide how we would set priorities. It was not that we lacked assessment protocols or information on where to obtain equipment. What we needed was a way of managing an overwhelming caseload. After much discussion, we made a decision, rather like the triage process in emergency care, that we would address the most critical issues first. We then had to determine what were the most critical issues for our clients that we could address through seating and mobility assessments. Using our clinical judgement and knowledge of seating and positioning, we developed a list of what we thought were essential criteria to include in the tool.
A decision was made early on in the development of the tool, to look at risk factors as criteria, and give each item a score. Initially we used a used smaller numbers (eg. 0-4) and simple categories to guide our decision making. We chose to assign numbers to the following criteria: eating; mobility; general health; pressure ulcers; frequent falls; referral source; and equipment status. We also thought it was important to include, but not score, the following criteria: complexity (high, medium, low) of seating; referral date; and funding source. As we will explain in the next section, we found as we began to use the tool, that the simple categories and low numbers were not giving us data that reflected our clinical observations. Over the following months, we modified our criteria and are currently using what is included on the attached Waitlist Scoring Guidelines.
As we began to use the tool, we noticed we needed to make modifications in our understanding and weighting of the criteria. We noticed for example, that a resident with a deep pressure ulcer might not have problems in any other area, and so was scoring lower than a resident with minimal problems in all areas. Another area that proved difficult was describing and scoring mobility. Was it more important for a resident to be able to move about in the bedroom, or to be able to go out with a family member?
Other factors besides the resident assessment and criteria impacted the use of the tool. Initially the tool was designed for one OT and two rehabilitation assistants to manage the needs of 225 residents, along with a .5 OT and .5 PT who were hired on a 10 week contract. We had a short time frame in which to meet the needs of many residents. Adding to this mix was the skill of the therapists, one was accomplished in seating, one was not. Another factor influencing our ability to use the tool was the lack of availability of trial equipment. Slowly over time, we accumulated a pool of wheelchairs and equipment, making it much easier to move through the waiting list. Another important factor influencing how we addressed the wait list was the complexity of the funding process for some of our residents.
The development of the tool was useful in helping to guide our decision making in setting priorities. What we learned was that it must be viewed as a tool and not as a prescriptive measure. If a resident was identified as being at risk, because of a change in health, or equipment, we put the wait list aside and attended to the urgent matter. As staff and resources changed we modified our approach to the tool. In presenting the tool to other therapists, we see that each setting might include a different set of criteria. Perhaps resident contractures or behaviour might need to be considered as criteria as would service requirements and monitoring. Prevention of deformities might be an important criterion in working with children.
Totals do not complete the picture. Residents and their situations are more complex than just a set of numbers. We continue to look at our process of assessment of residents, what to do first, what can wait. We will use this tool as the basis for discussion and application to other settings in the instructional session.
The authors would like to acknowledge the support of Martha McDougall, PT, Director Lifestyles and Community Services, and the contribution of Christie Diamond, PT, in the development of this tool.
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CURRENT DRAFT
Resident Name and Lodge:
Type of Equipment being Requested:
Manual wheelchair, power wheelchair or scooter
Current Equipment Type and Ownership:
Functional Goal:
Some examples are: independent mobility, safety, positioning, ease of portering, energy conservation. May be more than one goal.
Funding
Source:
VAC (Veterans Affairs Canada), self, family, Public Trustee, other.
Complexity:
Low: No anticipated problem with positioning. Private funding.
Medium: May require more in depth assessment of positioning needs and/or requires a lengthy process including a report to obtain funding. Veterans are never considered to be low complexity because of the extensive and time consuming process to obtain even a basic wheelchair.
High: Residents requesting a power chair or a scooter fit into this category because of the time required for training and testing. Residents with challenging positioning needs requiring a manual wheelchair are high complexity whether a report to an outside agency is required or not.
Referral Date:
Month and year
2 = reddened area or decreased skin integrity
4 = blister
6 = skin break
2 = at risk for falls (standing balance, judgement, cognition)
4 = recent history of falls
6 = documented, frequent falls
2 = Inadequate: Every resident has the use of mobility equipment, but the equipment he/she is using may not be the most suitable, for a variety of reasons.
4 = None: This score is to be used when mobility needs are changing, and the resident does not have a piece of equipment of the type being requested.
6 = Unsafe: May be due to either the resident being at risk in the current equipment, or to faulty equipment.
0 = no functional problems at meal times
2 = position at meal times could be improved, but not at risk for low intake, choking, and/or aspiration
4 = at risk for low intake
6 = at risk for choking and/or aspiration
2 = is independent for short distances, but would be able to go further with proper equipment
4 = ease of propelling will be improved, leading to: eg reduced fatigue, reduced shoulder or back pain, increased participation in activities.
6 = is currently restricted to own room, and will be able to access more areas with proper equipment.
NA = will always be dependent even with change of equipment.
4 = with proper equipment, will be able to be taken to more activities and/or home for visits and/or out in the community.
NA = will always be independent with this equipment.
0 = stable health x 2 months
2 = gradual decline in functional abilities
4 = moderate decline in functional abilities
6 = recent change significantly affecting functional abilities
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