1. OVERVIEW AND DESCRIPTION
Durable medical equipment (DME) is equipment that is considered medically necessary as prescribed by a physician for use in a patient’s home. Medicare considers DME as any equipment that can withstand repeated use when used for a medical reason. The equipment must have an expected lifetime of three years and it must not be considered useful to someone who is not sick or injured. Mobility- related DME includes equipment such as manual and power wheelchairs, scooters, canes, walkers, crutches, commode chairs, hospital beds and patient lifts.1 For individuals with a disability, DME can improve safety while decreasing the need for caregiver assistance. It can substantially improve overall quality of life by increasing a person’s independence with functional mobility and activities of daily living (ADLs). When evaluating a patient’s need for DME to enhance function, it is helpful to do so in conjunction with the multidisciplinary team, including physiatrists or other specialty physicians, occupational therapists (OTs), physical therapists (PTs), speech and language pathologists (SLPs), rehabilitation nurses, and social workers. It is important to understand medical needs, but also a patient’s functional needs in regards to the home environment, living arrangements, and also vocational and recreational activities. By determining appropriate equipment needs, individuals who were once dependent on others may regain independence in the hopes of returning to their prior level of function and home environment rather than needing to be cared for in an extended care facility.
According to Medicare, DME can also include non- mobility related medical devices, such as home oxygen and oxygen supplies including positive airway pressure (i.e.: CPAP) devices and nebulizers, diabetic supplies, enteral nutrients, infusion pumps, negative pressure wound therapy pumps and related supplies.1 Medicare payment for approved DME, as well as devices discussed elsewhere (prosthetics and orthotics, surgical dressings, therapeutic shoes and inserts) is equal to eighty percent of the change accrued. The patient is generally responsible for the deductible plus twenty percent of the calculated charge.1 While considering cost, home environment and a patient’s current and future DME needs, patients with a wide variety of impairments should be considered for the appropriate DME.
2. RELEVANCE TO CLINICAL PRACTICE
There are several medical, physical, and mental benefits associated with the use of DME. For example, DME allows individuals to become more independent and decreases the level of assistance needed from caregivers. With the potential for increased independence, there is a greater capacity to enhance the psychological wellbeing and social engagement of individuals with a disability. While there are many proposed benefits to using DME, there are several factors to consider prior to recommending and ordering specific equipment.
When determining the need for DME, one should consider the individual’s diagnosis, functional impairments and precautions in order to determine the appropriate equipment to serve an individual’s needs. The purpose of DME should be established as to whether the equipment is used to increase independence with self-care and to improve mobility or to decrease caregiver burden and improve safety. The patient’s individual goals, home environment and financial cost burden should also be considered. Cognitive impairments, such as decreased memory, decreased judgment, poor safety awareness, or a lack of self-awareness to disability, present challenges to medical staff when training individuals to incorporate DME into daily activities. For those individuals with cognitive impairments, training a family member or caregiver can ensure proper use, increase safety and improve compliance. Lastly, individual cultural and societal biases may influence the perception of DME, either positively or negatively, which is another factor to consider.
There are three main rehabilitative activities in which DME can provide assistance in order to increase independence and safety. These include activities of daily living (ADLs), transfers, and ambulation/mobility. ADLs encompass the following tasks: eating, grooming, bathing, upper extremity dressing, lower extremity dressing, and toileting. OTs play an important role in assessing a patient’s ability to perform ADL tasks such as evaluating safety during transfer to the toilet, tub or shower. For example, patients who experience difficulty with transitioning from a seated to standing position, particularly from low surfaces, may benefit from the use of the 3-in-1 commode chair or a raised toilet seat. Both increase the height of the toilet seat and provide handles for the individual to use when transitioning to a standing position when transferring on and off of the toilet. A drop arm commode chair would better suit individuals with severe lower extremity weakness or paralysis that may rely on a wheelchair for mobility with use of a transfer board for safe transfers. With a drop arm commode chair, the arms of the chair swing away or down in order to provide a level surface for safe lateral transfers for these individuals. Additionally, a patient may utilize a shower chair with or without back support to save energy while bathing and decrease the risk of falling. Patients with hemiparesis, specific range of motion restrictions, or those who have impaired balance often require a tub transfer bench in order to safely get in and out of the tub. This allows the individual to sit down outside of the tub and then maneuver their lower extremities into and out of the tub while maintaining a seated position.2 Recommendations for adaptive devices in addition to standard DME may include a hand-held shower head, grab bars to be installed in the shower and toilet area, or a floor to ceiling transfer pole to improve the safety in the bathroom.
Patients that experience difficulty transferring in and out of bed, typically because of medical conditions that result in weakness, de-conditioning, poor endurance, poor trunk control, or significant pain may benefit from bed rails, overhead trapeze, rope ladder, leg lifter, or even a hospital bed. Individuals that lack adequate strength in their lower extremities or core stability, such as in patients with spinal cord injuries, may also benefit from a transfer board to further assist with transfers from bed to wheelchair or wheelchair to other seated surfaces (tub bench, commode, car, etc.).
Throughout the rehabilitative process, physicians also work with PTs to assess a patient’s need for DME to assist with safety during ambulation. Up to nineteen percent of elderly individuals in the Unites States require assistance to ambulate and may benefit from the use of a cane, crutch or walker.3 These devices can increase efficiency of gait, reduce pain and enhance function with lower extremity osteoarthritis. 4 They can also enhance balance and reduce the risk of falls while providing sensory cues, improving posture and facilitating propulsion with many other diagnostic impairments. Numerous options exist for each device. Canes such as the single point or four point can increase stability and improve gait mechanics. Crutch options include axillary, platform or forearm. These can be used individually or in pairs and can assist with grip stability for those with poor dexterity or inability to hold a cane or walker. Walkers can include different hand grips, rolling components for maneuverability, rubber tips for stability and the potential for a seat. Individuals with hemiparesis following conditions such as a stroke, may require the use of a hemi-walker. Each of these devices can be made from a variety of materials including wood, aluminum, steel or titanium and may be rigid or folding. Other considerations include proper positioning to prevent positional nerve injury and appropriate height to enhance mobility while preventing mechanical overuse syndromes.5 There are many gait patterns with these devices such as alternating, reciprocal, two-, three- and four- point gait and swing through. Additionally, patients with lower extremity weakness may benefit from bracing or orthoses to improve their lower extremity stability, positioning and gait. PTs can assist patients in proper DME selection, safe use for the device and recommended gait pattern.
Individuals that are non-ambulatory will require either a manual or power wheelchair for mobility. It is important to consider each individual component of a wheelchair when evaluating a patient to ensure proper positioning, postural stability, and safety with mobility and ADLs within the home. Necessary components of a wheelchair include the frame, cushion, arm and leg rests, wheels tires and casters, handles, locks and anti-tippers. Other added components include (but are not limited to) positional devices such as straps, arm troughs or pads to assist with proper positioning while in the device. These can be used to correct or accommodate deformities and range of motion deficits. When considering specific populations, options such as hemi height can be utilized for stroke patients to utilize lower limbs to propel. For the self-propelling patient who is at risk of upper extremity overuse injury, power assist devices can be considered as an additional component of a manual chair. For power mobility, the device can be propelled not only by use of the upper extremity, but numerous options exist for head arrays and sip and puffs for the user who requires use of the head and neck to mobilize. For patients unable to self-propel with manual or power mobility, a dependent manual chair such as a tilt and space may be utilized by a caregiver to propel and shift weight for a patient requiring total assistance. Regardless of wheelchair choice, wheelchair training with a knowledgeable therapist cannot be overstated to ensure safe use.
Collaboratively, OTs, PTs, and physicians can recommend specific DME to increase an individual’s safety and independence with ADLs, transfers and ambulation/mobility.
3. CUTTING EDGE/UNIQUE CONCEPTS/EMERGING ISSUES
DME insurance coverage is dependent on the diagnosis, comorbidities, level of medical necessity, insurance type, and a patient’s currently owned items. In the current health care environment, documentation of medical necessity by the provider is crucial to reduce financial burden on the patient. Consideration of the insurance coverage and copayments can help make a realistic plan for the patient. For non-covered items, the patient or family is often responsible for the cost of the device, which can result in financial hardship and burden. Local equipment supply companies and online catalogs serve as a good resource for affordable prices. Most insurance companies will not cover replacement items unless the current item is broken beyond repair. Because of the limits for replacement items, it is important to consider not only current needs but also future needs to ensure appropriate equipment is available for patients with progressive diseases, such as multiple sclerosis, muscular dystrophy, and amyotrophic lateral sclerosis.
With recent advancements in technology, medical equipment is moving away from standard DME and quickly toward devices that fall under the area of assistive technology (AT). In 1998 (with provision in 2004), the Assistive Technology Act was passed, which provides federal funding for “state efforts to improve the provision of assistive technology to individuals with disabilities of all ages” in order for persons with disabilities to more fully participate in education, employment, and daily activities.6 Rehabilitative and Assistive Technology includes “tools, equipment, or products that can help a person with a disability to function successfully at school, home, work and in the community”.7 Examples of AT include devices that enable patients to live independently in a hands free or other assisted mode. Recent advancements include Bluetooth home automation and environmental control units (ECUs). Interestingly enough, many of these devices were not intended for individuals with a disability, however, individuals with motor, visual or language impairments may find the greatest satisfaction and independence by being able to control their home (door locks, light switches, television, etc.) through this type of technology. Additional communication devices such as eye gaze systems for those with little or no motor function from neurologic conditions, such as high cervical spinal cord injury, brainstem stroke, or amyotrophic lateral sclerosis, enable patients to navigate a computer and communication system using eye movements. Other devices are being developed such as brain-computer interfaces, exoskeletons and robotics which will give the user autonomous control and increase a patient’s ability to interact with the environment.
As technology continues to evolve, more devices will be available to compensate for various impairments. Unfortunately, insurance coverage may continue to be a barrier, as these devices are expensive and Medicare has limited coverage options. Currently, home modifications are generally an out of pocket expense despite the ability to potentially increase an individual’s independence. Consumer level devices, such as Bluetooth home control devices and applications for consumer phones and computers, provide hope to bring down the cost of these devices significantly. Many individuals may find it more cost effective to purchase assistive devices for home automation on their own as these non-medical devices are frequently offered at a considerably lower cost to the general public than through medical necessity. With the increased availability and accessibility to purchase these devices at the consumer level, there is hope that this will help drive down costs for medical necessity of adaptive technology devices. More research and legislation is needed to promote the effectiveness, clinical relevance and medical necessity of these devices.
4. GAPS IN KNOWLEDGE/EVIDENCE BASE
As the population ages and lives longer with disease, there will be an increase in disability, resulting in an increased need for medical equipment and adaptive devices. DME is widely available; however, it is underutilized in the chronically disabled population. A study in 2007 looked at DME use among older adults enrolled in Medicare and found that fewer than half the chronically disabled and less than one quarter of the newly disabled received any DME from Medicare.8 One of the main barriers to utilization of DME is the lack of physician awareness and sparse published literature to guide physicians in making appropriate choices. Multidisciplinary assessment of a patient, including specific mobility related recommendations from a therapy team can also increase the understanding and need for DME to enhance overall function, prevent injury and improve independence. Educating ordering physicians on the benefits of DME and providing simple guidelines may help to increase utilization. Other barriers may include a patient’s decreased awareness of available DME and their willingness to use the appropriate devices because of concern of self-image or denial regarding their medical condition. A lack of payment for adaptive devices, recreational equipment and assistive technology is a notable barrier in the 21st century as the equipment needs of this generation are evolving at a rapid pace. Providing educational materials and peer support could help alleviate some of these concerns and provide insight into an array of options for medical equipment. Further understanding of barriers to utilization and the potential for DME to improve quality of life and prevent complications or readmissions remain areas of needed research.
- gov. (2018). Durable medical equipment (DME) coverage | Medicare.gov. [online] Available at: https://www.medicare.gov/coverage/durable-medical-equipment-coverage.html [Accessed 21 Apr. 2018]
- James AJ. Restoring the role of independent person. In: Radomski M, Trombly C, eds. Occupational Therapy for Physical Dysfunction. 6th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2008:774-814.
- Dysfunction. 6th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2008:815-853.Van Hook F, Demonbreun D, Weiss B. Ambulatory devices for chronic gait disorders in the elderly. Am Fam Physician. 2003;67:1717-1724.
- Moe, R., Fernandes, L. and Osteras, N. (2012). Daily use of a cane for two months reduced pain and improved function in patients with knee osteoarthritis. Journal of Physiotherapy, 58(2), p. 128.
- Webster, J. and Murphy, D. (2018). Atlas of Orthoses and Assistive Devices. 5th Philadelphia: Elsevier, pp. 376-389.
- org. (2018). ATAP: Summary of the AT Act. [online] Available at: https://www.ataporg.org/ATActSummary [Accessed 6 May 2018].
- National Institute of Health. (2018). What are some types of assistive devices & how are they used? [online] Available at: https://www.nichd.nih.gov/health/topics/rehabtech/conditioninfo/device [Accessed 22 Apr. 2018]
- Iwashyna TJ, Christie JD. Low use of durable medical equipment by chronically disabled elderly. J Pain Symptom Manage. 2007;33:324-330.
Original Version of the Topic
Lyssa Y. Sorkin, MD, Emma Michel, OTR/L. Durable medical equipment that supports activities of daily living, transfers and ambulation. Original Publication Date: 09/20/2013.
Natasha Lynn Romanoski, MD
Nothing to Disclose
Kala Swope, OTR/L
Nothing to Disclose