Durable Medical Equipment that Supports Activities of Daily Living, Transfers and Ambulation

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.¹For 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 also important to understand both the patient’s medical and functional needs in regard to the home environment, living arrangements, and vocational and recreational activities when considering equipment. Appropriate DME can afford patients more independence and the ability to return to their homes, communities, jobs, and leisure activities.

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, the following table lists factors to consider prior to recommending and ordering specific equipment.

The above table focuses on the use of DME in the home to assist with ADLs. Providers should also take into account the International Classification of Function framework when considering how medical and adaptive equipment may be used outside of the home to further improve function, independence, and quality of life.²

DME is intended to increase independence and improve safety with 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. DME can additionally increase independence with IADLs as well, for example power mobility can allow for grocery shopping and running errands, and tools to utilize technology such as voice control and adaptive touch promote return to work.  Occupational therapists and physical therapists collaborate with patients and their caregivers to clarify which client factors are present in order to make individualized DME recommendations for each activity. The goal is always to ensure optimal independence as well as safety for the patient and caregivers.³ The following table lists ADL and mobility tasks with DME options that are available. It also highlights which equipment features are most influenced by client factors.

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 older adults in the Unites States use at least one form of mobility device such as a walker, cane or crutches.⁴ These devices can increase efficiency of gait, reduce pain, promote independence and decrease fall risk. They can improve gait speed, which has been shown to be predictive of overall function and mortality.⁵    While gait aids can provide numerous benefits, care must be taken in the selection of the most appropriate option. Inappropriate use of a gait aid can result in increased energy expenditure, postural concern, overuse injury, and even increased fall risk.⁶ Physical therapists can assist patients in proper mobility device selection and training for safe use of the device.⁷

Individuals that are non-ambulatory will require a wheeled locomotion device 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. There are many different classes of wheelchairs and added components that can assist with proper positioning and improve safety and function. Various adjustments may have a major impact on a patient’s function. For example, a patient may not be able to sit safely in a wheelchair unless the seat angle is adjusted to accommodate for postural instability.  Regardless of wheelchair type, a strategy for consistent pressure relief must be determined. Wheelchair users are at a higher risk for pressure related skin injury and a pressure relief strategy such as power tilt function or maximal forward lean, in addition to a pressure relieving and positioning cushion, can help mitigate this risk.  Evaluation by a seating specialist or assistive technology practitioner (ATP) is important for the appropriate prescription and management of wheelchairs.

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 Respiratory supplies can be utilized in multiple patient populations such as those with tetraplegia from spinal cord injury, neuromuscular weakness, or post-acute sequelae of COVID-19 to allow increased function and reduction of symptoms.  These supplies, along with others including those for enteral nutrition and wound management can allow patients to return home rather than reside in a medical facility.

Collaboratively, OTs, PTs, and physicians can recommend specific DME to increase an individual’s safety and independence with ADLs, transfers and ambulation/mobility.

Insurance Coverage and Documentation

When prescribing DME it is important to understand which equipment is not covered by insurance companies along with how long the equipment is covered and when it is able to be replaced.  For example, wheelchairs are typically covered every 5 years and orthotics and ankle/foot orthoses are covered every 2 years.  In addition, when multiple pieces of equipment are recommended, the provider should be aware that all pieces may not be covered even if they would be covered individually.  Gait aids such as walking sticks or trekking poles are not usually covered, nor are gait aids in combination with a manual or power wheelchair as the presumption is that the chair is necessary and will be the main form of mobility.  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.  Local equipment supply companies and online catalogs serve as a good resource for affordable prices. Other potential resources could include local equipment closets as well as disease-specific societies and associations.

Documentation is particularly important when regarding DME as there are required statements to get certain equipment covered by insurance. It is important to thoroughly document the indications for the equipment along with addressing many of the factors mentioned in the above tables.  For example, for wheelchair approval it is important to state that mobility related ADLs cannot be performed with walker, cane or other assistive devices.  Certain equipment such as a commode may necessitate indicating that the patient is “room bound”.  For approved DME, as well as devices discussed elsewhere (prosthetics and orthotics, surgical dressings, therapeutic shoes and inserts) Medicare will cover eighty percent of the charge accrued.  The patient is generally responsible for the deductible plus twenty percent of the calculated charge. These requirements are dictated by Medicare, but many commercial insurances use the same requirements, however it is important to reference the patient’s specific insurance as coverage varies.  Occupation-related DME or adaptive equipment may not be covered by Medicare but may be covered by the patient’s employer as a part of the “reasonable accommodation” clause under the Americans with Disabilities Act.

For many DME prescriptions, a “Face to Face” visit is required.  The chief concern for this visit must be a patient evaluation for said equipment and greater than 50% of the visit must be spent discussing the piece in question. The note should clearly state the indications for the equipment and the medical and functional benefits it provides along with a statement indicating the patient and caregivers have been educated on the costs and benefits of the equipment.  The patient and caregivers should also have already undergone therapy training to show that they can successfully utilize the equipment and that it has the intended effect on the patient’s function and quality of life, and/or that the patient and caregivers will undergo therapy while using the equipment.

Finally, even if a piece of equipment will not be covered by the patient’s insurance, the provider should still discuss the benefits and drawbacks, including affordability, in detail with the patient and caregivers.  For example, equipment that allows for return to recreational activities or participation in adaptive sports would not be covered by insurance but would certainly improve a patient’s quality of life and community integration. Out of pocket DME purchases can play an important role in improved function, independence, and quality of life.

Cutting Edge/ Unique Concepts/ Emerging Issues

Advancements in smart phones, smart home and communication technology have expanded equipment options for patients with disabilities. This type of equipment falls under the area of assistive technology (AT) and into its sub-category of Electronic Aids to Daily Living (EADLs) which were previously referred to as Environmental Control Units (ECUs). EADLs provide alternative means of controlling devices, primarily within the home environment such as lighting, TV, thermostats, and a means for calling for help/emergency services. Equipment that was once only able to be controlled via infrared or radio waves is now accessible via Wi-Fi and Bluetooth. This provides numerous new means of access for patients with little or no motor function from neurologic conditions, such as high cervical spinal cord injury, brainstem stroke, or amyotrophic lateral sclerosis. Patients can now use their voice to direct a virtual assistant to manage doors, blinds, tv controls, lights, etc provided the right accessory is installed. While this equipment is not considered medical equipment and is not typically covered by insurance, it can certainly increase independence, is often available quickly, and, in some cases, may even be lifesaving.   Mouse emulation is also now available on smart phones which means patients can use their drive controls of their power wheelchairs to run their smart phones/computers/tablets, thus eliminating the need to touch the screen. These advancements have also changed accessory benefits of speech generating devices (SGDs) as patients use these devices to deliver commands to the virtual assistant and in turn control their EADLs. Eye-gaze has become more mainstream within the gaming community which means any consumer can purchase an eye tracker bar that can be connected to a computer to allow for eye control. The sophistication of eye-gaze technology is demonstrated by the fact that there are now power wheelchairs which allow for a patient to drive with their eye movements. Work is still being done on using brain-computer interfaces as a means of access to technology for those who are unable to use any of the equipment listed above. Overall, AT is a rapidly expanding field which can be used to promote patients’ autonomous control within their home environment. As most smart devices are consumer level it has brought 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 not covered by insurance. However, thanks to the Assistive Technology Act (1998), almost every state has federally funded programs that offer the following:

• Information about what devices and services are available and where to obtain them
• Device loan and demonstration and potentially borrowing programs
• Funding resources for purchasing or acquiring AT
• Device exchange and recycling programs

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 21^st 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.

References

1. Gov. Durable medical equipment (DME) coverage Medicare.gov2022 [Available from: https://www.medicare.gov/coverage/durable-medical-equipment-coverage.html
2. The ICF: An Overview: Centers for Disease Control;  [Available from: https://www.cdc.gov/nchs/data/icd/icfoverview_finalforwho10sept.pdf.
3. Kirchner-Heklau U, Krause K, Saal S. Effects, barriers and facilitators in predischarge home assessments to improve the transition of care from the inpatient care to home in adult patients: an integrative review. BMC Health Serv Res. 2021;21(1):540.
4. Bluethmann SM, Flores E, Campbell G, Klepin HD. Mobility Device Use and Mobility Disability in U.S. Medicare Beneficiaries With and Without Cancer History. J Am Geriatr Soc. 2020;68(12):2872-80.
5. Middleton A, Fritz SL, Lusardi M. Walking speed: the functional vital sign. J Aging Phys Act. 2015;23(2):314-22.
6. Thies SB, Bates A, Costamagna E, Kenney L, Granat M, Webb J, et al. Are older people putting themselves at risk when using their walking frames? BMC Geriatr. 2020;20(1):90.
7. Bradley SM, Hernandez CR. Geriatric assistive devices. Am Fam Physician. 2011;84(4):405-11.
8. Iwashyna TJ, Christie JD. Low use of durable medical equipment by chronically disabled elderly. J Pain Symptom Manag. 2007;33(3):324-30.

 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. 9/20/2013

Previous Revision(s) of the Topic

Natasha Lynn Romanoski, DO and Kala Swope, OTR/L. Durable medical equipment that supports activities of daily living, transfers and ambulation. 9/7/2018

Author Disclosure

Kimberly Seidel-Miller, MD
Nothing to Disclose

Moriah Kane, MS OTR/L
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Ellen Farr, MD
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Hannah Von Arb, PT, DPT, NCS
Nothing to Disclose