Prescribing DME? Tips to help keep patients safe
From the April ACP Observer, copyright © 2005 by the American College of Physicians.
By Gina Shaw
When a Boston patient in his late 60s took a terrible fall down a flight of stairs, he fractured his cervical spine and became partially paralyzed in all four extremities. The man went to live in a first-floor apartment with his sister—whose rheumatoid arthritis left her unable to do much to help him.
Because he couldn't maneuver himself into the bathroom, the patient had to resort to wearing incontinence briefs. By the time he was referred to geriatrician Sharon Levine, MD, his sobbing sister was convinced she would have to put her brother in a nursing home.
Instead, Dr. Levine started to work the phones. "We brought in physical therapy," she said, "and they worked with him to request the wheelchair that was most appropriate for him, one he could maneuver with his partially paralyzed arms and had cushions so he wouldn't get skin breakdown." The therapist also recommended a manual hospital bed that could be raised and lowered, and a walker the patient could use to get to the bathroom. At night, he learned to use an inexpensive plastic bedside urinal.
Physicians should prescribe a walker only if patients aren't reasonably safe with a cane and an exercise program.
When patients with mobility problems get discharged from hospitals, facilities often have a wealth of resources to help patients get the durable medical equipment (DME) they need. Hospital discharge planners often bring in allied professionals—such as physical and occupational therapists, home health aides, and visiting nurses—to advise physicians about what wheelchairs, canes, tub chairs and other home devices they should prescribe.
But what happens when older patients haven't been hospitalized but become frailer or have a chronic condition that affects mobility? Or they have been hospitalized, but the hospital doesn't have a comprehensive discharge planning system?
According to physiatrist Heikki Uustal, MD, internists are often on their own when it comes to making decisions about DME and home medical equipment that patients need. Too often, he added, primary care physicians don't have the information on hand to make the right choice.
"Most physicians are taking an uneducated guess when they prescribe DME," said Dr. Uustal, medical director for the department of physical medicine and rehabilitation at St. Peter's University Hospital in New Brunswick, N.J. "It's difficult for the practicing internist to take the time to assess a patient's functional mobility in the office setting."
Not only is it hard to assess home needs in the office, but there's the complicated issue of what equipment Medicare will and will not cover. So how are internists supposed to keep up with the ins and outs of prescribing DME on their own? The simple answer is: They're not.
"It's getting harder and harder for internists to do everything themselves, particularly when it comes to something like DME," said Toni J. Brayer, FACP, a general internist in San Francisco and chief regional medical officer for the Sutter Health network. "You have to take a team approach to the care of these patients, and educate yourself about what other team players might have more expertise in."
When it comes to knowing the right DME to prescribe her patients, Boston's Dr. Levine credits one unusual aspect of her practice: She makes house calls.
"I see patients in their home environment, and it's really easy to see the functional limitations that need to be addressed," said Dr. Levine, who practices with Boston University Geriatric Services and directs the geriatric fellowship program at Boston Medical Center and Boston University School of Medicine. She takes residents and medical students with her on these home visits, and teaches them about ordering DME.
While most physicians won't be making house calls, they need to ask senior patients about function and DME requirements, even during crammed patient visits, said Bruce E. Robinson, FACP, chief of geriatrics at Sarasota Memorial Hospital in Sarasota, Fla., and a professor of medicine at the University of South Florida.
"It doesn't matter if you're treating someone's high blood pressure effectively," he pointed out, "if they then fall down and fracture a hip because you weren't paying attention to the fact that they were unsafe in their home." Dr. Robinson recommended that physicians ask about home safety, mobility and DME needs at every visit with an older or impaired patient, whether patients bring up those concerns or not. A good question to start with? " 'Is there anything that's more difficult for you today than it was a month ago?' "
If the answer is affirmative, then it's time to begin investigating DMEs. This umbrella term covers many different types of equipment, from tub chairs to oxygen tanks to hospital beds. (Home medical equipment, on the other hand, refers to disposable items, such as incontinence and wound care supplies and IV equipment.) Probably the most commonly used—and most confusing—DME category is mobility equipment, which includes wheelchairs, walkers, crutches, canes and scooters.
If you've prescribed crutches for a patient in the office or emergency room, you've done only half the job, said Dr. Uustal, who is giving a presentation on selecting and prescribing DME at this month's Annual Session.
"It's very common for people to prescribe crutches, but many people—especially the elderly—do poorly with crutches unless they've had training," he said. "The other half of your job is to make sure a properly trained therapist or aide is available to teach the patient safe crutch-walking."
Another popular mobility tool is the walker. For Dr. Levine's partially paralyzed patient, using a walker was the only way he could get around the house. But physicians often prescribe walkers to patients with less severe limitations, when something less restrictive would be a better choice.
"It's very easy to pull out a pad and say 'the patient would be safer with a walker, so here you go,' " Dr. Robinson said. But using a walker stops patients from practicing their normal gait, and it is tough to maneuver in tight spots. Instead, Dr. Robinson suggested that physicians start patients off with a cane and an exercise program, prescribing a walker only if those efforts don't result in reasonably safe mobility.
But prescribing the right cane isn't simple either. Quad canes, the kind with a four-point base, usually come in two sizes, with a large or a small base. While canes with the large base are more stable, Dr. Uustal said, those with the small base fit onto a step.
"If you need to go up and down stairs on a regular basis, you need a small base quad cane," he said. By contrast, a large base cane on stairs "is terribly unstable and an invitation to fall down."
And then there are wheelchairs, probably the toughest piece of DME to prescribe. Patients about to be discharged from hospitals have professionals who make sure they get the right wheelchair. But in the outpatient setting, "Doctors are struggling terribly with prescribing chairs," Dr. Uustal said, "and literally months can go by before patients get their chairs."
That's because there are so many different chairs, and so many Medicare rules as to who qualifies to be covered for which chair. A standard-weight wheelchair weighs about 50 pounds—too heavy for many spouses of older patients to hoist into a car trunk. Lightweight folding wheelchairs weigh only half that much, but patients have to give the right answer to a series of questions before Medicare will pay for a lightweight wheelchair for them.
If, for instance, patients say they can self-propel the standard-weight chair, then Medicare won't cover a lightweight version. Medicare also will not cover a lightweight chair if a patient's caregiver can propel a standard-weight chair.
Patients also need to answer what Dr. Uustal called "a trick question: 'Does the patient require the chair for indoor or outdoor use?' Most patients say they require it for outdoor use, but you must say they need it for indoor use to qualify for a lightweight chair."
Then there are scooters, which may look like the solution to many mobility problems—but in fact are minimally useful, if not counterproductive or even dangerous.
"When you become frail and lose mobility, every step is important to maintaining the ability you have," said Dr. Robinson, who said he can't remember the last time he prescribed a scooter. "You need that exercise when you're failing, so a scooter should be the very last resort."
Most scooters weigh around 250 pounds; even when broken down for trunk storage, each piece weighs 40 or 50 pounds. When his patients request a scooter, Dr. Uustal said he always asks them what they plan to use it for.
"Most say they'll use it to go to the store," he said. "But unless you have a house with a ramp and either a van with a lift or a store nearby that you can go to directly, a scooter doesn't make any sense."
For the elderly or impaired, the bathroom is one of the most dangerous rooms in the house. Here too, both patients and physicians make critical mistakes about the equipment they need to make bathrooms safer.
First, a cheap plastic chair from a local home and garden store does not constitute a safe tub or shower chair. But because Medicare does not generally reimburse for bathroom equipment, some patients may choose that inexpensive alternative. "A proper tub or shower chair has rubber feet for stability, while these plastic chairs usually have plastic feet and are much more slippery," Dr. Uustal said.
An even better option: a bench that spans the tub from the inside wall out, with two legs in the tub and two outside on the bathroom floor. About five feet long and usually with a padded vinyl seat, these benches allow patients to bathe while sitting on them. Patients can then slide across and get outside the tub before standing up to avoid slipping on wet tub surfaces.
According to Dr. Uustal, it's not just the recently injured or frail elderly who should use this kind of bathroom equipment. In fact, any patient who runs a slight risk of falling because of balance impairment, poor vision or an unsteady gait would benefit.
And for patients who've had surgeries like hip replacements—and who need to avoid bending the hip more than 90 degrees—even sitting on the toilet can be dangerous. An elevated commode that fits over the toilet, raising it six inches or so, can help prevent these patients from dislocating their hip, Dr. Uustal said.
Call in the team
Experts urge internists to follow one more critical piece of advice when it comes to prescribing DME: Rely on other professionals to help you figure out what patients need. Physical therapists and occupational therapists, as well as visiting nurses, will help give you insights into what patients need to be safe at home.
"A physician's primary resource is their local therapy department, whether hospital-based or not," said Laura Magnusson, manager of outpatient and acute rehabilitation services at Sarasota Memorial Hospital in Florida. To get in touch with a therapist, Ms. Magnusson recommended that physicians call their local hospital's rehabilitation unit, home health agency, or facility that has a physical or occupational therapy department.
Physicians also can call their local visiting nurse association for referrals to qualified therapists who can do home assessments. Medicare will pay for a therapist to do a one-time in-home assessment of patients' daily needs.
Therapists can function as internists' eyes and ears, said Boston's Dr. Levine, not only to come up with a list of needed equipment but also to talk directly with DME suppliers, with the physician's authorization. They are also savvy about the ins and outs of Medicare and other insurance coverage.
"I do this for a living and it's even hard for me," Dr. Levine said. "But therapists and visiting nurses do keep up on it, and they can often help with initiating DME orders and the nuances of insurers. They can also tell you which DME companies are patient- and family-friendly."
A reputable home equipment company is another good source of information. Internists may want to plan two or three 10-minute visits every year to DME distributors to look at products and talk to a representative (not a cashier) who is in charge of the equipment.
"DME suppliers have an enormous wealth of information that most internists don't take advantage of," said Dr. Uustal. "Of course, it's their job to sell you something. But reputable companies will give you good information, knowing that if they mislead you, you'll figure it out and won't return."
Patients who don't need a full assessment still need to understand that home safety is critical. Dr. Robinson advised keeping patient education handouts from the National Institute on Aging on hand. (The handouts are online.)
And taking a few minutes to discuss DME can help keep patients living independently at home for much longer. As was the case with Dr. Levine's patient, overwhelmed family members may think a nursing home is their only option, while patients may be convinced their function can't be improved.
"It's important not to prematurely abandon attempts to restore function," Dr. Robinson said. "The critical question to ask when a patient or family is looking for a nursing home placement is: Why now? Often, you'll find the answer to that question is something that can be addressed with adaptation."
Gina Shaw is a freelance health care writer based in Montclair, N.J.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
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