W. Ben Mortenson, Laura Hurd Clarke, Krista Best; Prescribers’ Experiences With Powered Mobility Prescription Among Older Adults. Am J Occup Ther 2013;67(1):100-107. doi: 10.5014/ajot.2013.006122.
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© 2019 American Occupational Therapy Association
Despite the potential benefits of powered mobility, many older adults do not have access to this technology. To date, few studies have explored how prescribers make decisions regarding provision of powered mobility. Therefore, we undertook a qualitative study to develop a better understanding of prescribers’ attitudes toward and practices with older adult candidates for powered mobility devices. Our analysis of 10 in-depth interviews identified three main themes: (1) “Deciding who should be entitled” explored how therapists decided who should have access to powered mobility, (2) “power wheelchair negotiation” described the discord between clients and therapists that became apparent during this process, and (3) “practical considerations” revealed how contextual factors shaped the provision of powered mobility. The findings suggest that the ways in which powered mobility is funded, provided, and accommodated should be improved so that more older adults have access to these devices and can use them to their full potential.
What ideas, attitudes, and beliefs do prescribers have about powered mobility for older adults?
How do prescribers provide powered mobility to this population?
How do funding policies and other contextual factors influence the prescription process?
All of a sudden, they’re coming out to the [local shopping center] and buying their own groceries, or they’re able to go to their son’s for dinner because now they can get out of the [facility] on their own and drive the power wheelchair to the bus [or] taxi. They’re not just having people come to them.
Talking stereotypically, as [people] age they are prone to more cognitive issues such as dementia, and that’s the biggest concern for me, and then the eyesight as well. [It] stereotypically can get worse as we get older. . . . [If an] older adult is more frail, then they’re at higher risk if something does happen.
I remember when I graduated, people would be very reluctant at giving power chairs, because they would be afraid the person would lose strength. So the [manual] chair was used as a personal training gym. . . . Now it’s becoming a functional tool.
I really like to screen people first. I like to do some sort of cognitive screening to know that they can make decisions and they’re safe in making those decisions. I like to do visual screening, I like to look at hearing, I like to look at all those factors first before I even introduce the discussion of a power chair with someone who’s elderly.
[There] was a ministry client [eligible for government funding, who] wanted a scooter. He said it would save his life because he needed to go bowling every week, but it was getting harder and harder for him to walk because he couldn’t breathe very well. . . . So I got him a four-wheeled walker from our office because he had never tried one. He didn’t want to use the walker; he wanted to proceed with power . . . but I had concerns around his vision. So I had to do a thorough assessment to really see if he was safe. Meanwhile, the man went down to the local supplier with his Visa card and bought a scooter. So he’s out there driving around, probably, to me, [in a way that is] quite unsafe.
I’ve seen people who had a powered [wheelchair, but] they left it at their cottage so nobody on their street would know they were using power. I would say this is an example of a person who really was not ready to accept it and got it.
I think the visibility of the chair is a big [issue]. And I know that there are flags that people can buy and stick up. You battle between wanting to have a chair that doesn’t look like a great big bulky thing, for body image, or, you know, what you feel you look like as a person, but something that is very visible to other people so . . . they can see it.
Moving from a scooter to a power chair is not an easy transition [so I would prefer them] to go into a power chair right away, if someone has a deteriorating disease. . . . I think they think they look more able if they’re in a scooter than if they’re in a power chair, [but] I want a chair that allows me to be able to change things.
If people [in the province of British Columbia] are [ministry clients] before they’re 65, [the government] will fund stuff, but if they are over 65 when they first have needs, the [government] often will not fund [powered mobility]. It’s just the funding rules, and [the government] thinks there are other resources for people over 65, which is a fallacy.
There’s a big differentiation between what’s medically necessary and what’s for quality of life. Things that are medically necessary are so that they can get from their bed to the kitchen to eat dinner. What’s more of a quality of life concern is whether they can access the computer. Whether they really need power mobility for mobility [inside] or if it’s only for outdoor mobility, they might consider “only outdoor mobility” more of a quality of life issue. So, again it depends on the funder where those lines are drawn. If you’re seeking government funding, [medically necessary is] life threatening only. A client who would benefit from getting around using power mobility might still only get funding for a manual chair, because they’re still alive if they can get up into a chair—even if they can’t move the chair.
I try to be as client-centered as possible [when applying for funding], and if I know it’s going to make a difference in their life, but at the same time you can’t lie either. So it’s trying to find that balance.
You learn what the funders consider to be a quality of life issue versus a medical necessity issue versus a functional issue which you might be able to [make a case for funding] if you argue it the right way.
It falls upon us to justify [funding for powered mobility] all the time. And it’s hard because we’re in the middle, because we see the client, we see their need. We have to try and translate that, what we see, into a description, so that the person in [the government bureaucracy] reading it can understand why it’s important. And sometimes it’s very clear and sometimes it’s not very clear.
There’s ramping options for a short amount of stairs, but other than that we’re talking major renovations—porch lifts, elevators—and often that’s a barrier. If you can’t have a client get in and out of their house with a power mobility device, then they’re not going to get one. And I’ve had that happen a couple of times. That’s their house, and some aren’t prepared to move. That’s a pretty big barrier.
Prescribers need to attend to the heuristics they use to ensure that older adults are not excluded from consideration for powered mobility.
Professional organizations should lobby for changes in how funding is provided for devices, training, and follow-up and how accessibility is facilitated.
Mobility should be considered as a basic right rather than as a privilege.
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