The Power of the Home Assessment

Mobility Management
Full article on mobilitymgmt.com
By: Laurie Watanabe

Why Measuring a Client’s Home Accurately Is So Crucial

In the history of wheelchair seating, assessing a client’s home environment has been conducted by different professionals.

Cindi Petito, OTR/L, MBA, ATP, CAPS, CEAC, CLIPP, a seating veteran who has specialized in home accessibility, recalls when clinicians often completed home assessments prior to hospital discharge: “When I used to work in-patient with brain injury and spinal cord injury [clients], back in the early 2000s, we did the home assessments,” she recalled. “That’s how I learned and entered this practice area [home accessibility] initially.”

But as funding sources cut fee schedule reimbursement rates and implemented new coverage criteria for therapy services, including hospitals paying clinicians to do home assessments, those visits began shifting to the supplier. “In 2005-06, when Medicare implemented new coverage criteria for CRT stating that a home assessment had to be completed, that’s where the shift solidified [to the supplier],” Petito said. (She’s hearing more payors are once again starting to pay therapists to assess patients’ homes before discharge, especially in workers’ compensation cases.)

Regardless of who on the seating team visits the client’s home, Petito said a quality assessment can yield valuable information.

“A home assessment is a vital component of the wheeled mobility process because it ensures individuals can function inside and outside their home and carry out activities of daily living with use of the chair,” she noted. “Without a home assessment as part of the wheeled mobility process, there is the risk of providing an inappropriate wheelchair that will end up sitting in a closet or garage.

“In general, a comprehensive home assessment is a way to capture the entire picture of what’s happening in the home and community. It can provide additional justification, supporting the need for the equipment outside of the standard Medicare criteria. A comprehensive home assessment can also identify additional equipment needs. It helps clinicians and ATP [suppliers] see beyond the wheelchair.

“Directly related to the wheelchair mobility process, a comprehensive home assessment helps to ensure clinicians and ATPs are assessing every aspect of that individual’s daily routine life and maximizing individuals’ ability to use the wheelchair to its full capabilities — not just in a few performance areas.”

The Value of the In-Person Visit
Regardless of who does the assessment, Petito said an actual home visit is much more useful than static photos.

“It would be great if the ATP [supplier] is in the home, and the clinician can Zoom in to see the home,” she said. “Or if the clinician can complete the evaluation in the home in person and the hospital can bill for that visit, then the [supplier] is the one telehealthing in — either way, I think that’s the best scenario.

“You should have a reliable person in the home who’s operating the measuring tape and measuring the environment accurately. One good example is how people measure doorways: Some people measure outside frame to outside frame; some people measure the inside frame. But the inside frame is not really the true wheeled space because you still have to take into account the inside corner of the door that takes up space inside the frame — when the door is fully open, it’s still taking up an inch to 2″ of space. That 1″ to 2” doesn’t seem like much, but it makes a big difference with somebody using a mobility device, whether it’s a walker or a manual chair or power chair.”

An in-home visit, Petito said, is just more revealing: “You don’t get to see potential barriers with pictures and a report. Measuring the environment — and measuring it accurately — is just as important as measuring somebody for a chair.”

When the real-life environment isn’t fully considered — when, for example, wheelchair training takes place in the open spaces of a clinic — clients can have trouble once they get home.

“Most clinicians in our industry work in clinics,” Petito said. “They’re training clients in a controlled environment, and they’re measuring for the wheelchair in that same controlled environment. Once [clients] are discharged home, it can be a totally different ballgame. The perception that I have being a wheelchair/seating clinician in the home is very different. There have been times when somebody’s discharged to home with a new chair, and they’re having complications related to unforeseen barriers. In a few situations, I’ve had to call the seating clinic therapist to let them know I’m going to recommend changes to the chair because of barriers in the home environment.”

In the past, Petito has arranged loaner wheelchairs for clients to test in their homes: “Being able to complete trials in the home is even one step beyond completing the home assessment: If we have the ability to perform a trial of a chair we think might work in the home, that yields the best outcome. But I know for hospital clinics and ATP [suppliers], getting that kind of time and availability is difficult.”

Choosing Home Assessment Priorities 
Petito listed her top three assessment priorities:

• Ensuring wheel configuration, turning radius, overall width/depth of the base and seating system are conducive to use in the home. “Measuring rooms’ floor space and doorways are just a few key factors,” she said.
• Examining floor-to-seat height for transfers to all sitting surfaces in the home, school, work, and community (i.e., bed, toilet, shower chair, vehicle).
• Considering the client’s reach ranges, which are often overlooked or forgotten. “For example, a home assessment is completed for an individual who’s still in in-patient rehab: Kitchen accessibility recommendations that include lower/upper kitchen cabinets cannot be made until reach ranges are measured from the permanent wheelchair — or at least from a loaner chair with a similar configuration. The same issues occur in the bathroom: The reach range from the wheelchair to the sink and water controls is an important factor in the configuration of the chair. If the client is tall with a long seat depth, their footrest and toes may hit the wall under the sink, preventing the person from getting close enough to safely reach.”

Home Assessments of the Future
Petito is a fan of the telehealth option that gained traction during the pandemic. “Telehealth home assessments are far more reliable, and provide more valuable information, than a family member providing photos of their home or filling out a self-assessment form for the clinic,” she said. “Telehealth assessments allow the seating clinic to see the home and gather important information about a person’s environmental and caregiver demands — which helps the clinician and ATP make informed decisions about wheelchair configuration and performance.”

Another significant impact to home assessments and equipment choices could come if the Centers for Medicare & Medicaid Services agrees to fund power seat elevation.

“If seating elevation was covered, that would be helpful in multiple areas of the home — primarily the kitchen, reaching the upper cabinets and pantries, the standard microwave-above-the-stove issue,” Petito said. “Being able to access clothes closets. Everyone knows seat elevation helps with transfers. But all the other tasks in their home and their community need to be assessed, like reaching shelves in a grocery store. Seat elevation can reduce the amount of modification somebody would have to make in their home, which is usually an out-of-pocket expense that many people cannot afford.

“Their reach ranges would be more safe. If you think about somebody with poor trunk control, if they have reach outside of their base of support or functional support, [seat elevation] is improving their functional reach.”

Incremental differences can significantly impact a client’s ability to perform daily activities, Petito added, thus expanding their independence. “It’s these little things you don’t think about,” she said, “until they happen.”

About Cindi Petito, OTR/L, ATP, CAPS, CEAC, CLIPP
As Director of Clinical Solutions, Cindi Petito oversees the performance of Paradigm management contracts, using data analysis to develop case specific management plans and ensure their successful clinical and financial outcomes.

About the Author
Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

This article originally appeared in the Mar/Apr 2022 issue of Mobility Management.