ADP Funding application for manual-tilt Chairs

(Updated April 2008)      Printer friendly version

 

Prescribing therapists must complete ADP forms to apply for funding for mobility devices.  PDG provides the following information to assist prescribing therapist with respect to Manual Dynamic Tilt Wheelchairs. Each client is an individual and answers must reflect the client’s situation. This is only a guide.

Here is a direct link to the application forms:


http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/AttachDocsPublish/014-2196-67~11/$File/Application+2196-67E.pdf


There are 2 levels of manual dynamic tilt chairs:

 

  1. Manual Dynamic tilt wheelchair – basic 
  2. Manual Dynamic tilt wheelchair – requiring an upgrade

 

The following information relates to areas on thee ADP Application for Funding Mobility Devices that must be filled out when applying for a manual dynamic tilt wheelchair.  Therapists must fill out all other required information.

1. Application for Funding Mobility Devices       (ADP - back of page 1)


Look for the following boxes to check on the back of Page. Choose ONE of these 2 choices:


□                 A manual dynamic tilt wheelchair to achieve independent mobility

or

□                 A manual dynamic tilt wheelchair to achieve mobility dependent  for propulsion


also check  ( if applicable)


□                 Positioning devices (seating) for a wheelchair – modular and/or custom fabricated

 

click here to go to ADP Application sample page (back of page 1)

 

 

2. Application for Funding Mobility Devices       (ADP - Page 3)


You must answer EVERY question.  Questions 7-10 specifically relate to TILT

 

Questions 7 – 10 Suggested responses (to qualify for manual dynamic tilt)

7.   Applicant can weight shift independently in the sitting position    NO

8.   Applicant demonstrates a history of tissue trauma and/or a significant risk of tissue trauma when sitting and skin integrity cannot be maintained with the addition of fixed seating alone. YES

9.   Applicant cannot maintain functional posture in sitting due to abnormal tone and/or joint Contractures and posture cannot be supported with the addition of fixed seating alone. YES

10. Applicant demonstrates an intolerance for sitting which cannot be increased for mobility with the addition of fixed seating alone. YES


Base Device and ADP Code – you check one


Check Either:


□                 WMA5 for an adult requiring a manual tilt chair

or

□                 WMK5 for a child requiring a manual tilt chair

 

click here to go to ADP Application sample page (page 3)

 

IF YOU ARE NOT REQUIRING AN UPGRADE, THIS IS ALL YOU NEED FOR A BASIC MANUAL DYNAMIC TILT CHAIR


If your client requires a tilt chair to improve independent mobility (you answered YES to question 1 and/or 2 of Section 3 on page 3)

or

to accommodate seating and possible change in seating angles/contours etc. (you answered YES to 8, 9, and 10 of Section 3 on page 3) you then need to ask for the additional ADP Funded Options required for prescribed manual wheelchair

 

3. Additional ADP Funded Options Requred for Prescribe Manual Wheelchair                            (ADP – back of page 3)

 

PDG Astrotilt, Bentley, Fuze T20, Fuze T50, and Stellar require the upgrade with respect to funding through ADP.


To qualify for additional ADP funded options, complete information required on the back of page 3.


This information is required to obtain funding for a wheelchair frame that offers ongoing adjustability such as seat to back angles, seat to floor heights, seat depths and centre of gravity adjustments. This part of the application is also needed to justify  a frame that facilitates independent mobility.


Clinical Rationale may include the following: (selected device provided by the dealer must meet the clinical requirements)


click here to go to ADP Application sample page (back of page 3)



The first part of this page asks for a variety of basic wheelchair dimensions required for this client.


Additional ADP Funded Options Required for Prescribed Manual wheelchair (check one or more)

 

The therapist MUST check off:

□                 Standard Manual Wheelchair Frame with Manual Dynamic Tilt *

 

*The therapist must write the clinical rationale as to why the upgrade is required.

 

Potential clinical rationale:


Client medical needs

Product requirements

Independent Mobility with arms

Adjustable axle, choice of wheel size

Independent mobility foot propulsion

Adjustable seat height, pivot from the front

Stability and safety/ shear reduction- postural support

Adjustable axle, suspension/centre of gravity adjustments

Postural support

Accepts custom or complex seating components

Independent tilt with stated functional objective(s)

Mechanism for self tilt

Changing needs /progressive disability

*use in conjunction with postural support justification not acceptable as a stand-alone justification for ADP funding

Adjustable components, seat height, depth seat to back angle

 













Sample sentences for the clinical rationale section:

(selected device provided by the dealer must meet the clinical requirements)

 

  1. Client requires a lower seat to floor height with adjustable axle positions and different size wheels in order to be independently mobile with their feet

  1. Client has many deformities in which very “complex” seating must be added to the chair. This complex seating can not be fitted into a more basic wheelchair as it does not allow for seat to back angle adjustments or accommodate for centre of gravity positioning once the seating is in place.

  1. Client requires different wheel sizes or heights with the ability to adjust centre of gravity to allow for independent hand propulsion.

  1. Client has anatomical deformities or changes in tone in which complex seating must be added to the chair (this seating would not fit into a more basic style wheelchair).

  1. The wheelchair can accommodate the seating system through adjustable seat to back angles and adjusting the centre of gravity/depth to accommodate for the seating changes. i.e. scoliosis, kyphosis, obliquity, rotation, windswept positioning.  These changes can be accommodated upon delivery and adjusted as the client changes over time. This system will improve overall performance, stability and safety of the client in the chair.

  1. Client requires a chair with many adjustments including seat to back angle for postural control, and an adjustable axle position for manual mobility and stability

 

  1. Client requires postural control for independent function both with their hands and feet.  Client requires a low seat to floor height for foot propulsion


The following statements will most likely NOT qualify the client for an upgrade:


 

  1. The client requires tilt for pressure relief as they are unable to weight shift on their own.  This is not sufficient as it simply justifies a WMA5 or WMK5 chair which is already addressed by answering questions 1-13 on page 3.

  1. Some clients simply need a chair to allow them to weight shift throughout the day but do not require complex seating nor are they independently mobile.

  1.  Note the request for an upgrade for a manual dynamic tilt wheelchair is not an addition to a previously funded by ADP.