SPECIAL NEEDS EQUIPMENT PROGRAM INFORMATION

Transcription

1 SPECIAL NEEDS EQUIPMENT PROGRAM INFORMATION General Program Information Special Needs Equipment Depot Locations Universal Loan Equipment Restricted Loan Equipment 1

2 GENERAL PROGRAM INFORMATION June 1, 2014 Special Needs Equipment (SNE) is one of the Saskatchewan Aids to Independent Living (SAIL) programs offered by the Ministry of Health. The Saskatchewan Abilities Council operates the program under contract with the Ministry of Health. Special Needs Equipment is: a loan program for people of Saskatchewan a recycle program equipment is provided to clients from an available pool of recycled equipment designed to meet the long-term needs of the client when equipment is required for more than three months administered from five SNE depots located throughout the province This manual has been prepared by the Saskatchewan Abilities Council to provide general program information. For a complete list of SAIL programs and policies please refer to their website at GENERAL ELIGIBILITY REQUIREMENTS UNIVERSAL LOAN EQUIPMENT Applicant must be a resident of Saskatchewan Applicant must possess a valid Saskatchewan Health Services Card Applicant must be referred for service by an approved health professional (Refer to the Appendix for the Special Needs Equipment Eligible Requisitioners list.) Unless authorized by Saskatchewan Health, the services must be obtained in Saskatchewan Applicant is not eligible to receive the service from any other agency or government: First Nations and Inuit Health Branch, Health Canada contact Non-Insured Health Benefits Saskatchewan at Department of Veterans Affairs Act (Canada) Canadian Armed Forces Federal Penitentiaries Workers Compensation Board Saskatchewan Government Insurance 2

3 ELIGIBILITY REQUIREMENTS - RESTRICTED LOAN EQUIPMENT Recipients of the Supplementary Health Program (SHP), Saskatchewan Income Plan (SIP), or the Family Health Benefits program (FHB) may be eligible for the loan of additional low-cost devices at no charge. The SAIL general eligibility requirements listed above must also be met. For clarification of SHP, SIP, or FHB coverage, contact the Ministry of Health at (306) SAIL benefits are provided to people residing in the community. Personal care home, special care home, and group home residents are only eligible for mobility equipment (walkers, wheelchairs with a cushion). Patients in an acute care facility are not eligible for SAIL benefits except as part of a definitive discharge plan. ACCESSING THE LOAN All equipment loans require a requisition to be signed by the appropriate requisitioning authority. Each piece of equipment in the manual has the approved requisitioning authority listed. Refer to the Appendix for a complete listing of program equipment and eligible requisitioners. Requisitions may be obtained by calling the local SNE depot or by ing [email protected]. Refer to the Appendix for printable (Adobe PDF) requisition and application forms. Special Needs Equipment Requisition Special Needs Equipment Wheelchair Requisition Requisitioners must be registered in the SNE database. Call your local SNE depot to confirm or have your name added to the requisitioning list. All requisitions must be complete and legible or they may be returned to the requisitioner and cause delays in equipment delivery for the client. Please note the following when completing SNE requisitions: A shipping (street) address is required if the equipment is to be delivered. Deliveries cannot be made to a PO Box. If the equipment is required to facilitate a discharge from an acute care facility, please include the discharge date to enable prioritization of requests. Replacement wheelchair requests for clients who already have a wheelchair issued to them will not be prioritized to facilitate a discharge. 3

4 Include relevant equipment sizing information (i.e. client wrist height for walker, desired seat-to-floor height for a wheelchair, cushion size, ceiling height for Sask-A-Poles, etc.) for all requests. Provide an explanation if similar equipment has been issued to the client previously. If equipment issued previously has not been returned and an explanation is not provided, the equipment will NOT be replaced. The weight capacity varies for all equipment types. Provide the client s weight to ensure that appropriate equipment is issued. Attach any additional application forms when ordering cushions, specialized wheelchairs, or hospital beds. Please ensure that equipment needs have been discussed with the client before equipment is requisitioned. Equipment if often shipped back to the program unopened and refused by the client resulting in unnecessary costs for the program. Frequently equipment is added on to requisitions in different handwriting or different pen colour. Please be advised that Special Needs Equipment will not provide this equipment unless it can be confirmed that the authorized signee has requisitioned and approved the safe use of the equipment. Models of equipment described within this manual are the current products purchased by the program. Alternate models may be substituted for models described dependent on availability. Requisitions can be submitted to any SNE depot by mail, fax or dropped off in person. Please confirm with the local depot that the fax has been received and is legible. To avoid duplication of orders please do NOT mail the form to the depot if it has been previously faxed. EQUIPMENT PICK-UP Clients wishing to pick up their equipment can do so at any SNE depot. Hours of operation are 8:30 to 4:30 Monday to Friday. (Depots are closed on statutory holidays.) Equipment does not have to be picked up by the client requiring the equipment. Family members or friends can pick it up on their behalf. A completed requisition must be presented in order for the equipment to be released. 4

5 DELIVERY In stock equipment that is to be delivered to the client is generally shipped within two weeks of the receipt of the completed requisition. Custom orders will be delayed. Clients living in an urban center that has a SNE depot are responsible for picking up their equipment. If they are unable to do so, delivery costs are charged to the client. SNE will cover the charges for equipment that is shipped to locations that do not have a SNE depot. Equipment is shipped by the least costly and most direct method. For larger items such as hospital beds, delivery companies will require assistance from the receiver to help with the unloading of the bed. INSTALLATION OF EQUIPMENT The SNE program does not install equipment. Installation of equipment is the client s responsibility, including any costs involved. EQUIPMENT REPAIRS Trained technicians at each SNE depot will repair loaned equipment at no cost to the client. Appointments are required to ensure that a technician is available to perform the service. The client s personal health services number is also required to book an appointment. If equipment cannot be repaired, SNE technicians will provide a replacement piece of equipment. Exact model replacements cannot be guaranteed due to product availability. SNE will cost-share the shipping of equipment coming in for repairs for clients living in a center that has a SNE depot. Clients and SNE will each pay for one-way transport. SNE will cover the costs of shipping both to and from the SNE depot for people living in communities that do not have a depot. If equipment is being sent in for repair, please ensure that a note is securely attached to the equipment. The note should include the following information: Full name, address and telephone number, and health services card number of client that the equipment has been loaned to. A complete description of the repair that is required. Equipment returned to a SNE depot without this information may be received into stock and re-issued to another client. 5

6 Maintenance and repair of privately-owned equipment is not a SAIL benefit. EQUIPMENT REPLACEMENT Equipment will be replaced for a client if: 1) The needs of the client have significantly changed making the existing equipment inappropriate (ex. weight gain/loss affecting wheelchair size, etc.) OR 2) The equipment requires extensive repair where SNE technicians have deemed it unrepairable (due to parts availability, cost to repair, etc.). Clients and/or therapists can request an assessment of the equipment be performed however, only SNE technicians will make the decision on whether the equipment requires replacement. EQUIPMENT OWNERSHIP The Special Needs Equipment program retains ownership of all equipment loaned to beneficiaries for their use. Such equipment must be returned to Special Needs Equipment when a beneficiary: has equipment replaced is deceased or no longer requires the equipment moves out of Saskatchewan becomes otherwise ineligible for the benefit. CLIENTS MOVING OUT OF PROVINCE Equipment such as wheelchairs may be taken to the new province of residency and used during an interim period (approximately 3 months) until coverage is available in the new province. We ask the client or therapist to contact the Special Needs Equipment Manager to obtain necessary approval and discuss equipment alternatives prior to the move. EQUIPMENT RETURN When equipment is no longer being used by the client, it must be returned as soon as possible to the nearest SNE depot. SNE will accept shipping charges for equipment that is being returned if the client does not live in a city that has a depot. Please contact the nearest SNE depot for courier/transport company referrals for your location. It is the responsibility of the client to make the necessary arrangements for pickup of the equipment. 6

7 Please do not return equipment to SNE that is not part of the loan program. All equipment issued is identified by a Saskatchewan Abilities Council return sticker and identification number. Clients/caregivers may contact any SNE depot for a list of equipment currently on loan. The client s health services card number will be required to access this information. MAINTENANCE Some items on the SNE program benefit list (i.e. bathtub lifts and hydraulic patient lifts) require regular scheduled preventative maintenance. Clients with equipment on loan will be contacted by letter when the equipment maintenance is due. Upon confirmation with the client, the nearest SNE depot will replace the client s equipment with newly-serviced equipment, and the old equipment will be returned to the SNE depot. SNE will cover the costs of shipping associated with this maintenance program. Clients should inspect all loaned equipment on a regular basis and should concerns arise, contact a SNE depot immediately. EQUIPMENT IDENTIFICATION All loaned equipment is identified by a 6-digit unique identification number. This number is the code used to track who the equipment has been provided to and it is not to be removed from the equipment. If equipment does not have this number, and you believe that it is a loaned item, please contact the nearest SNE depot. Please do not affix labels/stickers or write on equipment with marker to identify which client the equipment is on loan to. Should name identification be required, please use a hospital band, luggage tag or similar to label. TRANSFERRING EQUIPMENT BETWEEN CLIENTS Equipment must be returned to the nearest SNE depot when it requires maintenance, cleaning and safety inspections before being reissued, or if it is no longer required by the client. Please do NOT transfer equipment without the approval of the SNE program. PRIVATE EQUIPMENT PURCHASE Private purchases of equipment, within or outside of Saskatchewan, are not reimbursable by Special Needs Equipment or SAIL. 7

8 EQUIPMENT UPGRADES Equipment will not be ordered with features that are not a benefit of the program (i.e. seats on walkers, environmental controls on wheelchairs or an elevated seat in a wheelchair). Clients cannot pay the difference in cost to have an additional feature added to a loan item. 8

9 SASKATCHEWAN ABILITIES COUNCIL SPECIAL NEEDS EQUIPMENT DEPOT LOCATIONS October 30, 2014 Depots Mailing Address Telephone Fax Number Number Address Saskatoon 2310 Louise Ave. (306) (306) Saskatoon, SK S7J 2C7 Regina # Francis St. Regina, SK S4N 7N2 (306) (306) Prince Albert st Ave. E. Prince Albert, SK S6V 2A9 (306) (306) [email protected] Swift Current Yorkton # Chaplin St. W. Swift Current, SK S9H 0H1 144 Ball Road Yorkton, SK S3N 3Z4 (306) (306) [email protected] (306) (306) [email protected] Hours of operation are Monday to Friday, 8:30 a.m. 4:30 p.m. Depots are closed on all statutory holidays. Use the Saskatoon mailing address above for inquires to be directed to: Carrie McComber, Special Needs Equipment Manager [email protected]. Shirley Whiteside, Special Needs Equipment Coordinator [email protected] 9

10 UNIVERSAL LOAN EQUIPMENT April 1, 2014 Mobility Aids Wheelchairs Standard manual wheelchairs Standard recliner manual wheelchairs Ultralight manual wheelchairs Tilt-in-space manual wheelchairs Standard power wheelchairs Tilt-in-space power wheelchairs Wheelchair cushions Foam T-foam Contoured foam Matrx Posture Seat (PS) Gel Jay cushions Roho cushions Vicair Vector cushions Walkers Folding walkers Kaye postural walkers Gutter attachment (accessory) Auto-stop kit (accessory) Paediatric Mobility Aids Convaid Cruiser Kid Kart Forearm Crutches Environmental Aids Bathroom Accessories Transfer tub seats Stationary commodes Combination commodes Child s commodes Bathtub lifts Transfer Assists Sask-A-Poles Sask-A-Pole trapezes Sask-A-Pole kneeboards Versa Helper trapezes with floor stands 10

11 Hydraulic patient lifts Hospital Beds & Accessories Electric hospital beds with mattresses Overbed tables Other Environmental Aids Alternating pressure pump and mattress sets Lymphedema control units Mobility Aids and Environmental Aids listed above are available at NO CHARGE to all SAIL beneficiaries. See general eligibility requirements on page 2. 11

12 RESTRICTED LOAN EQUIPMENT (SIP, SHP AND FHB) April 1, 2014 Mobility Aids Canes & Crutches Off set handle canes Quad (four point) canes Gutter canes Walk canes Axillary crutches Quad crutches Gutter crutch attachment (accessory) Ice gripper (accessory) Environmental Aids Bathroom Accessories Bathtub clamps Wall bars Utility bath seats (with and without back) Raised toilet seats Toilet arm rest sets Other Environmental Aids Helping hand reachers Transfer boards See Eligibility Requirements for Restricted Loan Equipment on page 3. Restricted loan equipment types are also available for purchase at all SNE depots. 12

13 WHEELCHAIRS Wheelchair Policies Measurement Considerations Summary of Eligibility Criteria Standard Wheelchair Standard Recliner Ultralight Tilt-In-Space Manual Power Tilt-In-Space Power Wheelchair Tray (Accessory) Oxygen Tank Holder (Accessory) Elevating Leg Rests (Accessory) Anti-Tippers (Accessory) 13

14 WHEELCHAIR POLICIES April 1, 2014 GENERAL POLICIES Clients are eligible for ONE manual wheelchair through the Special Needs Equipment program. If a replacement wheelchair is requested, once it has been received by the client, the original chair must be returned to the program. Wheelchairs will be replaced in two scenarios: if there has been a significant change in needs of the client where the equipment is no longer appropriate or, if the wheelchair requires repair and parts are unavailable or it is no longer economical to repair. A requisition form signed by an authorized requisitioner is required for Special Needs Equipment technicians to make seating adaptations to wheelchairs (size changes, seat-to-floor height changes, etc.) Clients may contact the Special Needs Equipment program directly to make minor wheelchair repairs (such as replace arm pads, brakes, etc.) If equipment is custom ordered for the client (i.e. bariatric sized wheelchairs) it will not be re-ordered due to incorrect measurements being provided. Please measure carefully! GENERAL POLICIES POWER WHEELCHAIR CLIENTS Clients are eligible for ONE power or power tilt-in-space wheelchair through the Special Needs Equipment program. Clients using a power or power tilt-in-space wheelchair are eligible to receive a standard manual wheelchair as a back-up to their power mobility. Lightweight or ultralight wheelchairs will not generally be authorized as back-up to a power wheelchair. SASKATCHEWAN AIDS TO INDEPENDENT LIVING (SAIL) TWO SPECIALIZED WHEELCHAIR POLICY Two specialized wheelchairs are available to clients under the following circumstances: Clients with a tilt-in-space power wheelchair who require constant tilt and are engaged in the community on a regular basis may request a tilt-in-space manual wheelchair as a backup. Clients will be allowed to keep an ultralight manual wheelchair when transitioning to a power wheelchair if they have a degenerative condition. (The transition must be unplanned.) 14

15 When the ultralight requires replacement, a standard wheelchair will be issued. Applications for a second specialized wheelchair must include a letter justifying how the client meets the above criteria and should be sent to the Special Needs Equipment Manager. ADAPTIVE SEATING FOR ALL WHEELCHAIR TYPES Adaptive seating refers to modular or custom adaptations/modifications to a wheelchair. Examples would include headrests, bolsters, trays, drop seats, backrests or other supportive devices. Licensed occupational and physical therapists as well as specialists such as orthopaedic surgeons and physiatrists have requisitioning authority for adaptive seating components. Saskatoon A standard prosthetic and orthotic requisition form should be completed for all adaptive seating and forwarded to the Saskatchewan Abilities Council at 2310 Louise Avenue, Saskatoon SK, S7J2C7. In Saskatoon, clients may be assessed at seating clinics at Saskatoon City Hospital, at the Alvin Buckwold Child Development Program located at the Kinsmen Children s Centre or in conjunction with seating technicians at the Saskatchewan Abilities Council. Contact the Saskatchewan Abilities Council - Specialized Seating Department for more information. Regina Adult clients from Regina and southern Saskatchewan who require adaptive seating in their wheelchairs are assessed at weekly held seating clinics at Wascana Rehabilitation Center (WRC). A referral from a licensed healthcare practitioner is required for this service. Referrals can be faxed to (306) A team approach is used in the seating clinics and team members include a physical therapist, occupational therapist and seating specialist. Examples of seating that is provided include supportive seats/backrests (custom or commercial), foam in place seats/backrests, head supports, foot supports, custom wheelchair trays and other inserts as required to support and comfortably seat clients. Contact WRC Adult Program at (306) for more information. Therapists from acute care and the community may also access the WRC seating specialist by submitting a fully completed 15

16 Prosthetic/Orthotics requisition. In addition to the P&O requisition, accurate client and/or wheelchair measurements must also be sent in order to construct the seating components. The requisitioning therapist may be required to attend consult/fitting appointments at WRC with the seating specialist for involved clients. 16

17 MEASUREMENT CONSIDERATIONS April 1, 2014 SEAT WIDTH Measure across hips or thighs (whichever is widest) SEAT DEPTH Measure from the crease behind the knee to the back of the buttock For people propelling the chair with their feet, allow 2-3 of clearance between the seat and popliteal fossa (behind the knee) If a back cushion is to be used, add the compressed cushion thickness to the measurement SEAT HEIGHT Measure from the bottom of the heel to the crease behind the knee; knees should be at approximately 90 Wheelchair standard seat heights are as follows: Standard chair =19 ½ Hemi low chair =17 ½ If a seat cushion is to be used, subtract the compressed cushion thickness from the measurement ARM HEIGHT Measure from the seat to the bent elbow (90 ) If a seat cushion is to be used, add the compressed cushion thickness to the measurement BACK HEIGHT Measure from the seat platform to under the extended arm or to the inferior angle of the scapulae (shoulder blade) If a back cushion is to be used, add the compressed cushion thickness to the measurement 17

18 SUMMARY OF ELIGIBILITY CRITERIA April 1, 2014 Level of Mobility Used <1/week (occasionally required to enhance mobility) Used >1/week but <2 hours/day (can walk <50 m.) > 2 hours/day but <10 hours (can walk <20 m.) Full time (>10 hours/day). Totally reliant on chair for mobility and daily activities. Unable to functionally ambulate. Clients Residing in the community Independent Propulsion Clients Residing in the community Assisted Propulsion Not Available Standard Not Available Standard Standard Lightweight * Standard Lightweight * Lightweight * Ultralight* Lightweight * Ultralight * Clients Residing in Special Care Homes, Group Homes and LTC Independent Propulsion Clients Residing in Special Care Homes, Group Homes and LTC - Assisted Propulsion Not Available Standard Not Available Standard Standard Lightweight * Standard Lightweight * Lightweight * Ultralight * Standard Lightweight * 18

19 *Additional criteria must be met. Wheelchairs are loaned for long-term use only. (The need for the wheelchair should be a minimum of three months.) 19

20 STANDARD WHEELCHAIRS November 15, 2015 MODELS/DESCRIPTION Invacare Tracer SX5 SPECIFICATIONS Overall chair weight is 34 lbs. Seat widths of wide; seat depths of deep 250 lbs. maximum weight capacity (300 lbs. on the 20 and 22 chair widths) Standard adult wheelchair height is 19.5 from the floor 24 urethane rear tires with mag rims 8 front solid casters Standard swing-away foot rests Standard back upholstery height of 18 Adjustable height (10-14 ) flip-back arm rests with full arm pads (14 long) Auto-style buckle seatbelt Push to lock brake assembly AVAILABLE OPTIONS Lower seat-to-floor height options 16.5 or 17.5 (height requested will determine size of rear tires and front casters) Desk length arm pads (10 long) Elevating swing-away leg rests with calf pads Brake extensions Anti-tippers (rear or front) Angle adjustable foot plates Amputee kit 20

21 One-arm drive (must be previously trialed; not available on a 16.5 or 17.5 seat to floor height chairs) Oxygen tank bracket (for clients on SAIL Home Oxygen Program) Wheelchair tray ALTERNATE WHEELCHAIR MODELS The standard Invacare Tracer SX5 model of wheelchair may be substituted with a model listed below dependent on a variety of factors including client weight, requested chair size (width & depth), hip-angle adjustability, transit requirements, etc. Model Invacare 9000 XDT Available Widths Available Depths Seat To Floor Heights , 19.5 or 21.5 Invacare or Tracer IV 19.5 Quickie LXI Invacare or Topaz 19.5 (bariatric) Quickie M (bariatric) 20 * Dependent on configuration Weight Capacity Overall Weight 350 lbs. 36 lbs. 350 or 42 lbs. 450 lbs. * 265 lbs. 30 lbs. 700 or 82 lbs lbs. * 650 lbs. 53 lbs. Invacare 9000 XDT Quickie LXI Quickie M6 Wheelchairs wider than 22 are generally not kept in inventory. They may need to be custom-ordered for clients causing delivery delays. 21

22 ELIGIBILITY Must meet general eligibility requirements Must be required for use more than once a week (refer to Summary of Wheelchair Eligibility Criteria chart on p ). REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Chair sizes must be ordered in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) Please ensure that accurate measurements are provided and a home assessment has been completed to ensure that the chair will fit in the environment it will be used. Approximately 8 should be added to the seat width of the wheelchair to estimate the overall width of the chair needed. FORMS Special Needs Equipment Wheelchair Requisition 22

23 STANDARD RECLINER WHEELCHAIRS April 1, 2014 MODELS/DESCRIPTION Invacare Tracer SX5 Recliner SPECIFICATIONS Seat widths of Seat depths of 16 or 18 ; 20 depth available by custom order only Seat-to-floor height of 19 ½ 24 back height plus 10 removable head rest extension Dynamic recline range from 90 to 180 degrees 250 lbs. maximum weight capacity (300 lbs. on 20 and 22 widths) Full length arm rest pads Elevating swing-away leg rests Anti-tippers (rear) ELIGIBILITY Must meet general eligibility requirements Must be required for use more than once a week (refer to Summary of Wheelchair Loan Criteria chart on p ). OPTIONS AVAILABLE Hemi low chair height of 17.5 from the floor Desk length arm pads Wheelchair tray 23

24 REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists ORDER DETAILS Chair sizes must be ordered in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) Please ensure that accurate measurements are provided and a home assessment has been completed to ensure that the chair will fit in the environment it will be used. Approximately 8 should be added to the seat width of the client to estimate the overall width of the chair. FORMS Special Needs Equipment Wheelchair Requisition 24

25 ULTRALIGHT WHEELCHAIRS August 1, 2014 Photo Unavailable MODELS/DESCRIPTION Adult: Quickie 2 (folding), Quickie GPV (rigid) Paediatric: Zippie 2 (folding), Zippie GS (folding) SPECIFICATIONS Model Available Widths Available Depths Seat To Floor Heights Weight Capacity Quickie lbs. (HD lbs.) Overall Weight 29 lbs. Yes Quickie GPV lbs. 24 lbs. No Zippie lbs. 25 lbs. Yes Zippie GS lbs. 29 lbs. Yes Quickie 2, Zippie 2 and Zippie GS are transit approved models for the occupant 24 mag full polyurethane rear wheels 8 polyurethane front casters ELIGIBILITY Must meet general eligibility requirements Must be required for use more than once a week (refer to Summary of Wheelchair Eligibility Criteria chart on p ). In addition to the above eligibility requirements the following must be met: 16 YEARS OF AGE OR OLDER The client must have a complete cervical lesion or have a condition that would render the client functionally paraplegic; and The client must be completely non-ambulatory; and The client must be capable of independent propulsion Transit Option Available 25

26 CHILDREN UNDER 16 YEARS OF AGE The client requires the aid of a wheelchair to perform the activities of daily living, and The client can independently perform more activities using an ultralight wheelchair (i.e. demonstrates a significant improvement in functional independence), and The client can propel an ultralight wheelchair independently from both physical and cognitive perspectives, and The client does not require specialized seating or a tilt-in-space mobility base. Extra support for the child s trunk and sitting posture (adaptive seating) may be used if it does not impair the ability to propel the wheelchair. OPTIONS AVAILABLE 20 or 22 rear wheels and 6 casters; to accommodate varying seat heights REQUISITIONING AUTHORITY Physiatrist only NOTE: Licensed Occupational Therapists and/or Physical Therapists may requisition replacement wheelchairs for clients once the initial approval has been provided by the physiatrist. ORDER DETAILS Order chairs in even width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) whenever possible Odd sized wheelchairs (i.e. 17 width) are custom ordered and will only be considered for clients who are established independent wheelchair users. If a custom back is required, please consult with a Seating Technician to ensure that the back required is available in an odd width. Please ensure that accurate measurements are provided and a home assessment has been completed to ensure that the chair will fit in the environment it will be used. Approximately 8 should be added to the seat width of the client to estimate the overall width of the chair. FORMS Special Needs Equipment Wheelchair Requisition Specialized Wheelchair Application 26

27 Application for ultralight wheelchairs (signed requisition and completed application form) must be sent directly to the Special Needs Equipment Manager/Coordinator. 27

28 TILT-IN-SPACE MANUAL WHEELCHAIRS April 1, 2014 MODELS/DESCRIPTION Advanced Mobility Systems (AMS) itilt1 & itilt2 SPECIFICATIONS Seat widths of Seat depths of degrees of maximum tilt for itilt; 47 degrees on itilt2 Overall chair weight 60 lbs. Weight capacity of 250 lbs. (350 lbs on 22 and 24 widths) ALTERNATE WHEELCHAIR MODELS The standard AMS itilt model of wheelchair may be substituted with a model listed below dependent on a variety of factors. 28

29 Model Available Widths Available Depths Seat To Floor Heights Zippie TS paediatric Kid Kart TLC Invacare Solara 19 Quickie TS Weight Capacity Overall Weight lbs. 29 lbs lbs. 43 lbs. 30 PDG Stellar 20 PDG Bentley 20 * Dependent on configuration ELIGIBILITY Must meet general eligibility requirements 300 lbs. 73 lbs or 350 lbs. * 500 lbs. * 450 lbs. * 65 lbs lbs lbs. 20 The following guidelines are intended to assist therapists with applications. Although clients should meet the following criteria, it is not absolute. Each client will be considered individually. The client is wheelchair-dependent and their average daily use is at least 4 hours (adults) or 1-2 hours (children). They meet one of the following two categories: They have poor trunk and/or head control, and require support from the chair, or the client requires pressure relief that cannot be addressed with cushioning. The following factors will also be considered: The client cannot consistently perform independent transfers. Caregiver availability and safety may be an issue. The client demonstrates altered muscle tone that impairs trunk balance. There are orthopaedic considerations that interfere with upright seating. There are transportation, community accessibility, pain, or fatigue issues that are addressed through the use of a tilt-inspace system. Maximum Degree of Tilt 29

30 The client has demonstrated benefit from the system through a trial. REQUISITIONING AUTHORITY Physiatrist Selection Committee for Specialized Seating Designated therapist working as part of the seating team at Wascana Rehabilitation Centre SASKATOON Specialized seating refers to specialized manual wheelchairs (such as tilt in space) with custom or modular adaptations to provide a comfortable and supportive seating position for a client. Applications for specialized seating are completed by a licensed occupational therapist or physical therapist and are reviewed by the Selection Committee for Specialized Seating. The application form provides detailed information regarding orthopaedic/skin health considerations; critical details for fitting including height, weight, seating measurements; client and caregiver goals; identification of major seating concerns and therapist goals. A physiatrist serves as a member of the Selection Committee so requisitions are completed at the meeting as applications are approved. Specialized Seating clients may be assessed at seating clinics at Saskatoon City Hospital, at the Alvin Buckwold Child Development Program located at the Kinsmen Children s Centre or in conjunction with seating technicians at the Saskatchewan Abilities Council. Contact the Saskatchewan Abilities Council to obtain Specialized Seating application forms or for additional information contact Specialized Seating at REGINA Adult clients from Regina and southern Saskatchewan who require adaptive/specialized seating are assessed at weekly held seating clinics at Wascana Rehabilitation Center (WRC). A referral from a licensed healthcare practitioner is required for this service. Referrals can be faxed to (306) A team approach is used in the seating clinics and team members include a physical therapist, occupational therapist and seating specialist. Contact WRC Adult Program at (306) for more information. ORDER DETAILS Chair sizes must be ordered in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) 30

31 FORMS Special Needs Equipment Wheelchair Requisition Application for Specialized Seating Device 31

32 POWER WHEELCHAIRS August 1, 2014 Quickie P222 Invacare 3G Arrow Model Quickie Xperience (adult or paediatric) Invacare TDX Quickie Xcel Quickie P222 MODELS/DESCRIPTION Quickie Xperience Invacare TDX Quickie P222 Invacare 3G Arrow Quickie Z500 Invacare TDX Spree Quickie Xcel SPECIFICATIONS Drive Wheel Position Mid Wheel Mid Wheel Mid Wheel Rear Wheel Overall Chair Width Available Seat Widths Overall Chair Length Available Seat Depths Weight Capacity or 400 lbs. Seat to Floor Heights or or dependent on battery type 400 lbs lbs or 24.5 dependent on battery type lbs

33 Invacare 3G Arrow Invacare TDX Spree (paediatric) Rear Wheel Mid Wheel or 400 lbs lbs ELIGIBILITY In addition to meeting general eligibility requirements, the following must be met: 16 YEARS AND OLDER Beneficiaries who are functionally non-ambulant and are unable to manually propel a conventional lightweight or ultralight wheelchair, and the power wheelchair will be used as the client s primary mode of mobility; and beneficiaries who demonstrate sufficient cognition, judgement, spatial perception, and social interaction skills to safely control a power wheelchair in his/her environment, and beneficiaries whose home or place of residence is accessible for power wheelchair use CHILDREN UNDER 16 YEARS Children who are wheelchair-dependent and are unable to propel a manual wheelchair in an efficient manner Children who have had a home and/or school visit completed by a licensed occupational therapist and/or physical therapist Children who are aware of the cause and effect of using switches as determined by an assessment (preferably in a trial wheelchair) Children who will demonstrate sufficient cognition, judgement, spatial perception, and social interaction skills to safely control a power wheelchair in his/her environment A home assessment by a licensed occupational therapist and/or physical therapist is required. OPTIONS AVAILABLE Right or left hand proportional control Full or desk length arm pads 70, 80 or 90 degree swing-away footrests; Centre mount footboard; manual elevating leg rests Attendant control - NOTE: this option will not be provided for clients using a standard joystick controller. 33

34 REQUISITIONING AUTHORITY Physiatrist only NOTE: Licensed Occupational Therapists and/or Physical Therapists may requisition replacement wheelchairs for clients once the initial approval has been provided by the physiatrist. ORDER DETAILS Chair sizes must be ordered in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) FORMS Special Needs Equipment Wheelchair Requisition Specialized Wheelchair Application Application for power wheelchairs (signed requisition and completed application form) must be sent directly to the Special Needs Equipment Manager/Coordinator. Pediatric TDX Spree 34

35 TILT-IN-SPACE POWER WHEELCHAIRS August 1, 2014 Mid Wheel Tilt / Recline/ Power Legrests MODELS/DESCRIPTION Quickie Xperience Invacare TDX SP Quickie P222SE Invacare 3G Arrow Quickie Xcel Invacare TDX Spree SPECIFICATIONS Model Quickie Xperience (adult or paediatric) Invacare TDX Quickie Xcel Quickie P222 Invacare 3G Arrow Invacare TDX Spree (paediatric) Drive Wheel Position Mid Wheel Mid Wheel Mid Wheel Rear Wheel Rear Wheel Mid Wheel Available Seat Widths Available Seat Depths Weight Capacity or 400 lbs. Seat to Floor Heights or 400 lbs lbs lbs or lbs lbs Maximum Degree of Tilt

36 ELIGIBILITY In addition to meeting general eligibility requirements, the following must be met: Beneficiary meets the criteria outlined for a power wheelchair, and demonstrates compliance and understanding of using tilt-inspace feature, and has a history of pressure sores, or has a significant predisposing condition to skin breakdown, such as C5 or higher quadriplegia, or shows measureable limitations in respiratory function where documentation of objective data can be provided as to how a power tilt-in-space would maximize respiratory function, or requires trunk support from the chair, or experiences progressive fatigue due to diagnosis OPTIONS AVAILABLE Right or left hand proportional control Full or desk length arm pads 70, 80 or 90 degree swing-away footrests; Centre mount footboard; manual elevating leg rests Attendant control - NOTE: this option will not be provided for clients using a standard joystick controller. REQUISITIONING AUTHORITY Physiatrist only NOTE: Licensed Occupational Therapists and/or Physical Therapists may requisition replacement wheelchairs for clients once the initial approval has been provided by the physiatrist. ORDER DETAILS Chair sizes must be ordered in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) FORMS Special Needs Equipment Wheelchair Requisition Specialized Wheelchair Application 36

37 Application for power wheelchairs (signed requisition and completed application form) must be sent directly to the Special Needs Equipment Manager/Coordinator. 37

38 WHEELCHAIR TRAY (ACCESSORY) April 1, 2014 SPECIFICATIONS Made of white plastic Secures to wheelchair arm assembly with Velcro straps Fits wheelchairs 16 and 18 wide ELIGIBILITY Must meet general eligibility requirements Provided for use on Special Needs Equipment issued wheelchair only. REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Please provide the ID number and type of wheelchair being used by the client Can be ordered on chair with a new equipment issue or as a replacement part at a later date Custom size or padded trays are to be ordered through Specialized Seating Saskatchewan Abilities Council / Wascana Rehabilitation Center Prosthetic & Orthotic requisition required FORMS Special Needs Equipment Wheelchair Requisition (on chair) OR, 38

39 Special Needs Equipment Requisition (replacement part) 39

40 OXYGEN TANK BRACKET (ACCESSORY) April 1, 2014 SPECIFICATIONS Securely attaches to most models of manual wheelchairs ELIGIBILITY Must be on SAIL Home Oxygen Program Provided for use on Special Needs Equipment issued wheelchair only. REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Please provide the ID number and type of wheelchair being used by the client Can be ordered on chair with a new equipment issue or as a replacement part at a later date FORMS Special Needs Equipment Wheelchair Requisition (on chair) OR, Special Needs Equipment Requisition (replacement part) 40

41 ELEVATING LEG RESTS (ACCESSORY) April 1, 2014 ELIGIBILITY Must meet general eligibility requirements Provided for use on Special Needs Equipment issued wheelchair only. REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Indicate right leg, left leg or both legs as required Please provide the ID number and type of wheelchair being used by the client Can be ordered on chair with a new equipment issue or as a replacement part at a later date FORMS Special Needs Equipment Wheelchair Requisition (on chair) OR, Special Needs Equipment Requisition (replacement part) 41

42 ANTI-TIPPERS (ACCESSORY) April 1, 2014 ELIGIBILITY Must meet general eligibility requirements REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Please provide the ID number and type of wheelchair being used by the client Provide current seat-to-floor height of client s wheelchair Can be ordered on chair with a new equipment issue or as a replacement part at a later date FORMS Special Needs Equipment Wheelchair Requisition (on chair) OR, Special Needs Equipment Requisition (replacement part) 42

43 CUSHIONS Cushion Policies Foam T-Foam Contoured Foam Invacare Matrx Posture Seat (PS) Gel Jay 2 / Jay 2 Plus Jay 2 Deep Jay Active Jay Easy Roho Quadtro Select High/Low Profile Roho Enhancer Roho Contour Select Roho Nexus Spirit Vicair Vector 6 & Vector 10 43

44 CUSHION POLICIES June 1, 2014 GENERAL POLICIES Clients are eligible for ONE cushion with cover through the Special Needs Equipment program to use as an accessory to their wheelchair. If a replacement cushion is required, once it has been received by the client, the original cushion must be returned to the program. Note: An exception may be granted to the policy above to allow clients who are at such high risk of skin breakdown and cannot be without the cushion for an extended period of time (i.e over the weekend while the SNE depots are closed). A letter of medical rationale and requisition form signed by a Physiatrist or Plastic Surgeon is required. These requests should be directed to the Special Needs Equipment Manager. The back-up cushion provided will be the same type/size of the originally issued cushion. ONE cushion cover will be provided with the cushion. Clients who do not use a wheelchair for their primary mode of mobility are eligible for the loan of one cushion if they meet all of the following criteria: the client has a current pressure ulcer, past history of a pressure ulcer, or wound on the area of contact with the seating surface; the client has a Letter of Medical Necessity which demonstrates a valid medical rationale for the provision of this cushion; and, the client is eligible for coverage through the Supplementary Health Program, Seniors Income Plan, or Family Health Benefits Program. Cushions will be supplied in the most appropriate size to fit the wheelchair used by the client. 44

45 FOAM CUSHIONS April 1, 2014 MODELS/DESCRIPTION Low density foam with a cloth cover Low pressure relief and low positioning benefits Primarily used to provide comfort on wheelchair seat SPECIFICATIONS 2 foam thickness Available in widths and depths Weight capacity is 250 lbs. Cushion weighs approximately 1 pound ELIGIBILITY Must meet general eligibility requirements Client requires the use of a wheelchair for mobility and will use the cushion as an accessory to the wheelchair SIP/SHP/FHB clients may be eligible for a cushion without the use of a wheelchair see cushion general policies REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Specify size required Order in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) - odd-sized cushions are not available. 45

46 FORMS Special Needs Equipment Requisition 46

47 T-FOAM CUSHIONS April 1, 2014 MODELS/DESCRIPTION Medium density foam Provided with an incontinence cover zipper closure Body heat and weight causes the cushion to conform to body contours Good pressure protection for low to medium risk clients Firmness increases when cold SPECIFICATIONS 3 foam thickness Available in widths and depths (Note: not all sizes are kept in stock) Weight capacity is 350 lbs. Cushion weighs approximately 4 lbs. ELIGIBILITY Must meet general eligibility requirements Client requires the use of a wheelchair for mobility and will use the cushion as an accessory to the wheelchair. SIP/SHP/FHB clients may be eligible for a cushion without the use of a wheelchair see cushion general policies REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse 47

48 ORDER DETAILS Specify size required Order in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) - odd-sized cushions are not available. FORMS Special Needs Equipment Requisition 48

49 CONTOURED FOAM CUSHION April 1, 2014 MODELS/DESCRIPTION Nighthawk Superior Thin Contoured Cumfy Cushion Contoured foam cushion with a cloth cover (zipper closure) and a rubber non-slip base Soft Sunmate top layer with hard-medium density foam base Built in leg channels Design of cushion contours to eliminate pressure in the ischials Laterally beveled to accommodate sling of wheelchair SPECIFICATIONS Available in widths and depths Weight capacity is 220 lbs. Cushion weighs approximately 2 lbs. ELIGIBILITY Must meet general eligibility requirements Client requires the use of a wheelchair for mobility and will use the cushion as an accessory to the wheelchair. SIP/SHP/FHB clients may be eligible for a cushion without the use of a wheelchair see cushion general policies REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse 49

50 ORDER DETAILS Specify size required Order in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) - odd-sized cushions are not available. FORMS Special Needs Equipment Requisition 50

51 INVACARE MATRX POSTURE SEAT (PS) April 1, 2014 MODELS/DESCRIPTION Designed to provide superior positioning, stability, skin protection and comfort Contoured shape incorporating a waffled ischial relief recess to provide ischial/sacral immersion and helps maintain pelvic position and prevent sliding Reversible outer cover (incontinent/cloth) with zipper closure and inner liner provides moisture protection to the foam SPECIFICATIONS Available in widths and depths Weight capacity is 300 lbs. Bariatric sizes greater than 20 wide x 20 deep are available by special order Bariatric cushion weight capacity up to 600 lbs. Cushion weighs approximately 3 lbs. ELIGIBILITY Must meet general eligibility requirements Client requires the use of a wheelchair for mobility and will use the cushion as an accessory to the wheelchair. SIP/SHP/FHB clients may be eligible for a cushion without the use of a wheelchair see cushion general policies REQUISITIONING AUTHORITY Physiatrist 51

52 Plastic Surgeon Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse (in consultation with an Occupational Therapist or Physical Therapist) ORDER DETAILS Specify size required Order in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) - odd-sized cushions are not available. FORMS Special Needs Equipment Requisition Specialty Cushion Application Form 52

53 GEL CUSHION April 1, 2014 MODELS/DESCRIPTION Akton Gel Pilot Low profile cushion to enable foot propulsion Cloth cover with zipper closure Sheer/friction protection, pressure and shock protection The gel will not leak, flow, or bottom out SPECIFICATIONS 1 low profile polymer Available in widths and depths; other sizing available by special order Cushion weighs approximately 5 lbs. ELIGIBILITY Must meet general eligibility requirements Client requires the use of a wheelchair for mobility and will use the cushion as an accessory to the wheelchair. SIP/SHP/FHB clients may be eligible for a cushion without the use of a wheelchair see cushion general policies REQUISITIONING AUTHORITY Physiatrist Plastic Surgeon Licensed Occupational Therapist and/or Physical Therapists Home Care Nurse ORDER DETAILS Specify size required Order in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) - odd-sized cushions are not available. 53

55 JAY 2 & JAY 2 PLUS April 1, 2014 MODELS/DESCRIPTION Jay 2 / Jay 2 Plus pre-contoured foam cushions feature a Jay Flow fluid tripad with up to 3 of loading for superior skin protection and an easy to modify base with optional positioning components for optimal stability. Designed for the client who is high risk for skin breakdown and poor skin integrity Cushion contains molded foam base with non-skid bottom Fluid maintains its viscosity at high and low temperatures Requires no regular maintenance or adjustment Fluid level self-adjusts for different body types, resulting in less bottoming out Ballistic-edge stretch cover SPECIFICATIONS Jay 2 available in widths and depths; Jay 2 Plus widths and depths Jay 2 weight capacity is 250 lbs. Jay 2 Plus weight capacity is 650 lbs. Cushion weighs approximately 7 lbs. ELIGIBILITY Must meet general eligibility requirements Client requires the use of a wheelchair for mobility and will use the cushion as an accessory to the wheelchair. 55

56 SIP/SHP/FHB clients may be eligible for a cushion without the use of a wheelchair see cushion general policies REQUISITIONING AUTHORITY Physiatrist Plastic Surgeon Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse (in consultation with an Occupational Therapist or Physical Therapist) ORDER DETAILS Specify size required Order in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) - odd-sized cushions are not available. FORMS Special Needs Equipment Requisition Specialty Cushion Application Form 56

57 JAY 2 DEEP CUSHION April 1, 2014 MODELS/DESCRIPTION Jay 2 Deep pre-contoured foam cushions feature a Jay Flow fluid tripad with up to 3 of loading for superior skin protection and an easy to modify base with optional positioning components for optimal stability. Designed for the client who is high risk for skin breakdown and very poor skin integrity Fluid maintains its viscosity at high and low temperatures Requires no regular maintenance or adjustment Zipper enclosed ballistic-edged cover SPECIFICATIONS Available in widths and depths Weight capacity is 250 lbs. Cushion weighs approximately 7 lbs. ELIGIBILITY Must meet general eligibility requirements Client requires the use of a wheelchair for mobility and will use the cushion as an accessory to the wheelchair. SIP/SHP/FHB clients may be eligible for a cushion without the use of a wheelchair see cushion general policies REQUISITIONING AUTHORITY Physiatrist Plastic Surgeon 57

58 Licensed Occupational Therapist and/or Physical Therapist Home Care Nurse (in consultation with an Occupational Therapist or Physical Therapist) ORDER DETAILS Specify size required Order in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) - odd-sized cushions are not available. FORMS Special Needs Equipment Requisition Specialty Cushion Application Form 58

59 JAY ACTIVE CUSHION June 1, 2014 NOTE: This item is being discontinued by the manufacturer. Effective June 27, 2014 we will be no longer able to order new product and we will issue recycled stock only. MODELS/DESCRIPTION Jay Active is a lightweight, pre-contoured foam cushion with a Jay Flow fluid pad and AirExchange cover, designed for the active client at low risk of skin breakdown, who requires mild to moderate positioning. Includes removable lateral thigh supports Curved bottom helps neutralize the effects of sling seating Incontinence base cover to protect foam from moisture absorption Non-skid bottom SPECIFICATIONS Available in widths and depths Weight capacity is 250 lbs. Cushion weighs approximately 7 lbs. ELIGIBILITY Must meet general eligibility requirements Client requires the use of a wheelchair for mobility and will use the cushion as an accessory to the wheelchair. SIP/SHP/FHB clients may be eligible for a cushion without the use of a wheelchair see cushion general policies 59

60 REQUISITIONING AUTHORITY Physiatrist Plastic Surgeon Licensed Occupational Therapist and/or Physical Therapist Home Care Nurse (in consultation with an Occupational Therapist or Physical Therapist) ORDER DETAILS Specify size required Order in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) - odd-sized cushions are not available. FORMS Special Needs Equipment Requisition Specialty Cushion Application Form 60

61 JAY EASY CUSHION November 15, 2015 Photo Unavailable MODELS/DESCRIPTION Jay Easy is a skin protraction and positioning cushion featuring a hi-resiliency, contoured foam base that accommodates a curved or flat seating surface and Jay Flow fluid tripad Most suitable for client at moderate to high risk of skin breakdown SPECIFICATIONS Available in widths and depths Weight capacity is 250 lbs. Cushion weighs approximately 4 lbs. ELIGIBILITY Must meet general eligibility requirements Client requires the use of a wheelchair for mobility and will use the cushion as an accessory to the wheelchair. SIP/SHP/FHB clients may be eligible for a cushion without the use of a wheelchair see cushion general policies REQUISITIONING AUTHORITY Physiatrist Plastic Surgeon Licensed Occupational Therapist and/or Physical Therapist Home Care Nurse (in consultation with an Occupational Therapist or Physical Therapist) ORDER DETAILS Specify size required Specify base to accommodate flat or curved seat Order in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) - odd-sized cushions are not available. FORMS Special Needs Equipment Requisition Specialty Cushion Application Form 61

62 ROHO QUADTRO SELECT HIGH/LOW PROFILE April 1, 2014 Low High MODELS/DESCRIPTION Quadtro Select features ISOFLO Memory Control Unit offers shape-fitting capabilities while the client is seated, allowing quick and easy, on-demand adjustment to maximize function Cushion is divided into four sections, which allows for progressive positioning for short and long term changes Frequent monitoring of the cushion is required to ensure that proper levels of inflation are maintained SPECIFICATIONS Available in widths and depths Cushions are available in two different cell types: Low Profile: 2 cells High Profile: 4 cells Cushions weigh approximately 5 lbs. Do not overinflate the ROHOs as they are not designed to provide pressure relief when they are fully inflated. The general rule is to allow only a finger s space (½ ) between the buttocks and the base of the cushion. ELIGIBILITY Must meet general eligibility requirements Client requires the use of a wheelchair for mobility and will use the cushion as an accessory to the wheelchair. SIP/SHP/FHB clients may be eligible for a cushion without the use of a wheelchair see cushion general policies 62

64 ROHO ENHANCER April 1, 2014 MODELS/DESCRIPTION The Enhancer is a dual-valve system for midline channeling of the femurs, lateral stability and tissue protection Recommended for enhanced pressure distribution, positioning and posture Frequent monitoring of the cushion is required to ensure that proper levels of inflation is maintained SPECIFICATIONS Available in widths and depths Contoured cushion containing a combination of low (2 ) and high (4 ) profile cells. Cushions weigh approximately 4 lbs. Do not overinflate the ROHOs as they are not designed to provide pressure relief when they are fully inflated. The general rule is to allow only a finger s space (½ ) between the buttocks and the base of the cushion. ELIGIBILITY Must meet general eligibility requirements Client requires the use of a wheelchair for mobility and will use the cushion as an accessory to the wheelchair. SIP/SHP/FHB clients may be eligible for a cushion without the use of a wheelchair see cushion general policies 64

66 ROHO CONTOUR SELECT April 1, 2014 MODELS/DESCRIPTION The Contour Select stabilizes the pelvis back in the wheelchair and centers the client comfortably in the middle of the cushion Air is locked into each of the four quadrants Recommended for enhanced pressure distribution, positioning and posture Frequent monitoring of the cushion is required to ensure that proper levels of inflation is maintained SPECIFICATIONS Available in widths and depths Contoured cushion containing a combination of low (2 ) and high (4 ) profile cells. Cushions weigh approximately 5 lbs. Do not overinflate the ROHOs as they are not designed to provide pressure relief when they are fully inflated. The general rule is to allow only a finger s space (½ ) between the buttocks and the base of the cushion. ELIGIBILITY Must meet general eligibility requirements Client requires the use of a wheelchair for mobility and will use the cushion as an accessory to the wheelchair. SIP/SHP/FHB clients may be eligible for a cushion without the use of a wheelchair see cushion general policies 66

68 ROHO NEXUS SPIRIT April 1, 2014 MODELS/DESCRIPTION Nexus Spirit provides the stability of a contoured foam base and a Roho cell insert Allows for increased stability for transferring and positioning of the pelvis and lower extremities for enhanced sitting posture Frequent monitoring of the cushion is required to ensure that proper levels of inflation is maintained SPECIFICATIONS Available in widths and depths Cushions weigh approximately 3 lbs. Do not overinflate the ROHOs as they are not designed to provide pressure relief when they are fully inflated. The general rule is to allow only a finger s space (½ ) between the buttocks and the base of the cushion. ELIGIBILITY Must meet general eligibility requirements Client requires the use of a wheelchair for mobility and will use the cushion as an accessory to the wheelchair. SIP/SHP/FHB clients may be eligible for a cushion without the use of a wheelchair see cushion general policies REQUISITIONING AUTHORITY Physiatrist Plastic Surgeon Licensed Occupational Therapist and/or Physical Therapist 68

69 Home Care Nurse (in consultation with an Occupational Therapist or Physical Therapist) ORDER DETAILS Specify size required Order in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) - odd-sized cushions are not available. FORMS Special Needs Equipment Requisition Specialty Cushion Application Form 69

70 VICAIR VECTOR 6 & VECTOR 10 August 1, 2014 Vector 6 Vector 10 MODELS/DESCRIPTION Designed for high level skin protection and a stable seating position Reversible outer cover - cool breathable cloth on one side and incontinent on the other Inner cover features two elevated side compartments (front to back) and front-middle pommel filled with SmartCells TM air packets Low maintenance, no inflation required SPECIFICATIONS Vector 6 is a 2 high cushion; Vector 10 is a 4 high cushion Vector 6 available in widths and depths sizes larger than 20 x20 are not available Vector 10 available in widths and depths - larger sizes (up to 24 x24 ) are available however are custom and will not be kept in stock Weight capacity of 551 lbs. Cushion weighs approximately 2 lbs. ELIGIBILITY Must meet general eligibility requirements Client requires the use of a wheelchair for mobility and will use the cushion as an accessory to the wheelchair. 70

71 SIP/SHP/FHB clients may be eligible for a cushion without the use of a wheelchair see cushion general policies REQUISITIONING AUTHORITY Physiatrist Plastic Surgeon Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse (in consultation with an Occupational Therapist or Physical Therapist) ORDER DETAILS Specify size required Order in even-numbered width by depth dimensions (i.e. 16 x 16, 18 x 18, etc.) to fit wheelchair size. Odd-sized cushions are not available. Indicate cushion type desired Vector 6 (low) or Vector 10 (high) FORMS Special Needs Equipment Requisition Specialty Cushion Application Form 71

72 WALKERS Folding Kaye Postural Gutter Attachment (Accessory) Auto-Stop Kit (Accessory) Front Wheels (Accessory) 72

73 FOLDING WALKER April 1, 2014 Adult Walkers Bariatric Paediatric MODELS/DESCRIPTION Adult Large - G07755 Adult Medium - G07756 Bariatric Adult Large G30754B Bariatric Adult Medium G07768 Paediatric G07749 SPECIFICATIONS Lightweight aluminum material Height adjustable Walker folds flat to approximately 4 Provided with standard legs (as shown) 73

74 Model Walker Wrist Height Range G G Weight Capacity Overall Width Overall Depth Inside Grip Width Wheel Kit Options 350 lbs fixed single wheels and rear glides 350 lbs fixed single wheels and rear glides G30754B lbs fixed dual wheels G G lbs fixed dual wheels 200 lbs fixed single wheels ELIGIBILITY Must meet general eligibility requirements OPTIONS AVAILABLE Gutter Attachment Auto-Stop kit (3 fixed single front wheels and rear glides) Bariatric Front Wheels (5 fixed dual) Paediatric Front Wheels (3 fixed single) The 5 dual fixed wheels are NOT designed for use on the standard G07755, G07756 and G07749 models. REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapist and/or Physical Therapist Orthopedic Surgeon Home Care Nurse 74

75 ORDER DETAILS Specify client floor-to-wrist height If ordering an Auto-Stop kit or wheels; specify if they are to be installed on walker or provided separately. Note: Wheel kits add 1 to the overall height of the walker FORMS Special Needs Equipment Requisition 75

76 KAYE POSTURAL WALKER April 1, 2014 MODELS/DESCRIPTION Designed to accommodate children from 18 months to adolescence and young adulthood Designed for posterior use All models can be used in the reverse configuration (anterior position); W½ and W1 models require additional anterior wheel kits. Swivel wheel walkers cannot be anterior. SPECIFICATIONS Model Height to Top of Handle Weight Capacity Distance Inside Handles Width Distance Inside Handles Depth W ½ B lbs W 1 B lbs W 2 B lbs W 3 B lbs W 4 B lbs W 5 C lbs Provided standard with two front wheels and rear legs with tips 76

77 ELIGIBILITY Must meet general eligibility requirements OPTIONS AVAILABLE 4 wheeled design (front standard wheels and rear ratchet wheels) Front swivel wheels (swivel limiter available upon request) Rear silent wheels (one-way roller bearing wheels) Extensor assist pad Pelvic stabilizers Forearm supports (fits either right or left side) REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapist and/or Physical Therapists Specializing in Pediatrics ORDER DETAILS Specify appropriate size To determine correct walker size, measure the distance from the floor to the middle of the clients buttocks. This distance is the height to top of handle measurement. (See Kaye walker size chart). FORMS Special Needs Equipment Requisition 77

78 GUTTER ATTACHMENT (ACCESSORY) April 1, 2014 MODELS/DESCRIPTION Lumex 6132A Used with the folding walker secured with clamps to allow height adjustability Padded forearm trough with Velcro straps Adjustable hand grip ELIGIBILITY Must meet general eligibility requirements REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Specify quantity required Note: assembly to walker is required FORMS Special Needs Equipment Requisition 78

79 AUTO-STOP KIT (ACCESSORY) April 1, 2014 MODELS/DESCRIPTION Used on the folding walker Fixed 3 wheels attach to the front of the walker - Wheel attachments are not to be used on the back legs of the walker Glide brakes attach to the back legs of the walker SPECIFICATIONS Raises the walker up 1 ELIGIBILITY Must meet general eligibility requirements REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Specify if required If ordering an Auto-Stop kit; specify if they are to be installed on walker or provided separately. FORMS Special Needs Equipment Requisition 79

80 FRONT WHEELS (ACCESSORY) April 1, 2014 Bariatric Paediatric MODELS/DESCRIPTION 5 fixed wheels for bariatric walkers 3 fixed wheels for paediatric walkers Wheel attachments are not to be used on the back legs of the walker. SPECIFICATIONS Raises the walker up approximately 1.5 ELIGIBILITY Must meet general eligibility requirements REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Specify if required If ordering wheels; specify if they are to be installed on walker or provided separately. FORMS Special Needs Equipment Requisition 80

81 PAEDIATRIC MOBILITY AIDS Convaid Cruiser Kid Kart 81

82 CONVAID CRUISER April 1, 2014 MODELS/DESCRIPTION A supportive stroller product offered as an alternative to a wheelchair for paediatric clients Transit models provided standard with headrest extension, three point positioning belt with depth adjustable crotch strap, foot positioners and a Q-straint transit lap belt CX10 and CX12 models are provided with a five point positioning/restraint harness; all other models are provided with an H harness with padded covers Blue upholstery 30 degrees of tilt Overall weight of chair lbs. SPECIFICATIONS Model Seat Width Seat Depth Weight Range CX10T lbs. CX12T lbs. CX14T lbs. CX16T lbs. CX18T lbs. 7.5 front wheels and 12.5 rear solid knobby tires Angle adjustable footplates 82

83 ELIGIBILITY Must meet general eligibility requirements OPTIONS AVAILABLE Adjustable lateral support single or double flap with scoli strap Full torso support vest Padded or occi headwings Headrest canopy for clients with light sensitivities only Tray with hardware REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapist and/or Physical Therapist Specializing in Pediatrics ORDER DETAILS Specify size required FORMS Special Needs Equipment Requisition 83

84 KID KART LTC April 1, 2014 MODELS/DESCRIPTION Suitable for children who have medical needs and moderate to high positioning needs POSITIONING COMPONENTS Contoured and planar head supports Back support alternatives serve children of all sizes Butterfly harnesses allow anterior support of the thoracic cavity Planar or contoured lateral supports are offered in both fixed and swing-a-way models Seat cushions Abductors or medical knee blocks are offered in two sizes Padded foot-straps Therapeutic trays for upper extremity support Special equipment holders designed for ventilator/liquid oxygen tray, battery tray, oxygen tank holder, and IV pole SPECIFICATIONS Seat widths of Seat depths of degrees of tilt Weight capacity of 75 lbs. Overall chair weight of 43 lbs. REQUISITIONING AUTHORITY Physiatrist Selection Committee for Specialized Seating 84

85 Designated therapist working as part of the seating team at Wascana Rehabilitation Centre FORMS Special Needs Equipment Requisition Application for Specialized Seating Device 85

86 CANES & CRUTCHES Forearm Crutch Off Set-Handle Cane Quad Cane Gutter Cane Walk Cane Axillary Crutch Quad Crutch Gutter Crutch Attachment (Accessory) Ice Gripper (Accessory) 86

87 FOREARM CRUTCH April 1, 2014 MODELS/DESCRIPTION Adult Tall G05160 Adult G05161 Youth G05162 Child G05163 SPECIFICATIONS Vinyl coated, tapered, contoured 3 cuffs Metal push-button height adjustability Molded hand grips Rubber tip Model Client Height Weight Capacity G05160 (Tall Adult) lbs. G05161 (Adult) lbs. G05162 (Youth) lbs. G05163 (Child) lbs. ELIGIBILITY Must meet general eligibility requirements REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse 87

88 ORDER DETAILS Specify size required FORMS Special Needs Equipment Requisition 88

89 OFF SET-HANDLE CANE April 1, 2014 MODELS/DESCRIPTION Adult G Bariatric MDS86420XWG SPECIFICATIONS Height adjustable Contoured vinyl hand grip Rubber tip Model Height Adjustability Weight Capacity G lbs. MDS86420XWG (Bariatric) lbs. ELIGIBILITY Must meet general eligibility requirements Loan restricted to SHP, SIP, and FHB recipients OPTIONS AVAILABLE Ice Gripper REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapist and/or Physical Therapist Home Care Nurse 89

90 ORDER DETAILS Specify size required FORMS Special Needs Equipment Requisition 90

91 QUAD CANE April 1, 2014 MODELS/DESCRIPTION Adult Large Base G05340S Adult Small Base G05345S Bariatric Large Base MDS86228XWG Bariatric Small Base MDS86222XWG SPECIFICATIONS Height adjustable Four legs with rubber tips Hook handle Molded hand grip Model Height Adjustability Weight Capacity G05340S - Large Base lbs. G05345S - Small Base lbs. MDS86228XWG - Large lbs. Base (Bariatric) MDS86222XWG - Small Base (Bariatric) lbs. ELIGIBILITY Must meet general eligibility requirements Loan restricted to SHP, SIP, and FHB recipients REQUISITIONING AUTHORITY Physiatrist 91

92 Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Specify base and height required FORMS Special Needs Equipment Requisition 92

93 GUTTER CANE April 1, 2014 MODELS/DESCRIPTION Metal cane with arm trough Designed for people who cannot support weight through their hands SPECIFICATIONS Padded trough with Velcro straps Adjustable hand grip Rubber grips and tips Height adjustable ELIGIBILITY Must meet general eligibility requirements Loan restricted to SHP, SIP, and FHB recipients OPTIONS AVAILABLE Ice Gripper REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS This item is in limited supply. Call for availability. 93

95 WALK CANE (Side Stepper Hemi Walker) April 1, 2014 MODELS/DESCRIPTION Adult G07770 Youth G07771 SPECIFICATIONS Rubber hand grips and tips Adjustable and folds flat for storage and transportation Wider base for more stability Model Height Adjustability Weight Capacity G07770 (Adult) lbs. G07771 (Youth) 28 ½ lbs. ELIGIBILITY Must meet general eligibility requirements Loan restricted to SHP, SIP, and FHB recipients REQUISITIONING AUTHORITY Physiatrist Certified Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Specify height required FORMS Special Needs Equipment Requisition 95

96 AXILLARY CRUTCH April 1, 2014 MODELS/DESCRIPTION Adult Tall MDSV80534 Adult MDSV80535 Youth MDSV80536 Child G5163 Bariatric Adult Tall G60314B Bariatric Adult G1314B SPECIFICATIONS Rubber hand grips & axillary pads 2 diameter rubber tips Height adjustable Model Height Adjustability Approximate Client Height Weight Capacity MDSV ½ - 60 ½ lbs. (Tall Adult) MDSV ½ - 52 ½ lbs. (Adult) MDSV ½ - 44 ½ lbs. (Youth) G5163 (Child) lbs. G60314B Tall lbs. (Bariatric) G61314B Adult lbs. 96

97 (Bariatric) ELIGIBILITY Must meet general eligibility requirements Loan restricted to SHP, SIP, and FHB recipients OPTIONS AVAILABLE Gutter Crutch Attachment REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Specify size required FORMS Special Needs Equipment Requisition 97

98 QUAD FOREARM CRUTCH April 1, 2014 MODELS/DESCRIPTION Forearm crutch with a quad base SPECIFICATIONS Standard base of 5 x 7 Height adjustable Tall Adult ; user height of Adult ; user height of Youth ; user height of 4-5 ELIGIBILITY Must meet general eligibility requirements Loan restricted to SHP, SIP, and FHB recipients REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS NOTE: This item is in limited quantity. Call for availability. FORMS Special Needs Equipment Requisition 98

99 GUTTER CRUTCH ATTACHMENT (ACCESSORY) April 1, 2014 Photo Unavailable MODELS/DESCRIPTION LUMEX SPECIFICATIONS Padded forearm trough for axillary crutch Velcro straps Adjustable hand grip ELIGIBILITY Must meet general eligibility requirements Loan restricted to SHP, SIP, and FHB recipients REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse FORMS Special Needs Equipment Requisition 99

100 ICE GRIPPER (ACCESSORY) April 1, 2014 MODELS/DESCRIPTION Designed to flip up when not needed For use with single point canes SPECIFICATIONS 5-point claw tip Adjustable in diameter size ELIGIBILITY Must meet general eligibility requirements Loan restricted to SHP, SIP, and FHB recipients REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse FORMS Special Needs Equipment Requisition 100

101 BATHROOM ACCESSORIES Transfer Tub Seat Stationary Commode Combination Commode Child s Commode Bath Tub Lift Bath Tub Clamp Wall Bars Utility Bath Seat with Back Utility Bath Seat without Back Raised Toilet Seat Toilet Arm Rest Set 101

102 TRANSFER TUB SEAT November 15, 2015 MODELS/DESCRIPTION Standard G98309 and BE7200 Bariatric Merit A312 Non-padded transfer bench Extends over tub edge with two legs in the tub (with suction cups) and two legs out of the tub Drainage holes to prevent leakage onto floor Reversible back to left or right side SPECIFICATIONS Model Seat Height Range G BE Merit A Overall Width Seat Platform Width Overall Depth Seat Platform Depth Weight Capacity lbs lbs lbs. NOTE: Please lift the release tabs on the suction cup feet to release them from the surface of the tub. Not doing so can cause the suction cup to tear away from the leg of the transfer seat. 102

103 ELIGIBILITY Must meet general eligibility requirements OPTIONS AVAILABLE Leg extensions for G98309 and BE7200 models height range approximately REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse FORMS Special Needs Equipment Requisition 103

104 STATIONARY COMMODE April 1, 2014 Standard Bariatric MODELS/DESCRIPTION Standard - G Bariatric 650# Merit C315 Bariatric 850# Merit C316 Welded chrome steel main frame Fixed plastic armrests; bariatric has drop arms Plastic pail with lid Standard model can be used with pail or over most standard height toilets SPECIFICATIONS Model Seat Height Range Seat Width Between Arms Overall Width Seat Depth Weight Capacity G lbs C lbs. C lbs. ELIGIBILITY Must meet general eligibility requirements OPTIONS AVAILABLE 104

105 Splash guard REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse FORMS Special Needs Equipment Requisition 105

106 COMBINATION COMMODE November 15, 2015 MODELS/DESCRIPTION Artisan Models Standard ATS-500A Bariatric available upon request Commode with four small locking casters, padded seat cover, and pan Arms drop down to facilitate transfers Can be used with pan or over most toilets SPECIFICATIONS Model ATS- 500A Seat Width Overall Width Overall Depth Floor to Seat Height Weight Capacity lbs. ELIGIBILITY Must meet general eligibility requirements OPTIONS AVAILABLE Height insert (2 or 3 ) available for the ATS-500A model REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse FORMS Special Needs Equipment Requisition 106

107 CHILD S COMMODE April 1, 2014 MODELS/DESCRIPTION Sammons Preston Model Aluminum arms with white plastic seat and pail Adjustable hook and loop-chest strap SPECIFICATIONS Overall unit weight of 12 lbs. Overall width of 18 Width between arms is 14.5 Overall depth of 19 Height adjustable legs from lbs. maximum weight capacity ELIGIBILITY Must meet general eligibility requirements REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse FORMS Special Needs Equipment Requisition 107

108 BATH TUB LIFT April 1, 2014 MODELS/DESCRIPTION Guardian Spa SPECIFICATIONS Recline in lowest position Weight capacity of 308 lbs. Height range: Lowest 3 ; Highest 16.5 (without 2.5 height adapter) Size of base 25 long x 13.5 wide Seat width of 16.5 Battery powered hand control unit; provided with charger ELIGIBILITY In addition to meeting general eligibility requirements, the client must meet one of the following for a duration of two months or more: The client is unable to use any of the regular bath seats independently because of transfer requirements, endurance, or support requirements. The client is able to use a tub lift independently. The client can physically use a bath seat but would not receive sufficient immersion in water required by conditions such as: Perineal irritations Frequent diarrhea or bladder problems Skin problems 108

109 The caregiver is unable to assist transfers safely with any of the other bath seats available. The client cannot tolerate a shower or spray because of pulmonary conditions. The client s tub may not allow the use of any bath seats the client is capable of using. A home assessment to ensure suitability is required. This item requires scheduled maintenance. REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists ORDER DETAILS Specify the criteria that apply FORMS Special Needs Equipment Requisition 109

110 BATH TUB CLAMP April 1, 2014 MODELS/DESCRIPTION G SPECIFICATIONS Height of 13 Adjust to fit tubs thick ELIGIBILITY Must meet general eligibility requirements Loan restricted to SHP, SIP, and FHB recipients REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse FORMS Special Needs Equipment Requisition 110

111 WALL BARS April 1, 2014 MODELS/DESCRIPTION Silver enamel with knurled grip SPECIFICATIONS Available in 32 or 18 ELIGIBILITY Must meet general eligibility requirements Loan restricted to SHP, SIP, and FHB recipients REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Specify size required FORMS Special Needs Equipment Requisition 111

112 UTILITY BATH SEAT WITH BACK April 1, 2014 Standard Bariatric MODELS/DESCRIPTION Standard G30402 Bariatric MDS89745AXW Plastic seat and removable back Metal legs with rubber tips Fits inside tub SPECIFICATIONS Model Seat Width Seat Depth Seat to Floor Height Range Weight Capacity G lbs. MDS89745AXW lbs. (bariatric) 20.5 ELIGIBILITY Must meet general eligibility requirements Loan program restricted to SHP, SIP, and FHB recipients REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse 112

114 UTILITY BATH SEAT WITHOUT BACK April 1, 2014 Standard Bariatric MODELS/DESCRIPTION Standard - G30403 Bariatric - MDS89740AXW Plastic seat with metal legs with rubber tips Fits inside tub SPECIFICATIONS Model Seat Width Seat Depth Seat to Floor Height Range Weight Capacity G lbs. MDS89740AXW lbs. (bariatric) ELIGIBILITY Must meet general eligibility requirements Loan program restricted to SHP, SIP, and FHB recipients REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse 114

116 RAISED TOILET SEAT April 1, 2014 MODELS/DESCRIPTION Standard Round Bariatric - Savannah Standard Adjustable seat heights on standard model that can be tilted anteriorly or posteriorly Standard model fits only on toilet seats with round bowl Bariatric model made of molded plastic SPECIFICATIONS Model Height Weight Capacity lbs. Savannah lbs. ELIGIBILITY Must meet general eligibility requirements Loan restricted to SHP, SIP, and FHB recipients REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapist and/or Physical Therapist Home Care Nurse FORMS Special Needs Equipment Requisition 116

117 TOILET ARM REST SET April 1, 2014 MODELS/DESCRIPTION Lumex 6460A Two arms with mounting bracket that attaches to toilet seat bolts Aluminum legs with rubber feet Plastic armrests SPECIFICATIONS Height adjusts from depth at the arms; 12 depth at the legs Width between arms adjusts from lbs. maximum weight capacity ELIGIBILITY Must meet general eligibility requirements Loan is restricted to SHP, SIP, and FHB recipients REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse FORMS Special Needs Equipment Requisition 117

118 TRANSFER ASSISTS Sask-A-Pole Sask-A-Pole Trapeze Sask-A-Pole Kneeboard Versa Helper Trapeze & Floor Stand Hydraulic Patient Lift Transfer Board 118

119 SASK-A-POLE April 1, 2014 MODELS/DESCRIPTION Steel pipe frame Pressure mount - ceiling mount and floor base for support between joists SPECIFICATIONS Poles may be cut down to accommodate varying ceiling heights Model Classic 8 foot Classic 10 foot Standard (Heavy Duty) 8 foot Standard (Heavy Duty) 10 foot Bariatric SPHD 8 foot Ceiling Weight Heights Capacity lbs. Accessories Available lbs lbs. Sask-A-Pole Trapeze Sask-A-Pole Kneeboard lbs. 250 lbs. Sask-A-Pole Trapeze Sask-A-Pole Kneeboard ELIGIBILITY Must meet general eligibility requirements 119

120 Maximum of 3 Sask-A-Poles are loaned per client. REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Specify floor-to-ceiling height where the pole will be used FORMS Special Needs Equipment Requisition ASSOCIATED DOCUMENTS Sask-A-Pole Classic Installation Instructions Sask-A-Pole Standard HD and Trapeze Installation Instructions 120

121 SASK-A-POLE TRAPEZE April 1, 2014 MODELS/DESCRIPTION Attaches to a Standard (HD) Sask-A-Pole SPECIFICATIONS Weight capacity of 250 lbs. Radius of use (arm length) is 19 ELIGIBILITY Must meet general eligibility requirements REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse FORMS Special Needs Equipment Requisition ASSOCIATED DOCUMENTS Sask-A-Pole Standard HD and Trapeze Installation Instructions 121

122 SASK-A-POLE KNEEBOARD April 1, 2014 MODELS/DESCRIPTION Padded swivel kneeboard, which attaches to a Standard (HD) Sask-A-Pole Used for people who require additional knee stability while transferring SPECIFICATIONS Weight capacity of 250 lbs. ELIGIBILITY Must meet general eligibility requirements REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse FORMS Special Needs Equipment Requisition 122

123 VERSA HELPER TRAPEZE & FLOOR STAND April 1, 2014 MODELS/DESCRIPTION Height adjustable unit that attaches to a floor stand Floor stand includes two legs to support trapeze Unit rests it s base on floor under bed head or chair Unit is designed to provide support, increased stability and assist the user when repositioning. It is not designed to support the total body weight. SPECIFICATIONS Base clearance of 2 would be required Weight capacity of 250 lbs. Bariatric model to accommodate up to 1000 lbs. is available ELIGIBILITY Must meet general eligibility requirements REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse FORMS Special Needs Equipment Requisition 123

124 HYDRAULIC PATIENT LIFT April 1, 2014 MODELS/DESCRIPTION Hoyer HML400 SPECIFICATIONS Lift range of boom is Base length 43.5 Base width adjusts from Base clearance of 5.5 is required 400 lbs. maximum weight capacity for the lift 6 point cradle hook up Manual hydraulic lifting mechanism SLING TYPES Padded U sling with or without head support Nylon mesh bath U sling with or without head support Sling Sizes Small Medium Large Extra Large User Weight 55 to 110 lbs. 99 to 210 lbs. 198 to 350 lbs. 270 to 600 lbs. This item requires scheduled maintenance. 124

125 NOTE: This item is not designed to be used as a transport device to move clients from room to room. It is designed to transfer clients from one surface to another. ELIGIBILITY Must meet general eligibility requirements REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists ORDER DETAILS Specify sling type and size required FORMS Special Needs Equipment Requisition Mesh Sling 125

126 TRANSFER BOARD April 1, 2014 MODELS/DESCRIPTION Sammons Preston SPECIFICATIONS Moisture proof, high density plastic One side is striate-sanded for bare skin transfers and other side is buffed for clothed transfers Overall length of 29 Overall width of thick Weight capacity is 400 lbs. ELIGIBILITY Must meet general eligibility requirements Loan restricted to SHP, SIP, and FHB recipients REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse FORMS Special Needs Equipment Requisition 126

127 HOSPITAL BEDS & ACCESSORIES Policies Electric Hospital Bed Side Rails (Accessory) Over Bed Table (Accessory) 127

128 SASKATCHEWAN AIDS TO INDEPENDENT LIVING (SAIL) WIDE HOSPITAL BED POLICY April 1, 2014 Electric hospital beds are 36 wide. For clients who weigh more than 500 lbs., a bariatric bed is available. Bariatric beds are 54 wide. Wider beds may be issued in situations where a client weight is under 500 lbs. and their medical needs are not being met in a standard 36 hospital bed. Clients who require additional width due to girth, perform self-care in bed or need additional width due to medical necessity may request a wider bed. These requests must include a letter documenting the medical necessity for the extra width. For home care clients, confirmation that care will be provided on the wider bed is also required. 128

129 ELECTRIC HOSPITAL BED June 1, 2014 MODELS/DESCRIPTION Joerns Easy Care 3 Wooden head board / foot board Pendant control Standard 6 foam mattress (36 wide) provided with bed SPECIFICATIONS Bed platform size is 35 wide and 80 long Overall bed width is 39 Overall length with headrest/footrest is 88 Bed platform height range of 7 to 30 Weight capacity 500 lbs. Pendant control Provided with 6 thick foam mattress with vinyl cover (36x80 ) 42, 48 and 54 width beds are available; refer to the Wide Hospital Bed Policy. ALTERNATE MODELS Model Mattress Width Platform Height Range Weight Capacity Joerns - UCXT lbs. Rotech lbs. Multitech Rotech - Varitech lbs. 129

130 ELIGIBILITY In addition to meeting the general eligibility requirements, the client will be eligible for an electric hospital bed when he/she meets one of the hospital bed criteria A home assessment is required by a licensed occupational therapist, physical therapist, or a home care nurse (in consultation with an occupational or physical therapist). OPTIONS AVAILABLE Trapeze Over Bed Table Side Rails - half or split rails (full rails are available but only on specific models of beds) REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists ORDER DETAILS Specify the criteria that apply FORMS Special Needs Equipment Requisition Hospital Bed Criteria Form 130

131 SIDE RAILS (ACCESSORY) April 1, 2014 Half Rails Shown MODELS/DESCRIPTION Rail options vary by model of bed Side rail options may include half rails (head end) and split rails (half rail at head and foot ends) Full rails available for certain bed models ELIGIBILITY Must meet general eligibility requirements REQUISITIONING AUTHORITY Physician Licensed Occupational Therapists and/or Physical Therapists FORMS Special Needs Equipment Requisition 131

132 OVER BED TABLE (ACCESSORY) April 1, 2014 MODELS/DESCRIPTION Table on four small casters that fits over bed SPECIFICATIONS Height adjusts from ELIGIBILITY Must meet general eligibility requirements REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse FORMS Special Needs Equipment Requisition 132

133 ALTERNATING PRESSURE UNITS Alternating Pressure Pump & Mattress 133

134 ALTERNATING PRESSURE PUMP & MATTRESS April 1, 2014 No Photo Available MODELS/DESCRIPTION Mattress overlay system Pump circulates air within mattress chambers Alternating cycle time of 10 minutes SPECIFICATIONS Inflated mattress dimensions are 35 wide x 80 long Inflated mattress height is 2.5 Weight capacity is 250 lbs. ELIGIBILITY In addition to meeting general eligibility requirements, one of the following must be met: The client is unable to turn every 2-4 hours to prevent skin breakdown The client has fragile skin, a history of skin breakdown, or insufficient soft tissue over bony prominences Sensory loss is present to the extent that pressure sores are a risk Pain and disability make it difficult or impossible for the client to change positions. REQUISITIONING AUTHORITY Physiatrist Plastic Surgeon Licensed Occupational Therapists and/or Physical Therapists ORDER DETAILS Specify the criteria that apply FORMS Special Needs Equipment Requisition 134

135 LYMPHEDEMA CONTROL UNITS Policies 3 Chamber Pressure Pump & Sleeves 135

136 POLICIES April 1, 2014 A grant option is available to clients with a diagnosis of primary lymphedema for the purchase of a multi-chambered (six or more) lymphedema pump. To be eligible, clients must have a diagnosis of primary lymphedema, require the pump long-term and at least every second day, and demonstrate the pump is effective through a successful trial of a machine. Referral is required from a specialist physician whose letter must confirm the diagnosis of primary lymphedema. A physiotherapist must specify the type of equipment and accessories that are required. If approved, the client will be notified in writing. The client is responsible for purchasing the equipment and submitting the receipt to SAIL. SAIL will reimburse the client for 2/3 of the actual cost of the pump, sleeves and accessories to a maximum of $4,000. The grant is available once every five years. 136

137 3 CHAMBER PRESSURE PUMP & SLEEVES April 1, 2014 MODELS/DESCRIPTION Pre-set inflation and deflation cycle Alternating pressure units for one extremity at a time SPECIFICATIONS 3-chambered pump Amount of compression is adjustable (pressure range of mmhg) Sleeve sizes include: Regular Arm: 34 x 26 Regular Leg: 32½ x 30½ Long Leg: 37 x 32 Sleeve specifications: Soft nylon inner liner Colour-coded parts simplify hook-up 3 Chamber has alternating pressure pockets to produce a milking effect Includes a longitudinal zipper for ease of application Anti-reflux safety valves designed to prevent reverse inflation Machine washable 137

138 ELIGIBILITY In addition to meeting the general eligibility requirements, the following must be met for the client to be eligible for a 3 chamber JOBST Pump: The client must have vascular insufficiency lymphedema REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists FORMS Special Needs Equipment Requisition 138

139 OTHER EQUIPMENT Helping Hand Reacher 139

140 HELPING HAND REACHER April 1, 2014 MODELS/DESCRIPTION Patterson Medical Feather Reachers A length A length Used to extend reach and grasp light items. SPECIFICATIONS Available in two lengths: 26 and 32 2 ½ jaw opening with rubber tip Reacher weighs approximately 1 lb. ELIGIBILITY Must meet general eligibility requirements Loan program restricted to SHP, SIP, and FHB recipients. REQUISITIONING AUTHORITY Physiatrist Licensed Occupational Therapists and/or Physical Therapists Home Care Nurse ORDER DETAILS Specify length of reacher desired FORMS Special Needs Equipment Requisition 140

141 PAEDIATRIC WOODEN EQUIPMENT Paediatric Height Adjustable Chair Paediatric Height Adjustable Table Paediatric Therapy Bench 141

142 PAEDIATRIC HEIGHT ADJUSTABLE CHAIR October 30, 2014 MODELS/DESCRIPTION Wooden height and depth adjustable chair SPECIFICATIONS Available in three seat sizes: 10 x 10 (small) 11 x 11 (medium) 12 x 12 (large) Adjustable height on each size: Small 7 to 10.5 Medium 8 to 11.5 Large 9 to 12.5 Adjustable seat depth: Up to 4 adjustability on each size AVAILABLE OPTIONS Seat Pad 1 or 2 Wedge Seat Pad 1 or 2 Back Pad 1 or 2 Angled Back Pad 1 or 2 Side Pads 1 or 2 Lap Belt Footrest Note: Accessories such as butterfly vests, headrests, anti-thrust seats and bolsters are available through Adaptive Seating. Please follow the standard process for requisitioning Adaptive Seating components if these types of accessories are required. 142

143 ELIGIBILITY Must meet Special Needs Equipment general eligibility requirements for universal loan equipment Must be 17 years of age or younger Loan program provides one height adjustable chair only for inhome rehabilitation and therapy equipment required for other locations (school, daycare, etc.) may be purchased privately outside of the loan program - please contact the Saskatchewan Abilities Council directly regarding pricing REQUISITIONING AUTHORITY Licensed Occupational Therapists and/or Physical Therapists FORMS Paediatric Wooden Equipment Order Form 143

144 PAEDIATRIC HEIGHT ADJUSTABLE TABLE October 30, 2014 MODELS/DESCRIPTION Wooden height adjustable table SPECIFICATIONS Available in two sizes: 22 x 28 table top with 10 x 5 cut out (small) 13 to 18.5 height adjustment to table top 24 x 30 table top with 11 x 5 cut out (large) 14 to 24 height adjustment to table top AVAILABLE OPTIONS Book Box 6 x 6 x 10 (attaches to side of table) ELIGIBILITY Must meet Special Needs Equipment general eligibility requirements for universal loan equipment Must be 17 years of age or younger Loan program provides one height adjustable table only for inhome rehabilitation and therapy equipment required for other locations (school, daycare, etc.) may be purchased privately outside of the loan program - please contact the Saskatchewan Abilities Council directly regarding pricing 144

145 REQUISITIONING AUTHORITY Licensed Occupational Therapists and/or Physical Therapists FORMS Paediatric Wooden Equipment Order Form 145

146 PAEDIATRIC THERAPY BENCH October 30, 2014 MODELS/DESCRIPTION Wooden height adjustable bench with tilt SPECIFICATIONS Available in two sizes: 10.5 x 26 padded seat (small) 8.5 to 11.5 height adjustment 14 x 30 padded seat (medium) 13 to 21 height adjustment ELIGIBILITY Must meet Special Needs Equipment general eligibility requirements for universal loan equipment Must be 17 years of age or younger Loan program provides one therapy bench only for in-home rehabilitation and therapy equipment required for other locations (school, daycare, etc.) may be purchased privately outside of the loan program - please contact the Saskatchewan Abilities Council directly regarding pricing REQUISITIONING AUTHORITY Licensed Occupational Therapists and/or Physical Therapists FORMS Paediatric Wooden Equipment Order Form 146

147 EQUIPMENT MANUAL REVISION DATES Original Manual Release Date April 1, 2014 Revision Dates June 1, 2014 August 1, 2014 October 30, 2014 November 15,