2THE WORKSHOP The aim of the workshop is to: provide you with a better understanding of the Department’s requirements relating to prescribing and supplying medical grade footwear.
3Rehabilitation Appliances Program (RAP) The aim of RAP is to keep veterans in their own homes as long as possible andProvides equipment or appliances for self help and rehabilitation
4RAPProgram provides:Aids to daily living eg mobility aids, home modificationsTreatment aids eg continence products, oxygenMedical Grade Footwear (since July 2000)
5Spending of public money DVA, RAP can lawfully utilise public money in the provision of aids or appliances to eligible beneficiaries under the provisions of:Section 90 of the Veterans’ Entitlements Act andTreatment Principles Part 11The link below offers in depth material – Federal Register of Legislative Instruments (Frli):
6Who is EligibleGold Card Holders - full range of treatment (footwear supplied where clinically necessary)White Card Holders - full range of treatment for accepted disabilities (footwear supplied where clinically necessary for accepted disability)** White card holders need prior approval before podiatry andfootwear treatment
7The Cards GOLD card holders assessed on basis of clinical need The TPI Gold Card looks the same but references Totally & Permanently IncapacitatedGold Card
8No eligibility for RAP items Pharmaceuticals ONLY WHITE card holders assessed on basis of clinical need related to an accepted disability (AD)No eligibility for RAP itemsPharmaceuticals ONLYFACT SHEETSWHITE CARDORANGE CARD
9MEDICAL GRADE FOOTWEAR (MGF) MGF ReviewAn initial review undertaken in 2004/05The review included the definition of what constitutes MGF Footwear clinically prescribed for the purpose of correcting, alleviating or replacing deficiencies or deformities in gait, feet or lower limbs.As part of this review the MGF Register of suitable footwear was compiled
10MEDICAL GRADE FOOTWEAR Review of MGF Register (an accepted list of footwear which meet specific criteria, and referred to as medical grade) undertaken in 2010Some shoes removed due to their not being considered clinically appropriateSuppliers of MGF are selected from an open tender process, last completed 2010.
11MEDICAL GRADE FOOTWEAR Definition:Footwear clinically prescribed for the purpose of correcting, alleviating or replacing deficiencies or deformities in gait, feet or lower limbs.MGF is prescribed when readily available everyday footwear cannot be used or modified for this purpose.
12Medical Grade Footwear Ready-made Depth/WidthReady-made has specific features thataccommodate foot abnormalities. Listed onRegister of DVA Approved Ready-MadeDepth/Width Medical Grade Footwear.Determined by a technical advisory panelaccording to specific technical criteria.Custom MadeManufactured to individual specifications.
13Examples of Technical criteria Examples of technical criteria for ready-made Depth/Width footwear include a defined:Min Depth 6.0mm added evenly along the last. Inside back heights a min. of 67.0mm for size 7 women’s shoes and 72.0mm for size 9 men’s shoes, with a 2.0mm difference in back height between each size.Min Width should be avail in 3 width fittings with a minimum width sizing of a standard EE forefoot.Design should allow for easy donning and doffing. The shoe should be lace up, velcro or buckle closure and able to be modified in this respect.Quality and thickness of materials used for soles, in uppers, linings and torsional stability.
15Custom-made FootwearMade from lasts or casts built to replicate the feet.Specifically designed to accommodate gross deformity and/or biomechanical anomalies.
16WEBSITE LINKS MGF National Register and Fee Schedules RAP Schedule & Forms
17Non-medical grade footwear stock or off the shelf walking shoesslip-on shoes/boots/court shoesrunners/joggers“reef style” or “orthopaedic moulded” sandals
18Podiatry Advisors Are available for you to discuss MGF issues, treatment concerns etcDVA Health Provider Line(metro)(regional)Press Option 1 for RAP (aids and appliances & medical grade footwear)
19Procedures for assessing lower limb management Podiatrists must assess the client by the following order of interventions, as clinically appropriate.Consider the use of:more appropriate stock footwear;corrective insoles;modifications to stock footwear;ready-made footwear; orWhen no other clinically suitable option remains the prescription of :-custom footwear
20Key to Success 1Thorough assessment of the client’s foot type and shape is the first step to prescribing adequatetreatment interventionsorthoses or footwear.
21Assessment Guidelines step 1 full examination of footbony abnormalities/exostosestoe positionsoedemathe ‘at risk’ footunusual skin conditionsstep 2 gaitstructural weaknessabnormal functioncondition of footwear in use
23What Do I Want To Achieve when considering Footwear ? Key to Success 2What Do I Want To Achieve when considering Footwear ?To facilitate correction, support or gait assistance ?To facilitate stability ?; and / orAccommodating abnormal foot structures ?
24Is the existing footwear suitable for the clinical condition ? Key to Success 3Is the existing footwear suitable for the clinical condition ?Existing footwear can be improved withshoe modifications without need for MGFWhere necessary clients should be advisedto purchase more appropriate footwearReadily available footwear is an acceptable choice if it has adequate depth, width, and stability.
25MGF can be prescribed when: Appropriate treatment and appliance therapyhave been tried and failedWhere appropriate, shoe modifications to theveteran’s own footwear have been tried andfailedThere is significant clinical need and thedeformity or condition cannot be managedwithout the use of ready-made or custom MGF
26Key to Success What footwear and/or appliances are available to accommodate this clinical condition ?As the MGF prescriber it is your responsibility to keep abreastof the types of footwear available on the DVA MGF Register andany changes occurring within the industry.When prescribing MGF you should have an indication of whattype of shoe will be most suitable for your client and whatadditional appliance/s would be beneficial.Local suppliers are keen to work with Podiatrists to share informationabout the range and styles available to match to patient foot type andneed.DVA Pod Advisers may also be contacted for help with suggestions ofsuitable choices/styles to suit the clinical need.
27BASIC FOOTWEAR COMPONENTS Back Quarter - quarters are the back sections of the upper which support and help control the hind-footHeel Counters - extended medially and/or laterallyInsoles - cut from last shape and determines the shape of the shoe, waist support and flexibilityLinings - material used to contact the foot for the purpose of absorbing perspiration, reducing heel slip, durabilityLug Length - the top opening of the shoe which runs down the dorsum of the midfoot (the laces area). The length is usually a standard proportion of the shoe. May be extended down the toebox. E.g used commonly for high insteps or forefoot amputations
28BASIC FOOTWEAR COMPONENTS cont.. Outsole - base of shoe which contacts the ground – durableShank - reinforces the mid section of the shoe – critical !Toe Puffs - can be walled or extend onto the dorsum over the digitsTongue - may be padded or stitched downVamp - The material section of the shoe which covers the top part of thefoot
29Deciding Ready-made or Custom There are many factors which affect this decision.For example clinical conditions need to be stable before prescribingcustom footwear and MGF, e.g. presence of oedema. It is essential tohave an up to date medical history including medications.The following shoe features should also be considered:CounterLug LengthModifications
30CUSTOM OR READY-MADE Custom is generally required when: Toe box needs to be 30 mm or higherForefoot width is in excess of 3 fittings wider than hind-footEquinus foot shapeRocker bottom footSevere adducted or abducted forefootExcessive OedemaSevere Rheumatoid deformitiesOther deformities which cannot be accommodated indepth/width footwear e.g Marked asymetry between feet
31SUMMARYKey to success 1:Thorough assessment of the client’s foot type and shape is the first step to prescribing adequate footwear.Key to success 2:What Do I Want To Achieve With Footwear?Key to success 3:Is the existing footwear suitable for the clinical condition?Key to success 4:What footwear and/or appliances are available to accommodate this clinical condition?
32Referral MGF Flowchart Veterans can be referred by the LMO to either Medical Specialists or Podiatrists for MGF assessment.The process is the same.VeteranLMOPodiatristSpecialistSupplierDVA – RAP sectionfor approvals Modifications & repairs over $100 require approval
33New Patients Referral from LMO Confirm MGF History – Ask the Veteran - Do they have/ have they had footwear previously issued through the Department ?Ask DVA if unclear
34MGF Prescription Forms D0688 D0688 Forms are now available on the DVA website in pdf format for downloading go to:Forms can also be ordered as follows:Online – orTelephone: ; orFax: ; orPost: DVA Distribution, PO Box 251, Woden, ACT 2606
35The MGF Prescription Form – D0688 There are 2 forms required to be filled out in the process of prescribing MGF for eligible veterans.D Medical Grade Footwear Prescription (for the prescriber)D MGF Footwear Supply(completed by the supplier)Please note that the two pads of forms are companion items, ie when one is ordered, the other is automatically provided with it.
37Filling in the Prescription Form D0688 NOTE: the Guidelines for Prescribers on the coverpage of the prescription pad !Succinctly:Delays can be avoided by filling in the D0688 form completely, including all relevant:clinical information and footwear detailsinformation regarding modifications/repairslist clearly any special instructionsNB. When insufficient details are provided a request for additional information, will be made to the Prescriber.
38Prior Approval Process Approvals / RejectionsIf all criteria are met: ApprovedIf minimal criteria are met/provided: RejectedMGF will not be provided for the solepurpose of accommodating orthoses.
39Footwear SupplyDVA has contracts with suppliers of MGF. Some provide only ready-made depth/width, others only custom-made, others provide both types of MGF.Suppliers include:OrthotistsCommercial Shoe StoresMGF Specialists
40The Podiatrist prescribing the MGF is the case manager... AcquittalsThe Podiatrist prescribing the MGF is the case manager...Acquittal - is the formal “sign off” that the footwear is as prescribed by the case manager and suitable for the purpose for which it has been requested.Acquittal maintains the warranty.Acquittals are to be recorded on the D0688 or in patient’s clinical notes and comments made as necessary.
41Process of AcquittalClinicians are strongly encouraged to provide the information below at time of acquittal.Comments can include but are not limited to:Acquittal dates and informationAcquittals should be done within 1-2 months of footwear being suppliedProblems at acquittal are the responsibility of the prescriber to liaise with supplier to adequately resolve in a timely mannerPrescriber must review - all footwear issuedModifications to footwear must be reviewedExcessive wear and quality issues should be referred to DVA offices rather than condemn and replaceUnsatisfactory supplies MUST be addressed
42How Many? - Shoes 2 prs Day/Dress shoes at any one time 1 pr Recreational shoes - where MGF need to be modified to comply with a sporting club regulation. Must provide club letter confirming financial membership & playing status1 pr Work shoes if required by an employer, in addition to day shoes - may need confirmation from employer e.g. SAFETY SHOES1 extra pr day shoes for rural and remote residents (defined as >100km from a suitable Prescriber)
43Replacing Footwear“CONDEMN” FOOTWEAR when no longer repairable or clinically suitableWhen condemning footwear and requesting replacement shoes, write details on script e.g. date approved, make, style, size, or colour.Early condemning of footwear please write on prescription the reasons. Should only be a change in clinical circumstances not where a patient changes their mindPunch holes in the tongue or mark an X in permanent marker (this identifies that MGF have been condemned and repairs will not be paid by DVA)If high risk client - discard unsafe footwear
44Repairs and Modifications DVA pays for repairs to current DVA footwear - script given to clientRoutine repairs may be done by the original supplier without need for prescriptionContracted suppliers are required to manage any warranty needs e.g repairs (generally 12mths)An exception; unless extreme access issues exist in visiting or sending shoes to the contracted supplier. Prescriber to keep adequate notes.After warranty has passed - Local repairers are able to repair - send invoice into the Department with copy of script.
45How Many? Modifications to non DVA footwear Clinically required - e.g heel collars, sole raises, stretching etc. to non DVA footwearLimit of 3 self purchased pairs of footwear can be modified in any one yearNeeds a prescription form completedContracted suppliers are required to manage any warranty needs e.g modifications (generally 12mths)After warranty has passed - Local repairers are able to modify - send invoice into the Department with copy of script.
46How Many? - Orthoses/ Insoles Etc 1pr Customised - to move from shoe to shoeWhere a clinical need exists (e.g. issues with manual dexterity) another pair of orthoses may be requestedWhere different shoe style makes transfer of orthosis difficult the orthosis could be mildly modified to adapt to the different shoe or shoesVeteran could purchase appropriate footwear to accommodate the orthosisTo replace an orthosis:Replace by surrendering old one to podiatrist or supplierProvider supplying orthosis/es then clearly states this on prescription form
47Prescription of Stock Footwear Requested through Rehabilitation Appliances Program (RAP)Prescription form on website –DVA Forms Form D this is not the same form as when requesting MGFStock - AJ07 or Temporary - AJ06Issued as essential part of a leg appliance e.g. amputeeModification/s to self purchased footwear may be required to accommodate a calliperTemporary footwear (AJ06) also available - cast boots/shoes e.g. “DARCO”Guideline for the prescription of Pullman slippers; extreme oedema, current ulceration and subsequent leg and foot bandaging
48WarrantiesNewly manufactured MGF - 12 months (workmanship, materials, fitting)Repairs/modifications - 3 monthsAs a quality assurance measure – The Department may request the Prescriber returns those shoes that have failed to last an acceptable amount of time.
49Home Visits for Suppliers Needs prior approval from the Department to be able to claim travelRequested on the Prescription Form by the Prescriber outlining the clinical reasons why the veteran cannot be transported to supplierConsidered only where it is clear the client is medically confined to homeA general rule of thumb –1 (one) home visit for MGF and2 (two) visits for custom MGF when requested by the podiatrist
50Transport to Podiatry treatment Beneficiaries can claim reimbursement for travel costs for medical treatment to the closest practical provider - taxis or mileage(incl. to contracted footwear supplier or orthotist appt.)Service provider to sign travel form (available from the DVA’s Transport section)Booked Car with Driver (BCWD) scheme was made available to all beneficiaries over the age of 80 in 2006.See online DVA FACTS HSV125
51MEDICAL GRADE FOOTWEAR (MGF) COMPLICATIONS & DIFFICULTIES What to do when:Footwear provided is not suitable the Veteran should:NOT sign the voucher if presented by the Supplier;Contact the Prescriber to discuss with Supplier and organise modifications.Footwear provided is not suitable the Prescriber should:NOT acquit the footwear;Advise supplier ASAP;Discuss and organise modifications.The veteran changes their mind:Veteran has financial responsibility for costs.There are problems with the supplier;Contact DVA RAP if unable to resolve.
52MEDICAL GRADE FOOTWEAR (MGF) WHAT IF? Suppliersnearest contracted supplier is too far awayliaise with supplier to work out possible solution - eg foot tracings; girth measurements and let DVA know of issuesnearest supplier cannot supply most suitable MGF register shoesother suppliers can be contactedMaintain adequate records to support this approach
53MEDICAL GRADE FOOTWEAR (MGF) WHAT IF? Prescribersdo not complete the D0688 correctlyform will be returned with request for more detailsare unsure as to the most appropriate shoebe specific in description of MGF characteristicsdiscuss with a DVA Podiatry Adviserassess the beneficiary as not meeting clinical criteriaexplain to veteran and do not complete D0688 orsend completed D0688 directly to DVA and attach a note indicating assessment that stock footwear is suitablekeep precise clinical notes in case a review is requested
54MEDICAL GRADE FOOTWEAR (MGF) MGF SUPPLIER LOCATIONS Contracted MGF suppliers are located throughout each StatePlease see the link below to locate the closest contracted supplierList of suppliersNOTE: Names and locations as listed are correct at time ofpublication.
55MEDICAL GRADE FOOTWEAR (MGF) CONTACT NUMBERS DVA Health Provider Line(metro)(regional)PressOption 1 for RAP (aids and appliances & medical grade footwear)Option 3 for Medical & Allied Health (podiatry treatment)
56MEDICAL GRADE FOOTWEAR (MGF) Thank youThis completes the on line workshopShould you have further questions about MGF or the content of this presentationplease contactDVA Health Provider Line(metro)(regional)Option 1 for RAP (aids and appliances & medical grade footwear)