Overview

The overall goal will be to identify and investigate barriers and opportunities to current coverage policy for CRT to fully understand their benefits and shortcomings for the development of a new proposed coverage policy. The aims of the project are to: 1) identify and investigate barriers to current coverage policy for Complex Rehabilitation Technology via a scoping review of current health & disability policy recommendations; 2) engage with a diverse group of stakeholders (who mostly are part of our overall project team) to assist with the creation of an online survey that validates common themes from the scoping review ; and 3) create and distribute an online Qualtrics survey to multiple healthcare stakeholder groups relevant to CRT.

The work is led and collaborated by the University of Pittsburgh, The Ohio State University, and the University of Michigan all high-ranking academic institutions along with premier access to health science library systems and key stakeholders at Assistive Technology Centers.  Engagement of stakeholders is critical throughout this project from consumers/caregivers, clinicians, suppliers, industry groups, manufacturers, payers, and professional associations.  Each will assist in identifying the current barriers that exist with current health policy and the ingredients to a new accountable coverage policy as well as.

Findings of this project will be summarized and disseminated in documents suitable for press releases, policy briefs, white papers, and peer-review publication, and will serve as stakeholder-driven guidelines for future development of new policies for CRT. In addition, the survey data will help establish stakeholder group consensus to provide elements and attributes of a new CRT policy.

Update

As of May 1, 2025

Sub-project #1: Scoping Review – COMPLETED

Team members have completed all the steps in the scoping review process. The six steps are listed below and are based on the process described by Colquhoun et al. (2014).

1. Identifying the research question – COMPLETED
2. Identifying relevant studies – COMPLETED
3. Study selection – COMPLETED
4. Charting the data – COMPLETED
5. Collating, summarizing, and reporting the results – COMPLETED
6. Consultation – COMPLETED

The research question for the scoping review is “What is the complex rehabilitation technology (CRT) service delivery process for individuals with a disability that have a mobility impairment?”.

Based on the research questions we searched nine databases and four conference proceedings. The search resulted in 2,942 articles for review of title and abstracts. After completing the title and abstract review, we completed a full-text review for the remaining 314 articles. Finally, we identified 57 articles that were reviewed for data charting, collating, summarizing, and reporting. Based on the initial charting and collating process, we have identified 4 theme topics and 16 subtopics.

The four themes were wheeled mobility devices, policy, service delivery, and consumers.

Lastly, team members investigated Open Science Framework (OSF) (https://osf.io/) to assist with dissemination as it is a free, open-source web application that connects and supports research workflow, enabling scientists to increase the efficiency and effectiveness of their research. OSF allows researchers to collaborate, document, archive, share, and register research projects, materials, and data. The Scoping Discovery Review of CRT can be found at the following link, https://osf.io/rnqzx.

Dissemination Activities

DiGiovine, C.P., Schein, R.M., & Bet, M. (2022, February). Scoping Review Investigation of Complex Rehabilitation Technology and Next Steps. International Seating Symposium (ISS).

Betz, M., DiGiovine, C. P., Galbreath, P., Stojkov, A., Berner, T., Hibbs, R., & Schein, R. M. (2022). Service delivery for complex rehabilitation technology: a scoping review. Disability and rehabilitation. Assistive technology, 17(8), 853 – 871. https://doi.org/10.1080/17483107.2022.2111609

Schmeler, M. R., & Dicianno, B. E. (2022). Viewpoints on the scoping review for the development of a novel coverage and service delivery policy for complex rehabilitation technology. Disability and rehabilitation. Assistive technology, 17(8), 872 – 874. https://doi.org/10.1080/17483107.2022.2113457

Scoping Discovery Review of CRT has been listed in OSF’s Registries – https://osf.io/rnqzx

Betz, M., Galbreath, P., DiGiovine, C.P., & Schein, R.M. (2021, July). Complex Rehabilitation Technology Service Delivery: Scoping Review Process & Methodology. Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).https://www.resna.org/sites/default/files/conference/2021/ServiceDeliveryandOutcomes/68_Betz.html

• 2021 RESNA Student Scientific Paper Competition Runner-Up

Sub-Project #2: Description of Stakeholder Viewpoints on CRT Policy – Survey Development – COMPLETED

Based on the themes from the scoping review (sub-project 1) we developed the survey questions and conducted pre-testing of the survey. The survey questions were evaluated for clarity and relevancy. We created four iterations of the survey and received feedback from three groups on the survey questions. We received feedback from a sub-set of the DRRP team, the entire DRRP team, and external stakeholders. In developing the survey, we balanced the comprehensiveness of the survey with the time it takes to complete the survey. The final survey contained 19 questions and address all the steps in the RESNA Wheelchair Service Delivery Guide. The questions either addressed the steps directly (e.g., device description) or indirectly (e.g., overall question about the service delivery process).

Dissemination Activities

Beauregard, T., Schein, R., Berner, T., & DiGiovine, C. (2022, July). Development of an Online Survey to Examine Stakeholder Perception of the CRT Service Delivery Process. Paper Presented at the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). https://www.resna.org/sites/default/files/conference/2022/SeatingandMobility/StudentScientific/93_Beauregard.html

• 2022 RESNA Student Scientific Paper Award Winner

Beauregard, T., Schein, R., Berner, T., & DiGiovine, C. (2022, April 22). Development of an online questionnaire examining stakeholder perception of the CRT service delivery process. The Ohio State University School of Health & Rehabilitation Sciences Research Day, Columbus, Ohio.

Sub-Project #3: Description of Stakeholder Viewpoints on CRT Policy – Survey Administration – Dissemination Stage

Based on the survey development process, the final survey was sent to 30 plus stakeholder groups. The survey was launched on December 1, 2021 and closed shortly after the International Seating Symposium in March 2022. The data is further being analyzed by both quantitative and qualitative analyses.

Questions took the form of positive statements regarding the CRT service delivery process and participants rated their agreement with the statements on a standard six-point Likert scale. We used a snowball sampling strategy to recruit stakeholders in the CRT service delivery process. Snowballs were started by emailing the different organizations representing all the identified stakeholder groups requesting that the email be forwarded to the members of the organization.

We received 1069 valid responses. Percent of respondents that completely or mostly agreeing with the statements, indicating a positive perception of that aspect of the CRT service delivery process. The Respondents view the CRT service delivery process as not performing well with less than 18% of all responses indicating a positive perception. Questions regarding funding and procurement were viewed in the least positive light, with 5% positive responses on average, followed by questions regarding follow-up, maintenance, and repair with less than 10% positive responses. The aspect of the process viewed in the most positive light was fitting, training, and delivery with over 42% positive responses. Conclusions: The CRT service delivery process is not viewed as performing well by its stakeholders. Funding and procurement aspects are viewed particularly negatively which represents an opportunity for focused reform efforts.

In addition, there were interesting similarities and differences among each stakeholder group. For example, the consumer/care partners group completely disagreed with the statements almost 30% of the time, while the remaining stakeholders completely disagreed with the statement less than 15% of the time. A visual analysis of the results indicated that the suppliers, clinicians and manufacturers agreed (somewhat, mostly, completely) with the statements between 40% and 50%, while the consumers/care partners and payors only agreed with the statement between 30% and 40%. Over half of the responses were negative for all stakeholder groups. While there are differences among the stakeholder groups in terms of their overall satisfaction with the CRT service delivery process, it is evident that all groups have a negative view of the service delivery process. These findings show that further investigation into the service delivery process is needed for improvement to the process and ensure that all stakeholders find the process satisfactory and effective.

The newest information based on the revised qualitative analysis yielded additional information not reported on. The majority of the comments reflected a negative attitude (i.e., 256 negative / 19 neutral / 8 positive / 3 did not apply) about the CRT service delivery process. When analyzing the data an overarching theme of standardization emerged as our primary category. Secondary categories included: Geographical access (n=53 or 8.7%), client-centered care (n=76 or 12.5%), funding (n=268 or 44.2%), stakeholder knowledge (n=116 or 19.1%, and quality (n=68 or 11.2%). These results along with specific stakeholder breakdown of comments will be included in the revised manuscript to be submitted at a later date. Conclusion: The comments addressed every component of the wheelchair service delivery process and were overwhelmingly negative. The implementation of the wheelchair service delivery process is not working, with over 40% of the comments focused on funding. Lastly, there is a need to revise the wheelchair service delivery process and the implementation of it too.

Dissemination Activities

Chan, S., Beauregard, T., Parachini, J., Dicianno, B., Schmeler, M.R., & DiGiovine, C. (2025). Stakeholder Perception of Geographical Barriers in the Wheelchair Service Delivery Process. Poster Presented at the 39th International Seating Symposium. Assistive Technology, 37:sup13, S25, https://doi.org/10.1080/10400435.2025.2463822

Beauregard, T.A., Schein, R.M., Berner, T.F., McKernan, G., Schmeler, M.R., Dicianno, B.E., & DiGiovine, C.P. (2025). Investigation of stakeholder perceptions of the wheelchair service delivery process. Disability and Rehabilitation. Assistive Technology, 1–9. Advance online publication. https://doi.org/10.1080/17483107.2024.2442705

Beauregard, T.A., Chan, S., Parachini, J., Schmeler, M.R., Dicianno, B.E., Schein, R.M., Berner, T.F., & DiGiovine, C.P. Between Uniformity and Uniqueness: Stakeholder Views on Complex Rehabilitation Technology Devices and Services. (Under Review in Assistive Technology).

Chan, S., Parachini, J., Beauregard, T., & DiGiovine, C.P. (2023, July). Stakeholder Satisfaction with Complex Rehabilitation Technology Maintenance and Repairs. Paper Presented at the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). https://www.resna.org/sites/default/files/conference/2023/SeatingandMobility/66_Chan.html

Beauregard, T., DiGiovine, C., Schein, R.M., Berner, T., & McKernan, G. (2023, April 13). Stakeholder Perceptions of the Complex Rehabilitation Technology Service Delivery Process. Paper Presentation at the International Seating Symposium (ISS).

Parachini, J. , Beauregard, T., Chan, S., Schein, R., & DiGiovine, C. (2023, April 13). Satisfaction Survey Analysis of Funding and Procurement of Complex Rehabilitation Technology by State. International Seating Symposium (ISS). 

Chan, S., Beauregard, T., Parachini, J., Schein, R., & DiGiovine, C. (2023, April 13). Survey Results of Stakeholders Perception of the Complex Rehabilitation Technology Service Delivery Process. International Seating Symposium (ISS).

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Sub-Project #4: Common Reasons for Loss During Follow-up: Wheeled Mobility Service Delivery – Quality Assurance Reporting – COMPLETED

Based on the date in the Functional Mobility Assessment – Universal Data Set (FMA-UDS,  team members conducted a retrospective analysis to describe the type and frequency of “not active” responses. Specifically, we were examining the participation rate in the outcome measures portion of the wheelchair service delivery process, as this impacts the quality improvement program. Current barriers and facilitators for participation in the outcome measures step of the service delivery process include acceptability, appropriateness, feasibility, and sustainability.

Dissemination Activities

Stojkov, A. D., Schein, R. M., Berner, T., Beauregard, T., & DiGiovine, C. P. (2024). Common reasons for non-participation during the outcome measurement process: wheeled mobility service delivery quality improvement reporting. Disability and rehabilitation. Assistive technology, 19(4), 1210–1216. https://doi.org/10.1080/17483107.2022.2159077

Stojkov, A. & DiGiovine, C. (2022, April 22). Response Rate for Wheeled Mobility Service Delivery Quality Improvement Reporting. The Ohio State University School of Health & Rehabilitation Sciences Research Day, Columbus, Ohio.

Stojkov, A., Schein, R., Berner, T., & DiGiovine C. (2022, July). Response Rate for Wheeled Mobility Service Delivery Quality Improvement Reporting. Poster Presented at the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).

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Sub-Project #5: Wheelchair Service Delivery Process Policy Review – COMPLETED

One of the four themes that we identified during the scoping review process was the policies associated with the wheelchair service delivery process. The consultants, who reviewed the themes and sub-themes during phase 6 of the scoping review process, indicated that the policies that govern the wheelchair service delivery process had a significant impact on the quality of life of individuals who use complex rehabilitation technology. Therefore, team members decided to investigate the policies that address complex rehabilitation technology. Next literature was reviewed from the scoping review (sub-project 1) that fell in the policies theme. Team members then consulted with subject matter experts on the DRRP team to identify exemplar policies. Thirty peer-review articles, 8 Medicaid policies, 8 private insurance policies, and policies from the Department of Veterans Affairs were identified. Currently a manuscript is being drafted that compares the different policies.

Dissemination Activities

Betz, M., Beauregard, T., Stojkov, A., Schein, R., DiGiovine C. (2022, July). Complex Rehabilitation Technology Policy in the United States. Paper Presented at the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). https://www.resna.org/sites/default/files/conference/2022/PublicPolicyandAdvocacy/103_Betz.html

Other Project Dissemination Activities

**Schmeler, M.R., Schein, R.M. DiGiovine, C., Pramana, G., Busquets, M.P., Zhu, H., & Dicianno, B. (2025). Elements of a Value-Based Approach to Complex Rehabilitation Technology Service, Policy, and Payment. Instructional Course Presented at the 39th International Seating Symposium. Assistive Technology, 37:sup2, S25, https://doi.org/10.1080/10400435.2025.2463822

**Schein, R., Schmeler, M.R., DiGiovine, C.P., & Hibbs, R. (2023, July). Steps Taken into the Assessment and Investigation of an Equitable Wheelchair Coverage Policy. Paper Presented at the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). https://www.resna.org/Events/RESNA-2023-Annual-Conference/Program-by-Track/SM-Seating-and-Mobility-including-CRT/323-steps-taken-into-the-assessment-and-investigation-of-an-equitable-wheelchair-coverage-policy

**Hibbs, R., Schein, R.M., Schmeler, M.R. & DiGiovine, C.P. (2023,November). Towards an Evidence-Based Coverage Policy for Complex Wheelchair and Seating & Mobility Devices. Paper Presented at the Oceania Seating Symposium. Melbourne, Australia

**DiGiovine, C.P. Schmeler, M.R., & Schein, R.M. (2021, July). ‘Overview of NIDILRR DRRP Program: Research on Healthcare Policy and Disability ‘The Right Wheelchair for the Right Person at the Right Time.’ Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).

In collaboration with the R2 project and with invited panelists an ISS Webinar Series: Network ISS. University of Pittsburgh, Network ISS: A Prelude to Pittsburgh (Producer). (2021). Complex Rehabilitation Technology Service Delivery and Clinical Assessment Research: What Happens Behind the Curtain. http://rstce.pitt.edu/RST CE_Webinar/2021/RSTCE_ISS WS2021.04.html

Smith, S., Cutler, K., Betz, M., Frick, B. (2021, November). ‘Research Symposium: Using Technology to Support Mobility ’. OCALICON.

**Schmeler, M.R., DiGiovine, C.P., Hibbs, R., & Schein, R.M. (2022, July). Towards a Contemporary & Equitable Wheelchair Coverage Policy. Instructional Course presented at the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).

**Schmeler, M.R., DiGiovine, C.P., & Schein, R.M. (2023, June). Assessment and Investigation of an Equitable Wheelchair Coverage Policy. Course Accepted to present at Heartland Conference.

**Schmeler, M.R., DiGiovine, C.P., Hibbs, R. & Schein, R.M. (2023, July). Steps Taken into the Assessment and Investigation of an Equitable Wheelchair Coverage Policy. Instructional Course Accepted to present at RESNA.

**  above dissemination activities were paper presentations at conference/symposia in collaboration with other project updates