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.
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 12-20” widths and 12-20” 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
FORMS
Special Needs Equipment Requisition
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 12-30” widths and 12-22” 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
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
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 12-22” widths and 12-20” 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
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
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 10-20” widths and 10-20” 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.
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
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 16-20” widths and 16-20” 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
FORMS
Special Needs Equipment Requisition
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 14-24” widths and 14-20” depths; Jay 2 Plus 20-26” widths and 18-22” depths
Jay 2 weight capacity is 250 lbs. Jay 2 Plus weight capacity is 650 lbs.
Cushion weighs approximately 7 lbs.
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
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 14-24” widths and 14-20” 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
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
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 14-20” widths and 16-20” depths Weight capacity is 250 lbs.
Cushion weighs approximately 7 lbs.
ELIGIBILITY
Must meet general eligibility requirements
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
JAY EASY CUSHION
November 15, 2015
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 14-24” widths and 14-24” 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 Photo Unavailable
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 12-28” widths and 12-20” 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
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
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 12-20” widths and 12-20” 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
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
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 15-20” widths and 15-20” 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
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
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 14-20” widths and 14-18” 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
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
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 14-20” widths and 16-20” depths – sizes larger than 20”x20” are not available
Vector 10 available in 10-20” widths and 10-20” 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.
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