Attachment 3 FEMA HHS Paratransit Resource Utilization Guide.pdf

Contract Number Attachment 3

Attachment 3

FEMA/HHS PARATRANSIT RESOURCE UTILIZATION GUIDE

Guidance to Local/State Government and Emergency Management Agencies on How to Appropriately Assess the Need for Paratransit Transportation during Federally Declared

Disasters

Purpose

The purpose of this document is to provide guidance to state and local jurisdictions to identify patients and disabled paratransit passengers who will require transportation assistance from FEMA-contracted ambulance and paratransit resources in the event of a Federally declared disaster when state and local resources are overwhelmed, depleted or unavailable.

Administration

The National Response Framework (NRF) identifies Emergency Support Function (ESF) #8 -- Public Health and Medical Services Annex -- as the mechanism for coordinated Federal assistance to supplement State, local, and tribal resources in response to the medical care needs for potential or actual disasters and/or during a developing potential health and medical situation.

ESF #8 provides supplemental assistance to State, local, and tribal governments in identifying and meeting the public health and medical needs of victims of disasters. The U.S. Dept. of Health and Human Services (HHS) is identified as both the coordinator and lead agency for the Federal Government on public health and medical services.

FEMA resources coordinated through ESF#8 health and medical services will facilitate transportation for individuals with disabilities, individuals in nursing homes and assisted living facilities, and for homebound individuals impacted by an incident or disaster and other individuals necessary. These transportation services are intended for people with severe disabilities who cannot arrange their own transportation and cannot travel by conventional means.

Utilization

Effective use of paratransit resources will require an understanding of the different types of available vehicles as well as category limitations based on passenger mobility, disability and condition acuity. These limitations will determine whether individuals can be safely transported by ambulance (stretcher), paratransit vehicle or by more abundant general population conveyance. Passengers should be initially triaged into three major categories: A) Ambulance, B) Paratransit and C) General. Once passengers are categorized, Incident Management Team leaders will attempt to do the greatest good for the greatest number of people by matching passenger needs with the various types of transportation resources that are available.

Paratransit Transportation Defined

Paratransit transportation means comparable transportation services required by the Americans with Disabilities Act (ADA) for people with disabilities who are unable to use fixed route transportation systems.i Paratransit transportation is “demand responsive” vs. “fixed route”. A fixed route transportation system is one that operates along a prescribed route according to a fixed schedule. Fixed route systems typically include city bus systems, commuter and over-the-road bus systems, subways, light rail systems, and intercity rail transportation. Demand response i ADA. 49CFR37. Subpart A, Section 37.3, page 415.

transportation includes taxis, limousine services, van services, wheelchair vans, mini-buses, charter buses, and shuttle bus systems.

Disabilities Defined

The Americans with Disabilities Act of 1990 (ADA) includes a legal definition of disability, in part defining a person with a disability as one who has “a physical or mental impairment that substantially limits one or more major life activities.ii

U.S. Census Disability Categories

The U.S. Census Bureau uses two overall measures of disability status – non-severe disability and severe disability. Disabilities are further classified in one of three domains: communication, physical or mental iii.

Definitions of a disability in a communication, mental, or physical domain.

People 15 and older are identified as having a disability in a communication domain if they meet any of the following criteria:

1. Had difficulty seeing, hearing, or speaking

2. Blind or deaf

3. Identified one or more related conditions as the cause of a reported activity limitation (blindness or vision problem, deafness or hearing problem, or speech disorder)

People 15 and older are identified as having a disability in a physical domain if they meet any of the following criteria:

1. Used a wheelchair, cane, crutches, or walker

2. Had difficulty with one or more functional activities (walking a quarter of a mile, climbing a flight of stairs, lifting something as heavy as a 10 pound bag of groceries, grasping objects, getting in or out of bed)

3. Identified one or more related conditions as the cause of a reported activity limitation (arthritis or rheumatism; back or spine problems; broken bone or fracture; cancer; cerebral palsy; diabetes; epilepsy; head or spinal cord injury;

heart trouble or hardening of arteries; hernia or rupture; high blood pressure;

kidney problems; lung or respiratory problems; missing legs, arms, feet, hands, or fingers; paralysis; stiffness or deformity of legs, arms, feet or hands;

stomach/digestive problems; stroke; thyroid problems; or tumor, cyst, or growth) ii See Public Law 101-336 at www.usdoj.gov iii US Census Bureau Americans with Disabilities: 2002 Issued May 2006. Page 2. Figure 1.

http://www.usdoj.gov/

Severe Disabilities

People with severe disabilities are more likely to require paratransit transportation assistance during a disaster. A person has a severe disability if they:

• Used a wheelchair, a cane, crutches or a walker

• Unable to perform one or more of these functional activities: lifting/carrying, using stairs, walking, or grasping small objects

• Unable to perform one or more activities of daily living (ADLs): getting around inside the home, getting in or out of bed or a chair, bathing, dressing, eating, and toileting

• Have one or more specified conditions: mental retardation or another developmental disability, or Alzheimer’s disease, autism, cerebral palsy

• Have another mental condition that seriously interferes with everyday activities

Paratransit Transportation Eligibility

Paratransit transportation should be restricted to persons with severe disabilities, i.e., individuals with physical or mental impairments that substantially limit one or more of the major life activities such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, and breathing.

Passenger Categorization

Although Hospitals, Nursing Homes, Personal Care Homes, Assisted Living and Hospice Facilities may have pre-existing evacuation plans, a large disaster may require the use of additional federal supplemental resources. Since these types of facilities have a diverse range of sub-specialties, local coordination is essential for emergency managers to deploy the right mix of transportation resources. There are also people considered to have special needs who reside in non-institutional settings that may require the use of paratransit resources in times of emergency.

These special needs people can be those who suffer from poor health to those with severe

People 15 and older are identified as having a disability in a mental domain if they meet any of the following criteria:

1. Had one or more specified conditions (a learning disability, mental retardation or another developmental disability, Alzheimer’s disease, or some other type of mental or emotional condition)

2. Had any other mental or emotional condition that seriously interfered with everyday activities (frequently depressed or anxious, trouble getting along with others, trouble concentrating, or trouble coping with day-to-day stress)

3. Had difficulty managing money/bills

4. Identified one or more related conditions as the cause of a reported activity limitation (attention deficit hyperactivity disorder; autism; learning disability;

mental or emotional problems; mental retardation; or senility, dementia, or Alzheimer’s) disabilities. Also, a person may be considered to have special needs due to a disability but their disability may not impact their mobility. These people may utilize conventional transportation means.

To best serve the transportation needs of people both in institutionalized as well as non-institutionalized settings during periods of disaster they should initially triaged into one of the three major transportation categories:

• Category A: Ambulance – Advanced Life Support (ALS)iv or Basic Life Support (BLS)v

• Category B: Paratransit – ADA Demand response transportationvi

• Category C: Conventional Transportation, e.g., car, van, non ADA fixed routevii public transportation

The following will provide guidelines to determine what particular category an individual should be classified in.

Category A: Passengers Requiring an Ambulance

Category A passengers require recurring professional medical care, special equipment and/or continual medical surveillance. These patients should meet the HHS/CMS Medical Necessity requirements: “The patient’s condition is such that use of any other method of transportation is contraindicated and transportation other than ambulance could not be used without endangering the individual’s health.”viii Category A Passengers require an ambulance and should not be transported via paratransit or conventional transport vehicles.

Examples of ambulance passengers include, but are not limited to:

• Ventilator dependent patients;

• Persons requiring continuous IV therapy (pain control, or hydration);

• Oxygen dependent (whom require more O2 than typical self-sufficient container);

• Individuals who must have access to a constant power source for suction pumps, or any other bio-medical equipment usage.

iv ALS patients require procedures that are, in accordance with State and local laws, beyond the scope of authority of an EMT- Basic.

v BLS means transportation by ground ambulance vehicle and medically necessary supplies and services, plus the provision of BLS ambulance service. The ambulance must be staffed by an individual who is qualified in accordance with State and local laws as an EMT-Basic.

vi Demand response transportation includes taxis, limousine services, van services, wheelchair vans, mini-buses, charter buses, and shuttle bus systems.

vii Fixed route systems typically include city bus systems, commuter and over-the-road bus systems, subways, light rail systems, and intercity rail transportation.

viii HHS/CMS Publication 100-2. Medicare Benefit Policy Manual. Chapter 10 – Ambulance Services. B3-2120.2.A, A3-3114.B, HO-236.2. Rev. 10-01-03.

• Pregnant women who are experiencing contractions and/or women who are in the eighth month of gestation or beyond;

• Persons who report chest pain or have experienced chest pain in the last 24 hours;

• Persons with shortness of breath;

• Persons with communicable diseases which require isolation;

• Individuals with uncontrollable or violent behavior due to a physical or mental illness;

• Comatose patients;

• Persons who are bed bound;

• Persons who may fall out of a seat due to the lack of trunk control;

• Persons who do not have the ability to sit for long periods of time;

• Persons who cannot be safely transported by any other means;

• Others requiring the intensity of services provided at a hospital or skilled nursing facility;

Category B: Passengers requiring Paratransit Vehicles

Persons in this category have pre-existing conditions that make it unsafe for them to travel by standard fixed route public conveyance but are not disabled or ill enough to require transport by ambulance stretcher. They may require some medical surveillance from their own caregiver and/or special assistance. They may originate from an institution such as a hospital or nursing home or a non-institutionalized setting such as a residential dwelling. They are individuals whose age, mobility, functional and/or medical disability make them particularly vulnerable and at risk in disaster situations. Passengers who cannot sit safely in a standard vehicle seat or wheelchair should be transported by stretcher in an ambulance.

Examples of paratransit passengers include but are not limited to:

• Individuals with severely reduced mobility requiring a wheelchair, cane, crutches or walker;

• Medically impaired individuals who are able to maintain activities of daily living with special assistance from their caregiver;

• Persons who are unable to perform one or more of these functional activities:

lifting/carrying, using stairs, walking, or grasping small objects

• Persons unable to perform one or more activities of daily living (ADLs): getting around inside the home, getting in or out of bed or a chair, bathing, dressing, eating, and toileting

• Persons with one or more specified conditions: mental retardation, Alzheimer’s, autism, cerebral palsy, severe dementia, or another developmental disability;

• Persons with another mental condition that seriously interferes with everyday activities who are non-violent;

• Persons with chronic respiratory conditions that may require low-flow supplemental oxygen that is self-administered (passengers must supply their own oxygen).

Paratransit vehicles are staffed by non-medically trained drivers whose primary responsibility is safe vehicle operation. Medical personnel are not provided on paratransit vehicles, therefore personal caregivers from the facility, home, or other trained medical professional must accompany the passengers during transport. A maximum caregiver to patient ratio of 1 to 5 is recommended for disaster situations. This ratio may be decreased or increased as required due to the level of disability of the passengers. Caregivers must anticipate the potential for the health status of passengers to deteriorate or change rapidly due to stress, environmental conditions, etc.

Category C: Passengers capable of being transported by conventional means

This category includes individuals who are independent prior to the disaster or emergency with limited if any impairment in mobility. Some of these individuals may have pre-existing health problems that do not impede activities of daily living and do not require the constant attendance of a caregiver. These individuals should be able to function independently for an eight hour period of transport.

Examples include but are not limited to:

• Persons who could be safely transported by conventional fixed route means of conveyance;

• Persons with epilepsy (if controlled);

• Mild muscular dystrophy;

• Diabetics who are stable and do not require insulin injections;

• Persons with hemophilia;

• Persons with prosthesis;

• Vision or hearing impaired;

• Asthmatics who have their own medication;

• Persons with speech impediments;

• Language/cultural barriers.

1. Paratransit Vehicle Types

Paratransit vehicle types are based on the capacity and functionality of the response vehicle.

Each vehicle type has certain attributes that would make it preferable over another type of vehicle as it pertains to passenger types. It is the responsibility of disaster managers to become familiar with the different capabilities of various vehicles in order to assemble the best task force to complete a particular mission. In mass evacuation situations, it is important to note that there is no one particular paratransit vehicle type that should be used. The goal of an effective paratransit evacuation is to match passenger types with the most appropriate vehicle types.

Six types of vehicles that may participate in a paratransit disaster response

Type 1 - Sedan/Minivan up to 7 passengers Type 2 - Minibus 8-26 passenger Type 3 - Bus greater than 26 passengers Type 4 - Wheelchair Van 1-9 passenger Type 5 - ADA Minibus 10-26 passenger (wheelchair accessible) Type 6 - ADA Bus > 26 passenger (wheelchair accessible)

Additional Vehicle Information

Passengers are matched by the mode of ground transportation required for their specific condition.

• Paratransit Vehicles Types 1, 2, 3 - patients can ambulate with or without assistance and have the ability to sit in a taxi, van, or bus without requiring a high level of assistance or equipment (other than self-administered personal portable oxygen supply).

• Paratransit Vehicles Types 4, 5, 6 - patients are either ambulatory with assistance or wheelchair-bound and require a mechanical lift to get into a vehicle and can safely sit upright or in a wheelchair which can be secured. No other special medical equipment is required (other than self-administered personal portable oxygen supply). To safely utilize paratransit lifts wheelchairs cannot exceed 30 inches in width nor 48 inches in length measured two inches above the ground and cannot weigh more than 600 pounds when occupied.

• Ambulance - passengers or patients have a condition that prohibits them from being transported safely by any means other than in an ambulance or lying on a stretcher. They may also require special medical equipment during transport, e.g., acute supplemental high-flow oxygen (non-portable), ventilator, suction devices, or other biomedical equipment.

The foreknowledge of the number of and mix of passengers will aid disaster managers in determining the amount and types of vehicles to deploy.

The passengers and caregivers must be ready to depart when the transportation arrives.

Passengers are allowed to bring a minimal amount (2 bags) of personal baggage onto response vehicles. It is important for paratransit passengers not to stow or separate themselves from medications or medical equipment that may be needed.

Request for Paratransit Transportation

The following information is essential to determine an appropriate number and mix of paratransit vehicles to deploy for any disaster operation:

Total Number of Passengers to be transported (Category B passengers as well as caregivers)

Operational time frame Origin (location, number of passengers to be picked-up) Destination (locations, distance, estimated travel time). Host locations should pre-approved and confirmed.

Ambulatory status (wheelchair bound vs. ambulatory or ambulatory with assistance) Number and types of service animals Other special needs, e.g., home oxygen, durable medical equipment, etc.