Practices for Establishing ADA Paratransit Eligibility Assessment Facilities (2015)

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7 functional evaluation or testing of applicants. The substantive eligibility process is not aimed at making a medical or diagnostic determination. While evaluation by a physician (or professionals in rehabilitation or other relevant fields) may be used as part of the process, a diagnosis of a disability is not dispositive. What is needed is a determination of whether, as a practical matter, the individual can use fixed route transit in his or her own circum- stances. That is a transportation decision primarily, not a medical decision (7). TCRP Report 163 (5) examined the types of information and processes used by transit agencies to determine ADA paratransit eligibility. In 2012, a survey was sent to all transit agencies identified in the National Transit Database as pro- viding ADA paratransit service. Information about eligibil- ity determination processes was provided by 127 agencies. As shown in Table 1, most transit agencies (85%) reported using paper applications as part of the process. Most agencies (70%) also indicated obtaining information from professionals familiar with applicants to verify the existence of a disability and to acquire information about specific functional abilities. The use of in-person interviews was reported by just under half (48%) of all agencies. Twenty-seven percent indicated interviewing all applicants, and a subset of these reported that they use in-person interviews in lieu of paper application forms. Twenty-one percent noted that they ask only some applicants to participate in in-person interviews and use the interviews to supplement information obtained from paper application forms. Thirty-seven percent of respondents indicated that in-person functional assessments were used—with 13% reporting that all applicants participate in assessments and 24% using assess- ments only some of the time. “Other” information reported by 10% of agencies included a telephone follow-up with applicants and information from family members or friends. TYPES OF IN-PERSON DETERMINATION PROCESSES Determination processes that only involve reviews of paper applications or information provided by professionals do not require special facilities beyond staff offices. Similarly, processes that use in-person interviews but not functional assessments require no specialized facilities or equipment. The A review of the literature was conducted as a first step in the study. It focused on processes used to determine ADA paratransit eligibility and facilities created to support these processes. Other literature on the regulatory criteria for eligi- bility was identified, but is not included in this report. The literature review included a search of the Transpor- tation Research Information Services (TRIS) database as well as Google searches on ADA paratransit eligibility, ADA paratransit eligibility facilities, and other similar phrases. Reviews were also conducted of trade publications, including articles in Metro Magazine and APTA’s Passenger Transport magazine. Compliance review reports by FTA, which con- tained descriptions of eligibility determination processes, were also reviewed. ELIGIBILITY DETERMINATION INFORMATION Three basic sources of information for making determinations of ADA paratransit eligibility were identified in the literature (1–3). These included: • Information from applicants (application forms or in- person interviews), • Information from professionals familiar with applicant disabilities and functional abilities, and • Information from in-person functional assessments. Prior to the passage of the ADA in 1990 most transit agen- cies used only paper applications, sometimes with additional information from professionals, to determine eligibility for paratransit services (4). Since the creation of ADA paratransit eligibility, which is based on functional ability, there has been increased use of in-person interviews and in-person functional assessments (5, 6). These sources of information are better able to go beyond simple verification of a disability and deter- mine individual functional ability. The U.S.DOT regulation implementing the ADA antici- pated more thorough eligibility determinations and addressed the use of in-person functional assessment. In discussing eligibility determination and the general requirement for the process to not be burdensome, the interpretive section of the regulation states: The process may include functional criteria related to the sub- stantive eligibility criteria of §37.123 and, where appropriate, chapter two LITERATURE REVIEW

8 study therefore focused on processes that included in-person interviews and functional assessments. TCRP Synthesis 30 includes four case studies that describe eligibility determination processes used by transit agencies in Los Angeles (California), Pittsburgh (Pennsylvania), Las Vegas (Nevada), and San Mateo County (California) (4). Compliance review reports conducted by FTA since 2000 and posted on their website (http://www.fta.dot.gov/civilrights/ 12875_3899.html) also contain descriptions of the processes used by agencies to determine ADA paratransit eligibility. A study conducted in 2008 by Valley Metro in Phoenix (Arizona) also includes detailed descriptions of the eligibility deter- mination processes used in Salt Lake City (Utah), Las Vegas (Nevada), Los Angeles (California), and Orange County (California) (7). The literature suggests the following two general approaches to the use of in-person interviews and functional assessments. Interviews with Separate Physical, Cognitive, and Sensory Functional Assessments This first approach is based on a model developed by Easter Seals Project ACTION (ESPA), and was developed in 2003 with the input of seven transit agencies that had significant experience conducting in-person interviews and functional assessments. It was updated by ESPA in 2014 (8). Applicants first participate in the in-person interview. Determinations are made based on information from the interview when possible. If additional information is needed, one or more functional assessments are conducted. Separate functional assessments are used depending on the particular disabilities of the applicants. Physical functional assessments typically begin with a general assessment of balance and gait. Tools such as the Tinetti Balance and Gait Test, or the Get Up and Go Test, are used. This general assessment of balance and gait is used to determine if a more extensive physical func- tional assessment is appropriate. If appropriate, the physical assessment continues with a walk along a predetermined route that includes features such as curbs and curb ramps, street crossings, hills, cross-slopes, and various surfaces. Assess- ments are typically conducted outdoors in the real environ- ment. Back-up indoor routes are used when travel outdoors is not appropriate owing to severe weather. The ESPA model and guidance suggest that physical functional assessments be con- ducted by physical therapists (PTs), occupational therapists (OTs), or professionals with similar competencies. Assessments of cognitive abilities are conducted using one or more validated tests and tools. These include the Functional Assessment of Cognitive Transit Skills (FACTS) test or the Mini Mental Status Exam (MMSE). FACTS is a simulation of travel by fixed-route transit that was developed and validated for assessing applicants with intellectual dis- abilities. The MMSE is a test of memory, orientation, and counting skills that is often used to screen for dementia. Individuals trained in proper administration and scoring can conduct these tests. The ESPA model suggests that assessments of applicants who are legally blind be performed by orientation and mobil- ity (O&M) specialists. The assessment involves an interview with such a specialist and a walk in the real environment if appropriate. Applicants with low vision, but who are not legally blind, can be asked to participate in physical functional assessments conducted by PTs or OTs. As an alternative to functional assessments, the ESPA model suggests that the eligibility of applicants with vision impairments be based on information obtained from applicants and professionals famil- iar with them. Source: TCRP Report 163 (5). Sources of Information Total % of Total Respondents Paper applications completed by applicants or others on their behalf 115 85% Information from professionals familiar with applicants 95 70% In-person interviews of all applicants 37 27% In-person interviews of some applicants 28 21% In-person functional assessments of all applicants 18 13% In-person functional assessments of some applicants 33 24% Other 13 10% Total Respondents 127 TABLE 1 TYPES OF INFORMATION AND PROCESSES USED TO MAKE ADA PARATRANSIT ELIGIBILITY DETERMINATIONS, 2012 SURVEY OF TRANSIT AGENCIES

9 Interviews with Combined Assessments of General Mobility This approach also begins with an in-person interview. If information gathered in the interview is not sufficient to make a determination of eligibility, it is followed by an outdoor or indoor walk to assess general mobility. Physical, cognitive, and sensory functional abilities are all observed in this one assessment. Features such as curbs and curb ramps, slopes, street crossings, and rough or unstable surfaces are included along the walk to assess physical functional ability. Cognitive functional ability is assessed by asking applicants to follow directions to complete the walk, demonstrate safe street cross- ing skills, count change to simulate paying a fare, reading and understanding bus schedules, or recalling information provided during the walk. Sensory abilities are assessed by having applicants read street signs or recognize landmarks as they navigate the route. In some processes, outdoor walks in the real environment are used whenever possible. Indoor routes are developed for use when severe weather precludes outdoor travel. Other processes use elaborate indoor facilities, which are designed to simulate travel in the community. Ramps of vari- ous slopes are used to simulate hills, and mock-ups of street crossings and traffic controls are often included. Full-sized, fixed-route buses with lifts or ramps or mock-ups of buses are also often included within the facility. Curbs, curb ramps, and rough or unstable surfaces (e.g., artificial grass or gravel) are features along the indoor walk. Various types of professionals are used to administer com- bined assessments. Some transit agencies use PTs and OTs; others use nurses, social workers, or other social service or medical professionals. Processes similar to this are described in FTA compliance reviews and studies of industry practices (2, 7, 9). ELIGIBILITY DETERMINATION PROTOCOLS, FACILITIES, AND EQUIPMENT Relatively little literature exists that describes the protocols, facilities, and equipment used in ADA paratransit eligibility determinations. The most extensive information is contained in the ESPA guidance for the model process described previ- ously. Some information is also available for the standardized tests, such as the Tinetti, Get Up and Go, FACTS, and MMSE, which are sometimes used as part of the process to determine ADA paratransit eligibility. Physical Functional Assessments— ESPA Model Process The ESPA guidance contains detailed instructions for con- ducting physical functional assessments (10). The suggested assessment has 17 different elements. It is recommended that the assessment be conducted outdoors in the real environment whenever possible. It is important that back-up indoor facili- ties be available when severe weather precludes an outdoor assessment. Table 2 describes each element of the ESPA suggested physical functional assessment, with the outdoor route fea- tures needed to conduct the assessment in the real environment listed. Back-up indoor facilities are also provided. Special equipment and tools are also noted. The assessment begins with the Tinetti Balance and Gait test, which is described in the following section. Vital signs (pulse, blood pressure, and blood oxygen level) can then be recorded before and during the walk, although this is an optional part of the process. Based on these first two elements, an outdoor (preferred) or indoor (back-up) walk along a pre- determined route is then taken. Observations made along the route help to determine the ability to get to and from transit stops and stations include the ability to: • Walk up to 0.5 mile, • Go up and down curbs and curb ramps, • Negotiate various slopes and surfaces, and • Cross streets with and without traffic controls. Several abilities related to boarding and riding transit services are then assessed, including: • Navigating flights of stairs (if there are nonaccessible rail stations), • Using elevators (if there are accessible rail stations), • Navigating bus stairs (if there are inaccessible buses still in the fleet), • Boarding buses by means of lifts or ramps, • Paying fares, • Getting to and from securement areas on vehicles, • Standing on moving vehicles, and • Using the Stop Request system (for bus services). These abilities can be assessed by incorporating a trip on the bus or rail system into the outdoor walk or this can be done by using mock-ups or back-up indoor features. Tinetti Balance and Gait Test This common clinical test for assessing static and dynamic balance is suggested as part of the ESPA physical functional assessment. It can be used to assess an applicant’s risk of falling while standing on a moving vehicle or walking to and from transit stops and stations. It is also used to determine if full physical functional assessments are appropriate. If applicants are determined to be high fall risks, eligibility is typically granted without further assessment.

10 Assessment Element Outdoor Route Features (preferred) Indoor Facilities (back-up) Other Equipment Tinetti Balance & Gait Test (see separate description) Not applicable Armless and non-rolling chair; walking path with centerline and 12 in. marked variations None Measure Vital Signs (optional) Not applicable Private space Oximeter; blood pressure cuff and watch Distance/Endurance ½ mile (2,640 ft) route with markers every 330 ft; places to rest along the way Hallways or open spaces to simulate ½ mile walk with markers every 330 ft and places to rest Watch to record time for each 330 ft segment Curbs and Curb Ramps Two 6-in. curbs and two curb-ramps along the route (observe going up and down) Mock-ups of 6-in. curb and curb ramp None Different Surfaces Areas along route with as many of the following as possible: broken/uneven pavement, grass, gravel, loose dirt, sand Simulated broken/uneven pavement; artificial grass; gravel, loose dirt, sand None Slopes 1:16 slope for 30 ft; 1:12 slope for 30 ft; 1:8 slope for 16 ft; 5% cross-slope Ramps and walkways with these slopes and distances None Street Crossing One controlled and one uncontrolled intersection along route Simulated street crossing with controls None Stairs (systems with rail service) Rail station with stairs (or see Indoor Back-up) Flight of stairs Elevators (systems with rail service) Rail station with elevator (or see Indoor Back-up) Elevator None Bus Stairs (only if buses not 100% accessible) Spare bus or bus trip on route (or see Indoor Back-up) Mock-up of bus stairs (three 12 in. stairs) None Bus Lifts (if lifts used in fleet) Spare bus or bus trip on route (or see Indoor Back-up) Spare bus or bus lift mock-up None Bus Ramps (if ramps used in fleet) Spare bus or bus trip on route (or see Indoor Back-up) Spare bus or bus ramp mock-up None Pay Fare (both bus and rail, if applicable) Rail station/bus on route (or see Indoor Back-up) Farebox and/or fare machines Fare media Get to/from Securement Area Spare bus or bus trip on route (or see Indoor back-up) Spare bus or mock-up of entry to securement area None Stand on Moving Vehicle Bus or rail trip on route (or see Indoor Back-up) Tinetti Balance & Gait Test (see above) None Signal for Destination Bus or rail trip on route(or see Indoor Back-up) Actual or mock-up of stop signaling system None Source: Determining ADA Paratransit Eligibility: An Approach, Guidance and Training Materials (2). TABLE 2 FACILITIES AND EQUIPMENT REQUIRED FOR ESPA PHYSICAL FUNCTIONAL ASSESSMENT Minimal facilities and equipment are required to administer the Tinetti test. A nonrolling chair without armrests is needed. A walking path in a room or along a hallway is also needed. The walking path should have a marked centerline as well as markings on either side of the centerline. An ideal walkway includes 12 in. by 12 in. nonslip floor tiles. The assessment begins by observing the applicant’s posture while seated. The applicant’s ability to rise and be reseated without using her/his arms for support is assessed. Stand- ing balance, balance and recovery when nudged, and balance turning around with eyes closed, is then assessed. A short walk, turn, and return is then observed to assess gait, including step symmetry, step continuity, body sway, walking stance, and deviation from the walking path. Specific points (0, 1, 2) are given based on observations. A balance score, gait score, and total score are then tabulated. Instructions for administering the Tinetti Balance and Gait test are available online from a number of sources (10). Timed Get Up and Go Test An alternative to the Tinetti test is the Timed Get Up and Go test, or the more comprehensive Get Up and Go test. Like the Tinetti test, it requires limited facilities and equipment— again only a nonrolling, armless chair and a short walking path. The test has two parts; the first part involves timing how long it takes the applicant to stand, walk three meters, turn around,

11 walk back, and be seated. If applicants are able to do this without difficulty or unsteadiness within a prescribed time- frame, no further observations are needed. If unsteadiness is observed or the task takes longer than prescribed, additional tests and observations are made. These include tests and observations very similar to the Tinetti test (i.e., balance with eyes closed, balance and recovery when nudged). Instructions for administering the Timed Get Up and Go test or the Get Up and Go test are available from a number of sources online (11). Functional Assessment of Cognitive Transit Skills (FACTS) Test The FACTS test was developed for ESPA to provide a low- cost, reliable tool for assessing the independent travel abilities of persons with intellectual disabilities (12). FACTS incorpo- rates the features of several standardized cognitive tests into a simulated bus trip. The test begins with simple skills, such as recognizing bus stop signs, and progresses to more difficult skills, such as remembering and picking out the correct bus and route. The test starts with a trip requiring a single bus and progresses to a trip requiring two buses and a transfer. Appli- cants must also complete a wayfinding exercise along a route with four landmarks. Several parts of the test assess abilities to problem solve and handle unexpected situations. Judgment, safety skills, and appropriate reactions to strangers are also assessed. The test is hierarchical—it is terminated when the appli- cant’s abilities are exceeded. It also uses a train-test-train design to determine current abilities as well as potential to learn. If applicants respond incorrectly to a specific item, the tester reinstructs and tests a second time. If the applicants respond correctly with reinstruction, their score is reduced. A rigorous validation process was used to validate the test (13). It is the only test identified in the literature, specific to using fixed-route transit, which has been validated to be an accurate predictor of abilities. The test can be administered by trained nonprofessionals, and guidelines for administering the test are available free of charge from ESPA. Some equipment and props are needed to administer FACTS. This includes specific photographs of signs, buses, people, and street scenes. Nine large posters and a space at least 800 ft2 in size is also needed for the wayfinding exercise. Posters for the wayfinding portion of the test must be set up to meet very specific guidelines. Two set-up options are specified and are shown in Appendix C. Detailed instructions for creating the needed photographs and posters, and for setting up the posters, are available from ESPA. Mini Mental Status Exam (MMSE) The Mini Mental Status Exam (MMSE) is a brief test that is widely used to screen for memory-related issues, particularly dementia. The test includes questions that assess orientation to time and place, the ability to remember and repeat words, basic counting and arithmetic skills, and basic motor skills (by copying simple drawings). The test takes only about 10 minutes to administer and does not require any special props or facilities. Instructions for administering the MMSE are available from a number of sources online (14). Facility Costs TCRP Report 163 provides some information about the cost of building eligibility assessment centers (5). Costs are reported to vary significantly from system to system. The typical cost of setting up an assessment center is noted as being from $50,000 to $100,000. The report notes, though, that docu- mented costs have ranged from a low of about $15,000 to as much as $350,000. Set-up and build-out cost depends on the size of the facility needed and whether extensive testing is done indoors versus in the real environment. Ongoing facility costs depend on the size of the facility, local commercial rents, and whether a new facility is needed. The report notes that assessment centers range in size from 2,000 ft2 to 15,000 ft2. Different rents, utility costs, and mainte- nance costs vary significantly based on the size of the facility. DETERMINATION OUTCOMES The literature suggests that processes that use in-person inter- views and functional assessments have more thorough and accurate eligibility determination outcomes than processes that rely solely on paper applications and/or information from professionals familiar with applicants (1, 4, 5, 7, 15). These studies have found that, on average, transit agencies that rely on paper applications find 88% of applicants unconditionally eligible, 11% conditionally eligible, and 1% eligible on a tem- porary basis. Transit agencies that include in-person interviews and functional assessments in the process find, on average, approximately 63% of applicants unconditionally eligible, 28% conditionally eligible, and 9% eligible on a temporary basis. Information from these studies is presented in Table 3. The literature also suggests that there is significant “self- selection” in processes that use in-person interviews and func- tional assessments (4). Many people who initially express interest in applying for ADA paratransit eligibility do not

12 complete the process when asked to appear in-person for inter- views and functional assessments. Finally, the literature also suggests that with more thor- ough determinations, particularly better identification of spe- cific and measurable conditions of eligibility, it is possible to implement trip-by-trip eligibility (determining if certain trips requested by conditionally eligible riders can be made by fixed- route transit) (5). A review of trip-by-trip eligibility deter- minations by KC Metro in Seattle (Washington) found that about 7.5% of trips by conditionally eligible riders are made on fixed-route transit rather than ADA paratransit. A review of trip eligibility by ACCESS in Pittsburgh (Pennsylvania) found that 15% of trips by conditionally eligible riders are made on fixed-route transit rather than on ADA paratransit. The impacts of more rigorous eligibility determinations on ADA paratransit demand were studied and documented in TCRP Report 119 (16). An aggregate statistical model based on data from 28 sample systems was developed to improve the estimation of ADA paratransit demand. This model sug- gested a demand elasticity of -0.29 for the percentage of applicants found “conditionally” eligible (i.e., a 1% higher percent of applicants found conditionally eligible compared with the mean value of 21% corresponds to a 0.29% decrease in demand). It also suggested that systems that do trip-by- trip eligibility screening experience significantly lower ADA paratransit demand than systems that do not do trip screening. IMPORTANCE OF THOROUGH ADA PARATRANSIT ELIGIBILITY DETERMINATIONS As the paratransit requirements of the ADA have been imple- mented, the demand for and cost of this service has risen. Within the defined service area and hours of operation ADA paratransit service must be provided for all trips that cannot be made by eligible individuals on fixed-route transit. All trip purposes must be served and capacity cannot be constrained. Several papers and reports have noted the importance of making thorough determinations of ADA paratransit eligi- bility (17–19). Providing ADA paratransit only for people who meet the regulatory eligibility requirements and trips that they cannot make on fixed-route transit is an impor- tant part of being able to sustain appropriate and compliant services. IMPLEMENTATION OF IN-PERSON ELIGIBILITY DETERMINATION PROCESSES Finally, the literature review identified a few papers, articles, and case studies describing the implementation of in-person eligibility processes and the opening of eligibility centers. This included an online case study for the TriMet process in Portland (Oregon), three articles about the new facility and pro- cess implemented by Valley Metro in Phoenix (Arizona), and one paper describing the process implemented by SamTrans in San Carlos, California (20–24). Type of Process Determination Outcomes Unconditional Conditional Temporary Not eligible Paper Applications with Professional Verification 88% 11% 1% 7% In-Person Interviews and Functional Assessments 63% Range: 38%–75% 28% Range: 8%–54% 9% Range: 2%–17% 7% Range: 1%–23% Source: TCRP Report 163 (5). TABLE 3 REPORTED ADA PARATRANSIT ELIGIBILITY DETERMINATION OUTCOMES FOR PAPER VERSUS IN-PERSON DETERMINATION PROCESSES