​When caring for bariatric residents, multiple costs factors must be considered prior to accepting the resident for admission. The facility must be able to provide reasonable care for the bariatric resident in the same manner as other residents. One of the costs to consider is transporting the resident to appointments and other off-site visits. Safe options are expensive and not always available. This is not a one-size fits all approach. Some bariatric residents may do fine in a wheelchair and the facility van. Some residents may require extensive planning and an ambulance ride for a specialist visit.

Therefore, prior to admitting this resident, the need for specialist visits and other appointments (dialysis, wound care clinic, psychiatric services, support groups, and other services) should be carefully considered. Each resident will require individualized assessment to assure the service planned will be appropriate and cost effective.

In reviewing the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities,¹ it should be noted there are multiple regulations from the Centers for Medicare & Medicaid Services (CMS) regarding appointments and transportation. Two of the most basic requirements are: F685, which indicates the facility is required to assist the resident in gaining access to vision and hearing services by arranging for transportation, and F790, which states the facility must arrange for transportation to and from dental services if necessary.

This article will review transportation options and how to evaluate cost effectiveness.

Transport Companies

Many communities have wheelchair transport companies that supply transportation for people with disabilities to appointments (medical or otherwise). These companies charge varying fees. Some offer an assistant that attends the appointment with the resident. Others only offer transportation to the address, and facility staff or resident families will be required to assist the resident at the appointment. The cost of these services varies widely from community to community. 

The cost of this service can be as little as $95 per visit and up to $500. Insurance may reimburse some of the cost depending on the type of insurance the resident has. In some instances, the facility may be responsible for the entire cost.

Not all communities have appropriate transport companies. Many areas that are more rural may have medical transport companies, however, not all companies are capable of transporting bariatric clients. The facility must evaluate carefully the company that will be used to ensure the resident can be transported safely prior to planning the use of a company.

Items to consider:

• Do the personnel have training in safely moving bariatric clients?
• Is the vehicle designed to transport bariatric clients? (Doors open wide enough, ramp or lift can support the weight, there is room in the van for resident and chair, etc.)
• Will the size of the vehicle accommodate a larger wheelchair or transport chair?
• Are the tie-down straps for wheelchair/transport chair appropriate for larger weights?
• How will the transport personnel communicate their concerns to the facility?
• Will facility staff/families be expected to accompany the resident?
• Is the office/clinic wheelchair accessible? Is there a larger door at the office/clinic?
• Will the resident be expected to transfer from wheelchair to exam table?

Basic Ambulance Services

Ambulance services that provide basic life support are available in most communities. The service provided and the cost for that service will vary widely depending on locale and type of provider. A review of publications regarding basic ambulance transportation reveals an ambulance ride cost of around $950.² Some of this cost may be reimbursed by insurance. However, a recent study by the University of Michigan found that 72 percent of clients received billing that was not expected related to insurance denials.

It must be considered that not all basic services will be able to transport bariatric clients. If the services are appropriate, the cost may be higher. It would behoove the facility to develop a contract for provision of services prior to the need for transportation. 

Items to consider:

• Are the personnel trained in bariatric needs including transferring to and from stretcher?
• Is there sufficient room in the vehicle for this resident and their equipment? (door wide enough, stretcher strong enough and wide enough, etc.)
• Will facility staff or family be expected to accompany/meet the resident?
• What will occur if a more pressing emergent transport need occurs? (Will the ambulance place the resident’s transportation needs at a lower priority and thus put the resident at risk of remaining at the clinic/office with no return transportation?)
• How will the ambulance personnel communicate their concerns to the facility?

Family and Other Responsible Parties

Some facilities request that, as a condition of admission, families or responsible parties transport the resident to appointments. While this may be a viable option in some cases, there are variables that must be considered including family availability and comfort in performing the transportation task, resident preference, need for staff to accompany resident, and resident safety with transportation arrangement. Again, an individualized assessment is required.

The family may be very familiar and comfortable in transporting the resident to appointments. If this is not the case or if the care team has concerns regarding safe transportation, further evaluation is indicated. The need for therapy evaluation of resident and family abilities to transfer to and from vehicle may be indicated. Having the resident/family sign out of the facility should be considered.

Facility Van

Many providers now have vans that are facility owned. These vans are normally equipped to accommodate wheelchairs. However, not all wheelchairs are made to travel in vans. Bariatric wheelchairs bring yet another challenge.

Items to consider:

• Is the lift/ramp able to address the weight requirements?
• Are tie-down straps appropriate for weight and size?
• Is the door wide enough to allow access?
• Will the resident be required to transfer from wheelchair to exam table?
• Will extra staff be needed for safe transport?
• Will the office/clinic be wheelchair accessible?
• How will staff communicate their concerns?

Transport Chairs

Transport chairs used with facility vans may be the solution to many of the issues raised. There are chairs made for the specific purpose of transporting bariatric residents. These chairs have designated weight limits, are designed for outdoor and indoor use, and may serve as a stretcher as well as a chair.

The safety of these chairs may be evaluated by the Rehabilitation Engineering & Assistive Technology Society of North America (RESNA). RESNA is a professional organization dedicated to promoting the health and well-being of people with disabilities through increasing access to technological solutions. RESNA evaluates safety and makes recommendations for things such as wheelchair tie-down and occupant restraint systems for use in motor vehicles. 

Items to consider:

• What is the weight capacity?
• What is the seat width and height?
• How will the resident be transferred to the chair? Can the resident slide from the bed to the chair as with a stretcher or will a mechanical lift be required?
• Is the chair appropriate for indoor and outdoor use?
• Is the chair battery powered? Is there a remote feature? How is it charged?
• Where will the chair be stored when not in use? Is the charging cord long enough if it is battery powered?
• If the chair is not battery powered, can the staff safely move the weight of the resident in the chair?
• Is the chair cushion washable?
• Will this chair be used by more than one resident during the same time-period?

When evaluating the cost of a transport chair, there are several considerations, such as:

• Is there a warranty? If so, how long and what is covered?
• How many chairs will be needed?
• Will extra parts such as cushions be required?
• Who will maintain the chair?
• How can it be cleaned?
• How much would other means of transportation cost the facility if a transport chair were not available?
• Does the chair allow the resident to remain in the chair for examinations (by reclining or offering other positioning options)? If so, will this decrease the number of staff required to transport the resident to appointments?

Evaluating Cost Effectiveness

As you evaluate the transport options for a bariatric resident, it may help to compare the cost of a service, such as a medical transport company or basic ambulance service, to the cost of using the facility vehicle. This will include determining the minimum number of visits the facility will need to transport the resident. Bear in mind that more than one resident may use the transport chair either in the same time-period or in a sequence of stays.

Here is a sample formula to use for calculating the cost:

Transport Company
Transport Charges ______________
+ Staff hours required to assist resident ______________ (transfer to and from chair and time spent accompanying resident to appointment)
= Cost of transportation

Facility Van
Mileage to and from appointment ____________ (2023 rate is $0.585/mile)
+ Staff hours to assist resident __________ (transfer to and from chair and time spent accompanying resident to appointment)
= Cost of transportation

When calculating staff hours don’t forget to review how many staff will be required to transfer the resident to wheelchair and how many staff will be required to accompany the resident to appointment to assist in clinic with transfers if required.

Also bear in mind the cost of a transport chair might be a capital expense. This then would be able to show depreciation over the life of the chair.

Sylvia Bennett-Josephson, RN, BSN, CDONA, CDP, CDDACT, IP-BC, FACDONA, CO-Q, has been a registered nurse for over 38 years and a director of nursing in long term care for over 30 years. Bennett-Josephson is a fellow of the National Association of Directors of Nursing Administration and is certified as a dementia practitioner and a certified Alzheimer’s disease and dementia care trainer by the National Council of Dementia Practitioners. She is certified as an infection preventionist and as a compliance officer. She also serves as a health care specialist with Med Net Consults and maintains an educational website, SJJ Education.

References
1. https://www.cms.gov/files/document/appendix-pp-guidance-surveyor-long-term-care-facilities.pdf
2. https://www.acsh.org/news/2023/07/31/chasing-cost-ambulances-17221