PERSPECTIVES

Negotiating Rehabilitation Success:A Veterans Affairs-Community Partnership

Crystal Barker, MSN RNJoan Brosnan, PhD RNDonna Henriques, LVNA. Wassen EI Shaied, MSW RH

Crystal Barker is a restorative nurse in the rehabilitation ward,Joan Brosnan is associate director ofCommunity Care, DonnaHenriques is a staffnurse in the rehabilitation ward, and A.Wassen El Shaied is a rehabilitation social worker at the VA

Defining our rehabilitation problem:Accessible transportation

This article describes how we solved a significant problemwith the transportation needs ofour rehabilitation clients after dis­charge from our facility in West Los Angeles. Many ofour clients,who have disabilities ranging from the results of cerebral vascu­lar accidents to amputations, live more than 25 miles from our fa­cility, and a sizable number of them require wheelchairs for mo­bility. Our clients' average age is 65, almost one-quarter live bythemselves, and many have auditory or visual impairments. Eventhose ofour clients who are able to drive are physically unable toload their wheelchairs into their cars. Significant others, who couldprovide transportation, have work responsibilities and are caughtin the dilemma of having to choose between transporting theirloved ones or jeopardizing their own employment. Thus, lack ofadequate transportation was affecting our clients' quality of life.

Although one of our veterans groups does provide some trans­portation services, it was not able to meet the particular needsof our rehabilitation clients. Because volunteers provide thetransportation, the daily number of available drivers is limited.This program is also restricted to a 30-mile radius from our fa­cility. Most problematic for our population, the transportationprogram is unable to accommodate those who use wheelchairs.

Our transportation problem is not unique. At least 12 millionAmericans, the majority of whom live in the community, reportneeding help with everyday activities due to chronic health con­ditions (Banaszak-Holl, Allen, Mor, & Schott, 1998). Invari­ably, their needs include assistance with transportation. Thesepeople confront extensive architectural and psychosocial barri­ers (Norrbom & Stahl 1991; U.S. Congress, 1993; U.S. De­partment of Health and Human Services, 1990). In fact, Taylorand Taylor (1996) found that transportation was a significantproblem for those with handicapping conditions. Even individ­uals with a disability who do have a car and can drive probablycannot manage to move a regular wheelchair (average weight

126 Rehabilitation Nursing· Volume 25, Number 4· Jul/Aug 2000

Keywordspartnership, rehabilitation, veteran patients, transportation

Greater Los Angeles Healthcare System. Address correspon­dence to Joan Brosnan, Associate Director ofCommunity Care,IOH5, VA Greater Los Angeles Healthcare System, 11301Wilshire Boulevard, Los Angeles, CA 90073.

40 lbs.), or an electric wheelchair (average weight 185 l bs.) inand out of their vehicles.

When chronic illnesses or conditions prohibit people fromdriving, they are faced with the frightening isolation that comeswith being unable to do things they had taken for granted. Suchnecessities as grocery shopping and keeping medical appoint­ments are now impossible without assistance. They are forcedto ask friends or relatives for rides, or they struggle with publictransit. Too often, they do without.

The availability of transportation has been shown to be a sig­nificant and independent predictor of life satisfaction (Cutler &Coward, 1992). People for whom transportation becomes un­available are more likely to exhibit declines in life satisfactionthan are those who maintain access to transportation (Cutler,1975). If they live by themselves, they reported even lower lifesatisfaction (Collins & LeClere, 1996). Adequate transporta­tion, then, has enormous implications for continued rehabilita­tion success after discharge.

Identifying a possible solution: The partnershipWe were aware that there was a private, not-for-profit trans­

portation program in the community for individuals with dis­abilities who cannot use public transportation; this program ap­peared ideally suited to meet the needs of many of our clients.The program, which operates 24 hours a day, 7 days a week, hasa fleet of small buses, mini-vans (easily able to accommodateour wheelchair-restricted clients), and taxis. The fare is $1.50for trips under 6 miles and 50 cents for each additional 4 miles,with a maximum fare of $4 for each one-way trip. This com­munity program transports riders for any purpose, includingshopping; keeping medical appointments; seeing a movie; go­ing to the bank, the senior center, or church; or just visiting fam­ily or friends. If the client requires a caregiver's assistance withactivities of daily living, the caregiver is allowed to accompanythe client free of charge.

However, this community transportation service requiredthat potential users have a face-to-face interview with the pro­gram's medical specialist evaluator to determine eligibility, be­cause usage requires preapproval. The agency staff could notcome to our facility for these interviews, because it was not cost­effective. We thus transported our clients to their facility to havethis mandatory interview. Their office was far away and we didnot have the resources to make this effort consistently. It wasnot only time-consuming and cost-ineffective for our staff, butit also was exhausting for our clients. And if a client was dis­charged before he had an application interview, he was left tohis own devices or had to depend on a family member or friendfor transportation to the interview. We knew we needed to cre­ate a better system.

Implementing the partnershipWe invited the transportation program staff to our facility to

discuss our clients' needs and determine whether we could forma partnership that would be workable for all. Their representa­tives agreed that they could come to interview our clients at theirbedsides if we could provide at least six candidates whom wefelt met the referral criteria during each visit. Reviewing our his­torical client data, we believed we could provide this numberevery 2 weeks. Our rehabilitation team was informed that clientassessment for program referral had to be done upon admissionto our ward, and one of our staff members coordinated the sched­uling of six potential candidates for interviews. On a trial basis,their medical specialist evaluator came to our ward every otherFriday and met referred clients at their bedsides. Applications

were assessed on the spot and clients' eligibility was determinedthe same day.

Our rehabilitation staff members agreed that clients wouldbe evaluated during admission for referral to the transportationprogram and that staff would structure appointments for the in­terviewer in a systematic manner. Coordination between ourtwo agencies made the interviewer's trip to our facility cost-ef­fective and provided our clients with a fast solution to their mo­bility problems, because they could begin to use the service with­in the same week they were discharged.

Evaluating the partnershipAfter the partnership had been in place for 15 months, we

surveyed 50 clients who had been discharged at least 3 monthsearlier to determine their satisfaction with different aspects oftheir lives before and after they began to use the service (seeTable 1). Almost 50% of the respondents stated that they usedthis program more than 10 times per month (Table 2). Ninety­two percent (n = 46) indicated that this linkage had a positiveimpact on their lives. Client comments included the following:"Now I don't feel like a trapped animal ... my wife has her ownlife back ... I am so grateful because you have given me theability to take back control of my life ... I would be miserablewithout this program."

The creation of this VA-community partnership has improvedthe quality of care for our veterans. Before the implementationof this transportation program, only 14% of our clients statedthat they rarely missed a medical appointment. After enter­ing the program, 98% stated that they rarely missed medical

Table 1. Results of Client Satisfaction Survey (N =50)

Very Poor Poor Average Good Very Good

n (%) n (%) n (%) n (%) n (%)

How would you rate your health before you 0 10 (20) 32 (64) 8 (16) 0were approved for the program?

How would you rate your health now that 0 0 4 (8) 19 (38) 27 (54)you are using the program?

Never Once in a While About Average Often Very Often

n (%) n (%) n (%) n (%) n (%)

How often did you get out of the house to 15 (30) 27 (54) 7 (14) 1 (2) 0meet friends before you began to usethe service?

How often do you get out of the house 1 (2) 16 (32) 19 (38) 13 (26) 1 (2)to meet friends now?

How often did you miss medical appoint- 1 (2) 6 (12) 33 (66) 10 (20) 0ments before you began using the service?

How often do you miss medical 37 (74) 12 (24) 1 (2) 0 0appointments now?

Has this transportation program improved Yes Nothe quality of your life? 46 (92) 4 (8)

Rehabilitation Nursing' Volume 25, Number 4· Jul/Aug 2000 127

PERSPECTIVES

Table 2. Frequency of Clients' Usage of Trans­portation Program (N = 50)

ConclusionThe openness of staff members from both agencies to listen

to one anothers' needs and their willingness to be flexible and

appointments. Although we expected the survey to show thatclients were more frequently able to keep medical appointmentsand to leave the house to meet friends, we were surprised at howdifferent their perception of improved health was after they be­gan to use the program. Whereas only 16% of clients rated theirhealth as being "good" before they began to use the program'sservices, 92% of them ranked their health as being either "good"or "very good" after they were "hooked up" with the trans­portation program. In fact, more than half (54%) rated theirhealth as now being "very good," whereas previously none ofthem had rated their health as "very good."

Times Usedper Month

1-34-78-10

11-1314-20

Number ofRespondents n (%)

7 (14)12 (24)7 (14)

10 (20)4 (8)

change processes that were impediments for the other agencywere key to our negotiating a win-win situation. This partner­ship is now an integral part of our discharge planning process.We refer approximately 26 clients per month to the program andhave had a 100% acceptance rate. To date, more than 379 vet­erans who have been discharged from our ward are also theclients of this community transportation program.

ReferencesBanaszak-Holl, J., Allen, S., Mor, v.,& Schott, T. (1998). Organizational char­

acteristics associated with agency centrality in community care networks.Journal 0/Health and Social Behavior, 39(4),368-385.

Collins, J.G., & LeClere, F.B. (1996). Health and selected socioeconomic char­acteristics of the family: United States, 1988-90. Vital and health statis­tics-Series 10: Datafrom the National Health Survey, 195(i-vi), 1-85.

Cutler, S.1. (1975). Transportation and changes in life satisfaction. The Gerontol­ogist,15,155-159.

Cutler, S.1., & Coward, R.T. (1992). Availability of personal transportation inhouseholds of elders: Age, gender, and residence differences. The Geron­tologist,12,77-81.

Norrborn, E., & Stahl, A. (Eds.). (1991). Mobility and transportation/or el­derly and disabledpersons. Philadelphia: Gordon and Branch Sciences Pub­lishers.

Taylor, B., & Taylor, A. (1996). Social work with transport disabled persons:A wayfinding perspective in health care. Social Work in Health Care, 23(4),3-19.

U.S. Department of Health and Human Services, Office of Disease Preventionand Health Promotion. (1990). Healthy people 2000: National health pro­motion and disease prevention objectives. Washington, DC: GovernmentPrinting Office.

U.S. Congress. (1993). Office of Technology Assessment. Access to over theroad buses/or persons with disabilities. Washington, DC: GovernmentPrinting Office.

128 Rehabilitation Nursing > Volume 25, Number 4· Jul/Aug 2000