Research in Gerontological Nursing

Empirical Research Supplemental Data

Transportation of Older Adults: Common Behaviors Interfering With Safety

Justine S. Sefcik, PhD, RN; Christine K. Bradway, PhD, RN, CRNP, FAAN; Pamela Z. Cacchione, PhD, CRNP, BC, FGSA, FAAN

Abstract

There is a dearth of evidence on safely transporting frail older adults in the community. Therefore, the purpose of the current study was to gain a better understanding of behavioral expression exhibited by older adults during van transportation and to learn what actions van assistants and van drivers take to prevent or address behavioral expressions, which can create potential challenges to safe transportation. A qualitative descriptive approach was used and included four focus groups of van assistants and van drivers (N = 32) at one urban Program of All-Inclusive Care for the Elderly (PACE), which routinely transports approximately 90% of enrollees to and from the PACE center. Conventional content analysis was used to analyze the data. Four themes emerged. The first two themes were common behaviors: Removing Seat Belts and Verbal Behaviors. The remaining two themes addressed unusual behaviors that left lasting impressions: Physical Aggression and Conflict Between Passengers. Van assistants and van drivers used redirection and reassurance as preventive interventions to keep everyone safe. Transportation of PACE enrollees requires well-trained and astute van assistants and van drivers skilled with preventing and diffusing potentially unsafe behaviors.

[Res Gerontol Nurs. 2019; 12(4):184–192.]

Abstract

There is a dearth of evidence on safely transporting frail older adults in the community. Therefore, the purpose of the current study was to gain a better understanding of behavioral expression exhibited by older adults during van transportation and to learn what actions van assistants and van drivers take to prevent or address behavioral expressions, which can create potential challenges to safe transportation. A qualitative descriptive approach was used and included four focus groups of van assistants and van drivers (N = 32) at one urban Program of All-Inclusive Care for the Elderly (PACE), which routinely transports approximately 90% of enrollees to and from the PACE center. Conventional content analysis was used to analyze the data. Four themes emerged. The first two themes were common behaviors: Removing Seat Belts and Verbal Behaviors. The remaining two themes addressed unusual behaviors that left lasting impressions: Physical Aggression and Conflict Between Passengers. Van assistants and van drivers used redirection and reassurance as preventive interventions to keep everyone safe. Transportation of PACE enrollees requires well-trained and astute van assistants and van drivers skilled with preventing and diffusing potentially unsafe behaviors.

[Res Gerontol Nurs. 2019; 12(4):184–192.]

As the aging population grows, more and more older adults will have to stop driving due to age-related frailties and visual and cognitive impairments (Dickerson et al., 2007). Older adults with chronic conditions and/or cognitive impairment require assistance with transportation once they can no longer safely navigate their own transportation. Therefore, it is essential for communities to provide transportation options for older adults to meet basic mobility needs to facilitate their ability to remain as independent as possible in the community. Older adults are heterogeneous; therefore, one-size-fits-all transportation solutions are inadequate. To address this challenge, the 5A's of senior-friendly transportation were developed. The 5A's include: availability, acceptability, accessibility, adaptability, and affordability (Beverly Foundation, 2010). Despite these recommendations, there is a dearth of evidence around the phenomenon of transporting frail older adults.

Furthermore, there is no known evidence on the types of behavioral expressions (e.g., restlessness, verbal or physical agitation) exhibited during transportation. Information on strategies used to promote safe transportation experiences for all passengers are also missing. Two research teams have focused on behaviors occurring within adult day services (Cohen-Mansfield & Werner, 1998; Cohen-Mansfield, Werner, Watson, & Pasis, 1995; Woodhead, Zarit, Braungart, Rovine, & Femia, 2005). These studies, although dated, demonstrate that behaviors (e.g., agitated behaviors, general restlessness, crying, pacing, verbal interruptions) were common among older adults in adult day services (Cohen-Mansfield et al., 1995; Woodhead et al., 2005). Although adult day centers in one study provided transportation to and from the center (Cohen-Mansfield & Werner, 1998), staff (i.e., Activity Directors) who rated older adults' behaviors were not involved in the transportation side of the program so only reported what occurred at the center (J. Cohen-Mansfield, personal communication, August 30, 2018; Cohen-Mansfield et al., 1995). This research supports the presence of behaviors in adult day centers yet does not provide insight into whether behaviors are occurring during transportation.

To address this gap in the literature, a qualitative study was the necessary first step to gain a better understanding of the phenomenon of behavioral expressions exhibited during transportation on Program of All-Inclusive Care for the Elderly (PACE) vans. PACE vans transport nursing home–eligible older adults to and from the PACE center (Table A, available in the online version of this article). Therefore, the purpose of the current study was to gain a better understanding of the behaviors passengers exhibited during transportation on the PACE vans and what actions van drivers and van assistants took to prevent or address these behaviors.

Programs of All-Inclusive Care for the ElderlyPrograms of All-Inclusive Care for the Elderly

Table A:

Programs of All-Inclusive Care for the Elderly

Method

Design

A qualitative descriptive approach (Kim, Sefcik, & Bradway, 2016; Sandelowski, 2000) was selected to understand the experience of PACE van assistants and van drivers who witnessed and managed passengers' behavioral expressions during transportation to and from the center. This approach was selected because little is known about this phenomenon. A focus group data collection strategy was used because of the value in participants' responses acting as mental cues for other participants, thus triggering relevant memories and eliciting rich responses (Krueger & Casey, 2000). Four focus groups were held, two with van assistants and two with van drivers. Separate focus groups were held for van assistants and van drivers so they could share experiences unique to their positions.

Setting

The PACE center involved in the current study was in a northeastern urban environment serving 14 urban zips codes with 430 enrollees at the time of study. According to the National PACE Association (NPA; 2015) Biannual Benchmark Report, mean age of PACE enrollees was 78 years, and 72% (n = 310) were female in this center. Most enrollees were dually eligible for Medicare and Medicaid (89.4%), and the majority (62.6%) of enrollees were dependent in at least three activities of daily living (NPA, 2015).

At this PACE center, 90% of enrollees were transported to and from the center, with the remaining arriving by other means (e.g., family transport). The average number of per passenger per month transportation trips was 13.4 (NPA, 2015). On average, a PACE passenger came to the center 8.24 times per month (NPA, 2015). At this center, vans were staffed with a van assistant (certified nursing assistant) and driver, or a two-man crew comprising two drivers who manually assisted passengers in wheelchairs up and down residential stairways. The van drivers and van assistants received annual mandatory training on safely transporting older adults. Each van transported between six and 14 passengers depending on the number of assistive devices and wheelchairs on each van. Passengers may spend a maximum of 1 hour on the van each trip.

Sample

A convenience sample (Flick, 2018) of van assistants and van drivers from one PACE center who rode on or drove the vans with passengers as part of their job responsibilities was recruited. Focus group inclusion criteria were current employee of the PACE center functioning as a van assistant or van driver. In addition, participants had to be older than 18 and speak and understand English.

Data Collection

Permission for this study was obtained from the PACE center's Committee on Research and Education and Council of the Elders, a group of cognitively intact older adults enrolled in this PACE who approved all research at their center. The University of Pennsylvania provided Institutional Review Board approval. The study team collaborated with the directors of transportation and nursing for this study. Department heads posted flyers about the study and a sign up sheet for employees with the focus group dates and times. The study team confirmed with employees who planned to attend. Focus groups were held after employees ended their shift for the day with refreshments provided. All focus groups were held in a private and convenient conference room at the center.

Following informed consent and prior to each focus group, participants completed a demographic form and were asked to create pseudonyms for use throughout the session. The pseudonyms helped ensure confidentiality of participants during transcription and data analysis. Audio recording of the sessions began once these steps were completed.

The four focus groups lasted an average of 90 minutes. A neutral moderator (J.S.S.) without ties to PACE led the focus groups (Krueger & Casey, 2000). She had previously attended the PACE center as a nursing instructor for students' clinical days and was familiar with the services and operation of the center. The moderator used a semi-structured interview guide developed by the research team to address the study aims (Table 1). The team included the second author (C.K.B.), who was also familiar with operations having served as a Faculty Advisor/Executive Committee Member for the center, and the last author (P.Z.C.), who practiced at the PACE center as a gerontological nurse practitioner focusing on geropsychiatric care. She was often consulted for behavioral expressions that were disruptive or posed safety issues on the vans. A second moderator, whose responsibility was to take field notes and assist with probing questions, was present during all focus groups.

Sample Interview Questions

Table 1:

Sample Interview Questions

Participants were encouraged to make positive and negative comments (Krueger & Casey, 2000). Participants received a $25 gift card at the end of each focus group as a token of appreciation for their time and contributions to the study. Procedures were the same for all four focus groups.

Data Analysis

Transcripts were analyzed with qualitative software Atlas.ti version 7, which was used to store and manage the data. An inductive qualitative content analysis approach was taken, as former knowledge on the phenomenon of interest is not available (Elo & Kyngäs, 2007). The first author (J.S.S.) immersed herself in the data and completed open coding keeping the research question in mind and focusing on the text related to behavioral expressions occurring on the vans. The codes were then sorted into categories based on similarities. From these categories the themes emerged, which were named based on the participants' words. A second author (C.K.B.) audited the coding and the team met several times to discuss findings and confirmed the final themes.

Trustworthiness

Several measures were instituted to enhance trustworthiness/rigor. The focus group milieu enhanced truth value, defined as the credibility and confirmability of the findings (Sandelowski, 1986). Specifically, focus group moderators used discussion-generating questions as a guide while encouraging open discussion and opportunities for sharing of ideas and expressing disagreement or alternate views, without being manipulated to respond in a certain way (Rothwell, Anderson, & Botkin, 2015). Truth value was further enhanced by use of a paid transcription service for verbatim transcripts. The team compared transcriptions to audio recordings of the focus groups and created a clear code book and audit trail for data analysis. The authors adhered to procedures for inductive content analysis. To enhance credibility, a process for referential adequacy was performed by having a second coder (C.K.B.) audit emerging findings by re-analyzing the data and checking any new findings against the original interpretations (Tashakkori & Teddlie, 1998). In addition, the first author engaged in peer debriefing regarding data collection and study findings with an Advanced Qualitative Collective, a group of peers focusing on qualitative research but not involved with this project (Abboud et al., 2017). Finally, all authors reviewed and confirmed final codes, themes, and findings.

Results

Participant Demographics

Van assistants (n = 20) and van drivers (n = 12) were primarily African American (90.3%), reflecting the population served at the PACE center (Table 2). The sample was equally split between male (48.4%) and female (51.6%) participants. The average age of the sample was 40.8 years. The majority of the sample had completed high school or received a GED (61.3%), and the remaining participants had college or other technical training. Most participants (87.1%) worked >30 hours per week.

Participant Demographics (N = 32)

Table 2:

Participant Demographics (N = 32)

Qualitative Findings

Overall, most participants were engaged and contributed to the discussion. Van assistants and van drivers described a variety of passenger behavioral expressions they believed interfered with safe transportation. Only one van driver joked while hearing stories shared in the focus group and said, “I guess I'm a drill sergeant. I don't have no problems. They love to see me. My clients love to see me. They love me.” Similarly, one van assistant expressed that she did not have behavioral expressions on the van, stating:

On our van we just listen to gospel [music] because they older and always, they grew up off of church music and they always listen to church music inside the center, so they keep them calm and they also sing along with the songs, so gospel is the key on our van and there is no problem...

One primary theme emerged for a common behavior on the van: Removing Seat Belts. The second theme addressed another common behavior, Verbal Behaviors (e.g., cursing at the van assistant or van driver), which could be distracting and lead to safety issues. Two additional themes emerged: Physical Aggression and Conflict Between Passengers. These behaviors were unusual and episodic, yet they left lasting impressions with van assistants and van drivers.

Removing Seat Belts. Passengers removing their seat belts while on the van occurred regularly. This behavior was most concerning when passengers got out of their seats while the van was in motion. One van assistant (#1) described the removal of seat belts as “the biggest problem” on the vans and a “safety hazard.” No matter how many times a passenger removed his/her seat belt, van assistants fastened it again or van drivers requested it be re-buckled while reiterating the importance of seat belts for the passenger's safety. A van driver (#4) stated “you always have one” who unbuckles the seat belt right away:

Within, let's say 30 seconds, they unbuckle the seat belt, ‘cause you can hear it click. “Can you please buckle the seat belt?” Within the next 15 to 20 seconds they do it again and this might go on from the house to the center. Then when they get to the center, now they want to buckle.

Although a van assistant (#1) and van driver (#5) acknowledged that some passengers did not like being “strapped in,” other participants reiterated that it is not safe for passengers to have their seat belts unbuckled. A van driver (#5) shared that it is “kind of scary” when passengers gets out of their seats when the van is in motion stating, “You can only do so much as a driver while you're maintaining your eyes on the road,” while the van assistant is paying attention and can redirect the person back to his/her seat. This van driver shared a situation where he was driving and an older adult removed her seat belt and then walked up to the front of the van surprising him. She was standing next to him looking out the front window telling him it was her stop, which it was not her stop.

Participants also described instances where some passengers with dementia would take their seat belts off when arriving at another passenger's home thinking it was their stop and would attempt to get off the van. This action, in turn, required redirection by van assistants or van drivers to keep the passenger on the van until it was his/her actual stop. Examples of redirection given included sitting next to restless passengers; providing redirection through conversations and questions, such as “What are you going to do when you go home?”; and reconnecting seat belts while explaining safety. One van assistant (#5) provided an exemplar, stating:

I have one that comes out of her belt all day long and she plays like, “That ain't me, that's him, that's him,” but she's holding the seat belt together but it's not locked and stuff, so I redirect that conversation with her, so I'm trying to redirect her to stay in her seat, so some days it's hectic.

Verbal Behaviors. Another common behavior described was verbal behaviors from passengers directed at van assistants and van drivers. These behaviors included passengers insulting, snapping at, and most commonly, cursing at the worker. Verbal behaviors from passengers were conveyed as a routine behavior, particularly if passengers believed they were not having a good van experience or were not in a good mood. Multiple examples were given of passengers cursing at van drivers and name-calling for reasons such as what radio station was playing on the van, not getting the passenger to the center on time for breakfast, the van was making too many stops, or the van driver took a wrong turn. One van driver (#8) said, “I have a client that cuss me out every morning…I know he's gonna cuss you out” and further explained that the passenger will also curse at the van assistant if he is not able to get on the first van trip home and must wait for the second trip.

One van assistant (#13) recognized that if a passenger is in pain and not happy about something “they cuss you out…and say nasty things to you.” She expressed that no matter how nice she was, members still might snap at her. Another van assistant (#5) conveyed:

And then we have some who um…is a little more demented than others, when you talk, they think everything you're saying you're talking directly to them or it's directed at them, no matter what you say, and they just take offense to it and then it's just…they blow up and you can't stop them. Like you just have to walk away.

The same van assistant (#5) described using redirection as an intervention when passengers were being disrespectful:

There's a lot of things we have to put up with on being disrespected by the passengers. We still have to put up with that, have to redirect our conversation, um…you know, watch what we say, try not to agitate them more.

One van assistant (#16) described a passenger who was crying all the time when she first started coming to the PACE center. The van assistant was able to provide one-on-one attention to this passenger and described her interaction with her:

…me picking her up in the morning, talking to her, having a lot of communication, showing her the attitude, like I care about you, I want you to be okay, I don't want you to be crying…. Her attitude every day was changing, she was eating at her house, laughing, dancing, like personal attitude was changing....

Physical Aggression. Although not mentioned as frequently, the third theme focused on the behavioral expression of rare episodic physical aggression toward van employees. Some passengers attempted or actually scratched, bit, punched, or hit van assistants and/or van drivers with their hands or assistive devices, such as canes or walkers, which were referred to as weapons in this context. Physical aggression primarily occurred while older adults were getting off and on the van. Van assistants and van drivers described being worried about their physical safety when passengers became physically aggressive.

Van assistants and van drivers spoke about times they were hit or punched, and they were able to identify the trigger either before or after the incident. One example was picking up a passenger at her home and learning from her daughter that she had a “bad weekend.” The van assistant (#7) stated, “When she got on the van, she started punching on the driver, hitting on the driver.” Another van driver (#7) related that when he reached out to stop a passenger from falling, she started hitting his arm and yelling “don't touch me” and identified the trigger of her behavior being her fingernail falling off. Van drivers also described other passengers who would hit and grab them when they “didn't expect it.”

Van assistants provided two examples in which they were concerned about their personal safety because of passengers' actions. In the first example, a van assistant (#5) recalled a time a male passenger was “shouting all in my face” and “threatening” her because she asked him to sit in a seat near the front of the van (because he was going to be dropped off first) and he wanted to sit in the back of the van. The passenger “blasted” the van assistant and got into a stance to lift the van assistant off her feet and throw her. The van driver heard the van assistant screaming and ran on to the van to get the older adult off the van and into the PACE center. In the second example, a van assistant (#8) described witnessing a passenger physically threatening a van driver:

He was upset because he felt as though another older adult was sitting in his seat. And the driver explained to him that there's no assigned seats. He was at him [physically threatening].... Having to talk him down from that was an experience, you know try to explain to him you…really don't want to hurt anybody and you're scaring the ladies that's on the van. It was something else. I mean he finally calmed down, but that reminded me how serious they are about those seats on the van.

Approaches that van assistants and van drivers have taken when working with passengers who were physically aggressive included trying to calm the passenger and making “light” of the situation with redirection and joking. Van assistants and van drivers also reported these incidents to the PACE center nurse practitioners (NPs), which resulted in NP consultations, medication changes, staff in-services, and, depending on the situation, suspension from van services. Van assistants and van drivers believed follow up from the NPs was sometimes helpful in reducing the behavior. One van assistant (#13) felt supported by the PACE center's behavioral health team:

We have a good behavioral health system here because we have people having a situation or they agitated and everything and we take them there…. And also, we have in-services that they help us with, with the people that are problematic and so that helps us a lot. I am noticing now that we have a lot of members now that are coming in here with a lot of psych issues and they [NPs in the behavioral health department] are addressing it more and more, so that helps us how to handle that.

There have also been cases where van assistants and van drivers had talked to the PACE administrator to request and subsequently been granted that the passenger be removed from their van, at least temporarily, due to concerns about safety.

Conflict Between Passengers. The final theme was conflict between passengers. Van assistants and van drivers discussed conflicts they observed among passengers on the vans, which were primarily verbal behaviors, although in some cases escalated to physical behaviors. Examples given were passengers insulting, cursing at, and threatening each other. In some instances, the conflict involved arguments over what radio station to listen to during the van ride. Many times seating arrangements provoked the conflict. Van assistants and van drivers described that there were no assigned seats on the vans because of variability with pick-up and drop-off schedules. Despite explaining this to passengers, some wanted to sit in the same seat all the time or did not want certain (or any) older adults sitting next to them. One example given by a van driver (#6) was: “She thinks she owns the seat wherever she sits. So, if someone sits beside her, now she wants to try to throw hands and thinks she can bully this person off of the van.”

Physical aggression among passengers was not “common place” (van driver #10) but did occur. One van driver (#10) shared a story of two older adults physically fighting, which was the first time he witnessed an incident like this in 3 years of working on the vans:

There's two passengers that we had to separate ‘cause they were fighting. Uh…I just think that they don't like each other and so when they would get on the van, if one person's jacket hit the other person on the head when they were sitting there, they'd argue. It would escalate…but I mean it's just no different than any other mode of transportation where we got a bunch of people. Sometimes…you know, sometimes people are irritable.

In addition, one van assistant (#9) described how passengers were anxious to get off the van when they arrived at the center, stating “they be trying to fight on the van to get off. One woman will bum rush other older adults to get off, pushing them with her walker so she can be the first person off the van.” When conflicts did escalate, administration was made aware.

Participants mentioned that they work to calm passengers, particularly if they were anxious and it was influencing other older adults. One van assistant (#5) described it as:

A lot of people with the dementia [when disturbing others on the van], they don't hear you when you're talking, so I normally go to them, touch them and let know, or let them see my face, or whisper in their ear and most of the time they… you know, they calm down…can be redirected or even I just strike up another conversation.

Discussion

The purpose of the current study was to gain a better understanding of the behaviors PACE van passengers exhibit and learn what actions van assistants and van drivers take to address or prevent these behaviors. The authors were interested in exploring this phenomenon because the safety of older adults is dependent on van assistants and van drivers, and no previous studies investigating behaviors of older adults during van transportation have been identified. Focus group interviews revealed four themes: Removing Seat belts, Verbal Behaviors, Physical Aggression, and Conflict Between Passengers. Van assistants' and van drivers' use of redirection, reassurance, and gospel music in one instance as preventive interventions facilitated keeping the passengers and themselves safe.

Previous research examining behavioral problems of older adults attending adult day care centers that transported at least some attendees has focused on behaviors exhibited within centers and at home as reported by relatives (Cohen-Mansfield, Taylor, & Werner, 1998; Cohen-Mansfield & Werner, 1998; Cohen-Mansfield et al., 1995). There was no examination of behaviors during transportation or how these behaviors impacted safety during transportation. General restlessness and agitation (physical and verbal) were reported as common behaviors (Cohen-Mansfield et al., 1995; Woodhead et al., 2005), which is consistent with findings that passengers regularly removed their seat belts during transportation and that verbal behaviors directed at staff were also common.

Cohen-Mansfield et al. (1995) reported that 63% of participants exhibited an average of three agitated behaviors per week at the day care center and approximately all participants' relatives (90.3%) reported at least one agitated behavior once per week at home. Agitation was rated on the Cohen-Mansfield Agitation Inventory for Community. Physical aggression among these participants was rare; however, verbally agitated behaviors were common. In the current study, physical aggression toward staff on the vans was rare, yet left lasting impressions on van assistants and van drivers, particularly when they feared for their personal safety. It is essential to note that this PACE has policies in place, including calling the police if necessary, to keep passengers, van assistants, and van drivers safe if an enrollee becomes violent.

Another study among adult day care attendees found that cognitive impairment and poor quality of relationships were predictors of physically aggressive behaviors, whereas verbally aggressive behaviors were predicted mainly by depressed affect, low quality of relationships, and poor physical health (Cohen-Mansfield & Werner, 1998). With 50% of PACE participants having dementia (Mukamel et al., 2007) and all participants having multiple chronic health conditions, a situation is created on the vans where multiple older adults are together who are susceptible to diminished self-control potentially leading to behavioral challenges. It is important for van assistants and van drivers to be aware and prepared to de-escalate aggressive behaviors as necessary to maintain safe van transportation. Examining education and in-services provided to van assistants and van drivers and altering educational materials as necessary to account for this information is an important next step.

Deeper examination of relationships between van assistants and van drivers and their passengers is also an important next step, as poor quality of relationships has been found to be a predictor of physical and verbal aggression (Cohen-Mansfield & Werner, 1998). Only one van assistant and one van driver did not perceive having any behavioral issues on their vans. Whether they worked on the same or different van is unknown. Further exploration is needed to determine the kind of relationships and interactions, as well as van environments, that avert or minimize behavioral expressions during transportation to the center.

Redirection and distraction were the main techniques used by van assistants and van drivers to maintain safety when working with passengers exhibiting behavioral expressions. Frequent transportation of older adults to and from the center and appointments requires well-trained, astute van assistants and van drivers who are skilled in diffusing potentially unsafe behaviors. Proper verbal and non-verbal communication with passengers to prevent or manage agitated behaviors is important for supervisors and the behavioral health department providing consultations and in-service trainings to reinforce with van assistants and van drivers (Sefcik & Cacchione, 2015). As a future direction, having NPs from the behavioral health department ride on the vans to witness first-hand what is occurring during transit and to model appropriate communication and de-escalation techniques is recommended. Recording the number of incidents before and after having the NP ride on the van is also recommended to assess the impact on decreasing behavioral expressions and safety concerns on the vans.

Woodhead et al. (2005) found that study participants with dementia who partook in more engaging activities at a day care center had a significant decline in restless behavior problems over 3 months. Further research is needed to determine whether this engagement is effective in reducing behaviors during transportation. Providing tailored, engaging activities to restless passengers unbuckling seat belts on vans deserves further investigation as well. Use of the radio on vans to play music was mentioned as a point of contention in some cases or as a calming effect. Providing culturally appropriate music for passengers is worth further investigation as an intervention to prevent or reduce behaviors during transportation and is recommended as the next step for future research.

Limitations

The current study provides an important first step to understanding van assistants' and van drivers' views of behaviors exhibited by PACE passengers during transportation. One limitation is that all participants within the focus groups work with each other on a regular basis at one facility. It has been cautioned that focus groups comprising individuals who work together may inhibit disclosure when it comes to discussing certain topics (Krueger & Casey, 2000). From the authors' perspective, many participants were comfortable speaking in the focus groups and freely shared their thoughts and experiences. Often, other participants in the room were saying words in agreement when a story about van transportation or working with older adults resonated with the group. Van assistants and van drivers also expressed appreciation for the opportunity to share their experiences. Furthermore, only one van assistant and one van driver stated they did not have any behavioral problems on their vans. This finding may have been the result of convenience sampling and self-selection by drivers and assistants who wanted to discuss safety issues on the vans.

Conclusion

PACE and other community-based long-term care settings transport significant numbers of older adults to PACE centers, appointments, and senior centers. Safely transporting older adults will remain a critical element of community-based long-term care. Developing environments, policies, and procedures is critical for keeping older adults, van assistants, and van drivers safe.

Passengers on the vans were frequently unbuckling their seat belts and often exhibited verbal behaviors directed toward van assistants and van drivers. These behaviors could interfere with safe transportation. Less commonly exhibited behaviors were physical aggression and conflict among passengers, which were also safety concerns when they occurred. Based on these rich focus groups, important insights were identified as potential interventions to enhance safety on the vans. Providing culturally appropriate music for passengers is worth further investigation. Future studies in transportation of older adults to PACE centers should focus on providing training for van assistants and van drivers in proper communication, redirection, distraction, and de-escalation techniques for passengers who are restless and agitated. In addition, providing person-centered activities on the van that distract individuals with dementia to decrease their restlessness and episodes of un-buckling seat belts may be beneficial and warrants further investigation.

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Sample Interview Questions

Describe a typical van route experience, from the moment you start until you are finished.
When you are feeling the best about your work, what is happening?
What prevents you from having a good van experience?
Describe how passengers act or behave when they are riding on the van.
What do you do about passengers' not so good actions or behaviors on the van?
We are interested in how best to keep the vans safe. Tell us some of the things you do to make sure the vans are safe for passengers, yourselves, and other staff members.
Tell us about times on the vans when you were worried about safety for passengers, yourself, and/or other staff members. What happened?
Behavioral Health at PACE sometimes makes suggestions about how to work with passengers who are having a difficult time during van rides. What experiences do you have with these suggestions? How are they helpful or not helpful?

Participant Demographics (N = 32)

VariableMean (SD) (Range)
Age (years)
  Total sample40.8 (13.25) (22 to 67)
  Van assistants41.62 (12.58) (22 to 61)
  Van drivers39.3 (14.85) (22 to 67)
n (%)
Gender
  Male15 (48.4)
  Female16 (51.6)
Race
  African American28 (90.3)
  Caucasian1 (3.2)
  Missing2 (6.5)
Van assistants20 (64.5)
Van drivers12 (39.7)
Education
  High school or GEDa19 (61.3)
  Associate or Bachelor's degree3 (9.7)
  Other5 (16.1)
  Missing4 (12.9)
EMT training3 (9.7)
Hours worked per week
  10 to 302 (6.5)
  31 to 4015 (48.4)
  40+12 (38.7)
  Missing2 (6.5)

Programs of All-Inclusive Care for the Elderly

Program of All-Inclusive Care for the Elderly (PACE) is an integrated model of care for Medicaid and dual eligible older adults. These older adults, referred to as PACE enrollees, are low income and nursing home eligible with multiple co-morbidities in addition to having functional and/or cognitive impairments (Mukamel et al., 2007). Frequent interaction with the PACE interprofessional team allows for identification of changes in health status enabling early intervention for enrollees leading to lower hospitalizations and decreased mortality (Ghosh, Orfield, & Schmitz, 2014). PACE has grown to 126 sponsoring organizations with 260 PACE centers in 31 states in 2019, serving 49,000 older adults (National PACE Association, 2019). The majority of older adults who attend PACE rely on PACE provided round-trip transportation services to and from their home to the center. Transportation services are essential for older adults to access PACE coordinated managed care and other benefits provided at the center, such as socialization and recreation. The Centers for Medicare and Medicaid Services (CMS) mandate that transportation be provided as indicated in the PACE enrollees individualized care plan and must include a communication plan for the van drivers to notify the interprofessional team of an enrollee's change in condition [42 CFR §§ 460.76(e),460.92(i), 460.102(e)] (Centers for Medicaid and Medicare, 2011). PACE models of care are both health providers and health care insurers delivering community-based long-term care for nursing home appropriate persons who are Medicaid eligible (9%) or dually eligible for Medicare and Medicaid (90%) (Hostetter, Klein, McCarthy, 2016; Naylor & Buhler-Wilkerson, 1999; Hirth, Baskins & Dever-Bumba, 2009; NPA, 2019). Older adults who enroll in PACE receive care from an interprofessional team including: primary care providers (physicians and/or nurse practitioners), nurses, social workers, physical therapists, occupational therapists, recreation therapists, dietitians, certified nursing assistants (CNA), transportation coordinators, van drivers (Fretwell & Old, 2011; Hostetter, et.al., 2016; Nath, Hirshchman, Lewis & Strumpf, 2008; Sullivan-Marx, et al., 2011). The PACE transportation departments typically include dispatchers and drivers that facilitate the safe transportation of enrollees. Drivers are key members of the interprofessional care team. They are often the first team members to observe and report changes in a passenger's health or behavior. PACE transportation aligns with the 5 A's of senior friendly transportation which include: availability, acceptability, accessibility, adaptability and affordability (Beverly Foundation, 2010 as cited in Silverstein & Turk, 2016). Based on an individual's care plan, PACE transportation is available for trips to and from the PACE center, doctor's appointments, and group trips for recreational activities. PACE vans are safe, clean and user friendly supporting acceptability. Specialized PACE vans are accessible for those with physical disabilities including wheelchair lifts. The adaptability of PACE transportation is exhibited by individualizing transportation for each passenger. Since transportation is a service provided by PACE there is no charge. Despite following the 5 A's there are still challenges transporting older adults with physical and cognitive impairments on PACE vans. Research is required to better understand the challenges and to provide evidence-based interventions for improvement. Additionally, there is a significant gap in our understanding of the population PACE serves since approximately 50% of PACE enrollees nationally have a dementia diagnosis at risk for associated behavioral expressions (Mukamel, Peterson, Temkin-Greener, et al., 2007). Health services research on the PACE model is common with 22 studies reviewed in the latest review of the literature (Ghosh, Orfield, & Schmitz, 2014), however more research is needed to address gaps in knowledge.
Authors

Dr. Sefcik is Post-Doctoral Research Fellow, Dr. Bradway is Associate Professor of Gerontological Nursing, and Dr. Cacchione is Ralston House Endowed Term Chair in Gerontological Nursing, Associate Professor of Geropsychiatric Nursing, University of Pennsylvania School of Nursing, Dr. Sefcik is also Associate Fellow, and Dr. Cacchione is also Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania; and Dr. Cacchione is also Nurse Scientist, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

This work was supported by the University of Pennsylvania Frank Morgan Jones Fund and the National Institutes of Health (NIH; T32NR009356, J.S.S.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Address correspondence to Justine S. Sefcik, PhD, RN, Post-Doctoral Research Fellow, University of Pennsylvania School of Nursing, Associate Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, 3615 Chestnut Street, Room 332, Philadelphia, PA 19014; e-mail: jsefcik@nursing.upenn.edu.

Received: December 04, 2018
Accepted: February 27, 2019
Posted Online: June 03, 2019

10.3928/19404921-20190522-03

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