TRANSPORTATION UTILIZATION ASSESSMENT TOOL

Every person on APD's Medicaid Waiver will need to justify their need for transportation. Support Coordinators are currently being called by APD and asked to answer the questions below. In some districts, support coordinators are being asked to print the form and complete it themselves for each person.

TRANSPORTATION UTILIZATION ASSESSMENT TOOL

Purpose: To assess the utilization of transportation for all waiver enrollees who are currently using or applying to use waiver funds to pay for transportation.

SECTION 1: GENERAL INFORMATION

1. Date: __________________

2. Name of Person: _______________

3a. Date of Birth: _______________ 3b. SSN: ___________

4. Waiver Support Coordinator: _______________

5. QSI Scores: Overall ____ Functional ___ Behavioral ___ Physical _____

6. QSI Completion Date: _______

7. Person’s Current Residence: Independent Living ____ Family Home ____
Group Home ____ Foster Home ____ Other ____

SECTION 2: TRANSPORTATION UTILIZATION

1. Is the person currently using the following transportation sources? (check all that apply):

Public transportation/fixed route system ___
Family/friends/community sources ____
Waiver Transportation Provider, i.e. Group Home Provider, Adult Day Training Provider, Independent Waiver Provider ____
Foster Home ____
Other ___

2. The above transportation sources are used for the following reasons (check all that apply):

Medical appointments ___
Employment ___
Waiver services ___
Educational ____
Other ____



3. Which of the following transportation sources are used to travel to and from waiver services? (check all that apply)

Public transportation/fixed route system ___
Family/friends/community sources ____
Waiver Transportation Provider, i.e. Group Home Provider, Adult Day Training Provider, Independent Waiver Provider ____
Foster Home _____
Other ___

4. Is the DD waiver being used to pay for transportation to and from any waiver services other than Adult Day Training, Supported Employment, Therapies and Adult Dental? Yes __ No ___

5. If yes, indicate which services.

Companion ____
Other ___

6. If “Waiver Transportation Provider” in Question# 3 is checked, how often is this source used?

1 – 2 one-way trips per week _____
3 – 4 one-way trips per week _____
4 or more one-way trips per week ____

SECTION 3: EXPLORING OTHER TRANSPORTATION OPTIONS

7. If “Waiver Transportation Provider” in Question# 3 is checked or if the person is requesting waiver funding for transportation for the first time, can other sources be used to provide the transportation? Yes ____ No ____

8. If not, check the reasons that apply:

Public transportation/fixed route not a viable option ____
Medical/Behavioral/Physical condition of the person ____
Family Members/Relatives not available ____
Cannot afford the cost of other transportation options _____

List other transportation options person has explored and the cost
Option 1 _________ Cost ______
Option 2 _________ Cost ______

9. If the public transportation/fixed route system is not a viable option to and from waiver services, please state why.

Public transportation/fixed-route unavailable at person’s location ____
Public transportation/fixed-route available but not when needed _____
Person’s medical/behavioral/physical condition _____
Other ____

10. If “yes” in Question #7 is checked, indicate why other transportation options are not being utilized. (check all that apply)

Never considered using other options ____
Not aware other options could be used ____
Other ___

11. Have family members transported the person in the past to waiver services? Yes ___ No ___

12. If yes, can they resume? Yes ___ No ___

13. If no, why not.

Unavailable due to work schedule ____
Moved away ____
Cost issues ____
Other ____

SECTION 4: ASSESSMENT FOLLOW-UP AND OTHER CONSIDERATIONS

1. The waiver pays for transportation to and from waiver services. Those services include: Adult Day Training, Supported Employment, Therapies and Adult Dental

2. If it is clear a person is using the waiver to fund transportation for services other than those listed, the practice should end immediately.

3. If it is clear a person can utilize the public transportation/fixed route system, family members or other sources to access waiver services, efforts should be implemented to do so immediately.

4. This assessment tool should be used for all new and existing waiver enrollees requesting transportation.

5. Effective September 1, 2011, the Agency will only pay for one round trip or two one way trips maximum per day per person.