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AOTA’s NBCOT® Exam Prep

Community Mobility
I. General considerations (Eby et al., 2006; Stav & McGuire, 2012; Womack, 2012;
Womack & Silverstein, 2012)
A. Community mobility: “planning and moving around in the community using public or
private transportation, such as driving, walking, bicycling, or accessing and riding in
buses, taxi cabs, ride shares, or other transportation systems” (American Occupational
Therapy Association [AOTA], 2020; Stav & McGuire, 2012)
B. Forms of community mobility
1. Public transportation: means of moving more than one person at a time from point to point
that is available to all citizens of an area and funded, at least in part, by taxes (Womack &
Silverstein, 2012, p. 28)
a. Fixed-route transportation: transportation alternatives with a fixed route and schedule for
travel between destinations. Fixed-route transportation is most typically offered in the form
of bus, subway, train, and light rail services.
i. Performance skills required
• Cognitive skills: ability to consider transit options, read a schedule, figure out a route,
calculate the time required to travel to a destination, determine the optimal departure time
to arrive at the destination on time, remember which station to disembark at, and use the
stop-request control at the appropriate time
• Motor and praxis skills: ability to step on and off the vehicle, maintain balance while walking
in a moving vehicle, and maintain postural control while standing or sitting in a moving
vehicle
• Sensory–perceptual skills: ability to identify obstacles on a public vehicle and judge spatial
relationships to identify seats, the stop-request control button, and the gap between the
vehicle and the sidewalk or platform
• Emotional regulation skills: ability to adjust to a crowded versus empty environment and to
handle unexpected events
• Communication and social skills: ability to ask for directions and obtain information
• Money management skills: ability to obtain a monthly pass, have the correct fare ready, and
use the change or ticket machines at the station
ii. Occupational therapy evaluation and intervention
• Assessment in the community setting
• Intervention using both remedial and compensatory strategies to address deficits in each
performance skill area
• Family and caregiver education on use of compensatory strategies
b. Paratransit services: transportation alternatives operated by transit systems for clients
who have functional impairments that limit their access to regular fixed-route services.
Paratransit is most typically offered in the form of van, shuttle, or microbus services that
pick up riders outside their home and take them to specific locations rather than requiring
them to be at a centralized bus stop. Even though some paratransit systems offer
customized assistance, most require that the rider be functionally able to meet the vehicle
at the street (Womack & Silverstein, 2012, pp. 28–29).
i. Performance skills required

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• Cognitive skills: ability to plan and make reservation ahead of time, problem-solving skills
for contingency when a ride does not show or is late, and ability to plan for and adapt to
longer rides
• Motor and praxis skills: ability to get on and off vehicle with limited or no assistance, ability
to get from door to curb without assistance, and sufficient endurance for postural control
during rides
• Sensory–perceptual skills: ability to judge spatial relationships in navigating between the
vehicle and the curb or sidewalk
• Emotional regulation skills: ability to handle unexpected events, such as a no show or late
ride, and longer rides
• Communication and social skills: ability to communicate needs on the telephone to reserve
rides, communicate destination addresses clearly and accurately, and communicate with the
driver about individual needs
• Money management skills: ability to prepare fare or manage tickets
ii. Occupational therapy evaluation and intervention
• Familiarity with policies of the local transit company
• Orientation and assistance to the client in the application process for paratransit
• Assistance with planning for ride reservations and contingency and safety preparations for
longer rides
2. Personal transportation: means of moving about in the community using either one’s own
bodily capacity or vehicular or nonvehicular transportation technology (Womack, 2012, p. CE1;
Womack & Silverstein, 2012, p. 31)
a. Private automobile
b. Other motorized or nonmotorized vehicle (e.g., golf cart, bicycle, scooter, skateboard)
c. Walking and other nonvehicular travel (e.g., running, skiing, skating)
i. Performance skills required for walking
• Cognitive skills: pathfinding ability, including selection of an alternate route when needed;
ability to observe pedestrian safety, such as using the sidewalk, crossing the street at an
intersection with a marked crosswalk, and waiting for the cross signal before crossing; safety
judgment, including checking traffic thoroughly before crossing at an intersection without a
cross signal; and multitasking ability
• Motor and praxis skills: ability to walk on uneven surfaces and inclines, walk around
obstacles, turn head to check traffic and maintain the path on the sidewalk, step up and
down from the curb safely, carry items while navigating with or without use of mobility aids,
cross an intersection within the required time, and maintain sufficient endurance
• Sensory–perceptual skills: ability to identify traffic, judge spatial relationships at the curb
and sidewalk, and maintain topographical orientation
• Emotional regulation skills: ability to adapt to crowded versus empty environments, observe
road safety precautions, and handle unexpected events
• Communication and social skills: ability to multitask in maintaining social conversation and
observing road safety, ask for directions, and observe social etiquette as a pedestrian
ii. Occupational therapy evaluation and intervention for walking
• Assessment in the community setting
• Intervention using both remedial and compensatory strategies to address deficits in each
performance skill area
• Family and caregiver education on use of compensatory strategies
3. Commercial transportation: transportation services operated as for-profit enterprises for which
people pay privately (Womack & Silverstein, 2012, p. 31)
a. Commercial carrier (e.g., airline, train)

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b. Taxi service
c. Shuttle and van service (small-vehicle fleet)
4. Supplemental transportation: volunteer, nonprofit, or community-based transportation options
serving older adults and people with disabilities who either are unable to use existing
transportation services or desire more flexible travel options (Eby et al., 2006, p. 446; Womack
& Silverstein, 2012, pp. 29–31)
a. Senior-friendly supplemental transportation is ideally based on the “Five As”: availability,
acceptability, accessibility, adaptability, and affordability (Womack & Silverstein, 2012, p.
31).
b. Supplemental transportation for seniors is particularly important because most U.S. older
adults who cease driving ride as passengers in private automobiles rather than use public
transportation (Stav, 2008; Womack & Silverstein, 2012).
5. Terms related to paratransit and supplemental transportation (Freund, 2002; ITNAmerica,
n.d.; Womack & Silverstein, 2012, pp. 32–33)
a. Curb-to-curb: Passengers are picked up at the curb of their point of origin and dropped off
at the curb of their destination. Drivers may assist riders with getting on and off the vehicle
but do not assist riders into buildings or with things they are carrying.
b. Door-to-door: Passengers may be assisted from the doorway of their point of origin to the
entrance to their destination but are not assisted to enter.
c. Door-through-door: Passengers may be assisted to exit their travel point of origin and to
enter the building at their destination, as well as on and off the vehicle. This assistance
may be direct physical assistance or assistance with packages.
d. Arm-through-arm: Passengers may be physically assisted by drivers to board, disembark,
and safely reach their final destination (similar to door-through-door, but specifies physical
assistance).
e. Demand-responsive: Transportation is provided between a specific point of origin and
specific destination requested by the traveler. Demand-responsive service travels on a
requested as opposed to a fixed route but may require advance reservations and may or
may not include physical assistance for the client.
C. Legal and political issues related to community mobility
1. Americans With Disabilities Act of 1990 (ADA; Pub. L. 101-336; Bolding et al., 2018, pp. 260–
262; Koketsu, 2018, pp. 191–192)
a. Established accessibility guidelines for public transportation (e.g., wheelchair lifts in buses,
wheelchair ramps or elevators around facilities)
b. Included guidelines to provide for priority seating, handrails, public address systems to
announce stops, stop-request controls, and clearly marked destination and route signs
(Bolding et al., 2018, p. 260)
c. Established a mandate for complementary paratransit services under Title II
(Transportation)—Part B (U.S. Department of Transportation, Federal Transit
Administration, 2020)
i. Paratransit eligibility criteria: Eligibility for paratransit refers to the determination
that a person, regardless of disability, cannot access fixed-route public transportation
and is therefore eligible for complementary paratransit service. The three categories of
eligibility are (1) inability to navigate the fixed-route transportation system, (2)
unavailability of the public transportation system at the time or place a person with a

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disability needs to travel, and (3) impairment-related inability to board or disembark at


a specific location (Americans With Disabilities Act & Information Technology Technical
Assistance Centers, n.d.).
ii. Determination of paratransit eligibility: Each entity required to provide complementary
paratransit service is required to establish a process for determining ADA paratransit
eligibility. The goal of this process is to ensure that only people who meet the regulatory
criteria, strictly applied, are regarded as eligible. Best practice in eligibility
determination encourages functional assessment of the traveler’s ability to access
transportation resources (Americans With Disabilities Act & Information Technology
Technical Assistance Centers, n.d.).
2. SAFETEA-LU Act: The Safe, Accountable, Flexible, Efficient Transportation Equity Act: A
Legacy for Users (Pub. L. 109-59) was legislation that funded the Safe Routes to School
program from 2005 to 2012, providing 100% federal funding to facilitate states’ initiatives to
create safe environments surrounding schools and encourage children to bike and walk to
school as part of developing a healthy lifestyle. In 2012 these initiatives were combined with
others as part of the federal Transportation Alternatives Program
(https://www.saferoutespartnership.org/).
3. Medicaid transportation provisions: Recipients of Medicaid may be eligible for subsidized
transportation for health care and life maintenance trips (Womack & Silverstein, 2012, pp. 28–
29).
4. Disparities in availability of public transportation: Fewer than 25% of U.S. rural residents are
served by public transportation (Eby et al., 2006, p. 446).
5. Economics of public transportation
a. The long-term financial viability of public transportation systems might benefit from
investment in training younger people with disabilities to use available services (Precin et
al., 2012).
b. Lack of transportation alternatives for older adults may affect the economy of their
communities when they can no longer easily access local businesses (Freund, 2002; Stav,
2008).
II. Occupational therapy and community mobility
A. Occupational therapy practitioners’ role in addressing community mobility
1. Community mobility as an IADL: The Occupational Therapy Practice Framework: Domain and
Process (4th ed.; AOTA, 2020) includes community mobility as an IADL performance area in
the domain of occupational therapy practice to be addressed by occupational therapists and
occupational therapy assistants along with other IADLs (AOTA, 2016, p. 1). Occupational
therapy practitioners are also encouraged to view community mobility as an enabler of other
occupations (Stav & McGuire, 2012, p. 13).
2. Scope of practice: Occupational therapy practitioners across all practice settings should
consider the community mobility needs of their clients (Stav & McGuire, 2012, pp. 1, 13) and
follow a process consistent with that outlined by AOTA (2020) to address community mobility,
including an occupational profile; analysis of occupational performance; intervention planning,
implementation, and review; and determination of outcomes (Stav & McGuire, 2012, p. 11).
B. Assessment of community mobility

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1. Community mobility in the occupational profile: An occupational profile should include


consideration of community mobility relevant to the client and the client’s context, leading to
an analysis of occupational performance. The practitioner should refer clients to a certified
driver rehabilitation specialist for further assessment of driving skills when indicated (Stav &
McGuire, 2012, p. 11; Womack & Silverstein, 2012, pp. 36–37).
2. Assessment of skills and capacities for travel: After completing the occupational profile, the
practitioner continues the evaluation process with measures of client factors, performance
skills, and contexts of the client’s engagement in community mobility to determine areas of
need (Stav & McGuire, 2012, p. 12; Womack, 2012, p. CE3; Womack & Silverstein, 2012, pp.
32–33). The same factors that limit the ability to drive may interfere with use of public
transportation (Crabtree et al., 2009).
3. Assessment of Readiness for Mobility Transitions (ARMT): The ARMT (King et al., 2011) is a
means of assessing the readiness of older adults to make transitions regarding their mobility,
such as driving cessation. Understanding how a client perceives transitions in community
mobility allows the practitioner to use the most appropriate approach to address these changes
(Womack & Silverstein, 2012, p. 37).
4. Assessment of the travel context
a. General considerations: AOTA (2016) emphasized the importance of assessing travel
contexts when considering the IADL of community mobility—specifically, analysis of
available transportation options, accessibility of resources, and policy review—as
components of this process.
b. Walkability: extent to which the built environment is pedestrian friendly. Measures are
available in the public domain that occupational therapy practitioners can use to assess
walkability (DiStefano et al., 2012; Womack & Silverstein, 2012, pp. 34, 47).
c. Livability: extent to which a community fulfills principles outlined by the National Council
on Disability (2006) regarding the physical, social, and transportation environments (U.S.
Department of Housing and Urban Development, n.d.; Womack & Silverstein, 2012, pp. 34–
35).
C. Occupational therapy interventions
1. Addressing community mobility as a generalist: Occupational therapists and occupational
therapy assistants without specialty credentials in driver rehabilitation evaluate and intervene
regarding general community mobility issues and refer clients to certified driver rehabilitation
specialists as indicated (Dickerson, 2012, pp. 419–421; Stav & McGuire, 2012, pp. 11–13).
2. Specific community mobility interventions
a. Travel training: short-term, direct, and intensive training to teach older adults and people
with disabilities to use fixed-route public transportation safely and independently (Womack
& Silverstein, 2012, pp. 33–34)
b. Mobility management: services that promote collaboration and cooperation among
transportation providers and connect clients to those providers (Eby et al., 2006, pp. 444–
454)
c. Systems-level interventions: consultation with transportation systems on issues such as
design of the travel environment for accessibility and creation of eligibility determination
processes for paratransit service (AOTA, 2016; Stav & McGuire, 2012, pp. 13–14)
3. Community mobility challenges with specific populations (AOTA, 2016; McGuire & Davis,
2012)

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a. Older adults (AOTA, 2016; Andonian & McRae, 2011; Classen, 2010; Crabtree et al., 2009;
Stav, 2008; Womack, 2012)
i. Older adults with dementia
• Driving cessation
• Education regarding community mobility alternatives
• Family and caregiver education and support regarding community mobility
ii. Well elderly and community-dwelling older adults
• Education and resources regarding community mobility options
• Maintenance of driving fitness
• Personal safety during community mobility
• Age-related changes in function and intersection with community mobility
iii. Older adults facing driving cessation
• Community mobility alternatives: education, resources
• Psychosocial support
• Travel training
b. Infants and children (AOTA, n.d.; Case-Smith & Arbesman, 2008, p. 422; Heath, Case,
McGuire, & Law, 2007; Sharp, Dunford, & Seddon, 2012; Shutrump, Manary, & Buning,
2008; Stav & McGuire, 2012, pp. 4–5; Womack & Silverstein, 2012, pp. 32, 47)
i. Children who are wheelchair users
• Safe school bus transportation
• Education and support regarding vehicle restraints
• Parent and caregiver education regarding safe community mobility
• Passenger safety
ii. Children with sensory processing disorders (SPD)
• Occupational analysis of the intersection between community mobility and sensory
processing issues
• Education for transportation providers regarding SPD
• Parent and caregiver education and support
• Interventions to assist children with SPD to adapt to community mobility challenges
iii. Parents of infants in the neonatal intensive care unit
• Passenger safety education
• Education and resources regarding infant car seats
c. People with specific disabling conditions (AOTA, 2016; Atkins, 2014; Benson, 2009;
Crabtree et al., 2009; Eby et al., 2006, pp. 445–446; Hegberg, 2012; Lund et al., 2012;
Precin et al., 2012; U.S. Department of Transportation, Federal Transit Administration,
2020; Wendel et al., 2010)
i. Developmental disabilities (e.g., autism spectrum disorder, intellectual and
developmental disabilities in both children and adults)
• Occupational analysis of community mobility activities and contexts relative to clients’
abilities and performance deficits
• Modification of the community mobility context to match clients’ abilities
• Travel training
• Passenger safety training
• Training and support for transportation entities serving clients with developmental
disabilities
• Opportunities to practice social interactions associated with community mobility
ii. Mental illness

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• Occupational analysis of community mobility activities and contexts relative to clients’


abilities and performance deficits
• Modification of the community mobility context to match clients’ abilities
• Travel training
• Opportunities to practice social interactions associated with community mobility
• Training and support for transportation entities serving clients with mental illness
iii. Spinal cord injury
• Analysis of the sensorimotor demands of community mobility that intersect with clients’
functional presentation
• Determination of community mobility options relative to performance capacities
• Travel training
• Collaboration with transit providers regarding wheelchair safety restraint
iv. Muscular dystrophy
• Occupational analysis of community mobility activities and contexts relative to clients’
abilities and performance deficits
• Modification of the community mobility context to match clients’ abilities
• Travel training
• Passenger safety training
• Training and support for transportation entities serving clients with progressive
neuromuscular conditions
v. Rheumatoid arthritis
• Occupational analysis of community mobility activities and contexts relative to clients’
abilities and performance deficits
• Modification of the community mobility context to match clients’ abilities
• Travel training
• Passenger safety training
• Training and support for transportation entities serving clients with rheumatic conditions
vi. Stroke
• Occupational analysis of community mobility activities and contexts relative to clients’
abilities and performance deficits
• Modification of the community mobility context to match clients’ abilities
• Travel training
• Passenger safety training
• Training and support for transportation entities serving clients with neurological disorders
vii. Cerebral palsy
• Occupational analysis of community mobility activities and contexts relative to clients’
abilities and performance deficits
• Modification of the community mobility context to match clients’ abilities
• Travel training
• Passenger safety training
• Training and support for transportation entities serving clients with cerebral palsy
III. Resources related to community mobility (AOTA, 2016, n.d.; Crabtree et al., 2009;
McGuire & Davis, 2012; Womack, 2012)
A. General resources
1. U.S. Department of Transportation Livability Initiative:
https://www.fhwa.dot.gov/livability/index.cfm
2. American Public Transportation Association: https://www.apta.com

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3. America Walks: https://americawalks.org


B. Resources specific to people with disabilities
1. Easter Seals Project Action: https://www.projectaction.com
2. National Council on Disability transportation policy: https://ncd.gov/policy/transportation
3. National Volunteer Transportation Center: https://ctaa.org/national-volunteer-transportation-
center/
C. Resources specific to older adults
1. National Aging and Disability Transportation Center: https://www.nadtc.org/
2. AARP Transportation and Livable Communities: https://www.aarp.org/livable-communities/
D. Resources specific to children
1. SafeKids Worldwide: https://safekids.org/
2. National AMBUCS–Amtryke Program: https://ambucs.org/
3. National Center for Safe Routes to School: http://www.saferoutesinfo.org/

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