Christen Occupational Therapy

The Airplane:
Another Solution to Transportation in a Rural Private Practice

James R. Christen, OTR

ABSTRACT. As a rural private practice in occupational therapy expanded to meet the service requests in a large, sparsely populated area, the need for fast, efficient transportation became obvious. A private pilot's license was acquired and then an airplane was purchased to meet that transportation need. The private practice, geographical area and the intervention methods are reviewed. The efficiency, cost, safety and practicality of flying, and its effect on the success of the private practice are then described.

An individual practice¹ was started in the geographical center of Nebraska (located in the town of Broken Bow—population 4,000) in 1976, following a subjective analysis of the possible needs for occupational therapy services.

THE GEOGRAPHICAL AREA

The 1980 census lists Nebraska's population as 1.6 million—this total is less than many of the nation's metropolitan areas. With an area of 77,227 square miles (475 miles long, 200 miles wide) the state's population density is 20.7. However, approximately two-thirds of the population is concentrated in the eastern one-sixth of the state, so the population density of the greater portion of the state is closer to 6 people per square mile and less than that in many areas. The American Heritage Dictionary defines rural as applying to sparsely settled or agricultural country as distinct from settled communities,² so it can be safely said that this is a rural practice. With the area being sparsely populated it does have some of the "strong flavor of Appalachia"³ and some of the abject conditions described by Seig.⁴ However, the area has no more of a monopoly on poverty and ignorance than it does on wealth and intelligence. there are many area farmers, ranchers and businessmen whose assets easily exceed the one million dollar mark. (As an example, Hyannis, a ranching community town of 330 in west central Nebraska has historically had the honor of having the greatest number of millionaires per capita in the state.) Several native businessmen, physicians, psychologists, etc., are nationally and internationally known and involved. this area being my home, my bias is understood.

Health care services and facilities are limited in many areas and it is not uncommon for people to travel up to 100 miles to obtain services. In contrast "Nebraska ranks second among the states in the number of licensed nursing-home beds in relation to its elderly population," according to the General Accounting Office.⁵ Although the people accept these facts as part of living in the area, the pioneering spirit is still strong and efforts are being made to improve the conditions. Thus the area was found to be receptive to the possible benefits of occupational therapy, and as Devereau suggested,³ the teaching/training by an occupational therapist enhances the effectiveness of the total treatment process and in turn, facilitates more referrals.

THE PRIVATE PRACTICE

The caseload of the "Practice" is difficult to define, particularly in terms of "caseload" as it refers to the number of patients being treated by a therapist in an occupational therapy department. The "Practice" consists of agreements/contracts with various agencies, facilities and individuals with each of these entities having a "caseload" in the classical sense. The variety of agencies, facilities and individuals is such that the occupational therapist must serve as a "generalist".

In pediatric, the "Practice" provides service to the State Department of Social Services/Services for Crippled Children's (SCC) program. This consists of serving on the monthly OT/PT Diagnostic Treatment Planning and Cerebral Palsy Clinics in four area cities located from 65 to 105 road miles from the home office. The SCC clinics recommend the amount of OT/PT services to be provided to the pediatric population, with the services then provided in, and reimbursed by, the local school district/State Department of Education. Services are provided in approximately fifteen school districts, located up to 135 road miles away from my office.

In geriatrics, the "Practice" has provider agreements with thirteen nursing homes (ICF & SNF), with the most distant being 225 road miles away. Agreements with four hospitals and a Home Health Agency (physical disabilities) could involve travel up to 70 road miles. On a weekly basic, psychiatric occupational therapy services are provided 105 road miles away to a state regional psychiatric hospital.

One of the more unusual provisions of occupational therapy service that the "Practice" has enjoyed, has been the request from two lawyers to provide evaluations/reports on their clients for Social Security Disability Court appeals when the report of the occupational therapy evaluation became the determining factor in the cases.

This total caseload is spread over monthly to quarterly schedule, and visits to facilities are often combined. Frequently, the schedule is arranged so that travel in an area will include stops in two or more places. For example: the SCC Clinics usually end in the early afternoon, so the remainder of the afternoon is then scheduled for school visits, individual patients, etc., in that city or perhaps a Home Health patient on the way back to Broken Bow.

In addition to serving as a "generalist" the occupational therapist is functioning primarily in a "consultant" role, as described by Mazer.⁶ The majority of the intervention time is spent working with the staff (or parents in pediatric cases). This involves working through the facility's system of treatment; i.e., the Individual Educational Plan in schools, the Overall Plan of Care in nursing homes, the Comprehensive Treatment Plan in the psychiatric hospital and the Individual Program Plan in the ICF-MR unit. Staff inservice presentations are also used as a means of affecting change in patient treatment.

The preceding description of the "Practice" and the geographical area that it covers further underscores, as documented by others,^4.7 the need for unique transportation when providing services in a rural area.

TRANSPORTATION MODES

The automobile is a common mode of transportation and serves the purpose well in the rural area. One very seldom encounters anything resembling a traffic jam (although I have had to wait up to five minutes, a few times, for a farmer transporting a large piece of equipment or a rancher moving cattle along or across a highway). The transportation problem can also be considered as a "time" problem, with "time" being an allocatable resource. One hour of traveling time by automobile, in this area, transports one approximately 50 road miles.

In December 1976, with the "Practice" just getting started, an opportunity arose to sign a provider agreement with a nursing home 135 road miles away. The nursing home was establishing an ICF-MR unit and anticipated needing occupational therapy services on a quarterly bias. The approximately three hours of travel time (six hours round trip), on a quarterly basis, was not felt to be unreasonable as the "Practice" needed the business. However, the need for occupational therapy service rapidly increased and by July of 1977, weekly visits were being made. The amount of time spent traveling had become unreasonable. In analyzing the situation, three options where considered: (a) terminate the agreement, (b) move to a location closer to the facility, (c) use a different mode of transportation—flying. the first option was felt to be unacceptable, as the "Practice" was still struggling to get established and the business was welcomed. The second option was also rejected as the geographically centered location of the "Practice" was proving beneficial in developing other agreements for services. The third option could not only solve the existing problem, but provide a means of developing more business and, at the same time, actualize a childhood dream. The decision was made to acquire a private pilot's license.

It was already known that the Broken Bow Municipal Airport offered flight instructions and aircraft rental, so a visit was made to the airport to obtain the particular details. After explaining the plan to my banker and obtaining a loan, ground school and flight instructions were started in the fall of 1977, and the private pilot's license was received in March of 1978.

The Dictionary of Occupational Titles⁸ worker functions rating for an airplane pilot is .263 as compared to .121 for an occupational therapist. The worker function ratings are a range from simple (higher numbers) to complex (0) with each rating including hose that are simpler and excluding the more complex. Thus an airplane pilot at .263 is said to react to Data at the Analyzing level, People at the Speaking-Serving level, and Things at the Driving-Operating level. An occupational therapist is said to react to Data at the Coordinating level, People at the Instructing level and Things at the Precision Working level. Therefore, according to this reference, there should be no problem with an occupational therapist becoming an airplane pilot.

Parts 61 and 67 of the Federal Aviation Regulations⁹ list the requirements for a private pilot's certificate. Generally stated, this involves obtaining a medical certificate, passing a written exam, having at least 20 hours of flight instruction and 20 hours of solo flight and passing a flight test. Another 20 hours of training, passing another written exam and another flight test are required to obtain an instrument rating. Part 91 of the Federal Aviation Regulations gives the requirements for Visual Flight Rules (VFR) and Instrument Flight Rules (IFR). for VFR flying, the pilot must maintain a required amount of visibility and distance from clouds, whereas IFR allows the pilot to fly in clouds—guided by instruments in the airplane, on the ground, and contact with an instrument flight control center.

EFFICIENCY

How efficient is private flying? The primary savings is time. In a sample analysis of one month's flying, 20 hours were flown traveling approximately 2,600 miles. Traveling to the same place by road would have resulted in 3,000 miles, and 60 hours of travel time (at an average of 50 mph). Thus, a savings of 40 hours was realized. The value of those 40 hours could be calculated by multiplying it by the "Pactice"s' hourly rate; however, those were 40 hours that the "Practice" would not otherwise have had available in which to provide services so it is felt that the benefits are greater than what simple multiplication would indicate. Perhaps a more precise formula would be: value equals time saved multiplied by the hourly rate plus the benefits of the services provided, or V = (T X R) + B. However, the benefits of the service provided are difficult to assign a numerical value to as they include both the facility's or patient's direct benefits and the benefits to the "Practice" in increased exposure that can result in more referrals.

It is also possible that this monthly time savings could be regarded as a one-fourth full-time-equivalent employee. To cite another example: Monthly visits to a nursing home 135 road miles away are combined with visits to a school 123 road miles from Broken Bow. The nursing home and school are 40 road mils apart, for a total round-trip mileage of 298 miles (5.98 hours travel time at 50 mph). By air, the round-trip mileage is 224 miles and the travel time 1.75 hours. This generates a savings, in one day, of approximately 4 hours; i.e., a one-half full-time-equivalent employee.

COST

An aviation rule-of-thumb is that over 150-200 hours of lying per year justifies owning a plane instead of renting one. Owning a plane also provides a marked degree of scheduling flexibility over renting. These factors were considered when the decision was made to purchase a plane in August of 1978, as airplanes had been rented for use up to that time. The "Practice"s' current aircraft, a 1978 Cessna Model 172N was purchased in March of 1979 with a 10-1/2 percent bank loan. The normal business tax advantages (investment credit, depreciation, etc.) further reduce the "apparent" cost so that when the travel time savings is considered (at a simple multiplication rate) the "Practice"s' flying cost is comparable to driving cost. The determining factor between flying or driving is the time saved. In this geographical area, with the distances traveled, the "Practice"s' current airplane is efficient. If one were regularly flying greater distances, or from an area of significantly higher elevation, different types of aircraft could be more appropriate.

SAFETY

In spite of the "front page" publicity that airplane crashes receive, private flying is safe. 91.1 percent of the 1982 transportation fatalities were highway related, while only 3.2 percent were aviation related.¹⁰ Even on long cross-country flights, other aircraft are seldom seen as regulations require pilots to fly at certain altitudes depending on the direction of flight—there are "highways" in the sky.

Airplanes do have their limitations and these must be respected. Each airplane has a maximum gross weight that includes the fuel, passengers and baggage. The pilot can vary the amount of fuel or load to meet a particular flight's requirements as long as the maximum gross weight is not exceeded. Each type of aircraft has its takeoff and landing capabilities, though modified by: the load being carried, the air temperature, the airport elevation, the type of runway surface and the wind velocity. The pilot does not always need a long, hard surfaced runway—landings and takeoffs are possible (and have been made) from farm fields.

The pilot's limitations must also be respected and accepted. A VFR rated pilot needs to avoid IFR conditions. Spatial disorientation, to the point of not even knowing which way is up, is possible. The training for IFR flying teaches the pilot to trust the airplane's instruments and ignore the body's vestibular system.

PRACTICALITY

A potential problem with flying is arranging for ground transportation once you arrive at the destination airport. Surprisingly, this is seldom a problem. The agreements/contracts are made with the understanding that I will be flying and that ground transportation will need to be provided by the facility. In most cases, the airports have a Fixed Base Operator (FBO) that can be called via the aircraft's communication radio while one is still ten to fifteen minutes away. The FBO staff then telephones the facility and advises them of my impending arrival (i.e., requesting transportation). Also, the FBOs usually have one or more "courtesy cars" that can be "borrowed" and for which one leaves a small "donation" upon returning. In the larger cities, the FBOs have rental cars or city taxis are available. When flying to an airport that does not have a FBO, I use a telephone in my airplane hanger to call the facility just before taking off, and give an estimate of my arrival time.

Weather can be a serious problem. It is standard procedure to check both the existing conditions and the forecast for the expected time of the return trip (this is one through the Federal Aviation Administration's Flight Service Stations). There have been times when it was possible/safe to fly but not drive; e.g., shortly after a winter storm when the sky was perfectly clear, the airports had been opened but some of the roads were still closed. More frequently, inclement weather forces the cancellation of flying plans and it is still possible/safe to drive. Dense fog, blizzards, etc., present conditions in which it is not possible/safe to fly or drive. Again, agreements/contracts are made with the understanding that weather conditions can, and do, affect the ability to travel. When travel is not possible, the visit is canceled and rescheduled. In such cases, a visit to a closer facility is substituted, if possible, or the time is spent in the home office (doing paperwork or reading).

In spite of weather problems the airplane has been a practical mode of transportation. There are more referrals than the "Practice" can accommodate. Time saving office procedures (e.g., using dictation and a typist, having a bookkeeper, etc.) are utilized. The consultation intervention role⁶ is effective in reaching a larger number of patients. Referrals are made to other occupational therapists whenever possible.

IN CONCLUSION

Using an airplane for transportation by a therapist in a rural occupational therapy practice will not be feasible in many settings; however, in this particular "Practice" it does work. In fact, it has worked too well! The benefits of occupational therapy services are being recognized in this rural area of Nebraska and consequently more services are being requested than the "Practice" is able to meet.

Rural areas have liabilities for living and working just as urban areas do. Perhaps if more attention (including during professional education) were given to the needs and rewards of practice in rural areas, then more therapists would consider and undertake rural practice. Rural health care service needs are tremendous, the challenges formidable yet manageable, and the rewards . . . isn't this what occupational therapy is supposed to be?

REFERENCES

1. Frazian BJ: Establishing and administering a private practice in a hospital setting. Am J Occup Ther 32: 296-300, 1978
2. American Heritage Dictionary, Second College Edition, Boston: Houghton Mifflin Company 1982, p 1079
3. Devereaux, EB: Community home health care in the rural setting. In Willard and Spackman's Occupational Therapy, HL Hopkins, HD Smith, Editors, Philadelphia: JB Lippincott Co 653-671, 1978
4. Sieg KW: Rural health and the role of occupational therapy. Am J Occup Ther 29: 75-80, 1975
5. Omaha World Herald, 17 January 1984
6. Mazer, JL: The Occupational Therapist as Consultant, Am J Occup Ther 23: 417-421, 1969
7. Magrun WM, Tigges KN: A transdisciplinary mobile intervention program for rural areas. Am J Occup Ther 36: 90-94, 1982
8. Dictionary of Occupational Titles, Fourth Edition. Washington, C.C. US Government Printing Office 1977, pp 59 146; 1369-1371
9. Colvin JK, Ed: AOPA's Handbook for Pilots 1983, Bethesda: Aircraft Owners and Pilots Association, 983, pp 271-408
10. "1984 Aviation Fact Card", AOPA Newsletter, January 1984, p 8

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James R. Christen is owner/operator of a private practice in occupational therapy with headquarters in Broken Bow, Nebraska. Because of scarcity of therapists in rural areas of the state, his caseload is spread over a wide geographic area and covers any kinds of patients.

this article appears jointly in Private Practice in Occupational Therapy (The Haworth Press, Inc., 1985), and Occupational Therapy in Health Care, Volume 2, Number 2 (Summer 1985).