Where NEMT riders fall, and the habits that stop it: curbs, ramps, steps, and doorways

Five points to guard on every trip

The points to guard are the moments a rider changes level or surface. Watch these five:

1. The van step. The rider lifts their full weight from the ground onto a step, often with one hand free.
2. The curb and walkway. Uneven pavement, puddles, and ice on the path from the house to the van.
3. Ramps and lifts. A wheel off the edge, a platform that is not level, or a standing rider without a grip.
4. Doorways and thresholds. Heavy doors, raised thresholds, and floor mats at homes and clinics.
5. Inside the moving van. A rider who stands up early, or a sudden stop before the belt is fastened.

The riders themselves carry risk into each of those moments. NIA counts more than a quarter of adults 65 and older falling in any given year, with the risk rising as people age. NIA links falls to weaker eyesight and reflexes, dementia and mild cognitive impairment, blood pressure that drops on standing up, loss of muscle, balance and gait problems, medications that cause dizziness or confusion, and backless shoes or high heels. Many NEMT riders have several of these at once.

Match the booking to the help the rider needs

A large share of fall risk is decided on the booking call. When a rider who can’t reach the door without help is booked as curb-to-curb, the driver stays at the van and the rider crosses the walkway alone. Broker manuals define the levels, and they differ on details:

Some help is outside a driver’s job at any level. CareOregon bars drivers from wheelchair or bed transfers and from carrying a rider’s full weight on a walk, unless the driver holds a license, has training, and has the brokerage’s go-ahead. On stairs, CareOregon drivers can guide a member, but carrying them or physically helping them up or down is off limits, and the driver reports the need to the NEMT manager. That rider needs a different level of service, for example a stair chair crew or a stretcher.

Add fall questions to your trip intake script:

• How many steps are at the entrance, and is there a handrail?
• Does the rider use a cane, walker, or wheelchair, and will they bring it?
• Has the rider fallen recently, or do they get dizzy when standing?
• Is there a closer door, ramp, or driveway the driver should use?

Put the answers on the manifest. A driver who knows about four steps without a rail brings the right help or calls dispatch before arriving.

The van step: stools, handholds, and light

Close the gap between ground and first step, and give the rider something solid to hold. Several programs write this into their vehicle rules.

• Texas health plans require a retractable step or a step stool when the vehicle has no running board or similar device, and ban milk crates and other makeshift stools.
• Georgia requires either a retractable step or a DCH-approved stool on every vehicle with a step up at the door, stretcher vans excepted. The stool has four legs with anti-skid tips and is sturdy metal with a non-skid tread, 8 1/4 inches high, 15 inches wide, and 14 inches deep, or an equally suitable replacement. Georgia states that a milk crate or similar substitute is never acceptable.

Federal accessibility specs for buses and vans (49 CFR Part 38) spell out the details, and MTM’s Virginia handbook makes meeting them a condition of service:

• Slip resistance. Steps, aisles, and floor areas where people walk must have slip-resistant surfaces (49 CFR 38.25).
• Contrast. Step edges, thresholds, and the boarding edge of a ramp or lift carry a full-width band of contrasting color, so a rider with poor eyesight sees where the step ends.
• Handholds at the door. Handrails and stanchions at the entrance must let a rider grasp them from outside the vehicle and keep holding through boarding (49 CFR 38.29).
• Light. Stepwells and doorways need at least 2 foot-candles on the step tread, and an outside light must put at least 1 foot-candle on the street surface for 3 feet out from the bottom step (49 CFR 38.31).

Technique matters as much as equipment. Texas drivers must step out to handle the doors and help members in and out. Set the stool on flat ground under the step, stand to the side the rider leans toward, and let the rider pull on the handhold while you steady rather than lift. Ask the rider to stand up slowly after a long ride, since NIA warns that getting up quickly can drop blood pressure and make a person unsteady.

Ramps and lifts

A ramp or lift is only as safe as the way it is set up and used. The lift and ramp specifications in 49 CFR 38.23 build in the safeguards, and the driver’s habits keep them working.

Two federal rules in 49 CFR 37.165 apply to how you use the equipment. Where necessary or when a rider asks, your staff must help with securement systems, ramps, and lifts, leaving the driver’s seat to do it. And riders with disabilities who do not use wheelchairs, including people who stand, must be allowed to use the lift or ramp to board.

Habits that keep the equipment safe:

1. Park on level ground so the ramp or platform sits flat, and away from slopes and drainage grates.
2. Check that the ramp is fully seated or the outer barrier is up before any weight goes on it.
3. Keep a standing rider holding both handrails for the whole cycle.
4. Secure the wheelchair only after it is fully inside, following wheelchair securement standards.
5. Stop using a lift that jerks, drifts, or will not stay level, and report it before the next trip.

Curbs, walkways, weather, and footwear

The rider is least supported on the walk from the house to the van. Choose the stopping point with care. MTM’s Virginia handbook tells drivers to park where passengers can reach the entrance safely without crossing streets whenever possible. A driveway that puts the rider on level ground is better than a high curb, even if it adds a minute.

Weather multiplies the risk. NIA advises extra care on wet or icy surfaces and suggests ice melt or sand on icy walkways. In winter, carry both in every van and use them before the rider steps out. Minnesota’s special transportation rules set an eight-hour minimum of passenger assistance training for any driver or attendant carrying riders seated in wheelchairs, and the course covers chairs on uneven, wet, or icy ground and moving chairs over curbs, steps, and ramps. Your broader bad weather policy decides when a trip should wait instead.

Footwear and free hands matter too. NIA recommends nonskid, rubber-soled, low-heeled shoes and warns against socks or smooth-soled slippers. It also suggests a shoulder bag or backpack so both hands stay free for railings. Drivers can carry the bag, ask a rider in slippers to change if time allows, and note repeat problems on the rider’s profile so the next booking includes a reminder.

Doorways and the handoff inside

The trip is not over at the curb for riders who need door-to-door help. MTM’s Virginia handbook says members are escorted safely inside at the destination before the driver leaves, and Rhode Island’s handbook has drivers confirm the member is safely inside before departing.

At the door, hold it fully open rather than letting the rider push a heavy door while stepping over a threshold. Point out raised thresholds and loose mats. For riders who need more than an arm, for example a rider with dementia, hand-to-hand or door-through-door service keeps a responsible adult with them past the entrance.

Inside the moving van

Once aboard, the fall risk comes from motion. Under MTM’s Virginia handbook, the van stays put until every passenger’s seat belt is fastened, and drivers help any rider who cannot buckle alone. Minnesota’s training rule tells drivers that passengers may have balance or mobility problems and may not be able to grab railings or brace for sudden stops, sharp turns, or abrupt maneuvers.

Drive for the most fragile rider on board. Brake early, take turns slowly, and ask riders to stay seated until the van is parked and the driver comes to the door.

When a rider falls

Have a fixed routine so the driver acts calmly instead of trying to fix it fast.

1. Do not pull the rider up. NIA warns that getting up too quickly or the wrong way can make an injury worse. CareOregon bars drivers from full-weight lifting unless trained and authorized.
2. Check and comfort. Ask where it hurts, keep the rider still and warm, and stay with them. Texas permits physical contact for first aid within the driver’s training.
3. Get emergency help. Call 911 for any injury, a head strike, or a rider who cannot get up alone. If the situation calls for an ambulance, CareOregon requires the 911 call plus an immediate call to the brokerage’s dispatch.
4. Call dispatch. The office arranges coverage for the rest of the run and notifies the broker. Rhode Island’s MTM handbook puts every injury in Tier 1, which means an immediate phone call plus written follow-up within 24 hours. CareOregon also wants written notice at once for any passenger injury.
5. Write it up. Fill out an incident report before the shift ends: where, how, what the rider said, who was called, and the time of each step.
6. Review the booking. Ask whether the level of service, vehicle, or entrance should change, and update the rider’s profile.

Encourage the rider or family to tell the rider’s doctor about the fall. NIA advises reporting any fall to a doctor, even one without pain, because it can reveal a medical or medication problem. The medical side is covered in on-board medical emergencies, and the lifting technique in safe passenger transfers.

Setting up vans and trips in HealthRide

HealthRide keeps a record of what each van can carry, such as a wheelchair, a stretcher, or oxygen, and scheduling reads it, so a wheelchair trip only lands on a van equipped for it. Drivers inspect their van in the app before every shift, and failed items show up for dispatch immediately, so a broken step or lift gets fixed in the lot, not discovered at a pickup. See fleet management for how vehicles and inspections work.