Recently, an industry expert jokingly referred to adaptive automotive equipment as "the biggest little industry in HME." Though said tongue-in-cheek, the statement bears a bit of truth. Think about all that goes into vehicle adaptations — lifts, ramps, securement devices, hand controls, accessories, van conversions — and the industry's definition stretches from a mere segment of mobility to a business unto its own.
Dana Roeling, National Mobility Equipment Dealers Association (NMEDA) executive director, headquartered in Tampa, Fla., says that adapting vehicles is absolutely a specialty business. "It is very, very specialized because each person with a disability has a different need," says Roeling. For that reason, adaptive automotive dealers must be experts, "so when (clients) say I've got this particular disease or I've got this particular disability, the mobility dealer has been trained and they know what equipment's going to work or what equipment won't. They also know what equipment will fit into their vehicle or if that vehicle could even be modified for that particular need."
NMEDA, the national organization at the forefront of qualifying dealers through the Quality Assurance Program, recommends that a client seeking a vehicle adaptation first visit an adaptive automotive dealer. As the first step to adaptive driving, dealers take on a huge responsibility for everything from safety to the perfect fit for clients.
The More You Know
To create the perfect adaptive automotive dealer, start with a person skilled in vehicle modifications who possesses a good working knowledge of mechanics. Then add in strong mobility dealer skills to include just the right seasoning of business sense, customer service skills, and a broad knowledge of mobility products, medical conditions, disabilities and aging-related mobility issues that might inhibit driving ability. Next, stir in manufacturer liaisons, doctor and driver evaluation specialists relationships, a NMEDA membership and an expertise in motor vehicle safety standards determined by the National Highway Traffic Safety Administration (NHTSA).
Explaining just what it takes to be an automotive access dealer sounds something like explaining what a surgeon does. A lot goes into it and each solution is different for each mobility user. Some clients might need only a ramp, which could require either little or no vehicle modifications or some very expensive vehicle modifications. Others might need a vehicle lift to raise a wheelchair into a van. Still others might require a securement device to lock a wheelchair into place during transport. For those who have limited mobility, special controls might need to be installed to make driving a possibility. And for many clients, a mix of all of these devices is necessary. Whatever the need, customization is key, and the dealer must walk a client through the entire process from picking out an adaptive vehicle and determining proper modifications to modifying the vehicle and final delivery.
"It's not easy to just open the door and get into (the industry)," explains Roeling. "It's not like a car garage."
Bob Nunn, NMEDA's president of the board of directors, agrees. "There's really a lot of background homework and studying and access to product that they're going to need before they can even really entertain the idea," he says.
As part of NMEDA's QAP, a nationally recognized accreditation program for the adaptive mobility equipment industry, dealers are classified by three categories: mobility equipment installers, structural vehicle modifiers and high-tech driving system installers.
A mobility equipment installer works with trunk lifts for wheelchairs and scooters; portable ramps; power and manual wheelchair tie-downs; simple non-driver devices; manual hand controls; steering devices; left foot accelerators; pedal extensions; rooftop carriers; low and zero effort steering systems with backup; low and zero effort braking systems with backup; driver and passenger power and manual transfer seats; wheelchair lifts; secondary driving aids (non-electrical); driver trainer brakes and power seat bases.
To be a structural vehicle modifier, a dealer must provide all structural modifications including lowered floors, power pans, raised roofs, raised doors and support cages. A high-tech driving system installer, on the other hand, would provide all high-tech primary driving systems including electronic and pneumatic gas/brakes; horizontal, joystick, hydraulic and electronic steering systems; and touch pads/secondary controls (requiring electrical).
Because of the complexity of the work, Roeling and Nunn recommend that anyone interested in establishing an adaptive automotive dealership first visit one. "My advice as executive director," says Roeling, "would be before they even consider joining or getting into the business is to go and visit various mobility dealers in the city or state where they live and really see what goes into the business of running a mobility dealership."
So, that's exactly what Home Health Products did.
Securement Devices: Get the Most from a Tie-Down
A Day in the Life
Advanced Mobility Systems of Texas Inc., Fort Worth, a QAP certified NMEDA dealer established in 1989, services all three segments of the adaptive automotive industry.
For new customers, Guy Tucker, president, and salesman Doug Knott first talk with the customer about his or her needs.
"The first thing we do is to let them explain where they're coming from, what they know, what their situation is," says Knott. "Is it for themselves, for a family member?"
The needs of one customer don't always match the needs of the customer before him. "It's really a big melting pot of all," says Tucker. "We have no one client that's the same. Everybody's uniquely different in their needs. … And it takes a lot of time to experience and learn people's needs. And we learn something new just about every day."
To stay on top of the different conditions and needs of their customers, Tucker and Knott attend conferences and work closely with the Association for Driver Rehabilitation Specialists (ADED). Tucker and Knott's understanding of the progression of conditions, such as the degenerative ALS, and the different characteristics of conditions, such as multiple sclerosis, which could be better or worse for a client depending on the day, helps them determine which vehicles and modifications to recommend for clients.
Tucker says the shop has developed relationships with doctors and asks clients for prescriptions or a driver evaluation to help facilitate the process.
Once a plan has been formed, Tucker and Knott help a client develop a plan for financing. Unlike the HME world, the Centers for Medicare and Medicaid Services (CMS) is not a primary payer. "Medicare doesn't pay a nickel on any mobility equipment that has to do with a vehicle," says Knott. "They'll pay for a wheelchair, a hospital bed, stuff like that, but you talk about getting around a vehicle, they don't pay anything on that. That's where we try to kick in on the other sources."
"A lot of people come in here with the assumption that it's out of their pocket money," says Tucker, "and we educate them on what products are available and talk to them about all their needs and we talk to them about third-party payers such as insurance (and) DARS, Department of Assisted Rehab Services, formerly TRC." Other agencies include the Veterans Administration, a big player in this market, different social agencies and the Medicaid waiver program.
Because of the funding issues, buying a modified vehicle is not a quick process. Tucker says it could take from three or four months up to a couple of years. If that becomes an issue, a lot of times, the Fort Worth shop will help a customer purchase a used vehicle and then buy it back when the funding comes through.
The full-service shop runs a gamut of services, including selling, converting, adapting, renting and repairing vans.
"The biggest need is people have this equipment and they'll get ready to go to work and maybe their door or ramp doesn't work or maybe their power seat doesn't work," says Tucker. "Most of these vehicles have some age on them, and the quick repair, that's what we see the most. It's real important to us to meet them at the door, take care of their issue and get them going for the day."
If repairs will take a while, the company, a member of Accessible Vans of America, a nationwide network of dealers that provide rental vans, offers a van equipped with lowered floors and power ramps and doors from its rental fleet so the customer experiences less interruption in daily life. Very few rental places offer adapted vans for people with disabilities.
For other customers, vehicle modifications might be needed, such as something "as simple as people that have trouble getting in a vehicle, like maybe opening the door or not being able to get into the seat, to real sophisticated high-tech driving controls for people that do not have enough strength to comb their hair or scratch their nose," says Tucker. "With the right process and evaluations, we get them driving vehicles."
Ideally, customers will go to Tucker before going to a car lot. In streamlining transportation for people with disabilities, the shop helps customers choose the best vehicle to meet their needs through a vehicle evaluation.
Tucker explains that in a lot of cases customers will go out and purchase a vehicle and then come to a shop that does vehicle modifications. And that, he says, is the wrong thing to do because oftentimes it results in very costly mistakes. "(It's a) sometimes disheartening fact that they've purchased the wrong vehicle and then they have to, in most cases, either live with an option that's not best for them or go trade that vehicle and lose money on it," says Tucker.
Once the correct vehicle selection has been made, another area of the shop gets busy installing the necessary hardware and securement devices.
Between the company's two stores — the other is located in Mesquite, Texas — a total of approximately 30 employees work on vehicles. The sales force handles both the personal and commercial aspects of the business. For technicians, "we have it broke down into three categories," explains Tucker. "We have our structural people that are cross-trained to do built-on installation. We have our repair and installation people, and then we have our high-tech department that mostly deals with driving systems."
The garage is organized to accommodate the different repairs that are made. One area houses all of the major equipment, including a TIG welder and a Vand saw that cuts wheelchair tie-down tracks. It is in this area that the van conversions and lift installations take place. The area directly off the office accommodates the installation of high-tech driving devices, and between the two garage areas, parts are stored.
The shop operates Monday through Saturday, 9 a.m. to 6 p.m. on the weekdays and 9 a.m. to 2 p.m. or until the last customer is served on Saturday.
To stay on top of technical issues, Advanced Mobility Systems participates in a number of service schools, like those offered by manufacturers Bruno, Braun, VMI and IMS and the various car manufacturers. Staff also attends the annual NMEDA conference, participates in training taught by the shop's technicians and visits other NMEDA dealers throughout the country. Tucker explains that NMEDA dealers often talk on the phone and visit each other's shops to learn about the latest practices and safety issues. On the day of HHP's visit, dealers from Grosse Tete, La., roughly 390 miles from Fort Worth, were taking a look at a new lift system and dashboard in one of the minivans on the lot.
Tucker says NMEDA has had a big impact on business. Circuit Breaker, a quarterly newsletter published by NMEDA, keeps the shop informed of new safety regulations and best practices, and the network helps dealers comply with those standards.
Before it was Advanced Mobility Systems, Tucker says the company started off in the conversion industry doing custom seats and paint. Gradually, the company phased into meeting the needs of mobility, especially repairing lifts.
The most rewarding part for Tucker is definitely, "the delivery, when people roll out in their new or used converted vehicle," he says.
Robin Maisel, a client who has MS, drives 90 miles from Waco, Texas, to have his van serviced by Advanced Mobility Systems. He recounts his first experience with the shop. A part for Maisel's van was needed that was no longer on the market. The technicians found a way to correct the problem without the new part. "They tried to charge me nothing," says Maisel. "That was my first experience." To Maisel, driving means freedom, and working with a dealer that understands and offers advice and cooperation makes a tremendous difference.
WC-19: What Does It Mean?
Talk from the Front Lines
One of the most important success factors, says Roeling, is communication, both between the dealer and manufacturer and the dealer and client, "because every person with a disability or aging senior has a different need. And it can't be cookie cut." In addition, says Roeling, "You have to be able to, in today's world, have a pathway to compliance. You have to be legal, you have to be able to be doing things the correct way."
NMEDA is the organization most adaptive automotive dealers turn to in order to follow that correct path. "You can't survive out there without being a NMEDA member basically," says John Quandt, of Advanced Wheels, East Granby, Conn., and NMEDA past president. "We'll watch everything that comes out of Washington as it pertains to our industry. We are the group that basically has found a way to set the rules and basically almost self-regulate our own industry. We recognize that there had to be a higher standard for doing stuff."
Modifying vehicles at a higher standard means a couple of things for dealers. First and foremost, you have to have the proper education and training. "I think what dealers need to know is a good background on the industry, where it's come from and where we are today with the new safety standards," says Bruce Ayers, of Ayers Handicap Conversion Center, North Quincy, Mass. "And it's paramount that we have the right training and equipment available for our customers."
Training involves connecting with manufacturers and visiting technical training schools throughout the year. Tucker says he visits about eight per year including the annual NMEDA conference. A commitment to quality would certainly involve adhering to the standards set by NMEDA through QAP. Ayers says every two or three years, his dealership gets recertified.
The right training enables the dealer to place customers in the right equipment. "Almost like a tailor fits someone to a suit," says Ayers, "we would measure (clients) seated in their wheelchair, we would measure the width of the chair, the length of the chair and then from the top of their head to the floor. And just based on those measurements, we can determine whether or not we need to raise the roof or lower the floor."
As gatekeeper to the adaptive automotive industry, NMEDA oversees a broad spectrum of safety regulations. Ayers says, "There's certain standards … (for) even right down to the nuts and bolts we use. There has to be a certain grade bolt, lock washers, lock nuts. I mean, it is very thorough, so God forbid if there was an accident, this conversion would give the maximum amount of safety to the individual."
The second thing a dealer needs is the right tools, which includes welding and electrical equipment, says Ayers. A lot of the equipment is similar to that found in a garage, but that's where the similarities end. "It's not like when you go to the garage and they put a muffler on your car and you're gone," says Ayers. "You're working with the individual personally, one on one, to determine how to design their vehicle to improve their lifestyle. So, when there are repairs that are needed and adjustments to be made or even new vans, you develop a relationship with your customer."
Probably one of the most important things a dealer will need is liability insurance beyond that of a standard garage. "If you don't have trained techs and folks that have been to the service schools and know how to install this stuff, then you just shouldn't be doing it," says Quandt. "Nor will you be able to have the proper insurance. Nor will anybody sell you products because … most of our stuff has heavy liability attached." To cover these liability issues, many states now require that dealers be a NMEDA member and even a QAP member.
Times have changed from the days when there were no organizations like NMEDA and no safety standards. "In the 70s, there weren't any regulations hardly," says Quandt. "I mean, literally, you could tie folks into vans with whatever held and your best guess, more or less."
In his 18 years of serving the adaptive automotive industry, Quandt has seen a lot of change, from the Vietnam era that really influenced the Veterans Administration's involvement in the industry, to the inception of the first minivan that rocked the industry, to today's safety standards.
"In those days, you could just look at someone and … say, 'OK, how do I get them into this vehicle?' Or, they can't turn the wheel; how to we get them to be able to turn the wheel?" says Quandt. "And it was as simple as that. And if you could find a way to do it, you could build it and you could attach it to the vehicle and they would drive off into the sunset. But you can't do that anymore. Products have to be tested."
Quandt calls the 80s and 90s a period of "huge development and enlightenment" when advancements in technology and medicine really started to happen for the industry. The minivan, for example, basically gave customers "a really nice vehicle that looks really mainstream that you can park in a garage and that isn't a big ark of a thing," says Quandt. "It's built so that the people in the wheelchairs can actually see out the windows because before they couldn't. We'd raise the roof and their head would be sitting up into this cave that we had installed on the top of the thing, much like the dial-a-rides are built now." Since then, the minivan, now the industry standard, has continued to evolve to meet the needs of consumers.
One thing that hasn't changed, however, is dedication and the desire to truly impact someone's life, essential for a committed adaptive automotive dealer. "I remember when we first started out," says Ayers. "We would find people on Cape Cod that didn't want to go out because they felt that they would be a burden on maybe a friend or a loved one. And … when they found out this type of equipment was available to make them independent, it changed their whole lifestyle. You start to see people who wanted to be more independent and not rely on other people. And with this type of adaptive equipment, it was the key to independence. They go out, they start getting jobs, they go back to school, they get more involved in their community."
Though the adaptive automotive industry may be unlike any other segment of HME, this commitment to the client is the tie that binds.
In the not so distant past, wheelchair manufacturers recommended that users transfer out of a wheelchair during transit in a motor vehicle, but the reality is such that transferring is not always convenient or possible. Recognizing the innate safety concerns for transporting people riding in wheelchairs, the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) sought to establish guidelines to make the ride safer.
The brain child of the ANSI/RESNA Subcommittee on Wheelchairs and Transportation (SOWHAT), WC-19 for Wheelchairs Used as Seats in Motor Vehicles was approved by the American National Standards Institute (ANSI) umbrella, a subcommittee within the RESNA Technical Guidelines Committee, on April 19, 2000. Under the voluntary U.S. national standard, wheelchairs are required to meet certain safety guidelines determined by crash tests.
According to the University of Michigan Transportation Research Institute, involved with SOWHAT, several specific features must be in place to make a chair WC-19 compliant. Those features include:
Though the standard is voluntary, many manufacturers recognize the importance of the standard and are taking steps to offer WC-19 wheelchairs. The impact on the industry remains to be seen.
Bob Nunn, NMEDA president of the board of directors, Tampa, Fla., says that the standard isn't currently having much impact for NMEDA dealers. "Obviously there are some wheelchairs that are built to that standard, but I'd say the majority of our clients don't use chairs or scooters that would meet that standard," he says. Nunn cites the conflict between WC-19 standards and user comfort for the lack of impact. "Typically a wheelchair's got to be quite a bit heavier and stronger to meet that standard," he says. "People in chairs, they're looking for lightweight, comfort and a number of things, so one sort of defeats the other where the chair needs to be strong enough to withstand some of the forces for some of the specified sled testing and stuff. … So, we haven't seen a big impact yet. We may down the road."
John Quandt, Advanced Wheels, East Granby, Conn., says dealers are already using tie-downs that adhere to safety standards, so it only makes sense that the wheelchairs meet the same standards. "For some time it just seemed incredibly ironic that we know the tie-down is crash tested but there were probably chairs that were being attached at the time that would snap like a match. So, I think it's punitive on the manufacturers to try to make everything to a standard that would hold up in a crash."
According to a study conducted by the Center for Urban Transportation Research at the University of South Florida, Tampa, the two most common types of devices used to secure a wheelchair in a vehicle are tie-down/belt systems and wheel-lock securement devices. In fact, the most common securement device is a tie-down that employs four straps, according to the Rehabilitation Engineering Research Center on Wheelchair Transportation Safety, University of Michigan, Ann Arbor.
The four-point tie-down, also known as a manual tie-down, features a four-point belt to attach to four corners of the wheelchair — two in the front and two in the rear — with a lap and shoulder restraint, says Bruce Ayers, of Ayers Handicap Conversion Center, North Quincy, Mass.
To provide the utmost safety to a wheelchair user, the following guidelines, offered by the University of Michigan, should be adhered to:
An electrical tie-down or docking tie-down device, another method of securement, requires adding adaptor hardware to the wheelchair frame. These devices enable a wheelchair user to secure and release the wheelchair without assistance. "People usually prefer the electric one if they can afford it because it's very simple," says Ayers. "You just roll back into the box and it locks you in."
Adaptive Driving Alliance
Nationwide group of vehicle modification dealers that provide van conversions, hand controls, wheelchair lifts, scooter lifts, tie-downs, conversion van rentals, paratransit and other adaptive equipment for disabled drivers and passengers.
The Association for Driver Rehabilitation Specialists (ADED)
Educational association devoted to supporting professionals working in the field of driver education and transportation equipment modifications for persons with disabilities.
National Mobility Equipment Dealers Association (NMEDA)
Organization committed to ensuring quality and professionalism in the manufacturing and installation of safe and reliable adaptive equipment in vehicles for drivers and passengers with disabilities.
This article originally appeared in the April 2006 issue of HME Business.