Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services (2021)

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1 The Relationship of Transportation and Health Care Efforts to improve health in the United States increasingly recognize that it is not just the health-care system that is responsible. It is a range of factors that collectively affect health and health outcomes. These factors are known as the “social determinants of health,” and, significantly, they include transportation. With available and reliable transportation, individuals can travel in their communities to access the medical appointments and services they need. Without that access, care is delayed or missed, which increases not only the potential for poor health outcomes but also the cost for health care. Particularly for those with chronic diseases, delays in care and missed appointments complicate disease management and may worsen patients’ health, which increases overall health-care expenditures. The federal government, through an initiative of the Centers for Medicare and Medicaid Services (CMS), is encouraging partnerships between health-care providers and commu- nity services, including transportation, that are available and responsive to the needs of community residents. But what does that mean for a community? • What is responsive? • What is effective transportation? • How are partnerships initiated and developed? • Are there examples of effective partnerships between the transportation and health-care sectors that can be highlighted as examples for other communities? These are some of the questions raised by this research project. Its two objectives that attempt to answer those questions include: first, develop a guidebook to help communities improve transportation to health care and second, develop a research plan that outlines future research needs and priorities to further the understanding of the transportation and health-care relationship. Why Should Communities Improve Access to Health Care? Access to health care is critical for promoting and maintaining health, preventing and managing diseases, and working toward health equity for all Americans. And transpor- tation has a significant role in that access (Exhibit i). It has been called fundamental to societal health. S U M M A R Y Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services

2 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Effective transportation ensures a connection to health-care services for residents in a community and improves access to other needed services and destinations. Local com- munities have a role to play in providing that transportation for their residents—not only improving health outcomes for their residents but also expanding access to a range of community services and places. The Research Project: Process and Findings The research began with a background literature review followed by surveys of pro viders of transportation as well as of health care and social services to learn about their efforts to improve access to health care. This work led to case study research of transportation and health-care relationships to try and understand how the arrangements began and what exactly was involved. The research efforts provided material for the guidebook, with sug- gestions on how to initiate a dialogue between transportation and health-care providers as well as subsequent actions and strategies for pursuing a partnership and implementing transportation solutions appropriate for patients. Successful programs and partnerships identified through the project were documented and described either as detailed case studies or as collaborative practices for the guidebook, providing ideas and resources for com- munities interested in improving transportation access to health care. Summary of the Project’s Background Research The availability of transportation influences the ability of individuals to access health care, whether in urban, suburban, or rural areas. Those lacking appropriate or available transpor- tation miss health-care appointments, resulting in delays in receiving medical interventions, which may then lead to poorer health outcomes. This in turn contributes to the rising cost of health care. Research has found that access to reliable and affordable transportation is associated with increased utilization of health services and improved health outcomes; that improved access to health care will provide for greater patient encounters and reduced no-show rates; and Exhibit i. The purpose of almost 10% of the ridership in this large rural system is to access health care. Photo courtesy of KFH Group.

Summary 3 that readily-available transportation can prevent extra stays in the hospital and generate overall cost savings. Available data do not show exact numbers of patients affected by a lack of transportation. According to research, the range is as great as 10% to 50% of patients who report transporta- tion as a barrier to accessing health care. Certain population groups have been identified as more likely to have transportation needs impacting access to health care. These include the elderly, those with disabilities, individuals with lower incomes, those without their own transportation, veterans using the Department of Veteran Affairs’ (VAs’) medical system, patients with chronic diseases, and those living in isolated rural areas (Exhibit ii). Barriers to improving transportation access to health care include transportation infra- structure issues—for example, limited, poorly designed or ineffective public transportation service; long travel distances to access health care; and limited communication, information sharing, and coordination between the health-care and transportation sectors that other- wise might work toward improving transportation access. Significantly, the research project has found that such barriers are not always unsurmountable. Guidance for Pursuing a Health Care and Transportation Partnership The guidebook addresses the various dimensions and elements of working toward a health-care and transportation partnership. These elements are not necessarily stepwise, and the development of a partnership may not include all the elements, but generally, the following dimensions provide a framework for pursuing a health-care and transportation partnership: • Understand Differing Motivations: An important consideration at the beginning is the need to understand that the motivations for a partnership may differ between the health- care and transportation sectors. On the health-care side, some organizations, such as non-profit hospitals, are respon- sible for investing in activities that address the needs of the communities they serve, Exhibit ii. Few places are as isolated as the Navajo Nation. Photo courtesy of KFH Group.

4 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services which could include supporting transportation services. Health-care organizations are also interested in attracting new patients and offering competitive services. The CMS administers a five-star quality rating system to help measure Medicare beneficiaries’ experiences. A health facility’s rating has a major impact on its ability to attract new patients and stay competitive. Investing in services that increase patient satisfaction, such as transportation, may be one way health-care organizations remain competitive. On the transportation side, the community’s transportation providers are interested in generating ridership, which could include patients of local health-care organizations. The transportation provider can increase its standing in the community with new rela- tionships established with local health-care organizations. • Identify Entities for the Partnership: Another element for improving community trans- portation to health care involves identifying appropriate entities to engage for pursuing a partnership. Potential participants on the health-care side include not only primary and specialty care facilities and hospitals but also both public and private insurers. On the transportation side, a focus in the guidebook is the community’s public transportation provider but not to the exclusion of other providers such as local non-profit agencies with vans and the new private mobility services available in many communities. • Identify Transportation Needs: Identifying the specific needs for transportation improvement is a key dimension. Who are the community residents with needs? Why do they have needs? The guidebook identifies possible data sources to help qualify and quantify transportation needs for health-care access. These include community health needs assessments (CHNAs), a requirement for non-profit hospitals through the Patient Protection and Affordable Care Act (ACA). Another source is community health assess- ments (CHAs), which the Public Health Accreditation Board requires health departments to develop every 5 years. • Start a Dialogue: With willing participants and identified needs, a dialogue between the health-care and transportation sectors is another element of developing a partnership. This communication may start from a random precipitating event or an unforeseen situation such as in Flint, Michigan where communication between the local health department and city’s public transit agency began with Flint’s drinking water crisis. Alternatively, communication may start in a deliberate way—perhaps initiated by a forward-thinking individual at the public transportation agency or a patient coordi- nator at a health-care provider. One of the interesting findings of the research project is that partnerships between health care and transportation arise from situations, environ- ments, and factors that may be unique to the particular community. If there is a common thread, it is that health-care access is a critical need for those individuals who lack their own private transportation. • Share a Goal: Effective communication can lead the participating health-care and transportation providers to develop a shared goal for improving transportation access. While not necessary for a viable partnership, it can be useful to memorialize the mission of a new transportation service in broad terms. Having an articulated goal may also be useful should the partnering health-care and transportation providers seek funding for the service beyond what the partners contribute. • Recognize and Address Barriers: Moving toward a collaborative arrangement for improving transportation access to health care may face obstacles. For example, the health-care sector has concerns about protecting patient privacy. The transportation provider may question if a dedicated service for a health-care facility may be disallowed because of the Federal Transit Administration (FTA) Charter Rule. These possible barriers and their solutions are described. • Develop Transportation Solutions: An important step is then to develop effective and appropriate transportation solutions to meet the defined needs for improving access

Summary 5 to health-care facilities. The guidebook explains key factors to consider and describes a variety of solutions and services that might be implemented to improve transpor- tation access. • Sustain the Improved Transportation: Assuming the partnership results in some type of transportation improvement, funding for the new service is needed to sustain its opera- tion. Key to this effort is coordinating diverse funding sources that can be facilitated by building a strong coalition of stakeholders that support the service. Need for More Research Relationships between the health-care and transportation sectors are evolving with a greater understanding that transportation is a key social determinant of health. The research project found a range of successful relationships and collaborations between health-care and transportation providers, but more work is needed to better understand how the partnerships between the health-care and transportation sectors develop and how they might be encouraged. Research is also needed to better document the specific ben- efits of improved transportation access and to develop metrics that provide evidence that improved transportation access can, in fact, improve health-care outcomes. Toward these ends, a research plan was developed that outlines topics that might be pursued through subsequent research. This plan is provided in the appendix at the end of the guide.