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

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23 Introduction Improving the role of transportation for health-care access requires that the transportation and health-care sectors communicate so that each understands the perspectives of the other and the actions needed to improve access. Effective communication can lead to collaboration and a partnership so that the two sectors work together to address not only each sector’s objective— transportation in serving its passengers and health care in serving its patients—but also a shared objective of improving access to health care. But how does the communication start? What does a health-care facility do when it realizes it needs to address patient transportation comprehensively rather than periodically providing a taxi voucher? Does the health-care facility know that its community’s public transportation provider may be a viable option for improving patient access? On the other side, what does the community’s public transportation provider do when a rider survey finds that passengers ask for service to a hospital beyond its service area? Does the community transportation provider know who to contact at the hospital to explore a possible solution for its passengers? Initiating the Process This chapter explores communication between health-care entities and community trans- portation providers and how that communication might develop into coordination, collabo- ration, and a possible partnership between the organizations that improves access to health care. A focus in this chapter 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 mobility services available in many communities that are also options for improving transportation access to health care. This chapter, from communication to coordination, sets the stage for the collaboration needed to develop the transportation solutions that follow in Chapter 4. The chapter begins with an overview of common factors affecting transportation to health care and then addresses the various dimensions of working toward a health-care—transportation partnership: C H A P T E R 3 Working Toward a Partnership: Health Care and Transportation

24 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Support from the Public Health Sector It is important to recognize that the public health sector also understands the importance of community transportation. Health care and public health are related as two components of the overall health sector. Health care focuses on services for individuals while public health focuses on protecting the health of a community at large, but, significantly, both components benefit from supporting community transportation. The Centers for Disease Control and Prevention (CDC) makes this case with a new action guide: https://www.cdcfoundation.org/sites/default/files/files/HI5_TransportationGuide.pdf The guide promotes increasing support of public transportation systems, finding that ade- quate access to public transportation is associated with various positive health outcomes for the community overall, such as more physical activity and better air quality. While the focus of the public health differs from that for health care, the CDC guide highlights opportunities for public health to partner with public transportation, aligning with objectives of this TCRP guidebook to improve access to transportation through collaborations and partnerships with health-care organizations. Common Factors Affecting Transportation to Health Care Individuals with limited access to health-care-related transportation often experience challenges related to geography, complex health-care needs, and costs. Geography and rurality. Urban and rural communities may face different barriers to access- ing transportation to health care. Rural residents often travel long distances to access medical care. In 2018, rural residents lived an average of 10.5 miles away from the closest hospital, com- pared to an average of 4.4 miles for urban residents (1). Rural transportation concerns often include lack of infrastructure, low population density, and long travel distances to access medi- cal services; many areas in the West see trip distances that exceed 50 miles on a routine basis (Exhibit 3-1). When communities are sparsely populated and spread out over large expanses of land, local transportation providers may lack the resources and ridership to support fixed- route public transit. Low population densities can also pose challenges to sustaining taxi service or TNCs. In urban areas, some riders may have difficulty navigating complex transit systems or lack a direct route between their home and their health-care provider. Even when fixed-route systems are available to urban residents, patients who are elderly or have complex health conditions Why Should the Health Care and Transportation Sectors Communicate and Collaborate? Who are Potential Health-Care and Transportation Participants? What Are the Specific Transportation Needs? Start the Dialogue Develop a Shared Goal Possible Barriers to Collaboration Resources for Addressing Potential Barriers

Working Toward a Partnership: Health Care and Transportation 25 may not have the capacity to wait at a stop or navigate a transfer among routes. Americans with Disabilities Act (ADA) paratransit can be an option for some. Lack of comfort or familiarity with technology can also create challenges to using applications to arrange rides with technology-based, on-demand mobility services or looking up transit schedules online. Considerations for people with complex needs. Passengers may have needs or conditions that affect their ability to identify a driver, board a vehicle, or sit for long distances. • People with mobility limitations may need assistance getting to and from their home to the vehicle, with stepping in and out of vehicles, and with navigating stairs. In addition, people who use wheelchairs often need wheelchair-accessible vehicles with special design features including ramps or lifts. • Some passengers may need assistance lifting or moving medical equipment such as oxygen tanks. • Other passengers may need to travel with a caretaker or a service animal. • People with visual impairments may need accommodations to schedule rides (e.g., using a phone number instead of a phone application). People with visual impairments may need assistance with identifying the driver and navigating from the vehicle to their destination. • People with certain mental health conditions may have difficulties riding in a vehicle with other passengers or navigating large crowds of people. Cost. Many passengers, especially those with fixed or limited incomes, may be unable to afford transportation to access health-care services. While some insurance programs cover the cost of NEMT, many patients do not qualify for transportation assistance and cannot pay for the ride out of pocket. Lack of familiarity with transportation systems. Patients may need additional support to use existing transportation services and resources. Some transportation programs offer travel training to help certain populations, such as older adults or people with disabilities, learn how to use public transit and navigate to their destination. Other programs also provide assistance to populations with limited English proficiency. Exhibit 3-1. This community in Arizona is over 50 miles from specialty care. Photo courtesy of KFH Group.

26 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Why Should the Health-Care and Transportation Sectors Communicate and Collaborate? Perhaps the most straightforward answer is that communication can lead to collaboration and then a partnership to improve transpor- tation access to health care, benefiting both an individual’s and soci- etal health. However, health care and transportation are two distinct sectors, and the reason why they might want to connect and coordinate are not necessarily the same. Understanding the different motivations of each side and establish- ing a common vision may be critical to planning a successful partner- ship to improve transportation access. Health Care Organizations’ Perspective Receiving timely health-care services is essential to preventing disease, maintaining good health, and diagnosing and treating illnesses. Health-care providers are invested in ensuring that their patients can safely and reliably access the care they need. Justifica- tions for getting involved in transportation to health care can include: • Improving health-care outcomes. In Transportation to Healthcare Destinations: How a Lifeline for Patients Impacts the Bottom Line for Healthcare Providers, the National Center for Mobility Manage- ment describes the benefits of health-care transportation and the costs of missed appoint- ments (2). Missed appointments are also missed opportunities to identify and treat health conditions before they worsen. No-shows represent loss of potential revenue for the health-care provider. • Promoting an organization’s mission and vision. Collaborations that improve health outcomes may strongly align with the stated values of health-care organizations. Increas- ingly, health-care organizations are focusing on the root causes of health and the social factors that contribute to well-being. Transportation is a key social determinant of health. • Fulfilling commitments to community health. Some organizations, such as non-profit hospitals, are responsible for investing in activities that benefit their local communities. Some hospitals address transportation to health care as part of their “community benefits” pro- gram, either through offering their own transportation program or by subsidizing bus passes or taxi vouchers. – Non-profit hospitals must provide “community benefits” to address the needs of the com- munities they serve. Hospitals can engage in community health improvement or commu- nity building activities as part of their community benefits, which can include investing in transportation assistance and services. – Non-profit hospitals must conduct CHNAs periodically. Through the CHNA process, hospitals identify and describe the major health needs of their community and service area and develop plans to address key health issues. CHNAs can help inform priority areas for community benefits. – Health departments must periodically develop community health assessments (CHAs) as part of their accreditation process, which involves identifying major health needs for the community. Health departments often articulate strategies to act on the findings of CHAs through community health improvement plans (CHIPs). Rio Grande Valley Health Alliance: An ACO Focused on the Social Determinants of Health Rio Grande Valley Health Alliance (RGVHA) is an Accountable Care Organization (ACO) located in McAllen, Texas, part of an urban area with a population of 900,000 on the southern border of the United States. RGVHA uses TNC “companies Lyft and Uber to improve access to NEMT for its patients. RGVHA funds transportation to and from hospitals, clinics, dialysis centers, and other health centers. For some patients who were “prescribed” exercise by their physician, RGVHA also arranges for transportation to and from the gym. Offering transportation services helps set RGVHA apart from other Medicare programs in the region.

Working Toward a Partnership: Health Care and Transportation 27 • Addressing the social determinants of health. Health-care pro- viders, insurers, and stakeholders are increasingly moving toward addressing the social determinants of health. The availability and accessibility of public transportation affect a community’s health- care access and may in turn affect a person’s health status. Organi- zations investing in these social determinants may be interested in working with their community transportation providers to improve health outcomes among community members. • Improving quality by preventing exacerbations of existing conditions. Consequences of missed medical appointments may include avoidable use of emergency services and hospitalizations. As policymakers and insurers become increasingly focused on quality of care, health-care providers are emphasizing the importance of pre- vention. Health-care providers may have substantial incentives to ensure that patients reliably attend scheduled appointments. • Attracting new patients and offering competitive services. The CMS administers a five-star quality rating system to help measure the Medicare beneficiaries’ experiences with their Medicare Advantage plans and with nursing homes. A health facility’s rating has a major impact on its ability to attract new patients and sustain operations in a competitive field. For example, some insurers determine eligibility for in-network services based on quality ratings. In order to remain competitive, health-care systems may invest in services that increase patient satisfaction with care, including transportation services. • Offering information about existing resources to patients. Health-care providers are often well aware of their patients’ challenges with navigating public transportation, including lack of awareness of available routes and schedules. Some providers work with public transporta- tion agencies to publicize existing transportation opportunities, including available bus routes and stops. Community Transportation Provider’s Perspective Coordination and collaboration with health-care organizations can support the mission and service of the community’s public transportation provider by: • Identifying the specific transportation needs of health-care organizations’ patients to help the public transportation provider better plan its services. • Justifying possible implementation of new services that improve health-care access, expanding the footprint of the public transportation provider. • Generating ridership with new trips taken by patients of local health-care organizations. • Increasing the standing of the public transportation provider in the broader community with new relationships established with local health-care organizations. • Enlisting support from local health-care organizations to advocate for increased local funding for public transportation, building on new relationships with the community’s health-care organizations. • Promoting coordination of local transportation services through planning efforts that iden- tify the role that local non-profit agencies and other community transportation providers might play in supporting improved access to health-care facilities. • Adopting technology and innovation through collaborations with health-care providers as new technologies and applications are introduced to the health-care industry. For example, by participating in applications such as Kaizen Health, the public transportation provider can allow patients/riders to schedule trips through an integrated mobility management platform. Rides Plus: Increased Rural Ridership in Southern Illinois Rides Plus is a call center funded by Rides Mass Transit District, a federally funded public transportation agency that serves 17 counties in Southern Illinois. Rides Plus works with transporta- tion agencies and health-care providers throughout the service area to help increase access to NEMT. Health-care providers contact Rides Plus to schedule rides to appointments for their patients. Rides Mass Transit District originally par- ticipated in a pilot project that preceded Rides Plus. The pilot demonstrated substantial increases in ridership after using the call center and mobility management services. Increased ridership led Rides Mass Transit to invest in Rides Plus.

28 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services • Promoting healthy communities by actively increasing access to health care while improving local mobility. • Providing financial support by sponsoring public transportation service through a partner- ship with a health-care provider. This strategy is seen more often in urban areas, but rural areas such as Paris, Texas, have enlisted health-care providers as sponsors of the community’s public transportation provider with benefits commensurate with their sponsorship level. Considerations when Pursuing Collaborations with Health Care Organizations A public transportation provider should consider a number of issues when considering collaborations with health-care organizations: • Highlight strengths of the public transportation provider: fully-trained drivers who receive comprehensive background checks prior to hiring; agencywide and extensive safety program; well-maintained vehicle fleet; wheelchair-accessible vehicles. • Propose transportation services that can realistically be provided. If the health-care organiza- tion requires same-day service, ensure operational capacity and capabilities to provide that level of service. • Obtain support from the public transportation provider’s executive director and board of directors to pursue formal health-care collaborations. • Prepare to answer questions regarding the Federal Transit Administration (FTA) Charter Bus rules if there is payment involved or if the service is not open to all (“open door” service). • Prepare to answer questions about patient privacy that govern HIPAA (Health Insurance Portability and Accountability Act), which establishes standards regarding the protection of patients’ medical records and personal information. • Ensure the health-care organization’s familiarity with the rulemaking by the U.S. Department of Health and Human Services (HHS) and the updating of the “safe harbor” regulations that now allow health-care providers to fund or provide local non-emergency patient transporta- tion with some limits. Who Are Potential Health-Care and Transportation Participants? Potential participants that might connect, communicate, and work toward improving transportation access to health care include a range of health-care and transportation organizations. Questions to Ask What are the health-care providers in the community? What are the transportation providers in the community? What organizations are involved in advocating for the needs of the target population? Are there existing community collaborations in place related to transportation or increasing access to care?

Working Toward a Partnership: Health Care and Transportation 29 Health Care: Identifying Stakeholders and Collaborators Primary and Specialty Care Facilities and Hospitals Primary and specialty care facilities and hospitals are all health-care organizations that may have a direct interest in promoting transportation access for patients (Exhibit 3-2). Primary care facilities may include different kinds of practices and health centers that provide non-urgent care for common medical concerns. Patients may need transportation to receive care for issues before they become urgent. Specialty care may include facilities that focus on a special health condition, such as dialysis clinics, or that provide specialized services, such as ambulatory surgical centers. Hospitals may be interested in coordinating efficient transportation home for patients who have been recently discharged. Transportation providers interested in getting involved in health-care transportation may need to reach out to the following staff at health-care organizations: • Community relations teams. Some health-care organizations may have staff dedicated to building relationships with community partners. Some hospitals may also have com- munity benefit programs that focus on funding investments in community health and well-being. • Case managers and care coordinators. Many health-care organizations use care coor- dinators or case managers to help address the physical and social needs of patients. Case managers and care coordinators are often well-aware of their clients’ transportation difficul- ties and could be important collaborators for transportation providers. These staff often set up informal relationships with local transportation providers. Primary Care Specialty and Urgent Care Hospitals Exhibit 3-2. Different care facilities by type.

30 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services • Health-care providers. In individual practices, health-care providers often serve as cham- pions for organizational change. Health-care providers can bring different types of health- care stakeholders together, including leadership and frontline staff, to advocate for change. • Leadership. New partnerships with outside entities may require sign-off by the leadership of an organization, such as a chief executive officer, president, or board of directors. Insurance Providers Insurers are critical partners for transportation providers interested in offering health- care transportation. Insurers are often interested in the cost benefit of providing coverage for services. Insurers may be interested in working with transportation providers if they can see evidence that initial investments in transportation will prevent future exacerbations of chronic health conditions or avoid costly emergency department visits or hospitalizations. Special health-care management organizations, such as ACOs, are tasked with managing a wide range of services for members in exchange for participation in shared savings. Many of these orga- nizations acknowledge the role that transportation plays in health. Exhibit 3-3 lists a range of insurance providers. Insurers that provide Medicare Advantage plans may be particularly interested in a col- laboration with the community’s public transportation provider given a new CMS ruling in 2019. This ruling gives Medicare Advantage plans more latitude to provide patients with supplemental services supporting the social determinants of health that previously were not covered by Medicare. CMS had previously required allowable supplemental benefits to be “primarily health related.” According to CMS, Medicare Advantage plans can now provide transportation for those with chronic diseases to meet non-medical needs, such as grocery shopping. For patients with heart disease, this might include delivery of healthy food and produce. For patients with diabetes, this might include trips to a diabetes education program or to see a nutritionist. These are opportunities for local transportation providers (3). Leveraging Health Insurance Resources to Cover the Cost of Transportation Receiving early, prompt, and consistent health care can help individuals identify and treat health issues and manage their chronic conditions. People who have a usual and ongoing source of care are often able to avoid preventable health complications, visits to the emergency Insurance Providers Medicaid Medicare Tricare Veterans Health Administration (VHA) Private Insurers Exhibit 3-3. Range of insurance providers.

Working Toward a Partnership: Health Care and Transportation 31 department, and hospitalizations. As health insurers are motivated to decrease costly emer- gency and hospital services, they often invest in transportation services to help ensure that enrollees can access the care they need. Health insurance programs are listed in Table 3-1. Connections to Transportation Transportation providers should consider what types of health-care organizations are within their service area and what types of transportation services they might be able to provide. A health-care organization may be part of a larger health-care network. For example, ACOs and managed care organizations (MCOs) are often made up of groups of hospitals and providers who agree to coordinate care for the population of patients. Transportation provid- ers may reach out to individual physician’s groups within an ACO/MCO or may determine Accountable Care Organizations (ACOs) MEDICAID Medicaid MEDICARE Medicare Medicare Advantage Medicare Advantage ACOs Table 3-1. Health insurance programs. (continued on next page)

32 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services whether the health-care organization has a department that focuses on building community relations and addressing the social determinants of health. Transportation: Identifying Stakeholders and Collaborators On the transportation side, a key participant is the community’s public transportation provider. Communities typically have transportation pro- viders that should be invited to participate including non-profit organiza- tions such as human service agencies with vans that serve their clients and private companies ranging from taxis to medical van companies to new on-demand mobility providers such as Uber and Lyft. Other community organizations and stakeholders may also be possible participants, depending on the particular transportation problems to be addressed and the design of the process established to work toward solutions. For example, in a large urban area, a repre- sentative of the organization responsible for administering FTA Section 5310 program funds may be helpful in identifying transportation needs of seniors and people with disabilities. In a more rural area, the local community action agency or another local agency that focuses on the needs of low-income individuals, may be a potential stakeholder with helpful input for the process. Table 3-2 lists various types of community transportation providers and how to contact them. VETERANS HEALTH ADMINISTRATION (VHA) VHA, There are two key health-care programs for veterans, active members of the military, and their families: TRICARE TRICARE PRIVATE INSURERS Table 3-1. (Continued).

Working Toward a Partnership: Health Care and Transportation 33 Community Transportation Providers Who/How to Contact Public Transportation Provider Executive director Mobility manager Planning director/manager www.apta.com “Transit links by state” at the top of the Information on a state’s rural public transit agencies can be requested from each state’s www.nationalrtap.org) under the link “State RTAP.” Human Service Agencies The community’s 211 service Volunteer Services The community’s 211 service Taxi Companies Taxi company owner or manager community’s business licensing department or Chamber of Transportation Network Companies (TNCs) and Other On-Demand Mobility Providers Two widely known TNCs are Uber and Lyft. Uber Health: Lyft and its Lyft Concierge service UZURV, Via, and zTrip SendaRide Table 3-2. Community transportation providers—who and how to contact.

34 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Other Potential Stakeholders and Collaborators Health-care and transportation organizations are the primary participants for improving transportation access to health care. However, other community organizations and individuals may also play a role supporting efforts to improve access to health care: • Local non-profit agencies providing services for low-income individuals and families, seniors, and people with disabilities. • Local department of health. • Organization administering FTA Section 5310 program funds. • Metropolitan planning organizations (MPO) and councils of government. • Local governments. • Riders/patients. A survey of the public transportation provider’s riders can identify access problems to health care. Questions directed to patients about possible transportation prob- lems can elicit useful information about transportation access problems. • Caregivers and families. Many individuals require or benefit from the assistance of care- givers or family members to travel to appointments. Caregivers can provide additional context about transportation access and mobility needs. • Frontline staff at health-care organizations. • Funders. Many successful transportation programs consider issues of funding and sustain- ability from the outset of collaboration. Funding availability from federal agencies, state agen- cies, local government, insurers, philanthropies, and multiple other sources often determines the size and scope of a program. For example, a program may be designed to show a return on investment or improved outcomes among a target population. Understanding the priorities and interests of different funders can help ensure long-term sustainability. • Other stakeholders. Other organizations and individuals that work with the target popula- tion may contribute knowledge and resources for planning a transportation program. Social workers, case managers, care coordinators, and other stakeholders often have valuable insight into the barriers and facilitators to transportation access. There may also be existing collaborations or community forums addressing community needs, including health care. Coordination with such groups may support or strengthen efforts to improve transportation access to health care. Other Organizations That Affect the Social Determinants of Health Access to health care represents only one facet of health and well-being. Individuals also have other physical, social, psychological, and economic needs that must be met in order to lead healthy lives. Transportation providers may consider reaching out to community organizations that help the community’s residents meet these other needs that promote health and well-being. Such organiza- tions include grocery stores and farmers’ markets offering fresh foods, recreational facilities, and social services programs such as Women, Infants and Children (WIC) programs. Public transit providers may offer routes or services to many of these destinations as part of their network and that could be highlighted by the transit provider through marketing outreach efforts and mobility management activities. What Are the Specific Transportation Needs? The issues and problems of transportation access to health care may be obvious to those who witness the problems first-hand. The patient appointment scheduler who repeatedly hears patients cancelling Identifying Existing Collaborations Community advisory boards at local health care organizations in transit areas Local consortia focused on social determinants of health Advocacy groups focused on populations with limited transportation access, including older adults, people with disabilities, and people with chronic health conditions

Working Toward a Partnership: Health Care and Transportation 35 appointments because they cannot get a ride understands there is a problem. However, effec- tively addressing a transportation problem requires data. Data that qualify and quantify the transportation problem will facilitate development of possible solutions that target the problem. Questions to Ask Who is most likely to miss appointments because of lack of transportation? What programs are already in place to serve this target population? What are the resources available to fund transportation services, and what are the eligibility criteria for that funding? Identifying and Defining Needs An early step is to identify the category of individuals who have transportation needs related to health care and define their specific needs. Who Are the Individuals with Needs? It may be low-income families without reliable private transportation who miss routine medi- cal appointments. It may be dialysis patients with disabilities who lack accessible service to reach their three-times-per-week treatments, or it may be non-English-speaking residents who have difficulty navigating public transportation. It is important to define the target group that needs improved access. In some cases, the target group may not be known. If a health-care clinic is experiencing high rates of no-shows on Saturdays, for example, research is needed to identify the individuals who are missing appointments. It could be transportation access issues or there could be other factors at play. Identifying the specific category of individuals can be important for planning improvements as some transportation programs and their funding parameters designate intended beneficiaries. For example, some transportation programs are available to all members of a community, while others are tailored to defined population groups such as seniors and people with disabilities. Transportation programs provided by the VA are designed for military service veterans and generally are not open to others. What Are Their Transportation Needs? Identifying the specific transportation needs of the defined category of individuals need- ing improved health-care access is necessary to consider the options or types of transportation service to meet their needs. Collecting and Interpreting Data The next step is to obtain and interpret data about the transportation access issue so that possible solutions can be considered. To understand the scope of lack of access to transportation to health care, transportation providers may need to have and interpret data about community needs. It is paramount that

36 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services transportation providers understand the barriers to health-care access in order to successfully address objectives of health-care providers, such as decreasing no-show rates and missed appointments. In addi- tion, funders often require applicants to describe the scope of the issue in order to determine eligibility for grants. Community Needs Assessments Needs assessments may help health-care providers and transporta- tion agencies understand the unmet needs and priorities of commu- nity members. Needs assessments typically include a review of key demographic information for local populations, such as the number of households with reported income below the federal poverty level, the distribution of ages, and other key characteristics. Key Questions What is the target population? What is the insurance status of the target population? What is the health status of the target population? What transportation options are available to patients? Why are patients not able or willing to use existing transportation options? CHNAs: One type of needs assessments are CHNAs—community health needs assessments—which specifically focus on the health needs of community members. CHNAs typically describe health outcomes (e.g., prevalence of chronic conditions), health disparities, and local health resources. The Patient Protection and Afford- able Care Act (ACA) requires non-profit hospitals to conduct CHNAs every 3 years. Hospitals must collect information from “persons representing the broad interests of the community” as part of CHNA, including public health department and underserved populations. CHAs/CHIPs: The Public Health Accreditation Board requires health departments to develop community health assessments (CHAs) every five years. To develop a CHA, health departments identify stakeholders and partners for the planning process, create a shared community vision, collect data, and use data to identify priority issues for the community. CHA collaboratives often outline specific strat- egies to address priority issues and achieve desired health outcomes through a community health improvement plan (CHIP). Transit needs plans: Public transit agencies may conduct needs assessments on a periodic basis as part of the ongoing planning function. These plans identify unmet transit needs and highlight potential service improvements and expansions. Devel- oping the plans should include specific attention to access to health-care facilities. Transportation providers may choose to get involved in existing needs assessment efforts facilitated by the health-care sector to share the perspective of the transportation sector and identify opportunities for collaboration. Hospitals and health departments often convene multi- sector advisory councils to carry out needs assessments. For example, the DC Health Matters Collaborative, which includes health systems, hospitals, and social services agencies, developed the 2019 CHNA for the District of Columbia that identified transportation as a priority health need. The collaborative reached out to the DC Department of Transportation to interview stake- holders for the CHNA process.

Working Toward a Partnership: Health Care and Transportation 37 Transportation providers may choose to use needs assessment tools to capture existing data about their service area and community needs. For example, the University of Missouri Extension’s Center for Applied Research and Engagement Systems (CARES) Engagement Network tool allows program planners to identify information about demographics, social and economic factors, the physical environment, clinical care, health behaviors, and health outcomes. The Robert Wood Johnson Foundation’s County Health Rankings help communities compare a range of health and access measures across counties and states. For example, CARES allows the user to compare information for counties, states, and national averages. Data visualizations can help convey disparities in health and transportation use. The example below (Exhibit 3-4) shows information about Medicaid rates, public transit use for work, and preventable hospital rates among Medicare enrollees in rural Marion County, Illinois. In another example, the CARES tool allows users to create maps with community data. In this example, a map of Washington, D.C. is over- laid with rates of Medicaid coverage, rail transit stations, and rail transit lines in the metropolitan area (Exhibit 3-5). Transportation providers could use similar maps to understand how access to transportation ser- vices may differ among socio economic groups or other key indicators (6). The final example, County Health Rankings, created by the University of Wisconsin Popu- lation Health Institute with support from the Robert Wood Johnson Foundation, provides key health indicators by county. The example below (Exhibit 3-6) shows information about uninsured rates, health-care workforce availability, and preventable hospital stays among residents of rural Marion County, Illinois. Primary Data Collection Conducting a needs assessment may involve collecting data directly from consumers and stakeholders. Transportation programs may consider conducting focus groups or interviews to Transportation Providers and CHNAs The National Center for Mobility Management developed a report, Opportunities to Improve Community Mobility through Community Health Needs Assessments, to describe the CHNA process and highlight examples of mobility considerations in the CHNA process (4). The authors suggest that transportation providers use the Trans­ portation to Healthcare Destinations: Resource Guide for Conversations Between Transportation Professionals and Healthcare Professionals to initiate a conversation with hospitals about CHNAs (5). Marion County State of Illinois United States Data Visualization Exhibit 3-4. Medicaid rates, public transit use for work, and preventable hospital rates among Medicare enrollees in rural Marion County, Illinois.

38 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Insured, Medicaid/Means-tested coverage, percent by tract, ACS 2013-2017 Exhibit 3-5. Medicaid coverage and access to transportation services in Washington, D.C. (6). Exhibit 3-6. Key health indicators by county.

Working Toward a Partnership: Health Care and Transportation 39 collect in-depth information from a select group of people. For example, a focus group with older adults could provide information about specific health-care needs and accommodations for that population. Transportation providers can also use surveys to obtain information about health-care access. A community-wide survey can ask specific questions related to access to local health-care facilities and unmet needs. Open-ended questions about “other transportation needs” are another source of information. Potential topics for primary data collection may include: • What kinds of transportation modes do you use? • Have you in the past or do you currently use public transportation? • Do you have any special needs affecting use of public transportation? • Do you have reliable transportation to health-care appointments? • Do you miss health-care appointments because of lack of trans- portation? How often? Start the Dialogue Dialogue between the health-care sector and the community’s public transportation provider may start from a random, precipitating event or an unforeseen situation such as in Flint, Michigan, with the city’s drinking water crisis. Communication may also start in a deliberate way. Perhaps it is initiated by a forward-thinking individual at the public transportation agency or a patient coordinator at a health-care organization. Or a local community group or task force may identify transportation problems for a certain segment of the community’s residents and champion improvements that would include better access to health care. For example, the collaboration between Lane Transit District (LTD) and health-care organizations in Oregon was started by a visionary individual at LTD who realized that coordinating the transit agency’s services with other transportation providers in the community, includ- ing Medicaid NEMT and veterans transportation programs, was the best way to improve transportation. The resulting service—RideSource—schedules health-care trips directly with hospital social workers and with the region’s entity that coordinates health care. Communication Strategies While the first communication step may be straightforward—perhaps a telephone call or email from the community’s public transportation agency to a health-care organization to discuss an issue with the transportation service—additional communication between the two sectors may be needed to coordinate efforts toward a solution. This might be: • Scheduled in-person meetings attended by key representatives of the two sectors. • A workshop with follow-up coordination activities that are defined. • A panel discussion to discuss needs and solutions. • A one-time event, such as a summit, held in conjunction with a particular day or week designated for a particular health-care issue. For example, National Child Health Day is the first Monday every October; National Public Health Week is the first week in April. Survey the Community to Ask About Access Needs to Health Care A community-wide survey, conducted as part of a plan for the public transporta- tion provider in rural Dorchester County, Maryland, identified residents’ concerns about the pending loss of the local hos- pital. Most of the hospital’s services were moving to a larger hospital in the neigh- boring county. Survey information pro- vided support for increased frequency and funding for the transit provider’s route that served the larger hospital. Flint’s Drinking Water Crisis Results in Partnership Between Public Transit and Health Department The partnership in Flint, Michigan, between the Mass Transit Authority (MTA) and the state Health Department began with the city’s water crisis. The Health Department approached the transit agency in crisis mode, asking the transit agency to provide trips for those city residents without adequate trans- portation to access bottled water, water filters, and medical services necessitated by the crisis.

40 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Addressing the identified transportation access issue may be accom- plished with direct coordination and collaboration between one trans- portation provider and one health-care organization. Other issues may be more complicated and need attention from multiple community partners, stretch across county lines, and/or require regular ongoing contact among stakeholders. In such cases, formation of a task force, committee, advisory group, or other ongoing mechanism to facilitate ongoing communication and coordination will be needed. Key Questions to Ask After the transportation needs have been identified, defined, and quantified to the extent possible, the stakeholders should consider a number of key questions: • What level of service is needed to address the transportation needs? • What level of service is the health-care provider willing to accept? • Are there regulatory issues, such as the ADA or Title VI of the Civil Rights Act of 1964? • Is the health-care organization able to provide funding? • Is the public transportation provider a feasible option to provide the service? – If not, what other transportation providers in the community might be feasible options? • When is improved access needed? During defined time periods? Ongoing need? • Are there patients with special needs? Chapter 4 provides specific guidance for identifying appropriate transportation services to match the transportation needs of a health-care organization. This is an important step in fur- thering the dialogue toward a collaboration between a health-care pro- vider and transpor tation provider. Understanding Different Conditions of Collaboration Communication and coordination between the health-care and transportation sectors requires that each side understands the condi- tions and issues that the other may have in order to move forward with a transportation service that improves health-care access. See Exhibit 3-7. Develop a Shared Goal Communication and collaboration should lead the participating health-care and transportation providers to develop a shared goal for improving transportation access. While this is not necessary for a viable partnership, it can be useful to memorialize the mission of the trans- portation service in broad terms. Having an articulated goal may also be useful should the partnering health-care and transportation providers seek funding beyond what the partners contribute. For example, the FTA has a new competitive funding program that is designed to enhance mobility and access to community services, specifi- cally including health care, for older adults, individuals with disabilities, Once the MTA in Flint, Michigan, had implemented its technology-based, same-day service for health-care trips, “Rides to Wellness,” it approached the community’s large hospital and asked if the hospital would like to join the collaboration. It took the hospital a year of observing Flint’s Rides to Wellness service in the community to decide that “yes,” it could trust the transit agency to provide non-emergency trips for its patients. The Mobility Management Office in Central Texas was involved in develop- ing the Community Health Improve- ment Plan (7) for the region that included a specific objective targeting transportation: “By 2021, decrease no-shows for health care appointments at safety-net health care providers by 10%.” “Work with transportation partners to expand and enhance transporta- tion options for members of the community who have difficulty reliably traveling to healthcare appointments.” “Connect health navigators with Mobility Management services so they can refer people to the right transportation resources for their needs.”

Working Toward a Partnership: Health Care and Transportation 41 and people with low incomes. An application that documents a partnership between a trans- portation provider and health-care organization and showcases a shared-goal statement to improve access to health-care services would strengthen a grant application. The responsibilities and tasks for working toward the goal are then needed to plan and implement the transportation service. Determining the type of transportation service and its parameters are the topic of the next chapter. Possible Barriers to Collaboration Moving toward a collaborative arrangement for improving transportation access to health care may face issues that the participants raise as possible obstacles to continuation. Experience shows that many of these can be addressed and overcome, see Table 3-3. Resources for Addressing Potential Barriers This chapter concludes with brief summaries of resources that may help transportation and health-care organizations address some of the potential barriers that could be encountered when working toward a collaboration. These include summary information on: • FTA Charter Rule. • Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements. • HIPAA. • Possible funding sources for transportation and health-care collaboration. Health Care Provider Public Transportation Provider Exhibit 3-7. Different concerns for health-care and transportation providers.

42 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Potential Barrier Issue/Rationale Solution Potential Solutions Found in the Guidebook Bridging gaps and building understanding and relationships between the health-care and transportation sectors. Health-care providers may need to demonstrate improved health outcomes to justify investment in transportation services. Lack of funding for transportation services. Funding silos. Health providers may be concerned about adhering to requirements of the Health Insurance Portability and Accountability Act (HIPAA). passengers’ information. For example, some ride scheduling software uses only patients’ Table 3-3. Potential barriers and their solutions.

Working Toward a Partnership: Health Care and Transportation 43 Potential Barrier Issue/Rationale Solution Potential Solutions Found in the Guidebook Special needs that in some cases can be inappropriate for �ixed- route and even ADA paratransit. Public transportation agencies have concerns that a partnership with dedicated service for a health-care facility may be disallowed because of the FTA Charter Rule. Health-care providers cannot fund transportation services due to the federal Anti- Kickback legislation. Enhancing transportation access to variety of services in rural areas. Table 3-3. (Continued). FTA Charter Rule (Charter Rule write-up being reviewed by FTA; draft provided 4/9/2020) The purpose of the FTA Charter Rule is to protect private bus operators from unfair competition from public transit agencies that have access to federal and state funds for purchasing buses and federal funds for their operation. Plans for a public transportation and health-care collaboration need to consider the type of transportation—whether the service is fixed route or demand response. The Charter Rule treats these differently. Background on the Rule Information on the FTA Charter Rule is available through this link: https://www.transit.dot. gov/regulations-and-guidance/access/charter-bus-service/charter-bus-service-regulations-0.

44 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services According to the FTA, “charter service” means, but does not include demand response service to individuals: • Transportation provided by a recipient at the request of a third party for the exclusive use of a bus or van for a negotiated price. The following features may be characteristic of charter service: – A third party pays the transit provider a negotiated price for the group; – Any fares charged to individual members of the group are collected by a third party; – The service is not part of the transit provider’s regularly scheduled service, or is offered for a limited period of time; or – A third party determines the origin and destination of the trip as well as scheduling. • Transportation provided by a recipient to the public for events or functions that occur on an irregular basis or for a limited duration, and: – A premium fare is charged that is greater than the usual or customary fixed-route fare, or – The service is paid for in whole or in part by a third party. Charter Rule Exceptions • There are limited exceptions when an FTA grantee may provide charter service, including: – For official government business; – To Qualified Human Service Organizations (QHSO) serving the elderly population, persons with disabilities, and low-income individuals; – When no registered charter provider responds to a notice sent by a recipient; – Leasing (must exhaust all available vehicles first); – By agreement with all registered charter providers; and – Petitions to the Administrator: Events of regional or national significance, or hardship. The term “Qualified Human Service Organization” deserves additional attention. What exactly is a QHSO? How old is “elderly”? And which organizations are qualified? To provide guidance, FTA Charter Rule Appendix A was published on January 14, 2008, providing a list of GAO-identified federal human service transportation programs and states: “(a) A recipient may provide charter service to a QHSO for the purpose of serving persons: (1) With mobility limitations related to advanced age; (2) With disabilities; or (3) With low- income. (b) If an organization serving persons described in paragraph (a) of this section receives funding, directly or indirectly, from the programs listed in Appendix A of this part, the QHSO shall not be required to register on the FTA charter registration Web site.” However, if an organization serving individuals described above does not receive fund- ing from a program listed in Appendix A, that organization can still register as a QHSO on FTA’s website (https://www.transit.dot.gov/regulations-and-guidance/access/charter-bus- service/charter-bus-service-registration). It is not complicated, but it is an additional step should an FTA-funded public transit agency wish to provide transportation for that organization. Considerations for Public Transit Agency and Health Care Partnerships If a transit agency considers some type of demand response service to help meet transpor- tation needs for a particular health-care facility, the FTA Charter Rule specifically excludes services that are demand response. The FTA definition of demand response can be compared to its definition for charter service (8): • Charter service is exclusive, whereas demand response service is shared ride. If the transit provider may mix passengers from a trip sponsor with other demand response passengers on the same trip, then the trip is shared-ride service.

Working Toward a Partnership: Health Care and Transportation 45 • Charter service is service to a group, whereas demand response service is service to indi- viduals. Service to individuals can be identified by a vehicle trip that includes multiple origins, multiple destinations, or both, even when the clients have exclusive use of the vehicle. Some demand response sponsored trips carried out as part of a Coordinated Human Services Transportation Plan, such as trips for Head Start, assisted living centers, or sheltered work- shops, may be provided on an exclusive basis, but are provided to service multiple origins to a single destination, a single origin to multiple destinations, or even multiple origins to multiple destinations. • Charter service is for a specific event or function, whereas demand response service is regular and continuing. Some demand response sponsored trips carried out as part of a Coordinated Human Services Transportation Plan may be exclusive, and may be for a group from a single origin to a single destination, but may occur on a frequently reoccurring basis, such as daily, weekly, biweekly, or monthly. • Demand response service may also include certain trips that are exclusive for a group from a single origin to a single destination and that reoccur on a less frequent basis than once per month so long as these trips are arranged and operated under the same terms and conditions as the demand response system for individuals. These terms and conditions include advance notice requirements, service windows for pick up and drop off, and price. Service carried out by the demand response units of transit providers that are exclusive for a group from a single origin to a single destination for a single event and not under the usual terms and conditions of the demand response system for individuals should be considered to be charter service. Transit providers should report these services to the charter registration web site. Should a transit agency consider some type of fixed-route service to help meet transportation needs for a particular health-care facility, one important key to ensuring that the service is not charter service is to ensure the route is open to the general public, not just patients traveling to and from the health-care facility, and publish the route with the transit agency’s regular fixed- route schedule. The FTA Charter Rule’s Appendix A Needs an Update The FTA Charter Rule’s Appendix A, which lists 64 automatically approved QHSOs that an FTA grantee can serve without a requirement to register with the FTA website, needs an update. This update would provide the new names of currently listed federal human service transpor- tation programs whose names or sponsoring federal agencies have been revised and include 66 new federal human service transportation programs that should be on the list. There are examples where the outdated Appendix A has been an issue. These include several coordination efforts between a CDC program and rural public transit agencies that are FTA Section 5311 grantees. More specifically, the CDC’s High Obesity Program (HOP) funds land- grant universities. Two of these universities have been actively trying to partner with their local rural transit provider to gain access to healthy food and recreation for the low-income rural residents in CDC’s HOP programs. However, the FTA Charter Rule emerged as the number one barrier for the coordination effort between these two CDC/university programs and rural public transportation. That is because a university does not qualify as a QHSO in the current Appendix A. If the Charter Appendix A was updated to include CDC’s transportation-eligible programs (as well as the other programs that should be included) this would not be an issue. Despite the FTA Charter Rule issue in this example with the CDC’s HOP program, assistance through the National Rural Transit Assistance Program found solutions that allowed the coor- dination efforts to proceed.

46 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements The U.S. Department of Health and Human Service issued a ruling in December 2016 that revised previous restrictions on the ability of health-care providers to provide patient trans- portation. The law allows health-care providers such as hospitals and clinics (but excludes entities that primarily supply health-care items such as pharmacies) to fund local non-emergency trans- portation for patients. The ruling also allows health-care providers to fund shuttle services for patients and others to access medically necessary services and items within specific parameters. The transportation can be free or discounted. Health-care providers and unrelated businesses may contribute together to provide the transportation. The ruling can be found here: https://www.federalregister.gov/documents/2016/12/07/ 2016-28297/medicare-and-state-health-care-programs-fraud-and-abuse-revisions-to-the-safe- harbors-under-the As background, the Anti-Kickback Statute provides criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce or reward the referral of business reimbursable under federal health-care programs. Because of the broad reach of the statute, there was concern that some relatively innocuous commercial arrangements were covered by the statute and therefore not allowed. With the ruling, “eligible entities,” which include health-care providers such as hospitals and clinics (but excluding entities that primarily supply health-care items such as pharmacies), are allowed to fund local non-emergency transportation for patients and shuttle services for patients and others to access medically necessary services and items within specific parameters. The transportation can be free or discounted. Health-care providers and unrelated businesses may contribute together to provide the transportation. The ruling defines the following details: • Types of transportation: Transportation can be provided on a door-to-door basis. And it can be various modes—buses, taxis, community vans, volunteers, etc. Transportation can also be provided via shuttle transportation, using buses, vans or other vehicles that operate along a fixed route with a fixed schedule. Health-care providers can provide the transportation or use vouchers or other subsidy methods to provide transportation for patients. • What does “local” mean? Local transportation is defined at up to 25 miles in urban areas and 50 miles in rural areas. Mileage is measured “as the crow flies.” • Who can be served? Individualized transportation (door-to-door) is to be provided for “established patients.” This means patients who have been served by the health-care provider, which includes per the ruling, a patient who has made his or her first appointment. The intent of this provision is to offer flexibility to improve patient care but to limit the risk of transportation being used as a recruiting tool or to bring patients in for unnecessary services. However, for shuttle service, transportation can be provided not only to patients but also family, friends, and even employees of the health-care provider. Restrictions on market- ing the shuttle service limit the risk that the shuttle would be used to recruit new patients. Other details include: • The transportation service cannot be advertised or marketed to patients. The ruling empha- sizes this: transportation cannot be used as a recruiting tool. Information about shuttle service, however, can be made available by the health-care provider with a posting of the schedule and stops.

Working Toward a Partnership: Health Care and Transportation 47 • The health-care provider is to establish a set policy regarding the availability of free or dis- counted transportation and must apply that policy uniformly and consistently. However, the Department of Health and Human Service’s Office of Inspector General’s revisions to the statute do not mandate specific parameters for such policy other than mandating that it cannot be based on the type of patients’ insurance. • Payment cannot be made on a per-patient basis. If transportation is available through a private company or driver hired by the health-care provider, payment is made on a dis- tance/mileage basis. If transportation is provided by public transit or taxi, the transporta- tion would be paid for or reimbursed to individual patients, for example, by taxi vouchers or bus fare. • Costs for the transportation must be borne by the health-care provider and not shifted to Medicare, a state health-care program, other payers, or individuals. The Health Insurance Portability and Accountability Act (HIPAA) What Is HIPAA? HIPAA was instrumental in establishing safeguards for the privacy and confidentiality of “individually identifiable health information,” also known as protected health information (PHI). HIPAA states that PHI is created or received by a health-care provider, health plan, or health-care clearing house. PHI describes the health or condition of an individual, the health care the individual receives, or payment for health care that can be used to identify the individual (9). There are two key aspects of HIPAA. The HIPAA Security Rule describes the standards that must be used to safeguard electronic PHI (10). This rule focuses on the requirements for protecting electronic PHI, such as passwords, employee training, and other policies and pro- cedures. The HIPAA Privacy Rule describes protections for the use and disclosure of PHI in all formats (11). This rule focuses on the rights of the individual and how their information is used. What Are the HITECH Act and the HHS Omnibus Rule of 2013? The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted in 2009, sought to increase the use of health information technology, including elec- tronic health records (EHRs). Part of the HITECH Act focuses on the privacy and security of PHI created or shared by EHRs, which involved building upon and strengthening certain aspects of HIPAA. For example, the HITECH Act made business associates of covered entities directly liable for complying with some HIPAA requirements, including the Security Rule (12). Business associates are people or entities whose work involves the use or disclosure of PHI on behalf of a covered entity. The HHS Office for Civil Rights implemented a final Omnibus HIPAA Rule in 2013 to implement provisions in the HITECH Act and to further strengthen privacy and security safeguards in HIPAA (13). The Omnibus rule extended parts of the HIPAA Privacy Rule to business associates of covered entities. How Does HIPAA Affect Transportation Providers? Laws surrounding the disclosure of health information are complex and fragmented. While HIPAA is a federal law that applies to all states, some states also have additional rules Key Resource The TCRP developed a key resource for transportation providers that has access to riders’ health information: Legal Research Digest 46: How the Health Insurance Portability and Accountability Act (HIPAA) and Other Privacy Laws Affect Public Transporta­ tion Operations (2014). This report provides a comprehensive overview of HIPAA, its applicability to subcontractors and business associates, examples from several transit agencies, and more.

48 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services and regulations that govern privacy of health information. While transportation providers and brokers are not considered covered entities, some states may consider transit agencies to meet HIPAA’s definitions of a business associate or subcontractor. For example, Washington State considers NEMT brokers to be HIPAA business associates of the state Health Care Authority. In addition, some health-care providers may put certain protections in place to ensure that they are in compliance with HIPAA requirements when working with trans- portation partners. Transportation providers should familiarize themselves with the TCRP’s Legal Research Digest 46: How the Health Insurance Portability and Accountability Act (HIPAA) and Other Privacy Laws Affect Public Transportation Operations, which provides a legal analysis of how HIPAA applies to transportation providers. Transportation providers should also consult state laws and work with their health-care partners to better understand the extent of their responsibilities to safeguard the privacy of their patients’ PHI. How Might HIPAA Affect Partnerships Between Health Care and Transportation Providers? Health-care providers and health plans are covered entities and must abide by HIPAA regulations. Some health-care providers and health plans may not consider transportation providers to be business associates. Others may ask or require transportation providers to implement certain policies and procedures to comply with HIPAA rules. Health-care providers/plans may ask transportation providers to implement certain safeguards because of the potential need to disclose PHI related to a passenger’s health ser- vices. For example, transportation providers might have access to an individual’s full name, Medicaid identification number, medical certifications, health-care destinations, and purpose for medical transportation. Some strategies to enforce HIPAA compliance from the transportation provider’s perspective may include: • Only allowing transportation providers/drivers to see first names for passengers. • Requiring drivers/scheduling staff to undergo training sessions on HIPAA rules and regulations. • Establishing security procedures such as keeping paperwork with PHI in a locked filing cabinet or password-protecting electronic files. Possible Grant Funding Options for Transportation and Health Care Collaborations Listed below are several possible grant programs that could support a transportation and health-care collaboration. However, do not be constrained by this list. There are likely other options such as foundations or other organizations at the local level that might support collabo- rations that improve transportation access to health care. Federal Transit Administration (FTA) Access and Mobility Partnership Grants. Access and Mobility Partnership Grants seek to improve access to public transportation by building partnerships among health, transpor- tation, and other service providers. This program provides competitive funding to support innovative projects for the transportation-disadvantaged that will improve the coordination of transportation services and NEMT services. There are two distinct grant programs: • The Innovative Coordinated Access and Mobility (ICAM) Pilot Program. • Human Services Coordination Research grants.

Working Toward a Partnership: Health Care and Transportation 49 Eligibility. Eligible applicants are organizations that are eligible to be recipients and sub- recipients of the Enhanced Mobility for Seniors and Individuals with Disabilities Program, (defined under FTA’s Section 5310 program): designated recipients, states and local govern- mental authorities. https://www.transit.dot.gov/funding/grants/grant-programs/access-and-mobility- partnership-grants Helping to Obtain Prosperity for Everyone (HOPE) Program HOPE supports planning, engineering and technical studies, or financial planning to improve transit services in areas experiencing long-term economic distress. It will also support coordi- nated human service transportation planning to improve transit service or provide new services such as rides to opioid abuse recovery and treatment. Eligibility. The HOPE Program provides funds to eligible applicants defined as eligible recipients or subrecipients under 49 U.S.C. 5307, 49 U.S.C. 5310, or 49 U.S.C. 5311 that are in areas of persistent poverty. Applicants are encouraged to work with non-profits or other entities of their choosing to develop an eligible project. https://www.transit.dot.gov/HOPE AARP Community Challenge Grants. The AARP Community Challenge provides small grants to fund “quick-action” projects that can help communities become more livable for people of all ages. Applications are accepted for projects to improve housing, transportation, public space, technology (“smart cities”), civic engagement, and more. Eligibility. The program is open to the following types of programs: • 501(C)(3), 501(C)(4), and 501(c)(6) non-profits. • Government entities. • Other types of organizations will be considered on a case-by-case basis. https://www.aarp.org/livable-communities/community-challenge/info-2020/2020- challenge.html National Center for Mobility Management Health Care Transportation Access “Ready-to-Launch” Implementation Grants. These grants, supported by the FTA, support communities in taking concrete steps toward implement- ing transportation solutions to address health-care access. https://nationalcenterformobilitymanagement.org/grants/2019-health-care-transportation- access-ready-to-launch-grants/ Eligibility. Eligible applicants are designated or direct recipients for funds under 49 U.S.C. Sections 5307, 5310, or 5311, or an eligible subrecipient of these funds. Eligible subrecipients under FTA programs include state or local government authorities, non-profit organizations, and operators of public transportation. National Aging and Disability Transportation Center Innovations in Accessible Mobility Grant. The National Aging and Disability Transpor- tation Center is funding up to 10 communities for projects designed to increase accessible

50 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services transportation options for older adults and people with disabilities, including projects related to coronavirus response. Grants of up to $30,000 each will be awarded. Recent grantees include: INCOG Area Agency on Aging (Tulsa, Oklahoma) and its Creating Access to Nutrition Program. https://www.nadtc.org/grants-funding/nadtc-grant-opportunities/current-nadtc-funding- opportunities/ Eligibility. Local and regional private non-profit or government organizations that directly provide transportation services may apply for this funding opportunity. Centers for Disease Control and Prevention (CDC) The CDC is one of the major operating components of HHS. Its mission is: to protect America from health, safety and security threats, both foreign and in the U.S. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same. Possible Support from Local and State Health Departments. As part of its mission is to support communities in addressing public health, the CDC provides funding to state and local health departments for various projects. These departments should be contacted as possible funding sources for a community-based transportation and health-care collabo- ration. Funding might be possible through CDC’s REACH program (see below) or other options. REACH. REACH is a national program administered by the CDC to reduce racial and ethnic health disparities. https://www.cdc.gov/nccdphp/dnpao/state-local-programs/reach/current_programs/index. html Through REACH, recipients plan and carry out local, culturally appropriate programs to address a wide range of health issues among African Americans, American Indians, Hispanics/ Latinos, Asian Americans, Alaska Natives, and Pacific Islanders. Eligibility. REACH gives funds to state and local health departments, tribes, universities, and community-based organizations. Recipients use these funds to build strong partnerships to guide and support the program’s work. Along with funding, CDC provides expert support to REACH recipients. • Eligible Applicants – City or township governments – County governments – Independent school districts – Native American tribal governments (federally recognized) – Native American tribal organizations (other than federally recognized tribal governments) – State governments – Non-profits having a 501(c)(3) status with the Internal Revenue Service other than institutions of higher education – Non-profits that do not have a 501(c)(3) status with the Internal Revenue Service (IRS), other than institutions of higher education – Private institutions of higher education – Public and state-controlled institutions of higher education

Working Toward a Partnership: Health Care and Transportation 51 – Public housing authorities/Indian housing authorities – Small businesses – Special district governments Rural Health Information Hub (RHIhub) RHIhub, formerly the Rural Assistance Center, is funded by the Federal Office of Rural Health Policy to be a national clearinghouse on rural health issues, with resources that support health care and population health in rural communities. Additional support is provided by the Health Resources and Services Administration of HHS. The RHIhub is a guide to improving health for rural residents and providing access to current and reliable resources and tools to help users learn about rural health needs and work to address them. Information is provided about a wide range of funding sources, including grants that include transportation. https://www.ruralhealthinfo.org/funding/topics/transportation Chapter Notes 1. Lam, O., B. Broderick, and S. Toor. How Far Americans Live from the Closest Hospital Differs by Community Type. Pew Research Center, 2018. https://www.pewresearch.org/fact-tank/2018/12/12/how-far-americans- live-from-the-closest-hospital-differs-by-community-type/. 2. National Center for Mobility Management. Transportation to Healthcare Destinations: How a Lifeline for Patients Impacts the Bottom Line for Healthcare Providers. 2016. https://nationalcenterformobility management.org/wp-content/uploads/2014/09/NCMM_Healthcare_Business_Case_Context.pdf. 3. “CMS Finalizes Medicare Advantage and Part D Payment and Policy Updates to Maximize Competi tion and Coverage.” CMS.gov Newsroom, Apr 1, 2019. https://www.cms.gov/newsroom/press-releases/cms- finalizes-medicare-advantage-and-part-d-payment-and-policy-updates-maximize-competition-and. 4. National Center for Mobility Management. Opportunities to Improve Community Mobility through Com- munity Health Needs Assessments. December 2018. https://nationalcenterformobilitymanagement.org/ wp-content/uploads/2018/12/FINAL-NCMM_Brief_CHNA.pdf. 5. National Center for Mobility Management. Transportation to Healthcare Destinations: Resource Guide for Conversations Between Transportation Professionals and Healthcare Professionals. 2016. https://national centerformobilitymanagement.org/wp-content/uploads/2014/09/Healthcare_Transportation_Resource_ Guide_AC.pdf. 6. Map developed from CARES Engagement Network Mapping Tool. https://engagementnetwork.org/ map-room/. 7. Community Health Improvement Plan: Austin/Travis County, Texas, Year 1 Action Plan. Austin Public Health, August 2018. 8. Federal Transit Administration. “Demand Response Service Explained” [PowerPoint]. Demand Response Service v. Charter Service, February 2013. https://www.transit.dot.gov/regulations-and-guidance/access/ charter-bus-service/demand-response-service-explained. 9. U.S. Department of Health and Human Services, Office for Civil Rights. HIPAA Administrative Simplification: Regulation Text. 45 CFR Parts 160, 162, and 164 (Unofficial Version, as amended through March 26, 2013). https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/administrative/combined/ hipaa-simplification-201303.pdf. 10. “The Security Rule.” HHS.gov, Health Information Privacy, U.S. Department of Health and Human Ser- vices, Office for Civil Rights, 2017. https://www.hhs.gov/hipaa/for-professionals/security/index.html. 11. “The HIPAA Privacy Rule.” HHS.gov, Health Information Privacy, U.S. Department of Health and Human Services, Office for Civil Rights, 2015. https://www.hhs.gov/hipaa/for-professionals/privacy/ index.html.

52 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services 12. “Direct Liability of Business Associates.” HHS.gov, Health Information Privacy, U.S. Department of Health and Human Services, Office for Civil Rights, 2020. https://www.hhs.gov/hipaa/for-professionals/privacy/ guidance/business-associates/factsheet/index.html. 13. “Omnibus HIPAA Rulemaking.” HHS.gov, Health Information Privacy, U.S. Department of Health and Human Services, Office for Civil Rights, 2019. https://www.hhs.gov/hipaa/for-professionals/privacy/ laws-regulations/combined-regulation-text/omnibus-hipaa-rulemaking/index.html.