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

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53 Introduction Once a dialogue has been established between health-care and transportation providers, as well as mobility managers and local leaders as appropriate, it is time to discuss the matching of patient transportation needs with appropriate transportation solutions. The term “appropriate” in this context means that the patients are willing and able to use the service and that the cost for the service is reasonable. In many cases, this chapter provides references to the case studies and collaborative practices in Chapters 5 and 6, respectively. In addition, Tables 6-1 through 6-9 in Chapter 6 allow a reader to identify practices and collaborations by type. Purpose of this Chapter The purpose of this chapter is to provide guidance to mobility managers and health care and transportation providers in developing and selecting the most appropriate transportation ser- vice to meet the identified health-care access needs. The development of transportation solutions is supported by the research in Chapter 2 that describes the need for transportation to health care and the activities undertaken as described in Chapter 3 that help initiate the discussion. Developing solutions also builds upon the case study research documented in Chapter 5 and the collaborative practices described in Chapter 6. Organization of the Chapter The development and selection of appropriate transportation solutions for the identified needs should include a series of steps. As discussed in this chapter, the steps are: • Understanding the Basics of Transportation: What Health Care Providers Need to Know—Health-care providers should understand the basics of transportation, economies of scale, and how decisions influence cost and quality of the transportation service. • Understanding Mobility Limitations of Riders: One Patient at a Time—Transportation providers should understand the limitations of individuals who need access to health care. In some cases, these individuals are similar to the general transit-riding public, but there are sig- nificant differences for segments of the riders. Transportation providers need to understand those differences. • Transportation Solutions and Services Design: One Size Does Not Fit All—Based on the wide range of patient transportation needs, appropriate solutions should, where possible, include a range of services to appropriately meet each need. • Sustainability: Building a Strong Transportation Support Network—Sustainability includes funding and support. Cost efficiency (doing things right) and effectiveness (doing C H A P T E R 4 Develop Transportation Solutions

54 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services the right things) are essential. Working toward sustainability often requires building a strong coalition of stakeholders. Understanding the Basics of Transportation: What Health-Care Providers Need to Know Passenger transportation is influenced by many factors. While transportation officials understand the factors, ensuring that health-care providers have a basic understanding will ensure the decision-making process is sound. There are various considerations and options for providing the service, and some are more appropriate than others. Transporting passengers to access health care can be done in different ways. An overriding objective is to strike the right balance of efficiency (doing things right) and effectiveness (doing the right things). In other words, providing the most appropriate service for each person at a reasonable cost. Spreading the fixed costs for transportation (e.g., cost of the garage, cost of the executive director, etc.) over a larger number of vehicles, miles, or hours will lower the cost per trip, cost per mile, and cost per hour as those fixed costs are then spread over a larger number of vehicles, miles, and hours. The following basics of transportation are discussed: • Economies of scale. • Collaboration and coordination efforts: reducing silos. • Grouping trips: What is productivity and why is it important? • Service design: Diversity is good. • Safe and professional services. Economies of Scale Passenger transportation is strongly influenced by economies of scale. Economies of scale become most apparent in rural and small urban areas where three systems are often doing the work of one: rural public transit, Medicaid NEMT, and veterans transportation. The inefficiencies of three transportation providers serving the same community result in the loss of economies of scale (among other issues, such as loss of local matching funds used to secure federal grants). Gaining economies of scale can be addressed through collaboration and grouping trips, which are discussed below. Collaboration and Coordination Efforts: Reducing Silos For over 40 years, many studies have expounded the virtues of col- laboration, coordination, or consolidation, beginning with the landmark GAO study in 1977 (1) and confirmed in the GAO’s 1999 study (2).

Develop Transportation Solutions 55 What the GAO report is saying (starting in 1979), essentially, is the elimination of trans- portation funding and program silos will gain economies of scale: management, facilities, and administration can be reduced, and all drivers and staff will be properly vetted, monitored, and trained. By definition, siloed transportation limits economies of scale. For example, with siloed veterans’ transportation and Medicaid NEMT, alongside public transit, there are three managers, three facilities, and three sets of virtually everything related to transit. Moreover, it is unclear if all three will have properly vetted and trained drivers. Collaboration and coordination take place when the health-care community and transpor- tation community come together, as is evident in the case studies and collaborative practices presented in Chapters 5 and 6, respectively. There has been an increase in siloed transportation for a variety of reasons. Two of the largest health-care transportation programs have, for the most part, chosen to operate separate services or brokerages: • VA—A federal agency, the VA often sets up its own transportation programs to serve only its beneficiaries (3). • Medicaid NEMT—This state-managed program gives states flexibility to design and manage their programs. Medicaid NEMT is far and away the largest passenger transportation program outside of the FTA. Many states have chosen to provide the transportation with a capitated brokerage, which typically does not employ public transit systems in a significant way (4). Coordinating the Silos Coordinating siloed transportation can be a difficult and typically a political or cultural process. Often the process involves federal and state agencies, insurance companies, MCOs, and local governments. While not easy, LTD in Oregon and two of Arkansas’ rural transit pro- viders show that under the right conditions, silos can be broken down and that, in turn, can help improve the community’s access to health care through cooperative efforts. In 1999, the GAO noted that: “Transportation coordination can reduce federal transportation program costs by clustering passengers, utilizing fewer one-way trips, and sharing the use of transportation personnel, equipment, and facilities. In addition, people in need of transportation often benefit from the greater and higher quality transportation services available when transportation providers coordinate their operations.” (2) Lane Transit District (LTD) is an example of eliminating silos and improving the quality of the transportation. The transit district has taken on the role of broker with a diverse set of programs, funding sources, and providers, allowing LTD to provide the best “fit” for each rider and funding source. This includes demand response and their network of fixed-route services (Exhibit 4-1), Medicaid NEMT, dialysis centers, and veterans transportation provided by LTD, and when combined with LTD’s ADA service and other health-care and human service transportation, there are notable economies of scale and professionalism.

56 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Communication Sometimes simple communication is a valuable form of collaboration. This could be as informal as a dispatcher talking or emailing a health-care office manager, case manager, or lead nurse, for example. It is important for field-level staff to communicate and work together; communication can minimize surprises. One approach is to schedule and hold regular face- to-face meetings at staff level for the transportation and health-care providers. Southeast Vermont Transit works closely with community health teams to assess and fill each need. Jasper County Community Services in Indiana calls the local nursing home prior to the vehicle’s arrival so that the staff will have the patient ready for the trip, reducing wait time significantly. In New Hampshire, Transport Central provides information and training to ever-changing health-care staff to ensure they are all working together. Health Care Facility Location Prior to settling on a site for a new clinic, hospital, or other health-care facility, those evalu- ating the site should consider the access to public and private transportation services. This is particularly important when the facility considers a move beyond the transit agency’s juris- diction or at a distance where a trip by taxi or TNC such as Uber or Lyft becomes expensive. Conversations with local public and private transportation providers should take place prior to the review of potential sites. Grouping Trips: What Is Productivity and Why Is It Important? More than anything else in the transportation world, productivity drives the cost per trip. Productivity is measured as one-way trips per Two rural transit operators in Arkansas, Central Arkansas Development Council and Southeast Arkansas Transit, eliminate silos by brokering Medicaid NEMT with its public transportation. This allows these operators to maintain a robust net- work of services for the general public and in particular access to health care as the public rides with Medicaid NEMT riders in many cases. Exhibit 4-1. LTD provides a wide range of services. Photo courtesy of KFH Group.

Develop Transportation Solutions 57 vehicle hour. Productivity, which must be balanced with providing a safe (social distancing is critical at the time of this report given the worldwide pandemic), timely, and comfortable service, is critical to cost control. Why is productivity important? Productivity: One-way passenger trips per vehicle hour. • In this example, it costs a transit agency $50 per hour to provide service: – Productivity of 1.5 trips per hour will yield a cost of $33.33 per trip. – Three one-way trips per hour brings the cost to $16.67 per trip. – Ten trips per hour, $5 per trip. – Twenty-five trips per hour, $2 per trip. Grouping Trips: Rutherford County Transit (RCT) RCT is an example of modifying service to improve productivity. Prior to the mod- ification, transportation to Charlotte (30 miles away) for major medical services was provided with paratransit service, with most vehicle trips having one rider on board. At that time, RCT had an operating cost of about $50 per hour with an average productivity of 1.5 one-way passenger trips per hour or $33.33 per trip. There was no attempt to group passengers’ trips. One of the best ways to lower transportation costs is through productivity improvements. The end result? That will depend on different modes or types of service which will yield different productivities (and costs per trip); see Table 4-1. Clearly, based on the productivities shown above, fixed-route service has the highest potential productivity and will provide the lowest cost per trip. But fixed-route service does not work everywhere, and many patients cannot use that service. This does not mean it should be ruled out as an option. For other service types, opportunities exist to improve productivity through revisions or a change of service design. Following are two examples of the power of productivity in reducing cost per trip and total costs. Service Type Productivity – – – – Source: KFH Group. Rural Transit Service Design - Matching Service to Meet Needs: An Introduction. Presented at the National Conference on Rural Public and Intercity Bus Transportation, Breckenridge, Colorado, October 2018. Table 4-1. Typical productivity for service types.

58 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Exhibit 4-2. RCT vehicles are attractive and easily recognized in the county. Photo courtesy of KFH Group. Service was changed to a fixed-schedule model (discussed in detail later in this chapter) using attractive vehicles (Exhibit 4-2) that can travel narrow country lanes, common in Western North Carolina. With this model, the vehicle operates on a set schedule (service is designated for specific days and times), but not on a fixed route. Rather, the vehicle picks up passengers at their door. Individuals who need access to Charlotte for health care or other purposes plan their trips according to the posted schedule. The manager of this transit agency states that most trips now include five or more people, yielding a productivity of 3.3 one-way trips per hour and cost per trip of $15, reducing costs by 55% with a reduction in mileage and other costs and the ability to serve more passengers overall; see Exhibit 4-3. Exhibit 4-3. Modifying service to improve productivity.

Develop Transportation Solutions 59 Summary: Grouping Trips Grouping passenger trips provides cost advantages. However, it should be understood that grouping trips is not necessarily a matter of placing seven or eight people on the small demand response bus when this is not appropriate. However, if the trips have common destinations, it could result in an increase in one passenger trip per service hour to two trips in that hour, which cuts the passenger trip cost in half. The bottom line: use the grouping of trips judiciously. Passenger safety, timely service, ride time, and a comfortable trip must be factored in when grouping trips. Performance indicators should also be considered, such as maximum ride times that should be determined and agreed upon by the collaborating partners. Service Design: A Variety of Options Is Good With an understanding of the importance of productivity, the next step is to look at service design. The objective is to apply the most appropriate service design(s) for the transportation needs. Various service designs can be considered, depending on whether the com- munity has urban or rural areas, the type of riders to be served, and their specific needs. (Note transportation services that require medical support on board are not addressed in this research.). These include: 1. Fixed route—Virtually every urban area and many rural areas and smaller cities have fixed- route service. 2. Hybrid services—Flex-route and fixed-schedule type services. 3. Demand response shared ride. 4. Demand response single ride. Fixed Route Description: Fixed-route service operates on a schedule along a prescribed route. Fixed-route transports the most people at the highest passenger productivity and the lowest cost per trip in urban areas as well as many smaller cities and towns. Transit service with attractive and acces- sible stops with electronic signs that tell the rider when the bus arrives can make it easy for many to ride (Exhibit 4-4). Grouping Trips: Lane Transit District When dialysis clinics, patients, and transportation providers work cooperatively to group trips, each entity wins. Some transit agencies and brokers, both urban and rural, work closely with their dialysis clinics to ensure the best productivity in a safe and comfortable environment. This is particularly important as the need and level of service required for dialysis patients are expanding and often considered a driver of costs (5). Lane Transit District in Oregon, for example, has been able to coordinate patient transportation with some of the dialysis clinics it serves, coordinating service with other transportation programs including Medicaid NEMT.

60 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Applicability: Fixed-route transit service can be a viable option for many riders to use for health-care-related trips. Many brokers and health-care providers routinely distribute tickets and passes to riders to use the community’s fixed-route system to get to and from their medical appointment. However, it is not the right service in all situations. Those who cannot either use the service or get to a bus stop because of a disability require a more specialized mode with door-to-door service. Fixed Route and Health Care: Fixed route is the dominant mode of bus transit in the country. While commuting is the most prevalent trip purpose, health care as a trip purpose remains important. A review of sampled rider surveys from 2015 to 2020 show that trips for health care comprise from 4% to 48% of total trips; see Table 4-2. According to the sampled surveys, on average, health-care trips comprise the following percentages on fixed-route buses by type of community: • Urban areas: 12% of trips were for health care. • Small urban areas: 15% of trips were for health care. • Rural areas: 18% of trips were for health care. • Small urban and rural combined: 14% of trips were for health care. Exhibit 4-4. Low floor buses and attractive stops can help riders use the service. Service Area Percentage Range of Health Care Trips – – – – – Table 4-2. Percentage range of transit trips for health-care purposes.

Develop Transportation Solutions 61 Fixed-Route Service Design: Effective public transportation does much to improve access to health care across the country. The effectiveness of a fixed route, however, is strongly related to how the routes are designed, and this is borne out by two of many examples across the country. An example of two communities, each with a population of 30,000, illustrates this point. The rural transit system in one community with a mid-sized university (and no university North Central Regional Transportation District (NCRTD): In New Mexico, a large rural system shows how small changes to fixed routes at no cost can make a significant difference to all potential riders. NCRTD operates predominantly fixed routes in very rural and remote areas as well as commuter service into more urbanized Santa Fe. One-way trips routinely exceed 80 miles. A recent survey indicated that 9% of NCRTD trips are to access health care. That is the equivalent of 25,000 one-way health access trips annually or 100 trips every weekday. In 2015, NCRTD refined and adjusted the start time of many of its routes to allow residents to travel for health care, shopping, or other needs in the morning and return midday instead of waiting until the end of day—eight hours later—to return. The new start and end times of the routes allowed for greater connec- tivity to transfer seamlessly (Exhibit 4-5) resulting in options for early and late appointments and to still serve commuters at the same time. These changes, among other low-cost route adjustments, helped NCRTD increase ridership by 50% in 1 year and 100% in 4 years. The service design changes virtually doubled health-care access transportation trips from 50 to 100 daily. Exhibit 4-5. NCRTD riders can seamlessly transfer at the Española Transit Center. Photo courtesy of KFH Group. Manchester, New Hampshire: A downtown fixed-route circulator which had initially failed was reintroduced with new partners, including a regional medical center. The route was redesigned, and ridership increased dramatically. Anecdotal evidence from medical center and transit staff suggests that much of that increase comes from the involvement of the medical center. This route change was all done at virtually no additional operating cost.

62 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services transit service) operates two separate one-way 1.5-hour loops so that virtually all round trips are at least 1.5 hours, and 3 hours if a transfer is required (Exhibit 4-6). In this scenario it may take a rider 10 minutes to get to the drug store by bus, but the return would take an hour and 20 min- utes. Productivity is under three one-way trips per vehicle hour, a low level of performance. The second system in Paris, Texas, operates a traditional route structure where there is two- way service (Exhibit 4-7). In this case, the return from that 10-minute ride to the drug store is also a 10-minute trip. This service operates at eight one-way trips per hour without a university at close to one-third the cost per trip of the first example. The result: the second system provides far more health-care related trips on public transit at a very low cost. Hybrid Services Description: Hybrid transit services are more flexible than fixed route but still follow a schedule to ensure a higher productivity than traditional demand response. They are typically a cross between fixed route and paratransit and have become common in some areas. The two forms of hybrid services presented include fixed-schedule service, briefly discussed in the previous section on productivity, and flex-route service (also referred to as route deviation), used more commonly in smaller cities and towns but also appropriate for long-distance routes. Fixed-schedule service can be relatively productive in remote rural areas where all the rules change due to the terrain and demographics, as can be seen in Exhibit 4-8. Fixed schedule can be used to serve an entire county and replace demand response service with a more productive service. Fixed-Schedule Service Applicability: Fixed-schedule service is most appropriate in remote rural areas. The vehicle follows a schedule but not a specific route. Those who want to use the service must follow the schedule; however, the vehicle will pick up passengers at their homes or a designated (limited number) stop. Exhibit 4-6. Fixed route with loop design.

Develop Transportation Solutions 63 Exhibit 4-8. Great distances in remote rural areas require a different set of service design rules. Photo courtesy of KFH Group. Exhibit 4-7. Paris, Texas, metro route map.

64 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services An example of a network of fixed-scheduled services, CARTS, is based in Central Texas. CARTS operates in eight rural counties and provides countywide service on a fixed schedule. Exhibit 4-9 is a county schedule that details the information needed by the rider. The fixed- schedule services connect to a variety of other public transit services. Flex-Route Service Applicability: Flex-route service would be most appropriate for rural routes of longer distance where paratransit service would be inappropriate. Flex route, also referred to as route deviation, is a fixed route with time built in for the bus to go off route for a limited distance to pick up passengers at their door or closest intersection. This flex service can be limited to persons with disabilities, meeting all of the requirements for ADA paratransit, or it can be open to the general public, in which case riders with disabilities are subject to the same policies as all riders, including increased fares, limits on distance (which may be less than three-quarters of a mile), and capacity constraints. It should be noted that flex-route service that flexes for all riders means that individuals with disabilities who cannot get to the bus stop to use the service are subject to possible trip denials as many of these services are on a first come, first serve basis. Demand Response Shared Ride Description: Demand response shared-ride service covers a wide range of services including new microtransit options. These services are found in urban areas in the form of ADA para- transit (Exhibit 4-10) and microtransit (including dial-a-ride). In rural areas, they could be microtransit and dial-a-ride or countywide demand response. Some of these services require one-day advance notice to schedule a trip, while the newer services that use smartphone apps require as little as 15 minutes notice for a trip. Applicability: For health-care access, shared-ride demand response can be appropriate for patients unable to use the fixed route or when it is not available to them. ADA paratransit is a viable option where available. Transit agencies require individuals to apply for the service and be deemed eligible prior to use. Various forms of shared-ride demand response service exist in many communities. Experience has shown that some individuals who could use fixed-route use the demand response service because they want the convenience of door-to-door service or they do not know how to ride the bus. It is important to understand riders’ capabilities and to provide transit training when this would benefit riders. Those patients who refuse to ride fixed route, when deemed capable, should be reviewed on a case-by-case basis by the health-care provider. Rural areas often use demand response service in both rural areas and small towns and cities. Rural demand response service is typically low productivity and costly on a per trip basis. The fixed-schedule solution will improve productivity without interfering with patient access to services. Demand Response Single Ride Description: Demand response service is used by a solo passenger with no attempt to group rides. Taxis and TNCs are the most common type of single-ride demand response service. Applicability: This type of service is most appropriate for an individual patient who should ride either alone, with a caretaker, or with an attendant for medical or safety reasons. The need for this type of service is typically best determined by the health-care provider. Due to its low productivity, it can also be an expensive trip. Often this type of service is offered

Develop Transportation Solutions 65 Exhibit 4-9. Fixed-schedule public transit.

66 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Exhibit 4-10. ADA complementary paratransit vehicle. by the VA, human service agencies, and health-care providers. It is important for after-hours discharges from a hospital or other medical facility when public transit and shared-ride services are not operating. These single-ride services have traditionally been provided by taxis and are now often pro- vided by TNCs as well. Safe and Professional Services Patients are entitled to a safe and accessible trip. However, one vehicle driver is not the same as the next, and one vehicle is not the same as the next. Effective transportation service will ideally be provided by trained staff with safe vehicles— in other words, professional transportation service, which is particularly impor- tant for vulnerable populations. Professional Standards for Vehicles and Drivers Appropriately vetted and trained drivers are essential as many trips are one-on-one with a vulnerable patient. Exhibit 4-11 details basic requirements for drivers and vehicles. All health-care providers should ensure that their transportation providers and drivers are properly vetted and trained to work with vulnerable patients. Efforts to improve driver pro- fessionalism enhance safety as well as customer service. Rio Grande Valley Transit Driver Academy is a pilot program designed to train new drivers to work at public transit agencies in the Lower Rio Grande Valley. The transit partners include the city of Brownsville, Brownsville Metro; city of McAllen, Metro McAllen; town of South Padre Island, Island Metro; and Lower Rio Grande Valley Development Council, Valley Metro. The training is provided by South Texas College and Texas State Technical College (6). Through economies of scale, each system receives professional training at a reduced cost.

Develop Transportation Solutions 67 Vehicles should be professionally maintained to stringent standards, including standards that address the age and condition of vehicles. Depending on the type of transportation service, health-care providers may consider the following minimum standards noted in Exhibit 4-11. Ideally, health-care and transportation providers collaborate to set the minimum standards for vehicles and drivers. Monitoring Drivers The transportation providers ideally have policies and practices in place to monitor their drivers to ensure adherence to standards and policies. Does the transportation solution being considered ensure that the transportation provider monitors the driver and that the entity in charge knows exactly who is driving? This requires the ability and exercise of real- time contact. Uber and Lyft apps, for example, allow the user (with a smartphone) to identify the driver. Without this assurance it is impossible to tell who is actually driving and what vehicle is being driven. The Result: Safe Service Placing vulnerable patients into a stranger’s hands for transportation can be a leap of faith. However, a leap of faith is not desired when transporting vulnerable patients. Improving transportation access to health care should include efforts to ensure the transportation pro- vider has safe and professional drivers and vehicles. As one example, Medicaid NEMT and TNCs typically involve the use of drivers’ personal vehicles. Health-care providers purchasing these services should have assurances that the vehicles used to transport their patients are appropriate and safe. Drivers Vehicles Exhibit 4-11. Minimum standards for drivers and vehicles.

68 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Understanding Mobility Limitations of Riders One Patient at a Time Articulating Service Needs of Riders (Patients) and Matching with Solutions The riders (patients) seeking access to health care cover a very wide range of people. Many are ambulatory and can negotiate a public transit network. Others may need a door-to-door ride and still others may require an attendant. Transit agencies are adept at determining if people can use a fixed route or require more specialized service, one that should be relied on by health-care providers where available. For purposes of developing transportation solutions to improve access to health care, it is useful to consider types of riders by their abilities to use transportation and the appropriate types of transportation service. The following four categories group riders by type of transportation service that is appropriate: 1. Ambulatory and independent riders are able and willing to use fixed-route service or other public transit mode. This would be the first option where appropriate. It is clearly the lowest cost option and requires no additional effort from public transit. These riders would also be able to ride on microtransit options that require persons to walk to a nearby intersection. 2. Riders in need of shared-ride door-to-door service are able to use a service such as public transit’s ADA paratransit, general public dial-a-ride, or microtransit (where door-to-door service is available) if they are unable to use or get to a fixed route or if in a rural area without fixed-route service. 3. Riders in need of single-ride door-to-door require a non-shared, door-to-door ride, which is generally beyond the capabilities for public transit agencies. These riders will need a direct, non-shared service and may require assistance into or out of a building. After-hours discharges often require a single-ride service such as taxi or TNC. 4. Highly specialized needs might be needed for a patient who must travel supine or with special medical equipment. The transportation service would require a trained professional driver or an appropriate attendant to assist the rider and may need a specific type of vehicle. The First Step: What Are the Riders’ Capabilities? The first step in determining the appropriate transportation service is to assess the riders’ capabilities. Virtually all fixed-route transit agencies in the country (almost all urban areas and many small urban and rural areas) have an eligibility determination process for ADA comple- mentary paratransit that assesses the type of transportation service required by an individual. Some of these determination processes are rigorous, requiring interviews, testing, and pathway assessments, while others simply require a doctor’s signature. The objective is to determine if the rider can ride a fixed route for all trips, for some trips (conditional eligibility), or if the rider needs ADA paratransit for all trips (unconditional eligibility). Using the ADA Eligibility Determination Process While an ADA eligibility determination process can be an effective way to determine if a person is capable of using a fixed route, it may not give the health-care professional the entire picture. For example, it may be that a patient is capable of riding a fixed route, but the health- care provider knows that, given that option, the patient in question would not use it and as a result would miss the scheduled medical appointment. In such cases, the health-care provider would be justified in selecting a door-to-door service for that patient.

Develop Transportation Solutions 69 Using the Eligibility Process for More than Public Transit Service A formal process for determining eligibility for different types of transportation service can be used for more than public transit. For example, LTD, which brokers a range of transporta- tion services both within an ADA service area as well as beyond, uses an eligibility determination process not just for its ADA paratransit service, but for its full array of services. This process is unique in that all applicants are subject to a home visit from an eligibility specialist. Summary: Mobility Limitations For purposes of determining the appropriate transportation services for improving access to health care, it is useful to consider the four basic categories of riders. These broad categories capture the transportation abilities of patients and allow the collaborating health-care and trans- portation providers to evaluate the types of transportation services that fit. Transportation Solutions and Service Design: One Size Does Not Fit All Depending on the transportation needs of patients articulated by the health-care provider, the transportation community can come up with solutions to meet most, if not all, needs. The previous sections of this chapter provide the basics of transportation, which include a review of the different service designs and a discussion of mobility needs for moving forward with the appropriate transportation solutions to improve access to health care. The next step is develop- ing the appropriate transportation solution. This involves, for example, decisions about how to operate the service, contract for service or use a broker, or perhaps the health-care provider wants to operate the transportation service directly. Consequently, it involves decisions about the type of service to provide. When finding a transportation solution, what matters most is the functional needs of the riders. Is it a matter of simply providing bus passes or does the rider require specialized care or a door-to-door, shared-ride service? Transportation solutions should recognize that the needs typically represent a continuum, from riders who are able to use fixed-route services all the time to those who can never use a fixed route and need some type of more specialized transportation service. One size does not fit all. It would be inappropriate to expect a person using an electric wheelchair to ride in an inaccessible taxi, as it would be inappropriate to place a person able and willing to ride the local fixed route on a far more expensive specialized service. Management and Operation of Service When the collaborating health-care and transportation providers are prepared to develop the transportation service, there are a number of operational and management decisions to be made: • Should the health-care provider contract for service or should they operate it themselves? • Should the health-care provider form a brokerage and, if so, what type? • What are the most appropriate solutions for the community?

70 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Contracting for Service When a health-care provider or consortium of providers initiate transportation service, the solution is often to contract the service either with local existing taxi companies and/or TNCs. At the same time, the health-care provider may purchase fixed-route bus tickets to distribute as appropriate. There are many examples of this type of arrangement, often less formal than contractual. Operate In-House Many human service agencies and health-care providers operate small numbers of vans for their patients or clients. For example, senior center vans typically take a group of seniors to health-care facilities from the senior center on select days, often grouping up to six or eight passengers. There are a number of examples of transit agencies provid- ing retired vans (in good condition) to non-profit organizations for passenger transportation. These non-profit organizations often need to address driver training and vehicle maintenance, functions that they may not have in-house. Brokerage: Many Variants In many cases, communities may use a brokerage for transporta- tion service, an option that is designed to meet the trip need with an appropriate transportation service at a reasonable cost. There are two types of brokerages that are intended to do different things: • Traditional Coordinated Broker–These services typically offer the best fit for riders: cost, service, or both. There are many variations of this model as the transportation brokerage can be managed by non-profit agencies, transit systems, health-care facilities, or for-profit companies. Tech- nology to allow for the most efficient use of vehicles is now the norm. These services typi- cally serve a diverse population, including the general public, with multiple funding sources. • Capitated Broker–A capitated brokerage for health-care transportation pays the broker a flat fee for each patient in the health plan. The risk of fluctuation in use of transportation and costs for transportation lies with the broker. This is a method used by many states for their Medicaid NEMT programs, which allows the state to stabilize costs. Typically, only Medicaid NEMT uses this model. Capitated brokerages have been discussed in detail in TCRP Research Report 202: Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination (8) and are typically not used for non-Medicaid NEMT trips. This discussion will instead focus on a variety of coordinated brokerages and the technology that they use. The value of the broker comes in its ability to deploy a diverse set of transportation providers to meet the varying needs of patients. The brokers reviewed for this study did just that—used multiple funding sources to serve multiple groups of riders while using a number of different providers, including public transit (for example, LTD and Denver Health). The transporta- tion broker has the ability to fit each trip to the most appropriate mode and provider based on passenger need and cost. Following are three examples of coordinated brokerages, each operated by different types of entities; all attempt to provide the best fit for each rider. Public Transit Brokers Public transit systems such as LTD have, at times, assumed the role of transportation broker for not just its ADA service but also for Medicaid NEMT, senior programs, and a number of Rather than work with the local Tribal Transit System, Indian Health Services in Winslow, Arizona, operates two vans to serve the same area as the transit system, albeit less productively (7). Taylor Hospital in Kentucky saw no alter- native to operating in-house. Other health-care providers have taken it a step further and now operate public transit in their communities including the Aaron E. Henry Clinic in Mississippi and Spartanburg Hospital in South Carolina. These organi- zations did so in order to fill a vacuum because there were no transportation providers in their community.

Develop Transportation Solutions 71 other organizations. Some rural public transit systems also act as broker-providers including Central Arkansas Development Council and Southeast Arkansas Transit. Vermont uses the state transit association to broker Medicaid NEMT trips to transit systems. Health-Care-Based Brokerages In Denver, a regional hospital has taken on the role of transportation broker funded through its foundation. Denver Health has developed a network of providers and uses brokerage soft- ware and accompanying technology to broker trips to their facilities as well as network partners. Informal Broker Informal brokering is typical across the country as hospital and health-care provider staff routinely make arrangements for patient travel. This could include using an app to call a taxi or TNC, distributing bus tickets, or dispatching a volunteer. This is a good solution if services are available and the demand is not excessive. Selecting an Approach for Managing and Operating Transportation Service Decisions regarding how to manage and operate a transportation service for improving access to health care should first determine what options are available. There are advantages and disadvantages to each approach. Transportation Solutions—Matching Needs to the Right Services There is a continuum of transportation solutions that can each be matched to a partic- ular transportation need. Based on cost and convenience, a health-care provider can attempt to maximize the use of fixed-route service (where available). After that, there are a number of options. Tables 4-3 matches patients with transportation solutions in urban areas. Table 4-4 matches patients with solutions in rural areas. Rural areas are distinguished from urban areas in the modes available. These tables depict matrices of services and needs and can serve as a guide in determining the type(s) of service to meet the individual needs in both urban and rural areas. Patient Types Taxi, TNC ADA Paratransit/ Microtransit Specialized or Volunteer Fixed Route Table 4-3. Matching patients with transportation solutions: Urban.

72 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services The matrices define groups of patients by their transportation abilities or needs. The groups do not specify age or disability, since some people can use fixed-route transit and others cannot. Exhibit 4-12 shows a flow chart depicting the continuum of transportation service annotated by the types of patient needs. The chart assumes that the options in the continuum of services are available, but that may not always be the case. First Stop: Fixed Route The first option, where available and appropriate, should be fixed-route or general public transit service such as microtransit. Fixed route is the least expensive mode and, while not for all riders, many needs can be met through the use of bus passes. Trips typically cost $1–$2. The cost of monthly passes for an unlimited number of rides is about the same as one or two single rides on paratransit. LTD in Oregon, Capital Metro in Texas, and Denver Health are all examples of using bus passes for health-care needs. These three systems dem- onstrate an effective use of low-cost bus passes to provide patient access to health care. Critical to successful fixed routes are bus stops. These stops should be accessible and safe in order to attract riders of all kinds. Exhibits 4-13 and 4-14 depict attractive stops. Rural and Urban Issues: Fixed Route Many urban areas have effective public transit, and many health-care facilities are on bus routes. Smaller cities and towns may have less public transit, and some may have service designs Table 4-4. Matching patients with transportation solutions: Rural. Patient Types Fixed Route (where available) ADA Paratransit (where available) Rural Fixed Schedule (shared ride) Rural Paratransit (shared ride) Taxi, TNC Specialized or Volunteer

Exhibit 4-12. Matching transportation needs with transportation services—a continuum.

74 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services that less effectively serve health-care facilities. Two examples of local fixed-route systems are depicted in Exhibits 4-15 and 4-16. Many rural systems operate longer-distance intercounty services. These are most prevalent in the West where there are many multi-county transit systems with some services extending over 200 miles. For example, Navajo Transit operates over 200 miles from one end to the other. NCRTD has a service that spans over 250 miles, from east of Albuquerque to Farmington. These are discussed in greater detail in Chapter 6. Hybrid Services Over the past 15 to 20 years, a variety of hybrid services have been developed—a cross between fixed route and paratransit. Two examples of this are demonstrated by Rutherford County Transit in North Carolina and CARTS in Texas (Exhibit 4-17). Both of these examples show how fixed-scheduled services allow for the grouping of trips and reduction of costs. The fixed-schedule service model has the most potential for a positive impact on ridership and service in rural areas. Exhibit 4-14. A small town bus stop is very attractive. Exhibit 4-13. This fixed route bus stop has no barriers.

Develop Transportation Solutions 75 Exhibit 4-17. CARTS country bus provides fixed- schedule services. Photo courtesy of KFH Group. Exhibit 4-15. Local fixed route in Los Alamos, New Mexico. Photo courtesy of KFH Group. Exhibit 4-16. Small urban fixed route in Coeur d’Alene, Idaho. Photo courtesy of KFH Group.

76 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Second Stop: Demand Response Shared-Ride Door-to-Door Service The next group of potential solutions are all demand response-based, typi- cally with door-to-door service. Shared-ride demand response or dial-a-ride is an appropriate service for many who cannot use fixed route. These typically take one of four forms: • ADA complementary paratransit. • General public dial-a-ride (microtransit). • Rural demand response service. • Human service or health-care transportation services. ADA Complementary Paratransit Every transit agency in the country with fixed-route service is required to provide ADA para- transit for individuals with disabilities who cannot use fixed route because of a disability. • Each transit agency has a process to determine eligibility for paratransit service. • Eligibility for paratransit takes two basic forms: unconditional eligibility where a person is declared eligible for paratransit for all trips and conditional eligibility where riders can use fixed route for some trips and paratransit for others. • Once determined unconditionally eligible, paratransit can be used for any purpose provided one calls the day prior to service. • Service is available a minimum of three-quarters of a mile from fixed route on the same days and at the same times. • Many transit systems extend beyond the minimum and some include seniors. • Paratransit fares can be no more than twice the fixed-route base fare. • Paratransit services typically generate between one and three one-way trips per vehicle hour. • These services can use transit system vans or buses, taxis, TNCs, and other third-party trans- portation providers. Health-care providers are encouraged to visit the website of their local public transit agency and open a dialogue with the transit managers to discuss how they could work together. General Public Dial-a-Ride (Microtransit) Dial-a-ride (microtransit) and similar flexible on-demand services have been around for over 40 years, but it was not until recently that this form of transit service began to expand, driven in large part by new technology. Microtransit has been enhanced by the variety of apps that are capable of using small vehicles (Exhibit 4-18), efficiently and effectively scheduling and routing trips. Site visits to various microtransit services reveal that productivity can get as high as six one-way trips per hour in suburban and moderate density communities in urban, suburban, and rural areas. Rural Demand Response Service Some rural transit systems continue to operate shared-ride demand response service, some- times countywide, operating at very low productivities of one trip per vehicle hour. This can result in trip denials due to the low-capacity service. These services are common in a number of states—for example, Arkansas, North Carolina, and Texas. Human Service or Health-Care Transportation Services There are many examples of human service or health-care agencies transporting patients using staff to drive their own vans that are sometimes donations. In addition, the use of FTA funds for seniors and persons with disabilities (FTA Section 5310) to purchase vans

Develop Transportation Solutions 77 is a common practice across the country. In some cases, the transit agency (e.g., COAST in Washington State) turns over its well-maintained yet retired vans to these agencies. With low out-of-pocket costs (no paid driver), these organizations can be encouraged to continue providing their service. Third Stop: Single-Ride Demand Response Some patients will need one-on-one service due to their specific needs. In other cases, one-on-one service is based on the nature of the trip. For example, after-hours discharges from a hospital will almost always be a solo trip by virtue of the low level of demand at that time, combined with the often last-minute nature of the trip. Transportation providers for these trips may include, but are not limited to: • Taxi • TNC • Volunteer • Private provider or individual contractor driver Most of these services are for ambulatory riders; however, very often private providers and some taxi companies have wheelchair-accessible vehicles (Exhibit 4-19). The issue of after-hours transportation service can be a difficult one especially in rural areas or where the discharge is far from the patient’s home. For example, Rutherford County, North Carolina, has an agreement with a Charlotte, North Carolina, taxi service for after-hours service. There are numerous examples of agreements with TNCs and taxi companies for single-ride demand response service (See Denver Health and LTD case studies in Chapter 5). Fourth Stop: Specialized Demand Response Specialized demand response transportation service is for individuals with unique transportation needs. Often it is necessary to have a highly trained driver or an attendant to support the driver. Riders often have physical or mental health issues and Exhibit 4-18. A small microtransit bus. Photo courtesy of KFH Group.

78 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Exhibit 4-19. An accessible taxi. Photo courtesy of KFH Group. require assistance in route. This assistance would be non-medical and would not require an ambulance and EMT. Fifth Stop: After-Hours Service For those anticipating after-hours discharges, in particular from hospitals, this service is essentially a taxi or TNC provider. In remote rural areas where there may not be a taxi or TNC, it may be possible to organize a volunteer trans- portation network or staff on-call. Another option for health-care providers would be to avoid after-hours discharges when the patient depends on the public service. Summary: All Stops Having a range of options for service provision is a strength when it comes to transporting people to health care. Transportation needs often range from those fully capable of riding fixed route to those who will always need specialized assistance on board. For those health-care providers that have only one or two of these passenger needs, then the range of options is not an issue. Sustainability: Building a Strong Transportation Support Network Transportation and health-care collaborations and partnerships often begin as pilots. If the effort is successful and improves transportation access to health care, funding is needed to move the service beyond pilot status and to sustain its operation. However, sustainability is more than just identifying funding support. It is first important to ensure the transportation service is cost efficient, with the appropriate service provided for the identified needs. Second, funding sources are needed to continue the service over the longer term. This second part of sustain- ability is discussed below. • A Diverse Funding Base • Public Transit Funding • Health-Care Providers • Public-Private Sponsorships and Partnerships • Maintaining Multiple Health-Care Funding Sources—the Search for Funding

Develop Transportation Solutions 79 A Diverse Funding Base Once a transportation service is successfully operating, the focus should be on sustainability. One approach to sustainability is to find and maintain diverse funding streams. Coordination and collaboration are important elements in this effort. Maintaining a diverse base of funding and revenue can take many forms, and the collaborating partners should be engaged to support a continuation of those diverse funds. Those sources of funds include but are not limited to: • FTA public transit funding. • Federal health-care funds such as Medicaid and VA. • Health-care providers (many local health-care providers support transit). • Private sector sponsorships and partnerships. Health-care providers, retailers, and others have found benefits of sponsorship. Following are examples of funding sources and approaches to sustainability. Table 4-5 is a matrix of funding sources among many that are used in the collaborative practices. Note the range of sources among these examples. Public Transit Funding FTA has a variety of funding programs for use by transit agencies to support transit. For additional information regarding FTA programs, it is best to start with the website: https:// www.transit.dot.gov/funding/grants/grant-programs. The key programs are: • Section 5307 program for operations funding for urban systems (under 250,000 population). This includes capital funding at an 80% federal match and operating assistance at a 50% match (for smaller urban systems only). It should be noted that large urban systems do not receive operating funds from FTA because that is a local, and in many cases a state, responsibility. • Section 5311 program for operating (50% federal match) and capital (80%) assistance for rural transit systems. • Other funding sources for capital and facilities (most notably Section 5339) where transit systems can receive an 80% federal match. The Rural Public Transit Advantage Federal Funding—Unique to rural transit, FTA treats rural transit systems differently than urban areas. This is particularly important in the rules established for matching funds. Rural transit systems have the ability to use other federal funds (such as Medicaid NEMT and veterans funds) as local match. Coordination and collaboration between public transit and health-care providers allow rural transit agencies to leverage these federal funds and reduce the need for local match, which is often difficult in rural areas. With the proper collaboration, transit expands and benefits all. Health-Care Providers Health-care providers have approached the funding of transportation in a number of different ways. • Some health-care providers choose to operate or fund the service themselves; in many cases, there are no other viable options: – Arron E. Henry Health Clinic, Mississippi, and Spartanburg Transit, South Carolina, are two examples of health-care providers operating public transit. These systems then take advantage of the FTA Section 5311 program and can use other federal sources for match.

Organization/Location Transit Providers Health-Care Providers Federal/State/Local Governments Sponsorships/ Private Sector Non-Pro�its/ Human Service • • • • • – • • • • • • • • • • • Table 4-5. Matrix of funding sources.

• • • • • • • • • ’s • • • • •

82 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services – Taylor Regional Hospital in Kentucky, citing a lack of available transportation, chose to develop a service for its patients and fund it directly with support from other health-care providers. – In Southeast Missouri, the Missouri Rural Health Association’s (MRHA) HealthTran pro- gram, members pay an assortment of fees such as annual membership fees and monthly subscriptions. Initiation and booking fees are imposed on health-care providers in order to be part of the network and ensure sustainability. – Indian Health Services in Winslow, Arizona, operates its own vehicles in service to the Winslow clinic. – Denver Health Medical Center (funded by the Center’s foundation) is an example of a health-care-funded brokerage. • Other health-care providers collaborate with and fund transit: – Capital Metro and its partner CARTS, a rural system in Texas, work closely with a health- care foundation to provide service in a small city beyond Capital Metro’s jurisdiction and collaborate with the city/county health department to provide bus passes to persons in need. – Two coordinated rural transit operators competed for and were selected to operate Medicaid NEMT brokerages in Arkansas. This funding can then be used to match FTA funds. – LTD receives funding from a number of human service agencies and health-care providers. This includes both Veterans and Medicaid NEMT. Public-Private Sponsorships and Partnerships Private sector participation in support of transit is not new. Various forms of partnerships and sponsorships have been in place for over 100 years. Advertising on transit was in use since the turn of the last century with advertisers tying banners to the sides of trolleys. Transit and the private sector each have much to gain. The private sector can advertise, promote their organiza- tions, and support their community, while the transit system generates flexible local revenue for the service. Paris, Texas, is an example of a sponsorship program with participating sponsors that include the local medical center, an oncology center, the city, and retailers. The public transit operator, TRAX, which is part of the Ark-Tex Council of Governments, generated $150,000 in revenue and in-kind facilities for the operation of the fixed-route system. Maintaining Multiple Health-Care Funding Sources— the Search for Funding There are a number of examples of services funded by a hospital or medical center’s founda- tion. In some instances, insurance companies (CareMost, for example) fund their own trans- portation service as well. Unless an organization or collaborative partner is willing and able to self-fund their transportation, it is best to generate partners willing to fund or support the program. Using public transit as a partner can ensure the program is leveraging the federal funds available to the community. This is particularly important in rural areas when transit systems can use other federal funds as a local match. The collaborative partners should embrace new organizations to support the transportation service and continually seek out new sources of funds to ensure sustainability. The case studies and collaborative practices documented in Chapters 5 and 6 of this guidebook provide many examples that demonstrate funding possibilities.

Develop Transportation Solutions 83 Chapter Notes 1. Report of the Comptroller General of the United States. Hindrances to Coordinating Transportation of People Participating in Federally Funded Grant Programs. CED-77-119, U.S. Government Accountability Office, Washington, D.C., 1977. 2. U.S. Government Accountability Office. Transportation Coordination: Benefits and Barriers Exist, and Plan- ning Efforts Progress Slowly. RCED-00-1, p. 2, 1999. 3. Ellis, E., B. Hamby, H. Menninger, J. Quan, B. Powell, R. Glauthier, V. Sedig, and H. Chase. TCRP Research Report 164: Community Tools to Improve Transportation Options for Veterans, Military Service Members, and Their Families. Transportation Research Board, Washington, D.C., 2013. 4. Hosen, K., and E. Fetting. TCRP Synthesis of Transit Practice 65: Transit Agency Participation in Medicaid Transportation Programs. Transportation Research Board, Washington, D.C., 2006. 5. Ellis, E., S. Knapp, J. Quan, W. Sutton, M. Regenstein, and T. Shafi. TCRP Research Report 203: Dialysis Trans- portation: Intersection of Transportation and Healthcare (2019). Transportation Research Board, Washington, D.C., 2019. 6. Coordinated Public Transit and Human Service Transportation Plan. Lower Rio Grande Valley Develop- ment Council, 2017. http://www.lrgvdc.org/downloads/transportation/Final%20LRGV%20Regional%20 Public%20Transportation%20Coordination%20Plan.pdf. 7. Ken Hosen, in-person interview, Indian Health Services Transportation Coordinator, Winslow, AZ, July, 2018. 8. Cherrington, L., S. Edrington, J. Burkhardt, D. Raphael, P.W. Collette, S. Borders, R. Peterson, et al. TCRP Research Report 202: Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Transportation Research Board, Washington, D.C., 2018.