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

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177 Introduction TCRP Research Report 223, Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services has two objectives. The first is to develop a guidebook to help communities improve transportation access to health care. The second objective of the project—the research plan—is to develop a plan that outlines future research needs and priorities. Future research is needed to further the understanding of the transportation and health- care relationship and to identify actions and strategies to strengthen and develop that relationship. Building on the research project’s Request for Proposal, this plan was developed based on the project team’s task work over the project period—both through the early litera- ture review and on the research on existing collaborative arrangements between health-care and transportation providers that were identified. Research Plan The research plan is presented below in four components. 1. Vision The overarching vision of the research plan is to provide a blueprint for pursuing and funding additional research that quantifies and better qualifies the benefits of improving transportation access to health care and how best to accomplish that vision. 2. Rationale Research conducted to develop the guidebook found that access to health care is impacted by various factors. Lack of adequate transportation is one barrier among others. Financial issues are another barrier and critical—specifically, a lack of health insurance prevents some from seeking health care. Lack of motivation can also be a barrier, particularly for those with chronic diseases and ongoing needs to access health care. Given sponsorship of the project by TRB, this research plan focuses on transportation and the extent to which it poses a barrier as compared to other barriers. There is agreement that access improvements to health care are needed, but questions remain. What are the most effec- tive strategies for pursuing improved access? How do the strategies vary by type of community A P P E N D I X Research Plan

178 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services (urban, suburban, and rural) and type of health-care issue (e.g., chronic diseases versus one- time medical appointments)? How can technology improve access? How can communities access and coordinate the different funding streams—those targeted to transportation and those dedicated to health care—to improve transportation access to health care? 3. Research Goals The goals of the research plan include: • To outline research topics for possible funding through TRB and potentially TRB in coop- eration with its sister division within the National Academies—the Health and Medicine Division. • To outline research topics that might be pursued through other organizations with funding for research, specifically public and philanthropic funders of health research. A small sample of these organizations includes: – Howard Hughes Medical Institute – Bill & Melinda Gates Foundation – Rockefeller Foundation – AARP – Universities with public health graduate departments • To stimulate research to better understand the role of transportation in health-care access, distinguished from other access issues and from other social determinants of health. • To document the importance of quantifying the contribution of adequate transportation access to improving health-care outcomes. • To encourage peer-reviewed research that estimates the savings in national health-care costs with improved transportation access to health-care services. 4. Research Framework Priorities The need for further research on transportation access to health care was clear from the work performed for the guidebook. More significantly, the need for improved access to health care has become startlingly clear with the health-care disparities shown in the country with the coronavirus pandemic in 2020. People living in communities with poor air quality and those in minority population groups seem to be more at risk for the disease caused by the virus—COVID-19. Is access to health care a factor contributing to the disparities? Does transportation access contribute to those disparities? The identified research needs are listed below (not necessarily in order of importance): • Develop a better understanding of the specific aspects of transportation that render it a potential barrier or success to health-care access and how those aspects play out in different types of communities. A better understanding will allow more focused attention on the key factors. What is the relative role of the following? – Cost of transportation – Distance to health-care facilities – Effective service designs—examining the types of transportation services available (fixed route, flexible route, curb to curb, door to door, etc.) and how those services are currently used – How to maximize the use of fixed-route services in rural and small urban areas – Geographic boundaries/service area constraints of available transportation services – Service span of available transportation resources

Research Plan 179 – Accessibility of transportation (e.g., vehicles) – Transportation’s role in the health disparities revealed by the pandemic in 2020 caused by the coronavirus • Identify the specific population groups with the greatest need for improved access to health care and determine, by population group, why the needs exist. Are the needs related to the following? – Language barriers – Cultural aspects (e.g., suspicions of Western medicine) – Cost – Availability of appropriate transportation – Other reasons • Develop an estimate of the medical and ancillary appointments missed due specifically to a lack of transportation. – Missed and delayed medical and related appointments stem from various reasons. To evaluate the benefit of improved transportation access, it is important to understand the degree to which missed and delayed appointments result specifically from transporta- tion access issues. – Define an effective and measurable metric to measure the specific role of transportation access in evaluating the causes of missed appointments. • Estimate the direct costs of the missed medical and ancillary appointments to the health-care industry. – Cost of health-care providers’ time and cost of lost use of health-care resources (e.g., scheduling the appointment, time set aside for the appointment if not reused for medical purposes that could be billed, costly medical equipment not used, etc.). • Estimate the longer term, indirect costs to society for the missed medical and related appointments due to transportation access issues. – Longer-term costs are related to increased hospitalization and costs for treatment due to worsened medical conditions. This is particularly true for those with chronic diseases. • Assess practices currently used in the health-care industry to better understand the role of transportation access to health care. – Document effective practice as well as deficiencies. • Research the role of technology as a strategy to improve access to health care. Technology is rapidly changing the transportation landscape with private mobility services as well as improving the practice of telehealth. – What is the role of the new private mobility services in access improvement? How can those services be harnessed to improve access to health care? What has been the experience in selected states (e.g., Georgia, Tennessee) that have included a TNC as an allowed provider of Medicaid NEMT? – What is the role of telehealth and to what extent does it substitute for the need for trans- portation to a health-care facility? – What is the role of telehealth in helping to establish a foundation for health-care access in times of a nationwide pandemic when actual transportation to non-urgent health-care services is limited? – What is the role of autonomous vehicles (AVs) in improving access to health care? How would AVs serve those with specialized needs (e.g., those traveling with larger mobility devices, those with cognitive disabilities)? • Define the steps that could be taken to better coordinate federal and state funding for health- care transportation, including funding for Medicaid NEMT. – Coordinating funding for transportation has been a topic since the 1970s. What are the specific barriers to improved coordination? What specific steps are needed to eliminate

180 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services the barriers? What is the role of the federal and state governments in addressing those barriers? – Examine the safety of various approaches to NEMT and the importance of properly vetted drivers, vehicles, and performance standards. • Disseminate the research plan to organizations that conduct health-care research and track the extent to which the research is funded, conducted, and shared within both the health- care and transportation industries.

Abbreviations and acronyms used without definitions in TRB publications: A4A Airlines for America AAAE American Association of Airport Executives AASHO American Association of State Highway Officials AASHTO American Association of State Highway and Transportation Officials ACI–NA Airports Council International–North America ACRP Airport Cooperative Research Program ADA Americans with Disabilities Act APTA American Public Transportation Association ASCE American Society of Civil Engineers ASME American Society of Mechanical Engineers ASTM American Society for Testing and Materials ATA American Trucking Associations CTAA Community Transportation Association of America CTBSSP Commercial Truck and Bus Safety Synthesis Program DHS Department of Homeland Security DOE Department of Energy EPA Environmental Protection Agency FAA Federal Aviation Administration FAST Fixing America’s Surface Transportation Act (2015) FHWA Federal Highway Administration FMCSA Federal Motor Carrier Safety Administration FRA Federal Railroad Administration FTA Federal Transit Administration HMCRP Hazardous Materials Cooperative Research Program IEEE Institute of Electrical and Electronics Engineers ISTEA Intermodal Surface Transportation Efficiency Act of 1991 ITE Institute of Transportation Engineers MAP-21 Moving Ahead for Progress in the 21st Century Act (2012) NASA National Aeronautics and Space Administration NASAO National Association of State Aviation Officials NCFRP National Cooperative Freight Research Program NCHRP National Cooperative Highway Research Program NHTSA National Highway Traffic Safety Administration NTSB National Transportation Safety Board PHMSA Pipeline and Hazardous Materials Safety Administration RITA Research and Innovative Technology Administration SAE Society of Automotive Engineers SAFETEA-LU Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (2005) TCRP Transit Cooperative Research Program TDC Transit Development Corporation TEA-21 Transportation Equity Act for the 21st Century (1998) TRB Transportation Research Board TSA Transportation Security Administration U.S. DOT United States Department of Transportation

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