Exploring Data and Metrics of Value at the Intersection of Health Care and Transportation Proceedings of a Workshop (2016) / Chapter Skim
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Appendix C: Environmental Scan
Appendix C: Environmental Scan
Pages 101-162
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From page 101... ...
and commissioned by the Health and Medicine Division (HMD) and the Transportation Research Board (TRB)
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102 INTERSECTION OF HEALTH CARE AND TRANSPORTATION CONTENTS PURPOSE 103 BACKGROUND 103 Health, 106 Transportation, 110 Return on Investment, 110 INTERVIEW BACKGROUND 112 SUMMARY OF THEMES 113 INTERVIEW THEMES: CHALLENGES 114 Defining Return on Investment, 114 Funding and Basic Infrastructure, 117 Missing Information and Data, 118 Technology, 122 Geography, 123 NEMT Destination and Service Gaps, 125 Cross-Sector Collaboration, 126 INTERVIEW THEMES: SOLUTIONS AND OPPORTUNITIES 130 Grants, 130 Shared Learning, 130 Start Small and Go Slow, 131 Let Patients Tell the Story, 133 Take the Care to the Patients, 134 Customer Experience, 134 Sharing Resources, Increasing Revenue, 135 Sharing Data, Analyzing Solutions, 137 AVAILABLE INFORMATION 138 Existing National Data, 139 Existing Local or Program-Specific Data, 143 RESEARCH AND RESOURCES 146 Completed Reports, 146 Reports Under Way or Planned for the Future, 155 Tools and Resources, 157 INTERVIEWEES 160
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. Transportation also impacts access to health care directly, and through access to care, transportation also affects health care costs and health outcomes indirectly.
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. The structure of IHSfunded clinics varies, and many provide transportation services to members in need who are not eligible for Medicaid or VTS.
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2006. Cost-Effectiveness of Access to Non emergency Medical Transportation: Comparison of Transportation and Health Care Costs and Benefits, Transportation Research Record:(1956)
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These different vocabularies affect, too, what it means to examine the return on investment of providing transportation services to health and health-related destinations. How transportation and health care professionals define each concept -- what is meant by health outcomes, health care savings, transportation, and return on investment -- will have an impact on how data are collected and analyzed.
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Improvements in health outcomes and improvements in some health conditions may result in reductions in health care costs. In addition, both health conditions and health outcomes may result in societal and personal benefits and avoided costs that may never be directly reflected in health care costs.
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Figure C-3 is not comprehensive; instead, it is focused on factors most relevant to transportation and health care partnerships. This environmental scan did not include transportation programs solely designed for social and recreational purposes, though a growing body of research indicates that these trips are important for maintaining health and some interviewees, especially those working in rural areas, mentioned isolation as an important health factor.
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From page 109... ...
This list reflects outcomes discussed by interviewees as well as outcomes suggested by McClintock's work and a national health improvement initiative.7 Health care and transportation partnerships explored through this environmental scan do not directly measure the results of transportation investments in terms of improved health outcomes. Instead, measurements are often focused on utilization of primary care, emergency room utilization, hospitalization, transportation trips provided, and other data directly related to the provision of transportation and care.
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transportation access to 8 Revised from FLPPS Transportation Committee Executive Summary, personal communica tion. (Committee information can be found at: https://flpps.org/Workstreams/Transportation, accessed October 25, 2016.)
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health care and returns in terms of health care savings or avoided health care costs. We were also interested in efforts to track changes in health outcomes related to transportation investments.
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To address the third challenge, one strategy often used in ROI analysis in other sectors is cost allocation, which would allow transportation providers to better understand the cost of providing each individual trip. While nearly every interviewee recognized some benefit to understanding the monetary benefits to health or health care of investing in transportation access, few programs were able to measure this directly.
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SUMMARY OF THEMES Across sectors and other variables like geography and client demographics, interviewees shared many of the same challenges and potential solutions. Overall, the most significant challenges interviewees face in creating health and transportation partnerships and measuring return on investment fall into seven categories (not listed in order of importance)
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Major concerns included Value or Return on Investment Outside of Health Care Costs Interviewees agreed across the board that investments in transportation are critically important to supporting access to health care, but they did not all agree that improving transportation access to health care would necessarily result in reduced health care costs. "We want to comment on the assumption about reducing the health care cost.
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They're not even showing up in the health care system yet at all, and maybe we can keep them out of the ER? " –Health services The Time Scale Over Which We Measure Many interviewees suggested that, while health care costs may be reduced as a result of better transportation access to care, these benefits might not accrue in the short term or even the medium term.
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From page 116... ...
Up front that first year or two out of the facility costs more than being in, but after that, the costs fall off greatly once a person is established at home. We talk all of the time about how much cheaper it is for an individual with a disability to live in the community than in a facility, but it costs more to actually get them there." –Health services "One of the things that we really believe, is that what we do supports people living in place, decreases isolation, so they're less likely to go to an assisted living facility." –Transportation services Return on Investment for Whom Interviewees described many benefits of improved transportation access to health care and health-related destinations that will not necessarily be reflected in health care costs.
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" –Human services "Caregivers often quite frequently die before the people they're caring for; so the ripples [of giving them a break from transportation] are spreading throughout the community and is ultimately just a win for everybody." –Transportation services For the Community "It would be great to quantify: economic contribution of individuals be cause they can get to work; increases on workforce participation for those individuals who coordinate transportation service or provide the rides di rectly; decrease in lost productivity costs for employers -- reduction in need to hire temporary employees; increased production or service; decreased health insurance costs; community costs -- costs on community integration, participation in religious and civic organizations.
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Others noted that health care providers may not have information about a patient's transportation barriers or if an appointment was missed due to transportation. For tribal transportation, data concerns were primarily focused on crash and other safety data and on GIS data.
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" –Transportation services "Ask outreach programs what they think their needs are. Our sense is that with health center data there's a bias, based on patients that are already walking into the health center doors.
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. ." – Transportation services Impacts of the Patient Protection and Affordable Care Act One challenge to measuring return on investment that many interviewees noted is the impact of health care transformation.
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. .,' but none of our partners would share anything meaningful with us because of HIPAA." –Transportation services Data on Tribal Lands Interviewees working in tribal transportation and health care discussed the challenges of funding and operating transportation infrastructure and services without basic data that other sectors often take for granted -- crash statistics and GIS in particular.
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In particular, interviewees noted the need for data standards and flexible and open software to support for partnerships. Even if an agency is up-to-date technologically, clients may not be able to access the technology due to a lack of awareness or because of their own technological limitations.
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If you don't have a card that identifies who the riders are, then the systems are not able to identify with great accuracy. They can probably make decent estimates of what riders fall into what categories, but if you're looking at a short period of time at increasing ridership, that can be challenging." –Consulting/technical assistance Geography Challenges related to density of population and different kinds of service boundaries were a common theme among interviewees. Rural Challenges Interviewees noted that transportation and health care needs and appropriate measures of success are different for rural areas, compared to urban and suburban areas.
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It took us a year." –Transportation services "That whole issue of not being able to cross lines or borders without those agreements -- I understand that intellectually. But is there something they can do to make that easier?
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We have many partners in that program." –Transportation services "A lot of nonprofits have rules about not going to group homes, but a lot of group homes don't have vehicles." –Brokerage "Even one of our local assisted living programs doesn't have an ADA vehicle. They won't buy one -- we've tried to sell them one." –Transporta tion services "A lot of these patients wouldn't have had any appointment for behavioral health [without our program]
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Even within the agencies that should know their own rules, there's a lot of misinformation out there." –Transportation services Different Motivations and Measures of Success Several interviewees suggested that diverging missions or measures of success create significant barriers to effective partnerships between health care and transportation. "We find that both public transit and Medicaid NEMT have a similar goal -- they want to provide individuals, especially those without other op tions, access to health care.
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People paying for health care (mainly Medicaid, since they pay for transportation) embrace attitudes of insurance company -- ‘the less we have to pay, the better, so more transportation is the opposite of better.'" –Transportation services One issue that interviewees mentioned repeatedly was that a strong emphasis on fraud prevention on the health care side might be hindering more effective partnerships between health care and transportation providers.
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really looking to prevent fraud and abuse -- including using transportation for any other trip purpose, even shopping. Doing so, even as trip-chaining, would be considered fraud or abuse." –Research/ academia Coordination Interviewees noted that coordination improves as it is mandated, and several commented on the importance of coordination at the federal level.
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Give adequate time and space to understand each other's language, build trust; it takes time, intentionality, real management whether at the highest level or within community. Be mindful of the longevity of the effort, what it takes in terms of the active management could be easy to overlook if you're just looking at it as part of the data and programmatic end." –Foundation/funding "It always takes more time to develop the connections than you can ever plan for.
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Several mentioned having met peers at conferences or learned about other projects through grantee meetings. Many interviewees suggested areas where it would be beneficial specifically to have more guidance from the federal agencies, including related to funding streams and associated rules and the Stark Law.
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[Our] core element at this point is planning -- not ready to run out and develop a service, say ‘Here is the answer.' Lots of outreach is needed in this initial buy-in to avoid push back and avoid low utiliza tion." –Transportation services
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To try to change how to provide what we're providing, this stuff takes time. A lot of times people are surprised by that." –Transportation services "For last 2 years, [we've been]
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How can we best get the results we need with what we've got? " –Transportation services "Some partnerships formed, a lot [are]
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Quantitative data isn't enough -- we need to know how their quality of life is being impacted." –Transportation services "We [dialysis patients] make a huge impact [talking to decision mak ers]
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Some transportation services staff discussed the revenue benefits of working more closely with health partners in terms of Medicaid transportation trips, too. "One of the things I did at the brokerage was to try to support the public transit agencies to contract with us, keep them busy.
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receptiveness to maximize the use of federal dollars by leveraging state money and trying not to leave any thing on the table. Regionally, having a transit agency willing to step outside of the box -- using private, state, and federal programs -- and hav ing a transit authority that understands that public transit goes beyond a fixed-route system and beyond ADA is a benefit in our community." –Transportation services "The transit system has allowed the health workers to go on the bus with patients without charging us to get people used to it. Don't know what that cost is to the transit agency." –Health services "First year of the [community health worker and transportation]
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Role of NEMT has been leavening for rural transit has allowed rural communities to do amazing things." –Consulting/technical assistance "From the transit's perspective, by setting up this model, compared to what it would have been if we had done it the traditional way of more in dividual rides which we are obligated to do, we're saving between $25,000 and $30,000 a month." –Transportation services Sharing Data, Analyzing Solutions While interviewees discussed many hurdles to sharing information between health care and transportation providers, some solutions emerged as well, ranging from Business Associates agreements to meet HIPAA requirements to housing transportation staff within the hospital or clinic. Others offered options for avoiding HIPAA issues by asking patients directly for information; some of these same solutions are included in the next section -- "Available Information." "Main programming is the navigator, and the navigator will work for the clinic.
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They agreed to let us have everybody's prescribed treatment times and monthly or quarterly documentation on the actual time on the machine so we can compare those." –Transportation services "Going to track over time evaluation measures -- mental and physical health (self-report) . Since they're going to get transit passes, we're going to track where they use them and how often they use them." –Transporta tion services Some interviewees noted that brokers are or could be collecting and analyzing data in a more sophisticated way then other service providers.
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The SPR data may be of particular interest to health care and transportation partnerships. It includes information about one-way trips funded through the Older Americans Act, including demo
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One of the least understood is the role that social support and personal relationships play in health and aging. The National Social Life, Health, and Aging Project (NSHAP)
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As in Waves 1 and 2, Wave 3 will describe health and health transitions of respondents, and how they relate to a different kinds of social relation ships in respondents' lives. For all waves, data collection includes/will include three measurements: in home interviews, biomeasures, and leave-behind respondent-administered questionnaires. The face-to-face interviews and biomeasure collection take place in respondents' homes." –NORC National Core Indicators http://www.nationalcoreindicators.org "National Core Indicators (NCI)
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NCI-AD is a collaborative effort between the National Association of States United for Aging and Disabilities (NASUAD) and the Human Services Research Institute (HSRI)
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[There is] limited information about the appoint ments in the software." –Transportation services "[They]
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So higher transportation and some care costs, and lower ED and ambulance usage." –Health services "The utilization of VA medical appointments has increased; the VA has reported no cancelations for people using this service." –Veterans services
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[We] determined that a significant percentage -- 20 percent of children under 200 percent poverty and 9 percent under poverty line -- were missing routine health care because of transportation barriers." –Foundation/funding "We do collect data out of that program, but it's principally the number of rides, associated health care visits for primary care and allied support services." –Foundation/funding Coming Soon Ride Connection Ride Connection, a nonprofit transportation services provider in Portland, Oregon, developed and is implementing a pilot program to improve outcomes for dialysis patients.
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hiccup.co (accessed September 27, 2016) RESEARCH AND RESOURCES Completed Reports GAO 12-647 Transportation-Disadvantaged Populations: Federal Coordination Efforts Could Be Further Strengthened http://www.gao.gov/products/GAO-12-647 Findings: "Eighty federal programs are authorized to fund transportation services for the transportation disadvantaged, but transportation is not the primary mission of most of the programs GAO identified.
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For example, state coordinating councils provide a forum for federal, state, and local agencies to discuss and resolve problems related to the provision of transportation services to the transportation disadvantaged. In other examples, one-call centers can provide clients with transportation program information and referrals for appropriate service providers and mobility managers may serve many functions -- as policy coordinators, operations service brokers, and customer travel navigators.
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For example, the council has not met since 2008 and has not finalized a cost-sharing policy that would allow agencies to identify and allocate costs among programs. GAO has previously found that agencies providing similar transportation services to similar client groups may lead to duplication and overlap when coordination does not occur.
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For example, nearly all of the groups indicated that excluding the NEMT benefit would impede access to services, particularly for those living in rural areas, as well as those with chronic health conditions." GAO 16-238 Nonemergency Medical Transportation: Updated Medicaid Guidance Could Help States http://www.gao.gov/products/GAO-16-238 Findings: "The nonemergency medical transportation (NEMT) benefits offered by Medicare and Medicaid differ.
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Officials from 15 selected states reported using a variety of models to administer NEMT, including transportation brokers, which are entities that contract with states to administer NEMT services. The Centers for Medicare & Medicaid Services (CMS)
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As communities and their public transit agencies explore the use of taxis for public transportation, there are lessons to be learned from those who sponsor and subsidize taxi programs for people with disabilities and older adults." TCRP Report 173 Improving Transit Integration Among Multiple Providers: Volume 1 http://onlinepubs.trb.org/onlinepubs/tcrp/tcrp_rpt_173v1.pdf "The purpose of this Manual is to provide guidance to transit agencies; planning organizations; local, regional and state governments; and the ar ray of organizations that are impacted by transit service or have a stake in the provision of transit service, based on the research presented in TCRP Report 173, Volume II. The research shows that transit integration among multiple transit provid ers is not necessarily easy, but it is successfully practiced in regions around North America and around the world and yields significant benefits in the communities where it occurs.
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We apply a data-driven latent class analysis (LCA) to model 54 specific health variables from the National Social Life, Health, and Aging Project (NSHAP)
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to improve access to care for the chronically ill and to pro mote community living for older adults and adults with physical disabili ties. However, relatively few states are expanding transportation services through these new initiatives for low-income people with mobility limita tions.
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Through this initiative the transportation community will become a rec ognized partner with the health/wellness and medical community. This initiative will demonstrate how partnerships across the transportation and health industries can reduce health care costs by leveraging public transportation assets." Smart Growth America Metrics for Transportation Investments That Support Economic Competitiveness, Social Equity, Environmental Stewardship, Public Health, and Livability http://www.smartgrowthamerica.org/documents/mndot-working-paper-1august-2014.pdf "This working paper provides a new framework for evaluating transporta tion projects in Minnesota based on established and emerging practices in the field of public sector teturn on investment (ROI)
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to support Smart Growth America's ongoing efforts to help states implement innova tive transportation initiatives that maximize the benefits of transportation expenditures and grow economies. The analysis is based on a review of national practices and case studies of innovative strategies being employed and various levels of government." Reports Under Way or Planned for the Future TCRP B-44 Examining the Effects of Separate Nonemergency Medical Transportation Brokerages on Transportation Coordination http://apps.trb.org/cmsfeed/TRBNetProjectDisplay.asp?
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This research should consider and address differences that affect transportation for kidney dialysis in urban and rural areas." Health Outreach Partners Rides to Wellness Community Scan https://outreach-partners.org/about-hop/transportation-initiative "Will quantify financial impacts of missed appointments. • ational Survey: Implementation of a national survey of health cen N ters, Veterans Affairs Medical Centers, and private providers to iden tify the impact of lack of transportation on health care costs.
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This model will engage community-dwelling Medicare and Medicaid beneficiaries of all ages (children and adults) ." One of the five focus areas is "transportation needs beyond medical transportation." Center for Medicare & Medicaid Innovation Health Care Innovation Awards https://innovation.cms.gov/initiatives/Health-Care-Innovation-Awards/ Project-Profiles.html https://innovation.cms.gov/initiatives/Health-Care-Innovation-Awards/ Round-2.html "The Health Care Innovation Awards are funding up to $1 billion in awards to organizations that are implementing the most compelling new ideas to deliver better health, improved care and, lower costs to people enrolled in Medicare, Medicaid, and Children's Health Insurance Program (CHIP)
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As a mission-driven organization, the technology and resources that we develop directly provide innovation for the future. We aim to make our custom tools publicly available whenever possible and our partners under stand and support this public-good mission." National Aging and Disability Transportation Center http://www.nadtc.org "To ensure that community transportation services are available to every one, particular attention should be paid to the needs and preferences of older adults and people with disabilities.
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To accommodate the unique issues older adults and people with disabilities face in accessing and using transportation options, NADTC promotes: • ngaging older adults and people with disabilities before new trans E portation options are created and using their insights and experiences to improve transportation programs, design new program,s and ensure that services are of the highest quality. • nsuring that older adults and people with disabilities know about the E transportation choices available in their community and understand how to access these options.
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Julie Bershadsky Human Services Research Institute Doris Boeckman Community Asset Builders Carrie Brown National Indian Justice Center Amy Carmola United Way of Chittenden County Charles Carr Mississippi DOT Kathryn Chandler Northwest Valley Connect, AZ Linda Cherrington Texas A&M Transit Mobility Program Mary Comtois United Way of Buffalo and Erie County, Buffalo, NY Dave Cooley OR Department of Veterans Affairs Troyce Crucchiola patient advocate, OR Dr. Moumita Dasgupta Amherst College Kelly Dixon Greater Buffalo Niagara Regional Transportation Council Virginia Dize National Aging and Disability Transport Center Esther Dyson Way to Wellville Jenna Estock Primary Health Network David Faldmo Siouxland Community Health Center Kathy Gale Interfaith Senior Programs, Inc., Waukesha, WI Cheryl Goldstone Primary Health Network Oscar Gomez Health Outreach Partners Roy Grant Children's Health Fund (formerly)
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Katherine Kortum Transportation Research Board Francois Larrivee Hopelink Brokerage, WA Valerie Lefler Liberty System, Data & Collaboration Doris Lookabill OmniRide, VA Kris Lyon Lane Transit District, OR Heather MacLeod U.S. General Accounting Office Janet Malley Whatcom Transportation Authority Randee Mason PYA Consulting Kelly Myers National Indian Justice Center Melanie Needle Chittenden County Regional Planning Commission Alex Page Ride Connection Ross Peterson GridWorks, Portland, OR Robin Phillips National Rural Transit Assistance Program Dennis Presley Southern Illinois University Center for Rural Health and Social Service Amy Rauworth Lakeshore Foundation, Birmingham, AL Dr.
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Sally Jo Snyder Consumer Health Coalition, PA John Sorensen Centers for Medicare & Medicaid Services; Money Follows the Person Maria Sotnikova Atlanta Regional Commission Kelsey Walter National Association of States United for Aging and Disability Jade Warren Access2Care Eric Weakly Administration for Community Living Elaine Wells Ride Connection, Portland, OR Dace West Mile High Connects Julie Wilcke Ride Connection, Portland, OR Sally Wilson Project Access of Durham County, Durham, NC Shirley Wilson Mississippi DOT Chris Zeilenger Community Transportation Association of America
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