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

Chapter: chapter 5 - case studies.

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84 Introduction This chapter presents five case studies, set in communities from Lane County, Oregon, on the West Coast, to the Denver metropolitan region, to 10 rural counties in South Central Missouri. These case studies describe relationships and partnerships created between transportation and health-care organizations, demonstrating efforts to improve transportation access to medical and other wellness-related appointments and services; see the map in Exhibit 5-1. C H A P T E R 5 Case Studies Exhibit 5-1. Locations of the case studies.

Case Studies 85 For those communities interested in and considering their own efforts to improve transpor- tation access to health care, the examples described in the case studies (as well as the collabora- tive practices presented in Chapter 6) provide ideas and possibly inspiration. One good place to start when considering transportation improvements to health care, as some communities and health-care organizations have found, is the community’s public transit agency. The local transit agency—with trained staff, a fleet of maintained vehicles and, importantly, operating experience in the community—is an existing resource that may be a willing partner for improving access to health. Beyond the community’s public transit agency, there are other transportation providers (as described in Chapter 3) that can be effective resources for improving access to health care. Taxis, for example, have been a resource for many years, and in just the past several years, new private mobility providers have entered the health-care market with options providing on-demand transportation. Additionally, technology solutions are increasingly available that facilitate the steps involved in providing transportation for patients—from trip booking to trip payment—with safeguards for patient privacy. The case studies in this chapter and collaborative practice described in the following chapter showcase a wide variety of transportation services and providers involved in improving access to health care. Case Studies The five case studies in this chapter include: 1. Two transit agencies in Central Texas—Austin’s urban public transportation authority and the transit agency serving rural counties surrounding Austin—partnered to develop a regional mobility manager to improve transportation options. A key issue has been expanding transit service to support health-care access. 2. Denver Health, a large medical system that includes a network of community health centers, coordinates a range of transportation services to meet patients’ needs in the Denver metropolitan region. Services include more traditional options such as the provision of bus passes for public transit use (including vouchers to ride the state’s intercity bus service) and use of Lyft for on-demand trips to serve hospital discharges and outpatient appointments. 3. Flint, Michigan’s, public transit authority developed the well-regarded “Rides to Wellness” program, providing mobility management, door-to-door service, and same-day trips for riders going to medical or other health- and wellness-related appointments. Using a ride-hailing-like model and cutting-edge technology, Rides to Wellness is pro- vided through agreements with local agencies and medical providers that fund the transportation. 4. LTD in Western Oregon, developed RideSource that brokers and coordinates a range of transportation services, including Medicaid NEMT, ADA paratransit, contracted human service agency client transportation, health-care transportation, and general public service. Health-care trips, for example, are coordinated directly with hospital social workers and local coordinated care organizations (CCOs), entities established by the state’s Medicaid agency. 5. Missouri Rural Health Association’s HealthTran program provides NEMT for rural residents in 10 counties in South Central Missouri who have no other means of accessing transpor- tation to health-care facilities. Initiated as a pilot with grant funding, HealthTran is now supported through subscriptions from participating health-care providers.

86 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Mobility Management—Improving Access to Health Care in Central Texas: Capital Metro Transportation Authority and Capital Area Rural Transportation System Snapshot of Collaboration Two transit agencies in Central Texas—the Capital Metropolitan Transportation Authority (Capital Metro) and the Capital Area Rural Transportation System (CARTS)— partnered to develop a regional mobility manager charged with expanding transit for those in need in the nine-county Capital region surrounding Austin. The resulting Office of Mobility Management (OMM) has coordinated funding and services with numerous health-care providers in: • Capital Metro’s service area of Austin and some close-in suburbs • Rural parts of nine counties surrounding Austin, six of which are entirely rural Additionally, the OMM helped build a number of transportation services in the geographic area between the two transit agencies’ service areas that previously had no service. One of the key issues in development of the OMM was determining how to expand transit service to support health-care access. OMM’s response: the office strives to integrate the region’s network of transit services to help connect people to needed goods and services in the Capital region. The coordinated efforts of Capital Metro, an urban transit agency, and CARTS, a rural agency, now provide access to almost 30 community partners through the OMM, which is dedicated to meeting the transportation needs of seniors, people with disabilities, veterans and others in need. This collaborative effort has increased fixed-route and specialized transporta- tion, improving access to health care through the expansion of public transit service in formerly underserved and unserved areas. How Did the Collaboration Start? Rapid growth brought changes to Central Texas. Areas previously served by CARTS had become urbanized and were no longer eligible for CARTS service. These newly urbanized areas were also not in Capital Metro’s service area, leaving them in a transit desert with no service. The collaboration was initiated by CARTS and Capital Metro in response to this loss of service and new unmet needs. The two organizations formed the OMM, which is hosted and funded predominantly by Capital Metro. The OMM was charged with building transit services in areas of high needs. Soon, Travis County joined forces and ultimately service was coordinated with the Transit Empowerment Fund. Texas’s capital area region is illustrated in Exhibit 5-2. Initiating the Effort Two important factors facilitated development of the OMM. One was the establishment of the Transit Empowerment Fund and its resulting funding support. The second was the close working relationship between Capital Metro and CARTS that helped the establishment of the OMM and with efforts supporting its work.

Case Studies 87 The Transit Empowerment Fund The Transit Empowerment Fund was established in 2011 through a partnership between Capital Metro, Austin’s public transportation provider, and One Voice Central Texas, a coali- tion of more than 100 health and human service non-profit organizations. The goal was to address the effect of rising public transit fares on low-income individuals. Capital Metro contributed $250,000 in seed funding in 2012, and in 2013, the transit agency increased its annual contribution to $350,000. An independent volunteer board representing non-profit health-care and human service agencies, the business community, and Capital Metro oversees the work of the Transit Empowerment Fund. Since 2012, the Transit Empowerment Fund has distributed thousands of Capital Metro transit passes to local non-profits for use by their clients. Recipients of the transit passes must have low income, reside in the Capital Metro service area, and use public transportation. The Transit Empowerment Fund Board’s target populations are adults over the age of 65, people with disabilities, youth under the age of 18, low-income workers or those enrolled in Exhibit 5-2. Texas’ capital area region.

88 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services job training programs, refugees, people experiencing homelessness, Medicare card holders, Medicaid recipients, and veterans. The goal of the program is to promote self-sufficiency by providing transportation for employment, health care, education, and social services. Additionally, the Transit Empowerment Fund Board has funded the following demonstra- tion projects to expand transit services in underserved areas in the Central Texas region: • In 2013, the Transit Empowerment Fund invested in a demonstration project that provided transportation to a non-profit organization’s clients who lived in designated areas to access the organization’s parent-child education programs. • In 2014, the Transit Empowerment Fund partnered with AGE of Central Texas, a non- profit serving older adults, to identify transportation gaps and resources and to create a plan to address identified transportation needs of older adults in the Austin area. The plan was completed in February 2015 and is guiding the future work of the Board to expand trans- portation access for seniors in the Austin community. • In 2017, the Transit Empowerment Fund provided a grant to “Ride Austin,” a local app- based, on-demand transportation service. This grant allowed the non-profit ride-sourcing organization to partner with a collaboration of Central Health and a regional hospital for a pilot program in which those without the means to pay for health-care transportation were able to request no-cost rides to health-care appointments or pharmacies within the collaborative’s network. • Also in 2017, the Transit Empowerment Fund awarded the Housing Authority of the City of Austin funds intended to expand and enhance the impact of its “Smart Work, Learn, Play” mobility equity program. Development Capital Metro and CARTS developed the OMM in 2013 to address findings of studies and local stakeholder concerns about gaps in transportation services arising from the growing urban area and shrinking rural area. Transportation needs were appearing in suburban, exurban, and smaller communities with populations between 10,000 and 120,000 that were not served by either the urban transit agency, Capital Metro, or the rural provider, CARTS. Since its initiation in 2013, the OMM has been funded and sustained primarily by Capital Metro, with additional funding from FTA Section 5310 grants. Critical to the development of the office was ensuring that all participants understood the needs, constraints, and capabili- ties of each type of participating organization. The approach of this mobility manager is that fixed route should always be the first choice of service for an individual when such service is appropriate and feasible. The low transit fares, subsidized through Capital Metro, help the mobility manager accom- modate many of the health-care transportation needs very cost effectively. Approximately 50% of the trip purposes associated with the bus pass program is for health-care access. Description The OMM conducts a wide array of services and activities in support of expanded access to destinations throughout the region: These services include: • Conduct planning efforts. – Planning efforts have focused on unserved and underserved areas in the large region, with plans completed for multiple small cities ranging in size from 10,000 to 120,000 popula- tion. So far, two of the small cities have implemented transportation service as a result of the planning efforts.

Case Studies 89 • Pursue funding and sustainability. – Pursue grant funding through the Georgetown Health Foundation, which has provided $200,000 annually to the city of Georgetown for transit for three years. – Obtain funding from Travis County, 1. Secured funding from the county and United Way for “Access to Health Care,” a program serving lower-income areas that were unserved outside of both Capital Metro and CARTS service areas. 2. Secured funding of low-cost bus passes (one-quarter fare). – Arranged Capital Metro funding for portions of service in Georgetown and Round Rock. – Coordinated funding with the Transit Empowerment Fund and Travis County. • Build new public service where none existed. – Travis County expanded transit service in unserved exurbs and suburbs, a crucial service driven by health-care needs. – Round Rock and Georgetown both initiated fixed-route service through the efforts of the OMM, expanding access to health-care and other needed services. – The city of Manor, through the OMM, initiated a loop-route shuttle that had very low ridership. This service was revised to an app-based, on-demand service provided by Via and ridership increased, with many of the trips providing access to health care. • Engage with the Community Health Impact Plan. • Provide a Trip Planner with 90% of trip planning for access to health care. • Develop information such as the “Greater Austin Transportation Services and Senior Ride Guide,” a comprehensive rider’s guide of transportation services in the region. • Administer FTA Section 5310 funding, ensuring coordination of services. The Need for Transportation While Capital Metro and CARTS provide well-regarded transit service, there are still gaps as identified in a recent coordinated plan (1). These areas are not eligible for federal transit funds as is typical for parts of an urban area that are outside of the transit system’s service coverage. Over 200,000 people live outside of Capital Metro’s service area, yet they are still in the urban area. Exhibit 5-3 depicts gaps in service in Central Texas in 2016. Since that time, two of the cities, where the OMM conducted transportation plans, have implemented some transit service. In addition, the OMM has teamed with Travis County to provide service in the unincorporated areas of eastern Travis County that are not in the Capital Metro or CARTS service area. Filling Transportation Gaps Many transportation needs can be met through fixed-route service, unless the individual cannot get to the service due to distance or mobility limitations or where there is no fixed-route service. For those who cannot use a fixed route, other services will be needed. OMM has worked hard to fill these gaps with appropriate service through its partnership arrangements. Exhibit 5-4 depicts one of Capital Metro’s microtransit vehicles serving a local community in Austin. Partners and Participating Organizations The greatest strength of the OMM is its ability to build services through partnerships with a diverse group of organizations, including: • Local governments • Transportation providers • Health-care organizations • Human service agencies

90 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Exhibit 5-3. 2017 service gaps in Central Texas. Exhibit 5-4. Pick up by Capital Metro, a microtransit option. Photo courtesy of KFH Group.

Case Studies 91 The OMM has close to 30 partners, most of whom provide support. These are depicted in Attachment 1 to the case study and are summarized as follows. Health-Care and Human Service Agencies Numerous health-care providers serve as partners. As noted above, the OMM has succeeded in securing funding from various health-care entities, the United Way, and human service agencies. The Georgetown Health Foundation has contributed over $200,000 to Georgetown’s new transit service. The OMM has been active in the development of the Community Health Improvement Plan: Austin/Travis County Texas, Year 1 Action Plan (2). This plan sets forward a wide range of goals to improve health care. The goals pertaining to transit are in Attachment 2 to the case study. Local Governments Travis County provides funding on a per-trip basis, and the Austin—Travis County health service, known as Central Health, has been actively involved in transportation and mobility management activities. This organization has been working actively with the OMM to imple- ment health-care transportation for isolated, lower-income communities beyond the Capital Metro and CARTS service areas. The cities of Round Rock and Georgetown implemented some fixed-route services to support those accessing health care, jobs, and other needs. These services were planned and supported by the OMM, CARTS, and Capital Metro. Technology and Innovation CARTS, in partnership with Capital Metro and Travis County, recently planned a service change in the city of Manor, which is a rapidly expanding suburb of Austin (9,200 population as of 2017). The service is now microtransit and an app-based, on-demand service that has proven to be very successful. Ridership has gone from an average of 40 one-way trips per month before the change to currently 100 per day in peak times (3). CARTS and Capital Metro use fare payment cards, paratransit software, and supporting technologies in their paratransit systems. Facilitators of Success The initiative started with a partnership between CARTS and Capital Metro. These two organizations continue to lead and facilitate new service development through the OMM. Strong leadership and collaborative skills of OMM, CARTS, and Capital Metro management continue to facilitate success. The funding provided by Capital Metro continues to ensure the sustainability of these services. Barriers, Constraints, and Challenges The OMM staff reported early challenges in gathering the coalition together and working with local governments to fund local transit service. Yet, because the transportation needs were so evident, the OMM found most of the organizations willing to participate and support the improvement of transportation services. Funding and Sustainability There have been four primary sources of funding for transportation services in the Capital region. First and foremost, the funding provided by Capital Metro to support the OMM

92 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services (in conjunction with CARTS) and the Transit Empowerment Fund is critical to both. Capital Metro has also provided FTA Section 5307 funding to Travis County as well as the cities of Round Rock and Georgetown, both outside the Capital Metro’s service area. Second, the Transit Empowerment Fund has been extremely supportive of the entire process of improving transportation services in Austin/Travis County. The fund provides a number of options for funding in concert with the OMM, including: • Micro grants that provide additional opportunities to meet the Transit Empowerment Fund mission of enhancing access to transportation for low-income, transit-dependent individuals in the Austin area. • Free and deeply discounted transit passes provided to non-profit health-care and human service organizations and governmental entities in Central Texas to help meet the transporta- tion needs of low-income clients. Third, local governments have been supportive of new transit services in Travis County and the cities of Round Rock and Georgetown. Without such local support, the transit services in these jurisdictions would be non-existent. Fourth is funding from health-care and human service organizations that provides matching funds for bus passes and other services in support of their programs. The Health Foundation of Georgetown in particular, provided $200,000 per year for 3 years for public transit in Georgetown. Overall, the OMM has been able to secure funding to implement much-needed services. The staff believes that, if the project is worthy, the funding will come. This echoes comments of transit managers leading innovative agencies that were reported in earlier TCRP research: “(Innovative) Managers do not let funding issues get in their way. They realize that if the service has merit, someone will pay for it” (4). Lessons Learned OMM staff cited the following steps that have led to their successful activities and efforts in providing mobility management in the Capital region of Texas: • Get engaged early in the process when transportation needs become evident and understand the stakeholders’ needs. • Make sure “the right people are at the table”—decision makers and people with influence in the community. • Seek funding from a variety of sources. • Offer an array of services. • Be resourceful and relentless in the pursuit of opportunities to provide transportation. Transferability Mobility management functions and activities are diverse. The OMM has chosen to focus on building transportation services and providing information to those who need it. These functions can be adopted by other agencies or organizations that pursue mobility management. Advocating for individuals in the community who are transit dependent includes: • Provide information on transportation resources as well as trip planning services. • Identify and secure a variety of sources of funding to help ensure transit sustainability. • Be resourceful in the pursuit of the mobility management objectives.

Case Studies 93 Contact Information Office of Mobility Management Austin, Texas Attachments to Case Study of Capital Metro and CARTS Office of Mobility Management for Central Texas Attachment 1: Partnering Organizations • Transportation Providers – CARTS – Capital Metro – City of Round Rock–Transit – The HOP – Burnet County Vet-Rides – Drive a Senior–Health Care • Health Care Organizations – Austin - Travis County Integral Care – Central Health, Austin - Travis County – La Grange VA Outreach Clinic – Easter Seals of Central Texas – Hays County Veteran Medical Transportation Services – Health Foundation of Georgetown – Hill County Mental Health and Developmental Disability Center – Road to Recovery–American Cancer Society – Medicaid Transportation – Multiple health-care providers • Agencies Supporting the Social Determinants of Health – Age of Central Texas – ARCIL, Inc. – Area Agency on Aging – Austin Parks and Recreation Department – Bastrop County Emergency Food Pantry & Support Center – Bluebonnet Trails Community Services – Community Action, Inc. of Central Texas – Hutto Community Resource Center – Mary Lee Foundation • Others – Commute Solutions – Regional Transportation Coordination Council – United for the People Attachment 2: Community Health Improvement Plan Austin - Travis County Objective 1.3: By 2021, decrease no-shows for health-care appointments at safety-net health-care providers by 10%. 1.3.1 Work with transportation partners to expand and enhance transportation options (e.g., number of accessible vehicles in the region, variety of transportation options to health care) for members of the community who have difficulty reliably traveling to health-care appointments.

94 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services 1.3.2 Advocate to expand care delivery in under-resourced areas via options such as co-locating, building new facilities, and use of telemedicine. 1.3.6 Promote awareness of existing transportation resources, including Capital Metro’s Mobil- ity Management program, through a variety of communication avenues. 1.3.7 Explore options for making Capital Metro’s Mobility Management program more robust (e.g., centralizing, tech/software solutions). 1.3.8 Connect health navigators with Mobility Management services so they can refer people to the right transportation resources for their need Coordinating Patient Transportation to Improve Access to Health Care: Denver Health Medical Center Snapshot of Collaboration Denver Health Medical Center (Denver Health) is a safety-net hospital with a Level I Trauma Center, multiple outpatient clinics, and a wide network of community health centers. Denver Health coordinates several types of transportation options to meet the needs of its patient population, with the goal of increasing access to preventive health-care appointments, improving health outcomes after discharge from the hospital, and decreasing preventable hospitalizations and emergency department visits. The transportation program includes the following components: • Medicaid NEMT. Denver Health case managers and patient navigators can arrange NEMT transportation for patients enrolled in Medicaid. However, patients have reported long wait times and difficulties in scheduling NEMT rides. Transportation options under NEMT include wheelchair-accessible vans, bus vouchers, and taxis, among others. • Bus services. Patients can receive passes to ride Denver’s bus system or vouchers for Bustang, Colorado’s intercity express bus service. Bustang can transport patients to major cities outside of the Denver metropolitan area, such as Colorado Springs and Fort Collins. • Taxis and Lyft. In November 2016, Denver Health partnered with Lyft to leverage the TNC’s large network of on-demand drivers in an effort to increase transportation options after dis- charge and to and from appointments at outpatient clinics. Prior to partnering with Lyft, Denver Health frequently provided taxi vouchers to help patients travel back to their homes. • Private car. The health system maintains one private car to transport patients to and from appointments, with an emphasis on patients with complex health needs who have no other means of accessing transportation. The private car service is staffed by three volunteer drivers, retired community members with clean driving records. Oprah Winfrey donated the car to Denver Health to help patients with limited resources. How Did the Collaboration Start? Denver Health has long acknowledged the importance of transportation in accessing health care and returning home safely after discharge. Prior to 2016, the hospital had heavily

Case Studies 95 relied on taxis and NEMT services to provide transportation to people who were unable to use public transportation. However, challenges with existing transportation options often resulted in hours-long waits for patients after discharge. For example, due to high demand, the broker could not always provide immediate transportation assistance for patients. In addition, Denver has a relatively small taxi fleet, which also often contributed to long wait times. A Clear Need for Transportation Assistance Denver Health consistently serves several populations that needed additional assistance with transportation, including: • Patients with limited resources—Denver Health serves many patients with limited resources that face challenges with accessing reliable transportation options, including a large popula- tion of Medicaid patients. Patients may lack access to a personal vehicle and may be unable to afford a taxi service or bus fare. Some patients rely on friends and family members for transportation. • Patients with limited English proficiency—Case managers report that some patients with limited English proficiency have experienced difficulties with navigating Denver’s public transportation system. • Patients with complex health needs and limited mobility—While Denver has extensive public transit services, many patients have complex needs beyond the capabilities of transit. For example, some patients cannot wait at a bus stop that leaves them exposed to the elements. A Turning Point in the Transportation Program In 2016, emergency department staff reported that one patient had waited in the hospital lobby for 7 hours after multiple failed attempts to secure a ride home, including an inability to connect with family members and existing taxi and NEMT services. The patient’s experience was a pivotal moment for Denver Health leadership and highlighted the fragmented nature of transportation assistance available to patients with limited resources. Partnering with Lyft At the same time that Denver Health was searching for a better transportation solution, TNCs such as Uber and Lyft had begun gaining popularity in Denver. The Chief Experience Officer at Denver Health reached out to Lyft to inquire about the possibility of establishing a partner- ship to coordinate rides for patients. Denver Health chose to partner with Lyft because the company’s community-oriented policies aligned well with Denver Health’s mission and values. For example, Lyft’s “Round Up & Donate” program provides riders with an option to donate to Lyft’s charitable partners. Development The Chief Experience Officer was quickly able to connect with Lyft, receive information about potential costs, and request funding from the Denver Health Foundation, the fundraising arm for the Denver Health and Hospital Authority. As soon as Denver Health established the partnership with Lyft, they received access to the Application Programming Interface (API). The API is the browser-based application that allows case managers and patient navigators to simply log in, input their patient’s address, and schedule the requested ride. As many of the ride coordinators had previously used a TNC application on their phones, they were familiar with the technology and required little training to begin scheduling rides.

96 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Description Case managers at the hospital and patient navigators in outpatient clinics work with patients to identify their transportation needs, provide information about public transit options, and schedule rides. For example, patient navigators have provided recent immi- grants with education about navigating the public transportation system. Case managers and patient navigators work to secure appropriate transportation for patients who need additional assistance, such as a wheelchair-accessible van provided by Medicaid NEMT or a wheelchair-accessible Lyft. Outpatient clinics in the Denver metropolitan area include nine family health centers and three urgent care centers. Facilitators for Success Denver Health worked closely with Lyft to improve patient’s experiences during drop off and pick up. For example, the physical address of the main hospital does not correspond to the locations where patients exit or enter the building. Denver Health identified the most appropriate drop-off and pick-up locations for patients, which Lyft mapped, or “geo-mapped,” onto the application. The geo-mapping process greatly improved the ability of patients to quickly connect with their driver. Barriers, Constraints, and Challenges Case managers and patient navigators had to adjust to the rapid nature of on-demand TNC services. As Lyft drivers only wait for a brief period after arriving at their destination, patients who were not immediately ready to leave the hospital missed their rides. In addition, some patients had never used TNCs and expressed confusion about entering an unmarked car. Staff educated patients on how to identify their driver, which helped improve the ability of drivers and patients to connect. Some systemic challenges remain, such as a driver unexpectedly cancelling a trip or a patient deciding to leave the hospital before their ride arrived. Funding The transportation program is funded by Denver Health Foundation. The foundation is dedicated to supporting Denver Health in its mission of improving the health and well-being of the region and frequently funds the hospital’s transportation programs. Denver Health’s Chief Experience Officer also worked closely with state policymakers to pass legislation that would allow Medicaid to reimburse for Medicaid NEMT provided through TNCs. The bill, HB18-1321: Efficient Administration Medicaid Transportation, was signed into law in May 2018 and directs the Colorado Department of Health Care Policy and Financing to “create and implement a method for meeting urgent transportation needs within the exist- ing NEMT benefit under the medical assistance program.” The Chief Experience Officer also testified in support of the bill, emphasizing the cost savings of TNCs over traditional taxi services and the effi- ciency of on-demand transportation in avoiding unnecessary visits to the emergency department. While the state has yet to enforce a policy that allows Medicaid to reimburse NEMT through TNCs, Denver Health anticipates that the health system will be able to partially finance TNC transportation through Medicaid reimbursements in the future.

Case Studies 97 Lessons Learned Denver Health created strict guidelines for rides provided through Lyft to address liability concerns. Patients may only be transported within 25 miles of the hospital, cannot make addi- tional stops on route to their destination, must be ambulatory, and must acknowledge that they are receiving a ride from a third-party vendor. Denver Health also worked with case managers and patient navigators to ensure that they preserved HIPAA while arranging transportation. For example, coordinators only enter the patient’s first name into the Lyft platform when they call for a ride. Similar to other safety-net hospitals, Denver Health relies heavily on the fundraising abil- ity of their associated foundation to fund investments in addressing the social determinants of health. The Chief Experience Officer’s strong existing relationship with the Denver Health Foundation helped the hospital secure funding for the transportation program. When making the case for the program to the foundation board, she focused on highlighting the successes of the transportation program, including the human impact of transportation access and stories from patients who had received help. In the future, Denver Health hopes to integrate Lyft into their EHR system, Epic, instead of requiring case managers and patient navigators to log into a separate system. Ideally, providers could place orders for transportation in Epic, and the ride coordinators could fulfill the order in the same system. Transferability Hospitals and medical facilities around the country have begun to use TNCs to support patient transportation. The two dominant TNCs—Uber and Lyft—have developed formal programs to serve the health-care industry. Contact Information Denver Health Medical Center Denver, Colorado Same-Day Trips for Medical and Wellness-Related Appointments: Flint MTA’s Rides to Wellness Snapshot of Collaboration The Flint, Michigan, Mass Transportation Authority (MTA) operates a comprehensive NEMT program called Rides to Wellness. The program provides mobility management, door- to-door service, and same-day trips for riders going to medical or other health and wellness- related appointments. Using a ride-hailing-like model and cutting-edge technology, Rides to Wellness is provided through agreements with local agencies and medical providers that fund the transportation.

98 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services How Did the Collaboration Start? Flint’s MTA points to two seminal events that catalyzed the transit agency’s well-known Rides to Wellness program: • Genesee County Department of Health and Human Services’ agreement to pay for a higher level of transportation service for the MTA dialysis riders, which acknowledged that presched- uled, shared-ride ADA paratransit service was not effective for dialysis riders who needed a more specialized service, and • Flint’s water crisis that resulted in dangerous levels of lead in the water at residents’ homes. Dialysis Transportation Provided by ADA Paratransit By 2015, the MTA realized that its ADA paratransit service for dialysis riders was not effec- tively meeting the riders’ needs, which are more specialized than those of most ADA riders. Dialysis riders are often not ready for their prescheduled pick up after treatment due to medical issues. Also, they are weak and depleted after treatment and often require extra assistance getting to and from the vehicle. ADA paratransit is prescheduled; the driver cannot wait until the dialysis rider is ready for the trip home. Not only does the driver have other passengers on board and a manifest to follow, ADA regulations prohibit any trip prioritization, so dialysis riders cannot be given special treat- ment. The MTA would then have to find another vehicle to return later for the rider, but that often meant a long wait for the second vehicle and the trip home. ADA paratransit is also shared ride, which means riders do not go directly from their origin to their destination. The extra time spent on the vehicle because of shared riding is difficult for dialysis riders due to their fatigue and weakness after treatment. When this is added to a long wait for a second vehicle to arrive for the trip home, dialysis riders are not well-served by ADA paratransit. Recognizing that dialysis riders need a service more specialized than ADA paratransit could provide, the MTA met with the county’s Department of Health and Human Services (DHHS) and proposed that the transit agency could offer a more personalized and specialized service for the dialysis riders—more flexible scheduling, including some same-day transportation so that trips would be scheduled when the rider is ready after treatment and a direct ride home with no shared riding. The MTA also offered to provide a bus attendant on board who could provide the extra door-to-door assistance for dialysis riders. However, the MTA said the service would require a higher cost—$14 per trip, not the ADA fare of $3.50. The county’s DHHS realized that this specialized service would benefit dialysis patients whom they covered through Medicaid and other assistance programs. Moreover, DHHS did not see the higher fare of $14.00 per trip as unreasonable; the department found it sometimes had to pay a private medivan service $40 or $50 to get a patient home when the patient needed a higher level of care than ADA paratransit could provide. If the MTA could reliably provide same-day, non-shared-ride service for the dialysis patients at $14 per trip, the DHHS decided it was a good arrangement. This was the early start of MTA’s Rides to Wellness service. Flint Water Crisis Flint’s water crisis that began in 2015 was the second catalyst for the MTA Rides to Wellness service. This crisis, which became national news, began when the city’s drinking water became contaminated, exposing more than 100,000 Flint residents to elevated lead levels. Residents

Case Studies 99 were told to use only bottled or filtered water for drinking, cooking, bathing, and cleaning. A federal state of emergency was declared in January 2016. The crisis required that residents had a way to obtain bottled water and address other consequences of the tainted water, including access to medical clinics to check on rashes caused by the water. The state DHHS approached the MTA in crisis-level response mode, asking the transit agency if it could provide transportation for those Flint residents without adequate transportation so that they could get bottled water, water filters, and get to medical services necessitated by the water crisis. The state DHHS also wanted the MTA to help those residents get to full-service grocery stores so residents could obtain fresh fruits and vegetables, which are known to help mitigate lead exposure. The MTA said, “Yes, we can provide this transportation,” thinking that it would build on the same-day service model that had just begun for dialysis riders. Development While the same-day specialized service for dialysis riders had been successfully underway for some months, the MTA realized that providing trips for Flint residents to address the water crisis required a service more nimble and with higher capacity than that for dialysis riders. Such a service, the MTA realized, was something like that provided by a TNC, such as Uber or Lyft, with the ability to respond quickly and ramp up capacity rapidly. 2016 The transportation service for the state’s DHHS began in September 2016, purposefully slowly. The MTA branded the service under its existing Rides to Wellness umbrella. Starting the new service required the MTA to lease cars and recruit drivers. Advertisements for drivers offered part-time, flexible work hours. Unlike a traditional TNC, the MTA provided the vehicle for the drivers, a bonus for recruitment efforts. Scheduling the trips for the Flint residents to deal with the water crisis initially relied on the transit agency’s paratransit scheduling/dispatch software, but this software was not designed for TNC-type service, so the MTA went out to bid to find a technology company that would develop software with real-time scheduling. Within only 4 months—by December 2016—a local technology company had been selected for the work and had the new software up and running. By then, the MTA was providing about 1,000 trips per month to address the water crisis. These were trips for Flint residents eligible through the state’s DHHS for Medicaid program or some other state or federal assistance program. The state was paying $15.00 per trip. The MTA was also providing about 1,000 trips per month for the same-day dialysis service. 2017 and 2018 By 2017, agencies providing health-care services were taking notice of MTA’s Rides to Wellness branded vehicles (Exhibit 5-5) traveling throughout Flint and surrounding Genesee County, providing trips for dialysis patients and residents impacted by the water crisis. Some of these agencies contacted the MTA and asked if they, too, could benefit from the new transportation service. The MTA had meetings with the interested agencies and organizations, explaining that the service was not ADA paratransit at $3.50 a trip but a premium service, with same-day service, door-to-door assistance for riders, and without shared riding. As a premium service, the MTA

100 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services was clear that the cost was higher—$15 per trip. According to the MTA, none of the agencies “blinked an eye at the cost” during these meetings. These were agencies very much in need of reliable transportation for their patients or clients and saw MTA’s Rides to Wellness as their answer. Engaging a Large Hospital System as a Partner The MTA’s experience in partnering with the community’s large hospital system, the McLaren Health Care System, provides insights into how Rides to Wellness has grown. In 2017, the MTA approached the hospital, thinking it might be interested in joining Rides to Wellness and gave them what amounted to a sales pitch. The hospital was non-committal— “We’ll think about it.” Hospital management was skeptical that the transit agency could provide effective service when it had experienced problems with other community transportation providers, such as taxis. By 2018, the hospital was ready for the MTA’s help. McLaren indicated it was interested in turning over its non-emergency transportation to the MTA Rides to Wellness service. Apparently, the hospital had determined by that time that it could trust the MTA. However, the hospital had requirements. The key requirement was that it wanted its own online portal so that its trips were kept separate from other Rides to Wellness trips. The MTA went back to the local company that had built the Rides to Wellness software to create the online portal. The new portal was installed on computers throughout the hospital, allowing nurses and patient navigators to book rides for their patients. Initially, most of the trips were discharges from the emergency room, but now they include a variety of trips, including to and from out- patient services. The number and types of trips for the hospital continue to grow. During one month in 2019, Rides to Wellness provided approximately 400 trips for McLaren, which pays the MTA $15.00 for each trip. Exhibit 5-5. Branded vehicles helped develop the service

Case Studies 101 Description By 2019, the MTA had 13 agency-partners in the Rides to Wellness program. Several of these are listed on the MTA website, including the Genesee Health Plan, which offers free rides to health and wellness destinations for their Spanish-speaking clients, and the American Cancer Society, which supports trips for patients in its Road to Recovery program. Other part- ners indicated that they do not wish to be listed on the MTA website, preferring to keep the information within their own organizations. MTA’s information about Rides to Wellness makes clear that the service is intended for and limited to individuals who are eligible for or connected to one of the Rides to Wellness partner agencies. The MTA has approximately 80 vehicles in use for the Rides to Wellness program. By mid-2019, the program was providing over 11,000 trips a month as shown in Exhibit 5-6. On a monthly basis, ridership more than doubled from 2017 to 2019. Revenue generated from the trips also grew. Based on annual data, revenue from the Rides to Wellness program increased from $114,925 in 2017 to more than $280,000 in 2019. Trips can be booked by calling an MTA mobility navigator as well as electronically via smart- phone, tablet, or computer. Drivers have a tablet for receiving and documenting trips. Response time averages about 30 minutes. Given FTA funding support, the service complies with FTA requirements. Drivers, for example, are included in MTA’s drug and alcohol testing program, and trip and other operational data are included in the transit agency’s National Transit Data (NTD) reports. Facilitators for Success According to the MTA, a key factor that facilitated success for Rides to Wellness was the branded vehicles out on the street. Community agencies and organizations kept seeing the white sedans and minivans (Exhibit 5-7) with the red and blue lettering traversing streets throughout Flint and Genesee County. The branded vehicles served, in effect, as rolling advertisements. The familiarity of seeing the vehicles led a number of organizations to contact the MTA and inquire about joining Rides to Wellness. The MTA concludes that the community was very 4,597 8,643 11,218 0 2,000 4,000 6,000 8,000 10,000 12,000 July 2017 July 2018 July 2019 Rides to Wellness Ridership Passenger Trips Exhibit 5-6. Rides to Wellness ridership.

102 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services eager to find a reliable and reasonably priced transportation service that could take people to and from health-care services. Barriers, Constraints, and Challenges At the start, one of the MTA’s major challenges to its Rides to Wellness service was teaching the agency’s staff that this new service was not traditional ADA paratransit. Unlike paratransit, the focus is not getting the vehicle from point A to point B on a predetermined schedule nor is it ensuring that drivers follow a manifest. This new service focuses on the individual rider and their needs. The service also does not use manifests. Once the purpose-built software was up and running, trip requests were sent in real time to the drivers. A second challenge was getting the community to trust that the transit agency could deliver a high-quality service that improves access to health-care and related services. The transit agency, like so many across the country, had periodic issues providing ADA paratransit, and the community was not convinced that the MTA had the ability to provide a same-day, high-quality service. What was important for the MTA was to get one community orga- nization to sign on as a partner for the Rides to Wellness service and then prove that it could deliver effective and reliable same-day service for that organization’s patients or clients. With the first success, the building of trust could begin. The MTA’s current challenges include the need to hire more drivers given the demand for service and the accompanying need for more vehicles to meet demand. Funding The original funding to support the initial Rides to Wellness service, which provided the specialized service for dialysis riders, came Exhibit 5-7. Attractive Rides to Wellness vehicles were noticed. Photo courtesy of Flint MTA. Serving Genesee County Veterans through MTA’s Rides to Wellness The MTA is particularly proud of its service for veterans and their spouses through a partnership with the Genesee County Veterans Services Office. With this arrangement, veterans honorably discharged from military service and a resident of Genesee County can book free trips to medical appointments, the pharmacy, grocery stores, farmers’ markets, and other community resources with MTA’s Rides to Wellness. Genesee

Case Studies 103 from the higher fares charged for the trips and MTA’s local operating money. The MTA then received a grant of $310,000 from FTA’s Rides to Wellness grant program in 2016. (This grant has since been re-named the Transit and Health Access Initiative.) The grant allowed the MTA to hire staff for the service (called mobility navigators), purchase 10 vehi- cles, and pay for the new software. As the program has grown, the transit agency has continued to rely on federal grants for capital purchases and to receive funds to support operations from its participating partners. To ensure the program is operationally sustainable, the MTA was careful to calculate the actual operating cost of providing the Rides to Wellness trips. Taking into account driver salaries ($11 per hour), vehicle operating costs, and productivity (three passenger trips per hour), the transit agency determined that each one-way trip cost the MTA $14.98 to operate. This was rounded up to $15, and that is what each partner agency pays for the trips it sponsors. Capital costs, which are primarily the cost of the vehicles, come from several different federal grant programs, including the FTA Transit and Health Access Initiative as well as FTA Section 5307 (Urbanized Area Formula Grants) and Section 5339 (Grants for Bus and Bus Facilities). The vehicles purchased for the service are primarily sedans. However, to accommodate riders using wheelchairs and other mobility devices, the MTA also purchased ramp-equipped minivans. Lessons Learned The Flint MTA reports that it is critical to prove to the community that a transit agency can provide a reliable and effective same-day, on-demand service. This is the cornerstone of developing collaborations with health-care organizations to improve transportation access to health care. A second lesson is to price the transportation service fairly and accurately. The MTA was quite clear on this, stressing, “Do not underprice yourself.” If the transit agency is going to provide same-day, real-time, door-to-door service to improve access to health care, then it should charge for that higher quality of service. A third lesson for building partnerships is to identify and target community organizations that understand that transportation is a barrier to health care. The MTA stresses the importance of this advice—find the organizations in the community that realize patient transportation is a problem, because they might be interested in a partnership to improve transportation. For those transit agencies interested in developing collaborations with community partners to improve transportation access to health care, the MTA suggests seeking help and advice from other transit agencies that have developed successful collaborations in their own community to improve such transportation. These agencies have been through the growing pains and can share their experiences that can help guide another agency in another community. Assistance is also available through national associations such as the National Center for Mobility Management. Transferability Flint MTA’s Rides to Wellness service has already been the inspiration for similar services in neighboring jurisdictions. Three other transit agencies in Michigan have implemented Rides to County’s Veterans Services Office has provided an annual $50,000 grant that funds up to four free round trips monthly per eligible veteran and spouse. Given the success of the program, the annual grant was increased recently to $75,000, giving veterans and their spouses five free round trips per month. One notable result of this partnership is new support and recognition of the MTA from local veterans groups and other community service groups. Before the partnership, such organizations had little awareness of the transit agency. The MTA’s arrangement with the county’s Veterans Services Office has brought new recognition and standing for the transit agency in the community.

104 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Wellness services (they even use MTA Rides to Wellness logo): Greater Lapeer Transit Agency, Shiawassee Area Transit Agency, and Saginaw STARS. Contact Information Mass Transportation Authority (MTA) Flint, Michigan Coordinating Public Transit, Human Service, and Medicaid Transportation: Lane Transit District’s RideSource Snapshot of Collaboration Lane Transit District (LTD) is the public transportation agency in Lane County, Oregon. Based in Eugene, Oregon, LTD provides fixed-route bus service, bus rapid transit, and demand response transportation for a service area population of about 375,000. LTD, through its RideSource program, brokers and coordinates a range of transportation services including Medicaid NEMT, ADA paratransit, contracted human service agency client transportation, health-care transportation, and general public service. Health-care trips are coordinated directly with hospital social workers and the local CCO. RideSource providers include LTD through its ADA paratransit service, private providers that involve taxis and TNCs, and human service agencies. How Did the Collaboration Start? The origins of RideSource date to the late 1990s with one visionary individual who was the accessible services coordinator with the Lane Council of Governments (LCOG). LCOG is involved in passenger transportation as the region’s MPO. LCOG also serves as the Area Agency on Aging through its Senior and Disability Services (S&DS) division and provides funding for senior transportation needs. As an employee of LCOG, this visionary actively sought out ways to work with LTD. In 2000, she was then hired by LTD to coordinate service with other organizations and actively worked with human service and health-care organizations to build the RideSource program. The program more than doubled in 2008 when RideSource became the Medicaid NEMT broker for the county. This allowed RideSource to take on services of additional agencies and needs as the program continued to expand. Initiating the Effort LTD’s journey toward coordinated paratransit came about through a combination of circumstances. Clearly the vision of one individual was important, but more to the point it became the vision of LTD and its partners. According to the most recent Lane Coordinated Public Transit Plan, “a growing body of evidence supports the connection between successful health outcomes and access to afford- able and appropriate transportation options resulting in synergy between health and transportation availability.” Lane Coordinated Public Transportation Plan, 2019 Update, pg. 7.

Case Studies 105 Breaking Down the Funding Silos Through a series of local and state decisions in Oregon, historical transportation funding silos were broken down at a time when many states were building silos. In Lane County, Medicaid NEMT and veterans’ transportation programs were combined with transit and other programs, addressing needs for health-care and human services. Rather than operate small, separate siloed services, the various programs decided to take advantage of an already established professional transit service—LTD—and the economies of scale offered by forming a consortium. In this way, the programs pooled their resources and used LTD’s dial-a-ride service through RideSource. This was a positive development. The individual agencies no longer had to purchase and maintain their own vehicles, employ and fully train driving staff, or obtain insurance. The foundation of that enterprise is present today in the RideSource program that includes multiple relationships, contracts, and under- standings that represent 25 years of coordination between public transportation and human service agencies in Lane County. The Spark: Seizing the Moment In 1990, Oregon began coordinating Medicaid NEMT through transportation brokerages, managed by transit agencies. TriMet, the Portland area public transit agency, became the first Medicaid NEMT broker in the state, and gradually other regions in Oregon followed suit. LTD first became a Medicaid NEMT broker in 2008. In 2012, the Oregon Health Plan (OHP) began to transform into a coordinated care model, under which all health-supportive services (physical health, mental health, substance abuse treatment, and dental care) are provided through an umbrella entity/network. Each CCO is responsible for a specific geographic area. Lane County was one of the first two areas in the state to adopt this model. The CCO Trillium Community Health Plan approached LTD (as the exist- ing broker), and in 2013 they began a formal relationship. The CCO conducts stringent oversight of LTD. LTD, in turn, conducts rigorous over- sight of its service providers, ensuring that they have the required training, meet insurance minimums, conduct driver background and license checks, and have the required safety equip- ment on vehicles. At the beginning, LTD and Trillium had to work through the growing pains with their partnership. But now, LTD finds Trillium cooperative and responsive, reporting that the health-care organization completely understands the importance of transportation for improving health outcomes. According to LTD, the objective is: “Focus on the benefit. Money will be part of the conversation, but we want to know what we can do. We need to spend to save” (5). The model chosen is to expand public transit access to all. As stated in a recent National Rural and Intercity Bus Conference workshop, and also applicable in urban as well as rural areas: “The best way to coordinate human service transportation is to provide excellent public transportation that most people can use” (6). Simply put, as public transit fixed-route and paratransit services improve and expand, more people have access to safe transportation for trips to health care as well as other trips that address the social determinants of health. Further, as costs are reduced through the use of fixed routes, the savings can be used for patients who cannot appropriately use a fixed route.

106 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Development and Description Starting almost 20 years ago, LTD developed and perfected the concept of a fully integrated human service, health-care access, and public ADA transportation program operated by an urban transit system with multiple contracted providers through RideSource. Since its start, RideSource has expanded to serve a wide variety of human service and health-care agencies and providers. Currently, all requests for specialized transportation services in the county includ- ing for Medicaid NEMT, ADA paratransit, senior transportation, employment transportation for individuals with developmental disabilities, and related trip requests are handled by the RideSource Call Center (RSCC). RideSource determines the most appropriate and cost-effective transportation service for each trip request and schedules the ride as needed. RideSource uses its own fleet as well as the services of more than 30 providers in its coordinated network: • Private taxis. • Transportation networking companies. • Other specialized private for-profit and non-profit providers. • Volunteers coordinated through the Area Agency on Aging. • Reimbursement of clients for their own mileage. When fixed-route bus travel is possible, RideSource provides the individual with a bus pass. For trips from remote areas of the county into the LTD fixed-route service area, RideSource may provide a demand response trip into town, and then the passenger can use the fixed-route service for in-town travel needs. RideSource brokers trips for the general public as well as trips funded under numerous human service and health-care programs, including Medicaid. Service is provided on a shared-ride basis so that passengers of different programs are commingled when feasible. In addition to ongoing program-sponsored travel needs, RideSource can meet short- term “critical connections” needs often by matching a rider with a volunteer driver. RideSource has used TripSpark Novus technology since July 2017. This product was customized for the LTD brokerage and is now available off-the-shelf for other organizations. Through TripSpark Novus, RideSource can send actual trip assignments to external pro- viders and those providers can bill back directly for trips they serve. For requests for longer trips, Ride Source’s providers are invited to bid their cost, helping to ensure cost-effective service. RideSource also manages bus passes, mileage reimbursement, volunteers, and external providers. The Early Years LCOG and LTD worked together to coordinate multiple transporta- tion programs in developing RideSource. LCOG managed the senior services program through S&DS, which provided senior transporta- tion. LCOG was also responsible for FTA Section 5310 funding for seniors and persons with disabilities. Further, as the host for the MPO, LCOG has had a stake in transit. LTD has a dedicated tax base and a philosophy of serving the community. Key Elements and Steps in Forming RideSource • A visionary individual and a willing organization. • A reduction in funding among transit, human service, and health- care providers led to the decision to coordinate or consolidate. Multiple agencies participated. • In 2008, LTD became the state Medicaid NEMT broker for the region, more than doubling its service. • RideSource continued to grow and expand services to a wider audience, including veterans. LTD’s Mission Statement: We believe in providing people with the independence to achieve their goals, creating a more vibrant, sustainable, and equitable community. See Attachment 1 to the Case Study for LTD’s Mission Objectives.

Case Studies 107 LTD and LCOG together were able to recruit other partners and, most importantly, Medicaid NEMT. Including Medicaid transportation in the coordinated mix changed the dynamics of RideSource in a positive way. Local governments that supported rural and small city shuttles and services into Eugene also facilitated the growth of LTD’s commitment to rural parts of the county. The State Structure for Medicaid NEMT Facilitated Coordination The Oregon Health Authority’s (OHA) approach to Medicaid NEMT brokerages—those that use professional public transit providers and employ safeguards (well-trained drivers, properly maintained vehicles, full control over the driver force)—has put the state in the role of facilitator of integrated transportation. The OHA determines the structure for the state’s Medicaid NEMT program, which is a major funder of transportation to health care. Its decision to coordinate services through transit dis- tricts enhances the ability of the transit agencies to coordinate or consolidate transportation services. This has been accomplished typically through a brokerage model, where the transit agencies are paid on a per-trip basis, unlike the capitated model used by many states. As more states turn to managed care for their Medicaid programs, this approach to Medicaid NEMT is relevant for addressing transportation access to health care. Attachment 2 to the case study details the evolution of the Medicaid NEMT program in Oregon and its coordination with public transit. Under the previous payment model utilized by OHA, the RSCC functioned as a gatekeeper to transportation services by ensuring the Medicaid-eligible individual was receiving services only when all other resources had been exhausted. With the focus of the CCOs on health out- comes for members, many (including Trillium) are working to enhance access to transportation. In effect, RideSource is evolving into a service to enhance access to health-care services for all in need. This is a major shift from the capitated for-profit brokerages, where the less service provided, the more money the broker makes. Partners: Participating Funding Organizations A major strength of RideSource has been its ability to break down funding silos through collaboration, most notably with Medicaid NEMT (facilitated with the state’s structure for its Medicaid program) and the VA transportation. The Medicaid NEMT service is discussed above. The other agencies and funding streams coordinated through or working with RideSource are listed below. • Transportation for Lane County veterans—RideSource coordinates with the Lane County Veterans Services Office, providing transportation to and from VA medical and Lane County Veterans Services appointments. During the calendar year 2018, 197 veterans made 2,314 one-way trips, a 400% increase in 8 years. • Community health improvement plan—In 2016, four agencies—Lane County Public Health, PeaceHealth Oregon West, Trillium CCO, and the United Way of Lane County—developed a community health improvement plan. This plan identified strategies for improving health outcomes of county residents. • Funding for developmental disabilities transportation—In the early 2000s, the state provided developmental disabilities funding for transportation to employment training. • Mental health transportation—White Bird Clinic is a crisis intervention, mental health counseling, and information and referral center. The counseling program serves adults on the OHP (Medicaid). The clinic arranges transportation primarily to mental health treatment and other activities.

108 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services • RideSource ADA—This is LTD’s origin-to-destination ADA paratransit service within the metropolitan area for people unable to use regular bus service (some or all of the time) because of a disabling condition. RideSource ADA meets ADA requirements. • Eligibility evaluation—Transportation coordinators from Alternative Work Concepts, S&DS, and White Bird Clinic perform in-person evaluations to determine eligibility for all riders that RideSource serves. • Volunteer Escort—This is a door-through-door service for people who need a high level of assistance and do not have other transportation options. Medical Transportation Manage- ment, S&DS, and the Senior Companion Program participate to support the volunteers. • Immediate (non-emergency) needs—Crucial Connections is an organization that provides transportation to relieve an immediate (non-emergency) or evolving situation when no other transportation option can be identified. The service offers quick relief to allow time to for- mulate a long-term resolution. Crucial Connections pays for a limited number of trips that are situation specific. • South Lane—The non-profit agency, South Lane Wheels, is supported by the city of Cottage Grove and the Rural General Public Program for areas with a population less than 50,000. South Lane Wheels provides local dial-a-ride services and a metro shuttle to take people to Eugene and Springfield for health care, shopping, and other needs. • West Lane—The Rhody Express is a local shuttle service within the city of Florence that is operated by River Cities Taxi for health care, shopping, and other needs. The shuttle is supported by Florence and the federal Rural General Public Program for areas with a popula- tion less than 50,000. • East Lane—Service for the community of Oakridge includes demand response service and an intercity shuttle called the Diamond Express, both operated by Pacific Crest Bus Lines for health care, shopping, and other needs. It is supported by Oakridge and the state’s Intercity Passenger Program that connects communities with a population of 2,500 to the next larger market economy and to other transportation services. • Medical and community non-medical transportation under Medicaid—The RSCC administers three Medicaid NEMT programs: (1) NEMT for the OHA; (2) NEMT for Trillium Community Health Plan; and (3) community non-medical transportation. Eligibility Assessments: A Unique Approach LTD assesses the individual transportation needs of all the riders it serves (including, among others, riders for Medicaid NEMT and ADA paratransit) through an in-person functional assessment process. LTD contracts with three different contractors that make a home visit to the vast majority (estimated 99%) of applicants and conduct a comprehensive assessment of the applicant’s needs and transportation resources available to the applicant. The assessors can then determine the most appropriate service for applicants’ travel needs (Medicaid NEMT or otherwise) and connect them with other types of services they may need that are beyond transportation. Documentation and reporting for the assessments are electronic and paperless. As an integrated process with a holistic approach to each applicant, the specific travel needs of the applicants—for any trip purpose—are addressed through RideSource. The assessors are able to identify other social service needs that applicants may have beyond transportation. Embracing Technology and Innovation In addition to the comprehensive eligibility certification program that incorporates home visits for virtually all applicants, LTD and its partners have embraced other innovations and effective strategies. In July 2017, new software was implemented at RideSource that consolidates different data- bases and functions. The software—TripSpark—incorporated the function of four databases

Case Studies 109 and 17 different applications and processes that previously managed all of the services at Ride- Source, from call intake to service delivery and billing. The TripSpark software now provides all of these features in a single database. In January 2018, LTD changed the design of the half-fare and “honored” (senior) rider cards. The new cards are easier to read, and the larger font expiration date allows transportation opera- tors to inform the riders when they need to get their card renewed. During the 2018 calendar year, nearly 6,000 riders received or renewed half-fare and “honored” rider cards. Also in January 2018, LTD began an innovative new service animal pilot project. The inten- tion of this voluntary program is to streamline the boarding process for riders who have service animals. LTD now provides the option to include a “paw print” endorsement on riders’ identi- fication cards. This informs drivers that the individual has had a conversation with LTD acces- sible services staff to assess the need for the service animal and discuss with the rider the transit agency’s expectations. LTD, through RideSource and in conjunction with the Oregon Department of Transporta- tion’s Department of Rail and Public Transit, assisted in the development of a pilot transporta- tion service between two communities on the Pacific Coast, Yachats (85 miles from Eugene), and Florence (60 miles from Eugene). The Florence/Yachats Connector runs four times a day, Monday through Friday, and began service in September 2018. The service is operated by River Cities Taxi, the organization also responsible for operating the Rhody Express fixed-route service in Florence. At the time of this writing, this pilot appears to be successful, and riders are accessing the service daily for health care and other needs. LTD Accessible and Customer Services Accessible fixed route is a key element to the RideSource program. Those persons able to use a fixed route are given incentives for riding a fixed route. Co-location of LTD-accessible services and customer services staff has led to an improvement in the quality of service to LTD customers, with better coordination of services for older adults, people with disabilities, and persons of low income. LTD has two discounted fare programs aimed at providing lower-cost, fixed-route public transportation: half fare for customers with disabilities and free fare for persons over the age 65. Clients of partnering private non-profit agencies also pay half fare. Facilitators of Success Various factors have facilitated the success of RideSource. LTD’s holistic mission state- ment along with the range of funding sources have been important. Support from the LCOG and S&DS was crucial in the beginning and helped pull other participants to the consortium to share costs. Oregon’s structure for Medicaid NEMT, not typical among states, is another key factor— coordinating Medicaid transportation through transit agencies. This allowed LTD to bring Medicaid NEMT into the RideSource fold, along with Medicaid funding. Having Medicaid transportation coordinated with public transportation allows the Medicaid service to gain from economies of scale and the professionalism provided by public transit agencies. Barriers, Constraints, and Challenges LTD did not identify many barriers in developing RideSource. The agency was able to work cooperatively with most of the relevant organizations that plan, fund, or use transportation for clients or patients.

110 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services LTD reported that procuring a new call center contractor at the same time as implementa- tion of new software in 2017 was a challenge. The outgoing contractor had developed its own software, and the transition to the new contractor and software was not easy. RideSource has also found that meeting certain transportation needs can be challenging, including: • Hospital discharges—LTD is considering using transportation network companies, which currently serve the Eugene metropolitan area, to meet these trip needs. • Dialysis transportation—The demand is growing. RideSource can often place dialysis patients on fixed-route service when traveling to the appointment, but provides demand response service for the return trip. LTD is currently in discussions with several dialysis centers to coordinate its service with patients’ treatment schedules for more efficient transportation. • Affordable options—Reasonably affordable, accessible specialized service when ADA para- transit is unavailable is needed. Accessible taxi service is limited, and other private providers are expensive. • Access issues—Particularly in rural areas of the county, providing transportation can be challenging. Funding and Sustainability RideSource brokers about 500,000 trips per year across a wide range of funding streams. An estimated 68% of these trips are for Medicaid NEMT. RideSource also provides approximately 2,500 bus passes a month for Medicaid NEMT, the majority of which appear to be related to counseling and methadone treatments. In addition, it is estimated that, among the non- Medicaid NEMT riders, about 30% of their trips are to health-care services. LTD provides about 15% of the overall system costs, which include Medicaid NEMT. Taking Medicaid NEMT out of the equation, LTD is paying about 46% of the non-Medicaid NEMT service through its dedicated funding source (payroll tax). Local agencies pay the bulk of the remainder of the funding. The state provides both transit funding and human service health- care-related funding. These sources are depicted in Attachment 3 to the case study, which details RideSource’s diverse funding. The diversity of funding sources is in part what makes RideSource successful. While LTD and Medicaid NEMT funding are dominant, a number of local and state funding streams contribute to the funding mix. Lessons Learned LTD shared a number of lessons learned from its experience in developing the highly coordi- nated RideSource program: • Maximize the use of accessible fixed routes to provide transportation. • Seek a diversity of funding sources. • Ask organizations: What do you need transportation to do? How can we help you meet your transportation needs? • Seek out Medicaid insurance providers and then work closely with them on transportation issues. • Ensure adequate time and attention when contracting for broker and technology support. • Try not to do too much at the same time when working toward coordination and con solidation.

Case Studies 111 Transferability Can any urban transit agency with a service area population of 500,000 develop a highly coordinated service to meet the transportation needs of their community’s seniors, persons with disabilities, and others in need, either fully or in steps? The answer may be yes, if at least the following are addressed: • A transit agency willing to make a commitment in funding and staff—LTD has commit- ted to serving the mobility needs of seniors, persons with disabilities, and persons with a low income and has expressed that in its mission statement (Attachment 1, Lane Transit District Mission and Attachment 4, Long Range Plan). • Human service agencies and health-care providers that understand the benefits of coor- dinated transportation—Organizations involved in the program are required to pay a portion of the service costs and gain the benefit of a transit agency subsidy with the support of professional staff and trained drivers. • Willing local governments—Some of the services developed by RideSource are focused on rural areas, and local governments are expected to pay for a portion of the service. • State funding availability—A state Medicaid agency that understands what public transit can do for Medicaid NEMT. • Patience—Coordination of service takes time, often years. Experience indicates that it is best to start with the willing participants, and soon others will want to be part of the collaboration Contact Information Lane Transit District Eugene, Oregon Attachments to Case Study of Lane Transit District’s RideSource Attachment 1: Lane Transit District Mission At Lane Transit District, we asked our community why we do what we do. What we heard is summarized like this: We believe in providing people with the independence to achieve their goals, creating a more vibrant, sustainable, and equitable community. How we do it: • We serve the community with respect. • We continuously question if there’s a better way. • We collaborate internally and externally. • We care for our employees, customers, and business partners. • We plan for a sustainable future. What we do: • We provide reliable transit services that address the needs of the community. • We provide a viable alternative to the automobile through high-quality transportation options, programs, and services. • We provide leadership in the development of the region’s transportation system. • We practice safety and maintain safe and accessible vehicles, services, and facilities. • We practice sound fiscal and sustainability management.

112 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Attachment 2: Medicaid NEMT—Managed Care Oregon began changing how it provides health-care services for people who receive health- care coverage under the OHP (Medicaid) by creating CCOs in 2012. This is not unusual as many states are starting to turn to the managed care model. As described by the Oregon Health Authority (OHA), CCOs are: • Replacing MCOs, mental health organizations, and dental care organizations for OHP members. The CCOs will focus on improved wellness, prevention, and integration of behavioral and physical health care. These local health entities will deliver health care and coverage for people eligible for the OHP (Medicaid), including those also covered by Medicare. CCOs are a new way of doing business for the OHA. They will be the umbrella organizations that govern and administer care for OHP members in their local communities. • CCOs must be accountable for health outcomes of the populations they serve. They will have one budget that grows at a fixed rate for mental, physical, and, ultimately, dental care. CCOs will bring forward new models of care that are patient centered and team focused. They will have flexibility within the budget to deliver defined outcomes. They will be governed by a partnership among health-care providers, community members, and stakeholders in the health systems that have financial responsibility and risk. The RSCC is one of eight regional call centers within Oregon that handles transportation services for Medicaid recipients through an agreement with the OHA. Unique to the RSCC are features that offer a comprehensive approach to coordinating local transportation services: • Approved cost allocation methodology. • Cost sharing and integration of human service transportation. • Personal in-the-home interviews by trained transportation coordinators from S&DS and Alternative Work Concepts. • Interagency collaboration with case managers. • Innovative program development using a community care model. • Sophisticated application of technology and software. Attachment 3: Funding Sources Tables 5-1, 5-2, and 5-3 depict the wide range of funding sources that are critical to LTD’s success. Revenue FY18 Actual FY19 Budget — TOTAL $ 6,379,867.12 $ 7,755,574.00 Table 5-1. Accessible services fund: 2-year revenue budget FY18 and FY19.

Case Studies 113 Attachment 4: Excerpt from LTD Long Range Plan (7) GOAL 3: Ensure Equitable and Accessible Transit Service Throughout LTD’s Service Area Transit is an essential community service that provides personal mobility and freedom for people of every walk of life. The role of transit is to create connections and serve people efficiently, affordably, and safely. Persons with limited transportation options who depend on public transit have the greatest need for linkages to jobs, essential goods and services, and will be given special consideration in transit planning. POLICY 3.1: The allocation of resources for accessible service should consider the following priorities: 1) maintain a sustainable level of service for people who depend on public transpor- tation; 2) respond to pressures of growth and demand within the limits of resource availability; and 3) optimize the resources to accommodate emerging community needs. DEFINITION AND INTENT: The provision of transit service should consider future capacity needs as the local population increases and ages over time. Increasing frequency and span of service has direct impacts on fleet capacity, which is especially important in terms of the limited space for mobility devices on a bus. Strategy 3.1.A: Collaborate early with Eugene and Springfield to gain understanding about the relationship with economic development, multi-family housing, and other community services within proximity of transit routes, with priority within Frequent Transit Network (FTN) corridors. Strategy 3.1.B: Strengthen with rural areas and small cities connectivity of medical transportation services through coordination of the RideSource Call Center and health- care providers [bold added]. Strategy 3.1.C: Maximize ridesharing and grouped ride services to address non-medical transportation needs. Strategy 3.1.D: Develop strategies to provide cost-effective and equitable human services transportation beyond the District through coordination. Revenue FY18 Actual FY19 Budget TOTAL $ 9,751,920.69 $ 11,974,775.00 Table 5-2. Medicaid fund: 2-year revenue budget FY18 and FY19. Project FY18 Actual FY19 Budget TOTAL $ 11,567,987.18 $ 11,842,175.00 Table 5-3. Medicaid fund: 2-year project budget FY18 and FY19.

114 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Building Transportation Options and Solutions for Rural Missourians: Missouri Rural Health Association’s HealthTran Snapshot of Collaboration The Missouri Rural Health Association (MRHA)’s HealthTran program provides mobility management coordination and services through technology, education, and support. Unique in approaching transportation barriers through a community approach, the program offers MRHA members a one-stop scheduling platform with local, public, commercial, rideshare, and volunteer transport. The original HealthTran model began as a pilot program that connected rural residents to health-care facilities using existing public transit services. In 2016, Health- Tran transitioned from the grant-funded pilot program to a subscription-based model where transportation is generally provided through volunteer drivers. The 2020 program continues as a membership model and has expanded the community approach and addresses transportation solutions through assessments, education, technical assistance, non-traditional transportation, and technology. More Details Participating transportation providers load their availability, cost, and services onto the cloud-based system. Ride schedulers select service type (i.e., volunteer, rideshare), mobility need, and ride details. Rider profiles provide retained data and take less than 5 minutes to enter. Data collected provides statewide aggregate data and can be customized to address specific member requirements. In expanding transportation options, HealthTran staff work with local non-traditional orga- nizations to increase access. These may include FTA Section 5310 subrecipients, nursing homes, ambulance districts, churches, volunteer programs, and others with a desire to improve access in their communities. The HealthTran Transportation Manager provides technical assistance to get more vehicles on the road and on the platform. An example of a non-traditional provider is Delta Area Economic Opportunity Corporation in the Missouri bootheel, which is a community action agency currently working with HealthTran to support community transportation with 32 Head Start vans. As a trusted organization in the area, individuals will be more likely to use the transportation service. The delta region is one of the poorest areas of Missouri and faces multiple social determinants of health barriers. The MRHA volunteer driver program’s manager is building a statewide driver program and offering the technical assistance to local volunteer programs as well as individual drivers to improve sustainability and improve relationships in the communities served. A technology program tracks rides, driver profiles, vehicle requirements (insurance, inspections, driver’s license), and training. The program allows collection of statewide volunteer data to show the value of volunteerism. An 18-month FTA ICAM grant is supporting a Regional Mobility Coordinator (RMC) approach in four areas across Missouri. RMCs receive training and support in bringing Mobility Management Coordination and Service to local communities and they act as champions in addressing barriers to care.

Case Studies 115 The original HealthTran model began as a pilot program that connected rural residents to health-care facilities using existing public transit services. The pilot program hired local com- munity members as HealthTran Coordinators (HTCs) who served as single points of contact for the patient and provider. In 2016, HealthTran transitioned from the grant-funded pilot program to a subscription-based model where transportation is generally provided through volunteer drivers. The 2020 program continues as a membership model and has expanded the community approach, and addresses transportation solutions through assessments, education, technical assistance, non-traditional transportation, and technology. Each community is unique and can use components of MRHA’s HealthTran program to meet their needs. The annual 2020 membership dues are $250 for a non-profit agency and $500 for a for-profit/vendor. In the subscription-based model, a health-care provider (MRHA member) agrees to partici- pate in HealthTran and invests a one-time start-up fee of $1,500 per location. A minimum of two locations is needed to begin the process within a community. The HealthTran monthly subscription cost of $37.50 per month has unlimited usage and logins and provides ongoing technical support, expansion, and mobility management educa- tion. Members pay a $4 booking fee and the transportation cost is determined by the trans- portation provider. The MRHA volunteer program offers rides at $1.10 per loaded mile with “loaded” meaning when the rider is in the vehicle. The 2019 average ride distance was 11.1 miles, and the average cost of transportation was $1.10 per mile for an estimated total of $12.20. HealthTran continues to serve as a “last resort” transportation option for patients who have no other way of traveling to health-care facilities. Patients who can access NEMT through Medicaid are asked to use the state-funded program. When a Medicaid patient does not meet NEMT eligibility, the member has the flexibility to provide transportation through HealthTran. How Did the Collaboration Start? Health-care providers have long identified transportation as a major barrier to accessing care in rural Missouri. MRHA identified a gap in transportation access for patients who were not eligible to receive free or subsidized NEMT but did not have access to a personal vehicle. Many of these patients live in rural areas without adequate public transit infrastructure. In 2013, HealthTran reported that lack of access to transportation was a leading cause of missed appointments, which contributed to substantial loss of revenue for rural health-care providers. Lack of access to primary care led to poor patient outcomes, overuse of emergency services, and avoidable hospitalizations. Securing Funds for the Pilot Program In 2013, Community Asset Builders, LLC, a non-profit with a long history of work in grant writing and health-care consulting, helped facilitate a panel discussion at the Missouri Public Transit Association (MPTA) to discuss solutions to NEMT in rural South Central Missouri with other key stakeholders. After the panel discussion, Community Asset Builders, MPTA, and MRHA worked together to develop the HealthTran concept. MRHA presented HealthTran to the Missouri Foundation for Health in 2013 and received a 3-year grant from the foundation to pilot the program. MRHA administered the grant with support from MPTA and Community Asset Builders. Setting Policy Objectives At the outset of the pilot program, HealthTran established three policy objectives: • To gather data to test the hypothesis that connecting people to transportation leads to cost savings and improves health outcomes.

116 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services • To create a sustainable program model. • To document the development and implementation of HealthTran to promote replication at the state level and across different communities. Building Relationships and Identifying Partners The original model of HealthTran focused on improving connections between health-care providers and local transit agencies. To bring partners to the table, MRHA acknowledged the limited funding of rural transit agencies and scheduling difficulties for rural providers. MRHA emphasized the ability of HTCs to remove the burden of arranging transportation from health-care staff, transit agencies, and patients. MRHA also highlighted the benefits of increased transportation access: improved outcomes for patients, decreased missed appoint- ments for providers, and increased ridership for public transit services. To formalize collaborations among partners, MRHA and MPTA established the Health- Tran Consortium with participating health-care and transit providers. Consortium partners all signed an MOA (Memorandum of Agreement) that described three goals for Consortium members (8): • Strengthen HealthTran Consortium infrastructure and governance to effectively reduce transportation barriers to health care through development of a new service delivery model. • Obtain data to support increased long-term, dedicated state and federal funding for public transportation. • Improve patient outcomes for individuals enrolled in HealthTran. The MOA also established six objectives (9): 1. By August 31, 2014, a service delivery model will be developed and ready to implement as a pilot within the region. 2. By December 1, 2014, pilot will be ready to be implemented across the nine-county region. 3. By November 30, 2016, 10% or less of HealthTran participants will use the hospital emergency room for non-emergent conditions. 4. By November 30, 2016, 10% or less of HealthTran participants will experience a hospital readmission within 30 days. 5. By November 30, 2016, 80% of HealthTran participants will adhere to scheduled appointments. 6. By November 30, 2016, 80% of HealthTran participants will report 90% or greater satisfaction with service coordination services. HealthTran received 3 years of support (2018–2020) from UnitedHealthcare to support the MRHA and HealthTran mission. Additional funding through the Missouri Department of Transportation, using FTA Section 5310 Mobility Management funds, was received. In 2019, MRHA was awarded an FTA ICAM grant and will continue to expand mobility management coordination and education through the Coordinating Council on Access and Mobility grant. The FTA funding supports the following: 1. The Missouri Mobility Management Certificate program focused on health, community, and transportation designed to assist community health-care workers and case managers who are working in rural areas to break down and address transportation barriers. 2. Development of Regional Mobility Managers to become community champions and provide leadership and assistance. 3. Development of a one-stop scheduling system. 4. Expansion of the volunteer driver program. 5. Placement of MRHA as the Missouri Mobility Management technical assistance lead.

Case Studies 117 Development In the pilot, HealthTran worked with local health-care providers to understand their hours and typical patient needs. HealthTran then connected with ambulance districts and public transportation providers to expand times and routes to better meet the needs of providers and patients. The service started small with a handful of staff and providers (Exhibit 5-8). HealthTran staff traveled to providers’ offices to share information about the program and asked providers to share information with patients who could benefit from transportation assistance. The knowledge gained has been the impetus for the program designed today. MRHA is contacted by interested health and wellness providers, and an initial discussion helps define the need and service areas. Information is gathered, such as a community assess- ment and transportation data, to determine what aspects of HealthTran may be useful. When a community or member is ready, HealthTran connects transportation providers to the sched- uling system and provides technical assistance and support to the transportation programs to ensure they can be appropriately placed in the transportation network. Volunteer pro- grams, such as senior centers, RSVP programs, and veteran organizations, are introduced to the program, and volunteer drivers are recruited. In many rural areas, volunteers enjoy help- ing neighbors and they receive mileage reimbursement that offsets the cost of volunteering. The simple mobile system allows for volunteers to select rides that meet their availability and manage their time. Description During the pilot phase, HealthTran could help health-care providers cover specialized trans- portation services. MRHA partnered with a number of both transit and health-care providers to successfully implement the pilot program as shown in Exhibit 5-9. In the pilot, a manual access program and email connected members and HTCs. The system worked well during the pilot but would not work for state expansion. The current platform teams two technology companies, a scheduling platform designed for hospital transport with HIPAA and PHI security, and a volunteer driver program to track volunteer rides. The programs are linked and share only required information to ensure ride completion. The data collection and report capabilities have been developed for HealthTran and provide customized informa- tion to help drive access for all. Exhibit 5-8. HealthTran HTCs and partners on the first day of services in 2014.

118 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services The volunteer technology tracks hours of service, miles driven, training records, and awards. Alerts are given to the Volunteer Manager when vehicle documentation is due (inspection, insurance). Drivers are vetted through a nationally approved background screening program and drug testing. Two Missouri Regional Planning Commissions, Boonslick and Meramec, have developed a statewide referral system to help individuals find a ride. MO Rides, piloted in 2014, provides ride coordination and transportation provider contact information. Working on collaboration with HealthTran, MO Rides may soon be able to offer scheduled, self-pay rides. Facilitators for Success Clearly articulating the business case for investing in transportation access helped HealthTran establish partnerships with funders and providers. At the provider level, missed appointments required increased time spent on rescheduling, lower productivity, and revenue losses. At the patient level, missed appointments can lead to costly emergency depart- ment visits, hospitalizations, and exacerbation of chronic conditions. HealthTran is building the case for reducing employee absences, addressing social determinants of health related to medicine and nutri- tion, and attendee-required meetings, such as with educators regarding an Individualized Education Program (IEP). “I do not see any boundaries where transportation and HealthTran can go” stated the HealthTran Director. “HealthTran will continue to grow and adjust to meeting the needs of our rural communities.” Barriers, Constraints, and Challenges Rural health-care providers, and especially critical access hospitals, may have difficulties paying membership and subscription fees. While providers may acknowledge that upstream investments in health lead to downstream savings in avoidable hospitalizations, they may not Exhibit 5-9. MRHA partners: Transit and health-care providers. Making the Business Case HealthTran developed a case study on a patient who required several treatments to avoid a limb amputation. While HealthTran spent about $6,000 on transportation services for the patient, local providers were able to bill for over 60 visits and the U.S. Department of Veterans Affairs may have avoided more than $1 million in costs for a surgery, hospitalization, prosthetics, and associated follow-up care.

Case Studies 119 be able to justify allocating funding to transportation when they are operating in the red. Com- munity partners, including local public health departments or federally qualified health clinics, may be able to help rural providers offset transportation costs. HealthTran’s rural service area often lacks access to high-speed broadband internet. Mobility managers allocate substantial time to communicating with patients, providers, and volunteers via telephone. Funding The Missouri Foundation for Health funded the HealthTran pilot with a 3-year grant that totaled $499,906. HealthTran also received pilot funding from the National Center for Mobility Management, the Missouri Department of Transportation, and UnitedHealthcare. After the initial grant, the program shifted to a subscriber model that focuses on building transportation options. HealthTran services include: 1. Technology scheduling system linking public, commercial, rideshare, and the MRHA volunteer program. Scheduling a ride takes under 2 minutes, and setting up a rider profile takes less than 5 minutes. 2. Statewide volunteer program building and linking both individual drivers and volunteer programs. Drivers accept rides that meet their availability and location, and programs manage the volunteers that are dual enrolled. HealthTran offers a subscription to the Volunteer Management program or supports the program as needed. Volunteers receive mileage reimbursement that makes volunteering affordable and sustainable. 3. Community assessments and transportation gap analysis, technical assistance, and mobility coordination training. 4. Non-traditional transportation technical assistance for improving community transporta- tion options and sustainability. An example is in the bootheel of Missouri where the Delta Area Economic Opportunity Corporation is working to bring 32 Head Start vans under the HealthTran umbrella and provide community transportation when the vans are not trans- porting children. 5. Development of a Missouri Mobility Management Certificate program focused on health and community. The certificate will be expanded to a certification program by 2024. The certifi- cate training will be offered online through the University of Missouri Extension program. 6. Training RMCs through regional planning commissions and community action agencies to address local access needs. The RMCs will work independently and collaboratively on bringing resources, knowledge, and technical assistance to rural communities. Lessons Learned The MRHA and Community Asset Builders were able to leverage long-standing relationships with funders, community partners, legislators, and other key entities to ensure the success of the pilot program and continued investment in the current self-sustaining model. Program leaders suggest that partnering with local businesses and leveraging resources from collaborators can be critical to gaining buy-in and maintaining services throughout changes in funding. Similar programs should seek funding for a large initial investment in program infrastructure, including training ride coordinators and arranging logistics for drivers. MRHA and Community Asset Builders recommend including funding for investments in transportation planning in grant applications. Once established, the subscription-based service can require different kinds of resources to remain sustainable. Similar programs should consider whether there is sufficient local interest

120 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services among community members and providers to establish a system of volunteer drivers and enroll in a subscription service for transportation. Providers reported very high levels of satisfaction with the program. Providers also offered some suggestions that could benefit similar programs. For example, almost all providers suggested developing a flag in the patient’s EHR to record transportation needs and remind staff to contact HealthTran. One provider also recommended creating signage for clinic waiting rooms to prompt patients to ask about HealthTran. HealthTran listened, and the new scheduling platform has the capability to link directly with medical record systems, and national health measures are being explored for 2021 reporting. The data gathered through the scheduling system offers customizable reports from collected data including funding buckets and payor source. Transferability HealthTran successfully transitioned from a grant-based model to a subscriber-based model. Other programs could consider a similar trajectory: 1) using grant funding to make large capital investments in infrastructure, establish partners, and document the success of the program and 2) using a subscriber-based model to continue to provide NEMT with volunteer drivers. Contact HealthTran Jefferson City, Missouri [email protected] Chapter Notes 1. KFH Group, Inc. Coordinated Public Transit–Health and Human Services Transportation Plan, Capitol Regional Area Transportation Coordination Committee and Capital Metropolitan Planning Organization, Austin, TX, pp. 4–9, 2017. 2. Community Health Improvement Plan: Austin/Travis County, Texas, Year 1 Action Plan. Austin Public Health, August 2018. 3. CARTS management and observation of the technology, by Ken Hosen, January 3, 2020. 4. KFH Group, Inc. TCRP Research Report 70: Guidebook for Change and Innovation at Rural and Small Urban Transit Systems. Transportation Research Board, Washington, D.C., 2001. 5. Lane Transit District’s Human Service Transportation Coordinator, interview on-site, Eugene, OR, by Ken Hosen, September 2019. 6. KFH Group. Workshop: Rural Transit Service Design Matching Service to Meet Needs: An Introduction. Conducted for the Rural and Intercity Bus Conference, October 2018. 7. Long Range Transit Plan: Lane Transit District. March 2014. 8. Boeckman, D. Missouri Rides to Wellness. Missouri Rides to Wellness Summit Summary Report, 2015. https:// 9. Boeckman, Missouri Rides.

The availability of transportation influences the ability of individuals to access health care, whether in urban, suburban or rural areas. Those lacking appropriate or available transportation miss health care appointments, resulting in delays in receiving medical interventions that can lead to poorer health outcomes. This in turn contributes to the rising cost of health care.

The TRB Transit Cooperative Research Program's TCRP Research Report 223: Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services details how to initiate a dialogue between transportation and health care providers as well as subsequent actions and strategies for pursuing a partnership and implementing transportation solutions appropriate for patients.

Efforts to improve health in the United States increasingly recognize that it’s not just the health care system that is responsible. It’s a range of factors that collectively affect health and health outcomes. These factors are known as the “social determinants of health,” and, significantly, they include transportation.

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Medical Terminology in a Flash! A Multiple Learning Styles Approach, 3e

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The nervous system plays a key role in maintaining homeostasis, the state of dynamic equilibrium in the internal environment of the body. More complex than the most advanced computer, the nervous system is capable of storing vast amounts of data as well as receiving and sending thousands of messages throughout the body instantly and simultaneously.

While the nervous system functions as a total system, you may find it more easily understood if we divide it into its two major parts: the central nervous system (CNS) and the peripheral nervous system (PNS). However, we first begin by looking at the most essential element: the neuron.

Your brain is something like a very complex computer with infinite data-storage capabilities.

A nerve cell, known as a neuron, is illustrated in Figure 5-1 . Neurons vary in size and shape, but they all have the following key parts: cell body, axon, and dendrites. The cell body houses all of the microscopic structures that keep the cell energized and functioning. The dendrites, which resemble the branches of a tree, are responsible for receiving information from the internal and external environment and bringing this information to the cell body. The axon sends electrical impulses and transmits signals to other cells. The axon may be short or quite long and is sometimes covered in a special protective layer called the myelin sheath.


Use the illustrations by tracing them with your fingertip, naming the various parts aloud, and describing their functions as you do so. This is useful for visual, auditory, verbal, and kinesthetic learners.

The central nervous system (CNS) comprises the brain and spinal cord ( Fig. 5-2 ). This is where data storage and information processing occurs. The brain is made up of three major divisions: the cerebrum, which makes up the largest portion; the cerebellum; and the brainstem. The cerebrum is divided into two hemispheres sometimes called the left and right brains. They are connected by a structure called the corpus callosum.

Central nervous system: (A) brain, (B) spinal cord.


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