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29 VPTA members used fixed-route buses (36%), a network of trip and eligibility verification and assignment of hundreds of volunteers (27%), taxis (20%), and vans (8%), most appropriate mode, and to provide 490,383 Medicaid/Reach Up trips statewide. recruitment, training, administration payment, verifi- cation, and programs designed to retain volunteers. VPTA and the Agency of Human Services have coordi- Level playing field--VPTA determines the service stan- nated for 19 years, and there is a very high level of trust dards that all brokers must comply with. The playing between the organizations. VPTA also works closely with field is level. the Agency of Transportation (AOT). VPTA management reports state that NEMT was the impetus for initiating pub- lic transit in rural areas of the state and was the framework SUMMARY--CASE STUDIES for transit services, with transit service areas coinciding with Medicaid catchment areas. NEMT is essentially a state designed and managed program; therefore, there are a variety of effective approaches to coor- One concern that could affect coordination across the dination and service delivery. The five case studies repre- state is that the AOT believes that the Medicaid/Reach Up sented in this synthesis illustrate the flexibility states have in program should pay for depreciation of AOT-sponsored designing a NEMT program. vehicles. This issue is currently under discussion and likely to be resolved by the state. The case studies indicated that there are a number of lessons to be learned and that there are a variety of factors and actions that can determine coordination potential at the CCTA Coordination Efforts transit agency level. The most important are discussed here. CCTA is a small urban transit operator serving the greater Burlington area. In addition, CCTA operates and manages Lesson 1: Coordination of fixed-route service is encour- Green Mountain Transit, a rural transit agency in the state aged by most states--Florida, an early practitioner of capital of Montpelier. CCTA was designated the broker for fixed-route bus passes, has seen considerable cost sav- its service areas. As broker, CCTA's first priority is to place ings using this approach. Vermont and Oregon are also as many Medicaid customers on fixed-route service as possi- practitioners of the use of fixed-route service. Georgia's ble. Currently, more than 80% of the Medicaid trips in the private brokers see financial gain through the use of county that use Medicaid/Reach Up are on fixed routes and fixed-route service and presumably the state Medicaid use bus passes. Demand-response trips are provided by taxi agency benefits from this approach. However, although and coordinated through the nonprofit agency that contracts in the 1980s and early 1990s Texas relied heavily on for ADA service. fixed-route service, its use has been reduced since that time. With some exceptions, most states have seen sig- Activities That Affect Coordination nificant financial savings through the use of fixed-route service. The Medicaid agency trust level--There is a high level Lesson 2: Cost transferring onto paratransit is prob- of trust between the state Agency for Human Services lematic--Paratransit, the mode used by many clients, and VPTA, built over years of cooperation. Their trust operates differently from fixed-route service. Where level extends to the operators. the use of fixed-route service can benefit all riders, Coordination of state agencies--Each of the agencies paratransit typically requires fully allocated costs to be and the brokerage work well together and discuss issues successful. on a regular basis in a variety of forums. Lesson 3: Service model--The service model used will, Using the operators as brokers--This decision was in part, determine the level and ability of the transit agen- critical to the coordination effort and is an excellent cies to coordinate. The service model used by Vermont example of the state facilitating coordination. is built on trust at the local level and through state initia- High utilization of fixed-route service--Vermont has a tive with the transit association; this has introduced a high level of fixed-route use (36% for 11% of the cost). model of service delivery that is the epitome of coordi- Considering that Vermont is a very rural state makes it nation. Oregon also has a strong coordination model. In even more impressive. According to VPTA, the cost for each of these cases, the transit agencies serve as brokers a fixed-route trip is less than 20% of the average cost for or operators of service. Florida's model also fosters coor- the other modes. dination between transit agencies. NEMT has seen some Adequate funding for NEMT--Each of the brokers is transit agencies withdraw or consider withdrawing from reimbursed for the trip provided (volunteer or transit), the NEMT program owing to funding cuts. In the past, as well as for expenses related to administration and trip Texas was a highly coordinated state through the strength intake. The costs of trip intake are almost as much as the of its transit agencies. The recently introduced RFP is a trip itself and are related to: coordination neutral approach and several systems lost

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30 their contracts. Low price and other factors will deter- The local transit agency will also, in large part, determine if mine the selection process. Finally, Georgia has a model coordination will be used. that makes coordination difficult to achieve through its large regional brokers. Lesson 4: Building on trust--As in any business rela- tionship, coordination is built on trust. In Vermont and The approach used by each state will help determine coor- Oregon the trust level is high at all levels of manage- dination potential; however, coordination can still occur even ment. The other case studies indicated significant trust with a model that does not necessarily encourage coordination. at the local level where coordination was successful.