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31 CHAPTER FIVE CONCLUSIONS There were a number of coordination factors evident of successful coordination, whereas other models do throughout the synthesis. These factors can foster or impede not encourage or discourage coordination. coordination, and some can dictate the level of coordination. Urban and rural areas--It was determined that rural tran- For example, certain capitated brokerages will encourage sit is far ahead of its urban counterpart in the area of coor- competition among providers that is the opposite of coordi- dination in general and for Medicaid transportation as nation. It was also determined that rural areas are well ahead well. This was originally accomplished out of necessity; of their urban counterparts in coordinating public transit with however, it has become an integral part of most rural Non-Emergency Medical Transportation (NEMT). transit agencies in the nation. Use of fixed-route service--The appropriate use of The following are the elements of success--key factors fixed-route service is cost-effective and fosters mobility that can foster or inhibit coordination as expressed through for the clients served. It is true coordination where all the literature review; surveys of transit agencies, state depart- parties benefit. Where possible, bus passes should be ments of transportation and Medicaid agencies; and the case used. According to the literature and operator responses, studies. Not all agencies encountered all of these elements; the distribution of bus passes is often administratively however, each of the issues listed occurred multiple times more effective than distributing tickets two at a time. and were credited with influencing coordination. These fac- Make business sense--Coordination implies and requires tors are listed based on their affect on coordination: success mutual benefits; that is, each entity must find the arrange- factors, helpful factors, and challenges to coordination are ment acceptable from a business perspective. The alter- discussed here. native is for a transit agency to subsidize NEMT. SUCCESS FACTORS HELPFUL FACTORS These are the factors that must be present for coordination to If in place, these elements can help foster coordination; how- succeed. By themselves however, these factors do not guar- ever, without them coordination may still be possible, but antee success. more difficult. Operational coordination is local--Coordination of Understanding of transit concerns--Although NEMT is NEMT and public transit is fostered and implemented typically the largest source of transportation funding in at the local level whether encouraged or inhibited by rural areas, its managers often have no experience or state and federal government. In the long history of knowledge of transportation subjects. This lack of coordination, most of the successes were a result of understanding has been cited as a major barrier to coor- local level collaboration based on needs and sound dination by transit managers. NEMT managers cite business decisions. In the states reviewed as part of this concerns similar to those of transit managers when it synthesis, many local operators coordinated, whereas comes to NEMT services. the state agencies were not involved. State legislation/mandates--To date, legislative efforts Building trust--In a number of cases, the trust level have had mixed results across the country based on the becomes very important at the local level. The trust information collected for this study, as well as a report between entities and their management will, in part, by the National Conference of State Legislatures. determine the level of coordination. Some of the transit Level playing field--A number of transit operators cited agencies reported that they built this trust over many the difficulty of competing when the Medicaid service years. standards are low. Driver training requirements, mini- Service delivery model--The service model will, to a mum standards, vehicle standards, safety standards, and significant extent, dictate the potential levels of coordi- other requirements typically adhered to by transit are not nation. Some models clearly foster coordination, some always required by Medicaid agencies. This encourages give coordination a lower priority, and others are indif- two different levels of service--one for public transit ferent. The Oregon and Vermont models are examples and a lower standard for Medicaid clients.