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Summary There are approximately 23 million veterans of military service in the United States today. The U.S. Department of Veterans Affairs (VA) provides a comprehensive system of services to our veterans, about 40 percent of whom are currently 65 years of age and older. At this time, more than 8 million veterans are enrolled in services involving various kinds of medical care provided by the Veterans Health Administration (VHA), one of three administrations within the VA. Substantial growth is projected in the number of veterans requesting medical care. VA offers assistance to eligible veterans who are traveling for medical care. VHA administers the Beneficiary Travel program, under which certain transportation expenses can be allowed if those expenses are part of VHA-provided or VHA-authorized outpatient and inpatient medical services provided to eligible individuals. VHA reports FY 2010 expenses for the Beneficiary Travel program of $750 million. The Veterans Benefits Administration administers the program entitled Automobiles and Adaptive Equipment for Certain Disabled Veterans and Members of the Armed Forces, which had an estimated budget of $65.8 million in FY 2010. Thus, the combined value of VA's Beneficiary Travel and Automobile and Special Adaptive Equipment Grants programs is about $820 million per year in transportation assistance to veterans for FY 2010. 1

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Despite this level of support, there are numerous reports of veterans having difficulties accessing VA health care or other destinations that offer resources which are critical for life sustaining and life enriching activities. This Summary highlights mobility issues facing our veterans and illustrates some potential strategies for community transportation providers who are interested in enhancing mobility options for our veterans; details are provided in the full digest. ELIGIBILITY FOR VA TRANSPORTATION ASSISTANCE The VA, through VHA, provides health care benefits to eligible veterans; certain transportation costs can be considered as part of VHA-provided or VHA-authorized outpatient and inpatient medical services. VA's policies describe the kinds of persons and kinds of trips that are eligible under VHA's Beneficiary Travel program for reimbursement of travel expenses. Some of the persons and trips eligible for travel reimbursements include the following. More complete details are provided later in the digest. Veterans who travel to or from a VA facility or VA-authorized health care facility in connection with treatment or care for a Service Connected (SC) disability (regardless of percent of disability). Veterans with a SC disability rated at 30 percent or more who travel to or from a VA facility or VA-authorized health care facility for examination, treatment, or care for any condition. Veterans receiving a VA pension traveling to or from an authorized health care facility for examination, treatment, or care. An attendant who is accompanying and assisting a veteran or beneficiary eligible for beneficiary travel payments because of the veteran's physical or mental condition. Other persons (for example, a member of a veteran's immediate family or a veteran's legal guardian), if they are traveling for consultation or other specified services concerning a veteran who is receiving care for a SC disability; or a member of a veteran's immediate family traveling for bereavement counseling relating to the death of the veteran in the active military service in the line of duty. Trips by veterans to authorized health care facility for scheduled compensation and pension (C&P) examinations. Trips for emergency situations or other specified situations. 2

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More complete descriptions of eligibility requirements are found in VHA Handbook 1601.05 and in Chapter 2 of this digest. Veterans qualify for Special Mode Transportation (ambulance, wheelchair van, "and other modes which are specifically designed to transport certain disabled individuals") if their medical condition requires an ambulance or a specially equipped van, and they meet certain eligibility criteria (including some of those listed above), and the travel is preauthorized (preauthorization is not required for emergencies if a delay would be hazardous to life or health). TRANSPORTATION OPTIONS FOR VETERANS While there are numerous ways that veterans could travel to VA Medical Centers (VAMCs), veterans in many localities often experience quite limited transportation options available for their medical trips. The most common transportation options for veterans traveling to VAMCs are as follows: Veterans drive themselves to VAMCs. Veterans receive transportation services via nonprofit veterans' service organizations, including the Disabled Americans Veterans (DAV) and other veterans' organizations. VAMCs use their own staff to operate vehicles to transport veterans. VAMCs contract with local transportation vendors to provide trips to veterans. Veterans use transportation services operated by public transit agencies, local governments, or community-based organizations. Some VAMCs provide information about local transportation options for veterans. MOBILITY CHALLENGES FACING VETERANS This report and other reports have identified problems, concerns, and challenges with transportation services now provided to veterans. The kinds of problems that have been observed include the following: Veterans report problems accessing VA medical services. 3

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The need for veterans' transportation is growing rapidly due to an increase in injuries. Currently, for every fatality in Iraq, there are 16 wounded or injured soldiers, which is an injury rate five times greater than in the Vietnam War. With annual VHA medical transportation expenses increasing rapidly--$750 million was spent in FY 2010 on Beneficiary Travel--cost-effectiveness of transportation services is a growing concern. Rural areas offer special transportation challenges for transportation services serving veterans. o Forty percent of veterans live in rural areas. The younger veterans who served in Iraq and Afghanistan are more likely than other veterans to live in rural areas. o Veterans living in rural areas may need to travel extremely long distances to receive medical care and the other services to which they are entitled. o Veterans living in rural areas are reported to be in poorer health than veterans living in urban areas. Veterans who miss medical appointments exhibit higher rates of depression, poor health care access, socialization problems, and suicide. There is a huge and growing need for transporting aging and younger veterans with traumatic brain injuries. According to some sources, veterans' transportation services are frequently not coordinated with existing community and public transportation services at this time, with the result that neither the veterans' transportation services nor existing community transportation services operate as cost-effectively as they might. Some volunteer-based services (such as those provided by DAV) are struggling to obtain or maintain a sufficient number of volunteer drivers to meet the mobility needs of veterans. Most volunteer services do not now operate vehicles accessible to veterans in wheelchairs. Some of the current transportation services are characterized by excessive wait times for trips or for appointments for trips. As veterans' transportation services tend to be administered locally, local administrators may not be aware of other travel options or best practices in veterans' transportation services. With decentralized decisionmaking for transportation services for veterans, these services exhibit a lack of uniformity and consistency. 4

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APPROACHES FOR PROVIDING MOBILITY TO VETERANS There are exemplary approaches to serving the mobility needs of veterans all across this country. One problem is that there has not been a well-developed method of sharing the results of successful programs and other learning experiences among communities interested in applying innovative approaches. Table S-1 lists of few noteworthy examples of different approaches to improving the mobility of veterans. Table S-1: APPROACHES TO IMPROVING THE MOBILITY OF VETERANS Location Innovations Transit offers advance-scheduled out-of-county trips to VA health Ocean County, NJ care Indianapolis, IN Taxi-provided transportation for veterans Western Colorado Transit dispatches DAV vans Des Moines, IA Transit and paratransit serve the local VA hospital Washington State S. 5311 system provides feeder service to DAV vans Little Rock, AR Taxis transport veteran passengers and make deliveries Free travel for disabled veterans on all of the state's fixed route Minnesota transit services Reduced fares for disabled veterans, free BART rides for active duty San Francisco, CA soldiers, and accessible taxis Unlimited-use transit passes for veterans, vanpool vehicle assigned Orlando, FL to VA clinic, and veterans involved in transportation planning Foundation funds purchased over-the-road coach for long-distance Angelina County, TX travel to the Houston VAMC VA contracts with public transit to take veterans to rehab clinic Martinsburg, WV which is not at the VAMC 5

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COORDINATION STRATEGIES FOR COMMUNITY TRANSPORTATION PROVIDERS Besides the innovative approaches listed in Table S-1, community transportation providers will need to apply a variety of coordination strategies if they are interested in more coordination with agencies that are now offering transportation services to veterans. These coordination strategies include: Be proactive: Get to know the Veterans Service Organizations (VSOs) and transportation providers in your community. Gather information and research the operations of these organizations. See where you can assist: If you offer to help solve problems rather than take over services, your efforts are likely to be more successful. Focus on several key issues: o Veterans with disabilities: Current veterans' transportation services tend to focus on ambulatory riders; nonambulatory veterans can benefit from public transportation services. o Long-distance trips: Particularly in rural areas, long-distance trips can be a challenge for any transportation provider. The coordination of long-distance trips could serve the public and veterans at the same time, greatly enhancing the cost-effectiveness of both operations. o Scheduling trips: Most VSOs are unfamiliar with current paratransit dispatching and scheduling software and could benefit from assistance with these tasks. Help train, maintain, and facilitate: This includes training drivers and dispatchers, maintaining vehicles, and facilitating scheduling and transportation information dissemination. Coordinate transportation with medical appointment schedulers: Medical staff who schedule medical appointments often do not consider transportation problems when they set up appointments. Work with medical schedulers to ensure that resources are used cost- effectively. Develop plans that include all modes and providers, including volunteer services: The efforts received from volunteer drivers are a significant strength of current veterans' transportation services. These volunteers are crucial to maintaining cost-effective transportation services. Work closely with them; they may be able to help you too. Include veterans in the planning process for future transportation services: Veterans and their service organizations have significant transportation needs and can offer substantial inputs into future plans. 6

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SUMMARY Presently (in late 2010), mobility for our veterans is characterized by a large number of veterans with numerous and diverse needs, substantial expenses, and considerable opportunities for improvements. The Department of Veterans Affairs offers trips for medical purposes to veterans who meet certain qualifications; veterans need additional means of transportation for other types of trips and sometimes for medical care as well. VHA's costs for medical transportation have quintupled since FY 2001 due to increased mileage reimbursement rates and increased utilization of medical services. VHA's current expenditures on its Beneficiary Travel make this program the third- largest federal program for persons with special travel needs; adding VA's Automobile Assistance Program increases the estimated FY 2010 expenditures to about $820 million. Projected growth in these programs could push VA's annual transportation expenditures beyond $1 billion in the near future. This report describes innovative local examples of mobility improvement strategies that could result in large mobility gains elsewhere. Community transportation providers will need to be proactive in reaching out to veterans' organizations if significant improvements in coordination with veterans' transportation programs are to be achieved. To improve the mobility of veterans, broad scale, long-term efforts will be needed from key stakeholders at all levels of government. The continued involvement of relevant federal agencies is suggested. The new attention of the Coordinating Council on Access and Mobility to improving mobility for veterans is beneficial. States and localities can assist by supporting and expanding the kinds of innovative programs already under way. More immediate improvements can be initiated and implemented by local transportation providers. Instances of coordinated transportation services involving community transportation providers and VA or VSOs are inspiring but extremely limited at this time. There are significant opportunities for community transportation providers to serve a market segment--veterans--that they now seldom serve; there are significant opportunities for the VA and other groups serving veterans to increase the cost-effectiveness of their services and substantially increase the mobility of veterans by working with other community transportation providers. Reliable transportation is a key to maintaining personal independence. Without adequate, reliable, and affordable transportation, individuals are isolated and separated from society. 7