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Chapter 4 CURRENT INNOVATIVE OR EXEMPLARY PRACTICES This chapter (a) presents information about innovative or exemplary community transportation programs for veterans and (b) summarizes some overall lessons from these examples. KEY SPECIFIC CASES All Points Transit, Montrose, Colorado Description All Points Transit (APT) provides public transportation services in rural western Colorado using funds from FTA (Sections 5310, 5311, and 5316); several HHS programs (Medicaid and aging); local municipalities; grants; and donations. APT is the only local source of transportation for veterans in their two-county service area who are unable to transport themselves. The mission of APT "is to provide safe, reliable transportation for older adults, individuals with disabilities, and low-income 41

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workers and job seekers in Montrose and Delta Counties. Our goal is to facilitate independence and promote a high quality of life and productivity in our communities."38 APT has been providing transportation services to veterans since May 2009. From May through December, they scheduled 1,399 trips for 318 veterans; 1,042 trips were actually taken (the remainder were mostly cancellations with some no-shows). This is equivalent to about 2,100 trips scheduled on a 12-month basis. About 70 percent of those trips are destined for the VAMC in Grand Junction, Colorado, a one-way distance of about 60 miles. Most of the long-distance trips for veterans are billed directly to the Grand Junction VAMC. For local trips, veterans less than 60 years of age pay $20 per trip and veterans 60 years and older are asked for donations for their trips. In these counties, APT is the only local source of transportation for veterans who are unable to transport themselves. As a professional transportation agency, they are experts in scheduling, routing, coordinating with other human service agencies as well as providing rides. A Memorandum of Understanding has been executed between APT, the Grand Junction Veterans Administration Medical Center, and the Disabled American Veterans Transportation Program to describe the responsibilities of all parties in scheduling medical trips for veterans. If a veteran needs a ride to the VAMC in Grand Junction or to the Community-Based Outpatient Clinic in Montrose, they call APT, not the DAV Transportation Network. DAV Transportation Network, a volunteer driver-based program, has drivers and vehicles but the program does not have advanced scheduling software that can create optimal routes for each vehicle and driver. APT, on the other hand, has access to paratransit scheduling software because the software is used for everyday operations of its vehicles. As laid out in the MOU, APT receives calls and schedules trips for the DAV's vans. To ensure quality of the service, APT and VAMC staff communicate on a daily basis via fax to confirm schedules and service delivery. In addition to the scheduling and call center, APT is also in direct contact with riders. In cases of emergencies when DAV vans cannot operate (inclement weather or vehicle breakdowns), APT contacts veterans and informs them of the changes. The Grand Junction VAMC reports many advantages to this arrangement. Of those, having access to a full-time staff member who can handle the ride request calls from veterans is noteworthy. Previously, volunteers were responsible for taking calls from veterans, and volunteers were not 38 Mission statement formerly posted on APT's web site at http://www.allpointstransit.org/index.html . 42

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always available. The Grand Junction VAMC no longer worries whether veterans cannot get to their appointments because their requests for rides are now handled by professional staff. According to DAV Chapter 17, APT was involved in one-third of total veterans' trips to medical centers in the region, either through dispatching or directly providing rides. Even without providing rides to veterans, APT is able to serve veterans' mobility needs through dispatching and call center services. Key Features This human service private nonprofit organization: Receives calls and schedules trips for DAV's long-distance and local volunteer transportation services using paratransit scheduling software Provides coordinated local transportation for veterans, seniors, and persons with disabilities living in their rural service area Ocean Ride, Ocean County, New Jersey Description The Ocean County (New Jersey) Department of Transportation Services sponsors Ocean Ride, a county transportation program. Ocean Ride utilizes 75 accessible buses, each capable of carrying between 12 and 14 passengers, to provide 17 general public, fixed-route services and door-to-door, nonemergency medical transportation service to seniors (age 60 and older) and persons with disabilities. Ocean Ride also provides regularly scheduled transportation service for Ocean County veterans to access the major, out-of-county VA medical clinics. Different VA medical clinics are served on different days. Veterans must call at least 2 weeks in advance of their appointments to schedule rides. Most of the trips to medical clinics are from centralized pick-up sites. As part of Specialized Transportation Services, Ocean Ride provides nonemergency medical transportation to veterans. It transports veterans, free of charge, to VA clinics and VAMCs regardless of county boundaries. With the help of veterans' advocates and other veterans' service 43

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organizations, Ocean Ride developed prearranged schedules to transport veterans to medical facilities at the East Orange VAMC in NJ; the Lyons VAMC in NJ; the Philadelphia VAMC in PA; and the Fort Dix VA clinic in NJ and the Brick VA Clinic, which is the only veterans medical facility in Ocean County. With the exception of the Brick VA clinic, Ocean Ride goes to one out-of-county VA site each weekday on a fixed schedule. The service routes and service hours of the veterans' transportation are determined based on inputs from other agencies. These coordination efforts allow the transportation program to avoid duplication. While Ocean Ride handles client eligibility screening for its other Specialized Transportation Services, eligibility screening for its veterans' transportation program is determined by the Ocean County Veterans Service Bureau, which is a separate office within the county government. Once eligibility requirements are met, veterans contact the Ocean County Veterans Service Bureau to request trips. Staff members at the County Veterans Service Bureau are familiar with veterans' needs, documentation required for veteran status, and up-to-date changes in VA medical facilities. Given their expertise, it makes sense for the Ocean County Veterans Service Bureau employees to handle eligibility screening and reservation request. With administrative support from the County Veterans Service Bureau, Ocean Ride can focus on its expertise: transporting passengers reliably. The success of this system is in part due to the local transit agency's commitment to the veterans who reside in the county. As a county agency, Ocean Ride could have limited its service to destinations solely within county boundaries. Instead, different units within the Ocean County Government worked together to serve the transportation needs of county residents who are veterans. As the county with the largest veteran population in the State of New Jersey, Ocean Ride's veterans' transportation program receives funding from the county, the state, and the federal government as well as funds from New Jersey Department of Military and Veterans Affairs. Ocean Ride's veterans transportation program is much appreciated by veterans who have to travel outside of the county, sometimes even outside of the state to receive medical treatments. Key Features Ocean Ride, a public transportation agency, offers out-of-county trips for veterans to VAMCs on a prescheduled basis. These trips are free of charge to veterans; the service is funded by the county, state and federal government as well as funds from the New Jersey Department of Military and Veterans Affairs. Several county agencies collaborate to ensure smooth operations for this transportation service. 44

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Price County Human Services Commission on Aging Office, Wisconsin Description Price County is a rural county in northern Wisconsin without public transportation services. The Price County Veterans Service Office (VSO) serves the transportation needs of veterans by coordinating with the Price County Human Service Commission on Aging Office (COA), which has a pool of volunteer drivers that was established for its senior transportation program. The COA will provide rides for both younger and older veterans. The most frequently visited VAMC is in Madison, 4 hours away. Veterans who are unable to travel to VAMCs on their own may contact the Veterans Service Office, whose employees determine eligibility for benefits. VSO then submits ride requests to the Commission on Aging office, which locates a volunteer driver among their volunteer pool. The volunteer drivers are reimbursed at a rate of 50 cents per mile, the state mileage rate. Volunteer drivers often work more than 8 hours a day to transport veterans. In Fiscal Year 2009, about 50 round trips were completed for the purpose of transporting veterans to VA medical facilities. Collaboration between Veterans Service Office and Human Service Commission on Aging allows veterans to travel with little expense to their medical appointments. Veterans (regardless of age) can get rides through the Commission on Aging Office. The volunteer drivers are paid for their mileage. Typically, veterans are billed for a portion of the mileage and the VSO pays the rest of the cost. Some veterans get beneficiary travel benefits from VAMC and use these funds to pay for their rides. If veterans less than 65 years old need to travel for their medical appointments, they can get rides through the Aging Office's volunteer program by paying a reduced fee of 30 cents per mile; the Commission on Aging will pay another 20 cents per mile to ensure that volunteer drivers are paid 50 cents per mile. All veterans who need transportation within the county can use the Aging Office's transportation program for group shopping excursions (veterans 50 years and older or disabled) or other scheduled trips. The program is available without charge or at only a nominal fee. When veterans need to travel to VAMCs outside of Price County using the Aging Office's volunteer driver program, veterans may submit claims to VA's beneficiary travel program and receive reimbursement of 41.5 cents per mile. Veterans are billed monthly by the VSO for trips provided by COA's volunteer driver at a rate of 20 cents per mile. The Veterans Service Office pays an additional 30 cents per mile and reimburses the COA's volunteer drivers at the total rate of 50 cents per mile. 45

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Young or old veterans who are below the federal poverty level and do not receive beneficiary travel benefits are exempt from paying for their rides; the VSO pays the entire 50 cents per mile for them to the COA. This volunteer-based program has advantages and disadvantages. Unlike scheduled group rides or fixed route schedule services, some volunteers are flexible with their hours and willing to drive on weekends and holidays if a trip is required. On the other hand, this service operates on a first-come first-served basis, meaning that some requests cannot be filled if all volunteers are busy at that time. Also, veterans who need accessible vehicles cannot be transported in volunteer drivers' vehicles. Currently, 6 percent of the Aging Office's rides are for veterans. Transportation program staff indicate that open communication and coordination are essential. Communication among drivers, agencies, consumers, medical facilities, and even the police department is said to be vital in order to serve veterans with the trips that they need. The Price County transportation program acknowledges that their transportation program does more than transport people: transportation helps the veterans feel confident that they can get to their medical appointments. Key Features There is no public transportation in Price County and major destinations are several hours away. Too few veterans live in the county to sustain an independent transportation program. Through coordination and volunteer drivers, the Veterans Service Office and the Human Service Commission on Aging are collectively meeting the medical transportation needs of their rural veterans. Des Moines Area Regional Transit (DART) Description DART is Des Moines, Iowa's transit service. DART provides more than 425,000 trips per year. DART's ADA complementary paratransit service, Bus Plus, transports about 20,000 passengers with disabilities annually. Iowa's veteran population accounts for almost 9 percent of Iowa's population and a large number of veterans in the Des Moines area depend on DART and Bus Plus to fulfill their local travel needs. 46

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In 2005, the Veterans Administration announced that it would begin a 4-year phasing out of its services offered at its community-based outpatient clinic (CBOC) in Knoxville, Iowa, which is 32 miles southeast of Des Moines. DART officials realized that closing this facility might create serious hardships for some veterans who lived in the southeastern section of DART's service area and who depended on the services provided by the Knoxville medical facility. To accommodate those veterans, DART provided enhanced transportation services to the VA Hospital in Des Moines for those veterans who had used the closed CBOC in Knoxville, providing continuity of care to those veterans. According to DART's Director of Paratransit Services, both DART and Bus Plus now transport large numbers of veterans on a daily basis. The Veterans Hospital is a major stop on both the DART and Bus Plus daily routes: in the past 12 months, there were 774 trips in and out of the VA Hospital in Des Moines using the Bus Plus paratransit service and an estimated 16,584 boardings and alightings at the hospital. (The latter figure may include non- veteran visitors to the hospital.)39 This case should be seen as an example of a local transit authority ensuring that its services meet the needs of all of its citizens, including veterans, according to its official mission statement: "The Des Moines Area Regional Transit Authority (DART) will be a leader in improving Central Iowa citizens' quality of life by placing the customer first while providing safe, innovative, and efficient public transportation to the region."40 Key Features The urban-area public transit system enhanced their services to the VA hospital in Des Moines for veterans who had previously depended upon a medical facility that closed, ensuring that veterans could continue to access the health care treatments that they needed. Iowa's Information Services for Veterans Description Iowa makes many attempts to reach out to veterans and provide them with information about services available to them. IOWA Workforce Development created a compressive guidebook titled 39 Personal communication from DART's Director of Paratransit Services, November 23, 2010. 40 Information from DART's web site. See http://www.ridedart.com/overview-mission-statement.cfm, accessed November 23, 2010. 47

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"Iowa Veterans Benefits & Services: A Guide to Federal, State, and Local Veterans Programs." This guidebook includes transportation information under supportive services. A recent event was the "All The Way Home Conference" for veterans, held in Dubuque, Iowa in April 2010. The All the Way Home organization, a Tri-State effort in the Midwest operating on behalf of the area's veterans, was the sponsor of this regional conference. The event was designed to: Provide a forum for veterans and their families to access services available in Dubuque and the surrounding areas. Make information regarding these services available in one place. Provide an appropriate forum for the Dubuque community to thank veterans for their service. Offer information on these services and information in a casual atmosphere, reaching those veterans who normally would not seek services due to fear of stigma, as well as those who do not know where to get this information. Though most veterans are aware of the medical benefits available to them, many are not aware of their transportation benefit and how to access this service. Iowa also offers vets rehabilitation and vocational training, and those services can be accessed via transportation. Outreach events like this conference make access to these services easier for our growing veteran population. Key Features Providing information about existing transportation benefits and services helps veterans continue to access their medical services and other important destinations. The Olympic Peninsula, Washington Description The scenic Olympic Peninsula of Washington State is home to a growing population, including a large number of veterans who have chosen to retire in the area. In addition, there are many military bases throughout this geographically strategic location. 48

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According to the Veterans Administration, approximately one41 out of every ten people42 who live in the state of Washington is a veteran. The total number of veterans in the state is approaching 700,000 and that number is sure to increase as members of the military who are currently residing in the Greater Seattle region decide to follow their predecessors and remain locally after completing their active duty. These Seattle-area veterans will require health care services and the region is certainly set up to offer those services, with a huge VA medical facility in Tacoma, smaller ones in the Seattle area, an affiliation with the University of Washington to provide specialty training to job- seeking veterans, and a variety of other outreach programs. The Seattle region is famous for its bridges, and these structures play a critical role in connecting many parts of the region. The anticipated temporary closing of the bridge that is the primary link for travel between the Olympic Peninsula and the rest of the metropolitan area was expected to create serious traffic delays for mainland vehicles driving out to the Peninsula to pick up passengers, to deliver those passengers back to mainland destinations, and then to take the passengers back to the Peninsula. Vehicles operated by the DAV fit this description extremely well. Sensing a looming problem for local veterans seeking medical care, Washington State DOT staff came up with a solution: let veterans heading to mainland services access the existing DOT-funded rural public transportation routes, which would then connect on the mainland with DAV vehicles which would supply the last link to VA medical facilities. In other words, existing public transit services provide feeder route to transport veterans living on the peninsula. A voucher-based subsidy was used to fund the transaction. A win-win situation was created where a problem might have occurred. The state-funded vehicles did not have to change their operations to accommodate the veterans and the DAV vehicles were made more effective by eliminating a major part of their typical mileage and hours. Veterans seeking mainland health care services were not adversely impacted by the bridge closing; in many cases, veterans' transportation options actually improved. This effort to coordinate public transit and volunteer services could be duplicated in regions all across the country. 41 Department of Veterans Affairs.(2006). State Summary: Washington and the U.S. Department of Veterans Affairs. Available at http://www.dva.wa.gov/PDF%20files/USDVAwastatesummary.pdf, accessed on May 14, 2010. 42 U.S. Census Bureau (no dates) State and County Quick Facts available at http://quickfacts.census.gov/qfd/states/53000.html , accessed on May 5, 2010. 49

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After the bridge repairs were completed, veteran ridership on the service started to decline. Some of the decline is thought to be attributable to the end of special assistance veterans received as part of the efforts to mitigate construction impacts. According to the feedback from veterans who used the coordinated transportation services, they appreciated additional help they received: for example, the coordination team assisted veterans who applied for voucher programs through the VA. When the construction mitigation program ceased, a group of stakeholders created a plan to use the local Non- Emergency Medical Transportation Broker as a Regional Mobility Manager for veterans' transportation and to add veterans to existing Medicaid trips. Key Features State DOT staff acted to provide public transportation services for veterans living at some distance from Seattle whose access to medical care was about to be compromised by bridge closures for repairs. Transportation services from locations on the Olympic Peninsula were provided to the mainland by rural public transit operators who link to DAV volunteer services on the mainland. This solution shortened the ride for veterans and relieved the DAV services of significant mileage requirements. Based on this short-term project, the regional leaders have begun working on broader transportation issues for veterans. Houston and San Francisco Description Houston, Texas is the third-largest U.S. city in terms of population and has a service area of 1,285 square mile. The local transit system (METRO) has a daily ridership that exceeds 600,000 passengers. METRO's complementary ADA paratransit service, METROLift, has annual ridership of about 1.3 million. METROLift has innovative services in that, in addition to deploying a traditional paratransit service with large lift-equipped vehicles, they contract out a large portion of the METROLift service to a taxicab company, which, in turn, deploys a fleet of 160 wheelchair- accessible vehicles dedicated to this service. The San Francisco, California Metropolitan Transit Authority (SFMTA) provides a variety of transportation services including municipal bus routes, known as the "MUNI," along with shuttles, vans, light rail, trolleys, and even cable cars. MUNI is one of America's oldest public transit agencies 50

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(founded in 1912) and transports over 200 million riders per year. Like Houston, the local MTA offers complementary paratransit, known as ADA Access (for ambulatory persons) and Lift-Van (for persons who use wheelchairs). All are prescheduled, ADA-compliant van services providing door-to-door transportation. San Francisco's service area is much smaller than Houston's. Key Features An important element here is that public transit providers are offering discounted fares to veterans. While these cities are quite different geographically, they have many similarities in that they cater to veterans, and also to disabled passengers, including disabled veterans. Every transit vehicle in each city is wheelchair accessible. A wheelchair-bound passenger is able to access every vehicle provided by public transit in both cities. This access includes vans, shuttles, bus, and rail. In both cities, disabled veterans can apply to the transit system for reduced fares on the transit or paratransit services the veteran uses. After certification by the VA, the veterans receive ID cards designating them as eligible for these discounts. Both cities offer deep fare discounts to veterans who are more than 50 percent disabled (as certified by the VA). For example, according to transportation program staff, instead of paying a $2.00 fare each way, a veteran might only pay $0.75. Both cities provide service to all local VA medical facilities, including the local VA hospitals. Each city places a very large emphasis on wheelchair-accessible taxicabs. Houston, with close to 200 rear-entry minivan taxicabs, has the nation's largest supply of accessible cabs. San Francisco, with approximately 100 such vehicles, is second only to Houston. In each city, the paratransit services can be used by disabled veterans to travel to any location, VA related or not. 51

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El Paso, Little Rock, and Indianapolis: Quality Economical Service through Contracting Descriptions El Paso, Texas. The VA Medical Center in El Paso, Texas receives quality transportation service for its patients at a fraction of the price being paid in other cities. A local transportation company provides transportation to the local VA with reliable service and at an economical price. A number of factors should be considered to understand the success of this case. The first factor is that the City of El Paso regulates the local taxicab industry, but takes a broad view of the services taxicab companies can provide. While local cab companies are involved in paratransit and other forms of government contracting, El Paso does not mandate that all taxicab trips be conveyed at the metered rate. This means that agencies seeking nonemergency passenger transportation may accept proposals from taxicab companies to transport passengers at mileage rates; that is, fares are based upon a certain flat rate times the mileage for each trip. El Paso's transit system has contracted for such services for years. The local ADA paratransit service, known as The Lift, regularly uses taxicabs in its service and pays a flat mileage rate to the contracted taxi company. Other El Paso contracting agencies use the same method, and the result is that most El Paso cab drivers are accustomed to being paid these flat rates. In most major cities in the United States, flat rating by taxicabs is not permitted by local regulators. This precludes the practice of accepting less than the metered fare by taxi cabs. The second factor is that the core of Fort Bliss, the nation's second-largest Army post, is part of Greater El Paso in Texas. The base has a population of more than 8,000 people and is expanding its infrastructure. The base's population is expected to double or triple within just a few years. Fort Bliss has contracted with Sun City Cab of El Paso to transport passengers on request and serve the needs of the entire base for several years. Sun City Cab's contract includes transporting patients to and from the VA hospital and other VA medical locations. Many local government services are provided on the base or nearby: the local VA Hospital is located a short distance west of the entrance to Fort Bliss. As is the case with El Paso's ADA paratransit contract, this Fort Bliss contract is established on a mileage basis. When transporting any Fort Bliss passenger, including those going to and from the VA Hospital, Sun City's taxicab drivers do not charge the metered fare (which would be much 52

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higher) but rather calculate the trip fee based on a flat rate of $1.50 per mile times the number of miles driven. Taxicab customers in most American cities are used to paying several dollars per mile when the three components of the fare--initial meter drop charge, mileage, and waiting time--are factored in. The entire transaction is calculated automatically by the taximeter at the tariff set by the local taxicab regulators. Because, under Sun City's contract there is no initial meter drop, no waiting time, and a discounted mileage fee, El Paso VA Hospital passengers are currently being transported at a rate that might be 50 percent less than a normal taxi fare would be in El Paso (or in most other American cities). This combination of factors has resulted in a very good level of service and considerable passenger satisfaction. Because Fort Bliss as a whole is one of Sun City Cab's largest accounts, and because its primarily catchment area is contiguous to El Paso's business district, Sun City's drivers are well positioned throughout the base and service to all base locations, including the VA Hospital, is usually quite prompt. Sun City Cab regularly dispatches demand-response calls to pick up veteran clients since a good percentage of the taxi fleet is on or near the base throughout the entire business day. Quality of service is important, and when combined with the above-stated cost savings, the El Paso example is a win-win situation for the VA and Sun City Cab. Little Rock, Arkansas. The Central Arkansas Veterans Healthcare System (CAVHS) in Little Rock has established some transportation practices worthy of note. CAVHS contracts with Greater Little Rock Transportation Services, LLC (operator of Little Rock Yellow Cab and other services) to transport eligible patients as well as lab specimens and other items. Transportation services are generally provided between the Little Rock and North Little Rock VA campuses, to local shelters, and to homes when internal VA transportation resources are not available. Transportation services are available for patients who are ambulatory or who have folding wheelchairs and the patient can easily transfer to the seat of a vehicle. The longstanding relationship between the VA and the transportation company has created some excellent cost-savings practices. First, all local packages and specimens are conveyed at the same flat rate, regardless of the time or distance needed to complete the delivery. Second, the contract allows for standard rates for frequent destinations, such as shelters, bus stations, between VA campuses, and other specified destinations. Third, the cab service may be used for long-distance patient transport when VA transportation vans are not available. Costs are controlled on the occasional out-of-town trip by the transportation vendor pre- establishing the fare after calculating distance and rate via the company's GPS-based computer dispatch program. 53

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Indianapolis, Indiana. The Indianapolis VAMC contracts passenger transportation services to the Yellow Cab Company, which operates the largest private transportation fleet in the State of Indiana. Yellow Cab responds to all VA requests for both ambulatory and wheelchair accessible transportation. The VA benefits by Yellow Cab's experience, knowledge, expertise, and technological resources. Yellow Cab is a decades-old Indianapolis corporation with approximately 200 vehicles regularly dispersed through the metropolitan area. Yellow Cab's management team includes one manager dedicated to oversee the VA account on a daily basis. Their vehicles are all equipped with mobile computer dispatching and GPS-based vehicle locators. Yellow Cab has both pre-routing capabilities and also the ability to dispatch the closest vehicle to any VA demand response trip request. Furthermore, Yellow Cab has the ability to assign regular vehicles to regular geographic areas, which results in great familiarity between the VA's passengers and Yellow Cab's driver. This familiarity yields the desired result of providing the VA's riders with a high level of both customer service and overall satisfaction. Key Features El Paso, Little Rock, and Indianapolis each provide examples of how service contracts can be used to generate high-quality, cost-effective transportation services for veterans. All three cases involve contracts with local taxi operators that have devised special rate structures not based on taxi meter rates for the trips involving veterans. As professional transportation operators, these companies can offer trained dispatchers and drivers to fulfill trip requests; the companies also own and maintain their own vehicle fleets and have the experience needed to accommodate special mobility needs when such accommodations are necessary. Coachella Valley, California Description The Coachella Valley is in the rural southeastern portion of Riverside County in Southern California. This area includes many retirees, and many of them are veterans. The town of Palm Desert has a VA Medical Clinic, but the nearest VA hospital is nearly 60 miles away in the more urbanized portion of Riverside County. Despite this issue of distance, concerned 54