Appendix E contains an annotated bibliography of the literature found at the intersection of health care and transportation. This is staff-prepared as background material relevant to the workshop topic and is included for informational purposes only.
Staff-prepared background material
H. Aryeh Cohen and Alina Baciu
MEDLINE Search Strategy
Index terms (including sub-terms): socioeconomic factors or sociological factors or social conditions or social environment or social planning or social isolation or social problems or poverty areas or poverty or “health services needs and demand” or needs assessment or medically underserved area or health services accessibility or health equity or “delivery of health care” or health care disparities or social class or “delivery of health care, integrated” or health care reform or appointments and schedules or reginal health planning or community health planning or state health plans or “health care facilities, manpower and services” or “failure to rescue, health care” or social responsibility
Combined with index terms (including sub-terms): “costs and cost analysis” or cost-benefit analysis or quality improvement or “quality of health care” or quality assurance, health care or quality indicators, health care or treatment outcome or patient outcome assessment or fatal outcome or “outcome assessment (health care)” or “outcome and process assessment (health care)” or treatment failure or program evaluation or benchmarking or patient dropouts” or “early termination of clinical trials” or health impact assessment” or “social determinants of health” or quantitative research”
Results combined with the index term (including all sub-terms): transportation or any of these words: transit, transport, taxi, Uber, Lyft, or rideshare
Results were limited to items from the period 2000 to 2016.
Embase Search Strategy
Keywords: transport or transit or taxi or Uber or Lyft or rideshare
Combined with the index terms (including all sub-terms): “cost utility analysis” or “cost benefit analysis” or “health care cost” or “cost effectiveness analysis” or “program cost effectiveness” or outcome assessment or outcome variable or adverse outcome or treatment outcome or health impact assessment or patient assessment or behavior assessment or social support assessment or “quality of life assessment” or prognostic assessment or community assessment
Combined with any of these index terms (including all sub-terms): socioeconomics or social welfare or social support or social aspect or social
discrimination or social problem or social class or social needs or “social determinants of health” or social isolation or social environment or social structure or health care access or society or medically underserved or community or health care delivery or social justice or health disparity or health care policy or health care disparity or poverty
Also searched for results that mentioned: non-emergency medical trans* (with any additional letters after trans)
Results were limited to items published during the period 2000 to 2016.
Web of Science Search Strategy
TOPIC: health combined with TOPIC: transport combined with TOPIC: outcome
Also searched TOPIC: travel combined with TOPIC: barriers combined with TOPIC: health
Also searched TOPIC: (transport*) OR TOPIC: (transit) OR TOPIC: (taxi*) OR TOPIC: (Uber) OR TOPIC: (Lyft) OR TOPIC: (rideshar*) AND TOPIC: (health)
Also searched: TOPIC: (transport*) OR TOPIC: (transit) OR TOPIC: (taxi*) OR TOPIC: (Uber) OR TOPIC: (Lyft) OR TOPIC: (rideshar*)
Combined with TOPIC: (health)
Combined with TOPIC: (barrier*)
And then further combined with TOPICS: (“cost benefit analysis” OR “outcome*” OR “assessment”)
TRID Search Strategy
Index terms: Medical services or Medical treatment or Medical trips or Health care or Health care services or Health care facilities or Medical examinations and tests or Therapy or Public health
(brought up 710 results)
Combined with index term: Outcome (medical treatment) (brought up 14 results – 6 selected)
Also searched index terms: Medical services or Medical treatment or Medical trips or Health care or Health care services or Health care facilities or Medical examinations and tests or Therapy or Public health
Combined with index term: Accessibility (results: 45, and 3 new items selected)
Also search uncontrolled term: “Non-emergency medical transportation” (18 report records, 11 selected)
Also searched index terms: Medical services or Medical treatment or Medical trips or Health care or Health care services or Health care facilities or Medical examinations and tests or Therapy or Public health
Combined with these index terms: Economic and social factors or Economic factors or Economic conditions or Economic policy or Social factors or Social class or Socioeconomic factors or Impacts or Social impacts or Social service or Externalities or Public participation or Community action programs or Urban areas or Rural areas
Results: 150 items, 30 were selected
All the TRID searches were limited to the period 2006 to 2016.
Google and Google Scholar Searches
Searched for policy briefs, white papers, reports, and other examples of gray literature, using the search terms Health Care and Transportation, then added return on investment or value.
Results: 138 items, and excluded items that were:
- Published before 2000
- Referring to active transportation rather than transportation in context of access to health care (or other health promoting) services
Overall Exclusion Criteria
Items were removed from the bibliography if they were considered only marginally informative, for example:
- Referring to mobility and active transportation as part of interventions to address a specific health condition
- Transportation was incidental to the research—for example, if the study was controlling for access to transportation or a program was offering transportation vouchers to participants; or studies of case management interventions (which generally include arranging for transportation services) or supportive services for specific health issues, such as HIV/AIDS
- Interventions were overly specific interventions or not generalizable, for the purposes of the present search, for example, transportation as a barrier listed by patients in a project that piloted lay-person screening for eye disease; a small survey (e.g., N = 23) that established that “daily hassles” such as being able to get a ride, should be a consideration in behavioral interventions (e.g., helping patients not to delay needed care)
The changing face of non-emergency medical transportation: Challenging issues in NEMT. DigitalCT Magazine
http://web1.ctaa.org/webmodules/webarticles/anmviewer.asp?a=4487&z=60 (accessed October 25, 2016).
This issue of Community Transportation contains a series of articles (e.g., commentaries, analyses of state examples from Illinois to Kentucky) on key issues in the field, including the importance of policy changes to facilitate enhance non-emergency medical transportation.
Bellamy, G. R., K. Stone, S. K. Richardson, and R. L. Goldsteen. 2003. Getting from here to there: Evaluating West Virginia’s rural nonemergency medical transportation program. Journal of Rural Health 19(Suppl):397–406.
“With funding from the 21st Century Challenge Fund, the West Virginia Rural Health Access Program created Transportation for Health, a demonstration project for rural nonemergency medical transportation. The project was implemented in 3 sites around the state, building on existing transportation systems—specifically, a multicounty transit authority, a joint senior center/transit system, and a senior services center. An evaluation of the project was undertaken to answer 3 major questions: (1) Did the project reach the population of people who need transportation assistance? (2) Are users of the transportation project satisfied with the service? (3) Is the program sustainable? Preliminary results from survey data indicate that the answers to questions 1 and 2 are affirmative. A break-even analysis of all 3 sites begins to identify programmatic and policy issues that challenge the likelihood of financial sustainability, including salary expenses, unreimbursed mileage, and reliance on Medicaid reimbursement.”
Borders, S., C. Blakeley, L. Ponder, and D. Raphael. 2011. Devolution’s policy impact on non-emergency medical transportation in state children’s health insurance programs. Social Work in Public Health 26(2):137–157.
“Proponents of devolution often maintain that the transfer of power and authority of programs enables local officials to craft policy solutions that better align with the needs of their constituents. This article provides one of the first empirical evaluations of this assumption as it relates to nonemergency medical transportation (NEMT) in the State Children’s Health Insurance Program (SCHIP). NEMT programs meet a critical need in the areas in which they serve, directly targeting this single key access barrier to care. Yet states have great latitude in making such services available. The
authors utilize data from 32 states to provide a preliminary assessment of devolution’s consequences and policy impact on transportation-related access to care. Their findings provide mixed evidence on devolution’s impact on policy outcomes. Proponents of devolution can find solace in the fact that several states have gone beyond federally mandated minimum requirements to offer innovative programs to remove transportation barriers to care. Detractors of devolution will find continued pause on several key issues, as a number of states do not offer NEMT to their SCHIP populations while cutting services and leaving more than $7 billion in federal matching funding unspent. © Taylor & Francis Group, LLC.”
Community Transportation Association of America. 2001. Medicaid transportation: Assuring access to health care—A primer for states, health plans, providers and advocates: 37p.
“This report investigates the beginnings and current administration of non-emergency Medicaid transportation (NEMT). NEMT is a one-of-a-kind federally funded, state-administered program to provide quality health care to the nation’s disabled and poor. The report explores NEMT services under both managed care and fee-for-service environments, presents unique profiles of state Medicaid transportation programs, and identifies innovative practices. In addition, the report highlights a number of innovative models that managed care and state organizations have adopted in order to improve access to medical services and to control costs and abuses. The report also describes supplemental Medicaid transportation funding available under the Children’s Health Insurance Program and Home and Community-Based Waivered Services, and identifies those states that provide transportation benefits under these Medicaid expansion programs and those that do not.”
GAO (U.S. Government Accountability Office). 2013 and 2014. Transportation disadvantaged populations: Nonemergency medical transportation not well coordinated, and additional federal leadership needed.
This report to congressional committees found that six federal departments across 42 programs provide funding for nonemergency medical transportation, but total federal spending is unknown because it is not separately tracked—data is unavailable or NEMT is “incidental to a program’s mission.” HHS alone provided an estimate of at least $1.3 billion for its spending in 2012 (most attributable to Medicaid). Coordination of NEMT across federal programs is limited, leading to “fragmentation, overlap, and potential for duplication.” Although a coordinating body exists in the Interagency Transportation Coordinating Council on Access and Mobility
chaired by the Secretary of DOT, the council had not met since 2008 and had not finalized cost-sharing policy. The report recommended that the Secretary of Transportation convene a meeting of the coordinating council to: complete and publish a strategic plan, finalize a cost sharing policy and explain its application across programs represented on the council, and identify challenges to and solutions for lack of coordination between Medicaid and VA NEMT.
Hanley, P. F., N. Sikka, G. Ferguson, B. Kober, and J. Sun. 2008. Iowa Medicaid non-emergency medical transportation system review and options for improvements. 132p.
http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1004&context=ppc_transportation (accessed September 20, 2016).
“Inadequate transportation has long been identified as a major issue in rural Iowa, and it is particularly acute for people of all ages with disabilities and their families, including Medicaid members. Currently, Medicaid members are reimbursed for transporting themselves, or providers are reimbursed for transporting individuals, which places the bulk of the responsibility on consumers, Iowa Department of Human Services (DHS) Income Maintenance workers and case managers. Under a statewide, Medicaid-funded transportation brokerage, Iowa Medicaid Enterprise (IME) would contract with an entity to (1) establish a network of transportation providers; (2) maintain a call center; (3) ensure compliance with Medicaid regulations related to eligibility of the individual and trip; (4) arrange and pay for the trips; and (5) monitor services and transportation providers for compliance and quality. States that have established brokerages have, in general, experienced an increase in the number of trips and a reduction in the cost per trip. A goal of the study was to provide guidance for consistent access to non-emergency health care services by pointing the way towards coordinated non-emergency medical transportation services through a centralized transportation brokerage.”
Hanley, P. F., N. Sikka, G. Ferguson, B. Kober, and J. Sun. 2008. Appendices: Iowa Medicaid Non-Emergency Medical Transportation System Review and Options for Improvements. Iowa City, IA: The University of Iowa Public Policy Center.
These are the appendices for a study on non-emergency medical transportation in the rural areas of Iowa. “Inadequate transportation has long been identified as a major issue in rural Iowa, and it is particularly acute for people of all ages with disabilities and their families, including Medicaid members. Currently, Medicaid members are reimbursed for transporting
themselves, or providers are reimbursed for transporting individuals, which places the bulk of the responsibility on consumers, Iowa Department of Human Services (DHS) Income Maintenance workers and case managers. Under a statewide, Medicaid-funded transportation brokerage, Iowa Medicaid Enterprise (IME) would contract with an entity to (1) establish a network of transportation providers; (2) maintain a call center; (3) ensure compliance with Medicaid regulations related to eligibility of the individual and trip; (4) arrange and pay for the trips; and (5) monitor services and transportation providers for compliance and quality. States that have established brokerages have, in general, experienced an increase in the number of trips and a reduction in the cost per trip. A goal of the study was to provide guidance for consistent access to non-emergency health care services by pointing the way towards coordinated non-emergency medical transportation services through a centralized transportation brokerage.”
Kim, J., E. C. Norton, and S. C. Stearns. 2009. Transportation brokerage services and Medicaid beneficiaries’ access to care. Health Services Research 44(1):145–161.
This study sought to “examine the effect of capitated transportation brokerage services on Medicaid beneficiaries’ access to care and expenditures” and was undertaken between 1996 and 1999 in Georgia and Kentucky during their transportation brokerage services. Researchers “used difference-in-differences models to assess the effects of transportation brokerage services on access to care, measured by Medicaid expenditures and health services use” and found that “for asthmatic children, transportation brokerage services increased nonemergency transportation expenditures and the likelihood of using any services,” but increased transportation costs were offset by lower monthly expenditures. “For diabetic adults, nonemergency transportation costs decreased despite increased monthly use of health services; average monthly medical expenditures and the likelihood of hospital admission for an ambulatory care-sensitive condition (ACSC) also decreased” and “[t]he increase in access combined with reduced hospitalizations for asthmatic children and ACSC admissions for diabetic adults are suggestive of improvements in health outcomes.”
MacLeod, K. E., D. R. Ragland, T. R. Prohaska, M. L. Smith, C. Irmiter, and W. A. Satariano. 2013. Missed or delayed medical care appointments by older users of nonemergency medical transportation services. Gerontologist 55(6):1026–1037.
“Non-emergency medical transportation (NEMT) can prevent emergency care as a result of delayed or missed medical appointments. Medicaid
provides NEMT for low-income individuals who have no other means of transportation, and this is a critical component of the health care delivery system. This study examined cancelled trips in Medicaid adults of ages 65 and older to explore whether barriers persist for a growing segment of the population who face particular challenges of age-related declines in health and function. Multivariate logistic regression analyses were conducted using transportation brokerage data for Delaware members who intended to travel during 2008–2010, modeling the odds of all cancellations and then these mutually exclusive types: (1) client cancelled, (2) client obtained alternative transportation, and (3) client cancelled due to health. Over half of the cancelled trips were attributed to client reasons. Black race was associated with client canceling (OR = 1.4) and canceling due to alternative transportation (OR =1 .9). Compared to dialysis, trips for other medical care were more likely to be cancelled for client and health reasons (ORs ranged 1.6–7.9). Higher levels of service increased cancelling for health reasons (OR = 2.9 stretcher; OR = 1.8 wheelchair). Finally, pre-scheduled or subscription trips were less likely to be cancelled, and client factors differed for the cancellation of trips that were not regularly scheduled. The results of this initial study confirm that for this population additional transportation services are often not available and that more support for utilizing NEMT may be needed. Future research should evaluate persistent barriers, service delivery, and long-term outcomes.”
Musumeci, M., and R. Rudowitz. 2016. Medicaid non-emergency medical transportation: Overview and key issues in Medicaid expansion waivers. The Kaiser Family Foundation.
“This issue brief describes the NEMT benefit, how states administer it, and the reasons that beneficiaries frequently use NEMT. It also explores current policy issues related to NEMT in the context of alternative Medicaid expansion waivers.” . . . “Given the interest in NEMT waivers for expansion adults in other states, following developments in this area will be important in evaluating NEMT’s role in facilitating Medicaid beneficiaries’ access to care and its impact on health outcomes.”
Simon, M. 2014. Medicaid non-emergency medical transportation (NEMT) saves lives and money. Community Transportation (Spring 2012):11–12.
“One of the most common barriers faced by low-income populations in accessing timely and necessary medical care has been consistently shown by
research to be transportation. The Medicaid non-emergency medical transportation (NEMT) benefit fills the gaps by providing appropriate but least costly methods of transportation services, such as taxis, vans and public transit, for Medicaid beneficiaries to transport them to and from medical services. The details of this benefit are presented here.”
Texas A&M Transportation Institute. 2016. TCRP Project No. B-44. Task 6. Report key conclusions from case study experiences, Deliverable #8. Prepared for: Transit Cooperative Research Program; Transportation Research Board, National Academies of Sciences, Engineering, and Medicine.
To examine the effects of NEMT brokerage models on public transit, coordinated transportation services, access to Medicaid services, and general mobility, researchers conducted the case study research in accordance with the protocols approved by the TCRP Panel and Texas A&M’s Internal Review Board for Human Subjects Research. The research team visited with staff from state NEMT administration agencies, NEMT brokers, public and human service transportation providers, customer advocates, state departments of transportation, state transit associations, and lead agencies responsible for regional coordination. The team reviewed state legislation, transportation data requests for proposals, and state-specific research reports. The team documented case study results in structured working papers and requested reviews from key contributors for accuracy and additional data where necessary.
Transportation Research Board. 2014. Impact of the Affordable Care Act on non-emergency medical transportation (NEMT): Assessment for transit agencies. TCRP Research Results Digest.
“TRB’s Transit Cooperative Research Program (TCRP) Research Results Digest 109: Impact of the Affordable Care Act on Non-Emergency Medical Transportation (NEMT): Assessment for Transit Agencies assesses the potential impact of implementing the NEMT provision of the Affordable Care Act on a state-by-state basis. The report also collates information to inform the transit community on how public transit and NEMT providers may integrate or use their respective resources and services.”
Transportation Research Board. 2016. Examining the effects of separate non-emergency medical transportation (NEMT) brokerages on transportation coordination. (Work in progress, to be completed Spring 2016.)
“The Medicaid program is the federal government’s largest provider of human services transportation (HST), spending between $2 and $3 billion
annually on non-emergency medical transportation (NEMT). The successful coordination of federally funded human services transportation is affected by the extent to which resources for NEMT are coordinated with and complement public transit and human services transportation. Because the Medicaid program is administered by states, which are able to set their own rules and regulations within the Centers for Medicare & Medicaid Services (CMS) framework, coordination of NEMT with public transit and human services transportation is highly dependent on state Medicaid agencies’ policies and priorities. Over the past decade, many states have made significant progress coordinating NEMT with other federally funded transportation services, most often by allowing local or regional organizations to broker NEMT trips with numerous other types of trips. This approach results in transportation resources and costs being shared across multiple programs and transportation providers. Medicaid NEMT presents both opportunities and challenges for public transit and human services transportation providers wishing to coordinate more closely the various trips being provided in their service areas. The most frequently cited examples of coordination typically involve NEMT, Americans with Disabilities Act (ADA) paratransit (provided by public transit agencies), and human services trips coordinated on a local or regional basis. In recent years, numerous state Medicaid programs have separated their transportation services from local or regionally coordinated transportation systems in order to create a statewide or regional brokerage for all NEMT trips. This approach is often pursued for cost savings, fraud deterrence, or administrative efficiency. Transportation coordination and mobility management professionals have expressed concerns about this trend, saying that it leads to less coordination, more service duplication, loss of local revenue for transportation providers, trip shifting, and challenges for transportation of disadvantaged people who may be required to book trips through multiple systems, depending on their type of trip. Most research conducted on NEMT brokerages has focused on the impacts on the specific Medicaid program and agency. Meanwhile, the broader fiscal, coordination, and customer service effects of statewide Medicaid NEMT brokerages have not been fully studied. As more states consider the statewide or regional brokerage options for NEMT, it is important to determine (1) what the larger outcomes are for human services transportation and public transit, (2) what motivates states to establish separate NEMT brokerages, and (3) what the actual costs and benefits are. The objectives of this research are to present options for providing Medicaid-funded NEMT services and evaluate the effects of different options for providing NEMT on: (1) access to Medicaid services; (2) human services transportation (in particular, coordinated transportation services); and (3) public transit services, including ADA complementary paratransit services. The key audiences for this research include state-level
policymakers and program administrators and other stakeholders affected by the different options for providing NEMT services.”
Wallace, R., P. Hughes-Cromwick, H. J. Mull, and S. Khasnabis. 2005. Access to health care and nonemergency medical transportation: Two missing links. Transportation Research Record 1924:76–84.
“Although the lack of access to nonemergency medical transportation (NEMT) is a barrier to health care, national transportation and health care surveys have not comprehensively addressed that link. Nationally representative studies have not investigated the magnitude of the access problem or the characteristics of the population that experiences access problems. The current study, relying primarily on national health care studies, seeks to address both of those shortcomings. Results indicate that in a given year about 3.6 million Americans do not obtain medical care because of a lack of transportation. On average, they are disproportionately female, poorer, and older; have less education; and are more likely to be members of a minority group than those who obtain care. Although such adults are spread across urban and rural areas much like the general population, children lacking transportation are more concentrated in urban areas. In addition, these 3.6 million experience multiple conditions at a much higher rate than do their peers. Many conditions that they face, however, can be managed if appropriate care is made available. For some conditions, this care is cost-effective and results in health care cost savings that outweigh added transportation costs. Thus, it is found that great opportunity exists to achieve net societal benefits and to improve the quality of life of this population by increasing its access to NEMT. Furthermore, modifications to national health care and transportation datasets are recommended to allow more direct assessment of this problem.”
American Public Transportation Association. 2007. Public Transportation: Benefits for the 21st Century. Washington, DC: American Public Transportation Association.
http://www.apta.com/resources/reportsandpublications/documents/twenty_first_century.pdf (accessed September 20, 2016).
“This report presents an overview of the benefits of public transit to people and their communities, and to this country as a whole. Some topics covered include: the different types of public transit available (ferry, fixed guideway, bus and highway vehicles); economic impacts and benefits;
impact on energy conservation and dependence upon oil; reduction of traffic congestion; environmental protection, health benefits and improvement of air quality; utilization of public transit during emergencies and disasters; mobility for rural and small urban areas; benefits to real estate values and development; access for all ages; human service and essential health care delivery.”
Bogren, S. 2015. Ride Connection: Portland’s hidden transportation gem. Community Transportation (Summer 2015):17–24.
“The city of Portland, Oregon, offers its local residents a variety of public transit options unrivaled in North America; from buses, light rail and streetcars to an aerial tram. Beyond the downtown core that is served by these services is Ride Connection (RC), which serves the city’s other residents. RC offers a more diverse array of people-centered transportation services from travel training to volunteer driving, mobility management to fare relief, and neighborhood shuttles to non-emergency medical transportation. There is above all a strong emphasis on customer service and a culture of collaboration, as this article shows in an in-depth look at Ride Connection.”
Cohen, J. M., S. Boniface, and S. Watkins. 2014. Health implications of transport planning, development and operations. Journal of Transport & Health 1(1):63–72.
“The links between transport and health are well documented, but the extent of the benefits and disbenefits of this relationship is not widely understood by non-health professionals. Additionally, there are less obvious, indirect ways in which transport and health are linked. This paper provides a broad overview of the literature, compiling empirical evidence that describes, and where possible quantifies, the health effects of transport planning for the reference of transport professionals. The paper makes the case for considering health alongside the environment when assessing a policy or development’s sustainability, and provides empirical evidence to assist transport professionals in considering benefits or disbenefits involved.”
Community Transportation Association of America. 2012. Better understanding the connection between mobility options and public health. Community Transportation (Winter 2012):30–34.
“This article focuses on the momentum that is building to fully articulate the benefits of livable communities, with a view to public health, considering the value that is added to a community by providing access to public transit. When integrated with a comprehensive strategy that
includes walking, biking and land-use elements, it is shown here through graphics and figures that when it comes to improving individual and collective health, transit service provides enormous value. The Robert Wood Johnson Foundation published an infographic titled, ‘Better Transportation Options = Healthier Lives,’ which is the basis for this article.”
Flynn, L., M. Budd, and J. Modelski. 2008. Enhancing resource utilization among pregnant adolescents. Public Health Nursing 25(2):140–148.
This small study, with a quasi-experimental design, involved 83 pregnant adolescents and a comparison sample of 216 (drawn from de-identified electronic birth certificate records) and found that intervention teens—who received health education and transportation assistance—made more prenatal visits to their providers, but there was no difference in mean infant birth weight between the intervention and comparison groups.
Iroz-Elardo, N. 2014. Participation, information, and community interests within health impact assessments (HIA). Dissertations and Theses Paper 1846.
“The health impact assessment (HIA) has recently emerged in the United States as a mechanism for potentially increasing social and environmental justice by bringing attention to health equity issues associated with project and urban plans. As a stakeholder process, this occurs in theory by expanding the information base upon which public decisions are made. The extent to which this expanded information base represents public health professional and/or community health interests remains unclear. Furthermore, little has been done to evaluate the extent to which the information provided in HIAs is influencing public decisions. By tracing health interests—both public health professional and community oriented—in 3 transportation planning cases through both the HIA and planning process, this dissertation seeks to understand how HIA treats various health concerns and the effectiveness of such treatment in influencing planning processes. In doing so, transportation planners will better understand the promise and limitations of augmenting technical best practices arising from a growing ‘active living’ literature with a health-focused participation exercise such as HIA.”
American Public Health Association. 2010. The hidden health costs of transportation.
https://www.apha.org/~/media/files/pdf/factsheets/hidden_health_costs_transportation.ashx (accessed September 22, 2016).
“Transportation investments and the systems that are developed from them shape lives and communities. The transportation system is a complex web of highways, sidewalks, bike paths, trains and bus services that connect people to each other as well as to places of work, play, prayer, medical care, and shopping. Transportation policies and decisions influence land use and how communities and neighborhoods are designed and built—whether sprawling and disconnected, or central and connected.”
“Health impacts and costs have typically not been considered in the transportation policy, planning, and funding decision-making process. There are few standards or models for estimating health costs. However, existing research can be used to estimate the population at risk, the magnitude of the health impact, and the health costs associated with those impacts.”
Detman, L. A., and P. A. Gorzka. 2000. A study of missed appointments in a Florida health department.
http://health.usf.edu/publichealth/chilescenter/pdf/missed%20appointments.pdf (accessed September 22, 2016).
“This article presents the results of a telephone survey of 160 people missing prenatal and pediatric health department appointments. Failure to keep appointments potentially affects patients’ health, disrupts the health care delivery system, and contributes to the poor utilization of resources. Further understanding of the reasons patients are unable to keep appointments can be useful in developing policy to address unmet patient needs and the effective delivery of health care services. Survey results will be presented and strategies for reducing missed appointments discussed. In particular, these data show a significant association among marital status, education level, and employment status and the inability to get a ride to the clinic, and between employment status and missing appointments because of a poorly scheduled appointment time. Findings indicate that special efforts should be made to help single, less-than-high-school-educated, non-working women and their children overcome barriers to keeping appointments.”
Godavarthy, R., J. Mattson, and E. Ndembe. 2014. Cost–benefit analysis of rural and small urban transit. National Center for Transit Research, Final Report 21177060-NCTR-NDSU03.
“This study focuses on the qualitative and quantitative benefits of small urban and rural public transit systems in the United States. First, a thorough review of previous literature is presented. Then, a framework is developed which focuses on three main areas of transit benefits most relevant to rural and small urban areas: transportation cost savings, low-cost mobility benefits, and economic development impacts. Data for small urban and rural transits systems from the National Transit Database (NTD) and Rural NTD were used for calibrating the transit benefits and costs. The benefits, costs, and benefit–cost analysis results of small urban and rural transit for this study are presented nationally, regionally (FTA regions), and locally (statewide). Sensitivity analysis was also conducted to illustrate how the national transit benefits and benefit–cost ratios vary with changes in key variables. With estimated benefit–cost ratios greater than 1, the results show that the benefits provided by transit services in rural and small urban areas are greater than the costs of providing those services.”
The Hilltop Institute. 2008. Non-emergency medical transportation (NEMT) study report. University of Maryland, Baltimore County.
This report was prepared to meet a state legislative requirement to assess “the feasibility of creating a uniform statewide NEMT program; any cost savings that might arise from the creation of a statewide program; any potential for quality improvement that would result from the creation of a statewide program; and [t]he impact that a statewide program would have on local health departments.” The authors “found no compelling indication that Maryland would necessarily realize cost efficiencies and/or quality improvement by merely creating and implementing a different NEMT system” and specifically concluded that shifting to a different NEMT design would eliminate funding “for 85 full-time equivalent positions and $5.6 million in total administrative funds.”
Hughes-Cromwick, P., and R. Wallace. 2006. Executive summary: Cost–benefit analysis of providing non-emergency medical transportation. Research Results Digest 75.
http://www.trb.org/Main/Public/Blurbs/156624.aspx (accessed September 20, 2016).
This digest summarizes the final report of Transit Cooperative Research Program (TCRP) Project B-27, “Cost Benefit Analysis of Providing Non-
Emergency Medical Transportation.” It contains information on the relative costs and benefits of providing transportation to nonemergency medical care for individuals who miss or delay health care appointments because of transportation issues. Paratransit operators and other transportation providers, legislative policy makers, and health care providers responsible for cost-effective transportation and health care decisions will find this digest of interest.
Hughes-Cromwick, P., R. Wallace, H. Mull, J. Bologna, C. Kangas, J. Lee, and S. Khasnabis. 2005. Cost–benefit analysis of providing non-emergency medical transportation. Transportation Research Board.
http://altarum.org/sites/default/files/uploaded-publication-files/05_project_report_hsd_cost_benefit_analysis.pdf (accessed September 20, 2016).
“This document examines the relative costs and benefits of providing transportation to non-emergency medical care for individuals who miss or delay health care issues. The report includes a spreadsheet to help local transportation and social service agencies conduct their own cost–benefit analyses of non-emergency medical transportation tailored to the local demographic and socioeconomic environment. The study investigated the hypothesis that improving access to health care for the transportation-disadvantaged population will lead to improved quality of life and an overall decrease in health care costs. It also examined whether this hypothesized net decrease in health care costs exceeds the incremental increase in transportation costs.”
Kane, J., A. Tomer, and R. Puentes. 2016. How Lyft and Uber can improve transit agency budgets. Brookings Institution, Metropolitan Infrastructure Series, March 8.
The article discusses the fiscal constraints and other challenges faced by most local transit agencies and the opportunities—and roadblocks—transportation network companies offer to those working to improve demand-responsive and paratransit services.
Reed, T. 2016. Why MedStar Health just teamed up with Uber. Washington Business Journal, January 8.
The article describes the partnership between MedStar Health, Inc., a Maryland-based health system, and Uber to allow patients to request rides to medical appointments and help solve costly missed appointments. The health system intends to expand the transportation arrangement to also allow Medicare and Medicaid patients to get covered rides.
Wallace, R., P. Hughes-Cromwick, and H. Mull. 2006. Cost-effectiveness of access to nonemergency medical transportation: Comparison of transportation and health care costs and benefits. Transportation Research Record 1956:86–93.
“Although a lack of access to non-emergency medical transportation (NEMT) is a barrier to health care, national transportation and health care surveys and datasets have not comprehensively addressed this link. The current study builds on earlier work that identified and described the population that lacks access to health care because of transportation barriers by examining the combined transportation and health care impacts of providing access to NEMT for those who currently lack such access. The goal of this study was to compare the costs and benefits, including the potentially large net health benefits, of providing NEMT to those who lack access to it. This analysis uses data from the Medical Expenditure Panel Survey, which is administered by the Agency for Healthcare Research and Quality; the National Transit Database; and data provided by selected NEMT providers, as well as the transportation and health care literature. By a focus on 12 prevalent and costly medical conditions experienced by those who lack access to NEMT, it was determined that the provision of NEMT to those who currently lack it results in a net cost savings across the transportation and health care domains for four of these conditions (prenatal care, asthma, heart disease, and diabetes) and is cost-effective for the remaining eight conditions (influenza vaccinations, breast cancer screening, colorectal cancer screening, dental care, chronic obstructive pulmonary disease, hypertension, depression, and end-stage renal disease). These cost-effectiveness analyses take into account increased life expectancy and improved quality of life and indicate that the provision of additional transportation is worth the investment for these eight conditions. On the basis of these findings, it was concluded that the provision of NEMT to those transportation-disadvantaged individuals who lack access to it would result in net societal benefits for all 12 conditions examined.”
Watkins, L., C. Hall, and D. Kring. 2012. Hospital to home: A transition program for frail older adults. Professional Case Management 17(3):117–123; quiz 124–125.
This study examined the usefulness of social worker navigators in helping older adult recipients of Medicare and/or Medicaid transition successfully from the inpatient setting to their home and community. For a period of 30 days to 4 months, the navigator provides support for the newly discharged patient through follow-up calls or home visits. The transition program decreased hospital readmissions by 61 percent in a high-risk
population and a cost savings of $628,202 per year. The study showed the value of social support and health education as well as connecting patients to transportation and other needed service, thus helping patients avoid gaps in care that could cause readmission.
Zgibor, J. C., L. B. Gieraltowski, E. O. Talbott, A. Fabio, R. K. Sharma, and K. Hassan. 2011. The association between driving distance and glycemic control in rural areas. Journal of Diabetes Science and Technology 5(3):494–500.
People with diabetes need “adequate access to health care facilities and resources for self-management.” This study reviewed “[d]ata on 3,369 individuals with type 2 diabetes who received education at seven diabetes centers . . . collected prospectively between June 2005 and January 2007.” The driving distances of subjects with good hemoglobin A1C levels were compared with the driving distances of those without, and researchers tested the association between A1C and improvement in A1C with travel burden.” Researchers found that “[t]he mean distance subjects traveled to visit their center was 13.3 miles.” The results indicated that residing more than 10 miles from the diabetes management center increased likelihood of poorly controlled diabetes, while those who lived within 10 miles of a diabetes center “were 2.5 times more likely to have improved their A1C values between their first and last office visits.” Researchers emphasized the importance of provider awareness of transportation burdens for diabetes management and concluded that solutions include improved public transportation, more diabetes center locations in rural areas, telemedicine, or home visits.
Abbott, P. J. 2010. Case management: Ongoing evaluation of patients’ needs in an opioid treatment program. Professional Case Management 15(3):145–152.
This study examines the use of case management for individuals in opioid treatment through a survey of the treatment needs of 189 patients entering an opioid-treatment program over a 3-year period. Critical services most frequently requested by patients included transportation, and the study noted changes in the types of needs over a 12-month period, requiring ongoing attention to help support patients in their continued abstinence with the right mix of services.
Alexandraki, I., and A. D. Mooradian. 2010. Barriers related to mammography use for breast cancer screening among minority women. Journal of the National Medical Association 102(3):206–218.
“The purpose of this review was to better understand possible social, economic, cultural, behavioral, and systems barriers to breast cancer screening among minority women.”
Researchers reviewed abstracts of 515 manuscript published from October 1971 through April 2009 for “studies conducted among minority women in the United States and examining barriers related to screening mammography. . . . Of 64 relevant articles, 13 cross-sectional and 4 prospective studies met inclusion criteria. Study design; patient characteristics; outcomes regarding knowledge, attitudes, and beliefs; social norms; accessibility; and cultural competence regarding breast cancer screening were abstracted. Studies were rated using a methodological quality score (MQS).” Lack of transportation was among most frequently identified barriers.
American Association on Health and Disability. 2011. AAHD’s health promotion and wellness, part 2: Health promotion programs. Exceptional Parent 41(6):32.
“This article is part 2 of a 4-part series on “Health Promotion and Wellness” from the American Association on Health and Disability (AAHD). According to the U.S. Census Bureau, more than 54 million people—one in five Americans—have a disability, and these Americans are more likely to report: (1) being in poorer overall health, (2) having less access to effective health care, and (3) engaging in risky health behaviors, such as smoking and physical inactivity. While health promotion interventions commonly target those health risks for everyone, people with disabilities are often left out of healthy people/community health initiatives. Barriers to participation include inadequate public transportation, inaccessible health care facilities or health screening equipment, discriminatory attitudes, poverty, and lack of knowledge. Health promotion programs for people with disabilities need to be designed to eliminate or at least minimize the barriers keeping them out.” This article describes the characteristics of better health promotion programs.
Arcury, T. A., J. S. Preisser, W. M. Gesler, and J. M. Powers. 2005. Access to transportation and health care utilization in a rural region. Journal of Rural Health 21(1):31–38.
“This study examined the association between transportation and health care utilization in a rural region, using ‘survey data from a sample of 1,059 households located in 12 western North Carolina counties.’ Individuals who had a driver’s license had more than twice the health care visits for chronic care than non-drivers, and those who had access to transportation from family or friends had nearly twice as many visits for regular checkups as their peers who did not have access to such rides. ‘The transportation variables that were significantly associated with health care visits suggest that the underlying conceptual frameworks, the Health Behavior Model and Hagerstrand’s time geography, are useful for understanding transportation behavior.’ Such research is needed to ‘inform policy alternatives to address geographic barriers to health care in rural communities.’”
Barrio, C., L. A. Palinkas, A.-M. Yamada, D. Fuentes, V. Criado, P. Garcia, and D. V. Jeste. 2008. Unmet needs for mental health services for Latino older adults: Perspectives from consumers, family members, advocates, and service providers. Community Mental Health Journal 44(1):57–74.
This study qualitatively assessed the need for mental health services among Latino older adults in San Diego, California. The primary mental health issue was depression. Primary organizational barriers to accessing services were language and cultural barriers secondary to a lack of translators, dearth of information on available services, and scarcity of providers representative of the Latino community. Other challenges included a lack of transportation and housing, and the need for socialization and social support. Latino older adults experienced their unmet needs in ways associated with their cultural background and minority status. Age- and culturally appropriate services are needed to overcome these barriers.
Bailey, J. M., M. E. Bieniasz, D. Kmak, D. E. Brenner, and M. T. Ruffin. Recruitment and retention of economically underserved women to a cervical cancer prevention trial. Applied Nursing Research 17(1):55–60.
“This review contrasts the planned and actual recruitment and retention efforts for a cervical cancer prevention study within a predominantly underserved population. Recruitment was a primary obstacle to trial progression and multiple strategies to improve recruitment were implemented to meet objectives. The actual recruitment strategies were expansion to five geographically distinct clinical sites, use of nurse practitioners focused primarily on patient issues, extremely flexible study hours and location, honorariums, support for transportation and child care, and creativity in maintaining contact with study participants. With these strategies, 90 percent of eligible patients consented to participate in the study.”
Battista, G. A., B. H. Y. Lee, J. Kolodinsky, and S. N. Heiss. 2015. Exploring transportation accessibility to health care among Vermont’s rural seniors. Transportation Research Record 2531:16.
“The aging ‘baby boomer’ generation will profoundly impact the demand for health care services in the United States. This change will be felt strongly in rural areas, where the population is generally older and the supplies of health care services and alternative transportation are limited. The authors employed a mixed-method approach to assess health care accessibility among seniors in Vermont. They used geographic information systems to project health care accessibility according to the spatial characteristics of the health care and transportation systems. They subsequently assessed the mechanisms shaping accessibility through semi-structured interviews with 20 seniors and caregivers. The authors find that health care accessibility varies among seniors depending on local health care supply, transportation, and individual resources at their disposal. Health care accessibility is also shaped by less-tangible factors including social connectedness and personal preferences for care and transportation. The results suggest that mixed methods provide a more nuanced and valid perspective on health care accessibility, which can better inform policy makers as they strive to accommodate rural senior preferences to age in place in a healthy manner.”
Bircher, H. 2009. Prenatal care disparities and the migrant farm worker community. American Journal of Maternal Child Nursing 34(5): 303–307.
“The pregnant migrant farm worker faces many barriers to accessing health care in the United States due to poverty, language/literacy issues, transportation difficulties, and geographic isolation. The advanced practice nurse has the opportunity to contribute solutions to the problems of lack of adequate prenatal care among the migrant farm worker community, if he/she is aware of the need and can institute novel models of care. This article describes the problem of migrant farm worker health and suggests ways that advanced practice nurses can provide cost-effective, competent professional care to reduce or eliminate the obstacles to care for this population.”
Campbell, J. D., R. A. Chez, T. Queen, A. Barcelo, and E. Patron. 2000. The no-show rate in a high-risk obstetric clinic. Journal of Women’s Health & Gender-Based Medicine 9(8):891–895.
“We wished to determine the reasons for an average missed appointment rate of 28 percent in a high-risk pregnancy clinic. Only 41 percent
of the 261 women in the study group could be reached by telephone. The reasons included not having a phone, the phone had been disconnected, incorrect phone number on the chart, the patient had moved, and the patient did not respond to the answering machine message. The reasons for missing the appointment included lack of transportation, scheduling problems, overslept or forgot, presence of a sick child or relative, and lack of child care. The response of patients to assessing prenatal care may reflect their priority of medical care relative to other priorities associated with day-to-day existence. There may be a baseline missed appointment rate for prenatal care in lower socioeconomic populations of women. The commitment of personnel time and energy to attempt to modify the no-show rate should be reexamined.”
Community Transportation Association of America. 2014. Improving transportation for patients receiving dialysis treatment. Community Transportation 48–51.
http://web1.ctaa.org/webmodules/webarticles/articlefiles/MedCT14rc.pdf (accessed September 21, 2016).
“Portland, Oregon’s ‘Ride Connection’ and a ‘Strengthening Inclusive Coordinated Transportation Planning’ project are the sources for a report that is excerpted here. Numerous ways in which the health outcomes of patients are affected by barriers or inadequacies in their transportation options are highlighted. The implication is that improving these options could potentially reduce overall health care costs by reducing medical complications for patients down the road, in addition to improving health outcomes. Issues and areas of concern that were uncovered included dependability, flexibility, waiting and indirect routes, cost/affordability, driver training, and geography. Possible solutions can be grouped into two categories: (1) developing education, advocacy, recruitment and outreach activities; and (2) creating collaborative pilots to effect change.”
Cronk, I. 2015. The transportation barrier. The Atlantic, August 9.
The article offers a personal vignette about a stranded discharged patient with no way to get home who is helped by a lucky coincidence, along with discussion of recent research documenting the great need for transportation—often invisible to health care providers—to routine health care services, especially in low-income and minority populations, who may have additional literacy and other barriers. Some individuals lacking transportation may wait until their condition worsens to enable an ambulance ride.
Dabelko, H. I., and V. A. DeCoster. 2007. Diabetes and adult day health services. Health & Social Work 32(4):279–288.
“The purpose of this study is to provide a profile of individuals with diabetes who receive services in adult day centers. This exploratory study uses an administrative dataset (N = 280) from five programs in central Ohio to examine four areas: demographics, health and mental health, financial and social resources, and disenrollment status. Older adults with diabetes were more likely to be African American and younger than other clients; had more diagnoses, limitations with activities of daily living, and hospitalizations; and were at greater nutritional risk at intake. These older adults also relied more on public funding, primary caregivers from the immediate family, and transportation assistance, and they paid less for participation in the day program. The two groups did not differ in length of program stay or reasons for disenrollment. Adult day centers serve a number of individuals with diabetes with unique needs and risks, providing an important location to test innovative and culturally responsive approaches to disease management. Caregivers are important partners in adult day services utilization and in diabetes management. Targeting public funding for diabetes care within adult day centers is recommended.”
DeGood, K. 2011. Aging in place, stuck without options: Fixing the mobility crisis threatening the Baby Boom generation. Transportation for America.
http://t4america.org/resources/seniorsmobilitycrisis2011 (accessed September 22, 2016).
This policy report, written to inform the pending reauthorization of federal surface transportation programs, describes the array of challenges faced by the baby boomer generation as most of them age in place with diminished ability to drive and increasing reliance on others, including their municipality, to provide transportation support. The nation’s demographic shift to the largest population of older adults ever (20 percent of the population) highlights the needs for dedicated and flexible funding to expand transportation options for non-driving persons, with strategies including public–private partnerships, “intelligent transportation” technology, and complete streets that are accessible to people of varying physical mobility.
Denham, S. A., K. Remsburg, and L. Wood. 2010. Diabetes education in the Appalachian region: Providers’ views. Rural and Remote Health 10(2):1321.
The authors conducted a survey about diabetes education resources with federally qualified health centers, health departments, and certified diabetes educators in the Appalachian region. Areas characterized by a history of economic distress were more likely to lack educators and physicians and to report transportation and staffing challenges, but both areas with and without economic distress experienced barriers to diabetes education affecting patients and health professionals.
Flaherty, J. H., B. Stalvey, and L. Rubinstein. 2003. A consensus statement on nonemergent medical transportation services for older persons. Journals of Gerontology Series A: Biological Sciences and Medical Sciences 58(9):M826–M831.
“Transportation is an essential part of our community infrastructure that helps people gain access to goods, services, and social contacts that support their daily activities and quality of life. Our reliance on transportation systems has grown over the years as populations have shifted from the city to more remote suburban areas, and transportation remains vital for populations in rural areas. Absence of transportation among any population impairs quality of life by decreasing personal independence, access, choice, and opportunities, which can lead to social isolation. Older adults, for whom quality of life and health are intimately connected are one of the populations who often lack transportation. This is particularly true for the large emerging population of frail elderly adults. As our health care system continues to struggle to find ways to keep older persons healthy and functional, the link between transportation services and health care becomes increasingly critical.”
Freeman, E. E., S. J. Gange, B. Muñoz, and S. K. West. 2006. Driving status and risk of entry into long-term care in older adults. American Journal of Public Health 96(7):1254–1259.
“This article reports on a study of the role that automobile driving plays as a risk factor for entering long-term care (LTC) institutions. The authors consider whether, given the importance of driving in American society, older non-drivers may be unable to meet basic needs while living independently. Data were used from 1,593 older adults who participated in the Salisbury (Maryland) Eye Evaluation cohort study and who completed an additional telephone survey. The results showed that former- and never-drivers had higher hazards of LTC entry after adjustment for demographic and health variables. Also, having no other drivers in the house was an independent risk factor for LTC entry. The authors conclude that although older adults are expected to make good decisions about when to
stop driving, the hardships imposed on older adults by not driving are not widely recognized. As the data suggest, being a nondriver increases the risk of entering LTC, which can be a significant drain on financial resources. This information could be used to better prepare older adults, their families, and society for the difficult circumstances that can result from not being able to drive. Innovative transportation options for older adults must be considered to help address this situation.”
Friedmann, P. D., S. C. Lemon, M. D. Stein, R. M. Etheridge, and T. A. D’Aunno. 2001. Linkage to medical services in the Drug Abuse Treatment Outcome Study. Medical Care 39(3):284–295.
The study examined “whether organizational linkage mechanisms facilitate medical service utilization in drug abuse treatment programs” through a prospective secondary analysis of the Drug Abuse Treatment Outcome Study, a national longitudinal study of drug abuse treatment programs and their patients from 1991 to 1993. In addition to establishing that on-site delivery of medical services increases patient use of medical services during the first month of treatment, the study found that it could be helpful to consider transportation assistance as a facilitator in the delivery of medical services.
GAO (U.S. Government Accountability Office). 2013. Transportation-disadvantaged populations: Coordination efforts are underway, but challenges continue. GAO-14-154T.
http://www.gao.gov/products/GAO-14-154T (accessed September 22, 2016).
“This statement describes: (1) the federal programs that provide funding for transportation services for the transportation-disadvantaged populations, including older adults, and (2) the types of challenges federally funded programs face in providing services to transportation-disadvantaged populations. This statement is drawn from a body of work that we completed from 2004 through 2012 regarding transportation-disadvantaged populations.”
Garney, W. R., K. Drake, M. L. Wendel, K. McLeroy, H. R. Clark, and B. Ryder. 2013. Increasing access to care for Brazos Valley, Texas: A rural community of solution. Journal of the American Board of Family Medicine 26(3):246–253.
“Compared with their urban counterparts, rural populations face substantial disparities in terms of health care and health outcomes, particularly
with regard to access to health services. To address ongoing inequities, community perspectives are increasingly important in identifying health issues and developing local solutions that are effective and sustainable. This article has been developed by both academic and community representatives and presents a brief case study of the evolution of a regional community of solution (COS) servicing a seven-county region called the Brazos Valley, Texas. The regional COS gave rise to multiple, more localized COSs that implemented similar strategies designed to address access to care within rural communities. The regional COS, known as the Brazos Valley Health Partnership, was a result of a 2002 health status assessment that revealed that rural residents face poorer access to health services and their care is often fragmented. Their localized strategy, called a health resource center, was created as a ‘one-stop shop’ where multiple health and social service providers could be housed to deliver services to rural residents. Initially piloted in Madison County, Texas, the resource center model was expanded into Burleson, Grimes, and Leon counties because of community buy-in at each of these sites. The resource center concept allowed service providers, who previously were able to offer services only in more populous areas, to expand into the rural communities because of reduced overhead costs. The services provided at the health resource centers include transportation, information and referral, and case management along with others, depending on the location. To ensure successful ongoing operations and future planning of the resource centers, local oversight bodies known as health resource commissions were organized within each of the rural communities to represent local COSs. Through collaboration with local entities, these partnerships have been successful in continuing to expand services and initiating health improvements within their rural communities.”
Goins, R. T., K. A. Williams, M. W. Carter, M. Spencer, and T. Solovieva. 2005. Perceived barriers to health care access among rural older adults: A qualitative study. Journal of Rural Health 21(3):206–213.
This article describes qualitative research conducted through focus groups with 101 participants 60 years and older living in rural areas to understand barriers to care among them. The research identified five categories of barriers to health care, including transportation difficulties, social isolation, and financial constraints.
Graham, S., B. Lewis, B. Flanagan, M. Watson, and L. Peipins. 2015. Travel by public transit to mammography facilities in 6 U.S. urban areas. Journal of Transport and Health 2(4):602–609.
“This study examined the lack of private vehicle access and public transportation travel times of 30 minutes or longer to mammography facilities for women 40 years of age or older in the urban areas of Boston, Philadelphia, San Antonio, San Diego, Denver, and Seattle in order to identify transit-marginalized populations—women for whom these travel characteristics may jointly present a barrier to clinic access. This ecological study used sex and race/ethnicity data from the 2010 U.S. Census and household vehicle availability data from the American Community Survey 2008–2012, all at U.S. Census tract level. Using the public transportation option on Google Trip Planner, the authors obtained the travel time from the centroid of each U.S. Census tract to all local mammography facilities to determine the nearest mammography facility in each urban area. Median travel times by public transportation to the nearest facility for women with no household access to a private vehicle were obtained by ranking travel time by population group across all U.S. census tracts in each urban area and across the entire study area. The overall median travel times for each urban area for women without household access to a private vehicle ranged from a low of 15 minutes in Boston and Philadelphia to 27 minutes in San Diego. The numbers and percentages of transit-marginalized women were then calculated for all urban areas by population group. Black women were less likely to have private vehicle access, and both Hispanic and black women were more likely to be transit marginalized, but this outcome varied by urban area. White women constituted the largest number of transit-marginalized women. The study results indicate that mammography facilities are favorably located for the large majority of women, although there are still substantial numbers for whom travel may likely present a barrier to mammography facility access.”
Hobson, J., J. Quiroz-Martínez, and C. Yee. 2002. Roadblocks to health: Transportation barriers to healthy communities. Transportation and Land Use Coalition.
http://www.transformca.org/sites/default/files/roadblocks_to_health_2002.pdf (accessed September 22, 2016).
As residents of low-income communities of color know and research has confirmed, “inadequate transportation is one of the primary reasons that low-income families miss, or forego scheduling, medical appointments. The problem is particularly acute with chronic and preventative care, and when children have to be transported as well.” This report “is the product of a remarkable collaboration between social justice community organizers and transportation advocates—a 2-year project dedicated to making the health of low-income communities of color a topic of transportation priority.” The report includes mapping, survey results and analysis of transporta-
tion barriers among the Bay Area’s most disadvantaged communities (e.g., in Alameda, Contra Costa, and Santa Clara counties) and includes recommendations for investment and policy solutions that will meet basic transit needs of low-income communities of color, such as making California Medicaid transportation assistance available to all recipients and guarding against reductions in transportation access to health care.
Horton, S., and R. J. Johnson 2010. Improving access to health care for uninsured elderly patients. Public Health Nursing 27(4):362–370.
“The purpose of this article is to explore the barriers that the uninsured elderly population encounter when accessing health care in the United States. These barriers include, but are not limited to, lack of transportation, insurance, or family support; the daunting complexity of the health care system; poverty; culture; poor patient–health care provider communications; race/ethnicity; and lack of health care professionals such as nurses and doctors with adequate geriatric preparation, or generalists who are undereducated in geriatrics. The number of health care professionals currently available to treat elderly persons in the United States is inadequate. The federal government should take steps to develop solutions to improve access to health care and decrease health disparities for older adults. As a nation, we should be proactive in addressing these concerns instead of waiting for new barriers to arise that further limit access to health care for elderly patients and their families. In this article, we provide an assessment of the barriers that limit access to health care in the uninsured elderly population and suggest recommendations and possible solutions to eliminate or reduce these barriers.”
Hwang, J. M., J. Clemente, K. P. Sharma, T. N. Taylor, and C. L. Garwood. 2011. Transportation cost of anticoagulation clinic visits in an urban setting. Journal of Managed Care Pharmacy 17(8):635–640.
“Patients being managed on warfarin make frequent or regular visits to anticoagulation monitoring appointments. International studies have evaluated transportation cost and associated time related to anticoagulation clinic visits. To our knowledge, no studies have evaluated the cost of transportation to such clinic visits in the United States. This study reports findings from a survey of 60 patients on ‘questions regarding mode of transportation, distance traveled in miles, parking payment, and time missed from work for clinic appointments. The mean distance traveled was translated into cost, assuming 50 cents per mile based on 2010 estimates by the Internal Revenue Service.’ Researchers found that “the round-trip cost of transportation to an anticoagulation clinic in an urban setting in the United States may translate
into a substantial expense, ranging from weekly appointments ($560 annually) to once-monthly appointments ($130 annually).”
Iowa Department of Transportation and Iowa Department of Public Health. 2012. Health care and public transit: A spotlight on transportation and access to care.
http://www.iowadot.gov/transit/publications/HealthCareandPublicTransit.pdf (accessed September 22, 2016).
The document is intended to inform relevant constituencies of the link between transportation and health care. It highlights key findings of the report Understanding Community Health Needs in Iowa, “an analysis of the state’s Community Health Needs Assessment and Health Improvement Plan, [in which] 41 counties identified access to transportation as one of their top 10 health needs.” The report provides an overview for health sector leaders and practitioners of key issues in transit relevant to their work, from the way services are organized, to funding flows and needs, to planning and policy issues. It also includes an extensive resource list for the state.
Katz, M. L., M. E. Wewers, N. Single, and E. D. Paskett. 2007. Key informants’ perspectives prior to beginning a cervical cancer study in Ohio Appalachia. Qualitative Health Research 17(1):131–141.
“Higher-than-average cervical cancer incidence and mortality rates occur in Ohio Appalachia. Little is known, however, about the societal norms and social determinants that affect these rates. To examine county-level sociocultural environments in order to plan a cervical cancer prevention program, the authors interviewed key informants from 17 of 29 Ohio Appalachia counties. The findings include the perceived offensiveness of the term ‘Appalachia,’ the importance of long-standing family ties, urban and rural areas within counties, the use and acceptability of tobacco, the view that cancer is a death sentence, and the stigmatization of people with cancer. Barriers to screening included cost, lack of insurance, transportation problems, fear, embarrassment, and privacy issues. These findings highlight the important role of geography, social environment, and culture on health behaviors and health outcomes. The interviews provided information about the unique characteristics of this population that are important when developing effective strategies to address cancer-related health behaviors in this medically underserved population.”
Kibbey, K. J., J. Speight, J. L. Wong, L. A. Smith, and H. J. Teede. 2013. Diabetes care provision: Barriers, enablers and service needs of young adults with Type 1 diabetes from a region of social disadvantage. Diabetic Medicine 30(7):878–884.
This study examined barriers and enablers to accessing diabetes care through a survey completed by 86 respondents. Researchers found that young adults with Type 1 diabetes “had identifiable logistical barriers to accessing and maintaining contact with diabetes care services, which can be addressed with flexible service provision.”
Krupski, A., K. Campbell, J. M. Joesch, B. A. Lucenko, and P. Roy-Byrne. 2009. Impact of Access to Recovery services on alcohol/drug treatment outcomes. Journal of Substance Abuse Treatment 37(4):435–442.
“The purpose of this study was to assess the impact of providing recovery support services to clients receiving publicly funded chemical dependency (CD) treatment through the Access to Recovery (ATR) Program in Washington State. Services included case management, transportation, housing, and medical. A comparison group composed of clients who received CD treatment only was constructed using a multistep procedure based on propensity scores and exact matching on specific variables. Outcomes were obtained from administrative data sources. Results indicated that ATR services were associated with a number of positive outcomes, including increased length of stay in treatment, increased likelihood of completing treatment, and increased likelihood of becoming employed. The beneficial effects of ATR services on treatment retention were most pronounced when they were provided between 31 and 180 days after treatment began. The results reported here offer evidence for the value of ATR services.”
Lawthers, A. G., G. S. Pransky, L. E. Peterson, and J. H. Himmelstein. 2003. Rethinking quality in the context of persons with disability. International Journal for Quality in Health Care 15(4):287–299.
Researchers formulated “a multi-dimensional model of quality of care for persons with disability” and applied it to a systematic review, searching “MEDLINE and other databases for primary research and review articles containing the phrases ‘quality of care,’ ‘patient safety,’ ‘access,’ ‘patient experience,’ and ‘coordination of care’ in conjunction with the words ‘disability’ or ‘impairment.’” Researchers identified “physical bar-
riers, transportation, communication difficulties, and client and provider attitudes present barriers to receiving appropriate client-centered care” and found a multi-disciplinary approach and coordination to be key ingredients connecting “all areas of quality for a person with disability, presents the most significant opportunity for improvement, because multiple medical and social providers are typically involved in the care of individuals with disabling conditions.”
Maxwell, A. E., S. Young, C. M. Crespi, R. R. Vega, R. T. Cayetano, and R. Bastani. 2015. Social determinants of health in the Mixtec and Zapotec community in Ventura County, California. International Journal for Equity in Health 14:16.
“An academic–community partnership research team developed a survey to assess basic needs that are known to be social determinants of health in the Mixtec and Zapotec indigenous Mexican community in Ventura County (speakers of native non-written languages, and therefore, with poorly understood needs). Respondents (N = 989) reported lack of transportation (59 percent) as a key challenge.” Most respondents “reported access to medical care for children (90 percent), but only 57 percent of respondents were able to get health care for themselves.”
It will require many different resources and services to address the needs of this community and to overcome longstanding inequities that are experienced by immigrant farm workers.
McCann, J., and J. Nichols 2005. Medical transportation toolkit and best practices. Community Transportation Association.
http://www.ctaa.org/webmodules/webarticles/articlefiles/medtoolkit.pdf (accessed September 22, 2016).
“This publication on medical transportation offers resources for nonemergency medical transportation. It is divided among 7 chapters and 14 supplemental items. They are as follows: Introduction; Chapter 1 — Transportation: The Critical Link to Health Care; Chapter 2 — An Introduction to Community Transportation; Chapter 3 — The Consumer’s Search for Transportation; Chapter 4 — Seniors’ Needs for Medical Transportation; Chapter 5 — Coordination: Working Together, Working Better; Chapter 6 — Medicaid: America’s First Medical Transportation Model at Work; Chapter 7 — Special Needs Medical Transportation: Looking at Dialysis Transportation; Medical Transportation Supplement: Part A — National Transit Resource Center Glossary; Part B — Managed Care Terms and Methodologies; Part C — Principles of Managed Care Contracting;
Part D — Payment Methodologies-Capitation: Sharing the Risk; Part E — RFP Outline; Part F — Sample Transportation Contract; Part G — Sample Memorandum of Understanding; Part H — State Medicaid Transportation Contacts; Part I — National Transit Resource Center Brochure; Part J — Bibliography; Part K — Current Practices in Medical Transportation; Part L — Medicaid Transportation: A Primer for States, Health Plans and Advocates; Part M — Community Transportation Magazine; and Part N — Report: Benefits of Transportation Services to Health Programs.”
Mohammadian, K. 2015. TRB Standing Committee perspectives: Traveler behavior and values: Establishing associations with public and individual health. TR News 299:32–33.
“In this article, Kouros Mohammadian, chair of the Transportation Research Board Standing Committee on Traveler Behavior and Values, discusses the link between travel behavior and public and individual health. The difficulty of measuring the impact of transportation-related factors on health, including those associated with livable communities, is also discussed.”
Muskegon Community Health Project. 2012. Imagine our community healthy!: Community health needs assessment for Muskegon, Oceana and Newaygo Counties 2012. Mercy Health Partners.
http://www.mercyhealthmuskegon.com/documents/MercyHealthPartnersMuskegon/MU68330%20LakeshoreCHNAbook%20912.pdf (accessed September 22, 2016).
This document provides an overview and findings of the Mercy Health’s Community Needs Assessment conducted in Muskegon, Michigan. The assessment, performed in accordance with Patient Protection and Affordable Care Act requirements, included the local public health agency, federally qualified health centers, school district, the local university, and key social services and nonprofit organizations, and a major local employer. Transportation to medical appointments surfaced as one of the four most frequently requested services between October 2009 and March 2012 in the three counties of the Muskegon area. The report included data from specific assessments of Native Americans and individuals with disabilities, which showed transportation was a key barrier to accessing health care. Transportation issues also arose in response to the question about access to fresh fruits and vegetables.
National Association of Community Health Centers. 2013. Removing barriers to care: Community health centers in rural areas.
http://nachc.org/wp-content/uploads/2015/06/Rural_FS_1013.pdf (accessed September 22, 2016).
The fact sheet provides an overview of the services community health centers provide in rural areas, including meeting transportation needs.
Nelson, R. E., B. Hicken, A. West, and R. Rupper. 2012. The effect of increased travel reimbursement rates on health care utilization in the VA. Journal of Rural Health 28(2):192–201.
In an analysis of a cohort of 250,958 veterans, 76.7 percent (N = 192,559) were eligible for increased reimbursement for travel to U.S. Department of Veterans Affairs (VA) facilities from 11 to 28.5 cents per mile. This policy change, enacted in 2008, made eligible veterans 6.8 percent more likely to have an outpatient visit and 2.6 percent more outpatient visits.
Nonzee, N. J., J. M. McKoy, A. W. Rademaker, P. Byer, T. H. Luu, D. Liu, E. A. Richey, A. T. Samaras, G. Panucci, X. Q. Dong, and M. A. Simon. 2012. Design of a prostate cancer patient navigation intervention for a Veterans Affairs hospital. BMC Health Services Research 12:340.
“Patient navigation programs have been launched nationwide in an attempt to reduce racial/ethnic and socio-demographic disparities in cancer care, but few have evaluated outcomes in the prostate cancer setting. The National Cancer Institute–funded Chicago Patient Navigation Research Program (C-PNRP) is aimed at implementing and evaluating the efficacy of a patient navigation intervention for predominantly low-income minority patients with an abnormal prostate cancer screening test at a U.S. Department of Veterans Affairs (VA) hospital in Chicago. From 2006 through 2010, C-PNRP implemented a quasi-experimental intervention whereby trained social workers and lay health navigators worked with veterans with an abnormal prostate screen to proactively identify and resolve personal and systems barriers to care. Men were enrolled at a VA urology clinic and were selected to receive navigated versus usual care based on the clinic day. Patient navigators performed activities to facilitate timely follow-up such as appointment reminders, transportation coordination, cancer education, scheduling assistance, and social support as needed. Primary outcome measures included time (days) from abnormal screening to diagnosis and time from diagnosis to treatment initiation. Secondary outcomes included psychosocial and demographic predictors of non-compliance and patient sat-
isfaction. Dates of screening, follow-up visits, and treatment were obtained through chart audit, and questionnaires were administered at baseline, after diagnosis, and after treatment initiation. At the VA, 546 patients were enrolled in the study (245 in the navigated arm, 245 in the records-based control arm, and 56 in a subsample of surveyed control subjects). Given increasing concerns about balancing better health outcomes with lower costs, careful examination of interventions aimed at reducing health care disparities attain critical importance. While analysis of the C-PNRP data is underway, the design of this patient navigation intervention will inform other patient navigation programs addressing strategies to improve prostate cancer outcomes among vulnerable populations.”
Redmond, P. 2007. Reducing barriers to health care: Practical strategies for local organizations. Covering Kids & Families Access Initiative Toolkit. Center for Health Care Strategies.
http://www.chcs.org/media/CKF-AI_Toolkit.pdf (accessed September 20, 2016).
“This toolkit is designed for local organizations and funders interested in improving access to health services for people enrolled in Medicaid. It draws on the successes and challenges in the Covering Kids & Families Access Initiative to offer realistic, practical approaches that can help organizations to identify and document barriers to care, discern what type of technical assistance is best, gauge the likelihood that a particular barrier can be addressed through an intervention ‘of a local organization working in partnership with other stakeholders,’ and ‘test specific interventions for improving access to specific health care services.’”
Schlosser, N. 2012. Healthcare’s fraying safety net challenges medical transportation. Metro Magazine November/December:24–31.
http://www.metro-magazine.com/accessibility/article/211691/health-cares-fraying-safety-net (accessed September 22, 2016).
This article highlights key transportation challenges (e.g., funding, coordination) that emerge as more people become Medicaid-eligible, with insights from the executive director of the Community Transportation Association of America and examples from Florida, Iowa, and Maine.
Shook, M. 2005. Transportation barriers and health access for patient attending a community health center. Field area paper.
http://web.pdx.edu/~jdill/Shook_access_transportation_chc.pdf (accessed September 22, 2016).
“This study describes the transportation problems encountered by patients visiting a community health center in the Portland, Oregon, metropolitan region. Community health centers are federally funded health delivery sites serving primarily poor, minority, and otherwise underserved populations vulnerable to transportation and other health access barriers. The study surveyed 75 adult patients about the transportation they use to access medical services. The survey assessed the type and occurrence of transportation barriers with the patient’s ability to obtain needed health care services. The paper begins with a general discussion on the context of access barriers and their relationship to personal health. A review of the planning and medical research literature regarding transportation barriers to health care access follows with a description of community health centers and the study’s objectives. Study methods and results are presented, followed by a discussion of findings and implications that conclude the paper.”
Stanley, S., K. J. Arriola, S. Smith, M. Hurlbert, C. Ricci, and C. Escoffery. 2013. Reducing barriers to breast cancer care through Avon patient navigation programs. Journal of Public Health Management & Practice 19(5):461–467.
This study examined the effects of breast cancer patient navigation programs operated by 44 out of 56 (81 percent completion rate) Avon Foundation for Women grantees funded since 2008.
The online survey found a high level of racial and ethnic diversity among patients, who were either uninsured (50.7 percent) or Medicaid recipients (32.4 percent). The surveyed programs identified barriers to care including transportation and found that “[m]any Avon [patient navigation] programs incorporated navigation services that span the cancer care continuum. They addressed disparities by offering navigation and on-site medical services to reduce multiple systems barriers and social issues related to breast care.”
Westin, S. N., D. Bustillos, J. B. Gano, M. M. Fields, A. L. Coker, C. C. Sun, and L. M. Ramondetta. 2008. Social factors affecting treatment of cervical cancer: Ethical issues and policy implications. Obstetrics & Gynecology 111(3):747–751.
“Health care in the United States has become a privilege rather than a right. Patients who have the greatest need are the ones most likely to be denied this privilege. Despite recent advances in disease detection and treatment, many patients do not receive even the bare minimum of care. The high complexity of the health care system in the setting of patients with low levels of health literacy significantly affects the ability to seek and receive
treatment in a timely fashion. In addition, the lack of insurance, transportation, and social support further complicate access to care. To truly provide a standard of care to all patients, regardless of resources, our health care system must evolve to address the needs of the population. In this paper, we report a tragic case where social factors affected the outcome of a single mother with advanced cervical cancer.”
Whetten, R., K. Whetten, B. W. Pence, S. Reif, C. Conover, and S. Bouis. 2006. Does distance affect utilization of substance abuse and mental health services in the presence of transportation services? AIDS Care 18(Suppl 1):S27–S34.
“Long travel times have been identified as a significant barrier to accessing mental health and other critical services. This study examines whether distance to treatment was a barrier to receiving outpatient mental health and substance abuse care for HIV-positive persons when transportation was provided. Data from a cohort of HIV-positive persons who participated in a year-long substance abuse and mental health treatment program were examined longitudinally. Transportation, which included buses, taxis, and mileage reimbursement for private transportation, was provided free of charge for participants who needed this assistance. Nearly three-quarters (74 percent) of participants used the transportation services. No statistically significant differences in retention in, or use of, the mental health and substance abuse treatment program were identified by distance to the treatment site. This analysis demonstrated that increased distance to care did not decrease use of the treatment program when transportation was provided to the client when necessary. These results provide preliminary evidence that distance to substance abuse and mental health services need not be a barrier to care for HIV-positive individuals when transportation is provided. Such options may need to be considered when trying to treat geographically dispersed individuals so that efficiencies in treatment can be attained.”
Wohl, A. R., J. A. Carlos, J. Tejero, R., Dierst-Davies, E. S. Daar, H. Khanlou, J. Cadden, W. Towner, and D. Frye. 2011. Barriers and unmet need for supportive services for HIV patients in care in Los Angeles County, California. AIDS Patient Care and STDs 25(9):525–532.
“Data from the Medical Monitoring Project (MMP), a national supplemental surveillance system for HIV-infected persons in care, was used to examine barriers to support service use and factors associated with need and unmet need for services. Interview data for 333 patients in care in 2007 and 2008 in Los Angeles County (LAC) showed that 71 percent (N = 236)
reported needing at least one supportive service and of these, 35 percent (N = 83) reported at least one unmet need for services (46 percent Latino; 25 percent white; 83 percent male; 92 percent 30+; 77 percent gay/bisexual; 40 percent response rate). The main reasons that supportive services were not accessed included lack of information (47 percent; do not know where to go or who to call); an agency barrier (33 percent; system too confusing, wait list too long); or a financial/practical barrier (18 percent; too expensive, transportation problems). In a logistic regression that included all participants (N = 333), African Americans (OR = 3.1, 95 percent CI: 1.1–8.7), and those with incomes less than $10,000 were more likely to have service needs (odds ratio [OR] = 3.5; 95 percent confidence interval [CI]: 1.3–9.3). Among those with at least one service need (N = 236), those who were gay or bisexual were more likely to report at least one unmet service need (OR = 2.8; 95 percent CI: 1.3–6.1). Disparities were found for need and unmet need for supportive services by race/ethnicity; income and sexual orientation. The reported reasons that services were not obtained suggest needed improvements in information dissemination on availability and location of HIV support services and more streamlined delivery of services.”
Yang, S., R. L. Zarr, T. A. Kass-Hout, A. Kourosh, and N. R. Kelly. 2006. Transportation barriers to accessing health care for urban children. Journal of Health Care for the Poor and Underserved 17(4):928–943.
“This article reports on a cross-sectional study undertaken to investigate the impact of transportation problems on a family’s ability to keep a medical appointment for a child. The study took place at the Texas Children’s Hospital Residents’ Primary Care Group Clinic, which provides primary care to urban, low-income children. The authors interviewed 183 caregivers of children with an appointment. Caregivers who kept their appointment were compared to those who did not; the authors investigated demographic and transportation-related characteristics. The authors found that the following caregiver characteristics resulted in a lower likelihood of keeping an appointment: not using a car to get to the previous kept appointment, not keeping an appointment in the past due to transportation problems, having more than two people in the household, and not keeping an appointment in the past due to reasons other than transportation problems. Those respondents who used transportation other than a car had 3.23 times the odds of not keeping their appointment than those who did use a car to arrive at the clinic. The authors conclude that in Houston, where transportation costs are the highest in the nation and where the public transit system is small but expanding, finding an economical and reliable means to get to health care appointments may be a challenge for lower-income families.”
Zittel-Palamara, K., J. A. Fabiano, E. L. Davis, D. P. Waldrop, J. A. Wysocki, and L. J. Goldberg. 2005. Improving patient retention and access to oral health care: The CARES program. Journal of Dental Education 69(8):912–918.
“Improving access to dental care for patients experiencing barriers such as financial, transportation, or mental health is a public health concern. Dental schools have an obligation to assist patients experiencing such barriers as well as to educate future dentists and allied professionals on how to assist these patients in overcoming barriers. Once admitted to the dental clinic, retention issues can further complicate the provision of dental care. This article will describe an innovative program designed to address biopsychosocial barriers to dental care. Needs assessments of patients sitting in the waiting room of the dental clinic were conducted by master’s of social work students. Based on needs assessment results, common dental care barriers were identified and served as the foundation for the establishment of a social work program in the dental clinic. Dental students, faculty, and staff refer patients to the social work program when barriers to care are found. These biopsychosocial barriers are addressed by social workers, uniquely qualified professionals in providing case management, advocacy, referrals, education, and services (CARES). Over the course of 3 years, 80 percent of patients experiencing an identified barrier to the receipt of dental care were retained through social work intervention. These patients were able to receive dental care within the past year. Dental schools can collaborate with social work schools to establish a protocol and assistance program for dental patients experiencing difficulty accessing care, thereby improving oral health status, retention rates, and dental student education.”
Alley, D. E., C. N. Asomugha, P. H. Conway, and D. M. Sanghavi. 2016. Accountable health communities—Addressing social needs through Medicare and Medicaid. New England Journal of Medicine 374(1):8–11.
This article describes the foundations for the Centers for Medicare & Medicaid Services’ Innovation Center’s Accountable Health Communities funding opportunity announcement to address social needs, which include the universal screening for social needs (from personal safety to transportation needs) at the point of care. The article then describes recent and ongoing state and national innovations, through health system transformation and payment reform, and states that the new funding opportunity aims to determine “whether systematically identifying and addressing health-related
social needs can reduce health care costs and utilization among community-dwelling Medicare and Medicaid beneficiaries.”
Bell, J., and L. Cohen. 2009. The transportation prescription: Bold new ideas for healthy, equitable transportation reform in America. PolicyLink, Prevention Institute, and Convergence Partnership.
https://www.preventioninstitute.org/sites/default/files/publications/The%20Transportation%20Prescription_0.pdf (accessed September 21, 2016).
The report, drawing on the book Healthy, Equitable Transportation Policies, commissioned by the Convergence Partnership,1 provides a synthesis of multisector leaders’ insights at the intersection of transportation policy, equity, and public health, and makes 11 recommendations to enhance equity through transportation funding, policy, and planning, including “[p]rioritize investments in public transportation, including regional systems that connect housing and jobs as well as local services that improve access to healthy foods, medical care, and other basic services.”
Fox-Grage, W., and J. Lynott. 2015. Expanding specialized transportation: New opportunities under the Affordable Care Act. AARP Public Policy Institute. Insight on the Issues 99.
http://www.aarp.org/content/dam/aarp/ppi/2015/AARP-New-ACATransportation-Opportunities.pdf (accessed September 22, 2016).
“The Affordable Care Act (ACA) provides new but limited opportunities to promote or fund specialized transportation services for older people and adults with disabilities. This paper explains how states can use these largely untapped options to expand services for targeted low-income populations with mobility needs. It also presents two case studies illustrating how the Atlanta region and the state of Connecticut are making this work.”
The Leadership Conference Education Fund. 2011. The road to health care parity: Transportation policy and access to health care.
http://civilrightsdocs.info/pdf/docs/transportation/The-Road-to-HealthCare-Parity.pdf (accessed September 22, 2016).
This brief is designed to inform the surface transportation reauthorization bill, and it provides an overview of how policies have shaped an environment (car-dependence, etc.) that limits transportation access to health care services, among other effects deleterious to health, especially for
1 The book is available at http://www.convergencepartnership.org/sites/default/files/transportation-rx.PDF (accessed August 8, 2016).
low-income communities and communities of color. The brief’s concluding statement is that “promoting healthy changes in transportation policy is a civil rights priority.”
Mackett, R. L., and R. Thoreau 2015. Transport, social exclusion, and health. Journal of Transport & Health 2(4):610–617.
“This paper explores the nature of social exclusion and how transport contributes to it by providing barriers to access. Transport influences health in several ways: by providing physical activity through walking and cycling, and by providing access to healthy food, recreation facilities, and health care. Transport produces externalities including traffic casualties and vehicle emissions. These effects impinge on society unequally with socially excluded people able to access fewer facilities than others but suffering more from the externalities. The paper is concluded by discussion about various interventions that have been used to address social exclusion by reducing the barriers to access.”
National Center on Senior Transportation. 2013. Everyone rides: Transportation access for culturally and ethnically diverse elders.
This report contains the final list of Recommendations for Action to Address the Mobility Needs of Culturally and Ethnically Diverse Elders from the National Coalition on Mobility Needs of Culturally and Ethnically Diverse Elders. The report provides an overview of key mobility challenges, including lack of materials and outreach suited to culturally and ethnically diverse populations of older adults, isolation or segregation, and long distances to services especially in rural areas. Recommendations to address the range of challenges are organized into five categories: advocacy/regulatory and policy change, data collection/research, local coordination of transportation, funding/grantmaking, and training/information/dissemination.
Padilla, S., and J. Hobson. 2006. Priorities for access to health: Transportation Equity and Community Health (TEACH) in Contra Costa County. Transportation and Land Use Coalition.
http://www.transformca.org/sites/default/files/priorities-access-to-health.pdf (accessed September 22, 2016).
The California Endowment wassupported the Bay Area Transportation and Land Use Coalition to study the problem of transportation access and later to launch the Transportation Equity and Community Health (TEACH) project to convene community and local government to jointly address the problems identified. This report outlines priorities—from improving
bilingual transit information to increasing coordination between health and transit agencies—identified by the TEACH project and progress in meeting them.
AASHTO Center for Environmental Excellence. 2015. Transportation and public health peer exchange: Summary and key findings. ICF International.
http://environment.transportation.org/pdf/2015_trans_health_exchange/transportation_and_public_health_white_paper_1214.pdf (accessed September 22, 2016).
The report shares highlights from a meeting of state transportation officials to discuss integrating public health in considerations for transportation, including brief examples from New Mexico and Minnesota of attention to transportation needs to reach health care providers.
Audino, M. J., and J. A. Goodwill. 2014. Impacts of dialysis transportation on Florida’s coordinated public transportation programs.
http://www.nctr.usf.edu/wp-content/uploads/2014/05/77951.pdf (accessed September 21, 2016).
“The National Center for Transit Research (NCTR) at the University of South Florida (USF) collected quantitative and qualitative data from Community Transportation Coordinators (CTCs) throughout Florida. An online survey and a series of personal interviews provided insight into the following issues: (1) How the supply of and demand for dialysis transportation has changed over the past 5 years. (2) How the increase in dialysis trips is affecting operations and financial condition of CTCs. (3) How the impacts of dialysis trips differ among rural-oriented CTCs, urban-oriented CTCs, and urban-oriented CTCs which are part of a public transit agency. (4) What unique transportation services are being implemented by CTCs to meet the increasing demand for non-Medicaid-funded dialysis trips. (5) How CTCs are preparing for increased transportation demand associated with increased need for dialysis treatment.”
Dannenberg, A. L., R. Bhatia, B. L. Cole, C. Dora, J. E. Fielding, K. Kraft, D. McClymont-Peace, J. Mindell, C. Onyekere, J. A. Roberts, C. L. Ross, C. D. Ross, A. Scott-Samuel, and H. H. Tilson. 2006. Growing the field of health impact assessment in the United States: An agenda for research and practice. American Journal of Public Health 96(2):262–270.
“Health impact assessment (HIA) methods are used to evaluate the impact on health of policies and projects in community design, transportation planning, and other areas outside traditional public health concerns. At an October 2004 workshop, domestic and international experts explored issues associated with advancing the use of HIA methods by local health departments, planning commissions, and other decision makers in the United States. Workshop participants recommended conducting pilot tests of existing HIA tools, developing a database of health impacts of common projects and policies, developing resources for HIA use, building workforce capacity to conduct HIAs, and evaluating HIAs. HIA methods can influence decision makers to adjust policies and projects to maximize benefits and minimize harm to the public’s health.”
Dannenberg, A. L., A. Ricklin, C. L. Ross, M. Schwartz, J. West, and M. L. Wier. 2014. Use of health impact assessment for transportation planning: Importance of transportation agency involvement in the process. Transportation Research Record 2452:71–80.
“A health impact assessment (HIA) is a tool that can be used to inform transportation planners of the potential health consequences of their decisions. Although dozens of transportation-related HIAs have been completed in the United States, the characteristics of these HIAs and the interactions between public health professionals and transportation decision makers in these HIAs have not been documented. A master list of completed HIAs was used to identify transportation-related HIAs. Seventy-three transportation-related HIAs conducted in 22 states between 2004 and 2013 were identified. The HIAs were conducted for projects such as road redevelopments, bridge replacements, and development of trails and public transit. Policies such as road pricing, transit service levels, speed limits, complete streets, and safe routes to schools were also assessed. Five HIAs in which substantial interactions between public health and transportation professionals took place during and after the HIA were examined in detail and included HIAs of the road pricing policy in San Francisco, California; a bridge replacement in Seattle, Washington; new transit lines in Baltimore, Maryland, and Portland, Oregon; and the BeltLine transit, trails, and parks project in Atlanta, Georgia. Recommendations from the HIAs led to changes in decisions in some cases and helped to raise awareness of health issues by transportation decision makers in all cases. HIAs are now used for many topics in transportation. The range of involvement of transportation decision makers in the conduct of HIAs varies. These case studies may serve as models for the conduct of future transportation-related HIAs, because the involvement of transportation agencies may increase the likelihood that an HIA will influence subsequent decisions.”
Feinglass, J., N. J. Nonzee, K. R. Murphy, R. Endress, and M. A. Simon. 2014. Access to care outcomes: A telephone interview study of a suburban safety net program for the uninsured. Journal of Community Health 39(1):108–117.
“Access DuPage (AD) currently provides primary care for about 14,000 low-income, uninsured residents of suburban DuPage County, Illinois, an area with a very limited health care safety net infrastructure. A telephone interview survey evaluated health care utilization, satisfaction, and health status outcomes and compared recent enrollees to individuals in the program for at least 1 year. Sequential new AD enrollees (N = 158) were asked about the previous year when uninsured, while randomly selected established AD enrollees (N = 135) were asked the same questions about the previous year when actively enrolled in AD. Established enrollees reported being more likely to get ‘any kind of tests or treatment’ (96.3 vs. 46.2 percent, p < 0.0001), fewer cost (78.5 vs. 21.3 percent, p < 0.0001) and transportation barriers to care, more preventive and mental health services, and better self-management care. However, established enrollees also reported 14 percent greater use of hospital inpatient and 9 percent greater use of emergency room care, as well as continued difficulty in accessing needed specialty and dental care services. Despite more (diagnosed) conditions, established enrollees were more than 2.5 times more likely to report good to excellent health status and more than three times more likely to rate their satisfaction with health care as good to excellent. Findings illustrate the substantial benefits of assuring access to care for the uninsured, but do not reflect immediate savings from reduced hospital utilization. Access to care programs will be an important tool to address the needs of the 30 million people who will continue to be uninsured in the United States.”
Ferguson, E. M., J. Duthie, A. Unnikrishnan, and S. T. Waller. 2012. Incorporating equity into the transit frequency-setting problem. Transportation Research Part A: Policy and Practice 46(1):190–199.
“This paper and the proposed formulation contribute to an apparent gap in transit research design by integrating equity considerations into the transit frequency-setting problem. The proposed approach provides a means to design transit service such that equitable access to basic amenities (e.g., employment, supermarkets, medical services) is provided for low-income populations or disadvantaged populations. The overarching purpose is to improve access via transit to basic amenities to: (1) reduce the disproportionate burden faced by transit-dependent populations; and (2) create a more feasible transportation option for low-income households as an opportunity to increase financial security by reducing dependence on
personal autos. The formulation is applied to data from a mid-sized U.S. metropolitan area. The example application illustrates that the formulation successfully increases access to employment opportunities for residents in areas with high percentages of low-income persons, as well as demonstrates the importance of considering uncertainty in the locations of populations and employment.”
Forti, E. M., and M. Koerber 2002. An outreach intervention for older rural African Americans. Journal of Rural Health 18(3):407–415.
“This article describes the process, approaches, and selected outcomes of a rural care management outreach intervention for older African Americans in South Carolina. The model is a community–academic partnership among a federally qualified community health center, a rural health clinic, and the Medical University of South Carolina. Its aim is to improve access to and utilization of health care and social services to enhance the quality of life of older African Americans. This is being accomplished by using paid, trained outreach workers (called geriatric coordinators), who function as advocates in linking clients to needed health and social services through activities such as arranging transportation to health care, rescheduling missed medical appointments, providing health promotion, and making referrals to public benefits and indigent drug programs. Outcomes demonstrated that the use of geriatric coordinators as care managers is a feasible way of increasing quality of life for older African Americans. The most notable outcome showed that 54 percent of clients who were eligible but not receiving benefits prior to this intervention were signed on for programs such as Supplemental Security Income, Specified Low-Income Medicare Beneficiary, Qualified Medicare Beneficiary, disability, railroad pensions, and Veterans Administration benefits. Health centers realized an increase in reimbursable services and new clients. Increased capacity for older adult services is being accomplished through geriatric-coordinator-directed collaborations with social service agencies and participation in community events and committees.”
Giusti, C., et al. 2008. Transportation infrastructure and quality of life for disadvantage populations: A pilot study of el Cenizo Colonia in Texas. 126p.
“This research is a pilot study aimed to identify environmental characteristics in colonias that are related to infrastructure and safety, access to goods and services, and quality of life. A secondary objective consisted of evaluating a variety of tools that could be used to identify and assess these environmental characteristics. El Cenizo in Webb County, Texas, was
selected as our study colonia after preliminary visits and investigations. A multidisciplinary approach framed this study, considering the transportation, urban design and planning, public health, and socioeconomic dimensions as potential determinants of the residents’ mobility behaviors, environmental perception, and quality of life. Three instruments were developed to collect data for this research: (1) a survey, (2) an activity diary or travel diary, and (3) environmental audit instruments. Additionally, this study included a small sub-group study testing the usability of wearable Global Positioning Systems (GPS) units as a research tool to capture spatial-behavioral data, combined with travel diary. First, the study has generated valuable data on transportation and mobility behaviors where almost no information is available. Second, the multidisciplinary approach has allowed a comprehensive approach toward a better understanding of the current needs of colonias, especially those related to pedestrians. Some of them could be easily addressed with direct short-term interventions while others require a more long-term plan. Third, the assessment of new research tools offers useful insights for future research in the context of similar low-income marginalized communities.”
Health Outreach Partners. 2014. Overcoming obstacles to health care: Transportation models that work.
The report provides an overview of The Kresge Foundation–supported project to address transportation barriers to health care access. The project undertook development and dissemination of six case studies, the convening of a policy advisory council, policy analysis, policy campaign, and training and technical assistance. The project also produced six key findings to facilitate patient-centered transportation, and made five recommendations (evaluate, develop diverse funding streams, create opportunities for coordination and bridging between the two sectors, encourage transportation leadership, and focus on health care utilization to inform transportation service expansions).
LaMondia, J. J., et al. 2011. Comparing transit accessibility measures: A case study of access to health care facilities.
“Despite the continued interest in transportation accessibility, it is still unclear how different types of accessibility measures relate to one another and which situations are best for each. The current study undertakes a statistical comparison among four transit accessibility measures (representing three main categories of accessibility models) to determine whether they are comparable and/or interchangeable. Specifically, this analysis considers a case study to measure individuals’ access to health care via paratransit.
Results indicate that the three categories of accessibility measures provide drastically different interpretations of accessibility that cannot be duplicated by each other. Furthermore, the more closely accessibility models capture individuals’ perceptions and true access to activity opportunities, the more consistent and evenly distributed the results.”
Loehn, B., et al. 2011. Factors affecting access to head and neck cancer care after a natural disaster: A post-Hurricane Katrina survey. Head & Neck 33(1):37–44.
This study is a small survey (83 respondents) of “factors affecting access to cancer care in patients with head and neck cancer after Hurricane Katrina. . . . In the postdisaster environment, patients who felt the lack of access to cancer care post-Hurricane Katrina would have sought treatment earlier with better access to cancer care. These patients also reported difficulty obtaining cancer treatment. Availability of transportation affected access to cancer care in patients with early-stage cancers. Clinical, demographic, and socioeconomic factors did not influence access to cancer care.”
Marsico, D. J. 2014. Medicaid expansion and premium assistance: the importance of non-emergency medical transportation (NEMT) to coordinated care for chronically ill patients. Community Transportation 17–22.
“Millions of chronically ill Americans relied on the Medicaid program in 2013 for transportation to life-sustaining medical care, such as kidney dialysis and treatment for severe mental illnesses, as shown by new data. The non-emergency medical transportation program (NEMT) provides crucial access to health care for millions of Americans, the importance of which is delineated in this article; however, its funding is currently being threatened in some states (such as Iowa, Pennsylvania, and New Hampshire) as they are proposing to waive the NEMT assurance requirement in premium assistance plans.”
Martinelli, S., et al. 2011. Transport as a system: Reorganization of perinatal assistance in Northern Lombardy. Journal of Maternal-Fetal & Neonatal Medicine 24(Suppl 1):122–125.
“The organization of perinatal care has been a pivotal mean for improvement in neonatal survivals. Despite the excellent standard of assistance in Lombardy, Obstetrics and Neonatal Units of MBBM Foundation-Monza, Manzoni Hospital-Lecco, and Niguarda Hospital-Milan put forward a pilot project proposing reorganization of perinatal care in the northern part of Lombardy. The main goals of the project are implementation of maternal
transport system and use of neonatal back transport as a system to increase the availability of intensive care beds. The project’s fundamental steps and critical points will be discussed.”
Mattson, J. 2011. Transportation, distance, and health care utilization for older adults in rural and small urban areas. Transportation Research Record (2265):192–199.
“Transportation is vital for access to health care, especially in rural areas, where travel distances are great and access to alternative modes such as transit is less prevalent. This study estimated the impacts of transportation and travel distance on the utilization of health care services for older adults in rural and small urban areas. With data collected from a survey, a model was developed on the basis of the Health Behavior Model, which considered transportation and distance as factors that could enable or impede health care utilization. A random sample of individuals age 60 years and older living in the rural Upper Great Plains states of Montana, North Dakota, South Dakota, and Wyoming were surveyed by mail. Responses were received from 543 individuals (20 percent response rate). Probit models were used to estimate trip frequency and the likelihood that an individual would miss or would delay a health care trip. Distance and transportation variables were not found to influence significantly the total number of routine or chronic care trips made overall, while emergency care visits were affected by the availability of transportation options. Additional results showed that those who could not drive made more trips if someone in the household could drive and that distance and access to transportation affected the difficulty reported in making trips and the likelihood of missing or delaying a trip. The greatest problems for people using public transportation for health care trips were inconvenient schedules, the need to match transit and medical schedules, and infrequent service.”
Okoro, C. A., et al. 2005. Access to health care among older adults and receipt of preventive services. Results from the Behavioral Risk Factor Surveillance System, 2002. Preventive Medicine 40(3):337–343.
Okoro and colleagues examined data from the Behavioral Risk Factor Surveillance System for “various barriers to access of health care and their effect on obtaining preventive care. . . . Of the 46,659 respondents aged 65 years and older, 93 percent had a regular care provider, 98 percent had a regular place of care, and 98 percent were able to obtain needed medical care. Those with a regular care provider or a regular place of care were more likely to receive clinical preventive services than those without either
of these. Reasons for not obtaining needed medical care included transportation or distance (9 percent).”
Orellana, E. R., et al. 2015. Access to mental health and substance abuse services by people living with HIV/AIDS: The case manager perspective. Health & Social Work 40(2):E10–E14.
Cross-sectional survey data were collected from 113 case managers who work with people living with HIV/AIDS, with findings that included structural challenges to mental health and substance abuse treatment, such as limited transportation. “Service delivery systems recommendations include increased social support systems, co-located and integrated services, and training of case managers to motivate clients to seek mental health and substance abuse treatment.”
Othieno, J. 2007. Twin Cities care system assessment: Process, findings, and recommendations. Journal of Health Care for the Poor & Underserved 18(3 Suppl):189–213.
“The Twin Cities Care system lacks services that are most needed in the later stages of HIV disease. Services in highest demand included housing, transportation, and translation; available translations services are generally limited to Somali, Oromo, and Amharic, the languages most widely spoken by the three largest African immigrant and refugee groups in the Twin Cities. The care system is not well-integrated, and most of the work of moving clients within the system is done by case managers and care advocates. The main technical competencies identified by providers as lacking are understanding mental health from the perspective of African-born people living with HIV/AIDS (PLWH) and addressing sexual issues, especially with women. African providers with foreign certifications not recognized in the United States are not able to use their professional skills. African clients are not well informed about HIV, and African women are more likely than men to seek and stay in care.”
Parra-Medina, D., et al. 2004. Successful recruitment and retention strategies for a randomized weight management trial for people with diabetes living in rural, medically underserved counties of South Carolina: The POWER study. Journal of the American Dietetic Association 104(1):70–75.
“We evaluated the feasibility of recruiting overweight adults with diabetes, living in rural, medically underserved communities, to a weight management intervention consisting of a 12-month clinical trial of two weight management programs and usual care. The sampling frame consisted of
adults ages 45 years and older with clinically diagnosed diabetes from two community health centers. The recruitment process included medical record review, prescreening telephone call, two screening visits, and a randomization visit. More than 1,400 medical records were reviewed; 78.6 percent met eligibility criteria; 60.1 percent were contacted for telephone prescreening; and 35.5 percent remained eligible and were interested in participating. Of these, 187 completed visit 1, 164 completed visit 2, and 143 were randomized. Forty-six people were randomized who entered the study as walk-ins at screening visit 1, resulting in 189 subjects. The final yield was 21.5 percent. Subject mean age was 60.4 years, mean body mass index was 36.4 kg/m(2), 80 percent were African American, and 46.6 percent had less than a high school education. Retention at 12 months was 81.5 percent. Successful strategies included partnering with community health centers, positive reinforcement and social supportiveness, monitoring progress, and free transportation. This work provides a useful example of an academic-community partnership designed to reach groups previously considered hard to reach.”
Pieh-Holder, K. L., et al. 2012. Qualitative needs assessment: Health care experiences of underserved populations in Montgomery County, Virginia, USA. Rural & Remote Health 12:1816.
“The objective of the study was to investigate and describe the perceptions, beliefs, and practices that impact health care utilization among underserved populations in Montgomery County, Virginia. This study was conducted as part of a comprehensive community assessment to determine the feasibility of developing a [federally qualified health center].” Study participants “reported using various coping strategies to overcome barriers to accessing health care services. These strategies included delaying treatment and self-care; seeking financial and transportation assistance; and using community resources to navigate the system.”
Racine, E. F., et al. 2010. Farmers’ market use among African-American women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children. Journal of the American Dietetic Association 110(3):441–446.
“This quasi-experimental pilot study explored farmers’ market use among Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants and the effects of previous Farmers’ Market Nutrition Program participation on farmers’ market use. African-American women who were pregnant and enrolling in WIC in Washington, DC (N = 71), and Charlotte, NC (N = 108), participated in the study. Surveys
were completed in May and June 2007 measuring farmers’ market use, barriers to farmers’ market use, previous Farmers’ Market Nutrition Program participation, previous redemption of Farmers’ Market Nutrition Program vouchers, and dietary consumption. Women in Washington, DC, might have previously participated in the Farmers’ Market Nutrition Program, while women in Charlotte had no previous Farmers’ Market Nutrition Program participation. Analyses included descriptive, chi2 statistic, analysis of variance, and unadjusted and multiple logistic regression. Participants’ average age was 24 years, average education was 12.2 years, and average daily fruit/vegetable consumption was 7.5 servings. Participants in Charlotte and Washington, DC, without previous Farmers’ Market Nutrition Program participation had similar farmers’ market use rates (32.4 percent and 40 percent, respectively); those with previous Farmers’ Market Nutrition Program participation in Washington, DC, had higher farmers’ market use rates (61 percent) (P = 0.006). Previous participation in the Farmers’ Market Nutrition Program (odds ratio [OR]: 3.30; 95 percent confidence interval [CI]: 1.57 to 6.93), previous redemption of Farmers’ Market Nutrition Program vouchers (OR: 4.96; CI: 2.15 to 11.45), and higher fruit/vegetable consumption (OR: 2.59; CI: 1.31 to 5.12) were associated with farmers’ market use. Controlling for city, women who previously redeemed Farmers’ Market Nutrition Program vouchers were more likely to use a farmers’ market (OR: 6.90; CI: 1.54 to 31.00). Commonly reported barriers were lack of farmers’ markets close to home and lack of transportation to farmers’ markets. Women who received and redeemed Farmers’ Market Nutrition Program vouchers were much more likely to purchase fruits/vegetables at farmers’ markets. Future research to explore barriers and incentives for farmers’ market use among WIC participants in urban and rural settings is warranted.”
Rosenbaum, S., et al. 2009. Medicaid’s medical transportation assurance: Origins, evolution, current trends, and implications for health reform. Policy brief (The George Washington University Center for Health Services Research and Policy) 1–24.
“This policy brief examines Medicaid’s assurance of medical transportation in the context of medically necessary but nonemergency health care. Reviewing the origins and evolution of the assurance and presenting the results of a 2009 survey of state Medicaid programs, the results of this analysis underscore Medicaid’s unique capacity to not only finance medically necessary health care but also the services and supports that enable access to health care by low-income persons since Medicaid covers nonemergency medical transportation. This ability to both finance health care and enable its use moves to the forefront as Congress considers whether to
assist low-income persons in health reform through Medicaid expansions or via subsidies for traditional health insurance, which typically does not provide comparable transportation coverage.”
Sagrestano, L. M., et al. 2014. Transportation vulnerability as a barrier to service utilization for HIV-positive individuals. AIDS Care 26(3):314–319.
“Research suggests that transportation vulnerability can negatively impact adherence to HIV-related medical treatment. Moreover, transportation can be a barrier to accessing ancillary services that can increase positive health outcomes for HIV-positive individuals. This study examines transportation vulnerability and its impact on HIV-related health and ancillary service utilization in the Mid-South Region. Focus groups and interviews were conducted with service providers and HIV-positive individuals, and survey data were collected from HIV-positive individuals (N = 309) using the five A’s of access to frame transportation vulnerability: availability, accessibility, accommodation, affordability, and acceptability. Study results indicate that transportation vulnerability can present significant barriers to service utilization for HIV-positive individuals, including insufficient transportation infrastructure, incompatible fit between transportation and health systems, and insensitivity to privacy issues. One consequence of transportation vulnerability is reliance on weaving together multiple modes of transport to access care and ancillary services, creating additional barriers to service utilization and medical adherence. The research team recommends more investment in public transit systems, expanded services, and innovative approaches to solving procedural problems.”
Sanchez, T. W., et al. 2007. Integrating urban service delivery research for distributional analyses and transport equity.
“In metropolitan regions, public services such as public transit, parks, libraries, health services, public safety, etc., are not provided in such a way that all segments of the population have equal access to these services. The most frequently discussed impacts of unfair distribution of public services is the physical and social segregation of those receiving a greater share of benefits from those receiving a lesser share of benefits. Research has shown that biased service delivery occurs in relation to income class, race, and ethnicity, typically in relation to urban location. Because transportation service benefits and costs are distributed geographically and influence the location patterns of both social and economic classes, the examination of spatial patterns of transportation service benefits has inherent equity implications. Cases where citizens feel that there is unequal treatment by transportation services have been tested in court, especially where blatant cases of
racial discrimination have been presented. Although current laws prohibit discrimination in the provision of public services, institutional factors at the local and regional levels have neglected the issue of equitable service provision planning. This paper reviews approaches on undertaking analyses of distributional impacts or effects of transportation investments. We also propose a framework by which planning agencies, such as Metropolitan Planning Organizations, can conduct equity analyses based on concepts of distributional equity. There are strong linkages between distributional analysis and concerns expressed by advocates for [environmental justice] and transport equity.”
Sarnquist, C. C., et al. (2011). Rural HIV-infected women’s access to medical care: Ongoing needs in California. AIDS Care-Psychological and SocioMedical Aspects of AIDS/HIV 23(7):792–796.
“HIV-infected women living in rural areas often have considerably less access to care than their urban and suburban counterparts. In much of the USA, little is known about HIV care among rural populations. This study elucidated barriers to care for rural women in California. Methods included retrospective structured interviews conducted with 64 women living in rural areas and receiving HIV care at 11 California health care facilities. Facilities were randomly sampled and all HIV-infected female patients seeking care at those facilities during a specified time period were eligible. The most commonly cited barriers to accessing care included physical health problems that prevented travel to care (32.8 percent), lack of transportation (31.2 percent), and lack of ability to navigate the health care system (25.0 percent). Being divorced/separated/widowed (compared to being either married or single) was associated with reporting physical health as a barrier to care (p = 0.03); being unemployed (p = 0.003) or having to travel 31–90 minutes (p = 0.007, compared to less than 31 or greater than 90) were both associated with transportation as a barrier; and speaking English rather than Spanish was associated with reporting ‘difficulty navigating the system’ (p = 0.04). Twenty-nine women (45.3 percent) reported difficulty in traveling to appointments. Overall, 24 (37.5 percent) women missed an HIV medical appointment in the previous 12-month period, primarily due to their physical health and transportation limitations. Physical health and transportation problems were both the major barriers to accessing health services and the primary reasons for missing HIV care appointments among this population of HIV-infected women living in rural areas. Providing transportation programs and/or mobile clinics, as well as providing support for patients with physical limitations, may be essential to improving access to HIV care in rural areas.”
Schmalzried, H. D., and L. F. Fallon. 2012. Reducing barriers associated with delivering health care services to migratory agricultural workers. Rural and Remote Health 12(3).
The primary purpose of this study was to describe issues related to barriers associated with the delivery of health care services to migratory agricultural workers. A secondary purpose was to suggest strategies for reducing these barriers. Focus group data were used to develop a survey administered to migrant agricultural workers in employer-provided camps in Northwest Ohio. Based on 157 usable surveys, the researchers found that the most significant barriers to health care encountered by the migrant agricultural workers included travel distance (N = 88; 56.1 percent) and transportation (N = 82; 52.2 percent). “Approximately half (N = 82; 52.2 percent) said that they had access to transportation for traveling to a medical clinic. As a group, respondents were willing to travel an average of 29.1 km (18.1 miles) (range 0–129 km [0–80 miles]) to obtain medical services. Female heads of households had significantly less access to transportation compared with male heads of households (t = 2.35; df = 74; p < 0.05).” These data can inform providers in helping address barriers to health care, and that “can reduce the use of high cost hospital emergency room care.”
Schopp, L. H., et al. 2007. Life activities among individuals with spinal cord injury living in the community: Perceived choice and perceived barriers. Rehabilitation Psychology 52(1):82–88.
The study’s objective was to “apply the World Health Organization model of functioning to a study of perceived choice over life activities and barriers to engaging in life activities among persons with spinal cord injury” on a large community-dwelling sample that included 255 participants from 2 urban sites and 1 rural site. Researchers found that “[a]pproximately half of the participants reported little or no perceived choice with employment, and the majority reported low levels of satisfaction with choice with employment. Access to employment was limited by physical barriers (48 percent) and transportation (46 percent).” The study concluded that improvements of transportation accessibility along with other changes are needed enable persons with spinal cord injury participate in life activities.
Schwaderer, K. A., and J. K. Itano. 2007. Bridging the health care divide with patient navigation: Development of a research program to address disparities. Clinical Journal of Oncology Nursing 11(5):633–639.
“Americans who live in poverty as well as certain ethnic and racial groups have higher cancer death rates than other populations. Patient
navigators have been identified as an important weapon against these disparities. Navigators can address insurance, financial, and logistical issues (e.g., transportation, appointment scheduling, child or elder care). They can provide understandable health education that may lessen fears of cancer diagnosis and treatment. This article describes the development and implementation of a multisite patient navigator program involving five cancer institutions in Western Pennsylvania. Navigator programs have great potential to enhance cancer care by reaching underserved populations and opening the door for future research.”
Silver, D., et al. 2012. Transportation to clinic: Findings from a pilot clinic-based survey of low-income suburbanites. Journal of Immigrant and Minority Health 14(2):350–355.
“Health care policy makers have cited transportation barriers as key obstacles to providing health care to low-income suburbanites, particularly because suburbs have become home to a growing number of recent immigrants who are less likely to own cars than their neighbors. In a suburb of New York City, we conducted a pilot survey of low income, largely immigrant clients in four public clinics, to find out how much transportation difficulties limit their access to primary care. Clients were receptive to the opportunity to participate in the survey (response rate = 94 percent). Nearly one-quarter reported having transportation problems that had caused them to miss or reschedule a clinic appointment in the past. Difficulties included limited and unreliable local bus service, and a tenuous connection to a car. Our pilot work suggests that this population is willing to participate in a survey on this topic. Further, since even among those attending clinic there was significant evidence of past transportation problems, it suggests that a population-based survey would yield information about substantial transportation barriers to health care.”
Smith, R. J., et al. 2013. Conceptualizing age-friendly community characteristics in a sample of urban elders: An exploratory factor analysis. Journal of Gerontological Social Work 56(2):90–111.
“Accurate conceptualization and measurement of age-friendly community characteristics would help to reduce barriers to documenting the effects on elders of interventions to create such communities. This article contributes to the measurement of age-friendly communities through an exploratory factor analysis of items reflecting an existing U.S. Environmental Protection Agency policy framework. From a sample of urban elders (N = 1,376), we identified six factors associated with demographic and health characteristics: access to business and leisure, social interaction,
access to health care, neighborhood problems, social support, and community engagement. Future research should explore the effects of these factors across contexts and populations.”
Strunin, L., et al. 2007. Understanding rehospitalization risk: Can hospital discharge be modified to reduce recurrent hospitalization? Journal of Hospital Medicine (Online) 2(5):297–304.
A very small (N = 21) “qualitative study was conducted in order to understand the phenomenon of frequent rehospitalization from the perspective of discharged patients and to determine if activities at the time of discharge could be designed to reduce the number of adverse events and rehospitalization.” Limitations in transportation to medical appointments, among other supports, were frequently mentioned as a barrier post-discharge.
Thurman, D. J., et al. 2016. Health-care access among adults with epilepsy: The U.S. National Health Interview Survey, 2010 and 2013. Epilepsy & Behavior 55:184–188.
The authors intended to identify barriers to health care for adults with epilepsy based on data from U.S. adults in the 2010 and 2013 National Health Interview Survey. Employing SAS-callable SUDAAN software, the researchers “obtained weighted estimates of population proportions and rate ratios (RRs) adjusted for sex, age, and race/ethnicity.” They found that adults with active epilepsy are more likely to report being unemployed, disabled, unable to afford medication, and to report transportation as a barrier to health care (RR = 5.28).
Valverde, E., et al. 2004. Characteristics of Ryan White and non-Ryan White funded HIV medical care facilities across four metropolitan areas: Results from the Antiretroviral Treatment and Access Studies site survey. AIDS Care 16(7):841–850.
“The Ryan White Comprehensive AIDS Resources Emergency Act 1990 (CARE Act) is one of the largest federal program funding medical and support services for individuals with HIV disease. Data that report services and gaps in service coverage from the organizational perspective are very limited. The Antiretroviral Treatment and Access Studies included a mail survey of 176 HIV medical care facilities in four U.S. inner cities on clinic characteristics, services and practices, and patient characteristics. Characteristics of 143 (85 percent) responding Ryan White (RW)–funded and non-RW–funded facilities are described. RW–funded facilities reported offering
more services than non-funded facilities including evening/weekend hours (49 percent vs. 18 percent), transportation (71 percent vs. 22 percent), and on-site risk reduction counselling (88 percent vs. 55 percent). More RW–funded facilities reported offering on-site adherence support services, such as support groups (44 percent vs. 12 percent), formal classes (20 percent vs. 2 percent), and pillboxes (83 percent vs. 43 percent), and served a larger proportion of uninsured patients (41 percent vs. 4 percent) than non-funded facilities. Our analysis showed that the RW–funded HIV care facilities offered more clinic, non-clinic, and adherence support services than non-RW–funded facilities, indicating that the disparities in services were still related to CARE Act funding, controlling for private-public facility type.”
Ward, B. G. 2009. Disaggregating race and ethnicity: Toward a better understanding of the social impacts of transport decisions. Public Works Management & Policy 13(4):354–360.
“By 2042, racial and ethnic subgroups are predicted to make up more than half of the U.S. population. This shift in population distribution, along with population growth and an aging population, will present new challenges for all segments of society, including transportation. This paper provides an overview of the differences in and among ethnic and racial subgroups of the U.S. population and the intersections of these with age, functionality and geography. Adverse health outcomes may be anticipated where racial and ethnic minorities experience lack of access and mobility due to geographic isolation, income, and limited mental and physical functionality. Transportation’s role in increasing access and mobility may aid in offsetting or mitigating these adverse effects. Greater investments in pedestrian and bicycle facilities may aid in offsetting adverse health outcomes by providing safe places to walk and bicycle. Coordination of human service and public transportation may also serve to mitigate some of the adverse conditions by improving access to health care facilities and other activities that improve mobility.”
Washington, D. L., et al. 2011. Access to care for women veterans: Delayed health care and unmet need. Journal of General Internal Medicine 26: S655–S661.
A survey of 3,611 women veterans was used to examine both general and veteran-specific reasons for delaying health care or for unmet needs. “Among those delaying or going without care, barriers that varied by age group were: unaffordable health care (63 percent of 18–34 versus 12 percent of 65-plus age groups); inability to take off from work (39 percent of those <50); and transportation difficulties (36 percent of 65-plus).” The
study concluded that many of the identified barriers to health care access “are potentially modifiable through expanded VA health care and social services.”
Wheeler, K., et al. 2007. Inpatient to outpatient transfer of diabetes care: Perceptions of barriers to postdischarge followup in urban African American patients. Ethnicity & Disease 17(2):238–243.
This study sought to identify barriers to postdischarge followup of hospitalized diabetes patients transferring to outpatient care in urban areas. “Of 303 respondents (average age 50 years, 46 percent women, 91 percent African American), 95 percent indicated that they planned to use follow-up services” and half of respondents anticipated barriers, with transportation as a primary challenge. These findings are important to inform discharge planning, especially for “minority populations at particular risk for diabetes and its complications.”
Levasseur, M., et al. 2015. Importance of proximity to resources, social support, transportation and neighborhood security for mobility and social participation in older adults: Results from a scoping study. BMC Public Health 15(1) 19p.
“Since mobility and social participation are key determinants of health and quality of life, it is important to identify factors associated with them. Although several investigations have been conducted on the neighborhood environment, mobility, and social participation, there is no clear integration of the results. This study aimed to provide a comprehensive understanding regarding how the neighborhood environment is associated with mobility and social participation in older adults. A rigorous methodological scoping study framework was used to search nine databases from different fields with 51 keywords. Data were exhaustively analyzed, organized, and synthesized according to the International Classification of Functioning, Disability and Health (ICF) by two research assistants following PRISMA guidelines, and results were validated with knowledge users. The majority of the 50 selected articles report results of cross-sectional studies (29; 58 percent), mainly conducted in the United States (24; 48 percent) or Canada (15; 30 percent). Studies mostly focused on neighborhood environment associations with mobility (39; 78 percent), social participation (19; 38 percent), and occasionally both (11; 22 percent). Neighborhood attri-
butes considered were mainly ‘Products and technology’ (43; 86 percent) and ‘Services, systems and policies’ (37; 74 percent), but also ‘Natural and human-made changes’ (27; 54 percent) and ‘Support and relationships’ (21; 42 percent). Mobility and social participation were both positively associated with proximity to resources and recreational facilities, social support, having a car or driver’s license, public transportation and neighborhood security, and negatively associated with poor user-friendliness of the walking environment and neighborhood insecurity. Attributes of the neighborhood environment not covered by previous research on mobility and social participation mainly concerned ‘Attitudes,’ and ‘Services, systems and policies.’ Results from this comprehensive synthesis of empirical studies on associations of the neighborhood environment with mobility and social participation will ultimately support best practices, decisions and the development of innovative inclusive public health interventions including clear guidelines for the creation of age-supportive environments. To foster mobility and social participation, these interventions must consider proximity to resources and to recreational facilities, social support, transportation, neighborhood security and user-friendliness of the walking environment. Future studies should include both mobility and social participation, and investigate how they are associated with ‘Attitudes,’ and ‘Services, systems and policies’ in older adults, including disadvantaged older adults.”
Prohaska, T., K. MacLeod, S. Hughes, M. Smith, W. Satariano, A. Eisenstein, and F. Dabbous. 2012. Data analyses: Assessing the intersection between health and transportation.
“This report summarizes activities the research team completed to analyze LogistiCare data as part of Phase 2 of the project ‘Assessing the Intersection between Health and Transportation.’ Progress and findings reported here are based on the conduct of analyses of the database provided by LogistiCare to address proposed objectives. This research was funded by the U.S. Department of Transportation Federal Transit Administration cooperative agreements Easterseals Project ACTION (ESPA) and the National Center on Senior Transportation (NCST). Easterseals’ ESPA program and Easterseals and n4a’s NCST program are training and technical assistance centers that support the expansion of accessible transportation for people with disabilities of all ages and increasing transportation options for older adults.” The report analyzes data from the LogistiCare data file, eligibility files, and Census data, for five states with at least 5 years of complete data on LogistiCare Nonemergency Medical Transportation use (Delaware, Mississippi, Nevada, Oklahoma, Virginia).”
Prohaska, T., A. Eisenstein, S. Hughes, D. Ragland, K. MacLeod, W. Satariano, and F. Dabbous. 2012. Assessing the intersection between health and transportation: Literature review.
“This report summarizes activities the research team completed to conduct the literature review as part of the project Assessing the Intersection between Health and Transportation, funded by the Federal Transit Administration cooperative agreements, Easterseals Project ACTION in partnership with the National Center for Senior Transportation, and with in-kind contributions from LogistiCare and the American Medical Association. Findings reported here are based on a Phase 2 conduct of a literature review/summary of the literature on aging, health, and transportation. The purpose of the review was to identify what can be learned about the association between people with disabilities of all ages—with a particular focus on older adults who acquire functional changes that impact mobility. We report their need and use of transportation services in the context of health through an examination of the literature. The findings are summarized and recommendations for future research and policy are offered.”
Syed, S. T., et al. 2013. Traveling towards disease: Transportation barriers to health care access. Journal of Community Health 38(5):976–993.
“Transportation barriers are often cited as barriers to health care access. Transportation barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed medication use. These consequences may lead to poorer management of chronic illness and thus poorer health outcomes. However, the significance of these barriers is uncertain based on existing literature due to wide variability in both study populations and transportation barrier measures. The authors sought to synthesize the literature on the prevalence of transportation barriers to health care access. A systematic literature search of peer-reviewed studies on transportation barriers to health care access was performed. Inclusion criteria were as follows: (1) study addressed access barriers for ongoing primary care or chronic disease care; (2) study included assessment of transportation barriers; and (3) study was completed in the United States. In total, 61 studies were reviewed. Overall, the evidence supports that transportation barriers are an important barrier to health care access, particularly for those with lower incomes or the under/uninsured. Additional research needs to (1) clarify which aspects of transportation limit health care access, (2) measure the impact of transportation barriers on clinically meaningful outcomes, and (3) measure the impact of transportation barrier interventions and transportation policy changes.”
Whelan, M., et al. 2006. The elderly and mobility: A review of the literature. 134p.
“The ability to travel is associated with freedom, activity, and choice, and driving offers an important mobility option for most elderly. Driving cessation is linked to an increase in depressive symptoms and a decline in out-of-home activity levels and community mobility. Further, for at least some people, the same health conditions and functional impairments that cause a change in driving patterns will also limit access to other transport options (walking, cycling, public transport), thereby further contributing to restricted community mobility and its consequences. Driving status thus plays a critical role in the complex interactions among aging, physical and psychological health, community mobility, and use of health services. A good understanding of these relationships is required in order to enable older people to maintain economic and social participation and quality of life. This report provides a comprehensive review of international literature to assess the current state of knowledge with regard to the complex relationships between changing driving and travel patterns, aging, health status, and reduced mobility and the impact of poor mobility on quality of life. The findings from the literature review were used to compile a set of ‘best-practice’ recommendations to effectively manage the safe mobility of elderly road users. It is recommended that a coordinated approach that encompasses innovative strategies and initiatives to manage the mobility of older road users be adopted. Such an approach should include measures that focus on safer road users (appropriate management of ‘at-risk’ older drivers through appropriate licensing procedures and development of targeted educational and training programs), safer vehicles (improved crashworthiness of vehicles, raising of awareness among older drivers of the benefits of occupant protection, and development of ITS technologies), safer roads (creating a safer and more forgiving road environment to match the characteristics and needs of older road users), and improvements to alternative transport options (provision of accessible, affordable, safe and coordinated transport options that are tailored to the needs of older adults and promotion and awareness of alternative transport options among older drivers and their families/caregivers). Options for further research are also highlighted. Poor mobility places a substantial burden on the individual, families, community, and society, and there is a real need for policy makers, local governments, and communities to consider the transportation needs of the elderly to support ongoing mobility.”
Wright, D. B. 2008. No way to go: A review of the literature on transportation barriers in health care. World Transport Policy & Practice 14(3):7–23.
“This article presents a systematic review of the literature on transportation barriers to health care access and transportation interventions designed to reduce these barriers. The author conducted a systematic review of the published, peer-reviewed literature on transportation and access to health care in the United States from 1965 to the present using the MEDLINE and TRIS databases. Of the 35 studies identified, 23 were cross-sectional, 9 were qualitative, and 3 were longitudinal. The author considers transportation as an enabling resource, the lack of transportation as an access barrier, and seeks to identify what transportation barriers exist, whom they effect, and what the consequences of those barriers are. The study showed that transportation barriers were greatest among those under the age of 18 and over the age of 65, those on low-income, the unemployed, and those in fair or poor health. The findings from several transportation interventions can be used to determine possible cost-effective approaches to increasing access to health care. The author concludes that transportation barriers prevent millions of Americans from accessing health care. These transportation barriers can be overcome by designing user-friendly, cost-effective interventions that achieve buy-in from the target community.”
Clarke, P. M. 2002. Testing the convergent validity of the contingent valuation and travel cost methods in valuing the benefits of health care. Health Economics 11(2):117–127.
“In this study, the convergent validity of the contingent valuation method (CVM) and travel cost method (TCM) is tested by comparing estimates of the willingness to pay (WTP) for improving access to mammographic screening in rural areas of Australia. It is based on a telephone survey of 458 women in 19 towns, in which they were asked about their recent screening behavior and their WTP to have a mobile screening unit visit their nearest town. After eliminating missing data and other non-usable responses, the contingent valuation experiment and travel cost model were based on information from 372 and 319 women, respectively. Estimates of the maximum WTP for the use of mobile screening units were derived using both methods and compared. The highest mean WTP estimated using the TCM was $83.10 (95 percent CI $99.06–$68.53), which is significantly less than the estimate of $148.09 ($131.13–$166.60) using the CVM. This could be due to the CVM estimates also reflecting non-use values such as altruism, or a range of potential biases that are known to affect both methods. Further tests of validity are required in order to gain a greater understanding of the relationship between these two methods of estimating ETP.”
Cronin, J. 2008. Florida transportation disadvantaged services: Return on investment study.
This study attempts to assess the value state and local governments realize on their investments in programs that serve transportation disadvantaged groups (i.e., needing assistance with trips for medical, employment, nutrition, education, and life-sustaining purposes). The study concludes that trips for medical purposes bring the second highest return on investment, estimating a “payback” of $11.08 for every dollar invested.
Delamater, P. L., et al. 2012. Measuring geographic access to health care: Raster and network-based methods. International Journal of Health Geo-graphics 11(1):15.
“Inequalities in geographic access to health care result from the configuration of facilities, population distribution, and the transportation infrastructure. In recent accessibility studies, the traditional distance measure (Euclidean) has been replaced with more plausible measures such as travel distance or time. Both network and raster-based methods are often utilized for estimating travel time in a Geographic Information System. Therefore, exploring the differences in the underlying data models and associated methods and their impact on geographic accessibility estimates is warranted.” This case study examined Limited Access Areas defined by Michigan’s Certificate of Need (CON) Program and found that “[o]ver all permutations, the raster-based method identified more area and people with limited accessibility. The raster-based method was more sensitive to travel speed settings, while the network-based method was more sensitive to the specific population assignment method employed in Michigan.” Researchers further found that “[c]onsidering that the choice of data model/method may substantially alter the outcomes of a geographic accessibility analysis, we advise researchers to use caution in model selection” and recommended that Michigan “adopt the network-based method or reevaluate the travel speed assignment rule in the raster-based method” and “revisit the population assignment method.”
Economic & Planning Systems, Inc., Minnesota Department of Transportation, and Smart Growth America. 2014. Metrics for transportation investments that support economic competitiveness, social equity, environmental stewardship, public health, and livability. Minnesota Department of Transportation.
This working paper provides a new framework for evaluating transportation projects in Minnesota based on established and emerging practices
in the field of public sector return on investment (ROI). The paper outlines types of metrics for economic competitiveness, social equity, environmental stewardship, public health, and livability. Types of ROI metrics for social equity include improved access for economically depressed neighborhoods or rural services, and accessibility for individuals with disabilities or other disadvantages. Types of data include change in travel time to key origins/destinations for economically distressed or rural areas, and percentage of income spent on transportation.
Fasihozaman Langerudi, M., et al. 2015. Health and transportation: Small scale area association. Journal of Transport & Health 2(2):127–134.
“Public health, as a major factor influencing the livability and well-being of a community has been a subject of interest in many academic fields. It is postulated that public health has strong correlations with various factors including land development, urban form, and transportation system elements. However, due to scarcity of individual-level and confidential health data, such analysis has been typically conducted in an aggregate level resulting in less accurate results due to aggregation bias. In this paper, a methodology is developed and applied to disaggregate an individual-level health data in county scale into smaller geography by using an iterative proportional fitting approach while maintaining the marginal distributions of the controlled variables. Then, the disaggregated data are used to estimate various models of individual health condition as a function of socio-demographic, built environment, and transportation system attributes. It is noteworthy that the proposed approach can be applied to disaggregate any aggregate data in an efficient way.”
Grant, R., D. Johnson, S. Borders, D. Gracy, T. Rostholder, and I. Redlener. 2012. The Health Transportation Shortage Index: The development and validation of a new tool to identify underserved communities. Children’s Health Fund.
“Based on national and regional health survey data, Children’s Health Fund has developed a new tool, the Health Transportation Shortage Index (HTSI), to help identify areas and communities where transportation shortages contribute to difficulty getting health care.”
HTSI is designed to “serve as a tool to guide users in the assessment of the most important factors associated with transportation barriers to child health care access. The HTSI factors are: 1) population as a proxy for rural area and for travel distance; 2) poverty as a proxy for automobile ownership; 3) public transportation availability; and 4) health care provider workforce availability. Points are assigned for each factor based on area
characteristics and are added together. Higher scores indicate greater risk for transportation barriers to child health care access.”
Health Outreach Partners. 2014. 2013 National needs assessment of health outreach programs.
This report provides findings from an online survey of 104 health outreach professionals from community health centers across the nation. Transportation was one of the core themes, with a finding that 52 percent of respondents identified lack of transportation as a barrier for their clients. Transportation was also listed as one of the top 6 “outreach” services provided by the health centers, with 21 percent (of 89 respondents) listing it among the top 3 most frequently provided.
The Lewin Group. 2013. Exploratory study of the global outcomes of the older americans act programs and services.
This is a study that explores the data sources relevant to measuring impact/association of Older Americans Act programs and services used by older adults on the key outcomes of “health care utilization, home and community-based services (HCBS) expenditures, NH admissions, and community tenure.” HCBS include access services (e.g., transportation) that allow older adults to continue to live in their homes as long as possible. The literature review included findings that specific demographic groups had greater likelihood of using transportation services, and also discusses the comparative cost associated with transportation services for specific HCBS programs.
National Center on Senior Transportation. 2010. Transportation the silent need: Results of a national survey of area agencies on aging. Trend Report 1.
The report “details the results of a nationwide survey of the AAAs [area agencies on aging], conducted by the NCST during the late summer/fall of 2009. The report provides baseline information about AAAs’ involvement in transportation advocacy, planning and service delivery, as well as information about the availability of senior transportation nationwide.”
Rodman, W., D. Berez, and S. Moser. 2016. The National Mobility Management Initiative: State DOTs connecting specialized transportation users and rides. Final report. Transportation Research Board.
This Task 60 report and toolkit are designed to assist state DOTs—and other state, regional, and local entities from the planning, transit, and
human service agency communities—with the process of designing, developing, implementing, and evaluating linkages that connect customers of specialized transportation services and programs with rides. Target customers for most of these linkages have included people with disabilities, seniors, persons with low income, and veterans. The research unveiled though that most states, regions, and local entities have more broadly included other types of customers and a broader range of transportation services and programs beyond “specialized” transportation services, including human services agency transportation and transportation services available to the general public. The research unveiled different levels of linkage functionality, including those linkages that provide service matching, trip planning, and even trip booking from customers’ smartphones. Descriptions of each level of functionality along with case studies are provided. The stand-alone toolkit also directs lead agencies and partners through the decision process of what makes sense for their state, region, or county and with budget limitations in mind. Design decisions and evaluation criteria tailored to each functionality level are also provided.
Shier, G., et al. 2013. Strong social support services, such as transportation and help for caregivers, can lead to lower health care use and costs. Health Affairs 32(3):544–551.
“A growing evidence base suggests services that address social factors with an impact on health, such as transportation and caregiver support, must be integrated into new models of care if the Institute for Health care Improvement’s Triple Aim is to be realized. We examined early evidence from seven innovative care models currently in use, each with strong social support services components. The evidence suggests that coordinated efforts to identify and meet the social needs of patients can lead to lower health care use and costs, and better outcomes for patients. For example, Senior Care Options—a Massachusetts program that coordinates the direct delivery of social support services for patients with chronic conditions and adults with disabilities—reported that hospital days per 1,000 members were just 55 percent of those generated by comparable patients not receiving the program’s extended services. More research is required to determine which social service components yield desired outcomes for specific patient populations. Gaining these deeper insights and disseminating them widely offer the promise of considerable benefit for patients and the health care system as a whole.”