Dialysis Transportation: The Intersection of Transportation and Healthcare (2019)

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Chapter 6—Initiatives on the Transportation Side 6.1 Introduction This chapter responds to the second of the two stated objectives for the TCRP research project—to identify effective practices and new strategies for providing and funding transportation for dialysis. Chapter 4 described a number of projects and programs directly or indirectly related to dialysis transportation that have been initiated on the healthcare side, such as the pilots under way through CMS’s Center for Medicare and Medicaid Innovation. In contrast, this chapter describes practices and strategies initiated by transit agencies and identi�ied through the research project’s survey of more than 500 transit agencies, as well as by additional outreach to the transit industry. Transit Agency Initiatives in Five Categories The transit agencies’ practices and strategies are categorized into �ive groups: Policies enacted by transit agencies to provide more ef�icient and effective service for the agencies’ riders who travel to and from dialysis facilities. Education and outreach to dialysis facilities and transit riders that explain what the transit agency can and cannot do to serve dialysis trips and how transit riders can use the services more effectively. Operational strategies deployed to serve dialysis riders more effectively. Coordination with dialysis facilities where the transit agency works cooperatively with dialysis facility staff to plan and schedule trips for dialysis riders. Funding beyond traditional public transit grants that provide support for dialysis transportation. Chapter 6 Initiatives on the Transportation Side

6.2 Dialysis Transportation: The Intersection of Transportation and Healthcare Policies Fare Policy Encouraging Trips to Closest Dialysis Facility— Senior Citizens United Community Services, Audubon, NJ Transportation Agency Background Senior Citizens United Community Services (SCUCS) is a non-pro�it agency serving older adults and persons with disabilities in Camden, Burlington, and Gloucester counties, New Jersey. The agency provides a wide range of services, from in-home care, meals on wheels, and housing assistance, as well as specialized transportation service. Camden County’s transportation service is operated by SEN-HAN Transit, serving county residents 60 years of age or older and individuals with disabilities certi�ied by SCUCS. Eligible riders can make trip reservations from 2 days to 2 weeks in advance. In addition to the specialized service, the agency provides shopping service, which is open to all residents in the 24 municipalities in Camden County that do not have their own local shopping bus. Description Camden County’s specialized transportation service includes provision of non- emergency medical trips to the eligible riders. Service is provided on a door- to-door basis to doctors’ of�ices and medical facilities, as well as to the hospital in the county. Dialysis facilities are among the medical facilities served (there are four in Camden County). The fare is a requested $2.00 donation for each one-way trip. Additionally, limited service is provided to medical destinations in the Center City district of Philadelphia. With growing demand for dialysis trips, the agency adopted a fare policy in 2008 that encourages dialysis riders to have treatment at the dialysis facility closest to their trip origin, typically their home. The agency found it was scheduling dialysis trips to dialysis centers some distance from the rider’s home even though there was at least one closer dialysis center. For example, a rider might have requested a dialysis trip from Pennsauken to a dialysis facility in Voorhees, a distance of 15 miles, when there was a dialysis center closer to the rider’s home.

Chapter 6—Initiatives on the Transportation Side 6.3 The adopted policy requires a $3.00 fee for each dialysis center that is passed should the rider’s scheduled trip go beyond one or more dialysis centers when traveling to the rider’s selected dialysis center. Before implementation of the policy, the agency met with the staff at the dialysis centers to explain the new policy and reasons behind it. While there was some consternation at �irst, the staff understood why the policy was appropriate and accepted its implementation. After implementation and a few complaints and comments from riders, the small number of riders who were affected were grandfathered in and not charged the extra fee for traveling to their selected dialysis center even though there was a center closer to their home. Results Results of the policy are twofold. First, there are currently no dialysis riders who have booked trips to a dialysis center that is not the closest one to their home. In this regard, the policy has been effective. However, the agency noted that around the same time that the fare policy was adopted, it had to reduce its transportation service level, including service for medical trips, because of funding constraints. This meant fewer medical trips, including dialysis trips, at the same time the policy was adopted, thus the results of the policy were perhaps muted. Second, adoption of the policy initiated cooperation and coordination between the transit agency and the dialysis centers, which has resulted in more effective service—for the transit agency as well as for the dialysis centers. Staff at the dialysis centers realized that working jointly with the transit agency on their patients’ trip would ensure more effective service for their patients. Summary and Transferability Following outreach and discussion with the dialysis facilities in its service area, SCUCS adopted a fare policy for one of the two counties it serves—Camden— that encourages riders on dialysis to use the dialysis facility closest to their home. Should the rider choose to be treated at a more distant facility, the policy requires a $3.00 fee for each dialysis facility that is passed on the way to the chosen facility. All the dialysis riders currently served by the agency in Camden County use the dialysis facility closest to their home. The fare policy has had its intended effect, and the dialysis trips are shorter than previously with greater opportunity to group the trips for increased productivity.

6.4 Dialysis Transportation: The Intersection of Transportation and Healthcare An important secondary bene�it to the implementation of the fare policy was the start of coordination with the dialysis facilities. Staff realized that cooperating with SCUCS would result in better service for their patients who rely on public transit. Such a fare policy can be considered by a transit agency providing specialized transportation service. But a transit agency providing ADA paratransit has less latitude for differential fares for trips within the ADA service area. It might be possible to craft a policy that provides incentives for riders to use their closest dialysis facility with subscription service, which is not mandated by the ADA, as long as ADA’s mandated service criteria are met. Should a transit agency consider adopting such a fare policy, SCUCS’s experience points to the key role of outreach to the dialysis facilities prior to formal adoption to explain the policy and why it is important for the transit agency’s operations. The outreach might then initiate a cooperative relationship with the dialysis facilities should one not exist already. SCUCS’s experience also suggests that grandfathering in riders who might be negatively impacted by this type of fare policy will ease the policy’s acceptance in the community. Contact SCUCS 537 Nicholson Road Audubon, NJ 08106 856-456-1121 http://scucs.org/ Standing Order Policy for Dialysis Riders—Intercity Transit, Olympia, WA Transportation Agency Background Intercity Transit serves the Washington State capital city, Olympia, and the neighboring cities of Lacey, Tumwater, and Yelm. Intercity Transit provides �ixed route bus service, vanpool and carpool service, and ADA paratransit. The transit agency also has several other programs supporting its mission "to provide and promote public transportation choices that support an accessible, sustainable, livable, healthy, prosperous community," including travel training and a youth education program. In 2016, the transit agency provided about 4.9 million trips on its various services.

Chapter 6—Initiatives on the Transportation Side 6.5 Photo courtesy of Intercity Transit. Description Intercity Transit’s ADA paratransit service— known as Dial-A-Lift—provides door-to-door service for riders whose disabilities prevent their use of the transit agency’s �ixed route service. Dial- A-Lift served over 166,000 trips in FY 2016, with a �leet of 35 vans. Of total trips in FY 2016, an estimated 10,500 trips were for dialysis, which is 6% of the Dial-A-Lift total. Medical trips, including those for dialysis, have increased in recent years. According to a 2015 ridership survey that asked riders their trip purpose, trips for medical appointments/dialysis/rehabilitation were the most frequent trip purpose at 42%, representing an increase from 36%, which was measured 4 years earlier in a 2011 rider survey. The demand for dialysis trips experienced by Intercity Transit is most likely related to the growth in the number of dialysis facilities in the community. In 2008, there was only one dialysis facility in the transit agency’s service area; less than 10 years later, there were �ive. Subscription Service Policy Intercity Transit's policy for riders who wish to set up subscription service— so that routine trips are scheduled automatically without the need to contact the transit agency to request each individual trip—requires that riders �irst establish a 30-day "history" of trip-making. In this way, the transit agency can assess over that 30-day period whether the rider will adhere to his or her requested schedule, without issues such as no-shows and late cancellations. Assuming the rider establishes a pattern of use that �its the requested schedule and that the requested trips can be accommodated, the transit agency sets up subscription service at the end of the 30 days. An exception to the 30-day requirement is made for riders requesting trips for dialysis (as well as for those riders requesting trips for college and certain work trips). This allowance for dialysis trips has been in place for a number of years, and according to the transit agency, evolved as one strategy through transit agency staff efforts to provide effective ADA paratransit service. Results Granting the exception to the policy requiring a 30-day waiting period before scheduling subscription service has proved successful for dialysis trips—for both the rider and Intercity Transit:

6.6 Dialysis Transportation: The Intersection of Transportation and Healthcare Photo courtesy of Intercity Transit. • For the rider, setting up the 3-day-per-week transportation requirement as standing order rides eliminates one area of stress for someone new to dialysis. • For the transit agency, operating staff are able to schedule the trip more effectively into the existing run structure when the rider �irst starts dialysis. This provides more opportunity at that point to work with both the dialysis facility and the rider to make minor adjustments to the treatment time and therefore the trips, to ensure a "good �it" with Intercity Transit’s existing service structure. If the rider starts dialysis by booking trips for each treatment day—without any coordination with the transit agency at the outset—the rider gets set in a schedule and there is less opportunity to make adjustments so that the trips �it most effectively into the current runs. Summary and Transferability Intercity Transit allows dialysis riders to bypass the normal 30-day waiting period before subscription service can be established. This allowance bene�its the rider, who is able to set up the trips required for treatment as standing orders when initiating dialysis. The allowance also bene�its the transit agency. Essentially the transit agency has more control over the schedule if the transit agency sets up the standing order rides when the rider �irst starts dialysis. At this early juncture, the transit agency can work with the dialysis facility and rider to make any minor adjustments that ensure the trips can be effectively served by Dial-A-Lift. Any specialized transportation provider offering subscription service with a waiting period before establishment can consider such a policy. Waiting periods allow a transit agency to make sure riders requesting subscription service �irst establish a pattern of proper use. Waiving that waiting period for dialysis trips will give a transit agency a chance to �ine-tune the trips so they �it most effectively with the existing service structure before the rider gets set in a trip and treatment schedule that may be harder for the transit agency to effectively and ef�iciently serve. Contact Intercity Transit 526 Pattison SE PO Box 659 Olympia, WA 98507 360-786-8585 https://www.intercitytransit.com/

Chapter 6—Initiatives on the Transportation Side 6.7 Education ADA Paratransit 101—Omnitrans, San Bernardino, CA Transportation Agency Background Omnitrans is the public transit agency serving the San Bernardino Valley in Southern California. The transit agency's service area covers 15 cities and portions of the unincorporated portions of San Bernardino County, an area of 480 square miles. It carries about 16 million passengers annually. Omnitrans provides �ixed route bus service throughout its service area, circulator routes in three communities, ADA paratransit service known as Access, and several other specialized services, which include the "RIDE Taxi & Lyft Program." This latter program subsidizes trips for eligible seniors and people with disabilities on taxis and Lyft. Description Omnitrans provided roughly 23,000 dialysis trips in FY 2016 on Access, which is about 5% of the total 434,000 trips on Access that year. The transit agency reports that dialysis trips have not increased in the past 5 or so years and in fact seems to have decreased somewhat. The decrease appears to be impacted by several trends. First, some of the 30 or so dialysis centers in the San Bernardino Valley area have begun offering an early morning dialysis shift, starting at 5 a.m. The operating hours of transit service—�ixed route and the complementary ADA service—do not always allow a rider to get to the dialysis center for a treatment that begins at 5 a.m. Many dialysis patients who switch to or are scheduled for that early shift are not able to use Omnitrans, at least for the outgoing trip. Second, the transit agency reports fewer return trips from dialysis than would be expected given trips going to dialysis. This implies that patients must be �inding alternative transportation modes for their return trips. And it is those return trips on ADA paratransit that are often problematic given ADA service characteristics and regulations (e.g., use of a pick-up window, 5 minute dwell time, and shared riding). Omnitrans' relatively new RIDE Taxi & Lyft Program—which offers more personalized service than Access—may be a mode now used by dialysis riders for return trips. The transit agency subsidizes half of eligible particularly

6.8 Dialysis Transportation: The Intersection of Transportation and Healthcare Photo courtesy of Omnitrans. riders' use of taxis and Lyft up to $40.00 per month. Transit agency staff has heard anecdotally of at least one dialysis rider who uses RIDE Lyft exclusively for dialysis trips, reportedly �inding the more direct, solo rides provided by the Transportation Network Company (TNC) a preferred mode over Access. While Omnitrans may not be experiencing increasing numbers of dialysis trips on its ADA service as is more common in the industry, the transit agency has addressed the issues of dialysis trips for many years with concerted education and outreach to dialysis facilities. For more than 10 years, transit agency staff has given "ADA Paratransit 101" to dialysis facilities (as well as to other high- volume trip generators). Education and Outreach ADA Paratransit 101 is not a formal course in the sense that there is a syllabus and textbook. Instead, staff has honed a standard 10-minute presentation over the years that is given to countless social workers and other staff at the 30 or so dialysis centers in the San Bernardino Valley region. The course covers the important basics of what Omnitrans can and cannot do with Access—a federally mandated service for riders with disabilities—and also addresses any issues speci�ic to the particular dialysis center receiving the education. The transit agency reports that it may wait for a dialysis center to register a complaint about Access service to suggest that it provide ADA Paratransit 101 to the center staff. Or, in some cases, transit agency staff will reach out to the center's top administrator and offer to provide the education before any complaints arise. Results Results of education and outreach are mixed. Some of the dialysis centers are receptive to the offer for the in-person education, while other dialysis centers say they are too busy. In those latter cases, Omnitrans will then try to explain the basics of ADA paratransit and its Access service over the phone or via e- mail. The transit agency reports that dialysis centers do show a better understanding of Access service immediately after receiving ADA Paratransit 101. But there is notable staff turnover, so the social worker or other staff who

Chapter 6—Initiatives on the Transportation Side 6.9 may have received the education may have moved on and are no longer at that particular center, taking their new understanding of ADA paratransit with them. Summary and Transferability ADA paratransit is not the one-on-one, taxi-type service that many unfamiliar with public transit expect it to be, so it is important that dialysis center staff understand what the service can do, given the mandated federal requirements. Omnitrans has dedicated time and effort to educate the dialysis centers in its service area, with some success. Staff turnover at the dialysis centers is challenging Omnitrans' efforts, but the transit agency understands it must persist. Transit agencies that reach out to dialysis facilities for education and outreach might consider Omnitrans' future plans for ADA Paratransit 101. Given experience with dialysis center staff who are busy as well as staff turnover, Omnitrans plans to develop a written piece—what it calls an "e-�lyer"—that would supplement or, if need be, replace the in-person education. Such a document has the potential to reach more dialysis center staff than an in- person presentation to one or just a few dialysis center staff. Moreover, the document remains at the dialysis center for continuing reference. Transit agencies might also consider what appears to be an alternative to ADA paratransit trips for dialysis, particularly for the return trip after treatment— that is, subsidizing taxi and TNC trips. Contact Omnitrans 1700 W. Fifth Street San Bernardino, CA 92411 909-379-7100 http://www.omnitrans.org/getting-around/transit-services/access/ Educate Transportation Staff and Dialysis Clinic Staff—Ride Connection, Portland, OR Transportation Agency Background Ride Connection, based in Portland, Oregon, is a non-pro�it agency that provides specialized transportation as well as other support services such as travel training and information and referral on all transportation options in the greater Portland area.

6.10 Dialysis Transportation: The Intersection of Transportation and Healthcare Graphic courtesy of Ride Connection. The non-pro�it agency shares an important relationship with the region’s public transit agency—TriMet—with much of Ride Connection's funding coming from the public transit agency. TriMet is responsible for providing ADA paratransit, and its relationship with Ride Connection allows the transit agency to support services that meet transportation needs more specialized than what the transit agency can provide with ADA paratransit. Through experience over the years, Ride Connection recognized the challenges and problems with dialysis transportation—from its perspective as a transportation provider but also from the perspective of patients. With a planning grant in 2013, the agency conducted an extensive participatory planning process focused speci�ically on dialysis transportation—gathering information from the different parties involved, including dialysis patients, and developing improvement strategies. Armed with results from the planning process, Ride Connection applied to and received a 3-year grant from the state of Oregon for a project known as the Dahlia Pilot Project to test the improvements for dialysis transportation. The project has included two pilot services—the �irst one involving a dialysis clinic in an urban setting and the second one with a clinic in a rural area. Description A key �inding of Ride Connection’s planning process was that education and training were critically needed: • Transportation operating staff (drivers, dispatchers, and schedulers) were not necessarily informed about what is involved with dialysis, the impact of that treatment on the riders they served, and why there were so many changes with the trips; and • Dialysis clinic staff did not necessarily understand what is involved with transportation and the complexities of trip scheduling and operations on the street. Ride Connection set out to address this need. First, the non-pro�it agency developed a training course for transportation operating staff, with signi�icant input from an advisory group involved with the planning process and particularly from the patient surveys. The resulting 3-hour course explains chronic kidney disease, its progression to ESRD, the details of dialysis treatment, and, importantly, the effects of that treatment on the patients. The course explains why prescheduled return trips often need to be rescheduled, why patients feel poorly after treatment, why less shared riding bene�its patients, and why it is important to listen to patients' concerns (e.g., a patient may ask that the vehicle's heat be turned up and this is not an idle request but important to ensure the patient's comfort after treatment). Signi�icantly, a dialysis patient teaches the course.

Chapter 6—Initiatives on the Transportation Side 6.11 Photo courtesy of Ride Connection. Second, Ride Connection reached out to educate the dialysis clinic social workers about transportation, so they would understand the challenges faced by transportation providers and could then help problem-solve when necessary. Ride Connection also shared information about the Dahlia Pilot Project and its objectives to the wider clinic staff at a monthly staff meeting. Results On the one hand, Ride Connection found that the education for transportation operating staff was very effective. The information about kidney disease, ESRD, and dialysis and what that means for individuals undergoing treatment has given the drivers, dispatchers, and schedulers an understanding of why dialysis transportation is complicated. Ride Connection believes this is very important. On the other hand, its educational outreach to the dialysis clinics was less successful. While coordination with social workers was integral to the Dahlia project, these professionals had extremely limited time, often stretched to work with patients at more than one clinic. General clinic staff is similarly stressed for time and not always able to support the Dahlia Pilot Project. Nevertheless, working relationships between the pilot project's dedicated dispatcher and clinic staff who regularly coordinated trips for their patients have been effective. Summary and Transferability Ride Connection found that education for the transportation operating staff was very bene�icial. Once the staff—drivers, schedulers, and dispatchers— understood what is involved with dialysis and how treatment affects patients, they were more understanding with dialysis riders and the inevitable same- day and real-time changes with the dialysis trips. Such education could be considered by all transit agencies that serve dialysis trips. Education for the dialysis clinics can also be bene�icial so clinic staff understand the complexities of transportation operations. Ride Connection's experience suggests that such training include not just the nephrology social workers but also administrative staff, who often become the front line in working with the transportation providers in dealing with dialysis trips. Contact Ride Connection 9955 NE Glisan Street Portland, OR 97220 503-226-0700 https://rideconnection.org/

6.12 Dialysis Transportation: The Intersection of Transportation and Healthcare Regular Meetings with Dialysis Centers—Jacksonville Transportation Authority, Jacksonville, FL Transportation Agency Background The Jacksonville Transportation Authority (JTA) is an independent state agency serving the City of Jacksonville and Duval County since 1971. JTA provides public transportation and is also responsible for developing and improving local, as well as state-owned and city-owned, roadways and bridges. The Authority’s public transportation services include �ixed route bus, neighborhood community shuttles, a downtown peoplemover, and paratransit called Connexion. This latter service provides ADA paratransit as well as service for Transportation Disadvantaged (TD) riders. The TD program is a Florida state program that provides specialized service to those riders without access to their own transportation because of age, disability, or income. Day- to-day transportation service for ADA and TD riders is commingled; however, there are some differences. For example, the fare for TD riders is $0.50 more than for ADA; and TD riders may schedule trips beyond the ADA service area de�ined by three quarters of a mile of �ixed routes. Description JTA’s Connexion service has experienced increasing demand for dialysis trips in recent years. During FY 2016, JTA provided about 80,000 dialysis trips, representing 21% to 30% of all Connexion trips that year. More than 5 years ago, Connexion staff began meeting with the dialysis centers on a regular basis, following requests from a growing number of centers to interview patients at the centers for the eligibility certi�ication process. (JTA has been able to accommodate this request when possible, though, generally, eligibility assessments are done at JTA’s Eligibility Center.) Meetings with 38 Dialysis Centers Jacksonville now has 38 dialysis centers in its service area, and Connexion staff meets with all 38 over the course of a year. Some of the meetings are quarterly and organized by the major commercial dialysis companies for their center managers and social workers. The meetings are typically organized to include • An explanation by JTA staff of existing paratransit services (ADA and TD) as well as any service changes.

Chapter 6—Initiatives on the Transportation Side 6.13 Photo courtesy of JTA. Photo courtesy of JTA. • Discussion of service challenges from JTA’s perspective and the dialysis center’s perspective. • An open forum for discussion and questions/answers. The same transportation issues and problems are often addressed, given the high staff turnover experienced by many dialysis centers, such as • Dialysis center drop-off times for patients. • Dialysis center pick-up times for patients after treatment. • Limitations to service due to ADA and TD policies and requirements. Depending on the speci�ic dialysis center, other issues may be raised and discussed, such as problems with a particular transportation provider. Results JTA reports a number of bene�its from the regular meetings; one of the important bene�its is more effective communication with the dialysis centers. In turn, the dialysis centers have come to appreciate the meetings and like the fact that they are included in the transportation process. More speci�ically, bene�its include • Dialysis center staff now shares with JTA information and status updates on patients when these impact Connexion trip scheduling, such as when a patient has entered the hospital. JTA staff can then suspend the patient’s subscription trips, avoiding unnecessary no- shows. • JTA has provided Connexion Riders’ Guides to dialysis center lobby staff, which the staff can then hand out to patients or others who want information on JTA’s services. • The improved communication has helped dialysis center staff process some patients from the TD program to ADA paratransit, saving the patients $0.50 for each trip. Summary and Transferability JTA has been holding regular meetings with many dialysis centers in the Jacksonville area for a number of years,

6.14 Dialysis Transportation: The Intersection of Transportation and Healthcare resulting in open and direct lines of communication with the centers’ staff, which include, among other information-sharing, updates on patients’ status that directly affect trip scheduling. Other transit agencies facing growing demand for dialysis trips might consider such a practice: • Regular meetings with dialysis centers provide an ongoing opportunity to address and seek solutions for the inevitable issues and problems that arise with dialysis transportation, bene�iting the transit agency as well as the dialysis centers and their patients. • Dialysis centers appear to face high staff turnover, so it is important to keep an up-to-date list of center contacts to maintain communication channels. • If a transit agency has a signi�icant number of dialysis trips, it may be worthwhile to consider including at least a half-time staff position for communication and outreach with dialysis centers as well as with other major trip generators. Contact Jacksonville Transportation Authority—Paratransit Services 100 N. Myrtle Avenue Jacksonville, FL 32204 904-265-6999 www.jta�la.com

Chapter 6—Initiatives on the Transportation Side 6.15 Operational Strategies Taxi-Based Dialysis Transportation Program—Phoenix, AZ Transportation Agency Background Public transportation in metropolitan Phoenix is a hybrid operated primarily by two entities: the regional authority called Valley Metro and the City of Phoenix Transit Department. Light rail service is operated by Valley Metro. Bus service is operated by both Valley Metro and Phoenix, with Phoenix having the lion’s share, over 60%. Valley Metro is also responsible for ADA paratransit eligibility and certification as well as for the region’s ADA call center, and it operates paratransit service in the East Valley, Northwest Valley, and areas between the cities. Phoenix provides paratransit services within the city of Phoenix: Dial-a-Ride for people with disabilities and �ive taxi programs, one of which is dedicated to dialysis trips. A private transportation company under contract to the city administers this program and the other taxi-based programs. Description The Phoenix Dialysis Transportation Program began as a pilot in 1999, transitioning to an ongoing program 2 years later. The program subsidizes taxi trips for eligible residents undergoing dialysis treatment and certi�ied as ADA paratransit eligible. Eligible residents receive vouchers, which are printed with the individual's name, address of both home and dialysis center, and the calculated mileage. Each voucher subsidizes 75% of the cost of a one-way trip, with the subsidy capped at $15.00. Riders pay the remaining 25% of the trip cost with either cash or credit card and the full cost of any fare above $20.00 on the meter. For riders with de�ined low incomes, the Arizona Kidney Foundation pays the rider’s share. The city’s contract administrator produces the vouchers, individualized for each eligible rider, and coordinates with the nephrology social workers at the dialysis centers to help distribute the vouchers.

6.16 Dialysis Transportation: The Intersection of Transportation and Healthcare Dialysis Transportation Program Voucher. Courtesy of City of Phoenix. At the completion of each dialysis trip, the rider and driver both sign the voucher. The driver returns the voucher to the taxi company, which in turn sends the used vouchers to the city’s contract administrator, who reconciles the vouchers and provides reimbursement to the taxi companies. Since all the trips are repetitive—going to and from the same two locations on three pre- determined days per week—trip reconciliation is quite straightforward. The program, open to all taxi and van companies in the city, currently includes 14 participating taxi companies. The riders choose the taxi company for their trips and can change companies at any time. There are no contracts between the cab companies and the city’s administrator. Funding for the Program The Dialysis Transportation Program and Phoenix’s other specialized transportation programs for older adults and people with disabilities are funded, in part, with a portion of the city’s voter-approved sales tax dedicated to transportation. The transportation sales tax was �irst passed in 2000, with a 0.4% tax designated for public transportation. In 2015, Phoenix voters approved an increase to the transportation sales tax to 0.7%, providing additional funding for public transportation, through a proposition known as Transportation 2050. The increased transportation tax went into effect in January 2016, with a 35-year time horizon. Results The Dialysis Transportation Program served 75 dialysis riders in FY 2017, providing over 17,300 trips. The average trip was 5.6 miles with an average subsidy of $15.00, which is the limit. These are relatively short taxi trips, as the dialysis center staff attempts to schedule their patients at facilities reasonably close to the patients’ homes.

Chapter 6—Initiatives on the Transportation Side 6.17 The FY 2017 cost for the program’s taxi trips totaled $260,000. The management fee charged by the city’s contract administrator adds another 15% to the total. Cost Savings The program provides cost savings to Phoenix. The riders are all ADA paratransit eligible and could choose to use the Phoenix Dial-a-Ride (a service requiring ADA paratransit eligibility), which has a per-trip-cost more than twice the average trip cost on the Dialysis Transportation Program. Effective Service Beyond cost savings to the city, the program provides effective dialysis transportation for the riders. A 2014 survey of the dialysis riders found that the riders value the program. Social workers at the dialysis facilities were also surveyed at that time and echoed the positive comments of the riders. More recent surveys of the riders and social workers conducted in 2017 found the program continues to be effective. Half of the riders surveyed reported that their taxi picked them up within 5 minutes of the scheduled time. Another 20% reported the pickup was within 15 minutes of the scheduled time. Almost two-thirds had the same taxi driver providing their trips—by booking their trip directly with the driver. And more than half the trips, including trips home after dialysis treatment, were booked on the day of travel, re�lecting the real- time nature of taxi service. The social workers’ responses to the recent survey indicated a somewhat less positive assessment of on-time performance, but they did report that the taxi drivers provided the extra assistance to their patients when such assistance was needed. The social workers also reported that they had additional patients who wanted to participate in the program; however, the program was not able to add new patients that year due to budget constraints. The Dialysis Transportation Program typically reaches its budget limit before the end of the �iscal year. Program Characteristics Benefit Dialysis Riders The taxi-based transportation program offers a number of features that speci�ically bene�it dialysis riders, including: • Trips are scheduled for a speci�ic pick-up time, not a window of time, facilitating an on-time arrival for the dialysis appointment. • Trips can be scheduled in real time, not the day before the trip, an important feature particularly for the trip home, as prescheduled return trips often result in problems:

6.18 Dialysis Transportation: The Intersection of Transportation and Healthcare o Patients’ treatment times may be adjusted on the day of treatment, so the time for the trip home must then be adjusted; and o Dialysis patients may need extra time after treatment before it is medically safe to leave the facility. • Trips are provided on a one-on-one basis rather than a shared-ride basis, which is helpful particularly for the trip home when the rider is tired and depleted after treatment. • Trips are typically provided by the same taxi driver so that the drivers develop an understanding of their riders. Summary and Transferability Phoenix’s taxi-based Dialysis Transportation Program has proved cost-effective and valued over its more than 17-year history. The city’s experience with the program suggests the following: • The program bene�its from having many taxi company participants. This gives the riders a wide choice from which to select a transportation provider, and it also gives service redundancy. When the taxi company that provided a large share of the program’s trips recently decided to terminate its participation in the program, other taxi companies quickly stepped in with additional capacity. • While the paper voucher system has worked well—given that the program serves repetitive trips on prescheduled days, with participants traveling to and from prede�ined locations—the city is considering a change to electronic fare cards. The cards would be programmed with the key trip information and allow two trips per day, 3 days per week, for a set fare. The city has experience with the technology, which is used for other of its taxi-based programs serving older adults and people with disabilities. • Electronic fare cards will improve program monitoring, and input from the dialysis center social workers on the recent survey voiced almost unanimous support for the change. No longer would the social workers have to help distribute vouchers each month, freeing them from one transportation-related responsibility for their patients. Local governments and other public transit agencies have turned to taxi companies to provide or supplement their specialized transportation services for many years. Using taxis can be cost-effective, with cost-savings, given the lower cost structure typical of taxi companies and the fact that capital funds are not needed to purchase the vehicles. Taxi service is most effective when taxi providers offer accessible vehicles, so that the service is available to riders “The problem we encounter most frequently is that a rider is late getting off dialysis and we have to leave to do other scheduled trips. The rider is then left waiting until the driver is able to go back. I know this is hard on the rider as they are weak or ill and have to spend additional time waiting on a ride.” Quote from a transit agency respondent to the research study’s survey of 500+ transit agencies in April 2017.

Chapter 6—Initiatives on the Transportation Side 6.19 who are using wheelchairs or other mobility devices and who are not able to transfer to a sedan vehicle. Using taxis speci�ically for dialysis trips can be a successful strategy, as such trips are often dif�icult for public transit agencies to provide with ADA paratransit service. ADA paratransit is an advanced-schedule, shared-ride service that is prohibited from prioritizing trips. Using taxis provides more �lexibility and allows more individualized attention to the trips that is so often needed. In particular, the dialysis trips can be scheduled in real time, so that last-minute schedule changes are possible—a major advantage for return trips from treatment. One of the key concerns voiced by transit agencies regarding dialysis trips is that the riders are not ready for their prescheduled return trip. Phoenix also bene�its from the transportation sales tax revenues, with local funding that helps support a variety of specialized transportation services, including one designed for individuals on dialysis. Contact City of Phoenix—Public Transit Department 200 W. Washington Street Phoenix, AZ 85003 602-262-6011 https://sdg.valleymetro.org/phoenix_offers_taxi_voucher_pilot_program Mobility Management for Dialysis Transportation—MTA, Flint, MI Transportation Agency Background The Flint, Michigan, Mass Transportation Authority (MTA) provides �ixed route service within the City of Flint, regional routes serving Genesee County, and a variety of more specialized services, including ADA paratransit, branded as Your Ride, as well as other services—Senior Shopper, Ride to Groceries, and Rides to Wellness. In FY 2015, the MTA provided 5.5 million passenger trips. Description The Flint MTA provided dialysis trips for many years through its ADA paratransit service, Your Ride, though the service provided for dialysis riders could be challenging, given the nature of ADA service and its requirements.

6.20 Dialysis Transportation: The Intersection of Transportation and Healthcare Photo courtesy of Flint MTA. To address the challenges, the transit agency now uses its mobility management function to coordinate trip scheduling for the dialysis riders directly with the 14 dialysis facilities in the service area. One of the mobility managers handles only dialysis trips, working hand in hand with the nephrology social workers at the various dialysis facilities to schedule patients’ trips. The mobility manager collaborates with the social workers to improve service for the dialysis riders. As one example, they determined together to add 30 minutes to the end of each patient’s appointment (for what is referred to as “bleed time”) before scheduling the return trip home. Previously, patients’ return trips were scheduled right after their dialysis treatment ended, and many patients were not medically ready for that trip home. The mobility manager also tries to schedule the dialysis trips with the shortest travel time possible, something that is particularly important for the return trip after treatment when the rider is very weak and tired. The transit agency’s mobility management function is supported with an FTA Rides to Wellness grant of $310,040 received in FY 2016. This FTA funding has allowed the MTA to expand its non-emergency medical transportation service. Results With the Rides to Wellness funding, the MTA now serves a range of medical trips. Dialysis trips remain an important component of the service, which are now provided more effectively with the improvements put in place through the efforts of the mobility manager. The transit agency currently provides about 20,000 dialysis trips each year, serving between 300 to 500 dialysis riders in any given month. Summary and Transferability Flint MTA has used its mobility management function to work closely with dialysis center social workers to improve MTA’s service for the centers’ dialysis patients. The Rides to Wellness grant allows the MTA to enhance its services supporting dialysis riders as well as other riders with non- emergency medical trip needs. Mobility management helps individuals �ind appropriate transportation options from among the array of transportation resources in a community. It can be a valuable tool for a transit agency, with a mobility manager helping individuals �ind the right transportation option for their particular trip from

Chapter 6—Initiatives on the Transportation Side 6.21 Photo courtesy of FACT. the agency’s menu of services—whether it is accessible �ixed route, ADA paratransit, or some other specialized transportation service. While Rides to Wellness funding would provide extra resources to improve transit services for dialysis and other non-emergency medical trips, a transit agency does not need such a grant to improve dialysis transportation or to implement mobility management and strategies focused on dialysis trips. Strategies found effective in Flint include, for example, assigning one transit staff position to coordinate with dialysis centers on dialysis trip scheduling, particularly for return trips after treatment and to manage the ongoing scheduling of trips for dialysis patients. Contact Mass Transportation Authority 1401 S. Dort Highway Flint, MI 48503 810-767-0100 http://www.mta�lint.org/ Schedule Trips with Dialysis Riders, Rather Than with Dialysis Centers—FACT, Inc., Oceanside, CA Transportation Agency Background Facilitating Access to Coordinated Transportation, Inc. (FACT), a non-pro�it agency in Oceanside, California, coordinates public, non-pro�it, private, and other transportation services in San Diego County. Established in 2005, the agency has served as a mobility manager for individuals looking for transportation by referring them to the most appropriate mode. Transportation referrals are provided in person, via telephone, and through the web-based trip planner, Find-A-Ride. In 2012, FACT supplemented its mobility management function with implementation of RideFACT, a dial-a-ride service operating throughout San Diego County for seniors, people with disabilities, and other people with mobility challenges. RideFACT is organized as a brokerage: FACT purchases trips—in bulk and at reduced rates—from private and non-pro�it taxi-type providers (including one TNC) that have agreed to be part of the brokerage network. FACT then schedules trips for riders who have no other

6.22 Dialysis Transportation: The Intersection of Transportation and Healthcare Photo courtesy of FACT. transportation option. FACT additionally offers contracted transportation service tailored to agency clients—such as those of the Braille Institute and the Poway Adult Day Healthcare Center—using a mix of non-pro�it and private providers. FACT’s transportation services are intended to �ill in gaps that cannot be met by its referral service to the array of providers operating in the county. During FY 2017, FACT provided more than 29,000 trips through RideFACT and its contracted services. Of the trips provided, FACT estimates that currently about 10% are for dialysis. In addition, FACT has provided more than 130,000 transportation referrals during the past 5 years (FY 2012–FY 2017). Description When FACT initiated its transportation brokerage, demand for dialysis trips grew quickly. This growth was fueled in part by dialysis centers informing patients that FACT was starting a new transportation program. There was early concern that much of RideFACT’s capacity might be �illed with only dialysis trips. FACT reached out to the dialysis centers to inform them what RideFACT was and was not and, based on early experience, learned it was more effective to work directly with dialysis riders for scheduling trips. In many communities, dialysis center staff contacts the local transportation providers to arrange trips for their patients. Should this happen for FACT, operations staff at RideFACT asks to deal directly with the patient. Results FACT’s practice of working directly with dialysis riders for their dialysis trips helps the non-pro�it agency serve the rider more effectively. For example, should a dialysis center schedule an early morning shift for a rider when FACT does not have any available service provider, FACT will work with the rider, providing available transportation options that allow the rider to go back to the dialysis center to adjust the treatment schedule. This practice initially led to some pushback from dialysis centers but, in the end, both FACT and the dialysis centers share an objective of ensuring that those riders with ESRD receive their needed dialysis treatment. FACT’s practice also results in fewer no-shows and late cancellations as the rider’s connection to transportation is direct and not an indirect link through the dialysis center social worker. If a rider’s treatment is running late, for instance, the

Chapter 6—Initiatives on the Transportation Side 6.23 rider may phone FACT to inform the non-pro�it to reschedule the return trip for a later time, saving RideFACT an unnecessary trip. Another result appears to be a moderation of dialysis demand. Arranging transportation becomes the responsibility of the dialysis riders, not the dialysis center. The latter may have an interest in arranging transportation for as many patients as possible to ensure full use of their machines and then, given the workload and other responsibilities, center staff may not be able to work with a transportation provider for more effective and ef�icient transportation. Summary and Transferability FACT has found it bene�icial to schedule dialysis transportation directly with its riders rather than through the dialysis centers. The agency’s origins and core business as a mobility manager mean the agency’s inclination is to focus on the individual rider, even when scheduling trips to a destination generating multiple and possibly shared-ride trips. A public transit agency might consider this mobility management approach to address issues with dialysis trips, which are often more specialized than other types of trips. Contact Facilitating Access to Coordinated Transportation (FACT) 600 Mission Avenue Oceanside, CA 92054 760-754-1252 http://www.factsd.org/ Improving Dialysis Transportation Through Operational Strategies Tested by Pilots—Ride Connection, Portland, OR Transportation Agency Background Ride Connection, based in Portland, Oregon, is a non-pro�it agency that provides specialized transportation as well as other support services such as travel training and information and referral on all transportation options in the greater Portland area. The non-pro�it agency shares an important relationship with the region’s public transit agency—TriMet—with much of Ride Connection's funding coming from the public transit agency. TriMet is responsible for providing ADA paratransit and its relationship with Ride Connection allows the transit agency to support services that meet transportation needs more specialized than what the transit agency can provide with ADA paratransit.

6.24 Dialysis Transportation: The Intersection of Transportation and Healthcare Graphic courtesy of Ride Connection. Through experience over the years, Ride Connection recognized the challenges and problems with dialysis transportation—from its perspective as a transportation provider but also from the perspective of patients. With a planning grant in 2013, the agency conducted an extensive participatory planning process focused speci�ically on dialysis transportation—gathering information from the different parties involved, including dialysis patients, and developing improvement strategies. Armed with results from the planning process, Ride Connection applied to and received a 3-year grant from the State of Oregon for a project known as the Dahlia Pilot Project to test the improvements for dialysis transportation. The project has included two pilot services—the �irst one involving a dialysis clinic in an urban setting, and the second one involving a clinic in a rural area. Operational strategies tested in the pilots are described below. Description and Results Ride Connection's pilots proved that dialysis transportation can be improved through several strategies that follow. Flexible Return Trips from Dialysis Dialysis patients are often not ready for their prescheduled return trip home after treatment because of medical complications. Problems for those return trips arise when transportation providers adhere to a strict 5-minute wait time for patients for the trip home. Like many transportation providers, Ride Connection did not commonly allow for longer than a 5-minute wait for scheduled rides. This led dialysis clinic staff to believe that if their patients did not board within those 5 minutes, there would be no return trip at all or the wait would be hours long. This caused stress for the patients and the clinic social workers. During the pilots, the non-pro�it agency tested a more �lexible wait time, so the drivers would wait extra minutes for patients not ready at the prescheduled time. The social worker could be con�ident that a ride would be available for a patient despite unexpected last-minute changes and, in cases where a patient would require somewhat more time before a medically safe trip home, the staff was in a position to give Ride Connection an honest and realistic time for the

Chapter 6—Initiatives on the Transportation Side 6.25 return trip. Ride Connection could then schedule another trip for that later time. This shared understanding allowed Ride Connection and the dialysis clinic staff to work together to ensure that patients received their rides home after treatment without an undue wait. Interestingly, the success of the more �lexible wait time was adopted by other transportation providers serving the dialysis clinic. Even the Medicaid broker, which participated brie�ly in the advisory committee for the Dahlia Pilot Project, relaxed its wait time policy to provide more �lexibility. With an understanding that the transportation providers would wait extra minutes or de�initely return later for patients not ready for their prescheduled trip, clinic staff were more likely to give accurate times to the providers for their patients’ return trip home, particularly for any that had to be rescheduled. Improved Scheduling of Dialysis Trips Through its �irst pilot, Ride Connection tested several strategies related to trip scheduling that have been effective. First, the non-pro�it agency began managing all its same day dialysis transportation dispatching with one dispatcher. This dispatcher handles all the calls about dialysis trips, which often require extra attention with same-day and real-time changes and rescheduling. Rather than dispersing the dialysis calls and trips among different dispatchers, the dedicated dispatcher has the “full picture” of dialysis trips out on the street and can more effectively negotiate the changes so often required. Second, Ride Connection determined that it would schedule trips to minimize waits after treatment and to avoid longer, circuitous trips home with shared rides. Ride Connection learned through the planning process that long trips to, and particularly from, the dialysis clinic are taxing for the patients and their health. Typically, specialized transportation providers group trips for shared riding to ensure more ef�icient service. However, when such shared riding results in longer waits for return trips and longer travel times, the patients suffer. The non-pro�it agency established new parameters for trip scheduling, so that schedulers would not group trips for the dialysis patients, particularly return trips after treatment, which resulted in long waits for the ride or long, indirect Long travel times to dialysis and their negative impacts on dialysis patients are described in two studies: Longer travel time to dialysis treatment has a negative impact on ESRD patients’ health and quality of life. Patients traveling more than 60 minutes to dialysis had a 20% greater risk of death compared to those traveling 15 minutes or less. Patients with longer travel times also scored lower when their health-related quality of life was measured compared to those traveling 15 minutes or less (21). Shorter travel times and distance to dialysis clinics is associated with improved patient outcomes and a higher health-related quality of life. Comparing travel to a central dialysis center versus a satellite center, the study found that ESRD patients who traveled to a satellite center had a shorter travel time and lower transportation cost. For those patients traveling to the centers more proximate to where they lived, the study cited benefits of “less travel time, reduced driving stress, more time to spend with family and friends, less fatigue and increased energy and decreased cost” (22).

6.26 Dialysis Transportation: The Intersection of Transportation and Healthcare rides home. The parameters are not numerical, but rather the scheduler and dedicated dispatcher are to use their judgment so that the trips are "reasonable" given the objective. The result is less shared riding for the dialysis trips. While this means the per- passenger-trip cost is higher than otherwise, it also means the patients receive a more direct, less time-intensive trip home, which is particularly important after treatment when they feel so unwell. Ensure Quality Provider if Contracting Ride Connection’s pilots with both the urban and rural dialysis clinics demonstrated the importance of working with a quality contractor. While Ride Connection provided some of the trips, capacity constraints and �lexibility requirements meant that many trips were contracted to cab companies. Early experience with the cabs found service quality problems and complaints with some of the larger companies, but Ride Connection did �ind quality service from some of the smaller cab companies, which were then used for the pilot to supplement Ride Connection's service. One of these smaller cab companies demonstrated particular attention to its role in the dialysis transportation pilot. It participated in the Dahlia Pilot Project's advisory committee meetings, providing a valuable perspective for the larger group. And, recognizing that dialysis trips require extra attention and rider assistance, the company offered an incentive to its drivers for completing Ride Connection’s dialysis training in the form of a salary increase. Ride Connection, in turn, supported the company by sending trips to �ill in gaps in driver schedules, ensuring full shifts in the area of the rural clinic, which was remote from the company’s primary service area. The trained drivers were a particular bene�it. The drivers learned what is involved with dialysis treatment and its impact on patients. And the drivers got to know the patients. With this familiarity and their understanding of dialysis and its impact on patients, the drivers provided a higher quality of service. Patient surveys completed during the pilot showed an increase in patients' perceptions that drivers understood what dialysis is and showed an increase in patients’ trust of the drivers. Earlier patient surveys during Ride Connection's planning process before pilot implementation found that driver understanding is important to the patients. Ride Connection's Dialysis Patient Survey: "Drivers Need to Understand” One of the findings of the patient survey, part of Ride Connection's extensive planning process before implementation of the pilots, was the importance of driver understanding and compassion. The patients expressed great appreciation when their drivers were compassionate and listened to their needs. A Report on Findings: Improving Transportation for Patients Receiving Dialysis Treatment, January 2014.

Chapter 6—Initiatives on the Transportation Side 6.27 Summary and Transferability Building on �indings through its planning process and tested through the pilots, Ride Connection found several operational strategies effective for dialysis trips: a �lexible wait time after treatment; a dedicated dispatcher for dialysis trips, minimizing wait time and shared riding that result in long travel times; and more personalized trips with familiar drivers who are educated about dialysis treatment. When using a contractor, Ride Connection also learned the importance of using a contractor willing and able to ensure quality service for the dialysis riders. As a non-pro�it agency without an ADA paratransit obligation, Ride Connection is able to provide transportation more specialized than what a transit agency can provide with ADA paratransit. Yet several of the tested strategies might be considered by a public transit agency while keeping within ADA requirements. Contact Ride Connection 9955 NE Glisan Street Portland, OR 97220 503-226-0700 https://rideconnection.org/

6.28 Dialysis Transportation: The Intersection of Transportation and Healthcare Coordination with Dialysis Facilities Develop Rapport and Coordinate with Dialysis Facilities— Washington County, MD Transportation Agency Background Washington County—the �irst county in the United States to be named for President George Washington—is located in western Maryland, known as the state’s panhandle. The county’s Transit Department operates Washington County Transit (WCT), providing �ixed route and ADA paratransit service, as well as an employment-oriented service called JOBS. WCT runs eight �ixed routes serving the county’s largest city, Hagerstown. Several routes extend out beyond Hagerstown to serve small communities around Hagerstown. Service is provided weekdays and on Saturdays. ADA paratransit service complements the �ixed routes with a �leet of three vehicles. The county also sponsors a subsidized same-day taxi voucher program for older adults and people with disabilities, known as the “Ride Assist Program.” Description Trips for dialysis make up almost half of all ADA paratransit trips. Of the total 14,013 ADA paratransit trips provided in FY 2016, dialysis trips numbered 6,500. The demand for dialysis trips has grown over the years. Currently, there are three dialysis centers in the transit service area, operated by the leading private dialysis companies. Demand continues to grow, often spurred by ADA paratransit applications submitted by dialysis center staff. WCT staff indicated that one of the dialysis centers recently completed and submitted ADA paratransit applications on behalf of 10 new dialysis patients. The demand for dialysis trips impacts capacity for other trips. Particularly on Mondays, Wednesdays, and Fridays, WCT reports that it is very dif�icult to serve other trips during the peak times for dialysis trips. To meet the demand and ensure no capacity constraints, the county transit staff has worked to develop relationships with the dialysis centers to coordinate patient treatment times for more shared riding. Transit staff also

Chapter 6—Initiatives on the Transportation Side 6.29 Photo courtesy of KFH Group. knows many of their regular paratransit riders and works with those riders on dialysis as appropriate for their dialysis trips. Results WCT staff has developed an effective and cooperative relationship with two of the dialysis centers and in particular with the one treating the largest share of the transit agency’s ADA riders. This dialysis center has a staff person assigned to coordinate transportation, and WCT staff works directly with this person to ensure patients reliant on public transportation get to their treatment. Maintaining the relationships is facilitated by staff stability at the two centers. Apparently, these centers have not seen the staff turnover reported by several other transit agencies interviewed for the research project. As just one example of the working relationships, WCT coordinated with one of the centers to switch the treatment time for a patient who lived near two other patients who were already scheduled together for their dialysis trips. This allowed WCT to group the three riders for the trips to and from the dialysis center, allowing for more productive paratransit service. The transit agency works also with the local nursing home to coordinate transportation for the nursing home clients on dialysis. The nursing home has been able to schedule common treatment times for several clients, which in turn allows WCT to group the nursing home clients for their dialysis trips, again providing for more productive service. The transit agency staff also works directly with their dialysis riders when this is appropriate. One rider recently contacted WCT after he was offered a different and preferred shift for his dialysis treatment. He wanted to know if WCT would be able to accommodate his trips for the new shift before he accepted the change. Summary and Transferability WCT reports that it is the coordination with the dialysis centers that allows the transit agency to meet the demand for dialysis trips. WCT paratransit staff has a long history with the transit agency and with the community, providing a strong foundation for reaching out to the dialysis centers to establish rapport. The positive and mutual relationships—at least with two of the dialysis centers—bene�it WCT as well as the dialysis centers and, importantly, the

6.30 Dialysis Transportation: The Intersection of Transportation and Healthcare patients. The approach is perhaps best summed up by the paratransit manager who said, "We all work together as a team to provide transportation.” Establishing such cooperative relationships with dialysis centers might be easier in a smaller community, where there are fewer dialysis centers. It may also be easier where there is little dialysis center staff turnover. But it takes the initiative of transit agency staff to reach out, visit the dialysis centers, explain the public transportation service, and develop and maintain the relationships that facilitate coordination. Contact Washington County Transit Division of Public Works 1000 West Washington Street Hagerstown, MD 21740 240-313-2750 www.washco-md.net/index.php/2017/11/27/pubworks-transit-home- 2/#�leet Coordinate with Dialysis Facilities to Schedule Patients' Treatment and Transportation—Ride Connection, Portland, OR Transportation Agency Background Ride Connection, based in Portland, Oregon, is a non-pro�it agency that provides specialized transportation as well as other support services, such as travel training and information and referral on all transportation options in the greater Portland area. The non-pro�it agency shares an important relationship with the region’s public transit agency—TriMet—with much of Ride Connection's funding coming from the public transit agency. TriMet is responsible for providing ADA paratransit, and its relationship with Ride Connection allows the transit agency to support services that meet transportation needs more specialized than what the transit agency can provide with ADA paratransit. Through experience over the years, Ride Connection recognized the challenges and problems with dialysis transportation—from its perspective as a transportation provider but also from the perspective of patients. With a planning grant in 2013, the agency conducted an extensive participatory planning process focused speci�ically on dialysis transportation—gathering

Chapter 6—Initiatives on the Transportation Side 6.31 Graphic courtesy of Ride Connection. information from the different parties involved, including dialysis patients, and developing improvement strategies. Armed with results from the planning process, Ride Connection applied to and received a three-year grant from the State of Oregon for a project known as the Dahlia Pilot Project to test the improvements for dialysis transportation. The project has included two pilot services—the �irst one involving a dialysis clinic in an urban setting and the second one involving a clinic in a rural area. Description Ride Connection reached out to the nephrology social workers at the two pilot sites to try and coordinate the scheduling of patient trips. The objective was to better align trip schedules and dialysis treatment times, in consideration of the geographic location of patients' trip origins and the hours and capacity of the transportation service. This would result in more productive transportation service and lower per trip costs. As it turned out, one issue facing transportation service for the rural clinic was that the ending time of the third treatment shift was somewhat later than the transportation service’s hours of operation. Results Ride Connection's efforts were successful with the rural clinic. The social workers were willing to coordinate patient scheduling with the non-pro�it transportation agency so that trip scheduling was more effective. In fact, the cooperation went both ways: Ride Connection extended its hours for patients in the early evening to ensure that those riders who needed a ride home after the third shift would have one. Saturday service was also provided for patients. Ride Connection's efforts with the urban clinic, however, were less successful. The volume of patients and the workload of the clinic’s social workers did not allow the social workers to work effectively with Ride Connection to make any meaningful adjustments to treatment times, which made trip scheduling more effective. Summary and Transferability Coordinating schedules with a dialysis clinic can improve dialysis trip scheduling for the transportation agency, but it requires a clinic willing and able to coordinate. Ride Connection found that the smaller rural dialysis clinic was able to coordinate schedules, but this was not the case with the urban clinic—which had a larger patient population and an overextended staff.

6.32 Dialysis Transportation: The Intersection of Transportation and Healthcare Transit agencies may �ind it worthwhile to approach the dialysis clinics they serve with an offer to work with clinic staff to coordinate transportation and treatment. While the response may not always be positive, such coordination may improve service from both the transit agency's perspective as well as that of the dialysis clinic and its patients. Contact Ride Connection 9955 NE Glisan Street Portland, OR 97220 503-226-0700 https://rideconnection.org/ Coordination, Volunteers, and One-Call Center—Mountain Empire Transit, Big Stone Gap, VA Transportation Agency Background Mountain Empire Transit is a service of Mountain Empire Older Citizens, Inc., a non-pro�it agency based in rural southwestern Virginia. The agency provides a wide range of services in addition to transportation, including adult day care, congregate meals for seniors, support groups and volunteer programs. Transportation is provided to the general public on a demand–response basis on weekdays, from 7 a.m. to 5 p.m. The service area is large, covering the City of Norton and three counties— stretching over 4,000 square miles of rugged terrain in the mountains of central Appalachia. Description Mountain Empire Transit has seen increasing demand for dialysis trips in recent years. In FY 2016, dialysis trips made up almost 20% of the total 150,000 trips provided that year.

Chapter 6—Initiatives on the Transportation Side 6.33 Photo courtesy of Mountain Empire Transit. The trips require special attention and often receive one-on-one exclusive ride service, particularly after treatment. With the large rural service area and only one dialysis center, trips to and from dialysis are long, lasting at least an hour or more in length. The transit agency understands the fragile nature of dialysis riders after completing treatment and strives to get them home as soon as possible, which typically means scheduling an exclusive ride. This impacts productivity and cost per trip but, according to the agency, “we have made a commitment to these riders.” This commitment includes acquisition of four- wheel drive vehicles so that the agency can transport the dialysis patients in bad weather. To deal with the demand for dialysis trips and to serve them more effectively, Mountain Empire Transit has forged a cooperative relationship with the dialysis center and uses volunteers to help the drivers serve the dialysis trips. The agency has also used grant funds to establish a one-call center, where a mobility manager helps address the needs of the community for transportation and other services. Results Mountain Empire Transit’s efforts for its dialysis riders go beyond just providing transportation and re�lect the mission of its parent agency, which has become more than an area agency on aging. The agency also directs Healthy Families for Southwest Virginia, the Mountain Laurel Cancer and Resource Center, and the Southwest Virginia Children’s Advocacy Center. Coordination with the Dialysis Center Transit agency staff works directly with the area’s one dialysis center to try and coordinate patient scheduling with transportation service. The dialysis center appreciates and bene�its from the consistent and timely transportation provided by the transit agency, which apparently contrasts with service provided through other non-emergency transportation programs. The transit agency’s performance contributes to its building and maintaining an effective relationship with the dialysis center. However, given the growing demand for dialysis in the area and the limited capacity at the center, coordinated scheduling is not always possible. But the communication channels are open, and the two organizations help each other when possible.

6.34 Dialysis Transportation: The Intersection of Transportation and Healthcare Volunteers Mountain Empire Transit recruits volunteers from the community to support its transportation service, to serve as both drivers and aides on the vehicle. Finding volunteers to serve as aides is considerably easier, as the training period is much shorter. Volunteer aides are particularly helpful for dialysis riders, who need more assistance than other types of riders. The aides can provide the extra assistance to help the rider from the dialysis center to the vehicle. During the hour or longer trip home from dialysis, the aide can support the rider, providing a blanket for warmth and food—extra efforts that otherwise the driver would have to provide. The transit agency reports that sometimes the aide becomes more than just a helper on the vehicle and more of a buddy or friend in the community. This happens especially if the volunteer comes from the faith-based community. The transit agency has also found willing volunteers from among nursing students at the local community college. Helping dialysis riders during their trips gives the students some practical experience with ESRD patients. One-Call Center With a grant from the National Aging and Disability Transportation Center (NADTC), Mountain Empire Transit has developed a one-call center staffed by a mobility manager. This individual has varied responsibilities, including training the volunteer aides to support dialysis riders. She also helps new dialysis riders navigate the transportation component of treatment as well as coordinates with the dialysis center. Depending on the needs of the dialysis riders, the mobility manager can also steer the individual to other services and supports provided through the transit agency’s parent organization. Summary and Transferability Mountain Empire Transit’s service for dialysis riders is more specialized than some transit agencies can provide, re�lecting the mission it shares with its parent organization in serving the needs of the community, which are many. Southwestern Virginia is more economically disadvantaged than other regions of Virginia, and its population is poorer and older than the rest of the commonwealth’s population. Despite this, the transit agency’s experience in addressing dialysis transportation may be useful in all types of communities:

Chapter 6—Initiatives on the Transportation Side 6.35 • Build and maintain a cooperative relationship with the dialysis center. • Recruit volunteers to support the transit agency’s service. • Develop a one-call center with a mobility manager, who can help those new to dialysis and others with transportation needs �ind solutions. Mountain Empire Transit stresses that coordination is the key—develop and maintain relationships throughout the community to help provide and support transportation, including for those requiring life-sustaining dialysis trips. Contact Mountain Empire Transit Mountain Empire Older Citizens, Inc. 1501 Third Avenue East Big Stone Gap, VA 24219 276-523-7433 http://www.meoc.org/transportationmeoc.htm

6.36 Dialysis Transportation: The Intersection of Transportation and Healthcare Funding Funding from the National Kidney Foundation—TRPTA, Idaho Falls, ID Transportation Agency Background Targhee Regional Public Transportation Authority (TRPTA), based in Idaho Falls in southeastern Idaho, is a regional public transit authority established by Idaho Code. The voters of Bonneville County voted it into existence in 1994. TRPTA operates a variety of transportation services to meet mobility needs in the Idaho Falls region, including �ixed route service in the City of Idaho Falls, ADA paratransit within three quarters of a mile of the city’s �ixed routes, demand–response service for the general public in de�ined service areas and communities outside Idaho Falls, and feeder services connecting outlying communities to Idaho Falls and the city’s �ixed route network. TRPTA also provides Medicaid NEMT trips through an agreement with Veyo, Idaho’s statewide broker for Medicaid NEMT service. The transit agency provided approximately 103,000 passenger trips in FY 2016, including the specialized trips. Close to 14,000 trips were ADA paratransit trips. Description TRPTA provides dialysis trips through both its ADA paratransit service and the general public demand–response services operated in selected areas outside the ADA service area. There are two dialysis facilities in Idaho Falls, and two dialysis facilities in communities beyond Idaho Falls. The transit agency estimates that 10% or less of the paratransit and demand–response trips are dialysis trips. Staff reports that they have received a number of requests for dialysis trips that are outside the agency’s service days and hours, as well as outside the service area; thus, such trips are not served. For dialysis trip requests, TRPTA indicated that generally the agency is able to meet the demand, particularly given the ADA requirement that prohibits capacity constraints. However, during peak periods of dialysis trip demand, it can be dif�icult to serve other trip purposes.

Chapter 6—Initiatives on the Transportation Side 6.37 The transit agency also reports that it provides �lexibility for return trips from dialysis. For example, the dialysis facilities will typically communicate with TRPTA when they know that a patient will not be ready for the prescheduled return trip. TRPTA then provides such trips on a will-call basis. Funding Funding for TRPTA’s operations comes from several federal grant programs, including FTA Section 5307 and FTA Section 5311. Local funding for the grants’ match requirements comes from a number of sources including, for example, Medicaid, the local Area Agency on Aging, and Eastern Idaho Community Action Partnership. Funding received for the Medicaid service is an important source: payment is mileage based, with current rates providing $4.20 for the �irst mile and $1.17 each mile thereafter and, for riders using a wheelchair or other mobility device, $6.20 for the �irst mile and $1.17 each mile thereafter. Medicaid trips make up about 70% to 80% of the specialized transportation total trips. For capital purchases, TRPTA has the opportunity annually to apply for local grants such as Community Development Block Grants and the United Way as match to offset costs of bus purchases. Kidney Foundation Funding TRPTA reports that it receives funding directly from the National Kidney Foundation, which purchases "punch passes" for selected dialysis patients who are not eligible for other subsidized transportation. Results The funding amounts from the National Kidney Foundation are not large— TRPTA reports it received less than $1,000 in FY 2016—and the amount is not consistent year to year; however, the funds are important in supporting the dialysis trips for the selected riders. These are riders who must start dialysis but have dif�iculty affording transportation and are not yet eligible for free transportation, such as through Medicaid. In these cases, the dialysis facility contacts the Kidney Foundation to request transportation funding assistance for the new patients. The Kidney Foundation purchases 10-ride punch passes and provides them to the dialysis facility so that the dialysis facility can give a pass to those new patients who need transportation assistance. TRPTA’s punch passes are $35.00 for a senior or an individual with a disability, and these are the passes purchased by the Kidney Foundation.

6.38 Dialysis Transportation: The Intersection of Transportation and Healthcare Photo courtesy of KFH Group. TRPTA explained that such passes are typically used for a transitional period until the patient is eligible for subsidized transportation, usually Medicaid. Once patients are Medicaid eligible, the individuals are served by TRPTA through the agency’s Medicaid contract. Summary and Transferability While the funding TRPTA receives each year from the National Kidney Foundation is not large, it is important in supporting the dialysis trips of riders needing such assistance and contributes to the mix of funds that the transit agency receives to operate its transportation services. Many smaller transit agencies must look to various sources for local money to match available federal and often state grant programs. Sometimes it takes creativity, sometimes it requires pleas, and sometimes it involves partnerships and coordination with organizations that support the transit agency’s riders—as is the case for TRPTA—to assemble funding needed to support the transit agency’s operations. More important from the rider/patient perspective, the Kidney Foundation’s purchase of punch passes helps those dialysis patients who cannot afford the six trips per week necessary for their treatment. Contact TRPTA 1810 W. Broadway #7 Idaho Falls, ID 83402 208-529-1489 http://www.trpta.org/ Partnerships with Hospitals—CountyRide, Baltimore County, MD Transportation Agency Background CountyRide is a demand–response public transit system in Baltimore County, Maryland—a county of 831,000 residents that shares a name and borders with Maryland’s largest city.

Chapter 6—Initiatives on the Transportation Side 6.39 CountyRide is operated by the county’s Department of Aging, serving seniors and people with disabilities in the urbanized portion of the county and the general public in the non-urbanized northern portion. This distinction re�lects the funding sources received from the state, including FTA and state transit funds. With a �leet of 20 vehicles in service, CountyRide provided more than 40,000 trips in FY 2017. Medical trips are a frequent trip purpose, with dialysis trips a signi�icant portion of those trips. However, CountyRide’s trip reservation policies are structured so that dialysis trips do not overwhelm other trip purposes. Demand for dialysis transportation grew to such levels during the late 1990s and early 2000s that it impacted capacity for other trip purposes. To ensure riders could take trips for other medical purposes as well as non-medical reasons, CountyRide designed trip reservation policies to ensure capacity for a range of trips and address the demand for dialysis trips. This includes a time limit for standing order trips and capacity for dialysis trips on Tuesdays and Thursdays. Of the total trips in FY 2016, dialysis trips made up about 7%. Description For more than 25 years, CountyRide has received �inancial support directly from hospitals and medical facilities in Baltimore County and Baltimore City. This public–private partnership program generates annual funding for the transit system, supplementing federal and state grants as well as passenger revenue. Currently, 15 medical facilities are part of the partnership with CountyRide, and dialysis trips are among the medical trips scheduled to these facilities. Results CountyRide's partnerships with the medical facilities are informal, and the amounts provided may vary year to year. Nevertheless, the funds are an important contribution supporting CountyRide’s operations. In FY 2017, the partnership funding made up 13% of all fare revenues. Partnership Hospitals • Baltimore County medical facilities: o Franklin Square Hospital Center o Greater Baltimore Medical Center o The James Lawrence Kernan Hospital o Northwest Hospital o University of Maryland Saint Joseph Medical Center • Baltimore City medical facilities: o Good Samaritan Hospital o Johns Hopkins Bayview Medical Center o Johns Hopkins Hospital o Kennedy Krieger Spine Center o Mercy Medical Center o St. Agnes Health Care o Sinai Hospital of Baltimore o The Union Memorial Hospital o University of Maryland Medical System o League for People with Disabilities

6.40 Dialysis Transportation: The Intersection of Transportation and Healthcare Photo courtesy of KFH Group. CountyRide recognizes the support in several ways: • Extending its service into Baltimore City speci�ically to serve the participating medical facilities located within the city limits. Except for those speci�ic destinations, CountyRide does not serve Baltimore City. • Providing priority scheduling for riders traveling to medical appointments and including those at the partnership facilities. • Recognizing the medical facilities through CountyRide’s online and printed informational material. Summary and Transferability CountyRide's public–private partnership program began many years ago, initiated with growing demand from seniors and people with disabilities for medical trips and shrinking local funds to support the transportation service. A number of hospitals and medical facilities in both Baltimore City and Baltimore County stepped up to help support CountyRide, recognizing that the door-to-door service was critical for many of their patients to access appointments at their facilities. Transit agencies can approach medical facilities that they serve through their day-to-day operation and seek funding support. Data showing demand for trips to the targeted facility, growth in that demand over recent years, possible unmet demand, and other relevant data (e.g., rider survey data/testimonials of the transit agency's role in accessing doctors, appointments, etc.) can be collected, documented, and packaged to present to a medical facility. This will help demonstrate the importance of the transportation service to the medical facility's business and demonstrate why the medical facility should consider supporting its continued service with a �inancial contribution. A request for funding support can also reference the new revisions to the federal Safe Harbors Under the Anti-Kickback Statute, which now allow medical facilities to fund local transportation service within speci�ied parameters. The request could also emphasize transportation’s important role as one of the social determinants of health. Transportation is necessary for providing and improving healthcare, without which patients miss or delay medical appointments, and that may lead to poor health outcomes. Contact CountyRide 611 Central Avenue Baltimore, MD 21204 410-887-2080 www.baltimorecountymd.gov

Chapter 6—Initiatives on the Transportation Side 6.41 United Way Funding for Dialysis Trips—KVCAP, Waterville, ME Transportation Agency Background Kennebec Valley Community Action Program (KVCAP) is a non-pro�it community action agency serving Kennebec and Somerset counties in Maine. For more than 40 years, KVCAP has provided a wide range of social services, including employment services, child and family support, a health navigator, energy and housing services, as well as transportation. The agency’s transportation program offers �lex route service in three communities and door-to-door transportation, known as KV Van, for citizens of the two counties who are elderly, disabled, or low income. Service is also available for the general public. KV Van service is provided with 18 accessible vans, with supplemental service provided by volunteer drivers. KV Van is additionally a Medicaid provider, working with the state of Maine’s Medicaid transportation broker, and provides service on a contract basis to local human service agencies. Trips to medical destinations are common for KV Van, including trips for dialysis. KV Van provided more than 2,000 dialysis trips in FY 2016, estimated at up to 20% of all KV Van trips that year. KVCAP reports that the demand for dialysis trips has increased considerably over recent years. Ten years ago, there was one dialysis center in the agency’s service area; now there are �ive dialysis centers. Given the demand for dialysis trips, the agency indicates that on some days it can be dif�icult to serve other trip purposes. Description Funding for KVCAP’s transportation program comes from a number of sources, including FTA Section 5311, state transit funds, state human service agency funds, and Medicaid. The agency also receives funding from the United Way that is used to support dialysis transportation. Some years back, one of Maine’s United Way of�ices conducted a community needs assessment, identifying transportation for seniors as a priority need. These were “gap” seniors—those who were not low income enough to qualify for Medicaid or other assistance programs but who were without the means to afford ongoing private transportation.

6.42 Dialysis Transportation: The Intersection of Transportation and Healthcare Graphic courtesy of KVCAP. Results To meet the identi�ied needs, the United Way began donating $3,000 to KVCAP speci�ically for senior transportation. KVCAP appreciated the new funding and thought perhaps a second United Way of�ice in the state might like to match the �irst United Way of�ice’s donation. KVCAP approached this second of�ice, hoping that some sense of competitive spirit would encourage that of�ice to also donate. This effort was successful, and KVCAP was able to secure another $3,000 donation. Both United Way of�ices have continued to donate this amount each year to support senior transportation. With the high demand for dialysis trips for seniors in KVCAP’s two counties, the United Way funds are dedicated to supporting dialysis transportation. Summary and Transferability For the past 10 years, KVCAP has received funding from the United Way that is used to support dialysis transportation. With donations from two United Way of�ices, KVCAP receives $6,000 each year. At an estimated $18.00 per KV Van trip, the funds support roughly 15% of the agency’s dialysis trips. This is not a large proportion, but every funding source is important and contributes to the operating funds for the agency’s specialized trips and, speci�ically, its dialysis trips.

Chapter 6—Initiatives on the Transportation Side 6.43 The United Way supports community-based and community-led interventions that strengthen communities, focusing on education, income, and health. A transit agency might consider approaching its local United Way of�ice to explain the transit agency’s role in providing transportation access to healthcare and to request funding support. Transportation’s place as a key social determinant of health should be emphasized as well as the transit agency’s role in providing that transportation, particularly for those with unmet transportation needs and with chronic diseases requiring ongoing medical appointments. Contact KVCAP 97 Water Street Waterville, ME 04901 207-877-5677 www.kvcap.org/transportation/