Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services (2021)

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6 Efforts to improve health in the United States increasingly recognize that it is not just the health-care system that is responsible. It is a range of factors that collectively affect health and health outcomes. These factors are known as the “social determinants of health,” and signifi- cantly, they include transportation. With available and reliable transportation, individuals can travel in their communities to access the medical appointments and services they need. Without that access, care is delayed or missed, which increases not only the potential for poor health outcomes but also the cost for health care. Particularly for those with chronic diseases, delays in care and missed appoint- ments complicate disease management and may worsen patients’ health, which increases over- all health-care expenditures. The federal government, through the Accountable Health Communities Model [an initiative of the Centers for Medicare and Medicaid Services (CMS)], is encouraging partnerships between health-care providers and community services, including transportation, that are available and responsive to the needs of community residents. But what does that mean for a community? What is responsive? And how are those partner- ships initiated and developed? The answers to these questions vary from community to com- munity and partnership to partnership. This was clear from the work conducted by the research team in preparing this guidebook. The research began with a literature review, followed by surveys, as a means to hear from providers of transportation as well as health care and social services. The work also included case study research and identification of collaborations between transportation and health care to try and understand how the arrangements began and what exactly was involved. It Takes a Community One thing is clear from that work—it does take a community to have an effective partner- ship. It takes the community’s transportation provider (and sometimes multiple providers) and a community health-care organization (and potentially more than one health-care organi- zation) to coordinate planning and implementation to improve transportation access to health care. Sometimes the initiative comes from the health-care side and sometimes from the trans- portation side. As just one example, one of the collaborative practices featured in this guidebook began on the health-care side. A large health-care system in Pennsylvania decided that improving trans- portation access might help reduce no-shows for primary care and ancillary appointments. The health-care system reached out and collaborated with the region’s public transit agency to plan C H A P T E R 1 Introduction to the Guidebook

Introduction to the Guidebook 7 and implement a pilot service providing free trips from two selected areas to the health-care system’s facilities. On the other hand, the partnership may start on the transportation side. Two transit agencies in Central Texas—one urban and one rural—joined forces to develop a regional mobility manager to improve transportation options, recognizing that a key need was expanding transit service to support health-care access. Objectives and Products of the Research Project This TCRP research project had two objectives: first, to develop a guidebook to help commu- nities improve transportation to health care and second, to develop a research plan that outlines future research needs and priorities. The guidebook is the primary product of the research project. Its objective is to provide sup- port, information, and examples that assist communities—with a focus on providers of trans- portation and health care—build relationships and services that improve transportation access to health-care services. The second product is a research plan, which is included as an appendix to the guidebook. The panel that developed the problem statement for the TCRP project and guided the research during its conduct understood that the relationship between health care and transportation is evolving and that more work is needed. The research plan provides an outline for pursuing and funding additional research that quantifies and better qualifies the benefits of improving trans- portation access to health care. What Is in the Guidebook? The guidebook has the following components: • Chapter 1: Introduction to the Guidebook. Readers of the guidebook may want to start here to identify which chapters of the guidebook may be of particular interest. • Chapter 2: Why Should Communities Improve Transportation to Health Care? This chapter identifies research and evidence demonstrating the value of appropriate transporta- tion to access health care and health-care-related needs. Local health-care and transportation providers can use this information to make the case for transportation to access health care. • Chapter 3: Working Toward a Partnership: Health Care and Transportation. The trans- portation and health-care sectors must work together to provide appropriate solutions, but it starts with communication. Here, one can explore various approaches and examples of a community coming together to ensure transportation to access to health care. • Chapter 4: Develop Transportation Solutions. There are a variety of solutions to a commu- nity’s health-care access needs. In this chapter, a reader can find guidance on key transporta- tion issues and developing and selecting the most appropriate transportation solutions for each rider. One size does not fit all. • Chapter 5: Case Studies. Five case studies are detailed, describing relationships and partner- ships created between transportation and health-care organizations. They demonstrate successful efforts that improve transportation access to medical and other wellness-related appointments and services. Understanding how these relationships came about and the services provided may benefit other communities as they seek to improve transportation access to health care. • Chapter 6: Collaborative Practices. Sixteen examples of collaborative efforts between trans- portation and health-care organizations are described. These practices include those that are

8 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services relatively straightforward—such as a free van service provided by a hospital—to technology- enabled solutions that improve access to health care. For those communities interested in and considering their own efforts to improve transportation access to health care, the collabora- tive practices provide ideas and possibly inspiration. • Appendix: Research Plan. Research recognizes that transportation is just one of the social determinants of health, but it is increasingly recognized for its importance in promoting and maintaining health, preventing and managing diseases, and working toward health equity for all Americans. Through the efforts of this TCRP research, the study team found a range of projects in communities across the country that have improved transportation access to health care, but more work is needed to better understand how the partnerships between the health- care and transportation sectors develop and how they might be encouraged. Research is also needed to better document the specific benefits of improved transportation access and to develop metrics that provide evidence. Finally, research is needed to engage more patients to use fixed-route bus services where feasible. Toward these ends, the research plan outlines research topics that might be pursued through TRB and potentially TRB in cooperation with its sister division within the National Academies—the Health and Medicine Division. The plan also identifies other possible sponsors of the identified research topics, specifically public and philanthropic funders of health research. How to Use the Guidebook The guidebook is designed to support local-level health-care and transportation providers as they work together to support transportation access to health care. Depending on personal interest, a reader can start at any chapter and focus on specific issues or needs. For those interested in getting started and needing to make the case for transportation access to health care, Chapter 2 is a good place to start. If the reader is forming a partnership between health-care and transportation provider(s), then focusing on Chapter 3 would be instructive. For those who have a partnership in place and want to initiate a transportation service or want to change that service, then Chapter 4 will provide guidance. Chapter 5 (Case Studies) and Chapter 6 (Collaborative Practices) provide the reader with a wide variety of ideas, from initiating collaborations to operating a diverse set of services using the latest technology. What is clear from the research and what is illustrated by the wide range of projects and services described in Chapters 5 and 6 is that there are many successful approaches to improving a community’s access to health care.