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

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

121 Introduction This chapter presents 16 examples that describe a wide range of collaborative efforts that improve transportation access to health care, with examples from across the country. See Exhibit 6-1. The examples were selected from more than 50 collaborative practices that were identified early in the research project and that are briefly outlined at the end of this chapter in Exhibit 6-9. C H A P T E R 6 Collaborative Practices Exhibit 6-1. Location of the collaborative practices.

122 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services This exhibit groups the practices into nine categories, ranging from Innovative Funding and Reimbursement to Mobility Management to Brokerage Technology. Collaborative Practices The 16 collaborative practices described in this chapter include relatively straightforward examples such as the hospital in Campbellsville, Kentucky, with a free van service for patients in its surrounding counties. The examples also include a call center in southern Illinois that coor- dinates transportation between several health-care and transportation providers, facilitating not just health-care trips but also trips supporting wellness such as trips to grocery stores. Technology also plays a role in transportation improvements to health care. One of the examples profiled—Kaizen Health—provides a logistics hub that aggregates multiple NEMT providers in one place. Readers of the collaborative practices in the chapter will see that close to half address transpor- tation in rural areas. This is not a surprise given that rural communities lack the transportation infrastructure typical of urban areas. Rural areas also lack the range of health-care facilities seen in urban areas, exacerbated by the closing of rural hospitals as discussed in Chapter 2. The result is that many health-care trips in rural areas, especially for more specialized care, may require long trips across county borders that require extra coordination and collaboration. Health-Care Provider Operates Rural Public Transit to Improve Patient Access in Rural Mississippi: Aaron E. Henry Community Health Services Center, Inc. Description of Practice The Aaron E. Henry Community Health Services Center, Inc. (AEH) is a Federally Quali- fied Health Center (FQHC) that provides integrated, comprehensive care to people in the Mississippi Delta. AEH not only focuses on increasing access to primary and preventive care but also on promoting community economic development through access to transportation. AEH offers commuter public transportation, dial-a-ride services, and curb-to-curb services to passengers in seven rural Mississippi counties through the Delta Area Rural Transit System (DARTS). DARTS originally provided medical transportation to AEH patients but has since expanded to offer public transportation to the general public. DARTS offers commuter route buses that connect riders to local employers, medical facilities, and other key community loca- tions. Most DARTS riders use the program to access their jobs at local industries and casinos, but on-demand stops can also include shopping centers and human services agencies. DARTS currently operates more than 40 multi-passenger vans (1). In addition, DARTS provides on-demand, dial-a-ride services for elderly patients in the seven- county region with funding from the Area Agency on Aging. Eligible riders must call DARTS to make a 24-hour advance reservation. Older adults and individuals with disabilities are also eligible for low-cost, curb-to-curb van service in certain service areas. AEH provides Medicaid NEMT transportation. Medicaid beneficiaries call the Medicaid transportation number, and the Medicaid broker sets up payment with AEH. DARTS also participates Delta Rides, a network of private transit providers, other non- profit transportation providers, and social service agencies in the Mississippi Delta region.

Collaborative Practices 123 Together, the Delta Rides network provides transportation services to 21 counties in the Mississippi Delta region. Community members seeking to travel between counties can contact a Delta Rides mobility manager, who will coordinate between agencies to schedule their ride. Delta Rides’ representatives participate in monthly meetings to share lessons learned and discuss resources. AEH provides approximately 139,000 rides each year. About 70% of rides are for special populations (the elderly and individuals with disabilities) and the other 30% are for the general public. The number of AEH rides have generally remained steady, with minor changes in ridership that correspond to increased or decreased community demand (e.g., the closure of a local casino). Needs In 2018, AEH served a total of 15,182 patients (2). Approximately 89% of patients were at or below 200% of the federal poverty level. In addition, 22% of patients were uninsured, 36% were enrolled in Medicaid, and 14% were enrolled in Medicare. AEH also reports that their patient population has high rates of certain chronic health conditions. For example, in 2018, 45% of patients had hypertension and 23% had diabetes. AEH reports that DARTS has grown in tandem with the “expansion of the regional job market and the increased need for affordable employ- ment transportation.” How Did the Collaboration Start? In 1990, AEH identified a major need for transportation among patients in their rural Mississippi service area. The founder of the FQHC, Aaron E. Henry, was transporting patients in a personal van to help ensure they could attend critical appointments. AEH staff decided to develop the DARTS program to better meet patient needs for transportation to subspecialty care. At the same time that AEH began providing transportation to patients, some Mississippi Delta counties began experiencing new economic development after the passage of the Mississippi Gaming Control Act. The legislation restricted casino gambling to counties along the Mississippi River and the Gulf Coast. Local residents who gained employment at the new casinos needed reliable transportation to and from work. In 1993, AEH used a grant from the Mississippi Department of Transportation (MDOT) to expand services to the general public in recognition of unmet needs for transportation to employment opportunities. To decide on the most appropriate stops for the commuter routes, AEH reached out to local businesses, social services, and employment agencies to solicit sug- gestions. AEH prioritizes stops that provide access to places of employment. Other key stops include employment agencies, social services, health-care facilities, and recreational sites. DARTS began with two minivans with a 15-person capacity and has since expanded to 46 multi-passenger vehicles. Most DARTS riders now use the program to access jobs and human services. As of 2019, DARTS provides public transit services in Coahoma, Desoto, Panola, Quitman, Tallahatchie, Tate, and Tunica counties. Funding/Sustainability Fees for DARTS vary by age, residency, insurance status, and travel distance of the rider. Transportation fees for some senior riders are covered by the Area Agency on Aging, Medicaid, or Medicare. Some county governments in the DARTS service region also offer transporta- tion subsidies.

124 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services In addition, AEH receives federal funding from the U.S. Department of Transportation (USDOT) Formula Grants for Rural Areas (Section 5311), which is administered by the MDOT. In 2018–2019, AEH’s transportation budget was $2.5 million, with $1.1 million from MDOT. AEH also holds a purchase-of-services contract from the North Delta Planning and Devel- opment District to provide transportation services for the elderly and for individuals with disabilities. In addition, DARTS funded a Regional Transportation and Maintenance Center with grant funding from the U.S. Department of Agriculture, the USDOT’s FTA, Community Transportation Association of America, and the Mississippi Development Authority’s Energy and Natural Resources Division. Lessons Learned Stigma associated with public transportation presented challenges to encouraging use of DARTS services. Use of buses is associated with older, low-income, and ill individuals. Rural residents are still highly reliant on personal vehicles and unfamiliar with navigating public transportation. AEH is taking steps to encourage the use of public transportation among people of working age and younger adults. AEH conducted community outreach about transportation options and worked with the drivers to create a standard branded look for the vehicle fleet. Drivers wear uniforms and adhere to standards for clean vehicles. AEH leveraged one-time funding opportunities for capital investments in the service fleet. For example, AEH used American Recovery and Reinvestment Act funding to purchase new vehicles for DARTS and to renovate the vehicle maintenance shop. Capital investments are critical for implementing new services and maintaining vehicles. A key lesson learned for communities seeking to implement a similar program is to under- stand the needs of the targeted population. Programs need to understand how much com- munity members are willing to pay, where they want to go, and how long they are willing to travel. In rural areas, patients may need to travel for hours for medical care. Programs also need to understand how to accommodate their target population, including their physical and social needs. Resources • AEH’s website provides additional information about Delta Rides and AEH public transpor- tation services: https://www.aehchc.org/darts/delta-rides/ The Takeaways • AEH leveraged several sources of funding to not only offer transportation to and from medical facilities but also to support local economic development and employment opportunities. • Periodic capital investments in infrastructure are critical to maintaining the integrity of a vehicle fleet. • Rural programs may need to conduct outreach or implement strategic marketing and branding to help address stigma related to public transportation services.

Collaborative Practices 125 Health Care Insurer Offers Free NEMT Transportation: CareMore Health System Description of Practice CareMore Health is a physician-founded, physician-led integrated health insurer and care delivery system. CareMore’s focus is on chronically ill patients and developing holistic solutions. For many patients enrolled in its Medicare plans, CareMore provides a diverse range of NEMT services free of charge. Most ambulatory riders can use Uber and Lyft. Patients that require extra assistance or specialized transport have access to door-to-door service and accessible vehicles. CareMore has established a call center that takes all requests for service and monitors that service. All patients (or clinic staff) in need of transportation contact the call center. The call center then determines the most appropriate mode of service. The call center either contacts the TNC or CareMore’s transportation broker who will then assign the appropriate level of service for each patient. Exhibit 6-2 depicts the key steps. CareMore’s focus on holistic solutions had to include transportation for those in need—estimated to be about 18% of their patients. CareMore determined that transportation was an essential need. Their previous service had a number of issues that needed to be addressed. A service was designed to match need and service with the help of Lyft and American Logistics Company (ALC). Technology was an integral part of the solution (Interview with CareMore by Ken Hosen, December 2019). Exhibit 6-2. Key steps. Image used with permission from CareMore. Needs In 2016, CareMore Health, a physician-founded, physician-led care delivery system serving more than 150,000 patients in nine states and the District of Columbia, began a pilot program to offer its most chronically ill patients more reliable NEMT.

126 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services CareMore had provided patients with wheelchair vans and other specialized transport for years, but after receiving numerous complaints from patients that the services were inadequate, CareMore sought out a solution to improve the transportation program. The pilot was so successful that after just a few months CareMore expanded the program systemwide. The problems to be resolved revolved around the following issues: • Driver education—With the high-needs service typical of CareMore patients, many of the typical TNC drivers were not equipped and did not know how to properly transport chroni- cally ill patients. • Poor service—On-time performance was poor, resulting in patients being late or missing their appointment. • Lack of appropriate service availability—Rural areas pose a particular challenge where trips are longer, costs are higher, and often no service is available. • Needs of patients—Most new technologies require the use of a smartphone. CareMore worked with TNCs to eliminate the need for a smartphone through calling the CareMore call-taking function • Full access—Some benefits did not include access to certain destinations. How Did the Collaboration Start? Realizing that the needs of CareMore patients were not being adequately addressed, manage- ment determined that the solution included a number of key innovations. In 2015, CareMore established its call center and entered into a collaborative relationship with Lyft (a TNC) and American Logistics Company (ALC) acting as a broker for non-Lyft trips. ALC soon developed the software needed by CareMore to assure a level of control over the service. The key elements of the collaboration were as follows: • Collaboration—Having the right partners is critical to CareMore’s mission. CareMore first chose Lyft and later included Uber for ambulatory patients. ALC is the service broker for trips not appropriate for a TNC. • Service design and innovation—CareMore is able to match need to the most appro- priate service. Their call center allows full control over the service. • Technology—Optimizing and grouping trips where feasible, unlike many brokers, CareMore transportation and clinical staff can identify the actual location and on-time status of all patients on board a vehicle. This is a valuable tool for clinic staff in addition to being another tool to ensure safety of patients. Coordination of Services As all trip requests come into the CareMore call center, all coordination is accomplished through CareMore. CareMore determines the mode and then dispatches one of its contractors, either a TNC or schedules through the broker. Important for safety and on-time performance, the call center, broker, and clinic staff are able to track each trip using automatic vehicle locators. See Exhibit 6-3. Funding/Sustainability Funding for this service comes from CareMore. CareMore believes that the investment in transportation (in general) pays off in reduced health-care costs (e.g., reduced visits to the emer- gency room, illness, and missed trips, which are very costly).

Collaborative Practices 127 This is one more example of the for-profit private sector understanding the necessity of transportation and how important it is to appropriate health care. Lessons Learned Transportation access is crucial to health. CareMore reports that, through the use of TNCs and the revised model, missed trips are down as much as 12%, though that has yet to be verified. In addition, based on their over 3 million trips completed using this new model, CareMore has seen: • 32% cost reduction from previous model. • 30% shorter wait times. • 97% member satisfaction. Exhibit 6-3. My Ride Manager (MRM) 2.0 (ALC and Uber Health Technology). Diagram used with permission from CareMore (C2C, D2D, BLS/ALS = passenger codes). The Takeaways • Transportation is a key to holistic health-care solutions. • CareMore believes that this service is a worthwhile investment that reduces costs and missed trips (more research is needed on this, however). • Use the most appropriate service to meet the needs—one size does not fit all. • Invest in technology that can track every trip in real time.

128 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services NEMT Provided by a Health Care Consortium in Columbia County, New York: Children and Adults Rural Transportation Service (CARTS) Description of Practice The Children and Adults Rural Transportation Service (CARTS) provides free NEMT to residents of Columbia County, New York. While all trips originate in Columbia County, CARTS transports passengers to multiple counties in New York State and bordering areas in western Connecticut and Massachusetts for care. CARTS is a program of the Columbia County Community Healthcare Consortium, Inc. (the Healthcare Consortium), a non-profit, community-based organization that brings together multidisciplinary stakeholders to improve the health and well-being of residents in Columbia and Greene counties. CARTS receives reimbursement from Medicaid to transport enrollees and uses funds from a range of other sources to cover the cost of rides for non-Medicaid patients. CARTS also works with local hospitals and health and human services providers to provide transporta- tion for outpatient services and court-related appointments. The New York State Medicaid Transportation Program contracts with CARTS to provide transportation to individuals in Personalized Recovery Oriented Services (PROS), which supports the rehabilitation and treat- ment of people with serious mental health conditions. CARTS operates Monday through Friday from 8 am to 4 pm, though drivers often begin driving earlier to pick up passengers and end later to drop passengers off at their final destina- tion. On an annual basis, CARTS provides more than 16,000 trips to over 500 people. Clients enrolled in Medicaid call the regional transportation broker to confirm their eligi- bility and receive prior authorization for transportation services. Due to the state’s Medicaid freedom of choice provision, passengers can request CARTS when they reach out to the Medicaid broker. Clients who are not enrolled in Medicaid call CARTS directly to schedule a ride. Due to limited resources and the rural geography of the region, the CARTS model requires substantial advance planning. Passengers need to book their trips at least 2 days in advance for in-county rides and more than 2 weeks in advance for out-of-county rides. CARTS is supported by two staff members, a Transportation Program Director and a Trans- portation Program Coordinator. These staff work with the state Medicaid broker, individual passengers, and other clients (e.g., the local community hospital) to schedule rides. CARTS also employs 11 to 13 drivers at any time, generally at or slightly higher than minimum wage. Drivers are typically civically minded retirees who formally worked for local fire, police, or corrections departments. All drivers must have a clean driving record and pass a physical exam and a road test prior to hire. Needs Columbia County has a large aging, rural population. In 2018, an estimated 23.8% of Columbia County’s population was age 65 years or older. Many older CARTS clients are receiving health treatments that make it difficult for them to drive themselves to appointments,

Collaborative Practices 129 including dialysis or chemotherapy/radiation. Many older clients lack a social support system or family who can help provide transportation to health care or feel hesitant about driving in larger cities. CARTS makes several special accommodations to meet the needs of PROS program par- ticipants. For example, CARTS dispatches several vehicles simultaneously to pick passengers up at each group home and drop them off at PROS facilities. This prevents passengers from spending long periods of time in the vehicle, which could cause stress and exacerbate an existing condition. CARTS also holds a contract with the local community hospital to transport psychiatric patients to and from court appointments. Before they approached CARTS to arrange special transportation, the hospital reported that patients would often leave and not return while they were waiting for a taxi to attend court, therefore discontinuing critical mental health treat- ment. To better meet the needs of these patients, CARTS dedicates a car and driver solely for transporting patients between the hospital and court. The CARTS driver waits for the patient outside the hospital and the court building to ensure patients arrive safely to and from their destinations. Drivers also provide substantial personal assistance to riders with special needs, such as helping them into the vehicles and maneuvering equipment (e.g., canes or walkers). CARTS also educates drivers about transporting dialysis patients and keeps blood pathogen kits in every vehicle in case a rider has an issue with a port. In addition, CARTS tries to consider the experience of all passengers when scheduling rides. For example, some patients with behavioral health conditions prefer to ride alone. If necessary, CARTS will schedule fewer people than the maximum capacity of the vehicle to ensure that all passengers have a comfortable ride. How Did the Collaboration Start? The Healthcare Consortium was established in 1998 with the mission of increasing access to health care by promoting collaboration among health and human service providers in Columbia County. Representatives from county government, county departments and agencies, health- care providers, local business, faith-based organizations, and members of the community all serve on the Consortium’s Board of Directors. Lack of transportation to and from medical appointments was one of the first issues iden- tified by the Healthcare Consortium in 1998. Rural Columbia County lacks accessible and comprehensive public transportation options, and patients are often required to travel long distances to receive care. The Consortium began CARTS in 1999 to meet the transportation needs of community members. Funding/Sustainability CARTS receives substantial funding and in-kind support from Columbia County, which is critical to the continued success and sustainability of the program: • The Healthcare Consortium operates out of an office space in a county-owned building at no cost. • The county allows CARTS to purchase tax-free fuel from the county pump. • In previous years, CARTS has leased vehicles directly from the county at below market rate.

130 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services • CARTS uses the county garage for repairs and parks their vehicles in the City of Hudson- owned lot. • The Columbia County Board of Supervisors includes a small amount of funding for CARTS in the county budget each year. • Several county agencies, including the Columbia County Office for the Aging and the Columbia County Department of Health, commit small amounts of funding to the Health- care Consortium each year. CARTS also receives reimbursement from Medicaid for providing NEMT for enrollees. Non- Medicaid enrollees often support CARTS with donations. In addition, the Foundation for Community Health, a private foundation in Connecticut, provides CARTS with a small amount of funding to help support local community members. Lessons Learned In a rural community with limited resources, collaboration is essential to the sustained success of a transportation program. CARTS receives in-kind and budgetary support from many community agencies, local government, and other key partners who understand the value of transportation in promoting health and well-being. CARTS also leverages partnerships to continue to adapt to changes in transportation management. For example, several local health-care providers have started using Circula- tion, a web-based platform, to request rides for patients. Since CARTS works at capacity, mobility managers originally had to refuse last-minute trip requests. CARTS leadership reached out to partners at providers’ offices to find a way that CARTS could continue to serve patients in their service area. Case managers now call CARTS directly to first schedule the patient at a time that CARTS can accommodate before placing the request in the web- based system. Resources • The CARTS website is available at: https://www.columbiahealthnet.org/programs/medical- transportation/ The Takeaways • The Healthcare Consortium works closely with partners and the county government to leverage resources and in-kind support for long-term sustainability. • CARTS also works closely with partners to better understand and meet the needs of patients with a range of health conditions. • CARTS directly employs drivers instead of using a volunteer model. Drivers are typically long-time community members with a strong commitment to civic participation.

Collaborative Practices 131 County Demand Response Program Partners with Local Hospitals for Funding Support in Baltimore County, Maryland: CountyRide Description of Practice Baltimore County, Maryland, provides a demand response public transit system known as CountyRide (Exhibit 6-4). The service is operated by the county’s Department of Aging, with transportation provided for seniors and people with disabilities in the urbanized por- tion of the county and for the general public in the non-urbanized northern portion. This distinction reflects the funding sources received from the state, including FTA and state transit funds. Through a long-standing public-private partnership, CountyRide receives annual finan- cial support directly from hospitals and medical facilities in Baltimore County and Baltimore City. This funding supplements CountyRide’s federal and state grants as well as passenger revenue. CountyRide recognizes the support from the medical facilities in several ways: • Extending its service into Baltimore City specifically to serve participating medical facilities located within the city limits. Except for those specific destinations, CountyRide does not serve Baltimore City. • Providing priority scheduling for riders traveling to medical appointments, including those at the partnership facilities. • Recognizing medical facilities through CountyRide’s online and printed informational material. Exhibit 6-4. CountyRide vehicle. Photo courtesy of KFH Group.

132 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Needs Transportation access to hospitals and medical facilities in the Baltimore region is difficult for many seniors and people with disabilities without access to private transportation. Baltimore County saw rising demand for trips into Baltimore City for medical appointments but limited funding to expand service. How Did the Collaboration Start? CountyRide’s public-private partnership program began more than 25 years ago, initiated because of 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 County- Ride, recognizing that the door-to-door service was critical for many of their patients to access appointments at their facilities. There are currently 15 medical facilities (shown in Exhibit 6-5) that contribute funding to CountyRide to support transportation access to their facilities. Exhibit 6-5. Partnership hospitals.

Collaborative Practices 133 Funding/Sustainability CountyRide’s partnerships with medical facilities are informal and the amounts provided by individual hospitals and health-care organizations 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. Lessons Learned Coordination and collaboration between a county-based specialized transportation service and the hospitals and health-care organizations which it serves can lead to funding support for the transportation provider. Recognition of that support furthers the partnership. The Takeaways • Community transportation programs can establish relationships with medical facilities they serve that include financial support. • The transportation program should emphasize that many riders travel to medical facilities, and the program provides access for these individuals to needed health-care appointments (and avoids missed appointments). • The transportation program should recognize the support of the medical facilities through its own resources and in the broader community. Transportation Pilot in Central Pennsylvania to Improve Patient Access to Health Care and Reduce No-Shows: Geisinger Health System’s Partnership with rabbittransit Description of Practice Geisinger Health System, a large integrated health-care system in central Pennsylvania, is piloting non-emergency transportation service for its patients in two different areas to improve their access to medical and other health-related appointments and to address patient no-shows. Geisinger is partnering with rabbittransit, a regional transportation authority serving 10 counties in central and southcentral Pennsylvania, to provide the service. Two pilot services were planned and initiated in April 2018. One serves patients in an urban area—those living within a 25-mile radius of the city of Scranton. The second serves rural patients—those living within 50 miles of the town of Danville.

134 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services rabbittransit serves as the coordinator of transportation service for the pilot. In addition to providing trips within its own service area, rabbittransit coordinates with neighboring public transit providers to deliver/perform trips within their respective service areas. If a patient’s trip needs cannot be met by one of the public transit providers in the coordinated network, the trip is scheduled to a taxi, TNC, or other private provider. Needs Geisinger was experiencing high rates of appointment no-shows—particularly for primary care appointments but also for ancillary appointments, such as for diagnostic services. Data from 2016 saw almost 324,000 no-shows for medical appointments and close to 88,000 no-shows for ancillary appointments. How Did the Collaboration Start? Geisinger determined that the rate of no-shows had to be addressed. Geisinger understood that providing a transportation service may not be the easy fix to missed medical appointments, but it decided nonetheless to try and improve patients’ access, particularly for those living in rural areas (3). Through community relationships, Geisinger was familiar with rabbittransit, the regional public transit provider. The two entities worked together to plan and implement the pilot. According to plans for the pilot, a referral from staff begins the process for scheduling a patient’s trip. The referral is reviewed, and the patient is screened. The health system then sends a transportation request to rabbittransit to schedule the patient’s trip. Geisinger’s plans also recognized the need to extend transportation service through the pilot for non-clinical but health-related activities—for example, access to pharmacies to get medica- tions and transportation to grocery stores for fresh food. Funding/Sustainability Geisinger provides the patients’ trip without charge, funding the cost through its health- care plan. Transition from pilot status to ongoing status will be determined once the pilots are formally evaluated to assess their effectiveness in addressing patient no-shows and improving transportation for other health-related needs. The pilot has connected those patients who were unaware of public transportation options to their local transit providers. This allows patients to have transportation for other purposes, and many have transitioned from the pilot program to traditional transit programs. Lessons Learned Data provided in 2019 with ridership figures for the pilots’ initial 9-month period showed 3,900 trips were provided for 1,459 patients. The average trip distance was 27 miles. Eighty-five percent of the trips were for medical purposes. Of the remaining, 13% were for food-related needs and 2% were for pharmacy needs and social service (4).

Collaborative Practices 135 Logistics Platform Connecting Transportation and Health Care: Kaizen Health Description of Practice Kaizen Health offers a platform that aggregates diverse types of transportation in one place. Kaizen Health aims to accommodate the needs of everyone, including people with limited mobility and children. Depending on the network area, Kaizen can partner with: • Rideshare companies, including Uber and Lyft, • Traditional NEMT fleets, • Taxi companies, • Wheelchair-accessible vehicles, • Small buses, • Non-emergency ambulances, • Medicars/stretcher vehicles, and • Courier services (for example, to deliver medication to patients at home). Multiple types of health-care organizations and stakeholders utilize Kaizen Health’s platform to arrange transportation for patients. Kaizen Health works with health-care providers (e.g., FQHCs, large health systems, academic medical centers, and safety-net hospitals), Medicaid, Medicare Advantage, clinical trial research coordinators, senior centers, municipalities, and non-profit agencies. Kaizen Health’s clients can use the platform to arrange NEMT transportation for any kind of medical services, from discharge from the emergency department, to routine transportation to dialysis clinics, or to follow-up primary care appointments. The Kaizen Health platform is available through a web browser or can be integrated with dif- ferent case management or EHR platforms (Exhibit 6-6). Staff helping to arrange transportation can browse the options available for their client and select the vehicle that best meets their needs. The passenger can select their preferred communication method (text/voice call/mobile app) The Takeaways • Health-care organizations understand that lack of transportation is not the only factor impacting appointment no-shows. • Yet, providing free transportation to medical and health- related appointments improves patient access and helps reduce no-shows. • Patients living in rural areas, where public transportation options are limited, have greater needs for transportation assistance to access health care.

136 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services and language of choice to receive updates about the ride. Passengers receive communication with the details about their upcoming rides. A typical ride arranged through Kaizen Health includes the following steps: 1. A patient is ready to be discharged from the emergency department or hospital. 2. A care coordinator assesses their transportation need and requests a ride through Kaizen Health to get the patient home. The care coordinator also sets up transportation in advance for a follow-up medical appointment. 3. On the day before the follow-up appointment, the patient receives automated communica- tion with a reminder about the ride. 4. Minutes before pick up, the patient receives communication with details about the driver and vehicle. 5. The driver picks up the patient and drops them off at their medical appointment. The care coordinator can track the progress of the ride on the Kaizen Health platform. If the patient cancels the ride for any reason, Kaizen Health notifies the care coordinator who made the appointment to facilitate rescheduling. Needs Kaizen Health offers transportation options that meet a range of mobility needs. In addi- tion to curb-to-curb services, Kaizen Health also arranges door-to-door, door-through-door, and bed-to-bed transport. The Kaizen Health platform includes decision-making support to help the user, typically a care coordinator or social worker, select the vehicle that best accommodates the patient’s needs. For example, if the user chooses a wheelchair-accessible vehicle, the system asks them whether the patient is able to ambulate or to choose the type of wheelchair that the patient is in so that a standard wheelchair vehicle is not sent for a patient that is in a motorized wheelchair. Many of Kaizen Health clients are arranging transportation for patients who have complex health conditions and are enrolled in Medicaid. Those whose transportation is not covered by Medicaid often struggle to pay out-of-pocket transportation costs. Patients who live in rural areas may also have unmet transportation needs due to a smaller pool of drivers. Other Exhibit 6-6. Example of Kaizen Health application with patient’s scheduled ride and mobility needs. Image used with permission from Kaizen Health.

Collaborative Practices 137 transportation barriers include lack of access to personal cars, limited public transit options, and lack of technology to arrange their own transportation. How Did the Collaboration Start? The inspiration for starting Kaizen Health was due to problems that their own family faced. When investigating the NEMT landscape to solve those family problems, they found that health systems often lacked the resources and space to manage their own fleet, including funding for drivers, gas, and maintenance. They also found that providers were interested in rideshare plat- forms, but hesitant about HIPAA limitations and the ability of drivers to help patients with limited mobility. Kaizen Health sought to address these issues by building a HIPAA/Health Information Trust (HITRUST)/SOC 2 (System and Organization Controls 2)-compliant platform that removed the burden of arranging transportation partners from providers. Kaizen Health mobilizes existing transportation providers under one platform to simplify the process of finding and requesting the most appropriate ride. When a client reaches out to Kaizen Health to inquire about using the platform, they are often interested in testing a proof of concept or piloting the program. For example, in 2017, the University of Illinois Hospital and Health Sciences System (UI Health) worked with Kaizen to implement the pilot PROgram for Non-emergency TranspOrtation—or PRONTO to investi- gate whether Lyft could help patients get home more quickly after discharge. The 3-month pilot program was highly successful; patients were typically transported home 1 hour after the social worker assessed their transportation needs (5). Funding/Sustainability Kaizen Health bills clients on a monthly basis. For pilot programs, Kaizen typically charges on a per-ride basis. Once the partner contracts with Kaizen Health for full services, the com- pany also charges a per-ride administration fee or a licensing fee, depending on the prefer- ences of the client. Kaizen Health also charges for other services, such as licensing fees for EHR integration. Resources • Kaizen Health’s website provides additional details about the platform: http://kaizenhealth.org/ • Kaizen Health presented a demonstration of their platform for the Center for Care Innovations: https://www.careinnovations.org/resources/tech-demo-connecting-patients-to-transportation- with-kaizen-health/ The Takeaways • Kaizen aggregates multiple NEMT providers in one place, allowing clients to pick the form of transportation that best meets the needs of potential passengers. • Small-scale pilot programs can help clients establish a business case or rationale for investing in NEMT.

138 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Health Care Transportation and Ride Hailing: Lyft Description of Practice Lyft is a ride-hailing company that offers health-care providers and payers access to NEMT through its network of over one million drivers. Coordinators can either schedule rides directly on the Lyft Concierge plat- form or integrate Lyft’s Application Programming Interface (API) into their existing health technology tools. A wide range of individual providers, hospitals, health plans, technology platforms, and other entities use Lyft as part of their health-care transportation solutions. Coordinators can schedule rides on demand or in advance and track the vehicle. Needs While some Lyft drivers offer wheelchair-accessible vehicles, Lyft rides are typically most appropriate for ambulatory patients without mobility limitations. Typically, clients use Lyft to provide easily accessible, on-demand transportation and partner with a different transportation provider to arrange for specialized services such as ambulances and paratransit vehicles. For example, the National MedTrans Network uses Lyft’s API to coordinate curb-to-curb pick up for patients who can exit and enter a vehicle without assistance. How Did the Collaboration Start? Prior to the launch of Lyft’s official health-care platform, third-party transportation pro- viders were already using Lyft to address gaps in NEMT. In 2016, Lyft detected unusual usage patterns in New York City, where several customers were taking rides that had been booked from Salt Lake City. The Lyft team discovered that an NEMT, National MedTrans Network, was using Lyft to book rides for ACO patients when their scheduled transportation ride fell through. The Lyft team reached out to National MedTrans and began identifying other issues related to medical transportation, including no-show rates and the costs of avoidable expenses. Lyft saw an opportunity to leverage its driver network to increase access to on-demand trans- portation and reduce the administrative burden of arranging transportation. Coordination From the outset of the program, Lyft acknowledged that partnerships would be necessary to provide the full spectrum of health-care transportation. The National MedTrans Network became one of Lyft’s first partners, and Lyft has since partnered with the nine other top NEMT brokers. These brokers can integrate Lyft’s API into their systems, allowing a coordinator to schedule Lyft rides for patients. Funding/Sustainability Pricing for Lyft rides is based on rates at the time the ride is booked. Costs can vary by type of Lyft service, geography, driver availability, time of day, and other factors. Clients are charged directly for Lyft transportation through a business account.

Collaborative Practices 139 The Centers for Medicare and Medicaid Services (CMS) has provided more opportunity for Lyft and other TNCs to provide health-care transportation with a 2019 ruling allowing for greater use of supplemental benefits in Medicare Advantage plans, which include transportation. Lyft was approved as an enrolled Medicaid provider in Arizona in 2019. It is the first such agreement between a state Medicaid program and a national ride-hailing company. Performance Measures Lyft’s 2019 annual economic impact report found that 29% of clients used the application for health-care trips. The report, which includes results from a survey of 30,000 Lyft users, also found that over one-third of riders who use Lyft to travel to health-care services reported decreased urgent care visits since using Lyft. Lyft also reports that the service contributes to decreased no-show rates, increased revenue, and improved patient satisfaction. Lyft’s clients report high demand and customer satisfaction. For example, Lyft partnered with major Medicare Advantage provider Cigna-HealthSpring in May 2017 to provide transporta- tion to doctor’s appointments and pharmacies in Alabama, Georgia, Maryland, North Carolina, Pennsylvania, Tennessee, Texas, and the District of Columbia. Cigna-HealthSpring reported that by November 2017, patients had completed 14,500 rides. In satisfaction surveys, 92% of customers indicated that Lyft was their preferred NEMT option. Lessons Learned Patients may need additional assistance with identifying the location of their appointment on large medical campuses. Lyft uses venue mapping to allow clients to designate custom pick-up and drop-off zones for their medical facilities. Lyft’s on-demand transportation has proven popular with a range of health-care providers and their patients. The Takeaways • Ride-hailing companies have expanded their business lines, with an increasing presence in the health-care transportation space. • Ride-hailing trips tend to be more effective for ambulatory patients. Wheelchair-accessible service is limited. Service Design Matters: North Central Regional Transit District, New Mexico Description of Practice North Central Regional Transit District (NCRTD) is a large, four-county rural transit system that spans over 250 miles of service. NCRTD serves four very different counties, seven cities and

140 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services towns, and six pueblos. In 2013, NCRTD was a low ridership service with difficult-to-follow routes and schedules. Many routes did not connect, and the service was difficult to use for work, shopping, or health care. In 2013, new management initiated a 5-year plan with extended outreach to the health- care and human service sectors. Routes were revised to make them usable to most riders and included: • Reduced meandering and elimination of loop routes; • Re-timing of routes, which was critical to meet work schedules and provide midday service for health care, shopping, and personal needs; and • Better connections internally, with five connecting buses and trains. Through modifications to the routes and with no increase in service levels or costs, the exist- ing routes increased ridership by 45% in 1 year. When new routes were added to the mix, rider- ship doubled in 4 years (6). A 2020 survey conducted for NCRTD indicated that 9% of trips were for health-care services (7). This generates about 100 one-way trips for health care on a daily basis, doubling the previous level of service to health care. Management continues to make improvements, enhance bus stops and shelters, and make connections simple. Needs The NCRTD service area is quite diverse. Two counties have high poverty rates, while two have well above average incomes, and one county has one of the highest per-capita incomes in the nation. The distances people travel for work, health care, and college often extend 50 miles or more one way. Language barriers exist in many cases, and winter travel through the mountains can be challenging at best. At the same time, there is a major commuter network into Santa Fe with rail connections to Albuquerque. NCRTD connects with five other transit systems, including a commuter rail system. Visitors make up a large part of the potential users as well, with service geared for ski basins and communities on the Santa Fe to Taos corridor. Lastly, the needs identified in the agency’s 5-year plan became evident once new service was implemented with an over 40% increase in ridership in 1 year (8). Health-care access was dramatically improved as well. How Did the Collaboration Start? When new management came to NCRTD, it found a low-ridership system with poorly designed routes and timing that did not allow for commuter use or health-care access. NCRTD’s new management initiated a 5-year plan with extensive outreach to the community: health-care providers, human service agencies, visitors, and schools. There were over 20 meetings and focus groups as well as a variety of other outreach methods, including a focus group representing the health-care field. The new service network featured improved access to the region’s health-care facilities in Taos, Española, and Santa Fe, with an emphasis on needs in remote areas often well over 75 miles away. The improvements included allowing same-day return access to specialists in Santa Fe.

Collaborative Practices 141 Funding/Sustainability The service changes that resulted in the increased ridership were implemented at no addi- tional costs. Funding and sustainability, however, is no longer an issue for NCRTD as it has taken advantage of a New Mexico law that allows for the forming of a district with a dedicated sales tax (Gross Receipts Tax). In 2018, voters approved continuance of the tax with elimina- tion of the sunset provisions. NCRTD uses FTA funds, and some Tribal Transit Funds are used as well. Lessons Learned Outreach efforts make a difference. In addition, NCRTD’s board includes representation from seven cities and towns, six pueblos, and four counties, which allows for both internal and external collaboration. • Outreach: Focus groups, if attendees are chosen properly, can produce meaningful results. The health-care representatives in the focus groups and through interviews provided mean- ingful input. • Simple adjustments to schedules, connectivity improvements, and a variety of service design improvements helped boost ridership dramatically at no additional cost. The Takeaways • Service design has a major impact on service at very low cost. If a 20-minute round trip by auto becomes a 2-hour bus trip on poorly designed loop routes, then only the desperate will use it. Minor adjustments to routes can have a considerable impact: – Connectivity—a timed meet. – Less meandering. – Timing routes for commuters (full 8 hours, plus) and shopping, health-care, and other trips (often one-half day). Transit Sponsorship—A New Sustainability Model in Paris, Texas: Paris Metro Description of Practice TRAX, a nine-county rural transit system, part of the Ark-Tex Council of Governments, implemented a fixed-route service in Paris, Texas, a small city of 25,000 residents in north- east Texas. The fixed-route system (Paris Metro) supplanted demand response service in 2016.

142 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Ridership increased over 400% as the fixed route generated a highly successful service for a city of its size. Management believed that coordinated transportation provides better public transportation. The primary focus of this collaboration is the innovative sponsorship program imple- mented by the transit manager. Prior to implementation, the transit manager used a spon- sorship plan developed by consultants. Since traditional sources of funding had disappeared over the years, TRAX sought a new coordination/sponsorship model. This sponsorship pro- gram was designed to generate revenue for the service and in return allow advertising, pro- motional incentives, and other benefits. United Way immediately responded, and working with TRAX quickly added the Paris Regional Medical Center (PRMC) and Texas Oncol- ogy as partners. The city of Paris and the junior college also joined with the health-care- oriented sponsors. A secondary focus is the route design, which was pivotal in generating eight one-way trips per vehicle hour, higher than virtually every other rural city of a comparable population (about 25,000). Demand response service in Paris was never able to go over one to three one-way trips per hour, making service quite costly on a per trip basis. It was estimated that, for each fixed-route bus in service, the system could reduce demand response service by two vehicles. This was proven correct as now only ADA paratransit-eligible riders need demand service. Management estimated that at least 10% of the ridership is for health-care-related services. Annual ridership is 60,000 one-way trips or about 240 per day. Of that amount it is estimated that between 20 and 30 daily trips are for health-care access, which is a significant number for a small community. Needs The study that initiated this system identified transit-dependent persons, including seniors, persons with disabilities, youths, low income, and the limited English proficiency cohort. This was borne out by the actual ridership. TRAX worked with its sponsors and others (holding meetings at PRMC) to develop the service. Management states that the system transports many difficult-to-serve residents and increased travel training to encourage fixed route. Riders include: • Persons with opioid/substance use disorders, • Veterans to the VA clinic, • Cancer patients traveling to Texas Oncology where patients leave a light on when they need the bus to stop in the parking lot, • Older adults, • Persons with disabilities, • Students, and • Commuters to major manufacturers. How Did this Collaboration Start? In 2015, the new manager of TRAX, armed with a transit and sponsorship plan for the city, initiated a sponsorship program with private and public organizations. In return for funding

Collaborative Practices 143 and support, there would be advertising and promotional benefits for the sponsors. The manager stated that she went to the United Way first, and they agreed to support the project. United Way arranged the initial meeting with local businesses. What came out of that meeting in a matter of weeks were agreements with: • The PRMC allowed the use of office space as a transfer center, a $25,000 in-kind contribution for the facilities, plus additional funding in return for advertising and promotional benefits as well as having both buses transfer at the center. • The Texas Oncology provided funding. • The United Way provided funding. • The city of Paris provided in-kind support and funding. • The local high school gave support for transition/travel training for persons with disabilities. Once the plan was in place with the management, fully-trained drivers and vehicles were all in place, and the plan was within weeks of securing agreements and funding, the implementa- tion efforts began. Service began within months of securing the agreements. Ongoing leader- ship comes from TRAX and PRMC, while trust and commitment continue after 4 years. Coordination of Services: A New Model TRAX has been operating in Paris since the 1980s, initially coordinating Medicaid NEMT, Head Start, Administration on Aging Title 3 funds, and other local sources. Over the next 20 years, those funds were either eliminated or diverted to other organizations or needs. TRAX continued to provide service for seniors and other riders previously funded, but the funding and coordination ended. The new coordinated model employed by TRAX looked at other sources of funding and different types of organizations to work with. In particular, the health-care entities in Paris were called upon to support the system. These entities realized that public transit enhanced their patient’s access to health care. In essence, these new supporters took the place of the traditional coordination model of support and added to the credibility of transit through these new “sponsors.” Funding/Sustainability Sustainability has been greatly enhanced through the sponsorship program and the change in service design. First, implementing service has reduced the number of vehicles needed in Paris. Second, generating local match in rural areas can be difficult. The sponsorship program in this case not only generated additional revenue to match federal dollars, but it also gave the system an air of legitimacy among all residents of Paris. The implementation of fixed route allowed for a reduction in total vehicles in service as one fixed-route vehicle can transport (in this case) three to four times the ridership per vehicle. There were previously five vehicles serving Paris in demand response mode; there are now two fixed-route buses and two ADA paratransit vehicles with far greater ridership for health-care and other purposes. Using private and local funding and support allows TRAX to leverage FTA Section 5311 rural transit funding for 50% of the net deficit. The other 50% can come from local, state, other federal and private sources. The key for TRAX is the sponsorship revenue that allows TRAX to generate the all-important local match.

144 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Lessons Learned There were a number of lessons learned. Clearly, a change of service design from low productivity demand response to fixed route made a major difference in ridership and credibility. • Initial collaboration—Management states that getting the United Way on board at the begin- ning made the difference. • Building support—With United Way on board, others joined. • Funding—It is important to tell the system’s story and secure stakeholders to communicate that story. • Find niches—In addition to trips for health care, high school and junior college students use the service. • Outreach—With aggressive management, there were regular visits with case workers and health-care professionals to ensure needs were being met. • In-kind support works—The city gave assistance, providing in-kind support for shelters, facilities, and their installation. The Takeaways • You must ask if you want to receive. • Be prepared to tell your story. Have local leaders (business, community, and elected officials) tell the story. • It usually takes a lot of time. TRAX was lucky as the federal funding, staff, and vehicles were already in place. • Operate, promote, and market like a business: grand openings, bus dedications, meal delivery during a crisis for example. Healthy Hop: Pinellas Suncoast Transit Authority Description of Practice Pinellas Suncoast Transit Authority (PSTA) is partnering with AdventHealth North Pinellas and the city of Tarpon Springs to provide free transportation to medical services for low-income seniors in the Tarpon Springs community. This service is called Healthy Hop. Through the partnership, low-income seniors age 65 and older can receive two round trips or four one-way trips per month to medical services within Tarpon Springs. Seniors and medical facilities are able to call or use an app to access PSTA’s Goin software and book a ride for immediate service or up to 2 weeks in advance. Pro viders include Lyft, United Taxi, and Wheelchair Transport for transportation based on the rider’s needs.

Collaborative Practices 145 Needs Tarpon Springs, a part of the Tampa Bay region, is a city of 25,000. Tarpon Springs is a retire- ment community with 25% of the population age 65 and older. This is considerably higher than the Florida average of 20% or the national average of about 15%. In addition, the partners all believed through anecdotal evidence that a service was needed to support seniors in gaining access to health care. How Did the Collaboration Start? The collaboration was initiated by the mayor of Tarpon Springs in response to a concern from residents that some seniors were not getting to essential health-care appointments. The mayor collaborated with PSTA’s chief executive officer, and they brought in AdventHealth North Pinellas, the major medical center for the city. PSTA then deployed Goin software to broker trips with an app or by phone. Coordination of Services At the macro scale, service is coordinated through the partners. At the operational level, all trip requests come into the PSTA Goin app, and all coordination is accomplished through PSTA. Funding and Sustainability Funding for this service is shared by the city, PSTA, and AdventHealth, a public-private partnership. Lessons Learned The service has been in operation for 1 year. This small-scale service combined a number of transportation providers and brokered service based on need, using Goin software. The program, a 1-year pilot, was recently extended. The Takeaways • Transportation is a key to holistic health-care solutions. • The combination of a transit authority, the health-care community, and local political and community leaders makes for a strong coalition. • Use the most appropriate service to meet the needs—one size does not fit all. • Invest in the right technology. “PSTA’s mission is to safely connect people to places,” said Brad Miller, CEO of PSTA. “We pride ourselves on being innovative leaders in mobility, and partnering with Florida Hospital North Pinellas and the city of Tarpon Springs has allowed us to provide this on-demand medical transportation service (one of the first of its kind) to safely connect the most vulnerable in our community to receiving proper healthcare.”

146 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services A Call Center Increasing Access to Health Care in Southern Illinois: Rides Plus Description of Practice Rides Plus is a call center funded by the Rides Mass Transit District, a federally funded public transportation system that serves 17 counties in southern Illinois. Rides Plus works with trans- portation agencies and health-care providers throughout the service area to help increase access to NEMT. Health-care providers contact Rides Plus to schedule rides to appointments for their patients. Much of the infrastructure for the Rides Plus call center and coordination model was devel- oped by the Rural Medical Transportation Network (RMTN). The Center for Rural Health and Social Service Development at Southern Illinois University (SIU) Carbondale developed RMTN using grant funding with a goal of improving access to both emergency medical and NEMT transportation in southern Illinois. After the end of the grant period, RMTN no longer had sufficient funding to operate. Rides Mass Transit District had experienced substantial increases in ridership after participating in RMTN and offered to continue funding the call center (now called Rides Plus). In addition to continuing to work with health-care providers, Rides Plus also helps coordinate other types of appointments for Rides Mass Transit District clients, including visits to the grocery store and recreational facilities. Rides Plus works with several health-care and transportation providers to coordinate trans- portation services. Rides Plus also received a contract from the local Medicaid MCO to help arrange NEMT for their enrollees. First, the health-care provider or MCO will contact the Rides Plus call center with a request to set up a ride for a patient with at least 24 hours advance notice. Rides Plus then reaches out to the appropriate transportation provider to confirm whether they can schedule the ride. If the transportation provider cannot offer the trip, Rides Plus serves as a liaison between the providers and patient to find a new time that works for all parties. A major success of Rides Plus has been fostering collaboration among different trans- portation providers. Providers were originally hesitant to participate in the project due to fears of loss of revenue. Rides Plus emphasized the opportunities for increased ridership from coordination. Before working with Rides Plus, transportation providers would have to decline requests for rides beyond their service area. With the help of the Rides Plus coordinator, the transportation provider can accept the ride and simply transfer the rider at a drop-off point when they reach the end of their service area. The Rides Plus coordinator takes on the respon- sibility of scheduling the ride between the two transportation agencies and arranging the transfer. In FY 2018, Rides Plus provided 12,589 rides to residents of southern Illinois, a 20% increase over FY 2017. Rides Plus reports that ridership has been steadily increasing every year. Rides Plus has not been able to collect data from health-care providers on other performance measures such as changes in no-show rates. However, health-care providers have provided feedback that suggests that patients are missing fewer appointments due to transportation barriers. Needs Southern Illinois has a large rural population with limited access to transportation. Many residents are uninsured and live below the federal poverty level. Rides Plus typically helps coordinate demand response rides for rural residents with very limited access to fixed-route transit systems. Rides Plus also provides transportation for several patients receiving mental

Collaborative Practices 147 health services. Rides Plus takes additional steps to accommodate the needs of some of these patients, such as ensuring that they do not have to share a vehicle with another passenger. In addition, many patients have complex health conditions and require additional accommoda- tions to ensure their safety. For example, Rides Plus arranges transfers for some medically fragile patients at the Rides Mass Transit offices instead of a public location such as Walmart. To assess needs, Rides Plus mobility managers use a checklist of potential accommodations. For example, the manager asks about their need for assistance and whether they can navigate stairs. The managers note any special needs in the scheduling system to alert the driver ahead of the ride. How Did the Collaboration Start? The SIU Center for Rural Health and Social Service Development conducted a study of local health-care providers and found that missed appointments were contributing to avoid- able emergency department visits and hospitalizations. The SIU team developed RMTN to foster collaboration among health-care providers, emergency medical services, and mass transit agencies. To obtain buy-in from transportation providers, RMTN sought to establish a common understanding of transportation gaps in southern Illinois and costs associated with missed appointments and non-urgent use of emergency medical transportation. The Center for Rural Health and Social Service Development organized public forums that included legislators, hospital administrators, transportation representatives, and other key partners. After the end of the grant period, RMTN attempted to transition to a sustainability model in which health-care providers would help fund the call center through annual contributions. However, health-care providers ultimately did not have the capacity to sustain the center. Instead, Rides Mass Transit District extended an offer to continue funding a new iteration of the call center. Rides Mass Transit District had experienced a substantial increase in ridership by participating in RMTN, which provided justification for investing in coordination services. Funding/Sustainability The original RMTN call center was primarily funded with the support of grant programs. Rides arranged through the RMTN call center were reimbursed by Medicaid, private insurance companies, and, in some cases, individual health systems or providers. Rides Mass Transit District currently funds costs for the Rides Plus call center. The call center has approximately 11 full-time employees and operates six days a week, from 6 am to 8 pm. Medicaid enrollees account for approximately 85% of rides that the program arranges. Rides Plus takes care of the process of seeking authorization for Medicaid reimbursement for eligible riders to minimize the burden on the health-care and transportation providers. Other clients pay for their rides out of pocket. Lessons Learned Rides Plus staff attended many community meetings and conducted outreach to health-care providers to increase awareness of their services. Rides Plus staff invest substantial amounts of time in maintaining relationships with frontline staff who make referrals for their patients. Rides Plus has identified a point of contact at each major facility and makes repeated visits due to high staff turnover in many offices. Mobility managers also attend regional transportation meetings with stakeholders to identify concerns and share lessons learned with transportation partners. Attending community events and meetings also provides opportunities to address stigma associated with public transportation. In rural communities without traditional fixed-route

148 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services bus systems, residents may associate public transit vans with services for older adults or people with disabilities. Rides Plus staff anticipate that direct outreach will help community members become more comfortable with taking public transportation. Rides Plus recommends that communities seeking to implement similar programs should involve transportation providers from the very beginning of the planning phase. Bringing trans- portation providers to the table will help staff address early concerns and promote buy-in. Resources • RMTN developed a NEMT Resource Guide to help increase health-care providers’ under- standing of how to contact individual mass transit dispatch offices to schedule NEMT rides: https://www.hsidn.org/transportation-resources The Takeaways • The Rides Plus call center helps to both increase access to health care and improve use of public transit services in rural southern Illinois. • The original RMTN call center model provided critical infrastructure for Rides Plus. While the RMTN funding model was not sustainable, the pilot helped Rides Mass Transit District understand the value of mobility coordinators and eventually invest in Rides Plus. • Rides Plus staff allocate substantial amounts of time to building and maintaining relationships with health-care providers, transportation agencies, and other community stakeholders. Accountable Care Organization in the Rio Grande Valley, Texas: Rio Grande Valley Health Alliance Description of Practice Rio Grande Valley Health Alliance (RGVHA) is an ACO located in McAllen, Texas, a mid-size city that is part of a large urban area with over 800,000 residents on the southern border of the United States. RGVHA uses rides-hail companies Lyft and Uber to increase access to NEMT for their patients. RGVHA funds transportation to and from hospitals, clinics, dialysis centers, and other health centers. For some patients who are “prescribed” exercise by their physician, RGVHA also arranges for transportation to and from the gym. RGVHA case coordinators are responsible for arranging transportation for patients. In some cases, patients call directly and ask for a ride to an appointment. In others, case coordinators identify patients with multiple hospitalizations or emergency department visits and work with nephrologists and dialysis centers to identify barriers to care. If case coordinators determine that a patient could benefit from transportation assistance, they reach out to inform the patient

Collaborative Practices 149 about their options. Depending on the patient’s preferences or needs, the case coordinator can also offer vouchers for public transit or call Medicaid NEMT to arrange transportation. Case coordinators contact patients to inform them of their scheduled ride. RGVHA is currently assessing data to determine outcomes associated with the program. Staff will identify trends in hospitalizations, emergency department visits, and no-shows among patients who regularly receive transportation assistance. Needs Many RGVHA patients have unmet transportation needs. The Rio Grande region is sprawl- ing with a mix of rural, suburban, and urban communities. While local government is starting to invest in transportation infrastructure, public transit options are limited and not frequently used. In addition, many bus stops are not sheltered from the elements, which can pose safety concerns for older adults as they wait for transportation when temperatures are warm. RGVHA serves many patients who need reliable transportation to travel to dialysis clinics several times a week. Physicians and care coordinators were aware that patients were skipping appointments because of transportation limitations. Common issues included lack of a per- sonal vehicle, mobility concerns, and the inability of family members to miss work to transport patients to and from the clinic. How Did the Collaboration Start? RGVHA providers recognized that transportation was a key unmet need among their patient population and agreed to invest funds to address the issue. As an ACO, RGVHA receives incen- tives in the form of shared savings for improving the quality of care and decreasing the cost of care. The ACO uses shared savings to invest in a social determinants of health fund in an effort to continue to improve patient outcomes. RGVHA uses the social determinants of health fund to cover transportation costs. In 2017, RGVHA staff began discussing potential opportunities for improving transportation to health-care visits. Relying on public transit would be insufficient due to concerns about long wait times in high temperatures and infrequent bus stops. Traditional Medicaid NEMT was also inadequate. Case coordinators reported that NEMT wait times were long and required schedul- ing days or weeks in advance. RGVHA staff also considered the option of purchasing a private van but concerns about liability and limited rider capacity outweighed potential benefits. In 2018, the RGVHA Program Administrator attended a conference and learned about col- laborations between rideshare companies and health systems. RGVHA contacted Uber and Lyft to learn more information about using the platforms to coordinate rides for patients. RGVHA identi- fied several benefits from using rideshare platforms for patient transportation, including the ability to schedule rides on demand and on short notice. In spring of 2018, RGVHA began arranging transportation for patients with Uber and Lyft. RGVHA partnered with both rideshare companies to increase the number of ride options as some drivers only participate in one platform. Funding/Sustainability RGVHA funds the transportation program through Medicare shared savings. RGVHA con- siders several factors in making the business case for continued investment in transportation resources. For example, the ACO serves many patients with diabetes and end-stage renal disease who need frequent treatment. RGVHA is hypothesizing that, when patients can reliably attend check-ups and dialysis appointments, they are less likely to experience expensive hospitaliza- tions and emergency department visits. In addition, RGVHA competes with other Medicare

150 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services programs, including Medicare Advantage. The ACO wants to offer competitive benefits to potential members, and transportation assistance is a key factor for many patients. Lessons Learned RGVHA partnered with Uber and Lyft to maximize the number of available drivers for their patients. Similar programs could benefit from exploring existing rideshare providers and plat- forms to assess their geographic coverage and pricing. RGVHA can offer transportation assistance to any member, but care coordinators focus on high-need dialysis patients. Organizations seeking to implement a similar program could also benefit from identifying a small subset of patients who have a high need for transportation assistance and a high risk for health complications associated with missed appointments. RGVHA is currently identifying transportation solutions for patients who are not ambulatory and require additional assistance. RGVHA emphasizes the importance of identifying approaches that meet the needs of patients with limited mobility from the outset of the program. Programs should plan to reach out to local transportation companies to establish partnerships and identify opportunities to serve patients with complex needs. Resources • The RGVHA Program Administrator wrote a blog post that describes cost savings associated with a population health approach (including transportation services): https://hitconsultant. net/2019/03/20/texas-aco-medicare-population-health/#.Xgu7K0dKiUk The Takeaways • RGVHA uses ACO funding dedicated to social determinants of health to provide NEMT for patients. • RGVHA prioritized patients with complex medical needs for trans- portation services and, in particular, patients receiving dialysis services. Similar programs could assess which patients are in particular need of transportation. • Partnering with more than one TNC helped maximize the number of available drivers to provide NEMT. Fixed-Schedule Service Improves Access to Health Care in Western North Carolina: Rutherford County Transit Description of Practice Rutherford County Transit (RCT) operates in the remote mountains of Western North Carolina. This area has a predominance of back roads with few through roads. RCT provides

Collaborative Practices 151 general public service (Exhibit 6-7), as well as Medicaid NEMT, which is coordinated with the general public service. Rutherford County is rural yet small-town centered and home to many retirees. Parts of the service area are close to Greenville/Spartanburg, and parts are close to Asheville. Many medical needs are filled in those larger communities. In addition, there are also many needs for specialized care in Charlotte. Almost 10 years ago, the transit agency was taking people one-on-one to these cities, often three to four times a day, according to the system manager. This one-on-one service reduced RCT’s ability to meet not only health-care needs but other important needs as well. Exhibit 6-7. RCT vehicles are important in the remote parts of the county. Photo courtesy of KFH Group. RCT changed its service design to what is known as fixed-schedule service. While the schedule is fixed (often by community or section of the county), the vehicle will make curb-to-curb stops on demand. RCT examined existing travel patterns and worked with health-care providers to develop an appropriate schedule. Most passengers adhere to the schedule, but sometimes exceptions are made and, in these cases, RCT will dispatch a taxi. While no determination has been made as to the impact this service has on health care, RCT has dramatically reduced per trip costs due to the power of productivity. This in turn allowed RCT to provide far more trips to regional health-care centers than the agency otherwise could. This includes access to non-medical yet health-related transportation. Needs Rutherford County is a rural, mountainous county that has major medical needs in three cities in three different directions. Additional needs include some passengers have to stay beyond the scheduled return time and some may be discharged after hours. These needs were once overwhelming the transit agency and reduced its ability to provide service for other basic needs. Nine years ago, the new manager felt they needed to do something to rein in the costs of providing one-on-one service to three cities. Cooperation of health-care providers was requested and accepted by many of the providers.

152 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services The greatest recurring medical need was and is kidney dialysis transportation. In addition, the bulk of the passengers are frail seniors. Some dialysis clinics cooperate with RCT while others less so. Those that do, cooperate work with RCT to schedule patients based on geography so that RCT can group trips where possible. How Did the Collaboration Start? The effort was initiated in 2010 when a new manager started. The transit agency was over- whelmed with out-of-town needs, and they were not able to meet other basic transportation needs such as shopping and personal business. The manager set out to work informally with a wide variety of health-care providers locally and in the three target cities. Most of the health-care providers worked with RCT, though some did not cooperate. Most health-care providers collaborate and work with the schedule developed by RCT in coordination with health-care providers. Making the transportation schedule work well requires constant education due to staff turnover and as new providers serve the community. Coordination of Services RCT led the coordination effort. The transit agency already operated Medicaid NEMT, which was taking up considerable capacity for the system. Medicaid NEMT is operated in a fully coordinated manner. The long-distance trips to major medical facilities operate with both general public and Medicaid NEMT passengers at the same time. RCT also coordinates with a local taxi company that handles the after-hours trip needs (on a case-by-case basis). Those dialysis clinics that collaborate give RCT the required arrival time, treatment time, and return time to ensure that patients have enough time at the clinic. Funding/Sustainability Funding for this service comes from FTA Section 5311 rural transit funding (for capital). Medicaid NEMT funds trips, and RCT contracts with local human service programs. The county provides the rest of the local match for the service. The program sustainability is now in question as the state of North Carolina has decided to use a large Medicaid NEMT broker to manage NEMT across the entire state. RCT is concerned that Medicaid NEMT funds will be diverted to individual drivers at a very low cost with the broker’s capitated payment structure. If this is the case, RCT will need to reexamine its service levels. Performance Measures RCT’s performance measures center on the all-important productivity measure. When the program started, productivity for the out-of-county service was about one passenger trip per vehicle trip. Management reports that ridership on the fixed-schedule service is now about five one-way trips per vehicle trip. Exhibit 6-8 shows RCT’s schedule for the out-of-town service.

Collaborative Practices 153 The second performance measure, cost per one-way trip, is directly related to productivity. Taking a service from one to five one-way trips per vehicle hour reduces the cost by a factor of five and frees up service for other needs. Lessons Learned RCT stressed the need to: • Do your homework. RCT was already doing much of this service, so a wealth of data was available to identify the best days to go to each city to meet the transportation needs for health care. Using the data, RCT designed schedules and provided them to health-care pro- viders for comment. • Educate and communicate. There is a constant need to educate and communicate with sup- port staff, nurses, doctors, and management. RCT stated that turnover among health-care staff and management is often high, requiring education for new staff. RCT stated that it is critical to stay ahead of this and immediately educate new staff. • Have fall-back taxicabs to help ensure success. The flexibility of taxi service is a valuable asset. The transit agency stated that it is fortunate to have a backup taxi company that meets the agency’s requirements for safety and quality. • Have active dispatch and health provider staff. It often comes down to the ability of the trans- portation provider and the health-care provider to communicate on a daily basis. For example, sometimes RCT must intervene (with support from the passenger) to reschedule a trip to meet the transit schedule. • • • • • • • • • • All out-of-town medical visits should be made between 9:00 am and 12:00 pm. Transit goes to the cities listed below only on the following days. Transit must be informed if an additional passenger is required due to a limited number of seats available. Additional passengers must be approved prior to the trip. Requests for transportation on a non-standard day will be reviewed on a case-by-case basis. Exhibit 6-8. RCT’s out-of-county transportation shuttle schedule. Source: Rutherford County Transit website.

154 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Free Van Service Operated by a Hospital in Central Kentucky: Taylor Regional Hospital Description of Practice Taylor Regional Hospital in rural Campbellsville, Kentucky, provides a free private van service to residents of Taylor, Green, Marion, and Adair counties (9). The service includes two vans that provide daily transportation services from patients’ homes to several different health- care facilities, including clinics that are not owned by the hospital. In addition to providing transportation to the hospital and centers for dialysis, cancer, and drug rehabilitation, the van service also delivers prescriptions (10). Taylor Regional Hospital did not partner with other transportation providers, because Campbellsville does not have public transportation infrastructure or taxi services. To schedule transportation assistance, patients call the van service to speak to a ride coordinator. The hospital conducted outreach to local health departments, home health agencies, community organiza- tions, and community-based organizations to encourage providers to refer community members to the van service. Usage of van services has increased steadily since the inception of the program in 2007. From 2007 to 2016, total distance traveled by the van service increased from 18,481 miles to 104,972 miles per year. Over 25,000 people have used the service. Program staff report high patient satisfaction with the service and describe anecdotal evidence of decreased no-shows for medical appointments. Needs Taylor Regional Hospital regularly conducts community needs assessments to identify priority issues affecting the health of local residents (11). In 2007, results from the needs assess- ment indicated that lack of transportation was a major barrier to accessing timely health-care services. Staff from the hospital’s cancer center confirmed these findings and reported that cancer patients were missing medical appointments and radiation treatments due to lack of transportation. While Medicaid covered NEMT for enrollees, other community members who were uninsured or covered by Medicare or private insurance had limited transportation options. The van service seeks to fill gaps in existing transportations services; therefore, eligible The Takeaways • Present a transportation solution to a transportation problem. • Make a plan that is simple to implement. • Remember that higher productivity always yields lower cost per trip. • Collaborate with health-care providers continually. • Encourage cooperation between front line staff. • Offer flexibility for trips that cannot meet the schedule.

Collaborative Practices 155 patients cannot be enrolled in Medicaid and cannot have access to another means of trans- portation. Eligible patients must be ambulatory as the vans are not wheelchair accessible. How Did the Collaboration Start? Hospital leadership consulted with providers and analyzed data that showed high rates of missed appointments. Leadership acknowledged the importance of transportation in promoting the delivery of high-quality care and approved the initial investment in a van service in 2007. The hospital was unable to leverage existing transportation infrastructure because the closest taxi services and public transportation stops are located an hour away from Campbellsville. Instead, leadership chose to invest in a hospitality van service that would provide sufficient flexibility to meet the needs of patients across the four rural counties served by Taylor Regional Hospital. Funding/Sustainability Taylor Regional Hospital budgets for the van service each year, which includes mainte- nance costs and funding for drivers. Gas costs for the program are funded through monthly private donations of $80 from sponsoring organizations. Sponsors include Community Trust Bank, Citizens Bank & Trust, Taylor County Bank, TRH Auxiliary Volunteers, Don Franklin Campbellsville, HealthSouth Rehabilitation Hospital, James Medical Services, Columbia Medical Services, Wehr Constructors, Anthem, and Fort Knox Federal Credit Union. The hospital also holds annual fundraisers to cover the cost of purchasing new vans. Lessons Learned Taylor Regional Hospital staff have emphasized the importance of seeking buy-in from diverse stakeholders, including hospital leadership and city and county government officials. Collabo- rations with local community-based organizations have been critical to successfully securing resources for the program. Similar programs should consider building in maintenance costs to yearly budgets to fund potential repairs to vehicles. Resources • The Taylor Regional Hospital website provides additional information about the hospitality van service: http://www.trhosp.org/getpage.php?name=hospvan&sub=Patient%20Resources • The American Hospital Association prepared a case study of Taylor Regional Hospital van service, Case Study: Taylor Regional Hospital’s Van Program Increases Access to Care for Patients: https://www.aha.org/news/insights-and-analysis/2018-01-18-case-study-taylor- regional-hospitals-van-program-increases The Takeaways • Taylor Regional Hospital provides a van service that offers NEMT to patients, including those receiving care for end-stage renal disease, cancer, and substance use disorder. • Program leaders budget not only for gas and mileage, but also for regular maintenance and repairs. Large capital investments are necessary to purchase new vans periodically. • Multiple community partners provide small amounts of funds to the program on a monthly basis that help support day-to-day operations.

156 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Health Care Transportation and Ride Hailing: Uber Health Description of Practice In March 2018, ride-hailing company Uber launched Uber Health, a dashboard that allows health-care providers to schedule rides for patients, and an Uber Health Application Programming Interface (API), a tool that enables integration of Uber into existing health-care products and infor- mation technology systems. A key feature of Uber Health is flexible ride scheduling that allows coordinators to use a single platform to arrange rides for multiple patients. Coordinators can order rides for immediate pick up or schedule transportation up to 30 days in advance. Needs Uber Health acknowledges that transportation barriers are greatest for vulnerable popula- tions, such as those with complex chronic conditions. The company has created partnerships to improve the ability of health-care providers to arrange transportation for people with special considerations. How Did the Collaboration Start? Uber Health identified substantial unmet needs related to NEMT, including millions of missed appointments and high no-show rates across the country. The company created the Uber Health platform to ensure that third parties would be able to easily schedule rides for patients, taking advantage of Uber drivers. Coordination To increase the population served by Uber Health, the platform partners with other transpor- tation companies. Through a partnership with MV Transportation, a national transportation provider, Uber Health can offer access to wheelchair-accessible vehicles. Another Uber partner, Ambulnz, provides on-demand ambulance services. Health-care providers who are already using these transportation companies can use Uber Health’s API to integrate Uber Health as an additional option. For example, UCHealth, a non-profit health- care system in Colorado, streamlined transportation services by integrating Uber Health into their Ambulnz platform. Case managers can assess their patient’s need and select a car or an ambulance accordingly. Funding/Sustainability Uber Health bills health-care organizations on a monthly basis. Costs are based on standard Uber rates when rides are booked. Clients do not pay fees to use the Uber Health platform. Uber Health reports that most of their clients pay for rides from their own budgets after calculating upstream returns on investment. Uber rides are typically less costly than other private trans- portation options such as metered taxis. Uber has reported it has about 1,000 partnerships across the health-care landscape, includ- ing hospitals like BayCare Health System, Boston Medical Center, MedStar Health, and the Cleveland Clinic (12).

Collaborative Practices 157 Lessons Learned Uber Health service is best suited for ambulatory patients who can complete curb-to-curb trips without additional assistance. Uber Health is also more effective for on-demand trips when patients are ready for their trips. The Takeaways • Ride-hailing companies have expanded their business lines with an increasing presence in the health-care transportation space. • Ride-hailing trips tend to be more effective for ambulatory patients. Wheelchair-accessible service is limited. Brokering Medicaid NEMT: Vermont Public Transportation Association Description of Practice The 10 transit agencies in Vermont had for many years been operating the Medicaid NEMT program in Vermont through the Department of Vermont Health Access (DVHA). These transit agencies managed the entire program: they accepted trip requests, approved trips and passenger eligibility, and provided trips, typically using an array of providers. Volunteer drivers were often used to provide the Medicaid trips, and transit agencies and other providers were also used. DVHA decided to change its model to a capitated brokerage. This new model required a broker to do all of the intake and eligibility functions that the transit agencies were already doing. Based on experiences in neighboring states, the transit agencies felt that the capitated model was not conducive to the use of public transit. Moreover, without Medicaid NEMT, the transit agencies would lose critical funding that would impact all of their services, much of which was access to health care. The transit agencies through the Vermont Public Transportation Association (VPTA) formed a consortium to submit a proposal to manage and operate the Medicaid NEMT brokerage. The VPTA brokerage is a unique and innovative approach to providing safe and quality Medicaid transportation at a low cost, in part by avoiding use of a middle man broker in a small state. This “Vermont Approach” is innovative in how it utilizes the best of all NEMT models, minimizing overhead and at the same time adhering to many tried and true transit solutions that are proven to keep costs reasonable (13).

158 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Needs For decades, the public transit agencies in Vermont integrated Medicaid NEMT into their overall operations. Meeting transportation needs for accessing health care has always been an important service of the agencies, particularly in the more rural parts of the state. How Did the Collaboration Start? Vermont’s transit operators had been operating coordinated service for decades, mixing general public transit, senior transportation programs, Medicaid NEMT, and other specialized transportation programs. When the state decided to change its approach to Medicaid transpor- tation and go out to bid for a private broker, the transit agencies banded together to develop and submit a proposal to function as the broker. Their proposal was successful. The Current System Works • Trips must use the most suitable and cost-effective mode, which may be via a public trans- portation bus route, volunteer driver, or cab. • Transit providers combine riders from Medicaid along with other health-care transportation programs, such as the Elderly and Disabled, and the general public, to maximize coordination of trips paid for by various funding programs to be more efficient and lower costs for each program. • State law supports this coordinated delivery system (see 24 VSA § 5090). Dismantling Will Lead to Degradation of Service and Financial Risk • Contracting with an out-of-state for-profit broker will result in a separation of Medicaid from the Elderly and Disabled and the general public that could lead to a shifting of costs and degradation of service to Vermonters. • Financial impact on the overall system will be affected; riders and transit providers may take a couple of years to develop, but they will develop. • Other states’ experiences bear this out. Maine and Rhode Island are two recent examples. Coordination of Services Vermont’s transit agencies coordinated transportation for many years. The state’s approach to moving toward a capitated broker threatened to destroy the coordinated model. Research showed that states that introduced capitated brokers typically did not involve public transit (14). Funding/Sustainability The Vermont transit agencies had long before integrated transit with Medicaid NEMT and built a sustainable model that supported all Vermonters. Lessons Learned The service has been in operation for 3 years. Operators want to continue. The Takeaways • Two separate systems—public transit and Medicaid NEMT— are coordinated. Coordinated transportation is essential to the economic and health-care vitality of the state. • This ensures long-term sustainability.

Collaborative Practices 159 Types of Practice Tables 6-1 through 6-9 group health-care and transportation collaborative practices according to the following nine types: • Communication and Education • Coordination of Service • Innovative Funding, Payment, and Reimbursement • Health-Care Organization as Operator • Mobility Management • Service Design and Productivity • Brokerage Technology • NEMT—Broker or Provider • Collaborations Initiated Through Public Transit, TNCs, and Taxis The icons displayed in Exhibit 6-9 denote the service area for each provider in the tables. Service Area Metropolitan and large urbanized area (over 200,000 population) Small urbanized area (50,000 to 200,000 population) Rural with small city/town (5,000 to 50,000 population) Rural, isolated with city/town (under 5,000 population) Exhibit 6-9. Icons used to denote populations served in Tables 6-1 through 6-9.

# Description Transportation Organization(s) Health-Care Organization(s) City/ Counties State Service Area(s) Remarks 1 “ ” 2 3 4 Table 6-1. Communication and Education.

6 7 8 5

# Description Transportation Organization(s) Health-Care Organization(s) City/ Counties State Service Area(s) Remarks 1 2 3 Table 6-2. Coordination of service.

4 5 6

# Description Transportation Organization(s) Health-Care Organization(s) City/ Counties State Service Area(s) Remarks 1 2 3 4 — Table 6-3. Innovative funding, payment, and reimbursement.

5 6 7 8

# Description Transportation Organization(s) Health-Care Organization(s) City/ Counties State Service Area(s) Remarks 1 Administrator’s 2 Table 6-4. Health-care organization as operator.

Table 6-5. Mobility management. # Description Transportation Organization(s) Health-Care Organization(s) City/ Counties State Service Area(s) Remarks 1 — 2 3 (continued on next page)

6 # Description Transportation Organization(s) Health-Care Organization(s) City/ Counties State Service Area(s) Remarks 4 5 Table 6.5. (Continued.) Mobility management.

7 HeathTran has been described as “a mobility manager.” HealthTran from Medicaid or veterans’ services. 8 9 (continued on next page)

# Description Transportation Organization(s) Health-Care Organization(s) City/ Counties State Service Area(s) Remarks 10 11 — well as use the transit system’s new 12 Table 6.5. (Continued.) Mobility management.

# Description Transportation Organization(s) Health-Care Organization(s) City/ Counties State Service Area(s) Remarks 1 2 3 4 5 Table 6-6. Service design and productivity.

# Description Transportation Organization(s) Health-Care Organization(s) City/ Counties State Service Area(s) Remarks 1 Planning Committee, the “Smart Transit for Healthcare” project is developing 2 Table 6-7. Brokerage technology.

4 “Personal Choice Driver” is an option 5 rides) to doctors’ of�ices, hospitals # Description Transportation Organization(s) Health-Care Organization(s) City/ Counties State Service Area(s) Remarks 1 2 3 Table 6-8. NEMT—Broker or provider.

Table 6-9. Collaborations initiated through public transit, TNCs, and taxis. # Description Transportation Organization(s) Health-Care Organization(s) City/ Counties State Service Area(s) Remarks 1 2 3 — 4

5 notice. Depending on the patient’s 6 Children’s Hospital, Health System’s acute Nemours Children’s

176 Guidebook and Research Plan to Help Communities Improve Transportation to Health-Care Services Chapter Notes 1. “D.A.R.T.S” Aaron E. Henry Community Health Services Center, Inc. https://www.aehchc.org/darts. 2. “Health Center Program Data.” data.HRSA.gov, 2018 Aaron E. Henry Community Health Services Center, Inc. Health Center Program Awardee Data. https://bphc.hrsa.gov/uds/datacenter.aspx?q=d&bid=046150& state=MS&year=2018. 3. Knowles, M. “Geisinger Takes Aim at Rural Patient Transportation Issues with Pilot Program.” Becker Hospital Review, 2018. https://www.beckershospitalreview.com/patient-flow/geisinger-takes-aim-at-rural- patient-transportation-issues-with-pilot-program.html. 4. “Scranton Area Community Foundation Honors Geisinger as Community Partner.” Geisinger News Release, January 14, 2019. 5. “‘PRONTO’ Transport Initiative Moves into Full-Time Service.” News at UI Health, University of Illinois, 2017. https://hospital.uillinois.edu/news/pronto-transport-initiative-moves-into-full-time-service. 6. NCRTD.org. North Central Regional Transit District Board Agenda Packets, ridership by route and by month including archival data. See directly operated routes ridership reports for FY 2015–2016. 7. “NCRTD 2020 Rider Survey.” 2020 Rider Survey, https://www.ncrtd.org/2020-rider-survey.aspx. 8. NCRTD is very transparent and provides detailed reports on ridership, finances and other needs every month. These are available to all (including monthly detailed ridership reports) in each month’s Board packet. 9. “Hospital Van Service.” Taylor Regional Hospital. http://www.trhosp.org/getpage.php?name=hospvan&sub= Patient%20Resources. 10. “Case study: Taylor Regional Hospital’s Van Program Increases Access to Care for Patients.” American Hospital Association, 2018. https://www.aha.org/news/insights-and-analysis/2018-01-18-case-study- taylor-regional-hospitals-van-program-increases. 11. Taylor Regional Hospital. Community Health Needs Assessment. 2019. https://taylorregional.org/assets/files/ TRHCHNA19.pdf. 12. “Uber Health Plans to Double in Size.” HealthCareDive, January 21, 2020. https://www.healthcaredive.com/ news/uber-health-plans-to-double-in-size-this-year/570771/. 13. VPTA Proposal to Provide NEMT Brokerage Service, Narrative p. 1, 2016. 14. Hosen, K., and E. Fetting. TCRP Synthesis of Transit Practice 65: Transit Agency Participation in Medicaid Transportation Programs. Transportation Research Board, Washington, D.C., 2006.