Transportation to Support Rural Healthcare Introduction

Transportation is an important social determinant of health in rural communities. The availability of reliable
transportation impacts a person’s ability to access appropriate and well-coordinated healthcare, purchase
nutritious food, and otherwise care for him- or herself. Rural populations most likely to need transportation
services to maintain their health and well-being include:

  • The elderly
  • People with disabilities
  • Low-income individuals and families
  • Veterans
  • People with special healthcare needs, who often must travel long distances to access care

This guide focuses on how communities can provide transportation services to support access to rural
healthcare, which may also benefit healthcare providers by decreasing inappropriate use of EMS services,
improving utilization of healthcare services, and decreasing no-show rates. The guide also highlights
transportation as a community-based service that can allow the elderly and people with disabilities to live
successfully in a community rather than entering a long-term care facility or leaving the community.

Frequently Asked Questions


Where can I get help planning and funding transportation projects?

The following organizations provide resources and technical assistance related to rural transportation
projects:


  • Community Transportation Association of America

    Provides a wide variety of information on economic development, financing, technical assistance, and other
    issues related to rural and urban public and community transportation. Offers the Health Care and
    Transportation Resource Center
    , which includes resources, policy updates, and information focusing
    on the issues, opportunities and challenges impacting non-emergency medical transportation
    professionals.
    800.891.0590
  • National Rural Transit Assistance Program (RTAP)
    Provides training and technical assistance products and services that are developed nationally, for
    distribution and replication by the states to local transit agencies. Offers a National Transit Resource
    Center
    with access to information and expertise, and an online list of state RTAP contacts.
    888.589.6821
    info@nationalrtap.org
  • National Aging and Disability Transportation Center (NADTC)
    A cooperative agreement supported by Easterseals, the National Association of Area Agencies on Aging, the
    Federal Transit Administration, and assisted by the Administration for Community Living. NADTC provides
    communities technical assistance, training, information
    and referral, and community grants focused on the availability and accessibility of transportation for
    seniors and people with disabilities.
    866.983.3222
    contact@nadtc.org
  • National
    Center for Mobility Management
    (NCMM)
    Provides technical assistance, training, community grants, and helps communities implement transportation
    policies and mobility opportunities that enable people to live independently, as well as promote health,
    economic vitality, and self-sufficiency. Funded through a cooperative agreement with the Federal Transit
    Administration, and is operated through a consortium of three national organizations, the Community
    Transportation Association of America, the American Public Transportation Association, and Easterseals.
    866.846.6400
    info@nc4mm.org

Where can I get help finding local transportation programs and services?

To learn about transit options in your area and help rural residents find transportation:


What are the health-related consequences of not having transportation for rural residents, including the
elderly and people with disabilities?

Reliable transportation options can determine whether many people in rural areas have access to healthcare at
all. Often elderly individuals and individuals with disabilities have greater healthcare needs than other rural
residents, and living in rural areas isolated from healthcare providers can have a significant impact on their
quality of life, their health, and their safety.

According to a 2010 study from the
Upper Great Plains Transportation Institute, some of the negative impacts due to distance and lack of
transportation include:

  • Increase in delayed or missed trips to receive healthcare services
  • Disruption in ongoing treatments and services for chronically ill patients
  • Travel distance to health services and the related costs affect patients’ healthcare decisions
  • Travel time spent to access healthcare can affect patients physically and cause stress
  • Use of some medications, like insulin, declines as patients live farther from their source of care

Studies have shown that providing transportation for medical treatment to low-income, elderly, and disabled
patients is cost-effective and improves the quality of life. A 2005 study by the Transit Cooperative Research Program
showed the differences between the cost of poorly-managed and well-managed care, as well as the differences in
quality of life. They found that the reduction in healthcare costs and improvement in quality of life would more
than offset the costs required to provide non-emergency medical transportation. Missing a routine or preventive
care service because of transportation can lead to poorly managed care, a need for emergency care, and
preventable hospitalizations.

Providing effective transportation options to healthcare services for low-income, elderly, and disabled
residents
decreases hospitalizations and nursing home stays, allowing them to remain contributing members of the community
and lead healthier lives while keeping health costs down. In addition, transportation allows rural residents to
avoid social isolation, as discussed in the Rural Monitor article, Social Isolation and Loneliness:
Insights from Rural Clinical Providers and Other Experts
.


What strategies can rural communities and healthcare facilities use to provide non-emergency medical
transportation services?

According to a 2010 study funded by the Federal
Transit Administration (FTA):

“The greatest problems for people using public transportation for health care trips are inconvenient
schedules, the need to match transit and medical schedules, and infrequent service.”

Many strategies have been implemented in rural communities across the country to provide non-emergency medical
transportation services. Some strategies for communities who have some kind of transportation service available
include:

  • Hiring a mobility manager to streamline scheduling and dispatch efforts
  • Creating a website and customer service contact center for direct trip requests
  • Centralizing staff for trip eligibility determination and reservation requests
  • Setting schedules for medical trips to specialty care centers to reduce travel times and to provide
    consistent service.
  • Implementing an interactive voice response (IVR) system that calls the night before to confirm or allow a
    cancellation, as well as same day notification when the vehicle is near rider location
  • Broadly disseminating information about the availability of transit services

In some communities where formal transportation services are not available or are insufficient, healthcare
facilities or community
organizations have chosen to fill the healthcare transportation gap by:

  • Offering transportation services for healthcare appointments using paid or volunteer drivers
  • Coordinating a shared ride/cost transportation program (a door-to-door, advance-reservation, ride-sharing
    service)
  • Brokering out coordinated trips to qualified vendors
  • Using telehealth to decrease the travel required for local patients to access specialty care
  • Starting a mobile clinic to take healthcare services to patients in remote areas
  • Providing some services in local schools to reach low-income or high-needs children
  • Having Community Health Workers or Community Paramedics visit people in their homes, which
    may decrease the frequency of trips for medical care

Examples of non-emergency transportation programs in rural areas include:

  • HealthTran – A non-emergency transportation service that offers
    rides for patients demonstrating a transportation need for timely primary and preventive care access in
    South Central Missouri. HealthTran was also profiled in a 2016 Rural
    Monitor

    article
    .
  • Angel Flight West – A network of more than 1,400 pilots donate
    their skills, aircraft, and all costs associated with flying to help families and individuals in need in the
    13 western states of the United States. Angel Flight West was one of several charity flight services
    highlighted in a 2018
    Rural Monitor article
    .
  • Tri-Valley Opportunity Council Rural Transportation – A
    coordinated public transportation and volunteer driver system which serves a rural 8-county area in
    northwest Minnesota.

For more information on the development of rural transportation programs, see the Rural Transportation Toolkit.


What issues should facilities and organizations consider when providing transportation?

  • Screening and training of drivers
    Whether using volunteer or paid drivers, care should be taken to screen the drivers to ensure the safety
    of patients. In addition, drivers should be adequately trained just like any other staff member, including
    topics such as safety, how to assist patients, and the necessity of confidentiality.
  • Liability concerns
    Before implementing a transportation program, liability issues must be fully investigated and considered,
    particularly when using volunteer drivers or personal vehicles.
  • Funding the program
    How will the program be funded and maintained? Facilities might approach state transportation departments
    or local foundations regarding potential funding. In addition, facilities can explore partnerships with
    other organizations or agencies serving the community.

For additional information about volunteer driver programs, see the National
Volunteer Transportation Center Map of Volunteer Driver Programs
and the National Volunteer Transportation Center Resource Library.


Can Medicaid be used to subsidize non-emergency medical transportation?

Yes. States are required to cover non-emergency medical transportation (NEMT) to Medicaid beneficiaries who need
transportation in order to access medically needed services. This includes both local providers of care and
tertiary healthcare facilities. See the Henry J. Kaiser Foundation’s Medicaid
Benefits: Non-Emergency Medical Transportation Services
.

For further information on this rule, see the following resources:


What resources are available to assist my rural community in planning, developing or expanding public transit
services that would help the elderly, disabled, and low-income individuals access healthcare services?

Organizations that can assist rural communities with transit planning include:

  • State departments of transportation
  • Local councils of government
  • Private transportation companies
  • Economic and community development corporations
  • Regional planning organizations that can assist rural communities in undertaking transit planning projects

Also, individual state Rural Transit
Assistance Programs (RTAPs)
provide workshops, on-site training, educational materials, and peer
assistance. Contact your state’s department of
transportation
for information on your state RTAP resources.

The
Community Transportation Association of America
, a national organization, offers a variety of technical
assistance and guides for communities looking to initiate and/or expand transportation services and programs
that link people to jobs, medical care and other destinations necessary for quality of life.

In addition,
SBA.gov provides assistance with the development of small businesses that
could include a non-emergency medical transportation business.

Examples of transportation models that address the transportation inequities of elderly and low-income
individuals in rural communities include:

  • SMiles Senior Transportation – SMiles was
    implemented in Blount County, Tennessee to provide transportation to rural seniors who are no longer able to
    drive.
  • Kid One Transport – Provides rides to
    medical appointments for children and expectant mothers who otherwise have no other means of transportation
    in rural Alabama.

What are the types of accommodations rural transportation providers must support to comply with the Americans
with Disabilities Act (ADA), and who is eligible for these special accommodations?

Rural transportation providers are not required to provide fixed-route service in any rural area. However, if
they do provide a fixed-route service they are required to comply with ADA and be accessible. They must provide
ADA complementary paratransit service for those individuals with disabilities who cannot use fixed-route
service. If another type of transportation service is offered such as a taxi, shuttle, or
ride-share, or any
form of demand-response transportation, ADA
regulations
will apply and servicers are required to provide
equivalent and reasonable accommodations.

Regulations and technical
assistance materials
are available from the Americans with Disabilities Act website. Also,
the Federal Transit Administration (FTA) Topic Guides on ADA
Transportation
provide detailed information on equipment maintenance, stop announcements, and route
identification.

According to the section Eligibility for ADA Paratransit,
individuals are eligible for paratransit service if they meet one of these criteria:

  • Navigation of the transit system requires assistance
  • Individual needs an accessible vehicle
  • Bus routes or bus stops are inaccessible
  • Travel is prevented if a reasonable person
    with the disability would be deterred from making the trip

Are there programs or grant opportunities to help tribal communities improve transportation services?

Yes, there are several programs that fund tribal communities’ transportation needs, including:


  • Tribal Transit Technical Assistance Program

    Available through the Community Transportation Association of America. This program is funded through the
    Rural Business Cooperative Service of the U.S. Department of Agriculture (USDA) and is designed to assist
    tribal communities in enhancing economic growth and development by improving transportation services.

  • Social and Economic Development Strategies (SEDS)

    This program from the Administration for Native Americans (ANA) funds projects to develop community
    transportation activities that support the needs of the elderly, the disabled, and the local workforce.

  • Public Transportation on Indian Reservations (Section 5311c)

    Available through the Federal Transportation Administration (FTA). Provides planning, capital and operating
    assistance to designated tribal entities. For more information, contact your regional FTA office.

In addition, the majority of the funding opportunities for general rural transportation projects are
applicable to tribal communities.


Are there grants or programs to assist veterans in rural areas with transportation to VA medical centers and
other VA and non-VA facilities for medical care?

The U.S. Department of Veterans Affairs program, Highly Rural
Transportation Grants
(HRTG), awards grants to veterans service organizations that use innovative
approaches to assist veterans in rural areas with transportation to VA medical centers and other VA and non-VA
facilities for medical care. For information about this program and other programs that may assist veterans in
accessing medical care, see RHIhub’s Rural
Veterans and Access to Healthcare – Funding & Opportunities
.

Also, the
Disabled American Veterans (DAV) Hospital Service Coordinator Directory
provides a state-by-state list
of Hospital Service Coordinators (HSCs), their affiliated VA Medical Centers, and contact information. HSCs
manage DAV transportation programs for veterans needing medical care.

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