Chatham Health Alliance: Access to Medical Transportation

By: Ethan Wallenius-Caldwell, Marissa Bane, Rhea Wyse, and Veronica Simpson Executive Summary

Transportation is an important social determinant of health in rural communities. Specifically, the availability of reliable transportation impacts a person’s ability to access appropriate and well-coordinated health care.1 Low-income individuals and families within rural areas are the most likely subset to need transportation services to maintain their health.2 Studies have shown that the provision of medical transportation is cost-effective and improves a patient’s quality of life.3 Therefore, when looking specifically at Chatham County in rural North Carolina, it is important to increase access to non-emergency medical transportation (NEMT). This will likely be most successful through the implementation of a marketing campaign for local health services and the facilitation of increased coordination between local health providers and transportation networks within the county. By building relationships with key stakeholders and promoting local health-related resources, Chatham County residents will be more informed regarding the availability of health care services. As a result, there will likely be an increase in care coordination leading to overall better health outcomes. Introduction

The 2014 Chatham County Community Health Assessment: Obesity, Access to Mental Health Services, and Access to Healthcare identified access to health care as a top priority for Chatham County.4 With the implementation of the Affordable Care Act in 2010, the number of Chatham County residents with health insurance has risen; however, many continue to

struggle to receive health care within the county.5 Compared to the state of North Carolina as a whole, Chatham County has a lower number of primary care providers, nursing staff, and specialists per capita6. The county’s close proximity to large hospital systems within North Carolina leads many Chatham residents to seek services in neighboring towns and cities such as Chapel Hill, Durham, Raleigh, and Greensboro. For residents with financial barriers and limited access to transportation, the emergency department in Chatham County serves as a safety net provider for acute care services and primary care.7 The Chatham County Health Department aims to improve access to care by:

1. Promoting, providing, and assisting in coordination of healthcare services

2. Examining gaps in health care services 3. Promoting and increasing enrollment in

the health insurance marketplace8

In early 2015, the Chatham Health Alliance was formed to finalize action plans to address health priorities identified in the 2014 assessment. The purpose of this alliance is to bring together both traditional and nontraditional partners to work on issues affecting health outcomes in Chatham County, with a focus on the health needs identified in the assessment9. The alliance has specifically worked to better understand barriers in access to medical transportation.10 The alliance has requested the services of a team of Health Policy and Management undergraduate students from the UNC Gillings School of Global Public Health to help address the

problem of access to medical transportation. Therefore, the purpose of this report is to provide background on the status of access to care in Chatham County, identify gaps and opportunities for access to non-emergency medical transportation (NEMT), and provide relevant strategies to address the issue. Trends in Medical Transportation Background

Patients often rely on non-emergency medical transportation services to travel to and from doctor appointments. Patients utilize a variety of transportation options including private vehicles, public transit, and taxi services when accessing care. Medical transportation is an important social determinant of health and remains a vital concern for equitable access to health care for vulnerable populations.11 Moreover, research suggests that health care utilization rates are lower in rural populations compared to their urban counterparts due to lower access to care in terms of quality, distance and affordability.12,13 As a result, rural residents experience higher rates of mortality, morbidity, incidence of chronic disease, and disability than urban residents.14 This difference can be attributed to a complex network of factors, including physician shortages, low population density, long travel distances to services, and limited transportation options for rural areas.15

On average, those who do not have access to medical transportation are disproportionately female, poor, old, uneducated, and likely to be part of a racial/ethnic minority group.16 Income and age are the most direct barriers to accessing medical transportation. People with low incomes often are unable to afford adequate transportation. Further, older populations and those with age-related handicaps may not have the ability to drive themselves to appointments, which makes them dependent on outside services.17 In particular, the 2001 National Household Transportation Survey reported that

8.6 percent of all respondents had a medical condition that limited their ability to travel.18 As a result, more than 3.6 million Americans miss or delay appropriate medical care each year due to the lack of medical transportation.19

Chatham County, North Carolina

Chatham County is a predominantly rural county located in the Piedmont region of North Carolina. Its geographic location presents unique barriers to accessing medical transportation throughout the county. One such barrier is poor road conditions, which may deter or inhibit individuals from accessing health care services.20 Another common barrier is the cyclical outmigration of young and middle aged adults who often leave the rural area to find work. This leaves behind more vulnerable populations—such as the elderly and children—and increases the use of emergency transportation services for non-emergency situations.21 Further exacerbating the issue, Chatham County has fewer primary care physicians and registered nurses per capita compared to the state overall.22 Because of this, people may have an increasingly difficult time accessing health care. Due to these barriers and their impact on residents, the Chatham Health Alliance and Chatham Transit aim to increase medical transportation trips by five percent in efforts to improve the health outcomes throughout the county.23

Figure 1. Cities in Chatham County

Source: Weichert24

Implications

Failure to obtain routine care often leads to overutilization of hospital emergency departments; further, this administration of care is more expensive than preventive services. One of the largest barriers for residents accessing public transportation is the inability to coordinate transit routes and schedules with medical appointments. The National Health Interview Survey highlights significant differences between adults with regular transportation to health care compared to those who do not have such access. Results show that the percentage of adults who experience multiple conditions is higher for those who lack transportation to care.25 Moreover, those without proper access to transportation have higher rates of every single medical condition tracked, including arthritis, chronic obstructive pulmonary disease, depression, cancer, dental problems, and heart disease. These findings show that lack of access to medical transportation for disadvantaged populations can potentially exacerbate their existing medical conditions, leading to subsequent medical expenditures imposed on individuals and society.26 Benefits of better transportation

Coordination between transit authorities, regional health providers, and other community stakeholders is needed to ensure that rural populations obtain appropriate care. In addition, communities with effective transit networks can increase access to care for vulnerable populations such as the elderly, children, patients without cars, and Medicaid recipients.27 Moreover, consistent access to medical transportation helps to enhance health outcomes for vulnerable populations and leads to cost-savings since patients are able to avoid costly ambulance trips and emergency room visits.28 Many communities have had success with creative solutions and programs that address the issues of medical transportation,

which gives hope to other similar communities that are currently struggling. Existing Intervention Programs Michigan Developmental Disabilities Council

A transportation voucher program is a system where sponsoring agencies negotiate with private and public transportation providers to accept discounted rates for a segment of the population. These reduced rates are marketed and distributed in a small book of coupons that riders can purchase. Riders later present the individual coupons when purchasing and scheduling transportation to help subsidize out-of-pocket costs. The goal of transportation voucher programs is to help increase awareness of various transportation options available to the target audience, while also reducing the financial barriers that some riders may experience.29

Samuel et al studies the effectiveness of the Michigan Developmental Disabilities Council’s transportation voucher program that lasted from 2005 to 2008. The purpose of this program was to improve access to transportation for adults with disabilities. The program primarily served those who were physically disabled, aged 56 and older, unemployed, lived alone, and relied on family, friends, and public transportation services. Such an intervention could have positive outcomes in Chatham County as the majority of people in need of non-urgent medical transportation services fall within these same categories. Furthermore, this program focused on cost effective solutions, and cost is a significant constraint for the Chatham County’s key stakeholders.

According to Samuel et al, the majority of participants (39 percent) used the voucher program for about two years, and most used vouchers to help pay for transportation services through family and friends (42 percent) or volunteers (24 percent). Furthermore, although the transportation voucher program subsidized transportation for all types of services, 18

percent of participants reported using the vouchers to access medical appointments, and 20 percent stated that the program improved their access to medical services. Fifty-four percent reported experiencing a better overall quality of life due to the assistance provided by the transportation voucher program.

While the transportation voucher program increased access to non-urgent medical transportation services, Samuel et al points out that it also had some limitations. Although the program reduced some financial barriers, especially those placed on family and friends, it did not eliminate these barriers completely. For instance, the program did not significantly alter the behaviors of participants by incentivizing citizens to utilize public transportation or organize volunteer networks of drivers. Many still relied on family and friends to assist with transportation. Due to this strong dependence on family and friends, this program may not be sustainable for Chatham County long-term. In particular, such a program would not help to establish a standardized schedule for medical transportation services throughout the target area.30 West Virginia Rural Health Access Program

Bellamy et al discusses the West Virginia Rural Health Access Program, which began in 2000 to provide NEMT for people living in rural communities. These communities are encouraged to develop their own transportation systems by creating partnerships between organizations such as schools, churches, and public transportation services. This program consists of three organizations—the Potomac Valley Transit Authority, Preston County Senior Citizens, Inc., and Senior Life Services of Morgan County—that are jointly funded by the 21st Century Challenge Fund and the Claude Worthington Benedum Foundation. This program is relevant to Chatham County because the majority of people seeking NEMT

services are elderly, and the county does not currently have a system that organizes both formal and informal transportation providers.

Because the West Virginia Rural Health Access Program is based on organizing the various types of NEMT options, Bellamy et al says that each provider offers slightly different services. The Potomac Valley Transit Authority offers public transportation to a five-county service area via a fixed route as well as weekly demand-response services. A demand-response service is one in which the rider schedules to be transported to and from a specific location that is not along the typical service route. The Potomac Valley Transit Authority operates Monday through Friday from 4:30am until 7:30pm. The Preston County Senior Citizens, Inc. operates a transportation service called the Buckwheat Express, which is only accessible to those in Preston County. This service line provides riders the ability to request in advance transportation to medical services up to three-fourths of a mile off the regular service route. The Buckwheat Express operates Monday through Friday from 5:00am to 6:00pm. Lastly, the Senior Life Services in Morgan County provides general transportation services to the elderly and low-income populations within this county. This service line offers regular fix-route services as well as door-to-door services upon request. The Senior Life Services run Monday through Fridays from 7:30am until 4:30pm.

Overall, Bellamy et al believes the West Virginia Rural Health Access Program has accomplished its goal of reaching target populations. More than one-third of community members report using NEMT services, which highlight the reported needs of such resources. The majority of NEMT riders are female, aged 65 and older, or Medicaid beneficiaries. Furthermore, the NEMT services have very high user satisfaction ratings. Over 90 percent of the participants report being satisfied or very satisfied with scheduling, length of time riding in the vehicle, courtesy of the drivers,

promptness of the drivers, and the overall cost of services.

Bellamy et al also mentions that the program has some shortcomings. The first drawback is that the transportation services offered only operate Monday through Friday. This limitation introduces barriers for those seeking medical transportation during the weekend, as NEMT services do not operate during this time. The second drawback is that the West Virginia Rural Health Access Program has ongoing difficulties reaching a break-even point. Specifically, the program has significant expenses related to salaries and benefits. Furthermore, the number of riders varies significantly from month to month, resulting in unsteady revenue streams. Moreover, Medicaid beneficiaries comprise a significant proportion of the riders. Although Medicaid law requires beneficiaries to have access to NEMT services, it negotiates lower prices with these providers, which negatively impacts the program’s bottom lines. In short, a program modeled after the West Virginia Rural Health Access Program may not be sustainable in Chatham County due to the unpredictable nature of the program’s long-term financial feasibility.31 Addressing medical transportation in Chatham County

With the given time and resource constraints for addressing transportation needs in Chatham County, a marketing campaign to increase the awareness of NEMT services will likely be the most effective strategy for increasing local health care access. Such a marketing campaign would be used to expose high proportions of the population to health promotion messages, using the media as an educational tool. A mass media campaign would be favorable because of its capability to communicate information, increase awareness, and reach a large number of people.32 A mass media intervention could therefore produce positive health changes by enforcing positive

health behaviors among individuals. Methods to communicate health messages could include print media (such as infographs and brochures), television, and radio broadcast.

Research has shown that marketing concepts and tools improve the delivery of health care to vulnerable populations. For instance, the Paris Community Hospital in east central Illinois underwent a comprehensive marketing campaign in an attempt to inform community members of its services. Although the hospital was located in a small rural area and only had 25 licensed beds, it invested heavily in diagnostic equipment and a growing physician staff to become a full service provider. The hospital decided to upgrade its graphic image and web site, as well as create a unified graphics look for all written materials, including ads, newsletters, and a newly created monthly newsletter. Since the marketing effort began in late 2002, outpatient revenue has grown by 45.8 percent, MRIs by 16.2 percent, and cardiac stress test volumes by 38.1 percent.33

A marketing campaign could be an important step for the Chatham Health Alliance for several reasons. First, focus groups with key stakeholders have shown that Chatham County residents are hesitant to access health care locally due to past negative experiences. Although the health care system has evolved and improved over time, people are unaware of these positive changes, and consequently do not seek services locally. In addition, residents often travel to larger towns and cities to receive health care services because they are not knowledgeable about local health care providers. For instance, a patient might travel to Chapel Hill weekly for dialysis treatment, when a clinic offering dialysis is available in Chatham County.34

Therefore, the focus of this campaign in Chatham County will be rebranding available health resources, as well as creating and promoting a network of local physicians. The rebranding campaign will seek to educate

people on health improvements in Chatham County. To do this, key stakeholders will work with local physicians to disseminate a comprehensive set of resources that inform residents of the health care services available in Chatham County. The end goal will be creating and distributing an infographic to citizens that includes a summary of all health care providers in the county. It will also provide information on services covered by Medicare and Medicaid, as 31 percent of Chatham County residents qualify for Medicare and another 6 percent qualify for Medicaid.35 Methods

To specifically achieve the goals of this project, a framework will be followed that has been put together by the project’s preceptor. First, social service and health organizations, coalitions, and other potential partners who are interested in assessing and improving availability of transportation in Chatham County will be identified. Next, representatives from these groups will be gathered at the Chatham Health Alliance’s Access to Care Subcommittee. Those involved will include representatives from Latino and African-American communities of highest need, as well as local health and transportation providers. During this time, a motivating vision will be created through an engaging discussion amongst all committee members.

Additionally, the committee will broadly identify gaps and opportunities along with formal and informal resources within the county that could be enhanced to improve access to care and transportation. Through the use of follow-up interviews and focus groups, the greatest needs of the county will be assessed to better understand the intersection between access to health care and transportation. Next, previous efforts that the committee has studied and addressed will be assessed for efficacy, and the current status of these efforts will be further developed. Finally, more detailed assessments of assets and needs

will be planned for further examination throughout the duration of the project. Targeted Populations Aging population

The percentage of persons in Chatham County who were 65 and older in 2010 was 18.3 percent, compared to 12.9 percent for the state of North Carolina, and 13 percent for the United States.36 This number has risen to 23.6 percent as of July 2014, compared to 14.7 percent for North Carolina, and 14.5 percent for the United States.37 In short, almost one in every four residents in Chatham County is over the age of 65, and the proportion of elderly adults is expected to rise due to the continued “Graying of America”.

The elderly are an especially vulnerable sub-population; therefore, specialized efforts are needed to help target and address the specific barriers they face. One such barrier is the inadequate supply of caregivers and family members able and willing to provide transportation for non-driving elderly adults. 38 Stakeholder meetings confirmed this as a barrier for elderly adults in Chatham County, highlighting the fact that working family members are often unable to take time from work, or after work, to take their elderly family members to medical appointments. This leaves the elderly population relying on public transit, and demand-response services, which are unable to meet demand due to lack of funding. Another significant barrier elderly adults in Chatham County face is the distance from home to the public transit service. Even when they are able to afford the service the distance is often to far to reach them. Focus groups of 42 nationwide transportation systems identified shorter walking distances from home to transit stops as positive service attributes of an ideal transit system. 39 The sprawling, rural layout of Chatham County makes distance an especially difficult barrier for elderly residents. However, the burden of traveling from home to a transit stop can be lessened by pedestrian-

friendly infrastructure. This could include adequate sidewalks, bike paths, curbs/ramps, and rest areas along the way. A study conducted by International Communications Research in cooperation with the American Association of Retired Persons found that 50 percent of non-driver respondents couldn’t walk to a bus stop if they want to; yet, 32 percent said that the trip might be possible if resting areas existed along the way.40 These results are promising for Chatham County, as they have identified “encouraging healthy lifestyles through changes in the built environment” as one of the focus areas in their Community Health Assessment.41 While the main purpose of this is to combat obesity, a built environment that also enables the elderly population to safely travel from home to transit stops should be considered.

Figure 2. Chatham County Population by Age: 2000 vs. 2010

Source: 2014 Community Health Assessment: Chatham County, NC42 Hispanic population

The Hispanic population makes up approximately 13 percent of Chatham County, which is relatively large compared to the state average of 8.4 percent.43 Further, Siler City, the largest city in Chatham County with a population just over 8,000, is 50 percent Hispanic.44 Thus, Chatham County faces several challenges in regard to the Hispanic population, including insufficient distribution

of bilingual resources and a lack of translators within physician clinics and the health department.

Ricardo Salazar, who works as an interpreter for the Chatham County Health Department, has raised concerns related to Chatham Transit having only one bilingual employee. This inhibits communication between these two organizations as well as communication between the organization and Chatham County residents. He also highlighted the reality many elderly and undocumented Hispanics face: navigating complicated documents required for requesting transportation services without anyone to guide them through the process. Supporting Ricardo’s claims is the Chatham Food Access Network Focus Group, whom agrees many needs of the large Hispanic community “are not being met because of lack of resources and communication.”45

Additionally, the Protect North Carolina Workers Act was signed into law in October 2015, which prevents government officials or law enforcement, with some exceptions, from accepting consular documents (other than passports) to affirm someone's identity.46 This new law also invalidates ‘Sanctuary Cities’, which are cities and counties in North Carolina that voted to restrict enforcement of federal immigration laws.47 Overall, this law poses additional challenges for Hispanics in Chatham County, specifically if they are illegal immigrants, as governmental agencies will no longer accept their identification cards and they will no longer be able to access many government employee assistance programs.48 Because this bill authorizes law enforcement to arrest those without state issued identification the fear of being detained and possibly deported will likely keep many off the road, increasing the need for medical transportation to access health services. 49

Rural population

In 2010, the population density of Chatham County was 93.1 persons per square mile, which was less than half of the average population density of the state (196.1 persons per square mile).50 Additionally, 66 percent of the population lived in rural areas, which made up 97.5 percent of the county’s total area.51 This makes the coordination of medical transportation incredibly important and increasingly difficult as fewer individuals are supporting a transportation system that already has a stretched infrastructure.

Existing Transportation Networks

Chatham County’s population faces several unique barriers to accessing health care, and the current transportation resources are not sufficient for addressing those barriers. In order for Chatham County to adequately meet the health needs of its residents, local agencies will need to collaborate, and resources will need to be reallocated.

Chatham Transit Network is available to all residents in Chatham County. In 2013, 25 percent of the organization’s rides were for medical trips, which logged 43 percent of the total mileage.52 Chatham Transit is the largest provider of medical transportation within Chatham County, but the availability of its services is limited. Its cross-county transportation only offers a fixed route six times a day from Pittsboro to Chapel Hill, and three times a day from Pittsboro to Siler City at a cost of $3 each way.53

While this can be beneficial for residents that live in or close to Siler City and Pittsboro, the majority of those in Chatham County are unable to access these routes due to the distance from their home to the transit stop. When people cannot use Chatham Transit, they can fill out a form 48 hours in advance to request in-county transportation between 8am and 5pm, Monday through Friday. Still, this is problematic due to the unrealistic requirement of scheduling medical appointments 48 hours in advance, inability to transport outside of the

county, and the strict hours of 8am to 5pm. Not to mention these forms may be difficult to locate, hard to understand/fill out, and as mentioned earlier residents have little to no assistance if they are unable to read, write, or speak English.

Other medical transportation services are catered towards specific subpopulations, such as the elderly and Medicaid eligible individuals.54 A great resource that advertises many of these medical transportation options is ChathamConnecting.org, which is a website that provides information on relevant, local health resources.55

For instance, A Helping Hand is an organization featured on the website. This nonprofit organization is committed to assisting older adults and individuals with disabilities maintain independence and improve their quality of life. A Helping Hand serves individuals over the age of 60 as well as those with disabilities in North Chatham. Medical transportation is one of the many services A Helping Hand provides to its patients.56

Another resource found through the ChathamConnecting.org website is the Council on Aging, which has offices in Pittsboro and Siler City. The agency strives to support residents over the age of 60 as well as those with disabilities. The Council offers assistance in arranging transportation for medical appointments. Medical transportation is limited to three round-trip rides or five round-trip rides per month for a cost of $4.00.57 Stakeholder Analysis

After conducting meetings with several key stakeholders who have an interest in improving access to care for Chatham County residents, several gaps and key positives were identified. Existing gaps include a shortage of health care providers, stigma against receiving health care services in Chatham County, stigma against using Chatham Transit services, and the overall lack of coordination and advertising of

health care and transportation services available to Chatham County residents.

Stakeholders agree that the shortage of health care services in Chatham County is putting pressure on Chatham County residents to seek care elsewhere. This is especially concerning, as it will continue to decrease demand for health services within the county, which could deter providers from moving to the area. Moreover, there are no OBGYN services within the county, and mothers can only give birth in the Chatham Hospital emergency room. Cindy Bucy, a community relation’s specialist at Cardinal Innovations, has said there are only two private providers of mental health services in Chatham County.58 Stakeholders agree that increasing the demand for, and improving the reputation of, local health care services is crucial for increasing access to care for Chatham County residents.

Stakeholders also agree that a large portion of Chatham County residents is simply unaware of many health care and transportation services available to them. While most of the transportation services have predetermined routes and schedules, which are not always conducive to emergencies, residents could still use these services to make it to their routine check-ups and preventative care appointments. This would help keep residents healthier, reduce incidence of chronic disease, and hopefully eliminate the amount of health emergencies as a result.

In general, the stakeholders were optimistic in the progress that has been made in regards to increasing access to care. Everyone seemed excited to be talking about potential solutions and how to build upon existing positives.

Assessment

Following an assessment of medical transportation needs within Chatham County, a brief list of key issues was compiled. Funding streams

A significant barrier to accessing health care in Chatham County is the high cost of providing NEMT for patients. Medicaid provides funding for transportation services to allow eligible individuals to access a variety of government health care programs. Medicaid programs in North Carolina do not operate in isolation but rather in conjunction with other state and county organizations, overlapping transportation funding streams. Each of the funding streams has unique rules.59 Additionally, there is a lack of coordination amongst providers of medical transportation, which leads to higher costs and potential for duplicative services.60

Limited funding is available for organizations such as Chatham Transit and the Council on Aging, which provide transportation to medical appointments. As the number of low-income patients increases, there will likely be a tremendous need for additional transportation services at lower costs. Currently, many patients are traveling across county lines to seek health care services within Orange County and other surrounding counties. As a result, organizations are left to provide costly trips that transport patients up to 10 miles outside Chatham County. The current transit situation is neither cost-effective nor sustainable for these organizations. Furthermore, limited funding and strict regulations on the use of medical transportation funds bind facilities that receive grants from the North Carolina state government for non-emergency medical transportation. Further information is needed to assess the current cost per trip for medical transportation in Chatham County61 Care coordination

The Chatham County Access to Healthcare Subcommittee raised several pertinent issues in regards to coordinating care. First, they concluded that money was the number one barrier for Chatham County residents when accessing medical

transportation. The lack of money is a double edged sword; as the average income of residents often isn’t enough to cover the fees required by medical transportation, and the funding that Chatham County receives to operate transportation programs is insufficient. This is why coordinating available transit services to efficiently transport the most Chatham County residents to their medical appointments is so important. The subcommittee estimated the current cost of a round trip from Pittsboro to Chapel Hill to be about $100. This cost covers gas expense, vehicle maintenance, and the wage for the driver. The subcommittee also mentioned that the van that makes these trips often takes one or two patients when the van easily fits 15 to 20 passengers. This is extremely inefficient financially and likely places a greater strain on the organization covering the bill.

The subcommittee also feels that there is little to no cooperation amongst providers when it comes to scheduling patients’ appointments. For example, the Department of Veteran Affairs (VA) will not schedule all of a patient’s medical appointments in the same day. Therefore, this patient will instead have to arrange transportation on multiple days at multiple times. Coordinating a patient’s appointments to coincide with transit services’ times of operation, and scheduling multiple appointments on the same day would benefit the patient, the health care provider, and the transit service.

UNC Health Care has done a poor job (in the eyes of the Healthcare Subcommittee) in communicating with their affiliate hospital in Chatham County. Many of the health care services available to patients at UNC Hospitals in Chapel Hill are available locally at Chatham Hospital or elsewhere within Chatham County. Better communication between these hospitals would likely help to reduce unnecessary travel to UNC Hospitals, with the hope of funneling some of this demand back to health care services in Chatham County. Furthermore,

many physicians hold hours and appointment times at Chatham Hospital, eliminating the reason for Chatham County residents to travel outside of the county because they simply want to see ‘their doctor’. One possible solution to this matter is training referral specialists that work within the UNC hospital system to identify opportunities to provide health care services locally. Personal finances Another key issue Chatham County faces is the distribution of income. The median household income in Chatham County is approximately $57,000 and per capita income is $31,000.62 While the median household income in Pittsboro is approximately $53,000, the median household income in Siler City is just over $30,000.63,64 Furthermore, the per capita income in Pittsboro is $27,000 while the per capita income in Siler City is $14,000.65,66 The income disparities within Chatham County limit access to medical transportation, as residents living in the most rural and less affluent areas have less disposable income to spend on transportation. Health outcomes

Chatham County health outcomes are relatively good compared to averages across the state. However, 26 percent of Chatham County residents are obese, leading to high rates of chronic disease in the county.67 The prevalence of chronic disease continues to present a large health and economic burden for the county, and warrants improved transportation services, better screening, and the implementation of effective prevention strategies by local Chatham County providers. Given the association between obesity and prevalence of chronic disease, interventions that improve access to care are integral to improving health outcomes within the county.68

As a result, there are significant disparities in health outcomes for the county suggesting that specific segments of the

Chatham County population may not have adequate access to care. Thus, poor access to care and low utilization of preventative services can lead to serious health conditions and poor health outcomes for the county. Awareness of local alternatives

Access to health services includes the availability and awareness of services, and the ability of residents to attain them. Chatham County faces an overall lack of awareness of health and transportation services. Many residents within Chatham County travel to other counties such as Orange, Durham, Wake, and Guilford to seek care rather than utilizing local services within Chatham County. The primary reason people seek care outside the county is a general lack of awareness of the services offered locally. Many transportation and medical services offered in Chatham County are advertised by word of mouth, which may limit the amount of people who are well informed, especially due to the county’s large geographic area.69

Additionally, the majority of resources available are only in English. As a result, members of Chatham County’s large Hispanic population are often unable to learn about transportation and medical services, which reinforces the lack of awareness. Furthermore, some residents perceive the services offered within Chatham County as “lower quality” compared to those offered in other counties. This is a significant problem because people are typically not motivated to learn about local health services and subsequent transportation opportunities currently available.70 Anti-Kickback Statute

The federal Anti-Kickback Statute also complicates access to medical transportation in Chatham County. According to this law, the government can charge “criminal penalties for any individual or entity that knowingly or willfully offers, pays, solicits or receives ‘remuneration’ in order to induce or reward the

purchase of medical services covered by government programs such as Medicare and Medicaid.”71 More simply, exchanging anything of value with an individual or entity that participates in Medicare or Medicaid to incentivize someone to seek care at a particular health care facility is a federal crime. This includes hospitals providing free or discounted transportation for elderly and low-income populations to help them get to their medical appointments. Therefore, Chatham Hospital is limited in its ability to improve access to transportation for its patients, which increases the burden on other organizations in Chatham County. Key positives

Despite barriers faced, Chatham County has several assets to address medical transportation. First, there are already medical transportation networks in place. Chatham Transit offers medical transportation to Chatham County’s residents and contracts out to organizations such as the Council on Aging to help people access a variety of medical services.72 Furthermore, Chatham Transit is currently looking to hire someone full-time to organize the medical transportation schedule.73 Designating someone to solely coordinate medical transportation will help improve the access and coordination of care.

In addition to formal networks, many churches and volunteer organizations assist residents with medical transportation. Although Chatham County has several transportation networks, most are not being used efficiently.74 The county should work to improve these existing services to better serve the community.

Another positive aspect is that the community acknowledges the problem. Throughout the county, health care professionals and residents understand the need to improve medical transportation. As a result, key stakeholders have come together to address the problem. This collaboration is significant

because it allows multiple leaders from diverse backgrounds to work on this problem.75

UNC Health Care is currently trying to increase the marketing of Chatham Hospital. Specifically, UNC Health Care is focusing on improving Chatham Hospital’s image, which will potentially increase awareness and reduce stigma around using the hospital. Through the use of marketing strategies, the goal is to reshape the perception of Chatham Hospital and other health resources in the county.76

Priorities and Goals

In order to improve access to health services and medical transportation throughout the county, several objectives have been identified. First, a priority is to improve coordination of medical and transportation services. Many Chatham residents seek care outside the county. This puts a strain on transportation resources, such as Chatham Transit and volunteer networks. As a result, people have to travel further for appointments, which is cost intensive and time consuming. Increasing the number of residents who seek primary and secondary health services within Chatham County will make medical transportation more accessible as transportation organizations are able to serve more people during the day. Furthermore, many transportation organizations are operating single rider services, although their vehicles have the capacity to hold more passengers. Operating single rider services increases the cost of transportation because service providers are unable to split the cost of the driver and fuel among several payers. As a result, the single rider pays more money for transportation. Therefore, improving the coordination of medical services by having people with similar appointment times share rides will make medical transportation affordable and subsequently more accessible in Chatham County.

The second priority is to increase awareness of health services offered in

Chatham County. Many residents travel outside the county to obtain care because they are unaware of the services offered within the county. Improving the advertising of local health services will help educate residents. Providing these advertisements in Spanish as well as English will build awareness within the Spanish-speaking communities in the county. Updating current advertisements by making medical resources more “web-friendly” will increase their exposure and educate residents.

The final priority is to combat stigma against using local health services and public transportation. Many seek care outside of the county because they perceive Chatham’s services to be “lower quality” compared to those in surrounding counties. As a result, Chatham’s medical services are often viewed as safety net services for those who cannot afford to go elsewhere. This sentiment is engrained within the community; in particular, those who do not have access to transportation end up postponing care until their condition worsens.77 Rebranding Chatham County’s health services will hopefully reduce the stigma against them and encourage more people to seek care locally.

Similarly, public transportation in Chatham County is largely viewed as services for the elderly and low-income residents. This perception prevents some people from taking advantage of health services because they are afraid of being stigmatized by their community.78 Updating Chatham Transit’s web-presence will increase its visibility, which will help educate community members on the value of local public transportation. Rebranding the image of Chatham Transit as a “community service” in which everyone can enjoy, as opposed to a service that predominantly targets the elderly and lower income residents, will likely encourage more residents to ride. Potential Strategies and Implementation

A direct marketing campaign will be implemented to promote health services in

Chatham County. Specifically, an infographic will be created to display information related to local health and transportation resources. There will be two, double-sided infographics, with English translation on one side and Spanish on the other. The first infographic will focus on health services, such as highlighting clinics that accept Medicaid and Medicare patients. It will also emphasize the benefits of seeking care locally. For instance, health care services provided by Chatham Hospital will be promoted, and the infographic will discuss how available doctors include those from UNC Health Care. The second infographic will focus on transportation resources, such as providing information on different ways a patient could get from their home to an upcoming doctor’s appointment. This infographic will highlight resources for different targeted populations, including elderly, low-income, Hispanic, and chronic disease members. For example, the Council on Aging will be listed as a resource for elderly citizens. These infographics will be linked on the local Department of Health and Human Services (DHHS) website, and will also be available in common community spaces, such as the DHHS office, Chatham County Public Health Department, Chatham County Community College, and public schools throughout the community. The goal of this campaign is to rebrand health services, such as showing residents that Chatham Hospital is an effective place to receive care. An additional goal is to encourage residents to stay in Chatham County to receive health services.

Another strategy to implement in Chatham County is increasing health services and transportation coordination between local providers, UNC Health Care, and Chatham Hospital. This will be achieved by calling local providers to build awareness of the problem, in addition to talking to providers at UNC Hospitals and Chatham Hospital to find ways to improve care coordination within the Chatham community. The goal of these conversations will be to raise awareness of the current

medical transportation issues. Additionally, a long-term goal will be to adjust the Electronic Health Record system to notify patients when they could receive the same type of care at a closer location. Finally, to coordinate transportation services, partnerships will be formed with Chatham Transit and the Council on Aging to help develop a fixed medical transportation schedule.

Impact and Outcomes

The impact that is most desired from implementing these strategies is increasing the amount of medical transportation trips provided to Chatham County residents. Increasing medical transportation will provide many beneficial outcomes to the Chatham community. Primarily, more residents will be able to make their medical appointments, which reduces missed visits, improves continuity of care, and keeps Chatham County residents healthier and less likely to develop chronic conditions. Secondly, as a result of more residents utilizing medical transportation services, revenue streams to these services should increase, bolstering what the services can offer.

The action plan introduced by the Access to Healthcare Subcommittee expects a five percent increase, from a baseline of 16,100 medical trips provided in 2013, in the amount of medical transportation trips provided by Chatham Transit by December 2016.79 This would be a significant achievement that could only be possible with cooperation from community stakeholders, health care providers, and transportation services. Ideal System

There are many characteristics of an ideal medical transportation system, which should dictate the desired outcomes of strategies related to health services and medical transportation. Most importantly, transportation offered should be reliable and flexible. In particular, flexibility in trip planning and trip-

making is very important for transit services. One hundred percent of participants in a Transit Industry focus group mentioned “spontaneity” as an important feature in an ideal transportation system. They specifically said they wanted the ability to request and receive transportation for a medical appointment within the same day.80 For instance, Mountain Empire Older Citizens (MEOC), a rural public paratransit system serving southwestern Virginia, utilizes same-day scheduling to meet any trip request. Through computer scheduling and radio contact with drivers, MEOC can attempt to fit in any trip request, regardless of when it is made.81

In addition, dependability of transit services is of paramount importance to citizens, especially those from vulnerable populations. If service does not operate on time in a coordinated manner, appointments will be missed, frustration will grow, and the fear of being stranded will become a significant concerns. As a result, people will be less likely to utilize public transit to meet their travel needs. To increase reliability of transportation services, schedules can be reconfigured, and the monitoring of on-time performance can be increased. Moreover, technologies can be implemented to provide real-time arrival information for passengers. The implementation of such practices is ideal for improving health services and medical transportation in Chatham County.82 Action Plan 2016 The Chatham County Health Alliance is currently finalizing action plans to address non-emergency medical transportation, identified as a health priority within Chatham County's 2014 Community Health Assessment. Further, the health department will work to share the findings of the assessment with members of the community.83 1 Social Determinants of Health for Rural People. (2015, June 9). Retrieved November 19, 2015, from

https://www.raconline.org/topics/social-determinants-of-health 2 Transportation to support rural healthcare. (2014, October 13). Retrieved November 19, 2015, from https://www.raconline.org/topics/transportation 3 Ibid. 4 Chatham County Public Health Department,. 2014 Community Health Assessment. Chatham County, North Carolina: N.p., 2014. 17 Nov. 2015. 5 Ibid. 6 Ibid. 7 Zelek, M. (2015, October 10). Personal interview. 8 Chatham County Public Health Department,. 2014 Community Health Assessment. Chatham County, North Carolina: N.p., 2014. 17 Nov. 2015. 9 Ibid. 10 Ibid. 11 Myers, A. (2015). Non-Emergency Medical Transportation: A Vital Lifeline for a Healthy Community. Retrieved from http://www.ncsl.org/research/transportation/non-emergency-medical-transportation-a-vital-lifeline-for-a-healthy-community.aspx 12 Ibid. 13 Small Urban & Rural Transit Center,. Transportation, Distance, And Health Care Utilization For Older Adults In Rural And Small Urban Areas. Fargo: Upper Great Plains Transportation Institute, 2010. Web. 7 Oct. 2015. 14 Ibid. 15 Arcury, T. (2005). Access to transportation and health care utilization in a rural region . The Journal of Rural Health , 21(1), 31–38. 16 Wallace, R., Hughes-Cromwick, P., Mull, H., & Khasnabis, S. (n.d.). Access to Health Care and Nonemergency Medical Transportation: Two Missing Links. Transportation Research Record: Journal of the Transportation Research Board, 76-84 17 Ibid. 18 Highlights of the 2001 National Household Travel Survey. Publication BTS03-05. United States Department of Transportation, Bureau of Transportation Statistics, 2003 19 Small Urban & Rural Transit Center,. Transportation, Distance, And Health Care Utilization For Older Adults In Rural And Small Urban Areas. Fargo: Upper Great Plains Transportation Institute, 2010. 7 Oct. 2015. 20 Bellamy, G., Stone, K., Richardson, S., & Goldsteen, R. (2003). Getting From Here to There: Evaluating West Virginia's Rural Nonemergency Medical Transportation Program. The Journal of Rural Health, 19, 397-406. 21 Ibid. 22 Chatham County Public Health Department,. 2014 Community Health Assessment. Chatham County, North Carolina: N.p., 2014. 17 Nov. 2015.

23 Community Action Plan 2014. (2012, October 1). Retrieved November 19, 2015, from http://www.chathamnc.org/modules/showdocument.aspx?documentid=25352 24 Chatham County, North Carolina Rentals. (n.d.). Retrieved November 16, 2015, from http://www.weichertrents.com/NC/Chatham/ 25 Wallace, R., Hughes-Cromwick, P., Mull, H., & Khasnabis, S. (n.d.). Access to Health Care and Nonemergency Medical Transportation: Two Missing Links. Transportation Research Record: Journal of the Transportation Research Board, 76-84 26 Ibid. 27 Community Transportation Association of America. (2005). Toolkit and Best Practices. Medical Transportation, 3. Retrieved from http://www.ctaa.org/webmodules/webarticles/articlefiles/medtoolkit.pdf 28 Ibid. 29 Bernier, B. and Seekins, T. (1999). Rural Transportation Voucher Program for People with Disabilities: Three Case Studies. Journal of Transportation and Statistics, 2(1), 61-70. 30 Samuel, P., Lacey, K., Giertz, C., Hobden, K., and LeRoy, B. (2013). Benefits and Quality of Life Outcomes from Transportation Voucher Use by Adults with Disabilities. Journal of Policy and Practice in Intellectual Disabilities, 10(4), 277-288. 31 Bellamy, G., Stone, K., Richardson, S., & Goldsteen, R. (2003). Getting From Here to There: Evaluating West Virginia's Rural Nonemergency Medical Transportation Program. The Journal of Rural Health, 19, 397-406. 32 Bonita, R., Irwin, A., & Beaglehole, R. (2006). Promoting Public Health in the Twenty-First Century: The Role of the World Health Organization. Globalization and Health, 3, 268-283. 33 Ibid. 34 Zelek, M. (2015, October 10). Personal interview. 35 Chatham County Safety Net Planning Council,. Chatham County Safety Net Planning Council: 2009 Evaluation. Pittsboro: N.p., 2009. 36Community Facts. (n.d.). Retrieved November 19, 2015, from http://factfinder.census.gov/faces/nav/jsf/pages/community_facts.xhtml 37 Ibid. 38 U.S. DOT NHTSA. 2001. Older Road User Research Plan. http://www.nhtsa.dot.gov/ people/injury/olddrive/OlderRoad/ 39 Burkhardt, Jon, Adam McGavock and Charles Nelson. 2002. Improving Public Transit Options for Older Persons. V.1. (TCRP Report 82). Washington, DC: Transit Cooperative Research Program.

40 Ibid 41 Long, L, and B Enders. 2014 Community Health Assessment: Chatham County, NC. Pittsboro: Chatham County Health Department, 2015. 42 Ibid. 43 The United States Census Bureau/American FactFinder. (2013). Chatham County, NC. Retrieved from http://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml 44 The United States Census Bureau/American FactFinder. (2013). Siler City town, NC. Retrieved from http://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml 45 Long, L, and B Enders. 2014 Community Health Assessment: Chatham County, NC. Pittsboro: Chatham County Health Department, 2015. 46American Civil Liberties Union of North Carolina (n.d.). Explanation of HB 318: Prohibition of Sanctuary City Ordinances and Limitations on the Acceptability of Certain Forms of Identification. Retrieved from http://www.acluofnc.org/files/legislative/HB_318_Fact_Sheet_10052015.pdf 47 Ibid. 48 Ibid. 49 Lampmann, E. (2015, October 8). How H.B. 318 attacks North Carolina's immigrants and working class. Retrieved November 19, 2015, from http://www.scalawagmagazine.org/articles/hb-318-nativism 50 Chatham County Public Health Department,. 2014 Community Health Assessment. Chatham County, North Carolina: N.p., 2014. 17 Nov. 2015. 51 Ibid. 52 Chatham Transit Network - public transportation in Chatham County. (n.d.). Retrieved November 20, 2015, from http://www.chathamtransit.org/ 53 Ibid. 54 Ibid. 55 Chatham Connecting. (n.d.). Retrieved November 20, 2015, from http://www.chathamconnecting.org/ 56 Ibid. 57 Ibid. 58 Bucy, C. (2015, October 14). Personal interview. 59 North Carolina Department of Health and Human Services,. Family And Children's Medicaid Manual: Medicaid Transportation. Raleigh: Medicaid Eligibility Unit, 2015. 60 Ibid. 61 The Hilltop Institute,. Emergency Medical Transportation (NEMT) Study Report. Baltimore: University of Maryland, 2008. 62 The United States Census Bureau/American FactFinder. (2013). Chatham County, NC (Income).

Retrieved from http://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml 63 The United States Census Bureau/American FactFinder. (2013). Pittsboro town, NC (Income). Retrieved from http://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml 64 The United States Census Bureau/American FactFinder. (2013). Siler City town, NC (Income). Retrieved from http://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml 65 The United States Census Bureau/American FactFinder. (2013). Pittsboro town, NC (Income). Retrieved from http://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml 66 The United States Census Bureau/American FactFinder. (2013). Siler City town, NC (Income). Retrieved from http://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml 67 Chatham County Public Health Department,. 2014 Community Health Assessment. Chatham County, North Carolina: N.p., 2014. 17 Nov. 2015. 68 Ibid. 69 Girard, M. (2015, September, 11). Personal interview. 70 Testerman, A. (2015, September, 11). Personal interview. 71 Serbaroli, F. (2008). Offering Free Patient Transportation Poses Risks. New York Law Journal, 240(112). 72 Girard, M. (2015, September, 11). Personal interview. 73 Testerman, A. (2015, September, 11). Personal interview. 74 Girard, M. (2015, September, 11). Personal interview. 75 Testerman, A. (2015, September, 11). Personal interview. 76 Zelek, M. (2015, October 10). Personal interview. 77 Ibid. 78 Ibid 79 Community Action Plan 2014. (2012, October 1). Retrieved November 19, 2015, from http://www.chathamnc.org/modules/showdocument.aspx?documentid=25352 80 KFH Group, Inc.,. Mountain Empire Older Citizens Transit Development Plan. Bethesda: Cambridge Systematics, 2011. 81 Ibid. 82 Burkhardt, J., & McGavock, A. (2002). Improving public transit options for older persons. Washington D.C.: National Academy Press.

83 Long, L, and B Enders. 2014 Community Health Assessment: Chatham County, NC. Pittsboro: Chatham County Health Department, 2015.