BY: JOHN MORRISSEY
Illustration by Larry Moore
Before people can get care, they have to get there. That sounds simple enough, but it's often no simple matter for those who live alone, who are hobbled or weakened by chronic illness or the side effects of treatment, who can't afford to take a taxi, bus or train, or who struggle with language or physical barriers to getting around.
Finding rides for patients hasn't resonated as a responsibility of health professionals and facilities until lately, as the impact of personal environments on prospects for good clinical outcomes — the social determinants of health — becomes ever more evident.
"Within the past year and a half, or two years, it's almost like the country has awakened to this problem of transportation," said Richard Wender, MD, chief cancer control officer of the American Cancer Society, which has a long-established ride program. "The problem has been there for decades. It is not new. And like so many other things in the nation, nor is the problem experienced equally by everybody."
Evidence of the problem is out there, both long-standing and recent. A 2013 review published in the Journal of Community Health said that 1 in 4 lower-income patients missed or rescheduled their appointments for lack of transportation.1 A 2019 survey from the McKinsey consulting firm stated that people with unmet transportation needs are 2.6 times as likely to report multiple emergency department visits and 2.2 times as likely to report an inpatient visit during the course of a year.2
For sick people on a set schedule of chemotherapy, radiation therapy or similarly intense treatment, missing or having to reschedule appointments delays care and risks greater illness. "We've had situations where patients don't make it to an oncology infusion appointment because of transportation," said Rick Bone, MD, senior medical director of population health at Advocate Aurora Health's medical group in Chicago and suburbs. "Here's a patient who's in the middle of treatment, and then to miss a treatment is just devastating for overall care."
Or a patient with congestive heart failure may not have a ride to a checkup, deteriorates and "then three days later ends up needing a trip to the emergency room and a hospitalization," he said. "It's extremely costly and not great patient care."
Transportation-related problems for patient health extend to primary care, trips to the pharmacy and even getting to a decent grocery store for healthy food. Advocate is among the hospital systems in the Chicago region straining to respond to this community need, individually and collectively. As with like endeavors around the country, they are traveling far outside their comfort zones and areas of expertise.
AIMING FOR CONSISTENCY
The reasons patients miss appointments can stem from predictable problems, such as lack of money to pay for public or private transit, or last-minute snags if, say, a family member can't leave work to pick up the patient. Ride vouchers to defray costs can help up to a point, and hospital-supplied rides in a pinch can fill some of the gap, but those are just stop-gap measures.
Where consistency in meeting treatment schedules is most critical, patient transportation options can be better thought out. For example, AMITA Health, a 19-hospital system across the Chicago metro area, contracts with Superior Ambulance for a medi-car service through its Resurrection Medical Center on the city's Northwest Side for oncology and physical therapy, said Will Snyder, senior vice president and chief advocacy officer of AMITA Health. The logistics are effective, he said. Medi-car service provides non-emergency transportation and can transport people in wheelchairs or with other medical needs. Rides are scheduled when appointments are made. The two departments order a combined 300 trips per month.
At an Advocate clinic devoted to treating patients with multiple chronic conditions, the incidence of missed radiation or infusion therapy appointments among low-income patients "got to where the staff was taking up collections to start a fund to try and help patients with transportation," Bone said.
As transportation kept looming as a barrier to care of chronically ill people at that Advocate site, it began issuing vouchers for taxi rides. "When we got up to using about $4,000 a month in cab vouchers," said Bone, "we realized it was more cost-efficient to just lease a van and then start scheduling. It was better overall, more reliable and more cost-efficient."
Loyola University Medical Center in the suburb Maywood, west of Chicago, gets involved in arranging public transportation and subsidizing travel costs when needed. A regional para-transit service for those with disabilities or limited mobility, offers point-to-point rides in mini-buses, but it can take weeks to initially set up for a passenger, and each trip requires a call a day ahead, said Laura Morrell, a social worker at Loyola's Cardinal Bernardin Cancer Center. Loyola also has a patient assistance program and can use funds for transportation.
Personal attention is just as important as the transportation cost, said Morrell. "There are people who are all by themselves; they don't have support, and there's no way someone can navigate half the stuff they have to navigate when they're sick. So as social workers we do get involved with that, we're the ones they call all the time." But they can't work miracles. "Sometimes our hands are tied," she said. "In emergency situations we may provide a cab, but we can't provide a cab for six weeks of radiation."
TEMPORARY LODGING, CAREGIVER SUPPORT
For patients without local family or friends to drive them, or who live a long drive from the treatment facility, the gap can be filled in novel ways. Arrangements extend from bringing patients closer to the appointments, to bringing far-off family and friends to town to assume caregiving roles that include rides.
Morrell tells of a woman who could not get to treatments reliably, so Loyola personnel worked with the state Medicaid program to admit her to a nearby skilled nursing facility that could transport her to radiation treatments for the duration. Sometimes a patient already is in a nursing home but far away, and Loyola works to arrange transfer to a facility closer to the hospital.
Another mainstay of lodging for patients and their caregivers is the American Cancer Society, which places patient navigators at hospitals to identify people who can benefit from two of its programs: Hope Lodges, for patients actively receiving oncology services, and Road to Recovery, a ride service.
The 33 Hope Lodges nationwide offer a free room to a patient and one caregiver, said Wender. "We've had patients stay in a Hope Lodge for over a year, no cost." Most lodgers are traveling a distance; some, however, live only 30 to 40 miles away but need daily treatment and can't keep going back and forth. The Road to Recovery program, also free to patrons, deploys volunteers "using their own vehicles, their own insurance; they are not trained in medical transport," said Wender. Patients have to be able to get in and out of a car and walk to treatment.
For patients without family or friends nearby, but who have loved ones in another state who are willing to help with driving and other caregiver responsibilities, Morrell of Loyola said she makes good use of a Southwest Airlines program to fly in such helpers on free flight vouchers. The airline's Medical Transportation Grant Program, in its 13th year of service, leaves it up to participating health care sites to determine the need and issue complimentary e-pass certificates.
SYSTEMIC TRANSPORTATION REFORMS
Providing vouchers, taking up collections or fielding last-minute van orders when rides fall through won't cut it if health care systems are serious about heading off transportation gaps and their domino effects. "We recognize that we're spending a lot of time and energy being reactive when a patient can't get to us or can't get home," said Snyder of AMITA, "and we need to be more proactive [in that] we recognize that X percent of our patients are likely to have this issue, and to solve that problem."
AMITA and several other competing health care systems operating in lower-income neighborhoods of Chicago, including Rush University Medical Center, UI Health, Sinai Health System and Cook County Health took organizational steps to understand and deal with transportation and other social determinants of health by forming a coalition called West Side United.
Another coalition initiative, West Side ConnectED, has devised a uniform method of screening residents for these social needs and systemizing referral procedures to social service providers. These screenings target people who come to emergency departments with ills caused or worsened by inadequate housing, transportation, nutrition and other social deficiencies, hence the capitalized ED in the title. "If we get the data the same way and we're able to see it across the system, then it makes it a lot easier for us to figure out solutions," said Snyder, instead of "having five different conversations about transportation providers; that's something to avoid if we can."
Among the clear conclusions from data analysis was that people needed more on-demand transportation solutions, instead of having to rely on public transit with its long walks, inflexible schedules and the difficulty of accessing buses, subway platforms and elevated train staircases.
Hospital-operated vans are now part of the on-demand solution. Sinai, for example, runs a van service to oncology services located on its West Side hospital campus, primarily during daytime hours, said Phyllis Martiny, director of case management and social services. She said the service accommodates outpatient visits, typically arranged in advance, but may be able to fit in a last-minute ride when a patient's original ride falls through. For appointments off campus, a community group has stepped in to supply transport between patient homes and physician practices.
The sheer scope of the transportation demand, however, has fueled a rise in contracts with ride-share companies such as Lyft and Uber to increase capacity and timely convenience, and with companies operating more medically equipped transport vehicles for disabled patients, including those who use wheelchairs. Then, rather than getting into the dispatching business, hospitals have begun hiring logistics firms as a central point to act as broker or manager of the multiple means of transportation that can respond to different patient needs.
SETTING BOUNDARIES AND MEETING DEMAND
About three years ago, Rush initiated a small pilot project with Lyft as one remedy for patients clearly struggling with transportation, said Rachel Smith, program manager for social determinants in Rush's department of social work. The service covered patients leaving the medical center or going to doctor appointments. The pilot sought to create clear boundaries around eligibility, such as difficulty using public transit because of condition, medication effects, or reluctance to take a bus because of safety concerns in the neighborhood, Smith explained.
As a result, "We found that people overwhelmingly made their appointments, very few canceled," she reported. Costs were competitive with taxi vouchers. Rush paid all costs and patients rode free.
More recently, AMITA launched a pilot with Lyft at two of its urban hospitals after "assisted patient transportation was something that several donors recognized was a huge issue and wanted to help support," said Snyder. The initiative at AMITA Health Saint Joseph Hospital Chicago in the Lakeview neighborhood and its Saint Francis Hospital in Evanston went through challenges inherent to serving riders with medical needs, but it's now up and running, he said.
The same kind of supplemental expansion has greatly increased the ride service capacity at the American Cancer Society, which saw a 38% increase in the number of patients served by its Road to Recovery to 475,000 last year. The society realized a few years ago that the volunteer program alone could not meet demonstrated need, said Wender. So it now works directly with Lyft and has a partnership with Ride Health, a software-enabled brokering service that matches ride options with patients, which includes Uber among its contractual options. Another American Cancer Society contractor, Envoy America, provides door-to-door ride service and personal assistance to senior citizens and people with infirmities.
THE ROAD AHEAD
A maturing partnership between University of Chicago Medical Center and an up-and-coming medical transport management company may herald the next logical step for hospitals as they attempt to get comprehensive in their options.
The South Side hospital complex more than two years ago was seeking to improve efficiency by offering rides upon discharge for patients who were ready to go home but often waited for hours for a ride from family or a friend, thus tying up beds and other resources, said Joan Liput, a quality improvement manager in charge of the project. The center turned to a startup in Chicago called Kaizen Health. It had invented a HIPAA-compliant logistics platform and rounded up a full range of vehicle options that can be ordered by health care personnel to fit any scenario.
Kaizen partners with sedan-level ride companies including Uber and Lyft, taxi companies and medical-transport cars. It also contracts with non-emergency medical ambulances, and even includes vehicles identified as having car seats for pediatric patients. Additionally, Kaizen partners provide courier services for medication and prescribed healthy foods.
Since the launch for inpatient transportation, the service branded by University of Chicago as URides has averaged more than 1,000 rides per month, said Liput. Seeing the value, the medical center recently expanded it to all outpatient clinics.
The logistics of providing rides include a problem-solving component aimed at heading off missed appointments, said Mindi Knebel, founder and chief executive officer of Kaizen. "It's really important to get folks into appointments who might not otherwise show up," she explained. "Through our process and technology, we are actually having patients confirmed 24 hours in advance, to make sure they're coming in. If they don't confirm, or if they cancel that ride up front, we know there's a reason to touch base with them and make sure everything's OK and they have a different ride. Otherwise we can get them rescheduled."
Benefits like that have helped the company grow 400 percent in 2018, and it's on target for a repeat performance this year. In Chicago, Kaizen is expanding to UI Health, Sinai, Loyola, Lurie Children's Hospital and Northwestern Memorial Hospital, according to Knebel. Advocate's Bone said a pilot is ready to go at two campuses of its Advocate Children's Hospital. Then if evaluated as successful in the fall, it will roll out to all of the health system's Advocate and Aurora sites in northern Illinois and in Wisconsin, he said. Contract talks are underway with Rush and AMITA as well, Knebel said. Kaizen counts 45 clients nationwide.
That includes a new wrinkle in Columbus, Ohio, where it is working with providers to reduce a high infant mortality rate by creating a web app and mobile view so women can book their own unlimited rides to medical appointments, plus four rides per month to a source of healthy food — whether grocery store, food bank, farmers market. The plan envisions trips to the pharmacy or to social services, Knebel said.
Business rules control how many rides women can take, but they can set them up however and whenever they want, even down to how many car seats and the car seat type they need.
JOHN MORRISSEY is a freelance writer specializing in health care delivery, policy and performance measurement. He lives in Mount Prospect, Ill.NOTES
1. Samina T. Syed, Ben S. Gerber and Lisa K. Sharp, "Traveling Towards Disease: Transportation Barriers to Health Care Access," Journal of Community Health 38, no. 5 (2013): 976-93. doi:10.1007/s10900-013-9681-1.
2. Erica Hutchins Coe, Jenny Cordina, Seema Parmar, "Insights from McKinsey's Consumer Social Determinants of Health Survey," April 2019, https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/insights-from-the-mckinsey-2019-consumer-social-determinants-of-health-survey#0.