Case Study: Non-Emergency Medical Transport in Rural Areas

The following case study explores the existing conditions and emerging challenges of providing rural non-emergency medical transportation and highlights the innovative programs in Placer County that help fill the gaps when transit is not an option.

Population Growth in Rural Areas

Across California, the rural landscape is changing. Picturesque farming communities are giving way to suburban and exurban residential developments and senior retirement communities. In particular, the SACOG region’s rural areas are experiencing tremendous growth. In fact, rural populations in the SACOG region are projected to increase by 178% from 2005-2035, while urban and small urban areas are projected to grow by only 46% and 36% respectively.

Aging of the Population

Like the rest of the country, the SACOG region is graying. In 2000, 19% of the region’s population was 55+. By 2030 that number will reach 26%. In Placer and El Dorado Counties, the shift will be even more dramatic, as the senior population is expected to increase to 33% and 34% respectively¹. Not only are Californians getting older, they are living longer as well. Those who survive to age 65 can expect to live an average of 18.7 more years. Those who survive to age 85 can expect another 7.2 years (women) and 6.1 years (men)².

Chronic Disease

Living longer does not necessarily mean living without illness and chronic disease. As residents age, one of the most dramatic changes is an increased demand for medical services. A 2005-2006 nationwide survey revealed that 53.3% of the 65+ population has hypertension and 49.6% has arthritis. In addition, the prevalence of diabetes in adults has skyrocketed in the last decade³. These are not necessarily life threatening conditions, but those suffering from chronic diseases still need access to routine healthcare. The combination of an aging rural population and higher longevity rates creates a unique set of non-emergency medical needs for transit-dependent seniors.

Aging in Place and Functional Mobility

Unlike more affluent seniors in previous generations, the baby boom generation is retiring in place, meaning in the same community or same house they lived in before retirement. Census data show that more than 90% of Americans retire in place, which logically leads to the conclusion that many seniors are retiring or will retire in small urban and rural communities. Aging in place is an excellent option for seniors who are in good health and have access to transportation because they can take advantage of the lower cost of living in rural areas. However, most seniors plan their living situation based on their health and mobility now, rather than their situation ten years from now.

Also, many seniors with functional limitations choose to age in place, rather than enter assisted living or long-term care facilities. Nationwide, 26% of Medicare enrollees age 65+ living in traditional communities have one or more activity of daily living (ADL) limitations. As ADL limitations increase with age, driving a car and even riding on traditional fixed-route transit may be impossible, leaving seniors with few transportation options. As an example, 28% of Yuba County seniors (65+) and 42% of those aged 75+ did not have a license in 2000. With the expected increase in rural seniors, this translates into a scenario of more transit demand without a corresponding increase in service.

Aging and Poverty

As seniors retire, many must learn to live on fixed incomes and rely on Medicare for their medical needs. Regionwide in 2000, about 6% of all seniors age 65+ fell below the 1999 federal poverty line, as did about 3% of those age 75+. Yuba and Sutter Counties had the highest percentage of low-income seniors age 65+ at 7.4% and 7.2% respectively⁴. Since rural residents often have fewer healthcare providers nearby, lower incomes and fewer sources of retirement income, attending to medical needs can be quite challenging. Although only a small percentage of seniors rely solely on public transit for their transportation needs, adequate service is imperative for the low-income individuals who have no other options.

Challenges

An aging rural population with an increasing need for medical services creates unique challenges for rural transit operators. While urban dwellers can choose from a variety of transportation options, including transit services, walking, or taking a taxi, rural residents have far fewer options. Fixed-route transit has limited service in outlying areas, and walking is often impractical given the low density makeup of rural communities and the less developed pedestrian infrastructure. In addition, major medical centers tend to be in urban or suburban locations which make taxi rides extremely expensive for those living on a fixed income. Demand response transit is available in some rural areas, but outlying areas are underserved, and funding constraints keep programs from expanding. Because transit-dependent rural seniors have fewer transportation options, they make 15% fewer trips to the doctor⁵. With an aging rural population on the horizon, increasing transportation options for non-emergency medical appointments is critical to helping seniors maintain their health and quality of life.

Innovative Solutions: Spotlight on Placer County

Recognizing the unique needs of transit-dependent rural seniors, many rural operators in the SACOG region have designed innovative non-emergency medical transportation programs. In particular, Placer County has proven to be a leader in providing alternative non-emergency medical transit.

Placer County Health Express

Health Express is a public-private partnership in Placer County that provides low- to no-cost transportation to and from non-emergency medical appointments for seniors, persons with disabilities, and the general public. The service operates in Auburn, Roseville, Lincoln, Rocklin, Meadow Vista, Colfax, and the surrounding area, serving all major medical facilities. Seniors First took over the program in 2007 and plans to expand Health Express to include Sacramento County medical facilities in 2009.

According to Candace Roeder, Executive Director of Seniors First, many residents of Placer County rely on public transportation, but routes do not serve the areas they need to go for medical appointments. Health Express, by allowing access to routine medical care, can prevent conditions from developing into something worse in the future. About 525 passenger trips are provided each month, and 89% of the passengers are seniors. With the expected increase in the senior population in coming years, Health Express anticipates an increase in ridership and feels the organization has the capacity to meet future demand.

Health Express is a project of the Placer Collaborative Network (PCN), a voluntary association of local government, education, business, and non-profit organizations dedicated to improving the quality of service each agency provides to its clients and customers. Funding partners of Health Express include Sutter Auburn Faith Hospital, Sutter Roseville Medical Center, Health Net, Kaiser Permanente, and others. In addition, Health Express is supported by donations from community-based organizations and individuals.

The service operates by appointment only. To make an appointment or for more information call Health Express at 1-800-655-RIDE (7433) M-F 8 a.m. to 5 p.m. or visit http://placerhealthexpress.org.

Placer County—Consolidated Transportation Services Agency (CTSA)

The CTSA designation was created by California law to strengthen and coordinate transportation services offered by nonprofit organizations. Placer County’s CTSA coordinates the I-Ride, I-Med, Transportation Voucher program, and Seniors First volunteer transportation program.

• I-Ride—provides door-to-door trips to passengers for various purposes.

• I-Med—provides door-to-door trips to non-emergency medical appointments including physician, routine treatment, dentist, and mental health.

• Transportation Voucher Program—provides a voucher to those who cannot otherwise afford to pay for the cost associated with an occasional, necessary trip to medical appointments, job interviews, court appearance, etc.

• Seniors First Volunteer Program—volunteer drivers provide trips to passengers aged 60 and over and transportation disabled persons who are unable to use public transportation. The service area includes Lincoln, Roseville, Citrus Heights, central and northern Placer County.

The CTSA is an important link among non-emergency medical transportation providers. The CTSA’s coordination efforts can help leverage community resources by preventing overlap of services, ensuring adequate coverage, and allowing providers to streamline costs and share information.

For more information about the I-Ride, I-Med, and Transportation Voucher Program, call (530) 888-7433.

For more information about the Seniors First Volunteer Program, call (530) 889-9500 ext. 202 in Auburn or (916) 782-4202 ext. 204 in Roseville.

Additional SACOG Region Innovations

• El Dorado Transit runs a demand-response non-emergency medical service called SAC-MED. The service operates by appointment only two days a week. For more information, call El Dorado Transit at 530-642-5383, or visit www.eldoradotransit.com

• Paratransit, Inc. has improved communication with clients by implementing Interactive Voice Response. This system allows Paratransit, Inc. to use real-time information to alert passengers when a ride will be early or late. For more information on the IVR system, call Ed Radza, Paratransit’s Information Systems Manager, at 916-429-2009, ext. 309.

• Woodland Community Care Car offers volunteer-driven vans for senior transportation to medical appointments and other visits. The program is financed through donations from passengers. In 2004, the program provided about 7,500 round-trip rides through about 2,340 volunteer shifts. For more information, call Woodland Community Car Care at 530-662-7800.

Footnotes

i SACOG Senior and Disabled Mobility Study 2006
ii Keeping Communities Connected 2006
iii http://agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Documents/Health_Status.pdf
iv Senior and Disabled Mobility Study 2006
v Keeping Communities Connected 2006