A Hospital Transportation Program for Patients: changing a culture and reducing cost

Transportation Access Important to Health Care

Health care in the United States accounts for 13.5% of the U.S. gross domestic product. Health care expenses are increasing much more rapidly than the overall cost of living index (Levit et al, 2000). Health care is not distributed equally in terms of geography creating a disparity with persons living in rural areas with lower incomes, consuming less health care than those in urban communities, with higher incomes. Medical services are of little value to those individuals that cannot access them. In the 2003 US Department of Health and Human Service’s Community Transportation Assistance Project, Burkhardt reported that lack of transportation is a particular concern for rural areas, low-income persons, minority groups, and others whose access is constrained (including some older persons). For these individuals, affordable transportation options are important to access health care services.

A hospital’s transportation program can play an important role in delivering patients to a medical home for prompt care to avoid minor situations from getting worse; thus reducing unnecessary hospitalizations. Early health care access reduces late staging of disease leading to unnecessary emergency department visits reserving those services for acute emergent care. According to the American Counsel of Physicians (1995), the average charge of a non-emergent visit to an emergency department is approximately 2.3 times higher than the cost of an office visit. Other sources quote even greater differences in comparative costs. An Orlando hospital reported the cost of an office visit of $55, compared to $462 for an emergency room visit.

In a National Hospital Ambulatory Care Survey (1999) data revealed that approximately 13.2% of all emergency departments’ visits were actually non-emergent and unnecessary. The survey suggests that transportation access to ambulatory care and primary care sources (medical home) for targeted populations could actually decrease this number and save hospitals and federally funded Medicare thousands of dollars each year. Regular medical home access engages patients in prevention, self management of chronic disease, and counseling regarding high risk behaviors.

A dependable and reliable medical transportation program will also reduce cancellations for life saving oncology and dialysis treatments, physical therapy appointments, and cardiac rehabilitation services. Transportation as an out patient intervention helps to surmount the barriers of access to achieve longer lives of higher quality.

History

An ambulatory and non-ambulatory, specialized “group” transportation service was successfully implemented at Waukesha Memorial Hospital in 1992.  It was determined that any minimal charge to patients could be overwhelmed by the cost to administer a fee for transportation services, so it was provided at no cost to the clients. 

 The program was always intended for those who did not have another source of transportation. Maryann Day, manager of transportation, states “the program and department grew over the years from a single van and a couple of drivers to a fleet of 37 vehicles, 45 employees, and an annual budget of $1.7 million. The number of clients grew to 4545 with trip volume reaching 60,872 annually. Over 507,910 miles were logged; enough to circle the globe more than twenty times. If transportation was requested, no one was turned away.”

The care-provider and staff were responsible for determining the patient’s need for “door-to-door” courtesy transportation. They made the arrangements directly with the transportation department.  It was felt that this practice would eliminate any extra effort or added inconvenience for our patients.  Hospital campus surface parking spaces were reserved for driver escort services offering a high level of customer satisfaction.  Patient satisfaction was an early program driver as the hospital foundation received endowment gifts that significantly supported the program. 

The non-emergent transportation service was designed for outpatients undergoing oncology treatments, multiple physical therapy sessions, or on-going cardiac rehab visits.  Reliable transportation assisted patients and their families to ensure they kept their appointments, safely arrived on time, and even welcomed the camaraderie within the groups that were regularly traveling together and, or being treated for similar conditions. 

  Within a short period of time individual patient trips from rural areas, with limited or no transportation options, increased as clinic sites expanded and specialty services developed; i.e. behavior health, woman’s health, and orthopedic joint camps.  Dependable and reliable transportation helped clinic schedules to stay on time, as well as reduce cancellations due to weather or poor driving conditions. In addition to the new ambulatory surgery center activities, the “on-demand” hospital in-patient discharges to senior living, assisted or skilled nursing home facilities rapidly increased.  The ability to manage “on-demand” services reduced the hospitals cost to board a patient an extra day, or save the patient the out-of-pocket, high cost to travel by ambulance if non-ambulatory.

Problem

Maintaining the $1.7M operating budget and $150,000 in capital expenses annually became too much to bear in 2007. Methods needed to be implemented to reduce those expenses immediately while maintaining the mission of the organization.  The first step in the expense reduction program included implementing a $5.00 each way trip charge to our clients billed directly to their residence.  The effort generated a reduction in trips from 60,000 per year to roughly 35,000.  The corresponding impact to the operating statement through reduced resource requirements and operating income yielded a $680,000 gain.  On an annual basis the department budget dropped by 40%.

Patient volumes in hospital and clinic departments were examined and found to be stable. The net operating expense of the department continued to run at $1.0M per year. In addition, concerns of servicing the most vulnerable patients were continually raised. In 2008, with the acquisition of several new clinics in rural communities, a more critical look at cost reduction was needed. The mandate was clear, to decrease the budget further by $300,000 annually.

Medical Transportation Team Developed

A transportation team was assembled that represented multidisciplinary and intradepartmental perspectives to assess impact from clinical staff and external community stakeholders. There was representation from transportation, nursing, community benefit, oncology, out patient services, financial, operations, and medical. The following options and financial assumptions were presented and discussed at length.

  1. Eliminate adult day care trips for daycare services (7495 annual trips), affecting 102 individuals. At $28.50 per trip the total cost of services amounted to $213,607 expense reduction. The $5.00 trip charge revenue would be lost. This would result in a net expense reduction of $176,132
  2. Eliminate clinic trips (4017 annual) affecting 642 individuals. At $28.50 per trip the total cost of services amounted to $114,485 expense reduction. The $5.00 trip charge revenue would be lost. This would result in a net expense reduction of $94,400
  3. Eliminate both day care and clinic trips equating to $270,532 expense reduction.
  4. Increase the charge on all remaining trips $5.00 to $10.00 per one way trip. This would save the system $350,000.

Pros and cons were identified. The pro was achievable savings.  The cons were considered to be staff and patient confusion regarding eligibility and destinations, the plan may adversely affect those in true need of service, and create an unfair burden on external stakeholders groups providing transportation services. It was decided to explore other alternatives such as a strict rider eligibility screening, focus on clients truly in need, and standardize and centralize screening. Even though budget reduction and timing was uncertain there was support to explore alternatives.

Community Benefit Perspective

With a community benefit perspective on the team, the need for transportation access was discussed in light of most vulnerable patient’s needs. The goal of ProHealth Care’s community benefit initiatives is to improve the health and quality of life among the underserved, uninsured, and individuals with language and cultural barriers. The methods of improving health and quality of life include a combination of targeted health outreach programs, community health education, client focused self-care management programs, and culturally appropriate services that are provided by community-based nurses (parish nurses and community outreach nurses) and lay health promoters. Community partner sites provide entry to the targeted population and include churches, public schools, social service agencies, low-income and senior housing, and the Hispanic Community Health Resource Center.

ProHealth Care has been a catalyst in promoting health and access to care for the most vulnerable individuals as well as advancing services to improve the overall health of the community. Unique elements of the CB program include:

  • Connecting the uninsured and underserved to health care services
  • Developing community-based collaborative initiatives
  • Providing culturally-appropriate health care services including bilingual staff
  • Providing effective outreach efforts with a focus on primary care and prevention
  • Implementing programs for targeted populations
  • Enhancing hospital leadership and commitment
  • Developing a shared vision and trust among community partners
  • Financial support from both hospital foundations

Envisioning medical transportation as a community benefit initiative helped to reframe the discussions. Negative impact of decreasing access and creating increased transportation barriers for non-English speakers, isolated seniors and uninsured or underinsured families was foremost in discussions. As research supported, loss of transportation could result in decreased access to a primary health care, to life prolonging treatments or services, and to frequent visits for individuals with multiple chronic diseases.

Several considerations or next steps were recommended by the transportation team: 1) Identify regional medical transportation standards, 2) identify and organize an easy to use list of other local transportation resources available to patients, 3) collate community data that captures service area and demographic program utilization, 4) facilitate community advisory sessions and staff surveys, and 5) perform a literature review related to key concepts such as qualification, mobility, cost, hours of operation, low income criteria, pickup/drop off, and interventions used for discouraging misuse. It was suggested that a special task force form with members from transportation, community benefit, and high utilization internal departments. The goal was to create and use a transportation screening process supported by a communication plan and a system’s policy. The screening forms development framed the task force effort.

Work of the Task Force

Identification of community standards were sought by exploring what other hospital systems in the region were doing along the lines of transportation. Several offered taxi vouchers where taxi services were available, a couple offered ambulatory transportation by volunteer drivers when available; restricted to short distances. No other hospital system in the area was found to offer a specialized para-transit service as was provided by ProHealth Care.  In addition, there were other local transportation programs provided by non-for-profit organizations, for-profit businesses, and the County. We contacted these resources and collated data regarding cost, operations, application and screening processes. An updated list of transportation providers was developed with criteria, cost and contact information for staff and patients. Day, states, “Our thought was that the clients that rode the transportation system for convenience were able to find alternative means of travel and have been unaware of other transportation services offered.”

Inquiries were made of all departments with unusually high usage. Responding, staff felt transportation use was appropriate. They stated that indeed other transportation options were discussed with patients. It was suggested that a discussion of other available and possibly more appropriate transportation resources occur earlier in the scheduling process. A concise and easy to use screening tool, with scripts and a system’s policy was key to staff compliance. In addition, a patient transportation survey was sent to front-line staff who routinely scheduled transportation regarding process and procedure. The survey suggested that patients and staff may be confused by centralized transportation scheduling. Staff supported the point-of-care scheduling process and stated that they were willing to thoroughly screen patients before scheduling transportation. A survey was also sent to community based nurses.  The responses supported maintaining door-to-door service and keeping cost low. Patient stories were shared. One nurse spoke of patients isolated in rural areas where no other transportation service existed. Nurses stated that elderly relied on the hospital’s transportation program when they were no longer able to drive. Transportation was used for labs, treatments and clinic appointments. Many felt that the costs for one way trips were too costly for those patients needing multiple trips per week.

An advisory session was held with Spanish speaking patients. Inquires concerning transportation expectations were discussed. They commented that they counted on the program and were concerned that the process to schedule was difficult with forms in English. The transportation cost and their inability to “pay the bill” created barriers. When they thought they owed the hospital money they no longer sought out transportation services. Barriers to transportation were reported to be financial, lack of family support [daycare], lack of car use and public transportation programs, language, and ability to read.

Literature Review

A conceptual matrix was created to collect and collate key themes from a literature review. Key themes included criteria for qualification, mobility, cost, hours of operation, low income criteria, pickup/drop off, and interventions used for discouraging misuse. The literature review revealed ten similar programs providing non-emergent hospital transportation services.

  • Criteria: programs required a referral from a physician, or were developed solely for seniors, or designed specifically for rehab and behavioral health visits. Most insisted on an enrollment process or prior authorization before appointments.
  • Mobility: All but one program provided wheelchair assistance but one program required in/out independence.
  • Cost: most were free, or provided transportation vouchers through the physician’s office, or were reimbursable. Many were supplemented financially through county or state programs. The programs that charged, fees were based on miles traveled or regions or towns inside of service areas. One limited the number of times you could ride per week.
  • Hours of operations: most were M-F 8-5pm but some limited to certain days or limited hours.
  • Low income criteria: programs used a financial assistance fee scale based on Federal Poverty Guidelines (FPL) and insisted on prior enrollment.
  • Pick up/Drop off: most offered bus or van services with designated routes or pick up sites. Very few programs offered door to door services.
  • To discourage misuse: programs limited how long a van would wait, charged additional fees for missed appointments, and most insisted on prior registration.

Screening Tool

The development of a new screening tool (Exhibit A and Exhibit B) guided the work of the task force. The decision was to keep the one-way trip charge ($7.50) just above community standards to act as a dis-incentive for individuals who were qualified to use other options. Keeping transportation cost affordable for all patients and providing a reduced rate for those truly in need was the goal. Federal Poverty Guidelines (300%) were used to determine greatest financial need. Easy qualifiers for transportation discounts were those patients that already received a discount rate for services referred to as “Charity Care”. The discounted rate was set at $5.00. Other options discussed were voucher programs, allowing others [family members] the ability to gift the cost of transportation. It was decided to place the financial screening application directly on the back of the screening/schedule form for easy access. One central location where decision-making regarding discounts were desirable and the Hispanic Community Health Outreach Center was chosen for its central location and bilingual staff. The Center is a community-based department and community benefit initiative of the hospital. Decisions regarding transportation discounts are solely based on application data reported to keep administration hours manageable.

Mobility and special needs have been a priority since the transportation program began in 1992. The vans are equipped with wheel chair lifts and wheel chair securing systems. Drivers are specially trained and certified to assist those with mobility limitations and patients are encouraged to bring a care giver or to request an escort service at no additional charge.

The reason for transportation or acuity was mentioned as an important consideration and weighed accordingly. Providing access to clinic (medical home) and medical treatments, therapies and labs produced important revenues. Access to prevention and educational events, as well as visitor’s requests were important but did not produce the same level of consideration.

Communication Plan

A formal policy was created to standardize practice and procedures throughout the organization. It was used to frame communications to all internal departments at leadership and staff meetings. 

Purpose of the policy was to create a standard method of: 

  • Screening PHC client/patient for transportation services to and from PHC owned and staffed facilities within the designated service area based on need. 
  • Informing client/patient that transportation services are provided for a fee, and billed to their primary address (or other) at end of each month.  
  • Creating trip request(s) with specific, accurate details for each trip.
  • Screening for transportation services at reduced fee(s).

The policy states:

Specialized grouptransportation service is provided for a fee to individuals who do not have other transportation options.  To assist patients that require multiple trips within a one month period, a maximum billing limit (or ceiling) is set at 16 trips per month.    

The screening process requires all client/patients to be screened by the initial screener/care-provider department using the approved PHC Transportation screening and request form. 

In addition to a formal policy, information regarding updates was placed in iNet/Huddle pages, Websites, and on posters in vans. An easy to use 8×5 Transportation Pocket Guide was updated. The guide’s table of contents includes:

  • A quick reference to scheduling transportation which contains frequently asked questions
  • Guidelines for patients
  • Call script for internal staff
  • Screening tools
  • Approved service area Zip Codes
  • Approved area service map
  • Other service transportation service providers
  • Waiver form
  • Glossary
  • Service recovery job aid

Outcomes and Summary

The chart below illustrates the results since the inception of the expense reduction process. Alignment of patient volumes across the system remains steady yet transportation operating expense has decreased. In spite of the reduction in trips there is a high level of confidence that services are provided to those truly in need and other patients are finding alternative methods of transportation.

With the geographic service areas of the system expanding to include both urban and rural communities, a non-emergent medical transportation service between owned/staffed facilities and the patient/customer’s residence was developed in 1992. Inherent to service expansion, an internal and external culture of transportation entitlement grew.

Fundraising efforts helped to ease the financial burden of transportation operations but the mandate was clear, decrease cost while maintaining quality and mission. In 2007, with the implementation of a fee for service, patient trips decreased. In 2009, further budget reductions were necessary. A multidisciplinary and interdepartmental transportation committee was formed with community benefit representation. With a task force effort the transportation program was reframed. The culture of entitlement was changed to a culture based on transportation need for those patients that met three screening priorities: acuity, mobility, and financial. The priorities created a clear message for staff during point-of-service screening and provided a supportive environment for the most vulnerable in a culturally sensitive way. A clear communication plan that included a formal policy and an easy to use 8×5 transportation pocket guide was initiated. Leadership meetings, iNet/Huddle pages, Websites, and posters in vans were all vehicles used to announce the change.

Just one year later, patient volumes across the system remains steady yet transportation operating expense has decreased. In spite of the reduction in trips there is a high level of confidence that services are provided to those truly in need and other patients are finding alternative methods of transportation. Financial mandates, quality of service and mission deliverables have all been met.

Reference       

Bindman, A. B., Grumback, K., Osmond, D., Koraromy, M., Vranizan, K., Lurie, N., Billings, J.,

and Stewart, A. (1995). Preventable hospitalizations and access to health are. Journal of American Medical Association, 274(4), 305-311.

Burckhardt, J. (2003). Benefits of transportation services to health programs. Community

Transportation, 26-38. US Department of Health and Human Services Community Transportation Assistance Project.           

Centers for Disease Control and Prevention (1999). An ounce of prevention…What are the

 returns? (2nd ed.).Atlanta, GA: US Department of Health and Human Services, CDC

Health Care Financial Management Association. (2001) Hospital Benchmarks.

WWW.hospitalbenchmarks.com/product/report.asp

Levit, K.,Cowan, C., Lazenby, H., et al (2000). “Health Spending…: Signals of change.” Health

 Affairs, 19: 124-132.

Exhibit A

Date: ____________________ Re-screen prior to_____________________

Name (person completing form):_____________________________________

Department:_______Facility:_____________________

Phone:_______________________

Screening

Transportation service is provided for a fee to individuals who do not have other transportation options. —– (Please see back for fees)

1. Are you currently receiving Medicaid/Title 19 benefits? No___ (Proceed to next question) Yes____If yes, Meda-Care Vans may be a less costly solution for you. Would you like the number for ride information?  The number is ___________.  No____  (Proceed to next question)

2. Are you able to get in and out of a passenger vehicle or taxi with minimal assistance?  No_____ (Proceed to next question) Yes____   Would you like someone to contact you to help determine what other transportation options may be available to you?  Yes____ Refer to transportation resource person.      No____ (Process request using web/fax)                                    

3. Do you possibly have another source of transportation for some _____ or all_____ appointments such as a family member, friend or neighbor?  We have valet parking at Waukesha Memorial Hospital and Oconomowoc Memorial Hospital to assist you.  No____ (Process request using web/fax)

Request to Transport

CLIENT’S INFORMATION:      ¨  Non-English speaking, call interpreter at ______

Language type if known: ________________________

Transport Information:

Last Name:____________________________________First Name:_________________________Middle Name:______________DOB:_____/____/______

Address:______________________City:____________________Zip__________Telephone:_______-_______-____________

Name of Facility:___________________________________________________

Emergency Contact:__________________________Relationship:_____________Telephone:_______-________-___________

Billing Information if other than above:

Last Name:______________________FirstName:______________________MiddleName/Initial:___

Address:________________________City:____________________Zip__________

Telephone:_______-________-__________

 

PURPOSE:  The reason you are requesting the ride?      ¨  Dr.’s appointment     ¨  Treatment, therapy or surgery    

¨  Radiology and/or lab services   ¨  Other_________________________________________________________

MOBILITY & SPECIAL NEEDS:

  • Do you have physical limitations?……….. Yes_____(Non-Ambulatory Schedule W/C van)   No _____(Ambulatory)  
  • Do you require the use of a wheelchair?.. Yes_____  No_____
  • Do you have your own wheelchair?…….. Yes _____ No_____  (We’ll provide one) Size: Std ____  Wide ____  X- Wide ____

 NOTE: We are unable to safely transport you on a scooter, ultra-light wheelchair or some motorized wheelchairs.

  • Do you use crutches, cane or walker?…… Yes_____  No_____
  • Will you have an escort?…………………….. Yes_____  Name:______________________________No_____
  • Escort Special Needs: W/C or other:_____________________________________ (Note there is no charge for an escort)
  • Isolation precautions required?……………. Yes_____ (Describe i.e. MRSA)______________________________________ No_____
  • Use portable oxygen?………………………… Yes_____ (Please check supply)    No_____
  • Blind or visually impaired?…………………. Yes_____  No_____
  • Hearing impaired?..……………………………………Yes_____  No_____               
  • Speech impaired?..…………………………………….Yes_____  No_____

Any other special needs we should know about? (i.e. cannot be left alone; wanders; nausea, weakness, etc.) _______________________________

Transportation to department:_______________

Facility: WMH/OMH/PHCMA/OTHER___________­­­_______

Day

Date

Time-In

Time-Out

***Reminder: This is a group transportation service; we ask that you please be ready one hour before your scheduled appointment time to ensure on-time arrival and departure times can be met.

               

Exhibit B

Transportation Financial Application – optional

If you choose not to divulge financial information, our service fees are as follows:

One-way trip service fee = $7.50

All fees are billed to your home address at the end of each month.

FINANCIAL SCREENING

If you qualify for financial assistance, a one-way trip is $5.00.

  • Do you receive Community Care benefits from ProHealth Care Inc.?  Yes_______No_______

(Have already completed a Community Care application and are considered eligible for a reduced fee for healthcare at Waukesha Memorial or Oconomowoc Memorial Hospital.)

If yes to the above question simply fill out name, address and phone number below.  You are qualified for a reduced rate and may qualify for other transportation options.  If no to the above question, complete the application.

FINANCIAL APPLICATION

Please complete form and fax to: or mail to:

ATTN: Office telephone:

Date:_______/_______/____________

Name – First:_____________________Middle:____Last:________________________

Address:_________________________________City:_________________________________

State:________________ Zip Code:___________Telephone: _______-_______-__________

1. Average monthly income:_______________________________________________________________________

(Include your Social Security, pension, disability, wages, interest/dividends, rental income, and any other income you may receive.)

2. Average monthly medical expenses:_______________________________________________________________

(Include medicine, medical supplies, health insurance premiums, and dental, doctor or hospital bills.  DO NOT INCLUDE medical expenses paid by Medicare, or other insurance or program.)

3. Total liquid assets:_____________________________________________________________________________

(Including savings, checking, CD’s, stocks, bonds, trusts, and annuities.)

I believe the information provided in this application is true and correct.  I understand that deliberately providing false information may jeopardize the receipt of services and hereby authorize ProHealth Care Inc. to verify information on this application as deemed necessary.

Signature of Applicant:____________________Relationship to Applicant:_______________

*It is your responsibility to notify us with any changes by calling

Validated by:___________________________________________ Date: ______/_______/____________­­­­­­­­­­­­­­