The focus of this project was to assess issue with transportation as a potential barrier to accessing health care in Bangor, Maine. This pilot project involved interviews with community members and providers, as well as evaluated the needs in terms of transportation for accessing primary care. Research regarding this need was conducted through anonymous patient surveys, conducted by the author, and was used to guide the recommendations for future interventions that would address transportation issues in Bangor and the Penobscot County area.https://scholarworks.uvm.edu/fmclerk/1215/thumbnail.jp

Leon, David A

Leon, David A.

UVM ScholarWorks

University of VermontScholarWorks @ UVMFamily Medicine Clerkship Student Projects College of Medicine2016Transportation as a barrier to access to care inBangor and the surrounding Penobscot CountyareaDavid A. LeonUniversity of Vermont College of MedicineDavid A. LeonFollow this and additional works at: http://scholarworks.uvm.edu/fmclerkPart of the Community Health and Preventive Medicine Commons, Medical EducationCommons, and the Primary Care CommonsThis Book is brought to you for free and open access by the College of Medicine at ScholarWorks @ UVM. It has been accepted for inclusion in FamilyMedicine Clerkship Student Projects by an authorized administrator of ScholarWorks @ UVM. For more information, please contactdonna.omalley@uvm.edu.Recommended CitationLeon, David A. and Leon, David A., "Transportation as a barrier to access to care in Bangor and the surrounding Penobscot Countyarea" (2016). Family Medicine Clerkship Student Projects. Book 178.http://scholarworks.uvm.edu/fmclerk/178Transportation as a barrier to access of care in Bangor and surrounding Penobscot County areaDavid LeonMS III, University of Vermont College of Medicine7/5/2016 to 8/12/2016, Rotation 3, Family medicine, Bangor, MaineDr. Eric Brown, MDDr. Robert Pritham, MDDemographics of Penobscot countyTotal population 152,692; Third largest county in Maine (as of July 2015)Percent population              65 years of age or older17.2 % (July 2015)Percent population with disability, < age 6513.7 % (2010 – 2014)Percent population without health insurance,  < age 6514.3 % (2015)Percent population living in poverty18.0 % (2015)U.S. Census Bureau, Penobscot County, MaineIdentified problem: Transportation in the context of health care in Penobscot county Mean travel time to work (minutes), workers age 16 years+, 2010-2014 = 22.9 minutes each way [US Census Bureau ACS, Penobscot County, Maine, 2015] While many employed individuals have a stable commute, many older patients live significantly further, as do most of subutex patients. A significant cause of missed or canceled appointments, particularly at Center for Family Medicine of EMMC, has been attributed to lack of transportation Maine Health Access Foundation (MeHAF), who’s mission is “ to promote access to quality health care, especially for those who are uninsured and underserved, and improve the health of everyone in Maine.”, noted that a significant barrier to accessing care, especially for the underserved population, is transportation. Eastern Maine Transportation Collaborative, a combined effort between University of Maine, EMHS, United Way and University of Maine Center for Aging, did a review in 2005, sponsored by MeHAF, of the access needs of patients in Hancock, Washington and Penobscot counties.Goals of EMTC projectGoals of the EMTC’s Health Initiative Needs Assessment:1. Achieve a better understanding of the health transportation challenges in the tricounty area that impact access to chronic care services by older adults. 2. Develop innovative strategies for effective scheduling and coordination of health transportation in the targeted region, including designing methods for marketing and implementing the chosen transportation service model. 3. Successfully execute project activities and produce specified products for dissemination of findings to interested parties on a local, state, and national levelThe results of the EMTC’s Health Needs Initiative Assessment Vast majority of patients reported driving themselves or requiring a ride from a friend or family member; weekly rides were commonly needed for chronic care appointments and prescriptions. Only 37 % of patients reported they did not want or need public transportation services, meaning 67 % desired/needed these services 60 % of respondents reported not knowing of transportation resources available in their community. Average distance one-way for chronic care appointments = 14 miles 80 % of schedulers and social workers in medical offices surveyed revealed difficulties providing assistance to patients who required transportation was a major challenge, with 40 % of schedulers noting cancellations due to lack of transportation occurred at least once a week.In 2016, transportation remains a major barrier to accessing care – a public health cost In 2016, transportation to and from health center still remains a major barrier to care for many of Penobscot’s citizens living with chronic conditions and disability. Patients, particularly older adult patients, are still heavily reliant on cars, usually driven and owned by people other than themselves, most often family members Patients continue to have difficulty getting to appointment, follow-ups, specialists and retrieving medications due to inability to find transportation The ability to practice preventative medicine and chronic care at primary care clinics, such as CFM* of EMMC, are impaired if patients are unable to make their appointments, These transportation barriers can lead patients to avoid making/attending appointments until an emergency occurs, resulting in increased and potentially avoidable ambulance and ED usage*CFM = Center for Family Medicine, the Family Medicine Residency clinic of EMMCPublic health cost to Bangor area residents Despite past attempts to evaluate and mitigate issues with transportation for access to care, many patients still remain unaware of available services and alternative modes of transportation, resulting in impaired continuity of medical care. More than 1 in 5 Bangor residents have 3 or more chronic conditions, requiring regular PCP visits to adequately & appropriately manage their care. This percentage is 55 % in the elderly, age 65 and older Many elderly and disable patients are unable to drive, due to lack of car, personal physical disabilities, cost and difficult road conditions. Many of the Bangor and surrounding Penobscot county roads are in a state of disrepair, and piecemeal repairs are a constant presence, further delaying transportation Little to no bike lanes and harsh winter conditions discourage bike usage as means of transportation. BAT [Bangor Area Transit] bus service has limited hours, limited routes and few posted route times or maps at the stops dispersed through the greater Bangor area Despite Bangor’s higher population density, most patients attending CFM live outside Bangor and still report difficulty finding means of transportation Beverly Foundation’s “5A’s of Senior Friendly Transportation”: availability, accessibility, acceptability, affordability, and adaptability; not currently achieved in Bangor There are services available, but many people are unaware of alternative means of transportation other than personal vehicle or friends/family.Evaluating the extent of transportation as a barrier to access to care 1. Community perspectives from members of EMMC’s home visit team, CFM scheduling staff and practicing family physician 2. Assessment of the impact of the issue of transportation on patients, via 4-question anonymous surveys.For the 4 questions: 1. How did you get to CFM (mode of transportation)2. How many miles and how long, one-way, did it take you3. Have you missed or canceled appointments in the past 2 years due to lack of available transportation to CFM4. Do you know of any alternative options for getting to CFM other than your preferred mode of transportationPerspectives from community members and health care providers Interviews with X, scheduler at CFM:“In my audits of no-shows, missed and canceled appointments at CFM, at least 3 per day, on average, are due to transportation difficulties. These patients usually cite their reason  for missing/canceling their appointment as not having a car or not being able to get a ride from a friend. Some patients take taxis to get to their appointment on time, but more often than not, they simply do not arrive. It is frustrating both for the front desk, the providers but most importantly the patients…” Interviews with Y, CCT Social Worker for EMHS:“Many of the patients I see on home visits have multiple chronic conditions, and live 20 to 30 miles away from their PCP, on top of the fact that most of these patients do not drive…this all means they must make a significant effort for a routine check-up. Case management attempts to identify these individuals and meet their needs, or at least identify risk factors for a more urgent visit to their PCP, but usually, we only start seeing these patients once they’ve had multiple visits to the ED and repeat admissions…”Community interviews, continued Phone interview with Penquis Transportation Services“Penquis services do all they can to meet the needs of the community, but many patients still do not know about our services or find out the day of their appointment, which is unfortunately too late to set up a request unless the patient requires an urgent appointment. The difficulty with urgent appointments is that some of those may be better suited for EMS transportation...” Interview with Z, practicing Family medicine physician and full-time faculty at CFM“The bus system here in Bangor is fairly clunky, with multiple transfers to go a relatively short distance, and in the winter months, there can be cancellations. For some, the bus is not even an option, especially the suboxone patients traveling from as far way as Farmington. Penquis is fairly strict with their request times, and they only take the patients, not their children; additionally, Lynx does not usually operate if the bus system is closed for snow. Many patients are forced to take taxis or bargain with friends…”Patient survey results on their transportation needs for accessing care at CFM 28 4-question surveys collected from patients anonymously at the start of their visit 92.8 % arrived by car, either driven themselves or by friends and family only 1 of 28 reported using Lynx, and only 1 of 28 reported using combination of walking and BAT Average time spent traveling to clinic for appointment = 35.3 minutes Average distance traveled to clinic for appointment = 15.1 miles Of note, elderly patients and patients arriving for suboxone checks typically travelled the furthest. One outlier was excluded from averages (traveled 46 miles and spent 1.45 hours traveling) Patients with multiple chronic problems and opiod-dependent patients on suboxonetypically traveled the furthest distance to attend their appointments Only 11 of 28 (39.3%) acknowledged the existence of alternative means of transportation other than driving themselves or asking for a ride from friends/family or taxi Vast majority of patients (25/28) acknowledged that they have missed or cancelled at least 1 appointment within the past 2 years due to inability to find transportation to CFMProposed intervention Consolidate available transportation options onto a single handout, for patient information, with both internet and phone contact information. Educate patients directly during office visits regarding the various options available to them for transportation to and from CFM Educate health care professionals and support staff at CFM regarding the available community resources for transportation for patients  Encourage health-care professionals at CFM to talk about with patients regarding any barriers to accessing CFM and going to visits in the context of transportation, particularly patients with a past history of numerous missed and/or canceled appointmentsResults of intervention efforts The issue of missed/cancelled appointments discussed with scheduling staff as well as medical assistants and practicing physicians at CFM Investigation into the available resources provided by the State of Maine as well as organizations in the Penobscot area, such as EMMC’s CCT home visit program and EMHC [Eastern Maine HomeCare], Penquis Transportation Services, GoMaine, BAT and University of Maine’s Center for Aging Aggregated the available community resources onto a single handout, with internet websites and phone contact information listed. The handout was prepared and available at CFM for staff to hand out to any patientEffectiveness and limitations Effectiveness: limited ability to evaluate the effectiveness of such an intervention, given the long-time course of any potential benefits and the short duration of the rotation. Means of evaluating the effect on increased awareness and education include:• review of the number of missed/last-minute cancellations after implementing intervention• review of the percentage of patients aware of alternative means of transportation to CFM• contact Penquis Transportation Services and BAT to assess any change in rider frequency to CFM Limitations:• CFM is only a single clinic in Penobscot county, and may not indicate the average patient population, given its location in Bangor• CFM’s patient panel includes a large number of patients on suboxone, of which there are still limited number of providers that do such treatment; this could skew the travel/transportation needs, as these patients typically travel further for treatmentRecommendations for future interventions1. Expand the assessment of patients’ transportation needs to accessing medical care to other primary care clinics, such as in more remote parts of Penobscot county, and clinics with different patient panels, such as fewer suboxone patients, or more patients with private insurance rather than MaineCare2. Increase awareness with online advertisements and public notices about the various options available to community members that can aide them in getting to their medical care visits.3. Post BAT schedules & fare prices in public areas4. Analyze BAT usage to maximize efficiency of the system, in hopes of allowing increased coverage and access to areas in greater need.5. Increase coordinated care between hospitals in order to identify patients with high medical care usage, such as repeat admissions and ED visits. Combine these efforts with expansion of the home visit Case Management teams.6. Consider initiating a voucher program for taxis and transports for patients who identify transportation to appointments as a barrier to their ongoing careResources US Census Bureau, Penosbcot county, Maine, 2015 The Eastern Maine Transportation Collaborative’s (EMTC) Health Services Initiative Needs Assessment Research Final Report, November 18, 2015 Issue Brief: December 2013 Survey Finds Maine Residents Dissatisfied with Cost of Health Insurance and Health Care Prior to Rollout of Affordable Care Act. State of Maine Department of Transportation - http://maine.gov/mdot/ GoMaine Commuter connections - https://nuride.com/gomaine Maine Health Access Foundation – www.mehaf.org Eastern Area Agency on Aging - https://www.eaaa.org/ Bangor Area Transit - http://www.bangormaine.gov/communityconnectorThe transportation handout Gas can be expensive  So can ER visits  -Making all your visits with your PCP is essential to identifying health problems early on, and addressing them before they become a more serious problem that can land you in the hospital. -Here in Maine, it is not always easy to get to your appointments.  -If you need any assistance with transportation to and from your visit here at the Center for Family Medicine, there are resources available! Options: -Penquis Transportation Services http://www.penquis.org/index.php?&id=488&sub_id=3145 207-974-2420 or 1-855-437-5883 Volunteer-based drivers that provide transportation for all patients with MaineCare, including handicap and disability options as well as same day requests for sick/urgent appointments Eligibility: Must have Maine Care and must be attending a MaineCare-covered appointment; unless urgent, for typical appointments, must call 3 days in advance of the appointment. -Penquis Lynx http://www.penquis.org/index.php?&id=488&sub_id=3131 207-973-3695 or 866-853-5969 Provides transportation for NON-MaineCare patients to and from appointments, with variety of services depending on individual needs, such as their cancer service [Roads to Wellness and Access to Cancer Care], those with disabilities [New Freedom], and those with mental illness [TAP – Transportation Assistance Program] -Eastern Area Agency on Aging http://www.eaaa.org/index.php?id=518&sub_id=1628 1-800-432-7812 Provides transport to and from medical appointments for patients 50 and older who do not qualify for other transportation program and do not have Medicare or Medicaid   -BAT [Bangor Area Transit] http://www.bangormaine.gov/communityconnector 207-992-4670 Public transit system that serves the greater Bangor area, including Bangor, Brewer, Veazie, Orono, Old Town, and Hampden, 6:15 AM to 6:15 PM. Half-fare cards available for those who qualify. In addition to their normal services, offers transportation for the disabled, called ADA Paratrnsit. -West’s Transportation http://www.westbusservice.com/ 1-800-596-2823 Offers transportation to stops along from Calais to Ellsworth and Bangor. Special rates for those with Medicaid, and available 7 days a week upon request. -Road to Recovery 1-800-227-2345 Free, volunteer-based transportation for cancer patients to and from medical appointments, provided by the American Cancer Society Eligibility: Must be a patient with a diagnosed cancer and ongoing treatment and/or follow-up Downeast Transportation http://www.downeasttrans.org/ Wheelchair-accessible bus transportation extending from Bar Harbor, Ellsworth and into Bangor. Limited shuttles to Bangor, only Monday and Fridays Go Maine Commuter connections http://www.gomaine.org/ 207 871-7771 or 800-280-RIDE A free Maine DoT sponsored program that links commuters for rideshares and car-pooling, as well as provides referrals to regional transportation options, and an ‘Emergency Ride Home’, in which a free taxi ride with a registered taxi company or Enterprise Rent-a-Car home is provided in case of emergencies. Must register, for free, on NuRide system: https://nuride.com/gomaine If all else, call a taxi, from a legitimate, clean, registered taxi company My Taxi: 207-990-4CAB Dick’s Taxi: http://dickstaxi.com/ phone number: 207 942-6403  

Transportation as a barrier to access to care in Bangor and the surrounding Penobscot County area

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Transportation as a barrier to access to care in Bangor and the surrounding Penobscot County area

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