1 The Health Transportation Shortage Index SM A New Tool to Identify Underserved Communities A Special Report from Children s Health Fund CHILD REN'S HE ALTH FUND a
2 The Health Transportation Shortage Index SM AUTHORS Roy Grant, MA Dennis Johnson, MPS Stephen Borders, PhD CHILDREN S HEALTH FUND, NEW YORK, NY GRAND VALLEY STATE UNIVERSITY, ALLENDALE, MI COLUMBIA UNIVERSITY, MAILMAN SCHOOL OF PUBLIC HEALTH Delaney Gracy, MD, MPH Irwin Redlener, MD Corresponding Author: Roy Grant, Children s Health Fund, 215 West 125th Street, Suite 301, New York, NY ACKNOWLEDGMENT The authors acknowledge the important contributions of Lee Miringoff, Barbara L. Carvalho, PhD, and Stephanie Calvano of Marist College Institute for Public Opinion; John Green, PhD, formerly of Delta State University (Cleveland, MS); Arturo Brito, MD, MPH formerly at CHF; and Tracy Rostholder, MPH at CHF. This document summarizes a more comprehensive Children's Health Fund Special Report on the development of the Health Transportation Shortage Index SM. The full report is available upon request. Funding for the Health Transportation Shortage Index SM : A New Tool to Identify Underserved Communities was provided by the W.K. Kellogg Foundation.
3 Abstract Most discussions of barriers to access for child health care focus on the availability of comprehensive, continuous health insurance. Other factors, however, also may pose significant barriers, including shortages of health professionals and inadequate public transportation resources. Based on national and regional health survey data, Children s Health Fund has developed a new tool, the Health Transportation Shortage Index (HTSI SM ), to help identify areas and communities where transportation shortages contribute to difficulty getting health care. The HTSI SM is based on data from a national survey and a regional survey done in the rural Mississippi Delta. The national data show that each year 9% of children in families with income less than $50,000 (4% of children overall) missed at least one health care appointment annually because transportation was not available. In the regional survey, 10% missed a health care appointment because of lack of transportation. In both surveys, nearly one-third of these children later used a hospital emergency department for the condition associated with the missed appointment. The national survey included a question asking parents if they had difficulty establishing a usual source of pediatric care. A positive response to this was used to identify families with problems accessing child health care services, because difficulty establishing a usual source of care is associated with higher rates of hospital emergency department use for routine illnesses. In the national survey difficulty establishing a usual source of care was significantly associated with: 1) rural area, 2) low income, 3) longer travel distance to source of care (especially noted in rural areas), and 4) lack of public transportation. In the regional survey, it was associated with not having a car. Children s Health Fund developed the HTSI SM to serve as a tool to guide users in the assessment of the most important factors associated with transportation barriers to child health care access. The HTSI SM factors are: 1) population as a proxy for rural area and for travel distance; 2) poverty as a proxy for automobile ownership; 3) public transportation availability; and 4) health care provider workforce availability. Points are assigned for each factor based on area characteristics and are added together. Higher scores indicate greater risk for transportation barriers to child health care access. To overcome these barriers, targeted communities should be prioritized for additional public transit resources and/or improved coordination between health care and transportation providers. Some potential strategies are suggested at the end of this report. CHILDREN'S HEALTH FUND 1
4 1. Background Health insurance and cost of care are powerful barriers to child health care access. Solutions typically focus on expanding eligibility for Medicaid and Children s Health Insurance Program (CHIP). The principal benefit for children of federal health reform legislation will be a reduction in the number of children who are uninsured. Insurance, however, does not guarantee access. The supply and distribution of health professionals are also vitally important. An area with too few health professionals may be federally designated as a Health Professional Shortage Area or HPSA. This designation is frequently useful in bringing additional health care resources to an underserved area. Health care resources in HPSAs, however, may be distant from residential areas. Families may lack transportation resources to get to a health care site, impeding timely access to health care even for children with health insurance. Especially in rural HPSAs, families often have longer travel distances from home to health care sites. Providing non-emergency medical transportation to help bridge these distances improves access to preventive services, urgent care, and management of chronic conditions. It is cost-effective in large part because timely access to care reduces preventable emergency department (ED) use. 1 Non-emergency medical transportation is a required Medicaid benefit, but it is not provided or utilized at anywhere near the level needed. A study in Texas, for example, found that approximately one-fourth of children on Medicaid in that state had unmet health-related transportation needs. 2 2 The Health Transportation Shortage Index SM
5 2. The Health Transportation SM Shortage Index (HTSI ) The HPSA designation reflects the ratio of health care providers to population. There is no comparable measure to identify areas that lack transportation to support health care access. Focusing on child health care access, Children s Health Fund (CHF) has developed a tool to identify transportation shortage areas, the Health Transportation Shortage Index (HTSI SM ). This will supplement the HPSA designation and target communities in need of additional health transportation resources. The HTSI SM is a simple instrument that health planners can use to identify areas of the country where transportation shortages are likely to impact child health care access. Its design reflects the results of national and regional survey research. Based on these findings, four risk factors characteristic of areas with transportation shortages were identified. The HTSI SM is designed to capture the cumulative impact of these risk factors for child health care access barriers: 1) type of geographic area (based on population); 2) child poverty; 3) transportation availability; and 4) workforce (health professional shortages). Each factor is scored from zero to four using data that are readily available. Population and poverty data are available from the U.S. Census Bureau. Area scoring is done in accordance with population thresholds for area type from the U.S. Department of Agriculture. HPSA designation may be ascertained online from the Health Resources and Services Administration (HRSA). This site also lists safety net health care sites (federally qualified health centers, rural health clinics). Additional information may be available from state Primary Care Association websites. Public transportation by county (and often by area within county) is generally available online for each state. Personal vehicle ownership is strongly correlated with income: a higher percentage of population in poverty is associated with a higher percentage of population with no owned automobile. The poverty factor therefore serves as a proxy for automobile availability. CHILDREN'S HEALTH FUND 3
6 The Health Transportation Shortage Index SM Rate each of these 5 factors associated with transportation and health care access in points, as indicated, and add the points for the HTSI SM score. A total score of 6 or higher indicates a transportation shortage area. The higher the score, the higher the risk for transportation-related barriers to child health care access. 1 Type of area, based on population (using Census Bureau population data) RURAL POPULATION 5,000 SMALL TOWN POPULATION > 5,000 AND 10,000 SMALL CITY POPULATION > 10,000 AND 20,000 URBAN AREA POPULATION > 20,000 AND 50,000 METROPOLITAN AREA POPULATION > 50,000 4 points 3 points 2 points 1 point 0 points 4 5 HPSA designation YES ENTIRE GEOGRAPHIC AREA YES PARTIAL GEOGRAPHIC AREA NO 2 points 1 point 0 points FQHC in area (for high poverty areas; include rural health clinics) NO ONE 2 points 1 point 2 * Child poverty rate (% in poverty) exceeds US (using most current available data) TWO OR MORE NOT APPLICABLE (NOT A HIGH POVERTY AREA) 0 points 0 points YES BY 1.25X OR GREATER YES BY LESS THAN 1.25X SAME AS US LOWER THAN US 3 points 2 points 1 point 0 points 3 Public transportation availability NONE 3 points DEMAND-RESPONSE 2 points (E.G., PARATRANSIT) * NOTES: 1. There is a strong negative correlation between poverty and automobile ownership (i.e., higher poverty rate is associated with lower personal vehicle ownership). The HTSI SM incorporates personal vehicle ownership through the poverty factor as a component of assessing available transportation resources. LIMITED (DOES NOT RUN FULL-TIME AND/OR ROUTES DO NOT COVER TARGET AREA) YES 1 point 0 points 2. If child poverty rate is not available for an area, family or household poverty rates may be used as representative because of the strong correlation among these three indicators. 4 The Health Transportation Shortage Index SM
7 Data Sources for SM HTSI Scoring The following are suggested sources to obtain data for use in scoring the HTSI SM. For most data points, multiple sources are available. These recommended sources have proven reliable; however, when more than one source is consulted, further investigation may be necessary to resolve possible contradictions. 1 Type of area, based on population SOURCE: 2010 UNITED STATES CENSUS BUREAU DATA Specifically the Interactive Population Map is recommended and yields data for designated geographic areas, e.g., county or Zip Code. This can be found at: There is a link from this page to the American Factfinder 2010 Census search page which can also be used. This can be found at: 4 5 HPSA designation SOURCE: HRSA WEBSITE This can be found at: FQHC in area (for high poverty areas; include rural health clinics) SOURCE: HRSA WEBSITE 2 Child poverty rate SOURCE: 2010 UNITED STATES CENSUS BUREAU DATA Child poverty data are not uniformly available for all geographic areas. It may be necessary to substitute data for Families with Related Children Under 18. If 2010 Census data are not available for this category, the Census Bureau American Community Survey (ACS) can be used. The American Factfinder search page can be used to find ACS data for county or Zip Code. This can be found at: Together with HPSA status, federally qualified health centers and other health resources are listed at this site: aspx?bycounty=1. A list of rural health centers is available at: https://www.cms.gov/outreach-and-education/ Medicare-Learning-Network-MLN/MLNProducts/ downloads//rhclistbyprovidername.pdf An additional source is each state s specific Primary Care Association (PCA) Website, using the Community Health Centers link. 3 Public transportation availability SOURCE: SPECIFIC WEBSITE FOR EACH STATE A Google search of public transportation in each state is likely to yield useful results including links to transit resources. State Government websites often have links to that state s Department of Transportation. There is a page on the American Public Transportation Association (APTA) website with links to information on transit resources in each state. This can be found at: resources/links/unitedstates/pages/default.aspx CHILDREN'S HEALTH FUND 5
8 3. National and regional data SM that support the HTSI The HTSI SM was developed using data from a national survey by CHF and the Marist College Institute for Public Opinion designed to determine the scope of the problem and identify factors associated with transportation barriers to child health care access. 3 Further information was obtained at the local level using a similar survey in the Mississippi Delta. NATIONAL SURVEY DATA For access, the proxy used was difficulty finding a usual source of pediatric care. Difficulty finding a usual source of care is significantly associated with preventable hospital ED use, especially in rural communities. 4 The survey also provides data on the availability of transportation resources, revealing a wide and statistically significant variance in availability of public transportation among types of communities across the country. The range is from a low of 25% with public transit resources in rural areas to a high of 91% in big cities (p<0.01). By contrast, personal vehicle ownership did not vary significantly, ranging from 83% in big cities to 94% in rural areas. These data are summarized in Figure 1 below. FIGURE 1 Transportation resources by type of area 100% PERSONAL VEHICLE PUBLIC TRANSIT 80% 60% 40% 20% BIG CITY SMALL CITY SURBURB SMALL TOWN RURAL 6 The Health Transportation Shortage Index SM
9 Travel distance emerged as a significant factor associated with health care access problems. On average parents reported a travel distance of nine miles to their usual source of pediatric care, with 35% having to travel ten or more miles. Travel distance was significantly greater in rural communities and small towns compared to urban areas (p<0.01). Rural communities and small towns also had significantly higher poverty rates (p<0.01), adding to the potential economic burden of public transportation shortages. Difficulty finding a usual source of pediatric care varied significantly by type of community, from 18% of parents reporting this problem in rural areas to 9% in big cities (p<0.05). Difficulty finding a usual source of care was significantly associated with greater travel distance (p<0.05) and lack of public transportation (p<0.01). It was not significantly associated with lack of vehicle ownership. Families reporting difficulty finding a usual source of pediatric care were significantly more like to report using an ED for routine care, 20% vs. 6% (p<0.01). During the preceding twelve months, 16% of families reporting difficulty finding a usual source of care had missed a child health care appointment or did not schedule one because transportation was not available. Half of these (50%) reported later using an ED for the condition associated with the missed appointment. REGIONAL SURVEY DATA To get information at the local level, key questions from the CHF/Marist survey were replicated in a geographically targeted area of high poverty and limited public transit resources, the rural Mississippi Delta. 5 This area was selected as a representative rural community based on CHF s experience in its National Network of health care programs. In this survey, one-third (33%) of Mississippi Delta residents reported some type of public transportation in their community while 81% reported owning at least one personal vehicle. Ten percent of parents reported having missed a child health care appointment during the preceding twelve months because of lack of transportation, and 29% of these children later went to an ED for the health problem for which care was missed. Not having a personal vehicle was significantly associated with missing a child health care appointment. Forty-five percent of families without a car reported missing a child health care appointment; however, public transportation availability was evenly distributed between those who had or had not missed an appointment. We conclude that across a large area, e.g., comparing health care access among counties in a state, a focus on availability of public transit resources will identify transportation shortage areas. Within an area targeted with the HTSI SM, personal vehicle ownership may mediate the impact of public transportation shortages. CHILDREN'S HEALTH FUND 7
10 SM 4. Validating the HTSI Health professional shortage areas are generally also high poverty areas, and poverty is associated with higher rates of chronic illness. For children, this often means higher prevalence of conditions such as asthma, combined with worse access to primary care resources to bring the condition under control. Hospital use for asthma reflects poor primary care management, and a disproportionate percentage of pediatric asthma ED visits and hospitalizations each year are for children living in poverty. Thus, asthma is an example of an ambulatory care sensitive condition (ACSC), as it is generally more appropriately and effectively managed in primary care settings. 6-8 We validated the HTSI SM using a database that incorporated hospital discharge data and used the rate of pediatric ACSC-related ED use for the outcome variable as a proxy for access. The location of federally qualified health centers and public transportation routes and stops were mapped using GIS software. The hospital discharge data were obtained from the Texas Department of State Health Services and focused on three metropolitan areas, Austin (Travis County), Dallas (Dallas County), and Houston (Harris County). These counties were selected because of their mix of urban and rural areas and the availability of a relatively complete data set. Data were generally unavailable for highly rural areas. Target areas ( hot spots ) were those in which the three year average rate of ACSC-related ED use was above the 75th percentile. In practice, the HTSI SM correctly identified areas with high ACSCrelated ED use. The mean child poverty rate in the hot spot areas in Harris County was 57% higher than that in areas with the lowest rates of ACSC-related ED use, and was more than 25% higher than the U.S. child poverty rate. Hot spots were significantly more likely to be rural than urban areas. In Travis County, ACSC-related ED rates were significantly higher in rural areas and in areas with longer distances from the nearest health center and public transit routes. At the ZIP Code level, higher ED rates were associated with higher percentages of households with no personal vehicle. Finally, as part of the GIS mapping strategy, multiple factor analyses were done to determine correlations among key variables so those that were redundant to the analysis could be excluded. There were strong correlations between household income and automobile ownership, and between rural area designation and longer travel distances. Higher household poverty was strongly associated with lower car ownership (p=0.001), so this scoring algorithm effectively incorporates car ownership through the poverty factor. Rural area designation based on low population is strongly associated with greater travel distance to health care (p=0.001), so distance is incorporated in the HTSI SM through the area factor, with rural designation as a proxy for longer travel distance. 8 The Health Transportation Shortage Index SM
11 5. Conclusion and Recommendations Most discussions of barriers to child health care access focus on whether the child has health insurance. Strategies to improve access therefore focus on expanding the pool of insured children. This has been effectively achieved through state child health insurance programs, expanded Medicaid eligibility, and is expected to continue when key features of health reform are implemented. Having an insurance card, however, is not enough. In high poverty, low health care workforce areas, families must typically travel long distances to get to a health care facility and often do not have adequate transportation to make this possible. The Children s Health Fund Health Transportation Shortage Index (HTSI SM ) is designed to supplement the Health Professional Shortage Area (HPSA) designation by identifying areas for the infusion of additional transportation resources to facilitate child health care access. The cost of additional transit services is expected to be more than compensated over time by savings attributable to reduced reliance on hospital emergency departments for routine or other non-urgent care. The HTSI SM is a simple tool that reflects the cumulative impact of risk factors associated with barriers to child health care access and higher rates of hospital emergency department use: type of area, poverty, transportation resources, and workforce availability. It can be used to highlight counties or smaller geographic areas for best allocation of resources to improve child health care access. As these solutions to improve health care access should include specific steps to enhance the area s transit infrastructure, recommended strategies are presented on page 10 and 11. CHILDREN'S HEALTH FUND 9
12 Potential Strategies to Reduce Transportation-Related Health Care Access Barriers 1. Improve Medicaid NEMT services Non Emergency Medical Transportation (NEMT) is integral to the Medicaid program. Relative to need, this key component of Medicaid is under-funded and under-utilized. States have discretion as to how they will provide NEMT services and could increase its availability, better market the service, and loosen regulatory restrictions to increase transportation access to health care services. 2. Coordinate existing transportation resources (mixed-use model) In 2004, a federal inter-agency initiative was launched to support increased coordination and integration of existing federally-subsidized transportation resources through expanded use of vehicles targeted for specific populations (e.g., the elderly) or programs (e.g. Head Start). When these vehicles are idle they could be made available for other purposes including health care service access. 3. Develop hybrid demand-response transit systems The available transportation infrastructure in rural communities is often chiefly comprised of demand-response or paratransit systems. To improve access to health care services, these may be expanded to link geographically isolated areas with available fixed route transit systems. Using paratransit feeders would increase public transit utilization and facilitate mobility to and from locations distant from fixed route transit stops. 10 The Health Transportation Shortage Index SM
13 4. Coordinate health care scheduling with transportation availability Improved scheduling strategies at the health care site can ensure that health care appointments are arranged for times when transportation is available and accessible. As part of case management and care coordination activities at the health care site, the capacities of emerging health information technology may soon include the ability to simultaneously schedule a health appointment and transportation to get there. 5. Increase investment in public transportation Availability of public transportation strengthens access to health care in medically underserved communities. Research conducted by the Community Transportation Association determined that millions of Americans use public transit as their primary method of reaching a health care destination. As national focus is increasingly on outpatient care, the need for expanded public transportation is clear. Other benefits of public transit systems include less air pollution and reduced reliance on foreign oil. 6. Develop a Transportation Shortage Area designation The Health Transportation Shortage Index SM may be used to identify and target areas that lack an adequate transportation infrastructure to support health care access. Appropriate solutions may then be developed through ongoing dialogue among health care and transportation professionals and community stakeholders. The HTSI SM could act as a trigger for additional federal, state and local resources to enhance health care service access. CHILDREN'S HEALTH FUND 11
14 6. References 1. P Hughes-Cromwick, R Wallace, H Mull, J Bologna. Cost Benefit Analysis of Providing Non- Emergency Medical Transportation (Project B-27) Altarum Institute. Available online at: Accessed March 22, Borders, S. Transportation Barriers to Health Care: Assessing the Texas Medicaid Program [Ph.D. Dissertation] College Station: Texas A&M University. Available online at: pdf?sequence=1. Accessed April 22, Random Digit Dial (RDD) Equal Probability Selection Method (EPSEM), Random A telephone survey of 1,819 adults 18 years of age and older within the continental United States; 610 were parents with children age 18 and under living in their household. Interviews were conducted September 18th through 21st, 2006 in English and Spanish. The results of the entire survey are statistically significant at ±2.5% and ±4.0% for parents with children age 18 and under. Weighted analyses were done in SPSS Version Columbia University Institutional Review Board Number AAAB5764 applies to this survey research. 4. JH Sarver, RK Cydulka, DW Baker. Usual Source of Care and Non-Urgent Emergency Department Use. Academic Emergency Medicine. 2002; 9: The Delta Rural Poll was conducted in February 2011 by Wolfgang Frese Survey Research Laboratory at Mississippi State University in collaboration with the Delta State University Division of Social Sciences and Center for Community and Economic Development. The counties surveyed were Bolivar, Coahoma, Humphreys, Issaquena, Leflore, Quitman, Sharkey, Sunflower, Tallahatchie, Tunica, and Washington. Random digit dial methodology included households with unlisted numbers. The margin of error for the full data set (N=1008) is +/- 3%. 6. LJ Akinbami, JE Moorman. Asthma Prevalence, Health Care Use, and Mortality: United States, National Health Statistics Reports #32. January 12, Available online at: Accessed December 5, Akinbami LJ. The State of Childhood Asthma, United States, Centers for Disease Control & Prevention (CDC). Advance Data # 381. Revised December 29, Available online at: Accessed December 5, Gendo K, Lodewick MJ. Asthma economics: focusing on therapies that improve costly outcomes. Current Opinion in Pulmonary Medicine. 2005; 11:43 50.
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