1 Rhode Island Human Service Transportation Study October 2010
3 Executive Summary Over the past several years, there has been growing recognition on the part of state leadership and decision-makers in Rhode Island that being the smallest state brings opportunity to achieve economies of scale and operational efficiencies in the delivery of state services. Furthermore, current state budget constraints, a federal directive to better coordinate human service transportation, and projections for an increasingly transit dependant population, make this an opportune time to revisit the state s model for human service transportation delivery and to identify opportunities for increased efficiency and interdepartmental collaboration. Human service transportation (HST) is broadly defined as transportation specifically designated for older adults, individuals with low incomes, and persons with disabilities. It includes public and nonprofit agency sponsored transportation as well as complementary paratransit service required under the Americans with Disabilities Act (ADA). In Rhode Island, there are an estimated 38 federal and state programs supporting HST activities, and nearly 300 public, nonprofit or private organizations use these funding sources to provide HST. As a result, a complex service delivery model has evolved in Rhode Island, involving many organizations and programs, each with distinct eligibility and program requirements, and many with unique and differing service delivery models. It is against this backdrop that the Rhode Island Public Transit Authority (RIPTA) and the Executive Office of Health & Human Services (EOHHS) initiated the Rhode Island HST Study. The objective of the study was to understand how human service transportation is provided in Rhode Island and to develop broad recommendations about how the management, organization and delivery of these services could be improved. The study involved four main tasks: Funding Inventory: Federal and state funding programs available to support HST in Rhode Island were identified and inventoried to estimate the total level of federal and state spending on HST in Rhode Island. Provider Network Inventory: A comprehensive inventory was performed to identify organizations and spending associated with providing, arranging or purchasing HST in Rhode Island. Best Practices Review: A review of best practices used by other states was conducted to identify successful tools used in the management, organization, coordination, and delivery of HST. Key Findings & Recommendations: Based on the previous tasks, the study team identified specific strategies to improve the efficiency and effectiveness of HST in Rhode Island. These efforts are documented in individual technical memos prepared over the course of the study and summarized into a single final report. This executive summary presents key findings. Rhode Island HST Spending Rhode Island spent a conservatively estimated $62.4 million in SFY 09 on HST. This estimate is based on state and federal funding programs and represents traceable funding. For a variety of reasons many agencies do not closely track staff time spent providing or arranging transportation; as a result, the study team expects actual spending to be as much as 15% higher. At $62.4 million, however, the amount spent on HST is greater than the amount of money Rhode Island Page 1 Nelson\Nygaard Consulting Associates Inc.
4 spends on public transportation services for the general public. It also represents approximately 0.09% of the Rhode Island state budget. 1 Funding to support HST is primarily associated with two state agencies (RIPTA and EOHHS); three federal programs (Federal Transit Administration, Medicaid and Temporary Assistance for Needy Families (TANF); and state gas tax revenues. Slightly more than half of HST spending in RI is funded through the Executive Office of Health and Human Services (EOHHS). About a third of HST is funded through RIPTA. Much of this funding is associated with the agency s Half Fare and No Fare Pass Programs. A handful of other state programs fund HST. Figure ES-1 Rhode Island s HST Network by Funding Source Total Cost $62.4 M (SFY 09) EOHHS, $34.7 Other, $2.9 RIPTA, $24.8 Figure ES-2 Rhode Island Spending on HST Estimated SFY 09 (In millions, Rounded) State Funding Program Private Wheelchair Vans Transportation Providers RIPTA Services The RIde Program Independent Services* Sub- Totals RIPTA $17.1 $7.7 $24.8 Medicaid $18.2 $3.0 $0.7 $21.9 Elderly Transportation $3.9 $3.9 RIWorks $4.4 $0.1 $4.5 Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) Department of Children, Youth & Families (DCYF) Other State Programs (ORS, Veterans Affairs, Providence Public Schools, etc) TOTAL Human Service Transportation Funding Source: Nelson Nygaard Consulting ($7.30 of Medicaid $18.2) $1.5 $1.0 $2.5 $1.3 $1.3 $2.4 $1.1 $3.5 $18.2 $26.9 $13.8 $3.5 $62.4 Note: * Includes transportation provided by state and community based agencies, including buses, vans and agency staff driving personal or fleet vehicles. 1 Based on SFY 09 $6.9 billion state budget. Page 2 Nelson\Nygaard Consulting Associates Inc.
5 EOHHS Funding EOHHS is the largest funder of HST with a combined spending of $34.7 million in SFY 09. Funding includes resources allocated for transportation by state and federal agencies and does not include the resources of community based organizations, many of whom operate as contractors for EOHHS programs. Medicaid is by far the largest source of EOHHS funds used to support transportation. Medicaid, through the non-emergency medical transportation (NEMT) program, spent an estimated $21.9 million (SFY 09) on transportation services. Figure ES-3 EOHHS HST by Funding Program (In millions, Rounded, SFY 09) Elderly Transportation $3.9 RIWorks (TANF) $4.5 BHDDH $2.5 DCYF $1.3 Other (ORS, Veterans Affairs) $0.6 Medicaid $21.9 About half of the $21.9 million, or nearly $11 million, is funded with state resources. Most of the Medicaid transportation funding is spent purchasing services from private wheelchair van companies. A smaller amount of funding is used to purchase services through The RIde Program and RIPTA. In SFY 09, EOHHS used $4.5 million of TANF funds to purchase RIPTA bus passes for the RIWorks program. Another $3.9 million in funding provided through the state gas tax was used to support the Elderly Transportation Program, a state program that provides transportation to medical appointments, meal sites, and adult day care centers to Rhode Island residents aged 60 or above. RIPTA Funding RIPTA is also a major funder of HST, providing an estimated $24.8 million in SFY 09. RIPTA funding includes a mix of federal funds and state operating revenues raised through the state gas tax. RIPTA s HST programs include: The Half Fare and No Fare Pass Program cost $16.1 million in SFY 09. The Half Fare is available to older adults and individuals with disabilities. Depending on income level, Figure ES-4 RIPTA Funds Used to Support HST ADA Transportation $6.5 RIde Job Access Administration $0.5 $1.2 Mobility Management $0.6 Senior/Disabled Pass Program $16.1 some individuals may qualify for a No Fare bus pass. The Half Fare program is federally mandated, while the No Fare program is a state mandate. Complementary paratransit services is provided in accordance with the Americans with Disabilities Act (ADA), with costs of $6.5 million annually. ADA services are required by Page 3 Nelson\Nygaard Consulting Associates Inc.
6 federal law and support persons with disabilities who are unable to use regular fixed-route bus service. The RIde Program oversees and administers a variety of demand response services on behalf of state agencies, including ADA transportation. Agencies pay the direct cost of services but, per a state directive, RIPTA is responsible for program administration and management. Administrative costs are approximately $1.2 million annually. Other HST related activities include Job Access Reverse Commute (JARC) services and mobility management support offered to customers, state agencies and other partners. Other Funding Supporting HST in RI The remaining $2.9 million spent on HST in Rhode Island is associated with non-eohhs programs that provide HST for their clients. Example programs include the Rhode Island Housing Resources Commission, the Department of Corrections, the Providence School Department and the University of Rhode Island. Transportation Provider Spending The study also inventoried organizations providing HST for their clients. The study defined providing transportation as agency resources spent to directly operate transportation; purchase transportation from another vendor; and/or arrange transportation (i.e. staff resources used to find and/or schedule trips for clients). The transportation provider inventory identified a larger amount of resources spent funding HST. The inventory is larger because it includes all of the funding identified in the funding inventory but also includes community based agency resources, such as funding and staff time associated with operating, purchasing and/or arranging transportation. According to the transportation provider inventory, the State of Rhode Island, inclusive of public and private resources, spent $81.5 million in SFY 09 on HST. This estimate includes the federal and state funding ($62.4 million) plus an additional $19.7 million contributed by community based agencies. The provider inventory estimate of HST costs is based on a sample of agencies and includes both hard data such as actual costs associated to operate municipal vans (i.e. Transwick and Transvan) as well as soft costs such as staff time devoted to finding and securing trips for clients. As a result, the inventory incorporates broad assumptions about staff costs and staff time required to manage or transportation services. While the estimate is based on the best available information, it is a broad estimate and should be used for planning purposes only. HST Service Network Rhode Island s HST service network largely consists of four types of services. These services have evolved through a combination of funding source requirements, historic practices and agency efforts to respond to client needs. For the most part, individual services are unique and fulfill a specific market need. However, services largely operate independently from one another and vary significantly in terms of cost: RIPTA RIPTA is the statewide network of fixed-route and flex bus service. All buses are fully accessible and available to all Rhode Island residents who pay the fare. RIPTA directly sponsors several reduced fare programs for older adults and individuals with disabilities, including a Half Fare and No Fare bus pass program. Agencies can also buy RIPTA s book of 10 bus tickets fare product (Riptiks) for single, ad hoc trips. Page 4 Nelson\Nygaard Consulting Associates Inc.
7 The RIde Program - The RIde Program provides demand-response, door-to-door 2 transportation with wheelchair accessible vans and private taxis. Eligibility for The RIde Program is based on the requirements of the participating agencies, including ADA, human, health, education and vocational programs. Private Wheelchair Vans Private wheelchair van services provide demand response, door-through-door 3 service primarily with accessible vans. The service is run by a number of independent private, for-profit companies. Collectively, they represent the primary service mode for Rhode Island s Medicaid non-emergency medical transportation (NEMT) program. Nearly all individuals using these services are Medicaid eligible. 4 Independent Operators Some state agencies and publically-sponsored nonprofit organizations operate transportation services for their clients. These services are typically designed to meet the needs of a highly specialized client base and are not available to other individuals. Services are operated via a mix of buses, vans, taxis, and personal staff autos, depending on client need; not all are accessible. RIPTA The RIde Program Independent Operators Private Wheelchair Van Services Avg. Cost per Trip $4.14 Avg. Cost per Trip $22.73 Avg. Cost per Trip $21.10 Avg. Cost per Trip $37.82 Carrying about 67% of HST trips Carrying about 10% of HST trips Carrying about 16% of HST trips Carrying about 7% of HST trips Best Practices in HST Management and Coordination The study reviewed HST practices in other states, including North Carolina, Oregon, Massachusetts, Florida, Vermont and Delaware. This research concluded: The authority for increased coordination and management of HST resources is typically granted through legislative action, executive order, or a memorandum of understanding 2 Door-to-door transportation refers to transportation services that pick-up and drop-off passengers at (but outside of) their home or destination. Drivers may help an individual get into or out of the vehicle but will not escort an individual into their home or destination. Door-through-door transportation refers to a service level where the driver will escort an individual from the vehicle into their final destination. In some cases, drivers may help an individual check into their appointment. 3 See above. 4 Some individuals may use private insurance programs to pay for wheelchair van service. Page 5 Nelson\Nygaard Consulting Associates Inc.
8 between various agencies. Legislative action is the strongest and most enduring directive for coordination. It is also the most difficult to realize. Some states delegate responsibility for carrying out coordination and oversight of human service activities to a distinct state office with dedicated staff, or a more informal coordinating or advisory council made up of voluntary stakeholders. In both cases, statewide governing bodies are tasked to set overall HST policy guidelines and to promote service integration and coordination. States are increasingly setting up transportation brokers to help them manage and coordinate the delivery of human service transportation. Some large states tend to set up regional brokerages, while other smaller states have had success with statewide brokerages. Successfully integrating all HST functions, especially Medicaid non-emergency medical transportation and ADA complementary paratransit services into a single brokerage, however, has only been achieved by a handful of states. Figure ES-5 Best Practices for Human Service Coordination & Oversight Delegating Authority for Coordination & Oversight: - Legislative Action - Executive Order - Memorandum of Understanding Establishing a Structure for Coordination & Oversight: - Human Services Transportation Office - Coordinating Council - Advisory Committee Coordinating Service Delivery: - Individual Program Brokers (Medicaid) - Coordinated Statewide Broker - Central Call Centers Rhode Island s HST Network Key Findings The research shows Rhode Island s HST network works well in terms of meeting client needs and has a relatively high level of customer satisfaction. Existing transportation services are perceived as being of good quality and in general most stakeholders agree the amount of services provided are adequate. Yet, there are redundancies in the system that make it inefficient to operate overall, signifying the need for greater coordination and oversight. The challenge lies in organizing, managing and distributing trips more efficiently across the available services, while implementing controls to Page 6 Nelson\Nygaard Consulting Associates Inc.
9 ensure specific program requirements continue to be met. The primary sources of inefficiencies in the network are attributable to the following: There are no systems in place to manage RI HST services as a coordinated network. Therefore, most activities and services operate independently, and there are inconsistent policies between programs. Rhode Island has two agencies that operate parallel, but uncoordinated statewide services that effectively operate as independent brokerages (HP for Medicaid and The RIde Program). Despite having a fairly broad range of transportation modes available, most programs are not able for administrative and bureaucratic reasons - to access the full range of available transportation choices. Cost savings could be realized, if more individuals could be assigned to the lowest cost, most appropriate mode available. Cost shifting between programs has become a significant issue, especially for Medicaid. Cost shifting creates inefficiencies in the network because agencies assign clients to higher cost transportation services, often because it is easy to transfer clients to these modes, rather than because clients need higher service levels. In addition, because agencies arranging transportation do not pay the costs directly, they are not motivated to use the lowest cost, most appropriate mode. There is no long-term planning associated with HST in Rhode Island; therefore, there are no ongoing efforts to improve system efficiency, and no specific plans in place at the agency or state level to meet evolving service needs. There are only limited tracking, reporting and enforcement mechanisms in the system. As a result, most agencies only have a rudimentary understanding of how much their services cost, how they work and what they accomplish. Inefficiencies in the existing network of services are exacerbated by steadily increasing demands for service. These demands are a result of changing demographics and an increased use of community based service delivery models ( aging in place models and community-based services for persons with developmental disabilities). While anticipated future demand for human service transportation has not been explicitly projected, it is clear that demand will continue to grow. In the past three years, partly as a result of the above client population changes, costs associated with Medicaid NEMT have more than quadrupled from $3.8 million (SFY 07) to roughly $21.9 million in SFY Even though recent efforts have helped flatten the growth rate somewhat, even reduced growth rates are unsustainable. There are specific actions, however, that can be taken to control the magnitude of potential future increases and to improve overall service delivery. Strategies, Opportunities & Next Steps The RI Human Service Transportation Study was initiated not only to identify strategies to help control the cost of providing HST services, but also to provide recommendations on how to develop a HST network and management structure that is sustainable in the longer term. Four goals for creating a more cost-effective and efficient human service transportation network have been identified. 5 DHS (HP) March Page 7 Nelson\Nygaard Consulting Associates Inc.
10 Goals for Improving HST in Rhode Island 1. Set Consistent Policies & Oversight Controls Streamline service rules, regulations and policies to reduce system redundancies and management costs. Establish a structure for oversight and management of the HST program as a whole. Eliminate the ability of state agencies to shift transportation costs to other programs and budgets. 2. Make Best Use of Service Delivery Options Coordinate or consolidate as many service delivery functions as possible, such as call centers, trip assignment functions and eligibility certification. Ensure call centers are able to assign trips to all modes and have access to the least cost, most appropriate option. 3. Conduct Long Term Planning Conduct ongoing strategic planning to improve service delivery methods and plan to effectively meet future demand. 4. Control Future Costs Control the financial impact of anticipated increases in demand by increasing ride sharing and assigning as many trips as possible to the lowest cost mode. These strategies, while seemingly simple and straight-forward, are not easily achieved, especially in the short term. In order to help guide Rhode Island toward meeting these goals over the long term, a series of both long and short term strategies have been identified below. Longer Term Strategies & Opportunities Recognizing that implementation of a new HST management structure is an essential step toward meeting these long term objectives, four potential management options were identified. Each model offers the potential to improve service delivery and management of the HST network. These are high-level strategies for restructuring service on a statewide level, and each would require careful planning and, at minimum, months or years to implement. The four models include: A. Consolidated Statewide Brokerage Designate a single entity to administer all HST services. Duties assigned to this broker may include contracting with transportation providers, managing client eligibility, staffing a call center, scheduling and assigning trips, and invoicing and billing. The brokerage may be managed by a single department or jointly overseen by a multi-agency entity. B. Inter-agency Human Service Transportation Committee A committee comprised of agencies currently involved in human service transportation, with the aim of streamlining program rules and engaging in coordinated planning for the state s human service transportation. Page 8 Nelson\Nygaard Consulting Associates Inc.
11 C. State Human Service Transportation Office An office that employs full-time staff to work with the variety of agency stakeholders to streamline program rules and plan for the state s human service transportation needs in a coordinated, systematic way. D. State Human Service Transportation Office with Transportation Brokerage The office described in Model C above not only to set policy and plan for future needs, but also as the designated authority to oversee the coordinated statewide broker. Shorter Term Strategies While Rhode Island determines how best to move forward with a new service delivery model for HST, there are a number of short-term strategies that offer potential to increase service efficiency, save money and improve customer satisfaction. Taking one or all of these actions does not commit the State to any one of the particular long term strategies identified above. Conversely, advancement of any of the short-term strategies below would in fact begin to advance the State towards a more effective service delivery model, and would further inform stakeholders about the various complexities involved, leading Rhode Island towards the best possible model for future program administration. Figure ES-6 Short Term Strategies for Meeting HST Goals in Rhode Island Recommended Action Benefit Achieved Implementation Complexity Automate Key Functions Existing Call Centers Develop a web-based scheduling and reservation system Reduce resources required to schedule and assign trips Create self-populating call-taker software Increase the accuracy of trip requests, reduce system errors and increase monitoring ability Install transit trip planning software Reduce HST network costs Link trip requests to trip invoices to support program monitoring Decrease fraud and abuse lower costs Improve Program Capacity & Reduce Average Trip Costs Utilize all available modes/increase mode choice Reduce HST network costs Increase ride sharing and trip grouping Reduce overall cost per trip for most programs Incorporate new accessible taxicabs as providers once vehicles are in place. Reduce trip costs for certain trips Formalize Agency Agreements Create state policy designating RIPTA fixed-route as default mode for HST Reduce HST network costs Improve trust between agencies and Formalize agreements regarding policies and responsibilities increase agency collaboration. Should result under the No Fare bus pass program in increased use of lower cost RIPTA services Formalize agreements regarding policies and responsibilities under The RIde Program Streamline billing systems to create per trip billing and/or systems to support electronic invoicing Improve RIPTA s Senior/Disabled Pass Program Database Improve RIPTA bus pass database Formalize implementation of service changes made under Dialysis and Substance Abuse programs Increase predictability of cost Make database a more useful source of information. Reduce HST network costs Page 9 Nelson\Nygaard Consulting Associates Inc.
12 Recommended Action Limit Cost Shifting between Agencies Address shifting of transportation costs between departments and agencies Identify true costs of each service delivery mode Engage High Level Stakeholders in HST Discussion Create awareness of HST needs and costs Expand RIPTA Board to include a EOHHS/DHS representative or set up a Board subcommittee (with EOHSS representation) to address HST Create Working Group of Strategic Partners Form working group to address HST challenges and develop methods to address challenges Benefit Achieved Reduce HST network costs Ensure funding follows assignment of clients to a particular mode of service Encourage strategic planning for transportation among stakeholders Creates opportunities for sponsoring agency to participate in service oversight Increase trust among partners and work towards long term strategic goals Implementation Complexity High High Forecast specific future need/demand/impact from changes Identify clear strategies and systems to address increased demand Hold Regular Meetings with Transportation User Groups Hold regular meetings with client groups to identify and discuss HST problems Assign Trips to Multiple-Modes Create ability for programs to assign trips to all modes Simplify Riptiks program for HST use Create system that allows for easy management and distribution of Riptiks Educate partners Reduction of service costs Increase network capacity Reduce HST network costs Reduces fraud and supports use of lowest cost mode High Page 10 Nelson\Nygaard Consulting Associates Inc.