When Lack Of Transportation Becomes A Barrier To Health Care

http://www.theatlantic.com/health.archive/2015/08/the-transportation-barrier/399728/

Woman riding a Greyhound bus
photograph by Shannon Stapleton/Reuters
theatlantic.com

Hello Everyone:

Fresh week, fresh things to talk about.  First, yours truly wants to express the utter shock and revulsion over the destruction of the Baalshamin Temple ruins in Palmyra, Syria. The continued wonton destruction of cultural monuments is an attack on humanity itself by those who respect neither human life or civilization.

Now for today's subject, lack of reliable transportation as a barrier to proper healthcare. It is no secret that reliable and safe transportation in suburban and low-income communities is inadequate.  The inability to find a nearby bus or train station can mean missed appointments or poor health.  In his article "The Transportation Barrier" for The Atlantic, Imran Cronk, illustrates this dilemma with his own experience as an emergency room volunteer.  One evening he encountered an older gentleman who was having vision trouble from medication and did not have bus fare.  Mr. Cronk suggested the gentleman try the admissions-and discharge desk but that was no help to the gentleman.  Mr. Cronk watched with concern, as the gentleman was having difficulty pacing the waiting room.  Finally, after his shift was over he gave the gentleman a ride home.

East Baltimore, Maryland
weblogs.baltimoresun.com

The point of Imran Cronk sharing his experience is to highlight the fact that distance can still be a barrier for poor people living in suburban and urban areas.  The irony is that despite the closer proximity to medical and dental facilities, people still have trouble with finding reliable transportation.  One problem is "Some households don't have a vehicle, or share one among multiple family members."  Underscoring this point is Gillian B. White's article, "Stranded: How America's Failing Public Transportation Increases Inequality" in The Atlantic (May 16, 2015).  Ms. White quotes Moss Kanter, a Harvard University professor and author of the book Move: Putting America's Infrastructure Back in the Lead,

Without really good public transportation, it's very difficult to deal with inequality...Access to just about everything associated with upward mobility and economic progress-jobs, quality food, and goods...healthcare, and schooling-relies on the ability to get around in an efficient way, and for an affordable price.  (http://www.theatlantic.com)

Broken window field study
Lowell, Massachusetts
boston.com

Low-income neighborhoods are acutely affected by sub-standard transportation infrastructure-"subways may not service areas on the fringes of a city, buses may be unreliable, and both are vulnerable to strikes or service suspensions.  And for those who are disable, obese, or chronically ill, riding the bus or the subway can be a difficult undertaking."

Therefore, a trip to the emergency room or doctor's office, without a way to get there and back, can mean either being stranded or missing an appointment altogether.  Mr. Cronk cites a "...2001 survey of 413 adults living at or below 125 percent of the federal poverty level in Cleveland, Ohio, published in the journal Health & Social Care in the Community, researchers found that almost one-third of respondents reported that it was 'hard' or 'very hard' to find transportation to their health care providers..." A 1997 surveyof 593 cancer patients in Texas, published in Cancer Practice revealed "...that in some cases, trouble with transportation led patients to forgo their cancer treatments.  The problem was especially prevalent among minority survey respondents; 55 percent of African America and 60 percent of Hispanic survey respondents reported that transportation was a major barrier to treatment, compared to 38 percent of white respondents."

New York City housing project
stvinc.com

Imran Cronk continues, "More recently, 2012 survey of 698 low-income patients in a New York City suburb reported that patients who rode the bus to the doctor's office were twice as likely to miss appointments as patients who drove cars."  Also, in 2013, a study published in the Journal of Community Health, titled Traveling Towards Disease: Transportation Barriers to Health Care Access http://www.ncbi.nlm.nih.gov) concluded that about "25 percent of lower-income patients have missed or rescheduled their appointments due to lack of transportation."  Further, patient who had transportation problems "also missed filling prescriptions more than twice as often as patients without that same problem."  The study authors reported, These consequences may lead to poorer management of chronic illness and thus poorer health outcomes. (Ibid)

Random corner in Watts, California
ireport.cnn.com

University of Pennsylvania professor of medicine Shreya Kangovi explains, In some situations, patients without transportation access may for a medical emergency just to be able to see a doctor.  Dr. Kangovi continues,

Mr. Jones might a disability that makes it difficult for him to use public transportation, so he has been waiting until he's really sick, short of breath, and then calling an ambulance because there is no other good way to get care.

Dr. Samina Syed, the lead author for the 2013 study told Mr. Cronk,

If a patient can't get to see their health-care team, then it's a domino effect...Missed appointments mean they can't address their questions and concerns, or update physicians on changes in their history or life circumstances.

This is a particularly worrisome situation for patients with chronic illnesses, such as diabetes, which require active care management.

Community Health Worker in South Los Angeles
myemail.constantcontact.com

While the obvious remedy to the problem is to add more public transit (bus and subway) lines, which may not be feasible, there is another approach to making sure patients get to their appointments and their prescriptions filled.  Mr. Cronk writes, "Some health-care providers are trying to less the problem by employing community health workers (CHWs), people who help patients navigate the health care system."  CHWs are usually individuals, without health-care backgrounds, who are tasked with coordinating transportation to and from office visits, encourage them to take their medications, and educate individuals on healthy lifestyles.  As of 2014, there were about 50,000 CHWs in the United States.

The implementation of CHWs shows promise of positive change in health-care access.  Imran Cronk cites a 2003 study on health disparities from the Institute of Medicine, which praised the CHW model, stating that it offer[s] promise...to increase racial and ethnic minorities' access to health care and improve their quality of care.  Research has supported this concept: a 2007 study revealed that CHWs can help hypertension patients better manage their situation and a 2014 study concluded that "patients who worked with CHWs scheduled more primary-car follow-up appointments than those who didn't."

Care Coordinator reviewing a prescription with a couple
work.chron.com

Another approach to breaking down the transportation barrier to better health-care are care coordinators.  Care coordinators, unlike CHWs, do have training in a health-related profession (social work or nursing) and are used by some hospitals and doctors.  The coordinators support groups of low-income or chronically ill patients, helping them to navigate their care strategies and schedule appointments with primary-care physicians instead of repeat visits to the emergency room.

Nevertheless, a significant number of patients, especially those with limited resources, struggle to locate reliable and affordable transportation, there are options for those who know how to find them.  Every state offers a "non-emergency medical transport benefit to Medicaid recipients, which covers a set number of rides per month and some Medicare Advantage plans also allow for a specific annual number of trips (eligibility varies according to state).  Some states enter into contracts with local companies to provide transportation; others use volunteers, or hire cabs.  Uber, Lyft are you paying attention? There is a need for reliable transportation for low-income patients.  You could provide a real service to a community who desperately needs it.  Private insurers are also taking steps to make transportation accessible for their clients, albeit through a time-consuming bureaucratic process.

Interior of a Baltimore area bus
Photography courtesy of ArchPlan Inc
archplanbaltimore.blogspot.com

The restrictions surrounding these transportation programs can be daunting and can inhibit patients from availing themselves.  Returning to the patient Mr. Cronk encountered during his shift at the ER, he writes, "The patient I encountered in the ER at midnight, for example, did not have the luxury of planning his ride home in advance.  No one who undergoes emergency hospitalization has the benefit of foresight for planning how they might leave."  Those patients who received planned care through a doctor's office or other outpatient setting may not be aware of the resources available to him or her.  The very same low-income patients, who are impacted by transportation barriers, are also likely to lack health literacy which makes it difficult for them to climb the levels of bureaucracy just to get a ride.

Dr. Shreya Kangovi explains, If you have health-literacy issues and if you don't have good access to care to begin with, you're not going to be able to fill out the application and get your provider to fill out their side of it...Barriers like that, which seem small and detailed, end up being insurmountable barriers for patients.

If it is not the lack of health literacy that prevents patients from obtaining access to transportation, it is a sense of self-consciousness.  Mr. Cronk, citing Dr. Samina Syed, writes, "Often, doctors may not even realize that their patients have problems with transportation."  Dr. Syed elaborated,

There are things patients might not tell you, or that you don't ask them, and so they just hear from the doctor that you shouldn't miss appointments, and they say 'Okay,'...But there is more to it that is beyond their control...You can provide the best care in the world...but it doesn't matter if the patient has no way to get to it.