This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network. |
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Getting There: Helping People With Mental Illnesses Access TransportationPDF
version Emerging Best Practices for Providing Transportation to Mental Health ConsumersDespite the many transportation barriers facing mental health consumers nationwide, consumers in some communities have some or all of their transportation needs met through innovative programs. A number of these emerging best practices address the five barriers of affordability, accessibility, applicability, availability, and awareness. This chapter describes initiatives that take advantage of existing transit opportunities. These programs may expand the transit system’s half-fare program, issue transit passes to Medicaid recipients, or provide travel training to people with disabilities. Next, other programs, such as consumer-run transportation, volunteer-augmented programs, and voucher programs, which focus on providing transportation in situations in which transit is unavailable, are profiled. Finally, State programs that have coordinated all publicly funded transportation resources to maximize efficiency are discussed. More information about the transportation programs profiled is available directly from the programs or through the national technical assistance centers listed in the Resources section at the end of this report. Expanding Access to Public Transit
Many local communities and States have worked hard to expand the use of public transit—such as buses, trains, and subways—by people with disabilities. Often, health care and social service providers distribute transportation tokens that people can use to travel to medical or rehabilitation services. Other communities have enabled people with disabilities to use public transit for whatever reason they see fit. This approach encourages people with disabilities to seek and obtain employment, go shopping, attend school, participate in social activities, and attend support group meetings. Broad access to public transit helps people with disabilities become part of their communities, in the true spirit of the U.S. Supreme Court’s Olmstead decision, and the President’s New Freedom Initiative. Programs that expand access to public transit have many advantages according to the Federal Transit Administration (FTA), part of the U.S. Department of Transportation. Public transit agencies benefit by increasing their revenues through increased ridership. In fact, allowing unrestricted access to public transit boosts ridership at non-peak hours—such as during evenings and weekends—when many seats are unused. Therefore, the transit agency benefits financially without having to increase capacity. Bolstering public transit in this way helps not only people with disabilities but also the community at large. Agencies and government programs also save money when they enable people to use public transit instead of special vehicles. Expansion of public transit benefits people with disabilities by allowing them greater mobility and independence. People can ride when and where they want to, without the worry of making reservations in advance for rides that can be taken only for limited purposes. They can ride public transit alongside other members of the community, rather than being segregated by specialized transportation (FTA, 2004). Of course, the major shortcoming of these initiatives is that they demand the existence of public transit in a community. Expanded Half-Fare Programs. Expanded half-fare programs, enacted by State law or by local or regional transit authorities, increase the availability of reduced transit fares beyond that required by Federal law. Whenever a public transit authority receives Federal funds, it must offer a half-fare program for off-peak hours on trains, subways, and buses to qualified people with disabilities. Generally, an individual submits an application and verification of his or her disability, and receives a photo identification card. Under Federal qualifications, only people with a disability that interferes with the ability to ride transit unassisted and people receiving Medicare are eligible. Transit systems, however, are permitted to use a broader definition of disability for their half-fare programs. Some communities and States, recognizing that many more people with disabilities face great financial hardships, have expanded their half-fare programs. For example, anyone who receives services from the Massachusetts Department of Mental Health is eligible for a Transportation Access Pass that entitles the holder to reduced fares on all transit systems in the State. In New York State, mental health advocates argued for years to allow mental health consumers receiving SSI and Medicaid the same right to reduced fares as people receiving Social Security Disability Insurance (SSDI) and Medicare. People who qualify for SSDI and Medicare usually have had more work experience than SSI/Medicaid recipients, but advocates “didn’t think that a 2-year journey in a corporation should be more important than a 2-year journey on the street in determining who gets half-fare,” according to Fred Levine. Mr. Levine is an attorney and consumer advocate who participated in the Half-Fare Fairness Coalition. This broad coalition of advocates gathered support throughout the State for the expansion of the half-fare program. The coalition succeeded in convincing the State legislature to enact the Half-Fare Fairness Law, which now specifically states:
“The issue (of transportation) resonates in people’s hearts very strongly.” The passage of the law, however, was not the end of the story. An effective half-fare program also requires a fair, straightforward application process and proactive outreach to educate consumers about the availability of the discount. According to Mr. Levine, the Metropolitan Transit Authority (MTA) needed extra time to implement the Half-Fare Fairness Law in the New York City metropolitan area. Initially, the application they designed placed extra requirements on mental health consumers—including discussion of an individual’s diagnosis—rather than simply verifying the individual’s disability status with the Social Security Administration. Ultimately, advocates went to court to ensure fair implementation of the law. An out-of-court settlement resulted in a revised application that did not require disclosure of a specific diagnosis. Additionally, MTA agreed to promote the availability of the discounts by sending 10 copies of a letter to each of more than 1,200 mental health programs. By the end of 2003, over 6,000 mental health consumers had received half-fare cards under the new standards. The coalition hopes to increase that number to 25,000. In addition to expanding half-fare to include mental health consumers with financial need, simplifying the application process, and promoting the availability of the discounts, Levine suggests one more feature is needed to promote the utility of a half-fare program: Make it available for rush-hour commuting. Federal regulations do not require transit agencies to offer half-fare during peak hours or on express buses and trains. In the New York City metropolitan area, the system is not set up to differentiate between peak and non-peak fares; as a result, half-fare is available on regular transit vehicles 24 hours a day. However, advocates are still fighting to expand the half-fare program to express buses, which do not accept the half-fare card. Levine says that the half-fare program has allowed many people with disabilities to get real jobs. Discouraging people with disabilities from using commuter routes is inconsistent with State and Federal efforts to increase employment opportunities for people with disabilities. Medicaid Transit Passes. Like the half-fare program, Medicaid transit passes make transportation affordable for people with disabilities who are living in areas served by public transit. The passes enable people to obtain transportation for whatever purpose they desire. Each participant simply receives a monthly transit pass that allows him or her unlimited rides on public transit. Funding comes entirely from the State’s Medicaid budget, and experience shows that States actually save money by initiating this type of program. In fact, Medicaid transit pass programs originated with some innovative thinking by State Medicaid agencies. States are required to ensure that Medicaid recipients have transportation to services covered by Medicaid, which can include doctor and therapist visits, drug and alcohol programs, and psychiatric rehabilitation. Traditionally, this transportation has been provided either through special Medicaid transportation vans, by taxi, or by private shuttle service. The cost per trip is significant, and for people making several trips per month to doctors and other services, the costs mount quickly. In Miami-Dade County, Florida, Medicaid administrators realized that the cost of providing two round trips per month was roughly the same as the cost of a monthly transit pass. A monthly transit pass enables a person capable of using public transit to travel not only to all needed services, but also to anywhere else he or she desires. Miami-Dade found it less expensive to provide this versatile transit pass than to provide even three round trips per month. The Medicaid agency, therefore, established a partnership with the local transit authority to provide transit passes for Medicaid recipients requiring frequent transportation for medical needs. People who sign up for the program receive a transit pass and no longer are eligible for door-to-door transportation for non-emergency services. The Medicaid agency saves money on transportation, and the transit authority benefits from additional sales of monthly passes (Crain and Associates, 1998). The Metro-Dade Transit Agency (MDTA) handles applications and distribution of passes; the Medicaid agency pays for the passes plus a monthly administrative fee. To keep information confidential, Medicaid codes instead of diagnoses are used in the application process. To save money and to reduce the number of lost or misdelivered passes, MDTA distributes a large majority of the passes through agencies providing services to Medicaid recipients. MDTA also takes an active role in recruiting agencies that serve Medicaid clients to participate in the program. “Travel training provides the opportunity for independence for people who
have been encouraged to become reliant [on forms of transportation with less
flexibility].” As an aid to Medicaid agencies and transit authorities interested in starting a Medicaid transit pass program, MDTA has produced a detailed set of materials explaining how to establish a similar program (Metro-Dade Transit Agency, 1997). Several other Medicaid agencies across the Nation also have established local and statewide Medicaid transit pass programs using available technical assistance. An FTA publication, Medicaid Transit Passes: A Winning Solution for All, is available online at http://www.fta.dot.gov/CCAM/www/publications/medicaid.html. It describes several programs that have saved millions of dollars each. Additional information about cost savings is available in a report by the Transit Cooperative Research Program, Economic Benefits of Coordinating Human Service Transportation and Transit Services (Burkhardt et al., 2003). Travel Training. To increase the number of people with disabilities who use public transit, a number of local transit authorities and private organizations offer travel training programs that help people overcome any difficulties. Unlike half-fare and Medicaid transit pass programs, which address affordability issues, travel training programs focus on accessibility and raising awareness of public transit to foster greater independence. Using public transit, rather than demand-response services such as paratransit, gives people greater flexibility to make trips because there is no advance scheduling requirement; it also saves money for both the rider and the transit system (Crain and Associates, 1998). Although travel training programs traditionally have focused on helping people
with physical disabilities or vision impairments, a number of programs now
offer training to mental health consumers. Typically, travel trainers work
either with individuals or with groups of people enrolled in a particular rehabilitation
program. In addition to classroom-style workshops, travel training involves
experiential learning, such as taking bus or train trips. Such programs help
with skills that include finding the right bus stop, reading a schedule, calling
in for information, recognizing landmarks for the purpose of disembarking,
and transferring to other vehicles. “A person who we see today (for an office-based assessment) might be having
a very good day, so we’re not really aware of the issues the person might be
facing.” Fremont, California, initiated a peer-to-peer model for travel training by hiring people with disabilities and older adults who used public transit as peer instructors. The peer instructors were able to discuss overcoming their own fears and, thus, helped diminish the stigma often felt by trainees (Crain and Associates, 1998). When a person with a disability establishes a relationship with a peer trainer who has overcome many of the same obstacles he or she faces, the trainee develops confidence that he or she also can overcome those obstacles. In the Fremont program, a full-time transit authority employee trained and supervised the peer trainers. In other locations, peer trainers have received stipends from the transit authorities to conduct trainings. Another advantage of travel training is that it helps identify people who are not able to use transit independently, the qualification requirement for curb-to-curb paratransit service. People with mental disabilities often are not deemed eligible for paratransit because no reliable tool exists to evaluate the effect of a mental disability on the capacity to use transit. Yet, some people have disabilities that the transit system cannot accommodate. For example, a person might suffer extreme anxiety when exposed to the crowds in rail stations. In the words of one travel trainer, “Travel training provides a safety net, because it allows extensive contact (and shows) how a person reacts in ‘real life.’ ” The prolonged contact of travel training can be more effective than a single in-person assessment because of the sometimes episodic nature of mental illnesses. Further, if travel training is not successful in helping a person ride public transit, trainers then can help the individual qualify for paratransit. Providing Specialized Transportation
Many different specialized transportation programs exist. Some are limited to a certain group of people, for example, older adults or preschool children from families of low income. Some are available for just one purpose, such as attending a particular rehabilitation program. However, because everyone has transportation needs, many communities have found innovative ways—such as employing mental health consumers, recruiting volunteers, and issuing travel vouchers—to provide transportation to people who otherwise could not afford it. In the words of Betty Newell, board president of CART in Rockingham County, Virginia, “Just because you’re old, disabled, or low-income, doesn’t mean you shouldn’t be able to get where you need to go.” Consumer-Run Programs. Throughout the Nation, mental health consumers have started a wide variety of support programs, including self-help groups, drop-in centers, peer advocacy, employment supports, and crisis services. However, helping people obtain transportation to these services is a common problem. Such services generally are not covered by Medicaid, so Medicaid transportation is not available. Yet, many people find these peer-run services essential to the recovery process. In response to the lack of transportation, some groups have started peer-run transportation initiatives. Some provide transportation to peer-run services, while others have secured funding to employ consumers to transport other consumers whenever necessary. The consumer-run program that perhaps best exemplifies the more inclusive approach to peer transportation is Peer Transportation Services (PTS), a project of the West Virginia Mental Health Consumers’ Association. Much of West Virginia is rural with no public transportation; some small urban areas have only limited public transportation. Often, the public transportation operates on a very limited schedule, leaving people who cannot afford a car with few transportation options. PTS operates in five service areas, each with a 50-mile radius, and according to PTS, its services are available to “all adult consumers of mental health services who have no other means of transportation.” PTS operates as a typical demand-response transportation service. Users are required to make reservations a week in advance (when possible), and a consumer employee of PTS will transport the person using one of the program’s vehicles. PTS does not charge a co-payment for its services, which are available for a wide variety of purposes, such as grocery shopping, social outings, family events, and meetings of the mental health planning council. Many people use PTS to reach doctors’ offices and community mental health centers, and to access nonclinical services they consider essential to recovery, such as drop-in centers, peer support groups, Wellness Recovery Action Plan (WRAP) classes, and 12-step groups. Typically, PTS does not provide transportation to Medicaid-covered services, but does provide medical transportation to people not covered by Medicaid. PTS has played an instrumental role in community integration for many people. Several of the sites provide more than 1,000 rides per year to people who otherwise would have no transportation. PTS also arranges social outings, such as trips to yard sales or bowling nights. A growing number of rides are for job interviews and the first few weeks on a job, when meeting transportation costs is still difficult. PTS is exploring additional funding sources for this employment-related transportation. Currently, PTS receives reimbursement for its operating expenses from the State through Community Mental Health Services Block Grant funds administered by the Federal Substance Abuse and Mental Health Services Administration. These funds pay for gasoline and repairs, but PTS is not allowed to use the funds to purchase vehicles. Its vehicles have been donated. Although the program has been very successful, its wide service area makes gasoline costs significant. Because the program relies on donated vehicles that often are older models, repairs costs are also significant. Volunteer-Augmented Programs. Some remarkable programs have made great strides in alleviating local transportation shortages by using differing combinations of paid staff and volunteers, program vehicles and personal vehicles. By using volunteers and personal vehicles, a nonprofit transportation program can provide rides to a broader group of people for a wider variety of purposes than a program that is funded for a specific type of transportation. The Community Association for Rural Transportation (CART) in Rockingham County, Virginia, is an excellent example of a program that seeks to provide rides to as many people as possible for whatever reasons they need rides. CART’s motto is, “Getting people where they need to go.” CART is a nonprofit agency with an active board of directors and a large group of volunteer drivers. In a semi-rural county with several large employers but limited public transportation, CART serves anyone who is 65 or older, anyone who has any type of disability, and anyone who has a family income below the Federal poverty level. CART operates as a combination service broker and transportation provider. Some rides are provided by a private taxi service subsidized by CART, and some rides are provided by CART volunteers using either their own vehicles or one of CART’s vehicles. CART has a wheelchair accessible vehicle available for volunteers to use and provides thorough training in how to operate it. People can ride CART for any purpose they desire; thus, CART fills the gaps left by programs such as Medicaid transportation. When someone first calls CART, a staff person completes an intake form that establishes whether the caller is eligible for CART’s services, and equally important, whether the caller is eligible for rides from other services, such as Medicaid, the American Cancer Society, or paratransit. CART makes optimal use of its ability to offer rides by not providing rides that could be made available by other means. Of course, someone eligible for Medicaid transportation for medical purposes can use CART for nonmedical purposes. CART holds down costs by setting a weekly limit on nonmedical trips. “Getting someone to the beauty shop should be just as important as getting
someone to a medical appointment.” Once someone’s eligibility for CART services is established, he or she may arrange a ride by calling the participating taxi company or the CART staff, who can arrange a ride through the taxi company or a volunteer driver. Riders make a co-payment of $3, $5, or $10, depending on distance. One-day notice is required for local trips, and 3-day notice is required for trips to medical centers outside of the area. To ensure everyone’s safety, CART screens its volunteers by checking driving and criminal records, and by requiring proof of auto insurance. CART provides excess liability insurance to its drivers, which helps to protect volunteers against awards above their own insurance coverage limits. CART also offers mileage reimbursement; however, most volunteers decline the reimbursement and instead deduct the mileage on their tax returns. Volunteers always are free to accept or decline a trip. In addition to the use of volunteer drivers, another key to CART’s flexibility has been its diversified funding sources. Initially funded by a local Disability Services Board, CART has since received funding or vehicles from the county government, the Virginia Department of Rail and Public Transportation, retirement communities, the United Way, the State Department of Aging, the Virginia Health Care Foundation, and the local Area Healthcare Education Center. CART has also received a major grant from the Merck & Company Foundation. “(A) problem arises when a customer needs a ride from one publicly funded
service area to another, and the transportation provider is not permitted to
cross an imaginary administrative or political boundary that has nothing to
do with the customer’s transportation needs.” In Portland, Maine, Independent Transportation Network (ITN) relies on volunteer drivers to provide transportation to older adults. To help older adults who can no longer drive maintain their mobility and still feel comfortable, ITN uses unmarked cars to make riders feel less conspicuous when using the service. ITN requires membership. Members pay monthly into a prepaid account, so mileage and pickup charges can just be deducted from their account. Riders receive discounts in exchange for booking rides in advance or sharing rides, but riders also have the flexibility of not having to plan ahead or share rides. ITN also maintains flexibility through its selection of funding sources. It has chosen to forgo public funding, which its founder believes would result in rationing rides and limiting service areas. ITN relies heavily on user fees as well as financial and vehicle donations. It also has adopted some innovative approaches, such as helping an older adult sell his or her car and applying the proceeds to a prepaid ITN account, and providing stickers good for ITN credit that merchants can give to customers in place of validated parking stickers. For organizations interested in using volunteers to provide transportation, the Community Transportation Association of America (CTAA) offers a detailed publication, Volunteers in Transportation—Some Issues to Consider, which is available online at http://www.ctaa.org/data/rtap_volunteers.pdf. Travel Vouchers. In rural areas throughout the Nation, communities have initiated travel voucher programs that differ from other programs discussed in this report in that they do not rely on specific forms of transportation. Rather, participants are free to arrange their own rides and to present a voucher that is reimbursed by the sponsoring agency to the ride provider. Rides can be provided by taxi services, public transportation, and even friends and family—all of whom are reimbursed by the agency issuing the voucher. Even a service agency that maintains vans for a particular purpose, such as transporting older adults to senior centers, can offer its vans for other uses that can be reimbursed through these vouchers. Although the sponsoring agency might offer a list of potential transportation providers, the program participant has the flexibility to seek other arrangements if he or she prefers. The sponsoring agency issues travel vouchers with carbon duplicates to eligible participants who, in turn, present vouchers to the persons providing the rides. The person providing the ride then submits the voucher to the sponsoring agency for reimbursement, usually based on a fixed rate per mile. Depending on their funding sources, sponsors of voucher programs have a great deal of flexibility in determining who is eligible to receive travel vouchers as well as the purposes for which the vouchers may be used. In Montana and South Dakota, for example, participants in a demonstration project were people with a wide range of disabilities who used vouchers for employment, medical, daily living (e.g., shopping), and social purposes (Bernier and Seekins, 1999). In a pilot project being conducted by the Association of Programs for Rural Independent Living (APRIL) in 10 communities nationwide, vouchers are issued to people with disabilities who must use them for employment-related purposes. Dennis Stombaugh of APRIL noted the impact the voucher program can have for mental health consumers. Of one program participant he said, “He only worked one-and-a-half hours on Saturday and one-and-a-half hours on Sunday, but the opportunity to be out in the community meant a lot to him.” Voucher programs are very flexible because they allow participants to take advantage of whatever transportation opportunity is available. They also encourage social service agencies to use their vehicles to serve more people. The individual choice associated with vouchers makes them “compatible with an independent living philosophy that calls for maximizing individual control and community integration of people with disabilities” (Bernier and Seekins, 1999). Voucher programs also are eligible for Federal funding under FTA’s Capital Assistance Program for Elderly Persons and Persons with Disabilities (49 U.S.C. 5310, known as Section 5310 ) and Nonurbanized Area Formula Program (49 U.S.C. 5311, known as Section 5311) discussed in the next section. For organizations interested in travel voucher programs, the Research and Training Center on Disability in Rural Communities offers a detailed publication, Making Transportation Work for People with Disabilities in Rural America, available online at http://rtc.ruralinstitute.umt.edu/Trn/TrnManual.htm. APRIL also is developing a toolkit to help interested entities start and run a voucher program. Coordinating Transportation Resources Traditionally, Federal funding for transportation for people with disabilities and other people considered to be “transportation disadvantaged” has been a confusing patchwork subject to conflicting regulations. These conflicting regulations have resulted in considerable waste, such as when several programs drive half-filled vans on similar routes because they each serve a different clientele. The President issued Executive Order 13330 requiring coordination of Federal transportation programs to encourage programs to serve people more effectively. Noting that “Federally assisted community transportation services should be seamless, comprehensive, and accessible to those who rely on them for their lives and livelihoods,” the President established the Interagency Transportation Coordinating Council on Access and Mobility with representatives from the Departments of Transportation, Health and Human Services, Education, Labor, Veterans Affairs, Agriculture, Housing and Urban Development, Justice, and the Interior as well as the Social Security Administration. A central goal of the Council is to “promote interagency cooperation and the establishment of appropriate mechanisms to minimize duplication and overlap of Federal programs and services so that transportation disadvantaged persons have access to more transportation services” (Executive Order 13330, February 2004). Some States already have taken the initiative to coordinate transportation services and, as a result, are able to provide more services at a lower cost. In Florida, the Commission for the Transportation Disadvantaged monitors transportation throughout the State for people who are unable to obtain transportation because of their age, disability, or income. Its authority covers transportation programs both for general purposes such as shopping and social visits, and for special purposes such as medical transportation—any program receiving State or Federal funding to provide transportation to “transportation disadvantaged” people. The Commission oversees a network of 49 Community Transportation Coordinators (CTCs), which can be government agencies, private businesses, private nonprofit agencies, or transit authorities. These CTCs contract with transportation providers and are responsible for spending money in a cost-effective way and for monitoring fraud. An individual who needs a ride contacts the local CTC, which, in turn, determines eligibility and arranges for the appropriate service. Funding for transportation comes from various programs, such as Medicaid, the State Department of Children and Families, and the State Department of Elderly Affairs. For rides not covered by specific programs, funding might be available through the Transportation Disadvantaged Trust Fund, which receives money from the State’s transportation budget, from license tag sales, and from sales of temporary disabled parking permits. However, funding limits prevent a great number of requests for rides from being met; in 2002, over one million requests went unfulfilled. Nonetheless, the program has been successful in maximizing transportation with the funding available, with an average trip cost of under $6. Extensive information about the Commission’s methods is available directly
from the Commission. In addition, the National Governor’s Association has produced
an in-depth report, Improving Public Transportation Services through Effective
Statewide Coordination, which is available online at http://www.nga.org/cda/files/011503IMPROVINGTRANS.pdf. |
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