It is well-known that one of the most common barriers to care faced by patients—and one of the most often dealt with by navigators—is transportation. When patients do not have reliable transportation, they cannot receive care for their cancer. This has a clear and significant impact on patient outcomes.
Rachel Marquez, BS, MPH, regional operations leader at Galileo Health, was determined to change this and set up a thriving pilot transportation program at her cancer center, Cone Health. Not only did this program significantly increase the number of patients in the community who could reliably access care for their cancer, it also undoubtedly demonstrated the value of navigation.
“It takes money to set up these programs, and it can be a hard sell, especially after COVID,” she said. “But it essentially pays for itself.”
At the 2022 AONN+ Midyear Conference in Austin, TX, Ms Marquez detailed the challenges involved in implementing a transportation hub and the positive impact it had on her community.
The Cone Health Cancer Center is located in Greensboro, NC. “We are the largest employer, and we care for a lot of patients with cancer, specifically in radiation oncology,” she said.
Prior to the implementation of the pilot project, Cone Health already had a robust offering of gas cards and bus passes for patients who indicated a transportation need, but a long history of racism and socioeconomic disparities had left many in her community cut off from access. She pointed out an 18-year life expectancy gap between 2 racially disparate communities separated by less than 4 miles.
“I knew going in that we had a historical context that we had to overcome,” she said.
Also at play was the movement of healthcare from inpatient to outpatient. “It’s a lot of visits for patients, and they’re coming to us where we’re located,” she said. “And of course, we’re not anywhere convenient. I think that’s important in understanding the problem.”
Analyzing the Data
“I understood the problem holistically, but I wanted to understand the problem for individual patients,” she said. “I wanted to see who was really at risk for not coming to their appointments or delaying their care.”
So, the data and analytics team at Cone Health analyzed all cancellations and no-shows and stratified them by factors such as race, payer, age, time of day, and zip code.
The analysis revealed that disparities came down to zip code. Collectively, the cancellation rate across the entire cancer center was about 6.1%. However, 2 specific zip codes in historically redlined communities in southeast Greensboro had cancellation rates of 12% and 15%.
Redlining goes back to the 1930s, when the government withheld investment opportunities and economic development from communities of color. In addition to insufficient public transit, people of color in these communities are less likely to have a car at home.
“This helped us to understand conceptually what we had to do,” she said. “We knew who was affected and what the problem was in the community; that helped us move toward potential solutions.”
Strategies for Solutions
First, Ms Marquez set out to leverage Cone Health’s brand promise: “We’re right here with you.”
“We weren’t meeting on that promise by offering bus passes and gas cards,” she said. “We weren’t ‘right there’ with patients that were navigating multiple cancer appointments.”
She decided that solving this would involve providing direct transportation services through partnerships/programs, educating staff about transportation issues (and the appropriate time to have these conversations with patients), and promoting transportation options so that patients knew they had these options available to them.
The Pilot Program
The pilot transportation program was built around an online transportation platform that allowed for the use of rideshare options like Lyft and Uber.
“This was great for urban areas, but Lyft and Uber coverage is almost nonexistent in rural areas,” she said. “So we also developed a network of local nonemergency medical transportation (NEMT) providers.”
NEMT—consisting of local medical sedan and wheelchair transport providers—were also accessed through an online platform and could be scheduled in advance or requested as soon as a patient needed them.
“Since we were offering quite a few trips, we were able to negotiate contracts to make rides with NEMT providers a little cheaper,” she noted.
According to Ms Marquez, throughout the program, continuous conversations with patients led to a greater understanding of whether transportation was a barrier to them accessing medical care or other necessities of daily living.
If they indicated that transportation was indeed a barrier, they were then asked if they wanted assistance, and that triggered their enrollment in the transportation pilot program, she explained.
Barriers to Implementation
“I want to say that it was as simple as that. I got finances and operations on board, and we were able to start offering transportation to our patients. But we ran into a huge snag with our Risk and Compliance individuals,” she said.
They started raising questions like “What if a patient gets in a car accident in a ride that we paid for on the way to their treatments?” “What happens if they get dropped off at the wrong place?” “What happens if they get in the wrong car?” “We’re sharing patients’ names, phone numbers and addresses, so what about HIPAA?” According to Ms Marquez, if you can think of a possible scenario, they raised it.
Although addressing all of these questions was a long process, she was determined to get the program up and running. “I answered all of their questions and mitigated all of the risks,” she said. “We developed rider safety tip sheets in the 5 main languages we use for the patient populations that we serve.”
In addition, they developed rider waivers releasing them from any liability, as well as internal policies and procedures that allowed the program to establish criteria for the use of the transportation services.
“What happened after we implemented the pilot was so much more than we could have hoped for,” she said. “Our initial goal was just decreasing no-shows and cancellations, but that’s not all we did.”
According to Ms Marquez, the transportation program decreased staffing costs associated with those no-shows and cancellations, decreased the disparities that existed for patients completing treatment, and increased completion rates for treatment. Patient satisfaction was also increased, along with revenue due to more appointments taking place.
“They gave me enough money to run it for 6 months, and afterward, when I showed that we made over $60,000 after paying for transportation costs, they told me to go ahead and keep doing it,” she said.
The overall no-show rate in the cancer center dropped from 6.1% to 3.2% in 6 months, but specifically in the zip codes that were identified, implementation of the transportation hub eliminated the disparity entirely. The 2 areas with cancellation rates of 12% and 15% dropped down to 1.2% and 1.3%, respectively.
“This was due to understanding specifically the individuals that were affected and proactively offering transportation prior to a missed appointment or a delayed care event,” she said.
Patients were issued surveys after each ride, and when asked if they would have been able to attend their appointment if the Cone Health program did not exist, 94% answered that they would not have been able to attend.
Ms Marquez was able to leverage the return on investment of the program—as well as the impact on health equity—to establish a transportation services department, which is now expanding outside of cancer care to other departments within their health system.
“This department is not just about getting patients from point A to point B,” she said. “It’s meant to be used as a tool to promote equitable health outcomes for our community by implementing proactive and innovative care plan interventions that remove barriers of access and transportation.”