Se Lucile Packard Foundation
ZS /0r Children's Health

Case Study

Partnering to Create
Transportation Options for
Families of Children with Special
Health Care Needs

 

San Joaquin County 5Cs

Prepared By
Leslie S. Linton, JD, MPH

September 2020
www.|pfch.org/cshcn

ABOUT THE AUTHOR:

Leslie Linton, JD, MPH, is a research and evaluation consultant based in San Diego, California.
She has led evaluation activities for the California Community Care Coordination Collaborative
(SCs) and its county coalitions across three phases of the program. A former lawyer, Leslie has a
special interest in the impact of policy and systems on public health. In addition to her interest in
systems change to support children with special health care needs and their families, she continues
to investigate how policy and environment can support active living and healthy eating to prevent
childhood obesity.

The author gratefully acknowledges the generosity of each of the interviewees (see Appendix: List
of Interviewees) in sharing their time and expertise.

SG Lucile Packard Foundation
ZX jor Children's Health

400 Hamilton Avenue, Suite 340, Palo Alto, CA 94301 (650) 497-8365

www.Ipich.org

ABOUT THE FOUNDATION: The Lucile Packard Foundation for Children's Health is a public
charity, founded in 1997. Its mission is to elevate the priority of children's health, and to increase the
quality and accessibility of children's health care through leadership and direct investment. Through
its Program for Children with Special Health Care Needs, the foundation supports development of

a high-quality health care system that results in better health outcomes for children and enhanced
quality of life for families. The Foundation works in alignment with Lucile Packard Children's
Hospital Stanford and the child health programs of Stanford University.

Support for this research was provided by the Foundation. The views presented here are those of the
authors and not necessarily those of the Foundation or its directors, officers, or staff.

The Foundation encourages dissemination of its publications. A complete list of publications is
available at http:/www.lpfch.org/publications

Sign up for updates from the Foundation, including information on new publications, at
http://www.lpfch.org/cshcn/join-us
Lucile Packard Foundation for Children's Health

 

Table of Contents

3 Setting: San Joaquin County, California

4 Thelnception of San Joaquin 5Cs: A Collaborative of Agencies Serving
Children with Special Health Care Needs

5 A Coalition Process

8 The Development of Care Connection
10 Successes

13 Challenges

16 Still Moving Forward

18 Appendix: List of Interviewees

19 References

Pe Partnering to Create Transportation Options

 
www.|pfch.org/cshcn

"We have no major medical center in the county, so a lot of our kids go either to Davis or the Bay
Area. This is true for surgery, for sure, but also for heart specialists, pulmonary care specialists,
neurological specialists... We were told that families were canceling their appointments - families
weren't getting there. So we thought we should find out what the available transportation is. We
found 26 or 30 agencies that said they provided Medical Transport. Come to find out, there was
only one going out of county and at one point there was zero out of county transport. It turns out
they were not being paid for wait time, and so why go out of county when you could do six runs in
the county in the time it would take to take someone to Davis." - Ann Cirimele, former Director of
Family Resource Network and former 5Cs Project Director (interview in 2017 about why the 5Cs
Collaborative began working on access to transportation issue in 2015).

Setting: San Joaquin County, California

ocated in California's Northern Central Valley and east of the San Francisco Bay Area,
San Joaquin County has a total land area of more than 1,400 square miles. Children under
the age of 18 make up 26.8% of the county's total population of 762,000.' In San Joaquin
County, 16% of these children are estimated to have special health care needs, a prevalence
exceeding the overall prevalence in the state of 15%."

For many of these children, health care needs are profound. In San Joaquin County, 3.5% of chil-
dren have major disabilities compared to 3.1% of California, overall.? As of 2014, more than 4,200
children in the county were served by California Children's Services (CCS), a statewide program
that provides funding for treatment of children with certain physical limitations and chronic health
conditions or diseases.* Enrollment in Medi-Cal, California's Medicaid program, is also higher in
San Joaquin County, with children under 21 enrolled at a rate of 57.4% compared to California's rate
of 49.7%, as of 2018.° Medi-Cal in San Joaquin County is administered by two health plans, Health
Plan of San Joaquin with approximately 90% of enrollees, and Health Net with 10% as of 2019.

The county grapples with a shortage of health care resources and does not have a local children's
hospital. There is a shortage of physician specialists, as well as primary care providers. San Joaquin
County is located in a part of California that is designated as a Health Professional Shortage Area
by The Health Resources Services Administration.' The area of California known as the San
Joaquin Valley, of which San Joaquin County is a part, has just 39 primary care providers per
100,000 population compared to the recommended ratio of 60-80 per 100,000. The San Joaquin
Valley has just 65 specialists per 100,000 versus the recommended range of 85-105.' A 2019 report
of The California Health Workforce Commission warns that this disparity is growing and that
demographic trends portend future shortages.'
Lucile Packard Foundation for Children's Health

 

The Inception of San Joaquin 5Cs: A Collaborative
of Agencies Serving Children with Special Health
Care Needs

ith the assistance of a grant from the Lucile Packard Foundation for Children's Health

(LPFCH),' San Joaquin County SCs began working to improve systems of care

for children with special health care needs (CSHCN) in January 2015.° The group
built upon previous local collaboratives serving CSHCN to establish their county-based "5Cs"
group - San Joaquin's California Community Care Coordination Collaborative." With Family
Resource Network serving as the lead agency, the 5Cs Collaborative also included commitment
and participation from San Joaquin County Public Health Services, California Children's Services,
Valley Mountain Regional Center, First 5 San Joaquin/Help Me Grow San Joaquin County, Health
Plan of San Joaquin, and many other health care providers and school districts.

The 5Cs Collaborative baseline survey of its membership identified the need to access medical

care outside the county (usually in the San Francisco Bay Area) as a major challenge for families

of children with special health care needs. It typically takes two hours or more, one-way, to travel
to facilities in the Bay Area. Many San Joaquin families and the agency representatives who serve
them had reported that they could not secure transportation, frequently resulting in rescheduled and
missed appointments. This led the 5Cs Collaborative, in addition to pursuing broad issues of care
coordination at monthly or every other month meetings of the partners, to investigate what types of
systems changes would ease transportation problems faced by families.

The 5Cs Collaborative planned to prepare a guide identifying available resources for families, but
learned in the process of contacting the 26 licensed vendors in the county that only one, and, at one
point, no vendors were willing to actually provide these services. The vendors cited low reimburse-
ment rates and a preference for local trips because payment for out-of-town trips did not compensate
them for the lengthy and time consuming trip out of the county, including waiting time. The 5Cs
Collaborative prepared a memo about this lack of resources and circulated it widely, including with
local political figures, putting the issue on the agenda for a number of agencies.

5Cs Collaborative members continued to pursue change after their LPFCH grant had concluded in
the summer of 2016. Inspired by the possibility of making better transportation options a reality for
San Joaquin County families, the group applied for a new LPFCH grant and was issued a $12,000
grant for the period September 1, 2017, through August 30, 2018. The scope of the new grant was
to support the 5Cs Collaborative's work on systems change, including a plan to partner with San
Joaquin Council of Governments, coordinate payer agencies to support clients to use a new system,
and coordinate messaging information among service agencies and partnerships to maximize rider-
ship.'? The two leaders of the transportation project were Kelly Mraz of First 5 San Joaquin, and
Dr. Armando Valerio, Therapy Services Manager, California Children's Services Medical Therapy
Program. The story of San Joaquin 5Cs' collaborative efforts to secure and support systems change,
a new system of out-of-county non-emergency medical transportation services (NEMT), follows.
www.|pfch.org/cshcn

 

A Coalition Process

In mid 2016, Dr. Valerio met with Gary Prost, Senior Field representative for Congressperson Jerry
McNerney of California's 9th District. Dr. Valerio learned that improvements to public transporta-
tion options and the process to seek systems change were governed by the local Council of Govern-
ments. This was the second time he'd heard that the San Joaquin Council of Governments (SJCOG)
was the body with the power to fund and order changes to local transportation systems. A San
Joaquin Regional Transit District (RTD) official had also told him that changes and the funding to
support those changes would need to come from SJCOG. And so, as the initial San Joaquin County
5Cs' grant from LPFCH was concluding, Dr. Valerio made his initial appearance in front of the
full SJCOG Board in August 2016 during the time allotted for public comment. There, he shared
the purpose of the 5Cs Collaborative and the transportation challenges facing CSHCN, explaining
that the challenge was that there were no vendors offering this service. Per the minutes, Dr. Valerio
explained:

"[N]o transportation providers have been found and these are children with special health
care needs. The collaborative is looking for someone to be a champion for them because they
are running across barriers. Stanislaus County has a Medi-Van that they provide [for] medical
transportation out of their county to the Bay Area."

The Board directed SJCOG staff to collect information from the 5Cs Collaborative and to explain
processes within SJCOG that were designed to receive community requests for service additions.
In the ensuing months, Dr. Valerio and 5Cs facilitator Kelly Mraz worked closely with the SJCOG
staff. SJCOG staff explained their yearly process to identify and rectify "unmet transportation
needs," as well as the internal procedural avenue that could potentially lead to funding of services.
They would learn that "unmet transit needs" (UTN) are defined by SJCOG as "transportation
services not currently provided to those residents who would use public transportation regularly,

if available, to meet their life expectations. This includes but is not limited to: trips for medical
and dental services, shopping, employment, personal business education, social services, and
recreation." They also learned that through the Transportation Development Act (TDA), California
provides two sources of funding for public transportation, including the Local Transportation Fund
(LTF) and the State Transit Assistance Fund (STA). Funds are intended to support public trans-
portation needs. Designated funds are allocated to areas of each county based on certain formulas.
Counties with fewer than 500,000 people have the option to use LTF for local streets and road
projects if it can be shown that there are no unmet transit needs. Oversight of the process of deter-
mining whether there are unmet needs to be funded prior to further distribution is provided by the
California Department of Transportation. There are certain minimum requirements for conducting
an annual assessment to determine whether there are unmet needs in the county."

As part of its unmet needs process, SJCOG conducts an annual assessment and, using the informa-
tion gained, makes specific written findings about unmet needs. There is a two-step process in
making findings about needs:

1. An initial finding states whether each issue raised is, in fact, an "unmet
transit need" pursuant to guidelines; and
Lucile Packard Foundation for Children's Health

2. When there is an initial finding of unmet need, SJCOG uses guidelines to
arrive at a finding about whether the need is "reasonable to meet." Unmet transit
needs that are reasonable to meet must be addressed before Transportation
Development Act funds are allocated to local jurisdictions for non-transit
purposes.

The scope and nature of the assessment is described in SJCOG documentation:

In conducting the annual transit needs assessment, SJCOG's role is to perform
the following:

1. Ensure that several factors have been considered in the planning process,
including size and location of groups likely to be dependent on transit, adequacy
of existing services, and potential alternative services and service improvements
that could meet all or part of the travel demand.

2. Hold a public hearing to receive testimony on unmet needs.
3. Determine definitions for "Unmet Transit Needs" and "reasonable to meet."

4. Adopt a finding regarding Unmet Transit Needs and allocate funds to address
those needs, if necessary, before street and road allocations.

- Unmet Transit Needs Final Assessment 2017-2018."

Working with SJCOG staff, 5Cs members Armando Valerio and Kelly Mraz became immersed
in the unmet needs process and in building a plan for new transit options for CSHCN. Much of
the process is managed through the Unmet Transit Needs Subcommittee of a standing SJICOG
committee, Social Services Transportation Advisory Committee (SSTAC). Kelly Mraz and Dr.
Valerio both joined SJCOG committees as representatives of the 5Cs Collaborative. They began
attending monthly meetings and participating as regular committee members.

The 5Cs Collaborative also invited SJCOG staff to 5Cs meetings to explain the unmet needs
process, the existing county transportation services that were most accessible for CSHCN, and the
plan for public non-emergency medical transportation outside of San Joaquin County. In December
2016, 5Cs partners distributed and responded to the SJCOG annual survey designed to elicit unmet
transit needs. Through a SCs Collaborative partner, Family Resource and Referral Center, callers to
the county's line'* were invited to participate in the unmet needs transportation survey.

Following the close of the SJCOG unmet needs survey and public comment period in December
2016, the comments were compiled, and SJCOG staff noted that the most frequently requested
service was non-emergency medical transport (NEMT) to the Bay Area. The UTN subcommittee
and SSTAC committee reviewed comments and concluded that the request was, in fact, an unmet
need. Members could not reach a consensus, however, through multiple meetings, on whether the
need was "reasonable to meet," under the guidelines. SJCOG staff issued a written recommendation
that NEMT be identified as a "reasonable to meet" unmet transit need, notwithstanding the views
of SSTAC. The reasons expressed by staff were articulated in a report (included in an endnote),
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and focused on the fact that NEMT was the most requested service, that the service would benefit
disadvantaged populations, that there was considerable ridership in Stanislaus County (2,300 riders/
year) and much expressed need in San Joaquin County, and that the potential to partner with the
Stanislaus service could increase operational feasibility and save substantial cost.'5

Over the course of April, May, and June of 2017, further reviews and opportunities for feedback
about the recommendations of staff were held in multiple SJCOG committees, and 5Cs members
Armando Valerio and Kelly Mraz attended each to answer questions and offer feedback. As

with the joint meetings of SSTAC and ITC (Interagency Transit Committee), the members of the
SJCOG Citizen's Advisory Committee, the Technical Advisory Committee, and the Management
and Finance Committees all ultimately voted to recommend that there be a finding of an unmet
transit need that was not reasonable to meet. Reasons expressed largely focused around insufficient
ridership information and concern about cost effectiveness as well as funding. There was concern
expressed about impact to local community funding. The Executive Committee did vote to
recommend that NEMT be affirmed as an unmet transit need that was reasonable to meet as
recommended by SJCOG staff.

With this contradictory set of votes, the issue came before the full SJ}COG Board. On June 22, 2017,
SJCOG staff presented an overview of the process and committee votes and recommended that

the Board defer a final decision as to unmet transit needs and set aside $35,000 for implementation
studies about NEMT and another request for new transit service. Dr. Valerio brought a pediatric
wheelchair with a doll with braces and showed the Board a video he had made of a family with

a child with special health care needs. Kelly Mraz, responding to the concerns expressed in
committees about lack of data about numbers of patients requiring transportation from the County
for medical care in the Bay Area, read emails with information gathered from social workers based
at Bay Area providers and from local medical personnel. Tammy Evans, San Joaquin Public Health
Services Director, spoke of the universal benefit that improved transportation options could offer to
a great variety of patients. The president of Cancer Kids of San Joaquin County also spoke of the
considerable benefits the service could provide for the families reached by Cancer Kids.

After considerable discussion, the Board voted, five votes to four votes, to adopt findings that
NEMT is an unmet transit need that is reasonable to meet, and to set aside budget authority of
$250,000 to address development of service implementation of an NEMT service. The Board
stipulated that initial expenditures were limited to planning and that further Board approval would
be required before funds were spent for operations.
Lucile Packard Foundation for Children's Health

 

The Development of Care Connection

From July through October of 2017, RTD developed a service plan as contemplated by the SJCOG
Board. There were periodic meetings with 5Cs representatives during this timeframe to answer
questions and plan for potential rollout of services and promotion of those services to families and
agencies that might refer or pay for transportation services. The 5Cs partners were ideally situated
to partner in this effort.

"We can relay info back and forth to agencies who work with people whose
mobility is limited. So it's a good partnership for us - absolutely."

- Kelly Mraz, First 5 San Joaquin

"Working with Kelly and 5Cs has brought a lot of light to new ideas for mobility
options. It's given us new ideas."

- Bea Thao, Mobility Analyst, RTD

Ultimately, RTD developed a service plan which it presented to the SJCOG Board in October and
November 2017 with 5Cs members in attendance. The plan, which was ultimately launched in the
spring of 2018, identified the following Care Connection services to be implemented:

© Bay Area service via Stanislaus Regional Transit (StaRT) Medi-Van: Stanislaus County has
operated a Medi-Van service from Modesto to the Bay Area, four days per week for many years.
The service provides stops at medical facilities in Livermore, Oakland, San Francisco, Palo
Alto and other Bay Area locations. RTD negotiated with StaRT to add a connection stop in San
Joaquin County (Tracy) on the Medi-Van route. Passengers can access the service on their own,
or can use an RTD contracted "curb-to-curb" service via Uber or Journey Via Gurney (JVG) (for
customers functionally requiring that level of service). Pricing was ultimately $9 for Medi-Van
and $3 for connector service, per trip.

© Bay Area service via existing routes: ACE trains provide four roundtrips daily and RTD
Commuter Route 150 (bus) provides nine roundtrips daily to BART stations. The new services
added were the optional connections from home either by Uber or JVG as described above,
however passengers would need to book their own way from the train and bus route stops to
medical facilities.

© Sacramento service via existing commuter routes: RTD's added service allowed passengers
to access medical destinations in the Sacramento area after regular commuters were dropped
downtown with service to be requested in advance. Connection service, as above, available.
Pricing: regular fare of $7.

© Coordination services by RTD to allow inquiries and booking by passengers.

In April 2018, RTD launched the bus service to Sacramento, and in May launched the connection
services from passengers' homes. Service to the Bay Area via Medi-Van began operating in

June 2018, following delays in negotiations with StaRT, which was operating the Medi-Van from
Stanislaus County and had to agree to offer the stop in San Joaquin County.
www.|pfch.org/cshcn

The coordination services offered by RTD included telephone access to a trained outreach specialist
who responded to inquiries and advised customers about the available routes and how to access
them. Whether a prospective rider began the process through a telephone call or online, the initial
step was to fill out a registration form, available online. The coordinator filled out the form on
behalf of the passenger when inquiries came by telephone and also processed the registration forms
filled out and submitted online. Riders who wished to access the Medi-Van service to the Bay Area
were directed to contact StaRT to make a reservation. Riders who wished to travel to Sacramento
worked with the coordinator to arrange their stop. The Care Connection Coordinator arranged all
requested connections from passengers' homes to the Tracy stop to access Medi-Van, to the other
existing routes to the Bay Area, and to the bus stops for the Sacramento commuter routes. Ifa
connection was requested, the coordinator determined if the rider required Journey Via Gurney
service (for those requiring specialized medical accommodation) or Uber service and arranged the
initial pick up and return drop off, as requested.
Lucile Packard Foundation for Children's Health

 

Successes

Key Stakeholders

As seen above, the San Joaquin 5Cs Collaborative has been committed for the long haul, having
pursued the transportation issue for more than three years. This is an example of the importance
of a stable and consistent coalition that has a range of members who can draw on their collective
knowledge and networks to marshal data and information to support system change and to
advocate on behalf of CSHCN. With a coalition, too, there is more likely to be accountability

and maintenance of system changes over the long term, which is important for CSHCN. While it
appears that out-of-county transportation barriers in San Joaquin have abated, the presence of the
5Cs Collaborative makes it more likely that this will be monitored over time.

The network of partners in the San Joaquin 5Cs was indispensable to ultimate success. By way of
example, only, they prepared and submitted letters of support, circulated transportation surveys,
supported 211 access to clients to respond to transportation surveys, and helped accumulate
supportive data. They helped plan and promote the new transportation services, once in place.
The Director of Public Health Services supported Dr. Valerio in taking time from his duties to
participate in seeking this system change and also made an in-person appearance at the Board
hearing the night of the final vote to testify in support of the 5Cs mission there. Transportation
has become a familiar service structure to many San Joaquin County social and health service
community agencies as a result of these efforts.

The 5Cs team did not attempt to simply ask for changes at SJCOG and RTD without offering to
help in the process. They fully engaged, joining committees and partnering with those who knew
the system. They showed up, month after month, year after year. They worked with staff, gathering
information that was requested and partnering to brainstorm how to promote the new service. The
5Cs experience in transportation services broadened horizons for its partners, as well. Kelly Mraz,
who initiated new programs for First 5, advises, "Before it would not have occurred to me when
setting up a project to bring somebody from transportation. And now, I don't think I would set

up a project without bringing someone in." And RTD's Bea Thao says their organization, as well,
has benefited from the partnership. [The partnership] "has brought a lot of light to new ideas for
mobility options."

SJCOG was, and is, a key stakeholder. As the governing body that identifies local transit needs and
administers transportation funding, no system change was possible unless that body understood and
embraced the needs of local patients. As seen above, the process was complex, with deep regulatory
content and institutional process that was completely foreign to 5Cs representatives. The availability
and assistance of committed SJCOG staff was critical to the ability to traverse nearly two years

of processes before service changes were ultimately implemented. SJCOG staff are extremely
knowledgeable of the law governing unmet need and maintained a steady process, even in the face
of multiple negative votes at committee presentations prior to the final vote before the Board. The
5Cs team saw SJCOG staff as key partners in their own right.
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RTD, became a key partner after the SJCOG Board found NEMT to be an unmet transit need and
asked RTD to develop services in response to the need. RTD partnered with the 5Cs Collaborative
to identify the best ways to promote the new services, including attending 5Cs meetings to present
information for circulation to member agencies and providers who interfaced with families likely to
need out-of-county transportation. RTD developed a connection service and coordination service to
improve the likelihood that riders could understand the various services offered and to assist them in
planning their out of county appointments.

The partners in 5Cs were critical, throughout this process. At the outset, they were the source

of information from families about the nature of the problem. They worked diligently to catalog
and investigate transportation vendors and define the problem in a transportation memo that they
shared widely toward the close of their first LPFCH grant. They circulated the memo widely, but
did not stop their efforts on behalf of CSHCN during a lengthy period when they had no funding
or mandate to continue their work. They searched for possible solutions, and when SJCOG was
identified as a partner that could help effect change, they waded into the very deep waters of
transportation law and policy. This was a completely foreign world, as 5Cs primarily "lives" in the
disciplines of health and social services. Exercising diplomacy and determination, they learned the
lay of the land, found allies, and continued to support the efforts of their partners.

The 5Cs team was able to find allies at different points in time that bolstered their case. For example,
although the Director of "Cancer Kids" had never been part of 5Cs, his testimony in front of the
SJCOG Board was persuasive and may even have been more helpful because he was not part of the
5Cs Collaborative. It strengthened the premise that out-of-county transport was a need that spanned
across the community. Although the 5Cs is focused on children, adults and others who require
non-emergency medical transportation (NEMT) also stood to benefit, and this made the issue one of
even broader concern for the entire community, and one that Board members could relate to.

By broadening the concerns beyond CSHCN to include all children and all adults who might now or
someday need NEMT, most people could envision some personal impact. While it would have been
impactful to bring actual families of CSHCN before the SJCOG, that was not possible. Instead,

Dr. Valerio brought a pediatric wheelchair together with a doll fitted with braces typically seen on
children in his clinic. He brought a video he'd made of an interview with a family that struggled
with transportation. This took the issue of transportation out of the realm of abstract problems and
cost effectiveness considerations and focused concern on the disadvantaged population that required
the systems change.

Changes to the transportation system did not come easily or quickly. There were years of work and
much negative pushback before the 5Cs got a "yes" from policymakers.

"Even SJCOG staff who were concerned the COG board would not support the
proposal indicated they would be changing their recommendation to the Board
to vote on allocating $35,000 to study the proposal further...and we said we were
going forward with our presentation to the Board anyway."

- Armando Valerio, DPT
Lucile Packard Foundation for Children's Health

As it happens, on a parallel track, advocates were also working on systems change in the state
legislature to improve Medi-Cal coverage by incorporating transportation services to specialty
medical services, pharmaceutical services, and even behavioral health services. And that system
change may have solved the problem even more completely than the addition of services ordered by
SJCOG.

"Health care delivery and financing is never ending change. The only thing you
can do is keep standing up for the powerless people. I did not have any second
thoughts. And you know why? It's because I knew who I was advocating for.
And because the program I run is CCS [supported] and we provide care to these
children. So I knew intimately who it was that I was fighting for. So I never
thought am I going to give up? If they say no in the end, then at least I can say
that I tried for the kids."

- Armando Valerio, DPT
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Challenges

Timing

As of February 2019, ridership on Medi-Van was low. The RTD mobility analyst who answered
inquiries and arranged connections reported that 14 registrations had been completed and eight
"trips" (each one-way ride counted as a "trip"). This was likely a total of four riders. As of February

2019, there had been no trips on the commuter routes to Sacramento. There was one registration for
that route, but the rider later canceled.

The 5Cs journey to secure transportation options for families of CSHCN was a lengthy and
demanding one that involved multiple agencies and systems. The Stanislaus County StaRT
Medi-Van had been very successful in serving county clients for many years. The SJCOG record
during hearings shows that the Medi-Van generated 2,300 rides per year from Stanislaus County
to the Bay Area. The level of frustration expressed among patients and providers in San Joaquin
County with transportation to the Bay Area, combined with the fact that San Joaquin County has
a 35% larger population than Stanislaus County, led the 5Cs Collaborative to believe the service
would be very well used.

The reason for low ridership on Care Connection transit may not be fully understood. However,

a change in transportation benefits provided by Medi-Cal is a likely explanation. California's
Assembly Bill 2394, technically effective July 1, 2017, but likely not fully implemented immediately,
expanded the obligations of Medi-Cal to offer transportation services to medically necessary
treatment appointments.!* The legislative history of the bill reveals that much of the motivation by
sponsorship of the bill was the plight of residents in rural areas and specifically acknowledges the
need for residents to access care to specialists some distance from their homes, often on an ongoing
basis. The bill's author notes that even though previously existing law assured many transportation
benefits, the availability of transportation and implementation of these benefits varied widely across
the state.!"

An "All Plan Letter" to California's managed Medi-Cal health care plans (MCPs) following the
bill's effective date clarifies the existing as well as the expanded obligations of health plans.'* The
law expanded access to transportation benefits for recipients who do not require medically equipped
vehicles (NMT - nonmedical transportation) and coordination and reimbursement requirements

are set forth. Concerning NEMT (non-emergency medical transportation), the letter clarifies and
underlines the obligations of health plans:

MCPs are required to provide medically appropriate NEMT services when the member's
medical and physical condition is such that transport by ordinary means of public or private
conveyance is medically contraindicated and transportation is required for obtaining medi-
cally necessary services. MCPs are required to provide NEMT for members who cannot
reasonably ambulate or are unable to stand or walk without assistance, including those
using a walker or crutches. MCPs shall also ensure door-to-door assistance for all members
receiving NEMT services.
Lucile Packard Foundation for Children's Health

The law's affirmative duty on health plans to assure transportation services for their members is
believed to have changed practices among payers for services accessed, including the Medi-Cal health
plans covering patients in San Joaquin County. Both plans serving the county are reported to have
contracted with a service that coordinates and facilitates transportation requests from patients as of
October 2018.

Logistics

The RTD and 5Cs partners conducted a promotional campaign for the new services, marketed as "Care
Connection." Promotional efforts included:

© Brochures
© RTD website information

® Radio and television promotions. A video was produced by RTD."

Yet as of the end of June 2018, only one rider had used the Care Connection system. In July 2018 a
more targeted outreach and promotion campaign was conducted to agencies with eligible clients for the
Care Connection service. Promotional efforts included:

© Outreach to medical clinics and providers, including personal discussions and presentations about
the services and how to access them

© Presentations by 5Cs partner agencies and communications to SCs members to circulate
to agencies

© Inclusion of information in multiple listservs circulated to agencies and providers likely to work
with prospective users of the new services.

The transportation coordinator at Valley Mountain Regional Center voiced an objection, early on, as
to the difficulties posed by requiring customers to purchase tickets directly from StaRT for the Medi-
Van. She pointed out that many potential riders do not have credit cards and could not be expected to
buy their tickets online. RTD responded to this concern by buying some tickets to make available for
cash purchase at Stockton's RTD downtown transportation center. Even with this accommodation, it is
possible that working through multiple transport systems (RTD for connections and StaRT for Medi-
Van) is difficult for riders and for payers who would be motivated to provide the most efficient service
possible.

"... a little difficult because you almost had to have the health plan pay for the ticket or reim-
burse the client for the ticket and you needed two kinds of tickets - one for the servicer coming
from Modesto [Medi-Van] and another one coming from RTD [connection trip]."

- Armando Valerio, DPT

"Health plan has been giving people [in Stanislaus County] tickets to ride the van from Stan-
islaus County [StaRT Medi-Van] for years. But we do not believe they have been doing that in
our County since we got the new service."

- Kelly Mraz, First 5 San Joaquin
www.|pfch.org/cshcn

"We are asking different agencies to change their practice. I think most agencies who
provide transportation out-of-county already have vendors set up. So, when their client
calls, they can just easily forward that call or trip to the vendor. Whereas with this, it
requires some coordination with RTD, and I just think that extra level of work doesn't offer
them an incentive to change. That's just my personal opinion."

- Toan Tran, RTD

The 5Cs Collaborative tried on multiple occasions to identify those at Health Plan of San Joaquin
who are responsible for transportation coordination, but were unsuccessful in identifying the health
plan's considerations and potential for using public transportation for medical services outside the

county.
Lucile Packard Foundation for Children's Health

 

Still Moving Forward

hen the SJCOG Board approved and funded new transport options in San Joaquin

County, they did so with the provision that at the end of one year of service, SJICOG

would review ridership and performance to make a decision about whether to maintain
or discontinue the current service. At the time this report was written, the one-year period was
to expire in April 2019 for the Sacramento routes and in June 2019 for the Medi-Van service. It
appeared this matter would be scheduled for review and discussion in April or May 2019. There was
the possibility that the Medi-Van stop in San Joaquin County could continue in light of the fact that
there were no ongoing costs for RTD, other than supporting coordination and connections. It also
depended on agreement by Stanislaus County authorities to continue to operate the service.

It is encouraging that the 5Cs partners have not heard continuing complaints about out-of-county
transportation problems for families of CSHCN. In a meeting of family support counselors at First
5 San Joaquin, those gathered stated that transportation is no longer an issue. "There are so many
options now." The families of the patients that Dr. Armando Valerio treats no longer complain about
inability to travel to medical appointments. The "health navigator" partners at SCs meetings do not
bring this to the meeting table as a nagging issue.

All partners in San Joaquin 5Cs were surveyed at the end of 2017 and again at the end of 2018 about
their experience in participating in the SCs Collaborative. Partners were asked to rate a number of
potential community challenges to care coordination for CSHCN. During the initial survey period
of November-December of 2017, the partners' highest rated challenge was "families have difficulty
securing transportation to needed services." The average rating by SCs Collaborative partners at
that time was 9.5 on a scale of 1-10 with 1 signifying "not really a challenge in our community" and
10 signifying "one of the greatest care coordination challenges in our community."

When San Joaquin's SCs partners responded to a follow-up survey in November and December 2018
as part of follow up evaluation, they were again asked to rate the degree to which a range of possible
care coordination challenges impacted the San Joaquin County community. Unlike the previous
year, "families have difficulty securing transportation to needed services" was no longer the highest
rated challenge, and, in fact, fell to 7th place out of 11 listed challenges. That is not to suggest that
the underlying problem that leads to the need for out-of-county transportation has improved. In fact,
5Cs partners' highest rated challenge at the end of 2018 was, "specialty care is unavailable or scarce/
there is no major medical center in our community."

If it is the change in the Medi-Cal law that is leading to increased transportation options for
families, that change is a greater systems improvement than the newly offered public transportation
options. If families are able to call a line for transportation support or go online to schedule it, and
receive door-to-door transportation at convenient times, families will have fewer or no connections
and potentially little or no waiting time.

Another encouraging possibility is the continual evolution of technology in transportation. For
example, as of Spring 2019, RTD was piloting a program called "VanGo" that is an on-demand
service like Uber. RTD is partnering with Uber, but the VanGo vehicles are accessible and all
www.|pfch.org/cshcn

drivers are professionally trained and licensed. While the 14 vehicles are currently limited to travel
within the county, Toan Tran, the RTD Mobility Director, said that, in time, and with appropriate
funding, it could be possible for those vehicles to travel outside the county. "I am very confident that
there will be options for people who need assistance."

Since the conclusion of this case study, the SJCOG Board of Directors voted on August 22, 2019, to
discontinue NEMT services. Armando Valerio, appealing on behalf of 5Cs, expressed appreciation
for the Board's willingness to support the one-year pilot. The SJCOG staff thanked Dr. Valerio and
Ms. Mraz for their efforts on behalf of NEMT.
Lucile Packard Foundation for Children's Health

 

Appendix: List of Interviewees

Ann Cirimele, former Director of Family Resource Network

Kelly Mraz, Contracts Analyst
First 5 San Joaquin

Bee Thao, Mobility Analyst
San Joaquin Regional Transit District

Toan Tran, Director of Mobility and Strategic Affairs
San Joaquin Regional Transit District

Armando Valerio, PT, DPT, Therapy Services Manager
California Children's Services Medical Therapy Program
San Joaquin County Public Health Service

18 Partnering to Create Transportation Options

      
 
www.|pfch.org/cshcn

 

References

1. United States Census (estimate for July 1, 2019). Retrieved from https://www.census.gov/
quickfacts/fact/table/sanjoaquincountycalifornia/PST045219

2. Children with special health care needs are defined as those who have or are at increased risk
for a chronic physical, developmental, behavioral, or emotional condition and who also require
health and related services of a type or amount beyond that required by children generally. [Data
as of 2011-2012] As cited on kidsdata.org, Child and Adolescent Health Measurement Initiative,
Data Resource Center for Child and Adolescent Health, Advancing data-in-action partnerships
for children and children with special health care needs in California counties and cities using
synthetic estimation from the 2011/12 National Survey of Children's Health and 2008-2012
American Community Survey. Retrieved from https://www.kidsdata.org/topic/1920/special-
needs70/table

3, Estimated percentage of children ages 0-17 with one or more serious difficulties in hearing,
vision, cognitive ability, ambulatory ability, self-care, and/or independent living. Major
disabilities include serious difficulties in hearing and vision among all children, serious difficulties
in cognitive ability, ambulatory ability, and self-care among children ages 5-17, and serious
difficulties in independent living among children ages 15-17. [Data as of 2011-2015.] As cited on
kidsdata.org, U.S. Census Bureau, American Community Survey. Retrieved from https://www.
kidsdata.org/topic/600/special-needs-ccs/table

4. As cited on kidsdata.org, Stanford Center for Policy, Outcomes, and Prevention, analysis of CCS
claims data (2017, June). Retrieved from https://www.kidsdata.org/topic/600/special-needs-ccs/
table

5. Average percentage of children and youth, ages 0-20, enrolled in Medi-Cal per month, by age
group. As cited in kidsdata.org, California Dept. of Health Services, "Eligible Individuals under
Age 21 Enrolled in Medi-Cal (July 2019) California Dept. of Finance, Population Estimate
and Projections, 2000-2009, 2010-2060 (May 2019). Retrieved from https://www.kidsdata.org/
topic/733/medi-cal-monthly-enrollment-age/table

6. Health Resources and Services Administration. Health Professional Shortage Areas (HPSAs).
Retrieved from https://bhw.hrsa.gov/shortage-designation/hpsas

7. California Physicians: Quick Reference Guide, California Health Care Foundation, 2017, www.
chef.org/publication/2017edition-California-physicians-who-they-are-how-they-practice, cited
in Meeting the Demand of Health: Final Report of the California Future Health Workforce
Commission, California Future Health Workforce Commission (February 2019). Retrieved from
https://futurehealthworkforce.org/

8. Meeting the Demand of Health: Final Report of the California Future Health Workforce
Commission, California Future Health Workforce Commission (2019, February). Retrieved from
https://futurehealthworkforce.org/

9. Lucile Packard Foundation for Children's Health. Community Engagement. Retrieved from
https://www.lpfch.org/cshcn/community-engagement

10. First 5 San Joaquin, http://sjckids.org and Family Resource Network, www.frcn.org
Lucile Packard Foundation for Children's Health

11. San Joaquin County 5Cs Grant. Retrieved from https://;www.lpfch.org/cshcn/grant/san-joaquin-
county-5cs

12. Links to governing statutory authority can be found at: http://www.dot.ca.gov/drmt/sptda.html.
Retrieved from http://www.dot.ca.gov/hq/MassTrans/State-T DA.html

13. San Joaquin Council of Governments. Unmet Transit Needs, Fiscal Year 2017-2018. Retrieved
from http://ca-sjcog2.civicplus.com/ArchiveCenter/ViewFile/Item/497

14. San Joaquin 2-1-1. Retrieved from http://www.211sj.org/

15. Reasons for recommending "reasonable to meet" finding: San Joaquin Council of Governments.
Social Services Transportation Advisory Committee and Interagency Transit Committee Agenda.
Retrieved from http:/;www.sjcog.org/AgendaCenter/ViewFile/Agenda/_05012017-673, Staff
Report 5/17:

(1) Community Acceptance. NEMT was the most requested service from respondents, as San
Joaquin County residents that require medical services from hospitals outside the region (ex.
Oakland's Children Hospital, Stanford Hospitals and Clinics, San Francisco Hospitals, etc.) do
not have an existing transit option to travel to their destinations.

(2) Equity. This service would benefit disadvantaged populations including those below the
poverty line, disabled, elderly, and those who lack personal vehicles.

(3) Potential Ridership. Conversations with agencies such as the San Joaquin County Public
Health Services suggests that significant demand exists for a NEMT service, but it is difficult
to accurately estimate potential ridership due to the fact that no NEMT service currently
exists. Potential users of a San Joaquin County NEMT service currently make whatever
arrangements they can to reach appointments in the Bay Area, including taxi, transit (multiple
system transfers), and private automobile. The NEMT service in Stanislaus County yields
approximately 2,300 riders per year. San Joaquin County has a 35% larger overall population
than Stanislaus County.

(4) Cost Effectiveness. If deemed a "reasonable to meet" Unmet Transit Need in San Joaquin
County, NEMT service could be made possible by partnering with the Stanislaus County
NEMT. This service currently runs through San Joaquin County on its way to and from

the Bay Area, offering an opportunity for cost savings for both counties. The potential San
Joaquin County NEMT service would require a pick-up/drop-off point along the existing
route, a $50,000 per year "feeder van" serving San Joaquin County, along with a likely
contribution toward the $210,000 per year for the main bus that runs to medical facilities in the
Bay, thus reducing costs for both partners. Fares collected by San Joaquin County riders would
work to offset the $210,000 cost.

(5) Operational Feasibility. As described in the bullet above, NEMT service in San Joaquin
County could be made possible, and simplified, through a partnership with StaRT and their
existing NEMT service.

(6) Funding. Annual operating costs for a standalone service may total approximately
$260,000. Some of this cost could be reduced by partnering with StaRT on their existing
www.|pfch.org/cshcn

NEMT service. Typically, Unmet Transit Needs deemed "reasonable to meet" are funded with
Local Transportation Funds; however, SJCOG would like to explore the possibility of using
other funding types to minimize the impact to the Local Transportation Fund source. One
potential alternative could be the bus transit category of Measure K.

16. California Legislative Information. AB 2394 Medi-Cal: Non-medial Transportation. (2016,

September) Retrieved from https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_
id=201520160AB2394

17. Senate Committee on Health. Mental Health Services Act: County-by-County Spending Reports.

(2016, June) Retrieved from https://mhsoac.ca.gov/sites/default/files/documents/2016-07/
FINAL08-5_AB 2279 Enclosure04.pdf

18. Department of Health Care Services. Non-emergency Medical and Non-medical Transportation

Services. (2017, July) Retrieved from https://www.dhcs.ca.gov/formsandpubs/Documents/
MMCDAPLsandPolicyLetters/APL2017/APL17-010.pdf

19. RTD Care Connection. Reconnect with Health Commercial. Retrieved from https://www.
youtube.com/watch?v=-iEdtSnmf3U