Four health care safety net organizations have spent the past 18 months testing, refining, and implementing innovations to help combat transportation insecurity in their communities. Despite embarking on this work under unprecedented duress in the middle of a global pandemic, they still managed to strengthen and expand their capabilities and infrastructure to assess and address this crucial social determinant of health.

Below, these Los Angeles-based, federally qualified health centers, part of CCI’s Moving Clinics Upstream (MCU) program, share detailed, practical suggestions for tackling this challenging problem, whether an organization is just starting out, expanding its work, or introducing change during a healthcare crisis.

1. Pivot—Fast—In The Face of a Pandemic

Beginning in March 2020, all four clinics moved quickly and successfully to address the unique obstacles the coronavirus presented. Each organization shifted from in-person clinic visits to telehealth services to connect with clients during the pandemic. Virtual visits became the norm as the lockdown wore on.

Planned Parenthood of Pasadena and San Gabriel Valley was initially exploring telehealth services as an option as part of the MCU project, in the hopes that meeting patients where they are would reduce barriers in transportation, explains Ashley Leonard, the organization’s health centers systems manager. The pandemic forced the organization to move more quickly. “We launched our telehealth services within a week of the onset of the pandemic to keep our staff and patients safe, while still keeping access to our vital services open,” Leonard says. “We pivoted from holistic conversations about what offering telehealth would look like/flow like to offering the service in our clinics within a week!”

T.H.E. {To Help Everyone) Health and Wellness Centers provided an online Zoom tutorial and etiquette guide for those patients who were new to the platform.

Of course, these virtual services automatically eliminate transport obstacles and deprioritized public transit efforts to address transportation insecurity.

Clinics also found creative, collaborative solutions to transportation challenges as demand soared during COVID-19 shutdowns and widespread unemployment.

When patients stopped going to clinics for routine health care because of shelter-in-place mandates, some clinics started delivering services to patients at home. Case in point: Kheir Clinic began delivering “Kheir packages”: food boxes, face masks, and other essentials in clinic vans originally intended to transport patients to doctors’ appointments.

Clinica Romero used their in-house van to deliver medications to high-risk clients.  The center’s van service focused on patients with diabetes and the van was repurposed as a pharmacy program to deliver items such as insulin (which must be kept refrigerated so it’s transported with cool packs), high blood pressure medications, and other drugs used to treat conditions associated with diabetes.

2. Start With Screening

All four clinics now screen patients for transportation insecurity, using simple, customized in-house screening tools or PRAPARE, a nationally recognized standardized patient risk assessment protocol designed to measure patients’ social determinants of health.

Lessons learned along the path to screening clients:

  • Normalize social screenings with the goal of screening all patients. That said, a pilot program and roll out strategy may work well to address any workflow issues. Clinics might consider starting with a particular site location, care team, or group of patients enrolled in a specific program.
  • Identify a screening program champion within the organization. Many screening programs are understaffed, which can result in inconsistent screening and poor follow up on identified needs, notes a social screening guide compiled by MCU coaching collaborators Elevation Health Partners. Staff conducting transportation insecurity assessments are often not the same staff as those addressing patient needs. A program champion can ensure internal best practices so staff best placed to support screening work (including case managers, care coordinators, medical assistants, nurses, patient navigators, primary care physicians, and outreach coordinators) are engaged and informed about their role regarding this concern.
  • Select a screening tool, assess a clinic’s information technology, and embed the questionnaire in the clinic’s electronic health record intake process.
  • Develop an accountability plan and design workflows to capture data metrics and follow up. Outline staff roles and responsibilities: Who asks the questions? Where are the responses documented? How are the provider and care manager flagged when a patient screens positive? How is follow up documented, tracked, and reported?
  • Note that virtual screening can have a distancing effect. To counter this potential impact ask permission, screen everyone, and employ empathy: there may well be stigma and shame associated with transportation insecurity for many clients.
3. Secure Buy-In At All Levels of the Organization

It’s important to include everyone — administrative staff, nurses, medical assistants, social workers, physicians, IT team, drivers, volunteers, accounting, operations, marketing, and management — in this process. The engagement, input, and feedback of all stakeholders are a prerequisite for success.

When there is strong leadership support, commitment, and organizational buy-in, the main challenge becomes how to do something not with whom. Frontline staff are often the leaders and champions of this work. It takes a village.

Committed leadership understands a program’s budget and staffing needs, technical issues, reporting mandates, and operational concerns and works together with care teams to address barriers, develop community resources, and streamline services. Leadership shows commitment by showing up, engaging in process and progress, and demonstrating support through actions, and as our coaches at Elevation Health Partners and MCU participants note, is key to long-term success. Getting that buy-in in writing early in the process can help set the tone for this kind of programming.

Leadership doesn’t only come from the top. “The job of driver/transportation coordinator is very important…instrumental to the success of the program,” notes Kirby Rock, Kheir Clinic’s director of external affairs. “[Our driver] took ownership and promoted the service.” Shout out to Kheir’s Nelson Guevara for championing this initiative.

4. Listen To Patient Stories

By truly listening to patients and hearing their stories, clients learn to build connections through patient navigators, case workers, front office staff, and clinic practitioners. Even without formal data, this anecdotal information gathering helps to uncover what patients really need and how they might best be served.

Take time to understand people’s personal narratives. Public health data, client surveys, and patient questionnaires are helpful guides. But the real experts are clients. Ask patients: How can we help? What do you need to live a healthier life? What is preventing you from achieving that goal?

This kind of check in can help with patient retention, increased trust, and patient engagement in the clinic and its related services. These kinds of check ins with clients are important throughout the process: from screening, referral to resources and case workers, and in regular follow-up conversations. Transportation insecurity can be short-term and situational: such as during the pandemic when most people avoided using public transit and ride share services. It can also be a chronic, long-term challenge for some clients.

At Kheir Clinic, patients expressed their gratitude and the value of an internal van service with an in-house driver. Clients felt cared for, listened to, and seen. And they showed up for their appointments: No shows drop dramatically when a van service is an option “It’s not just a van and it’s not just a driver,” one patient told the Kheir team. “He [the driver] makes sure I am safe and he makes sure my needs are met.”

Said another Kheir Clinic patient: “Having transportation improves my mental stability, my physical condition, and helps me feel normal again.” Added another: “We need a GPS in all aspects of our lives.”

“The transportation has helped me get home quicker. I usually take the bus and it’s very inconvenient,” says Jorge, 56, a Koreatown resident who has received medical care at Kheir Clinic for 15 years. “The drivers are very patient with me since I walk very slowly and they are very nice and help me get in and out of the van.”

These kinds of ringing endorsements for an innovation and the people who make it happen go beyond bottom line considerations and clinic efficiencies.

“While the business case for the clinic van can be made on no shows and quantifiable data, we have yet to quantify the value in increasing confidence for patients to be able to arrive at their appointments more safely without obstacles,

the deepening of trust among patients with the van drivers, and belief that this trust increases retention and engagement in care,” notes Cheryl Trinidad, chief development and communications officer for T.H.E.

5. Embrace Virtual Delivery of Services

Technology proved key to supporting patients during social distance protocols. For example, T.H.E. now provides wellness classes online, including one dubbed Control Club, designed to help patients manage diabetes.

Kheir Clinic, which received funding last June from insurance provider Health Net to enhance its virtual programing by expanding telehealth practices, including live video visits, e-consultations and telehealth-psychiatry—all key tools in providing safe access and continuity of care for patients at home.

“Telehealth is a great way to break down barriers,” says Eric Schluederberg, a physician at Kheir Clinic. “Many of our patients work full time and take care of their families. It’s not easy to take a half day off of work, ride two buses, and sit in a waiting room, all for a short medical visit. With telehealth, they can complete their appointment during a break at work, instead of requesting several hours off. There’s no loss of income, and they don’t have to worry about transportation.”

“Telehealth addresses systemic issues in our overburdened healthcare system,” adds Navid Papehn, director of patient services at Kheir Clinic. “It offers a path to value-based treatment, instead of volume-based. We’ve been pushing toward it for years, and in many ways, telemedicine is the catalyst for change that we’ve been waiting for.”

6. Collaborate Within The Organization to Share the Workload

Identify resources, knowledge, skill sets, connections, experience, and expertise that already exists within an organization to help with this work. For instance, prior to the pandemic, Kheir Clinic in Los Angeles’ Koreatown already had an internal van service and employed a driver to transport some of their most fragile patients, including seniors, those with language barriers, and patients with vulnerable legal status. The van service, courtesy of transportation coordinator Nelson Guevara, proved a valuable resource during the pandemic—with enhanced safety protocols in place—and provides a level of attention, compassion, comfort, and safety that clinic patients appreciate.

7. Seek Outside Partners

Organizations need help to do this work. Court potential partners. Get to know their mission, values, and goals to assess how these align with your organization’s needs and the needs of your clients.

During the pandemic, Clinica Romero collaborated with other community organizations such as the Salvadoran American Leadership and Education Fund to distribute food among its vulnerable, food insecure patient population. And, in partnership with TruConnect, a free, government wireless service.  It’s working to ensure that every low-income individual has access to a telephone and telephone service, which is now crucial for routine health care. (Whether the current rate of reimbursement for telehealth services conducted via phone will remain in place is currently uncertain.)

The Kheir Clinic’s van service distributed boxes of food, diapers, and washable cloth masks, as well as hot meals for seniors, as part of a project in partnership with World Harvest Food Bank and Los Angeles City Council member Herb J. Wesson, Jr.

Ride share services—or transportation network companies–play an important role in addressing transportation insecurity for safety net clinics. One tip from an MCU clinic: When language barriers are a concern, sometimes using an internal van service for pick up, but switching to Lyft or Uber contacted by the clinic for drop off, is the most efficient way to go. These non-emergency medical transportation services include Uber Health, which allows providers to directly arrange transport for patients, as does a similar program at Lyft.

A relatively new program, LyftPass for Healthcare, allows patients to directly order rides to medical appointments.

8. Iterate, iterate, iterate.

It’s okay not to get it exactly right on the first try. Introducing innovations requires adjusting to meet patient needs and expectations; gathering information from patients, clinic staff, partners, and volunteers; and reconfiguring workflows, processes, and programs. Teams should expect to respond to client and staff feedback about an innovation’s usefulness, convenience, and sustainability. It’s important to solicit insights from all stakeholders. For instance, at Planned Parenthood of Pasadena and San Gabriel Valley, Leonard says while the shift to telehealth was quick it wasn’t seamless. It took time to smooth things out, ensure billing was correct, and make sure that providers and clinic staff working virtually provided the same compassionate care patients were used to receiving in person.

And it took a few different iterations of the transportation survey before the clinic “had dialed in on the key questions and feedback we were seeking from our patients,” adds Leonard.

Kheir Clinic already had a robust van service program but needed to put time into making sure clients knew the service was available, which they did. And during the pandemic it revised transportation workflows to enhance safety measures such as lowering capacity per ride, increasing sanitation between rides, and adding masks, hand sanitizer, and other PPE.

9. Meet Clients Where They’re At

It’s essential to adapt programs to match the needs of patients. Nowhere was that perhaps more apparent than in the delivery by some clinics of medications, food boxes, household supplies and other essentials to families in need.

But during the pandemic, providing virtual health care to clients who may not be tech savvy or have the resources for smart phones and tablets was also fundamental.

“The pandemic has taken a lot from me, including the ability for me to visit Clínica Romero and see my doctor in person,” says Natalia Lozada, a patient for five year. “I just learned how to use technology on my cell phone so when I was told that I could see my doctor for a digital health visit, I thought it would be too difficult for me. But Clínica Romero offered me so much support. The promotoras, nurses, and doctors were very patient with me and guided me on logging into my visit. I learned how to use the MyChart application and now I can schedule my appointments and have a video call with my doctor,” she says. “I really liked the video service because I can see my doctor and it’s very much like being able to see her in person. I truly appreciate this new way of communicating and staying in touch with my doctor so I can stay healthy. I am proof that with support, we can connect ourselves to our doctors.”

10. Strive for Financial Sustainability


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Out of necessity, clinics are creative about financing these kinds of upstream activities. Traditional federal sources, nonprofit grants, individual donors, internal funding streams, and outside partnerships—there is more than one way to find funding for innovation.

It’s true, there’s no magic bullet here—no one, steady, stable, sustainable way to support this work in the months and years to come. Many safety net organizations rely on a diverse stream of funding sources to sustain staff positions and food programs to continue this important work. Some funds are specifically earmarked for direct services, whereas other funding may have more flexible spending mandates, allowing clinics to use the funds for, say, infrastructure or staffing related to an in-house transportation program. For instance, Health Net’s technology grants can be used for laptops, cell phones, and software, Internet connectivity, and training/technical assistance.

Elevation Health Partners’ Deena Pourshaban points to the forthcoming California Department of Health Services CalAIM program as a potential source of reimbursement, and she notes that local health plan benefits programs, such as L.A. Care Health Plan, are a possible outlet for funding through community grants.

11. Connect Transport With Food Services

Often food insecurity and transportation insecurity go hand in hand. Keep in mind that hauling grocery bags on public transit may be too much to ask of clients in ill health, or with mobility challenges, or those with young children in tow. And during the pandemic, of course, many people avoided public transit as much as possible.

For clients with mobility issues or those who lack convenient access to transit,  LyftUp offers discounted Lyft car rides to low-income families and seniors heading to and from grocery stores, farmers markets, food pantries, and SNAP (CalFresh) benefits appointments. Uber Connect allows for the delivery of packages such as grocery bags to people’s homes.

12. Celebrate The Small Victories

Think about starting small and growing slowly.

Create an environment that starts with screening for social needs, then build interventions and link patients to resources. It’s important to understand if the changes work well for both patients and staff before spreading them clinic-wide.

Perhaps begin with a pilot project with a particular high-risk cohort or clinic, which can help a health center figure out the kinks in the system, program, and delivery.

Keep in mind that every patient that you serve, support, and connect to services is a success.

13. Keep Pandemic Changes For The Long Haul

Strengthening internal systems for assessing social determinants of health and improving internal workflows has benefits beyond transportation insecurity, they can be useful in other programs, for instance vaccine rollout. Tweaking best practices around data collection, case management referral, and delivery of services can go a long way to ensuring the viability of such programs.

“Comments of appreciation came pouring in from our patients letting us know how happy they were that they could do their visits online and come pick up their meds or go to a pharmacy,” says Leonard. “It really changed the way we provide care and we are excited to keep telehealth as a mode of service as we move out of the pandemic.”

As all four clinics can attest, making a commitment to do this work—and having a point person or leadership team that is passionate about meeting this basic human need with compassion, caring, and a capacity for overcoming obstacles while working closely with all community stakeholders—is crucial to continued success to combat transportation insecurity among clinic clients.

That’s not all. “Though our project was transportation, it was really wonderful to be a part of the cohort group at large to hear what the folks addressing food insecurity were doing,” says Leonard. “We were able to catalog and collect all the workflows, resources, ideas, and notes from that project and we are going to use them as a launching point to better our food insecurity resources over the next few months.”