Public Transportation's Role in Rural Healthcare Access, with Carol Wright Kenderdine

Organizations and resources mentioned in this episode:

• The Federal Transit Administration
• USAging
• National Rural Transit Assistance Program
• National Center for Mobility Management
• Shared Use Mobility Center
• National Center for Technology Innovation
• National Center for Applied Transit Technology
• USDA Transport Services Division
• CCAM Funding Braiding Guide

Transcript

Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson, and in this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved. This is part one of a three-part series about transportation in rural America. Today, we're talking to Carol Wright Kenderdine, the Assistant Vice President of Easterseals Transportation Group, and Executive Director of Easterseals Project Action Consulting. Thank you for joining us.

Carol Wright Kenderdine: Thanks a lot, Andrew. I'm excited to be here.

Andrew Nelson: First off, could you tell us a little bit about the National Aging and Disability Transportation Center and what you do there?

Carol Wright Kenderdine: Be glad to. Well, the National Aging and Disability Transportation Center is in its sixth year of operation, but it really came about long time before that. It is a federal technical assistance center that is funded by the Federal Transit Administration. And it originated out of the original Easterseals Project Action and the National Center for Senior Transportation. Project Action had been a technical assistance center for 28 years and the National Center for Senior Transportation for about 16. And what the federal government decided to do was to take both of those strong institutions and blend them together into one because they believe that so much of what affects older adults affects people with disabilities as well. And so they made one technical assistance center and put it out for as an RFP.

And Easterseals and the National Association of Area Agencies on Aging, which is now called US Aging, was able to compete for that particular program again. And we won the bid, which was the same two organizations that had worked on the projects previously. And so we are now in our sixth year of operation and we are so excited to be able to bring resources, education programs, training, and just conversation to the public and to providers of public transportation and human service transportation services that are really valuable insights into the kinds of work that they're doing. We're there to provide them with any kind of resources that they might need to do their jobs better.

Andrew Nelson: In your experience, what are some of the key challenges that rural communities face in helping older adults or people with disabilities access healthcare?

Carol Wright Kenderdine: Well, I think there's a lot of challenges that are out there. I'm from a rural area. I'm living in metropolitan area now just outside of Washington, DC, but I'm originally from North Dakota, and you don't get much more rural than that. And I served as a director of public transportation for almost 13 years in the center of North Dakota. I served 4,600 square miles of territory in terms of providing public transportation. And one of my counties had less than one person per square mile. So when it comes to understanding rural transportation, that's really my area of expertise. And really my passion is for rural transportation. I would put rural transportation up against urban transportation any day in terms of really needing to be able to tackle problems that are out there and find solutions.

But I think rural areas face their own particular set of challenges when it comes to transportation barriers, and probably the largest barrier of that people in the rural areas face is you have low density of population, but long distances that you have to travel. As it relates specifically to healthcare, I think there are lots of impacts when people do not have public transportation for getting where they need to go. And one of the things is you have missed appointments. If you don't have transportation to get to the doctor, then you miss appointments. You miss follow-up appointments after surgeries.

You miss routine appointments, just going to the doctor for preventive care or routine checkups. And that has a pretty major health outcome especially for older adults. Young people can miss appointments it seems for a year or two and maybe not suffer as many consequences, but when older adults tend to neglect their healthcare, then there are health outcomes that become what would've been maybe just a minor condition, becomes a major condition, and they end up not going to the doctor until the problem is much more severe.

I think other barriers to healthcare when you don't have transportation readily available to you, which is often the case in very rural areas, are things like socialization. And I think we sometimes overlook that because we think, well that doesn't have the impact that maybe not making it to dialysis or to your cancer treatment does. But you have people who are pulled apart from their community. As you get older, you tend to lose your social network around anyway, because many of your friends are no longer able to get out and do things with you like we take for granted when we're younger. And so you have people who retreat further and further into isolation and that affects their mental health. It can lead to depression and depression can lead to other physical ailments as well as having some issues of feelings of low self-worth or just average depression in its own.

Many older adults also find themselves in positions where they don't have family living next to them like they used to, or all their friends are the same age as they are. And so if they get to the point where they have to give up the keys, then it becomes really tough for them if they don't have a public transportation alternative. And so we call those people elder orphans, people who no longer have that network around them to be able to get them to the doctor. And then that has an impact on their physical and mental health as well.

But it's not only getting to the doctor that affects your health, it's access to healthy foods and it's access to a social services, it's access to community events. And so there are all kinds of things that add into the picture besides just getting to the doctor. One of the things that we have discovered now during the pandemic is that we have people not being able to get to vaccination sites for instance, and experts tell us that the only way out of this pandemic is if we're able to get everyone vaccinated and now get their booster shots, especially if they're people over 65 or they're vulnerable adults, such as people with disabilities. And so if we have pockets of the country that have a lack of access to public transportation or limited access to public transportation, then it will actually have those ripple effects as well for getting them to getting their booster shots and then having that overall effect of helping us try to get through this pandemic.

Andrew Nelson: When you have a lack of rural transportation, you can just kind of have this cascading system where people have more and more difficulty accessing healthcare, and they might come to just accept. It's like, this is I'm getting older and it's just inevitable that as I get older, I'll have less access to healthcare.

Carol Wright Kenderdine: I think one of the other things is that we kind of forget about. In rural areas many older adults have never ridden a bus ever. They didn't take a school bus to school. They don't know what it's like to get on a public transit vehicle. And we hear about travel training and people helping you learn how to ride public transit in the large cities. But one of the things that we like to try to educate people about is getting the transit systems to offer travel training to older adults and people with disabilities in the rural communities as well. That is, just teaching people how to ride the bus. Our buses are like big billboards as they drive down the street and they have a telephone number, but people think just giving people the telephone number is enough.

First of all, there's a lack of education about who gets to ride those buses. That it's public transportation and it's open to everyone. But secondly, it is just having people understand, what's it going to take to ride that bus? How do we access it? And what's it going to be like when we get on the bus? And many people aren't afraid to get on the bus, but they're afraid that when they get dropped off, how am I going to make sure that bus comes back to pick me up when I need my ride home? And so just some rural travel training can be immense in terms of its difference that it can make for older adults and people with disabilities in terms of their comfort level of knowing that that public transportation is going to serve them well.

As I was saying, we're pretty good at making sure we get our people to dialysis because that's a life-saving appointment three times a week. If you need to have cancer treatment, you're more likely to go because that is a set appointment that you need to make. But if you find out that you have a cough, you're more likely to just let it go and skip that appointment if you don't have anyone to take you to the doctor or you're unfamiliar with the public transit, or it's difficult for you to make all of those arrangements in advance. And so, I think it's really important for us to make public transit as easy to access as possible, and that for our society as a whole to put a larger emphasis on the fact that public transit is really a critical service in not only making sure people get where they need to go for quality of life, but actually to preserve their health as well.

Andrew Nelson: Can you tell us a little bit more about what types of programs or models rural areas can consider to help with transportation access?

Carol Wright Kenderdine: Well, I think in terms of what we want to make sure happens in rural areas is that we're truly meeting the needs of our communities. And so, one thing is that we need to ask people what it is that they need. We tend to do a lot of surveys. And when we do surveys, we do things like we ask people. If we had a service Monday through Sunday, would you use it? And, of course, people are going to say yes, because they want to make sure it's there for them just in case they might need it. Instead, I think we need to ask them, what would you use public transportation to do? Where would you go if you had public transportation? Let's ask concrete questions that tell us what the needs are. And if you are a transit system and people call in for rides and you have to say, "Oh, I'm sorry, we don't do that," I really encourage transit systems to write those requests down because those are really people telling you what it is they need that you aren't currently able to provide.

So, I think that we need to really listen, and people sometimes don't know what they don't know. They don't know what you could do. And so being able to indicate that you provide rides to get to grocery stores, or you provide rides to be able to take people out for social events or get them to work. Those are important things as well.

I think there are some things that I'd like to see rural transit be able to do in the next upcoming years that I think would make them more appealing to the public and really try to help meet more needs that are out there, things that I think they could be working on that would make public transit a lot more appealing. One of those things I think is real time technology. If you live in an urban area right now, you can call an Uber or a Lyft, and on your phone, you're going to be able to see exactly who's coming to get you and when they're going to be there. In rural transportation, what happens is you call and you make a reservation for a ride and they give you a window of time for that vehicle to arrive. They say, plus or minus 15 minutes. So if you want a ride at 9:00 AM, the bus can get there 15 minutes ahead of 9:00 or 15 minutes after 9:00. So, for a half hour window, you need to be available and watching for that vehicle.

For some people who are older adults and especially if they're nervous about the ride, that half hour of sitting by a window and waiting for a bus can be pretty significant. Now it could be that the bus is going to be there right at 9:00, but it could be that they're going to be there at 10 to 9:00 and you have to be ready for them. Or it could be that they're not going to get there until 9:15.

Wouldn't it be great if on their phone, it said, "Your bus is on the way. It will arrive at 9:02." I think that would be one of the greatest gifts we could give to people who are waiting for their public transit. What a relief it would be and how nice it would be for the dispatchers out there not to be getting five calls saying, "My bus isn't here yet. My bus isn't here yet. When is it coming?" So that's one of the top things I would love to see rural transit adopt as soon as possible. And like I said, the technology exists now. And I think that would be one of the best gifts we could give.

Let's say not everyone's able to access that technology at this moment. Fine. But for the people who could, it would be great. And if we're looking ahead, I think it will be a technology that pretty much everyone would be able to use even in the rural areas five years from now. Many years ago, when I was doing this in rural North Dakota, we had a 24 hour advanced reservation when I started. And I was just naive enough at the time to say, "I don't think we need to do it that way. And we're going to just take same day reservations." And everyone went crazy and said, "You can't do it." And we were able to do it and it didn't change our system. And instead we were able to give better service.

What we did do is we gave people an incentive. If they called 24 hours in advance to reserve their ride, they got a break on how much that ride cost them. So, there was an incentive to call ahead. We didn't raise the rates for them, people who called the same day. Instead, we reduced the rates for people who would call 24 hours or more in advance. Well, now all of a sudden it was a bargain to call in advance. And so, people would do that when they knew they had a doctor's appointment, or they knew they were going to have to do something in advance. But it made it possible for those of the people who wanted to live a spontaneous life just like the rest of us to be able to do just that and be able to do the things that they wanted to do when they wanted to do them just like the rest of us.

Now, they took a chance that they wouldn't necessarily be able to get on the transit that day, but at least they had the opportunity to be able to go somewhere the same day if they wanted to. I tell rural transit agencies all the time, if you ever wanted to try something new, do it right now, do it with COVID. People have had to adjust to all kinds of things in the last 24 months that they never ever thought they'd have to adjust to. So, if you ever wanted to try something new or make a change, now's the time to do it because I think people will accept it more than they ever would before.

Andrew Nelson: Yeah. I would imagine for some people it's, on top of everything else, it's kind of nice for them to have a couple of options as far as how they get transportation. They get to feel like they have a little bit more control over the access that they're getting.

Carol Wright Kenderdine: Andrew, you're absolutely right. We like to feel like we have control over our lives, and adults need to have that autonomy to feel like they really have choices. And I think that's what we all want in life, right? We want to be able to make choices and have some ability to control what happens to us instead of having somebody else make those choices for us. Now we're not the only technical assistance center. And I want to make sure I point that out. We have National RTAP which is the National Rural Transit Assistance Program. We have the National Center for Mobility Management. We have the Shared Use Mobility Center. We have the National Center for Technology. I didn't say N-CATT, the National Center for Applied Transit Technology.

And so, there are all these centers that are available to people and you can call any one of us and we'll refer you to the others so that you have a wide range of technical assistance centers out there with specialties in particular areas. And so, if it isn't our specialty, we'll put you in touch with one of the centers who does focus on that particular area. So, you have lots of resources out there that you can get to by just getting to one of us. It's kind of like the no wrong door. If you get one of us, you have access to all of us. And so, that's really good as well.

Andrew Nelson: Yeah. Yeah. It's really great that you can work together and kind of come up with different approaches that work for different areas so that if somebody comes to you looking for help, they don't have to reinvent the wheel. They can already look at different programs that have worked for different areas and pick what works best for them. What funding or technical assistance and other resources would you recommend for rural areas that are seeking to improve transportation availability?

Carol Wright Kenderdine: Well, funding always becomes an issue, right? Because you can never have too much funding. So one of the things that we try to do is we put out funding resources. Anytime that we find any examples of funding that people can apply for, we make sure that we have it on our website and we make sure we have it in our monthly newsletter. So let me give our website address so that people can use that as a reference. And it's www.nadtc.org, and you can sign up for our newsletter there and you can go there for our resources.

Also, I think really watch for local community foundations. USDA tends to have a lot of money that's available for rural areas. So have that as a bookmark on your computer so that you can watch for USDA funds that might be available. NADTC gives a yearly grant to communities. And we have just finished going through this round of grants. But the other technical assistance centers have a tendency to be able to do that as well. One of the things that has been worked on at the federal level right now is that there is called CCAM, two capital Cs, C-C-A-M funding. And it's a funding braiding guide. And it's showing how you can actually get one set of federal funding to match other federal funding. And so you can actually Google that and go CCAM funding braiding guide, and it will give you resources where you can use some of one person's federal dollars to match another federal dollars, therefore getting a hundred percent match on your money. And that can be really important when you can't come up with new funds from somewhere.

Andrew Nelson: Well, here's kind of a big one. How has COVID impacted the availability and delivery of transportation services?

Carol Wright Kenderdine: I think COVID has had a large impact on the delivery of transportation services. But I think most of our rural systems, even though they might have had to shut down in the very early days, most of them came back. And with the mask mandate and the ability to transport sometimes only one person at a time, our rural system systems have rallied more than maybe some of the larger systems have because they have recognized the need to get people where they absolutely have to go. And so, I would again put our rural systems up against a lot of the larger systems in being creative in figuring out ways to make sure that they get people place even during COVID.

The other thing is a lot of our transit agencies pivoted during this time. We know that many of them became the way for people to get to their vaccinations. Others delivered food. Some delivered home delivered meals. Others delivered pharmacy products to people right to their homes. So even though they might not have been able to take people to the pharmacy or to the grocery store, many of them did a reverse trip and instead became a delivery service to be able to get those things to people themselves. I'm encouraging transit systems to take lessons from COVID and not be waiting just for things to go back to the way they were before the pandemic, but rather figure out the things that worked well and maybe figure out how to continue some of those practices once the COVID crisis has subsided.

Andrew Nelson: When you look ahead five years, what are your biggest concerns about the availability of rural transportation?

Carol Wright Kenderdine: I do have concerns, but I am cautiously optimistic. I believe in the resiliency of the rural areas. We've always been a people who picks themselves up by the bootstraps and figures out a way to move forward. I think that it's tough in the rural areas to be recognized for the work that you do. It's always easy when people can throw out millions of rides as their numbers and bring that to Congress to say, "We have to take care of this because look at all the people we provide rides for." But it's a lot more than just the numbers. And I think the rural people, instead of concentrating on being able to sell themselves by numbers, have to be able to tell their story.

I was just with a rural system and they helped a woman who had been in her home for six years. She had left her home via ambulance once, but otherwise had not left her home in six years. She lived out on a farmstead. She didn't have any family in the area at all. People had brought her groceries. People had brought her medicines. But no one had taken her out of her home. She hadn't gotten a haircut. She hadn't been able to pick out her own groceries. She hadn't left her home for six years. Can you imagine how isolating that is? And when the transit system found out about her, they didn't do farmstead transportation. But they said, "I think we can make an exception and figure out how to get her and get her to the nearest small town," which by the way, was a town of less than a thousand people. But they were able to go and get her. Can you imagine the difference in the quality of her life when she could get out of her house after all that time?

I think those are the stories that we need to tell. I think rural has to, if it's going to survive, it can't be on the numbers. It has to be on the stories. It has to be on the difference that they make because no one has a bigger impact than the rural transit providers. So let's talk about the impact on lives that we have so that we can make the case for rural public transit. We need make sure that we're working with everyone we can possibly work with to ensure that our rural people aren't left behind.

If we don't do that, then I am concerned that our rural populations are not necessarily growing. They are growing in some pockets, but not necessarily uniformly. And we know that our rural populations are aging. And so, the numbers of people who are 75 plus, 85 plus in the rural areas are growing. And I think we need to figure out how we're going to do our best to take care of them because that's the population that's going to be the most dependent on transportation especially if we're going to keep them independent and living in their own communities.

Andrew Nelson: In the next five years, are there any other things you want to talk about as far as things you hope to see implemented or developed?

Carol Wright Kenderdine: Yeah, I think so. I would like us to have... There's a plan in place right now for open source data sharing. Right now, everyone has their own computer dispatch software for their system. And so it doesn't matter what software system you're using. There are a million of them out there. Okay. But everyone has their own proprietary software. But there is work in progress right now and it's being pilot tested in many parts of the country, but where one set of data software can be, the data can actually be open source and shared. And I think that would be absolutely phenomenal if we can get it so that my transit system, if I had one, can talk to the neighbor's transit system, and so that we can share that data. And therefore, if this passenger does need to go long distance somewhere, I don't just have to take my van and get them 200 miles away, but maybe I can get them part of the way and it can be a shared trip with someone else.

One of the stumbling blocks with that has always been a shared payment system as well. So what do we do? Who's going to pay for that trip? Who's going to get paid for that trip? And so along with that open data source needs to be shared payment. And so, I think that there is technology that is out there right now for coordinated payment systems between agencies. And so, between the open source data and the coordinated payment systems, I think we could do marvelous things. So, in the next five years, I'd really like to see us implementing that technology, especially in the rural areas. I think it's going to be a bigger boost to the rural areas than it's going to be for anyone else. So that would be one of my biggest things that I think I would like to see happen.

Andrew Nelson: How long did you say you've been doing this, this kind of work again?

Carol Wright Kenderdine: I'm old. I have been doing public transit since about 1990, I guess. And so long time. My background was aging prior to public transit. And when I was hired to do the public transit program in central North Dakota, I was also hired to do all their aging programs. I fell in love with transit. I think transit is the key to making the difference in quality of life for people more than almost anything else, especially in the rural areas between transit and food programs and services for seniors, that really changes the quality of life and makes a difference for people. And that's something I'm really incredibly passionate about.

One of the things that NADTC has undertaken as a major initiative, we did a diversity inclusion in equity survey of this past year in 2021. And we concentrated our efforts on diverse, older adults, people with disabilities and their caregivers, but people from marginalized communities, and so in terms of African-Americans, Asian-American, Pacific Islanders, Native Americans, we tried to take Hispanic populations, everyone that really has historically been marginalized and tried to figure out what their transportation needs were. Then we just dove deeper into that survey and looked at what is the geography, where do these people live? And we paid a lot of attention to individuals in these groups who are from rural areas, but along with our small rural towns, we have our tribal reservations. And I think we can't leave them out of the mix when we talk about rural and frontier areas. It's really important for us to recognize the needs of our tribal areas and recognize that many times they go underserved or unserved as well.

And so, I think when we look down the road in the next years too, it's really important that we put an emphasis on being able to make sure that our tribal areas receive rural public transit as well, and make sure that the needs of that population are not overlooked. I really encourage you to go to our website for the National Aging and Disability Transportation Center. There's never a charge for any of our services. So if you have any questions or you need some help, that's what we're here for. And so please make sure you reach out, and if we don't have the answer, we'll put you in touch with someone who does, and we'd be just very happy to answer questions and provide resources anytime.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. Today, we talked with Carol Wright Kenderdine, the Assistant Vice President of Easterseals Transportation Group, and Executive Director of Easterseals Project Action Consulting. Look at our show notes to learn more about her work and visit ruralhealthinfo.org for all things pertaining to rural health. Join us next time for part two of our three-part series on transportation in rural America here on Exploring Rural Health.