Federal Funding for Rural Health: Supporting Planning and Development Around a Regional Transportation Need

by Kay Miller Temple, MD

From experiences of living on the family farm in Missouri and as a mother, health initiatives leader, and community developer, Kelly Ast is intimately aware that transportation is not only one of the most influential social determinants of rural health, it is also one of the most influential determinants of a rural community's health and wealth.

"My involvement in my own local community's projects gives me a very clear understanding of how the lack of transportation options influences health and wealth in a rural community," Ast said. "There's an incredible level of stress around this problem topic that seems to never go away — an apprehension that even any potential solution is actually just another plan that's not going to work. Yet there's a way to make an important difference."

From Drawing Board to Regional Action

Ast said it's time for this stress to be relieved. As project director for a community development corporation, New Growth, nested within the West Central Missouri Community Action Agency (WCMCAA), Ast is now part of a nine-county regional transportation project — Rides to Health and Wealth — that first began to gather momentum in 2017. The western Missouri agency used funding from the Health Resources and Service Administration's Rural Health Network Development Planning Program grant to address the region's rural transportation need. Specific to the organization's one year grant-supported efforts are convening activities, coalition and network building, and creating a strategic plan outline. After six months of New Growth and West Central outreach regarding HealthTran as a resource for organizing and scheduling rides, the 11 original Memoranda of Agreement (MOA) partners joined the effort and supported work to fund planning and implementation. As of March 2020, 44 additional partners had joined the network.

 
"Within every wellness initiative, transportation always surfaces as a huge barrier," Ast said. "In rural areas, like my hometown of Nevada in Vernon County, with our small population, we just aren't big enough to qualify for most transportation grants. I actually got to the point where I didn't even want to get involved with another health and wellness initiative if transportation wasn't at its center. The grant provided funding and resources that supported a regional approach to building a transportation network."

Within every wellness initiative, transportation always surfaces as a huge barrier.

Although the network of healthcare and social service partners is core to the project, Ast emphasized the project is also important to many other community organizations since the health and wealth of a community include its resource abundance — and transportation options are one of those important resources.

Steering Wheels, Tires, and the Rural Transportation Status Quo

Ast pointed out that an initial focus of network planning and project development was changing attitudes around transportation.

The key to moving a transportation project is to push that status quo in order to elevate the needs of those who don't have a vehicle or can't drive.

"In rural areas, so many of us drive," she said. "When it comes to something with a steering wheel and a set of tires, there's a lot of vehicle choices that get us where we need to go. From tractors and trucks, to pickups and cars, to ATVs, motorcycles, and even golf carts, many of us have something to get us around. That generates a kind of status quo attitude. The key to moving a transportation project is to push that status quo in order to elevate the needs of those who don't have a vehicle or can't drive. These folks are often either our older residents with healthcare needs or people with a health condition that prevents them from driving."

When the grant funding arrived, Ast said the push to nudge that status quo started immediately with stakeholder meetings. She said that one early meeting was opened with a request for attendees to tell a transportation story. The emotional content of the shared stories caught organizers by surprise.

"The stories were so intense and powerful, they caused tears to flow and storytellers' voices to break," Ast said. "I was sitting beside a friend from a nearby county who happens to be a psychologist. I leaned over and whispered that we might need a therapy session after the meeting. Those intimate stories were certainly proof that transportation is the thing that builds relationships and the thing that connects relationships — and that is so important for overall health and well-being."

In addition to face-to-face meetings, Ast said she believed that early gains with community engagement also came as a result of additional outreach. Smaller meetings alternated with webinars and emails, along with that sometimes forgotten communication mode: phone calls.

"When we just picked up the phone, shared a few strategic facts and strategic numbers, people started to understand just how important transportation is," Ast said. "Most importantly, it seemed that with that phone call, they started to feel like they wanted to be part of a solution. Many joined us as stakeholders."

Ast said she found it interesting that an important project tool was providing tailored one-page fact sheets with financial and other transportation-related information gleaned from sources like the Housing and Transportation Affordability Index and medical outcomes information from MRHA.

"For example, one public health department completely understood their clients' transportation needs," she said. "For them to take on a new service, their county commissioners must be on board. Funds were even available, but transportation still was perceived as a big ask. However, those fact sheets provide proof that transportation is integral to positive individual health outcomes and integral to a community's health and wealth. To be able to provide the county commissioners a fact sheet with concise numbers was key for that health department to start their conversation around transportation. We've found that assisting others with their specific advocacy efforts helped them increase interest or gain approval for transportation. If invited, then we can come in and provide more detail and action."

Simplifying Transportation Complexities

Working under the umbrella of WCMCAA as a community development corporation, the mission of New Growth, Ast highlighted, is "connecting resources and building collaboration." Launching the project started with the environmental scan, a methodical review of the area's existing transportation options in order to identify barriers and facilitators. The results were complex and unwieldy.

 
Simplification involved organizing the information into what Ast referred to as a transportation value chain model, based on the WealthWorks community development approach. The model places partners and stakeholders into three categories: demand partners, or those serving people who have need for public transportation; those that supply or could supply the transportation options; and those that could provide some sort of support to the other groups.

In a March 2020 webinar, Ast further explained that demand partners, such as healthcare organizations, struggle with the transportation challenges of residents of all ages: for example, older adults who no longer drive or have a health condition preventing them from driving, those of any age with disabilities, or youth either too young to drive or in families where no vehicle is available. In addition to accessing healthcare, patients also need transportation for many other activities, such as grocery shopping, banking, and legal appointments. Other agencies, for example a family court system, also emerged from the environmental scan as a demand partner since their clients have many appointment needs.

The supply group includes existing public transit resources, as well as organizations that currently provide rides or could in the future with coordination support. This group includes churches and volunteer ride share options available through various agencies, usually with limited operation hours during weekdays and with time slots of 8:30 a.m. to 4:00 p.m.

The support partners included small community investment groups or small chamber or hospital foundations. Ast shared she was surprised that some businesses requested participation but not to get workers to job sites. Instead, they needed to find options for their workers who missed work in order to transport friends and loved ones to medical or other service appointments — often because the employee also served as the sole family or neighborhood transportation option.

Maintaining Momentum: Development and Planning in the Time of COVID-19

With COVID-19 came impact on New Growth's development and planning. Though grateful that meetings and outreach had moved the strategic transportation plan closer to completion, Ast said COVID-19 had its influence starting in April and May. Yet because of COVID, Ast said new opportunities emerged.

"In April, we had meetings and conference calls scheduled, but there was just no response from our stakeholders," Ast said. "With COVID-19, transportation went from being in the windshield to being in the backseat. We didn't want to fight to put our cause back in the windshield because we understood — like everyone else in the country — that our region's medical providers were dealing with an emergency unlike anything else they'd ever experienced. So, imagine our delight when one of them reached out to us and said, 'We're going to think beyond COVID and we're going to need transportation to do that.' We jumped on that interest."

Ast said her team quickly got to work for that organization, helping them connect with the HealthTran model. That effort made the team realize that there were probably other like-minded organizations, and her team continued their outreach work. According to Ast, adaptive strategies were key in resuming that work. As opposed to the original and more overreaching regional transportation solution approach, they began to compartmentalize their work by helping organizations with ongoing interests, she said. With that change, she said they again found themselves back in "big meetings with big partners."

 
Ast also talked about their group's work when Coronavirus Aid, Relief, and Economic Security (CARES) Act funds became available for transportation needs.

"I got really concerned that in this evolution of CARES money, people were going to forget that transportation needed to be in the equation of both the current and post-COVID planning," she said. "We got on the phones, talking to county commissioners in our 9-county region, talking to public health teams and health departments, reminding them of what CARES money could mean for the health and wealth of the region within long-term investment plans for transportation. We felt it was important to keep that conversation going and we used the phone to do it."

Surprises and Rewards

Of the many aspects of the network planning and development activities, probably the biggest reward of the effort, Ast shared, was in providing a platform to connect partners and stakeholders. In convening and strategic planning meetings, Ast said she was surprised that there were participants who for the first time were at the same table addressing a common health and wealth barrier. She said this included the region's public health leaders and physical and mental healthcare organization leaders at the same table — together with leaders of felony-friendly employers. Housing developers also joined the discussion with the awareness that their grant applications gained higher scores when they include plans for services like transportation.

"It's very important to not think too small with the environment scan," she said. "Make sure no one is left out. There are so many people out there providing some type of a limited transportation option that can either be expanded or paired with something else in order to increase the scope of what they're accomplishing. We've also realized that some of the people at the table will also accept our challenge of offering more than just an MOA. They'll also provide financial support when they see the connections and collaborations and understand the overall regional need and impact. It becomes more attractive to them to be a support partner."

 
"My biggest reward from doing this work is seeing these new and innovative collaborations," she said. "In rural communities, we've got calloused hands, we've got big hearts, and we'll bootstrap anything. To see these entities that have existed for years as somewhat siloed now come together and support each other is so rewarding. That's the only way we're going to get rural transportation needs fixed with a sustainable plan that will be cross-cutting in these communities."

The Power Word: Cross-cutting

Cross-cutting. That is a word that Ast said she uses frequently in presentations and fact sheets. Cross-cutting social determinants: A health focus is important, but an emphasis point is that community health is intimately tied to a region's wealth. Cross-cutting time: 8:30 to 4:30 transportation options are too limiting and transportation must cross-cut the 24-hour day. Cross-cutting also includes looking at the needs across the region's age spectrum. Ast said an illustrative story on this latter point came from a focus group meeting.

Think about this child. Think about all the risk factors already inherent in every step into her future health and well-being. Of all these risk factors that are against her, transportation should not be one of them.

"I'll never forget this woman who came to a focus group meeting because she wanted to know if an on-demand service option for evening transportation was going to be considered," Ast said. "The woman had found herself as the guardian grandmother of two girls in high school, one in choir. The grandmother sees too poorly to drive at night to get her granddaughter to and from practices. Their attempt to coordinate rides with willing families didn't work for multiple reasons. This grandmother clearly understands how participation in choir is so important to her granddaughter's healthy development. She wants her grandchild to be safe and have this opportunity that she deserves. But because we currently don't have an evening public transit option, her granddaughter's choir participation is at risk if she can't make practices. Think about this child. Think about all the risk factors already inherent in every step into her future health and well-being. Of all these risk factors that are against her, transportation should not be one of them."