Access to Medical Transportation in Rural Chatham County

Chatham Health Alliance: Access
to Medical Transportation
By: Ethan Wallenius-Caldwell, Marissa Bane, Rhea Wyse, and Veronica Simpson
Executive Summary
Transportation is an important social
determinant of health in rural communities.
Specifically, the availability of reliable
transportation impacts a person’s ability to
access appropriate and well-coordinated health
care.1
Low-income individuals and families
within rural areas are the most likely subset to
need transportation services to maintain their
health.2
Studies have shown that the provision
of medical transportation is cost-effective and
improves a patient’s quality of life.3
Therefore,
when looking specifically at Chatham County
in rural North Carolina, it is important to
increase access to non-emergency medical
transportation (NEMT). This will likely be
most successful through the implementation of
a marketing campaign for local health services
and the facilitation of increased coordination
between local health providers and
transportation networks within the county. By
building relationships with key stakeholders
and promoting local health-related resources,
Chatham County residents will be more
informed regarding the availability of health
care services. As a result, there will likely be an
increase in care coordination leading to overall
better health outcomes.
Introduction
The 2014 Chatham County Community
Health Assessment: Obesity, Access to Mental
Health Services, and Access to Healthcare
identified access to health care as a top priority
for Chatham County.4
With the implementation
of the Affordable Care Act in 2010, the number
of Chatham County residents with health
insurance has risen; however, many continue to
struggle to receive health care within the
county.5
Compared to the state of North
Carolina as a whole, Chatham County has a
lower number of primary care providers,
nursing staff, and specialists per capita6
. The
county’s close proximity to large hospital
systems within North Carolina leads many
Chatham residents to seek services in
neighboring towns and cities such as Chapel
Hill, Durham, Raleigh, and Greensboro. For
residents with financial barriers and limited
access to transportation, the emergency
department in Chatham County serves as a
safety net provider for acute care services and
primary care.7
The Chatham County Health
Department aims to improve access to care by:
1. Promoting, providing, and assisting in
coordination of healthcare services
2. Examining gaps in health care services
3. Promoting and increasing enrollment in
the health insurance marketplace8
In early 2015, the Chatham Health Alliance
was formed to finalize action plans to address
health priorities identified in the 2014
assessment. The purpose of this alliance is to
bring together both traditional and
nontraditional partners to work on issues
affecting health outcomes in Chatham County,
with a focus on the health needs identified in
the assessment9
. The alliance has specifically
worked to better understand barriers in access
to medical transportation.10
The alliance has
requested the services of a team of Health
Policy and Management undergraduate
students from the UNC Gillings School of
Global Public Health to help address the

problem of access to medical transportation.
Therefore, the purpose of this report is to
provide background on the status of access to
care in Chatham County, identify gaps and
opportunities for access to non-emergency
medical transportation (NEMT), and provide
relevant strategies to address the issue.
Trends in Medical Transportation
Background
Patients often rely on non-emergency
medical transportation services to travel to and
from doctor appointments. Patients utilize a
variety of transportation options including
private vehicles, public transit, and taxi
services when accessing care. Medical
transportation is an important social
determinant of health and remains a vital
concern for equitable access to health care for
vulnerable populations.11
Moreover, research
suggests that health care utilization rates are
lower in rural populations compared to their
urban counterparts due to lower access to care
in terms of quality, distance and
affordability.12,13
As a result, rural residents
experience higher rates of mortality, morbidity,
incidence of chronic disease, and disability than
urban residents.14
This difference can be
attributed to a complex network of factors,
including physician shortages, low population
density, long travel distances to services, and
limited transportation options for rural areas.15
On average, those who do not have
access to medical transportation are
disproportionately female, poor, old,
uneducated, and likely to be part of a
racial/ethnic minority group.16
Income and age
are the most direct barriers to accessing
medical transportation. People with low
incomes often are unable to afford adequate
transportation. Further, older populations and
those with age-related handicaps may not have
the ability to drive themselves to appointments,
which makes them dependent on outside
services.17
In particular, the 2001 National
Household Transportation Survey reported that
8.6 percent of all respondents had a medical
condition that limited their ability to travel.18
As a result, more than 3.6 million Americans
miss or delay appropriate medical care each
year due to the lack of medical transportation.19
Chatham County, North Carolina
Chatham County is a predominantly
rural county located in the Piedmont region of
North Carolina. Its geographic location
presents unique barriers to accessing medical
transportation throughout the county. One such
barrier is poor road conditions, which may
deter or inhibit individuals from accessing
health care services.20
Another common barrier
is the cyclical outmigration of young and
middle aged adults who often leave the rural
area to find work. This leaves behind more
vulnerable populations—such as the elderly
and children—and increases the use of
emergency transportation services for non-
emergency situations.21
Further exacerbating
the issue, Chatham County has fewer primary
care physicians and registered nurses per capita
compared to the state overall.22
Because of this,
people may have an increasingly difficult time
accessing health care. Due to these barriers and
their impact on residents, the Chatham Health
Alliance and Chatham Transit aim to increase
medical transportation trips by five percent in
efforts to improve the health outcomes
throughout the county.23
Figure 1. Cities in Chatham County
Source: Weichert24

Implications
Failure to obtain routine care often
leads to overutilization of hospital emergency
departments; further, this administration of care
is more expensive than preventive services.
One of the largest barriers for residents
accessing public transportation is the inability
to coordinate transit routes and schedules with
medical appointments. The National Health
Interview Survey highlights significant
differences between adults with regular
transportation to health care compared to those
who do not have such access. Results show that
the percentage of adults who experience
multiple conditions is higher for those who lack
transportation to care.25
Moreover, those
without proper access to transportation have
higher rates of every single medical condition
tracked, including arthritis, chronic obstructive
pulmonary disease, depression, cancer, dental
problems, and heart disease. These findings
show that lack of access to medical
transportation for disadvantaged populations
can potentially exacerbate their existing
medical conditions, leading to subsequent
medical expenditures imposed on individuals
and society.26
Benefits of better transportation
Coordination between transit
authorities, regional health providers, and other
community stakeholders is needed to ensure
that rural populations obtain appropriate care.
In addition, communities with effective transit
networks can increase access to care for
vulnerable populations such as the elderly,
children, patients without cars, and Medicaid
recipients.27
Moreover, consistent access to
medical transportation helps to enhance health
outcomes for vulnerable populations and leads
to cost-savings since patients are able to avoid
costly ambulance trips and emergency room
visits.28
Many communities have had success
with creative solutions and programs that
address the issues of medical transportation,
which gives hope to other similar communities
that are currently struggling.
Existing Intervention Programs
Michigan Developmental Disabilities Council
A transportation voucher program is a
system where sponsoring agencies negotiate
with private and public transportation providers
to accept discounted rates for a segment of the
population. These reduced rates are marketed
and distributed in a small book of coupons that
riders can purchase. Riders later present the
individual coupons when purchasing and
scheduling transportation to help subsidize out-
of-pocket costs. The goal of transportation
voucher programs is to help increase awareness
of various transportation options available to
the target audience, while also reducing the
financial barriers that some riders may
experience.29
Samuel et al studies the effectiveness of
the Michigan Developmental Disabilities
Council’s transportation voucher program that
lasted from 2005 to 2008. The purpose of this
program was to improve access to
transportation for adults with disabilities. The
program primarily served those who were
physically disabled, aged 56 and older,
unemployed, lived alone, and relied on family,
friends, and public transportation services.
Such an intervention could have positive
outcomes in Chatham County as the majority of
people in need of non-urgent medical
transportation services fall within these same
categories. Furthermore, this program focused
on cost effective solutions, and cost is a
significant constraint for the Chatham County’s
key stakeholders.
According to Samuel et al, the majority
of participants (39 percent) used the voucher
program for about two years, and most used
vouchers to help pay for transportation services
through family and friends (42 percent) or
volunteers (24 percent). Furthermore, although
the transportation voucher program subsidized
transportation for all types of services, 18

percent of participants reported using the
vouchers to access medical appointments, and
20 percent stated that the program improved
their access to medical services. Fifty-four
percent reported experiencing a better overall
quality of life due to the assistance provided by
the transportation voucher program.
While the transportation voucher
program increased access to non-urgent
medical transportation services, Samuel et al
points out that it also had some limitations.
Although the program reduced some financial
barriers, especially those placed on family and
friends, it did not eliminate these barriers
completely. For instance, the program did not
significantly alter the behaviors of participants
by incentivizing citizens to utilize public
transportation or organize volunteer networks
of drivers. Many still relied on family and
friends to assist with transportation. Due to this
strong dependence on family and friends, this
program may not be sustainable for Chatham
County long-term. In particular, such a
program would not help to establish a
standardized schedule for medical
transportation services throughout the target
area.30
West Virginia Rural Health Access Program
Bellamy et al discusses the West
Virginia Rural Health Access Program, which
began in 2000 to provide NEMT for people
living in rural communities. These
communities are encouraged to develop their
own transportation systems by creating
partnerships between organizations such as
schools, churches, and public transportation
services. This program consists of three
organizations—the Potomac Valley Transit
Authority, Preston County Senior Citizens,
Inc., and Senior Life Services of Morgan
County—that are jointly funded by the 21st
Century Challenge Fund and the Claude
Worthington Benedum Foundation. This
program is relevant to Chatham County
because the majority of people seeking NEMT
services are elderly, and the county does not
currently have a system that organizes both
formal and informal transportation providers.
Because the West Virginia Rural Health
Access Program is based on organizing the
various types of NEMT options, Bellamy et al
says that each provider offers slightly different
services. The Potomac Valley Transit Authority
offers public transportation to a five-county
service area via a fixed route as well as weekly
demand-response services. A demand-response
service is one in which the rider schedules to be
transported to and from a specific location that
is not along the typical service route. The
Potomac Valley Transit Authority operates
Monday through Friday from 4:30am until
7:30pm. The Preston County Senior Citizens,
Inc. operates a transportation service called the
Buckwheat Express, which is only accessible to
those in Preston County. This service line
provides riders the ability to request in advance
transportation to medical services up to three-
fourths of a mile off the regular service route.
The Buckwheat Express operates Monday
through Friday from 5:00am to 6:00pm. Lastly,
the Senior Life Services in Morgan County
provides general transportation services to the
elderly and low-income populations within this
county. This service line offers regular fix-
route services as well as door-to-door services
upon request. The Senior Life Services run
Monday through Fridays from 7:30am until
4:30pm.
Overall, Bellamy et al believes the West
Virginia Rural Health Access Program has
accomplished its goal of reaching target
populations. More than one-third of community
members report using NEMT services, which
highlight the reported needs of such resources.
The majority of NEMT riders are female, aged
65 and older, or Medicaid beneficiaries.
Furthermore, the NEMT services have very
high user satisfaction ratings. Over 90 percent
of the participants report being satisfied or very
satisfied with scheduling, length of time riding
in the vehicle, courtesy of the drivers,

promptness of the drivers, and the overall cost
of services.
Bellamy et al also mentions that the
program has some shortcomings. The first
drawback is that the transportation services
offered only operate Monday through Friday.
This limitation introduces barriers for those
seeking medical transportation during the
weekend, as NEMT services do not operate
during this time. The second drawback is that
the West Virginia Rural Health Access
Program has ongoing difficulties reaching a
break-even point. Specifically, the program has
significant expenses related to salaries and
benefits. Furthermore, the number of riders
varies significantly from month to month,
resulting in unsteady revenue streams.
Moreover, Medicaid beneficiaries comprise a
significant proportion of the riders. Although
Medicaid law requires beneficiaries to have
access to NEMT services, it negotiates lower
prices with these providers, which negatively
impacts the program’s bottom lines. In short, a
program modeled after the West Virginia Rural
Health Access Program may not be sustainable
in Chatham County due to the unpredictable
nature of the program’s long-term financial
feasibility.31
Addressing medical transportation in Chatham
County
With the given time and resource
constraints for addressing transportation needs
in Chatham County, a marketing campaign to
increase the awareness of NEMT services will
likely be the most effective strategy for
increasing local health care access. Such a
marketing campaign would be used to expose
high proportions of the population to health
promotion messages, using the media as an
educational tool. A mass media campaign
would be favorable because of its capability to
communicate information, increase awareness,
and reach a large number of people.32
A mass
media intervention could therefore produce
positive health changes by enforcing positive
health behaviors among individuals. Methods
to communicate health messages could include
print media (such as infographs and brochures),
television, and radio broadcast.
Research has shown that marketing
concepts and tools improve the delivery of
health care to vulnerable populations. For
instance, the Paris Community Hospital in east
central Illinois underwent a comprehensive
marketing campaign in an attempt to inform
community members of its services. Although
the hospital was located in a small rural area
and only had 25 licensed beds, it invested
heavily in diagnostic equipment and a growing
physician staff to become a full service
provider. The hospital decided to upgrade its
graphic image and web site, as well as create a
unified graphics look for all written materials,
including ads, newsletters, and a newly created
monthly newsletter. Since the marketing effort
began in late 2002, outpatient revenue has
grown by 45.8 percent, MRIs by 16.2 percent,
and cardiac stress test volumes by 38.1
percent.33
A marketing campaign could be an
important step for the Chatham Health Alliance
for several reasons. First, focus groups with key
stakeholders have shown that Chatham County
residents are hesitant to access health care
locally due to past negative experiences.
Although the health care system has evolved
and improved over time, people are unaware of
these positive changes, and consequently do not
seek services locally. In addition, residents
often travel to larger towns and cities to receive
health care services because they are not
knowledgeable about local health care
providers. For instance, a patient might travel
to Chapel Hill weekly for dialysis treatment,
when a clinic offering dialysis is available in
Chatham County.34
Therefore, the focus of this campaign in
Chatham County will be rebranding available
health resources, as well as creating and
promoting a network of local physicians. The
rebranding campaign will seek to educate

people on health improvements in Chatham
County. To do this, key stakeholders will work
with local physicians to disseminate a
comprehensive set of resources that inform
residents of the health care services available in
Chatham County. The end goal will be creating
and distributing an infographic to citizens that
includes a summary of all health care providers
in the county. It will also provide information
on services covered by Medicare and Medicaid,
as 31 percent of Chatham County residents
qualify for Medicare and another 6 percent
qualify for Medicaid.35
Methods
To specifically achieve the goals of this
project, a framework will be followed that has
been put together by the project’s preceptor.
First, social service and health organizations,
coalitions, and other potential partners who are
interested in assessing and improving
availability of transportation in Chatham
County will be identified. Next, representatives
from these groups will be gathered at the
Chatham Health Alliance’s Access to Care
Subcommittee. Those involved will include
representatives from Latino and African-
American communities of highest need, as well
as local health and transportation providers.
During this time, a motivating vision will be
created through an engaging discussion
amongst all committee members.
Additionally, the committee will
broadly identify gaps and opportunities along
with formal and informal resources within the
county that could be enhanced to improve
access to care and transportation. Through the
use of follow-up interviews and focus groups,
the greatest needs of the county will be
assessed to better understand the intersection
between access to health care and
transportation. Next, previous efforts that the
committee has studied and addressed will be
assessed for efficacy, and the current status of
these efforts will be further developed. Finally,
more detailed assessments of assets and needs
will be planned for further examination
throughout the duration of the project.
Targeted Populations
Aging population
The percentage of persons in Chatham
County who were 65 and older in 2010 was
18.3 percent, compared to 12.9 percent for the
state of North Carolina, and 13 percent for the
United States.36
This number has risen to 23.6
percent as of July 2014, compared to 14.7
percent for North Carolina, and 14.5 percent for
the United States.37
In short, almost one in
every four residents in Chatham County is over
the age of 65, and the proportion of elderly
adults is expected to rise due to the continued
“Graying of America”.
The elderly are an especially vulnerable
sub-population; therefore, specialized efforts
are needed to help target and address the
specific barriers they face. One such barrier is
the inadequate supply of caregivers and family
members able and willing to provide
transportation for non-driving elderly adults. 38
Stakeholder meetings confirmed this as a
barrier for elderly adults in Chatham County,
highlighting the fact that working family
members are often unable to take time from
work, or after work, to take their elderly family
members to medical appointments. This leaves
the elderly population relying on public transit,
and demand-response services, which are
unable to meet demand due to lack of funding.
Another significant barrier elderly
adults in Chatham County face is the distance
from home to the public transit service. Even
when they are able to afford the service the
distance is often to far to reach them. Focus
groups of 42 nationwide transportation systems
identified shorter walking distances from home
to transit stops as positive service attributes of
an ideal transit system. 39
The sprawling, rural
layout of Chatham County makes distance an
especially difficult barrier for elderly residents.
However, the burden of traveling from home to
a transit stop can be lessened by pedestrian-

friendly infrastructure. This could include
adequate sidewalks, bike paths, curbs/ramps,
and rest areas along the way. A study
conducted by International Communications
Research in cooperation with the American
Association of Retired Persons found that 50
percent of non-driver respondents couldn’t
walk to a bus stop if they want to; yet, 32
percent said that the trip might be possible if
resting areas existed along the way.40
These
results are promising for Chatham County, as
they have identified “encouraging healthy
lifestyles through changes in the built
environment” as one of the focus areas in their
Community Health Assessment.41
While the
main purpose of this is to combat obesity, a
built environment that also enables the elderly
population to safely travel from home to transit
stops should be considered.
Figure 2. Chatham County Population by
Age: 2000 vs. 2010
Source: 2014 Community Health Assessment:
Chatham County, NC42
Hispanic population
The Hispanic population makes up
approximately 13 percent of Chatham County,
which is relatively large compared to the state
average of 8.4 percent.43
Further, Siler City, the
largest city in Chatham County with a
population just over 8,000, is 50 percent
Hispanic.44
Thus, Chatham County faces
several challenges in regard to the Hispanic
population, including insufficient distribution
of bilingual resources and a lack of translators
within physician clinics and the health
department.
Ricardo Salazar, who works as an
interpreter for the Chatham County Health
Department, has raised concerns related to
Chatham Transit having only one bilingual
employee. This inhibits communication
between these two organizations as well as
communication between the organization and
Chatham County residents. He also highlighted
the reality many elderly and undocumented
Hispanics face: navigating complicated
documents required for requesting
transportation services without anyone to guide
them through the process. Supporting Ricardo’s
claims is the Chatham Food Access Network
Focus Group, whom agrees many needs of the
large Hispanic community “are not being met
because of lack of resources and
communication.”45
Additionally, the Protect North
Carolina Workers Act was signed into law in
October 2015, which prevents government
officials or law enforcement, with some
exceptions, from accepting consular documents
(other than passports) to affirm someone's
identity.46
This new law also invalidates
‘Sanctuary Cities’, which are cities and
counties in North Carolina that voted to restrict
enforcement of federal immigration laws.47
Overall, this law poses additional challenges
for Hispanics in Chatham County, specifically
if they are illegal immigrants, as governmental
agencies will no longer accept their
identification cards and they will no longer be
able to access many government employee
assistance programs.48
Because this bill
authorizes law enforcement to arrest those
without state issued identification the fear of
being detained and possibly deported will
likely keep many off the road, increasing the
need for medical transportation to access health
services. 49
Rural population

In 2010, the population density of
Chatham County was 93.1 persons per square
mile, which was less than half of the average
population density of the state (196.1 persons
per square mile).50
Additionally, 66 percent of
the population lived in rural areas, which made
up 97.5 percent of the county’s total area.51
This makes the coordination of medical
transportation incredibly important and
increasingly difficult as fewer individuals are
supporting a transportation system that already
has a stretched infrastructure.
Existing Transportation Networks
Chatham County’s population faces
several unique barriers to accessing health care,
and the current transportation resources are not
sufficient for addressing those barriers. In order
for Chatham County to adequately meet the
health needs of its residents, local agencies will
need to collaborate, and resources will need to
be reallocated.
Chatham Transit Network is available
to all residents in Chatham County. In 2013, 25
percent of the organization’s rides were for
medical trips, which logged 43 percent of the
total mileage.52
Chatham Transit is the largest
provider of medical transportation within
Chatham County, but the availability of its
services is limited. Its cross-county
transportation only offers a fixed route six
times a day from Pittsboro to Chapel Hill, and
three times a day from Pittsboro to Siler City at
a cost of $3 each way.53
While this can be beneficial for
residents that live in or close to Siler City and
Pittsboro, the majority of those in Chatham
County are unable to access these routes due to
the distance from their home to the transit stop.
When people cannot use Chatham Transit, they
can fill out a form 48 hours in advance to
request in-county transportation between 8am
and 5pm, Monday through Friday. Still, this is
problematic due to the unrealistic requirement
of scheduling medical appointments 48 hours
in advance, inability to transport outside of the
county, and the strict hours of 8am to 5pm. Not
to mention these forms may be difficult to
locate, hard to understand/fill out, and as
mentioned earlier residents have little to no
assistance if they are unable to read, write, or
speak English.
Other medical transportation services
are catered towards specific subpopulations,
such as the elderly and Medicaid eligible
individuals.54
A great resource that advertises
many of these medical transportation options is
ChathamConnecting.org, which is a website
that provides information on relevant, local
health resources.55
For instance, A Helping Hand is an
organization featured on the website. This
nonprofit organization is committed to assisting
older adults and individuals with disabilities
maintain independence and improve their
quality of life. A Helping Hand serves
individuals over the age of 60 as well as those
with disabilities in North Chatham. Medical
transportation is one of the many services A
Helping Hand provides to its patients.56
Another resource found through the
ChathamConnecting.org website is the Council
on Aging, which has offices in Pittsboro and
Siler City. The agency strives to support
residents over the age of 60 as well as those
with disabilities. The Council offers assistance
in arranging transportation for medical
appointments. Medical transportation is limited
to three round-trip rides or five round-trip rides
per month for a cost of $4.00.57
Stakeholder Analysis
After conducting meetings with several
key stakeholders who have an interest in
improving access to care for Chatham County
residents, several gaps and key positives were
identified. Existing gaps include a shortage of
health care providers, stigma against receiving
health care services in Chatham County, stigma
against using Chatham Transit services, and the
overall lack of coordination and advertising of

health care and transportation services available
to Chatham County residents.
Stakeholders agree that the shortage of
health care services in Chatham County is
putting pressure on Chatham County residents
to seek care elsewhere. This is especially
concerning, as it will continue to decrease
demand for health services within the county,
which could deter providers from moving to the
area. Moreover, there are no OBGYN services
within the county, and mothers can only give
birth in the Chatham Hospital emergency room.
Cindy Bucy, a community relation’s specialist
at Cardinal Innovations, has said there are only
two private providers of mental health services
in Chatham County.58
Stakeholders agree that
increasing the demand for, and improving the
reputation of, local health care services is
crucial for increasing access to care for
Chatham County residents.
Stakeholders also agree that a large
portion of Chatham County residents is simply
unaware of many health care and transportation
services available to them. While most of the
transportation services have predetermined
routes and schedules, which are not always
conducive to emergencies, residents could still
use these services to make it to their routine
check-ups and preventative care appointments.
This would help keep residents healthier,
reduce incidence of chronic disease, and
hopefully eliminate the amount of health
emergencies as a result.
In general, the stakeholders were
optimistic in the progress that has been made in
regards to increasing access to care. Everyone
seemed excited to be talking about potential
solutions and how to build upon existing
positives.
Assessment
Following an assessment of medical
transportation needs within Chatham County, a
brief list of key issues was compiled.
Funding streams
A significant barrier to accessing health
care in Chatham County is the high cost of
providing NEMT for patients. Medicaid
provides funding for transportation services to
allow eligible individuals to access a variety of
government health care programs. Medicaid
programs in North Carolina do not operate in
isolation but rather in conjunction with other
state and county organizations, overlapping
transportation funding streams. Each of the
funding streams has unique rules.59
Additionally, there is a lack of coordination
amongst providers of medical transportation,
which leads to higher costs and potential for
duplicative services.60
Limited funding is available for
organizations such as Chatham Transit and the
Council on Aging, which provide
transportation to medical appointments. As the
number of low-income patients increases, there
will likely be a tremendous need for additional
transportation services at lower costs.
Currently, many patients are traveling across
county lines to seek health care services within
Orange County and other surrounding
counties. As a result, organizations are left to
provide costly trips that transport patients up to
10 miles outside Chatham County. The current
transit situation is neither cost-effective nor
sustainable for these organizations.
Furthermore, limited funding and strict
regulations on the use of medical transportation
funds bind facilities that receive grants from the
North Carolina state government for non-
emergency medical transportation. Further
information is needed to assess the current cost
per trip for medical transportation in Chatham
County61
Care coordination
The Chatham County Access to
Healthcare Subcommittee raised several
pertinent issues in regards to coordinating care.
First, they concluded that money was the
number one barrier for Chatham County
residents when accessing medical

transportation. The lack of money is a double
edged sword; as the average income of
residents often isn’t enough to cover the fees
required by medical transportation, and the
funding that Chatham County receives to
operate transportation programs is insufficient.
This is why coordinating available transit
services to efficiently transport the most
Chatham County residents to their medical
appointments is so important. The
subcommittee estimated the current cost of a
round trip from Pittsboro to Chapel Hill to be
about $100. This cost covers gas expense,
vehicle maintenance, and the wage for the
driver. The subcommittee also mentioned that
the van that makes these trips often takes one or
two patients when the van easily fits 15 to 20
passengers. This is extremely inefficient
financially and likely places a greater strain on
the organization covering the bill.
The subcommittee also feels that there
is little to no cooperation amongst providers
when it comes to scheduling patients’
appointments. For example, the Department of
Veteran Affairs (VA) will not schedule all of a
patient’s medical appointments in the same
day. Therefore, this patient will instead have to
arrange transportation on multiple days at
multiple times. Coordinating a patient’s
appointments to coincide with transit services’
times of operation, and scheduling multiple
appointments on the same day would benefit
the patient, the health care provider, and the
transit service.
UNC Health Care has done a poor job
(in the eyes of the Healthcare Subcommittee) in
communicating with their affiliate hospital in
Chatham County. Many of the health care
services available to patients at UNC Hospitals
in Chapel Hill are available locally at Chatham
Hospital or elsewhere within Chatham County.
Better communication between these hospitals
would likely help to reduce unnecessary travel
to UNC Hospitals, with the hope of funneling
some of this demand back to health care
services in Chatham County. Furthermore,
many physicians hold hours and appointment
times at Chatham Hospital, eliminating the
reason for Chatham County residents to travel
outside of the county because they simply want
to see ‘their doctor’. One possible solution to
this matter is training referral specialists that
work within the UNC hospital system to
identify opportunities to provide health care
services locally.
Personal finances
Another key issue Chatham County
faces is the distribution of income. The median
household income in Chatham County is
approximately $57,000 and per capita income
is $31,000.62
While the median household
income in Pittsboro is approximately $53,000,
the median household income in Siler City is
just over $30,000.63,64
Furthermore, the per
capita income in Pittsboro is $27,000 while the
per capita income in Siler City is $14,000.65,66
The income disparities within Chatham County
limit access to medical transportation, as
residents living in the most rural and less
affluent areas have less disposable income to
spend on transportation.
Health outcomes
Chatham County health outcomes are
relatively good compared to averages across
the state. However, 26 percent of Chatham
County residents are obese, leading to high
rates of chronic disease in the county.67
The
prevalence of chronic disease continues to
present a large health and economic burden for
the county, and warrants improved
transportation services, better screening, and
the implementation of effective prevention
strategies by local Chatham County providers.
Given the association between obesity and
prevalence of chronic disease, interventions
that improve access to care are integral to
improving health outcomes within the county.68
As a result, there are significant
disparities in health outcomes for the county
suggesting that specific segments of the

Chatham County population may not have
adequate access to care. Thus, poor access to
care and low utilization of preventative services
can lead to serious health conditions and poor
health outcomes for the county.
Awareness of local alternatives
Access to health services includes the
availability and awareness of services, and the
ability of residents to attain them. Chatham
County faces an overall lack of awareness of
health and transportation services. Many
residents within Chatham County travel to
other counties such as Orange, Durham, Wake,
and Guilford to seek care rather than utilizing
local services within Chatham County. The
primary reason people seek care outside the
county is a general lack of awareness of the
services offered locally. Many transportation
and medical services offered in Chatham
County are advertised by word of mouth, which
may limit the amount of people who are well
informed, especially due to the county’s large
geographic area.69
Additionally, the majority of resources
available are only in English. As a result,
members of Chatham County’s large Hispanic
population are often unable to learn about
transportation and medical services, which
reinforces the lack of awareness. Furthermore,
some residents perceive the services offered
within Chatham County as “lower quality”
compared to those offered in other counties.
This is a significant problem because people
are typically not motivated to learn about local
health services and subsequent transportation
opportunities currently available.70
Anti-Kickback Statute
The federal Anti-Kickback Statute also
complicates access to medical transportation in
Chatham County. According to this law, the
government can charge “criminal penalties for
any individual or entity that knowingly or
willfully offers, pays, solicits or receives
‘remuneration’ in order to induce or reward the
purchase of medical services covered by
government programs such as Medicare and
Medicaid.”71
More simply, exchanging
anything of value with an individual or entity
that participates in Medicare or Medicaid to
incentivize someone to seek care at a particular
health care facility is a federal crime. This
includes hospitals providing free or discounted
transportation for elderly and low-income
populations to help them get to their medical
appointments. Therefore, Chatham Hospital is
limited in its ability to improve access to
transportation for its patients, which increases
the burden on other organizations in Chatham
County.
Key positives
Despite barriers faced, Chatham County
has several assets to address medical
transportation. First, there are already medical
transportation networks in place. Chatham
Transit offers medical transportation to
Chatham County’s residents and contracts out
to organizations such as the Council on Aging
to help people access a variety of medical
services.72
Furthermore, Chatham Transit is
currently looking to hire someone full-time to
organize the medical transportation schedule.73
Designating someone to solely coordinate
medical transportation will help improve the
access and coordination of care.
In addition to formal networks, many
churches and volunteer organizations assist
residents with medical transportation. Although
Chatham County has several transportation
networks, most are not being used efficiently.74
The county should work to improve these
existing services to better serve the community.
Another positive aspect is that the
community acknowledges the problem.
Throughout the county, health care
professionals and residents understand the need
to improve medical transportation. As a result,
key stakeholders have come together to address
the problem. This collaboration is significant

because it allows multiple leaders from diverse
backgrounds to work on this problem.75
UNC Health Care is currently trying to
increase the marketing of Chatham Hospital.
Specifically, UNC Health Care is focusing on
improving Chatham Hospital’s image, which
will potentially increase awareness and reduce
stigma around using the hospital. Through the
use of marketing strategies, the goal is to
reshape the perception of Chatham Hospital
and other health resources in the county.76
Priorities and Goals
In order to improve access to health
services and medical transportation throughout
the county, several objectives have been
identified. First, a priority is to improve
coordination of medical and transportation
services. Many Chatham residents seek care
outside the county. This puts a strain on
transportation resources, such as Chatham
Transit and volunteer networks. As a result,
people have to travel further for appointments,
which is cost intensive and time consuming.
Increasing the number of residents who seek
primary and secondary health services within
Chatham County will make medical
transportation more accessible as transportation
organizations are able to serve more people
during the day. Furthermore, many
transportation organizations are operating
single rider services, although their vehicles
have the capacity to hold more passengers.
Operating single rider services increases the
cost of transportation because service providers
are unable to split the cost of the driver and fuel
among several payers. As a result, the single
rider pays more money for transportation.
Therefore, improving the coordination of
medical services by having people with similar
appointment times share rides will make
medical transportation affordable and
subsequently more accessible in Chatham
County.
The second priority is to increase
awareness of health services offered in
Chatham County. Many residents travel outside
the county to obtain care because they are
unaware of the services offered within the
county. Improving the advertising of local
health services will help educate residents.
Providing these advertisements in Spanish as
well as English will build awareness within the
Spanish-speaking communities in the county.
Updating current advertisements by making
medical resources more “web-friendly” will
increase their exposure and educate residents.
The final priority is to combat stigma
against using local health services and public
transportation. Many seek care outside of the
county because they perceive Chatham’s
services to be “lower quality” compared to
those in surrounding counties. As a result,
Chatham’s medical services are often viewed
as safety net services for those who cannot
afford to go elsewhere. This sentiment is
engrained within the community; in particular,
those who do not have access to transportation
end up postponing care until their condition
worsens.77
Rebranding Chatham County’s
health services will hopefully reduce the stigma
against them and encourage more people to
seek care locally.
Similarly, public transportation in
Chatham County is largely viewed as services
for the elderly and low-income residents. This
perception prevents some people from taking
advantage of health services because they are
afraid of being stigmatized by their
community.78
Updating Chatham Transit’s
web-presence will increase its visibility, which
will help educate community members on the
value of local public transportation. Rebranding
the image of Chatham Transit as a “community
service” in which everyone can enjoy, as
opposed to a service that predominantly targets
the elderly and lower income residents, will
likely encourage more residents to ride.
Potential Strategies and Implementation
A direct marketing campaign will be
implemented to promote health services in

Chatham County. Specifically, an infographic
will be created to display information related to
local health and transportation resources. There
will be two, double-sided infographics, with
English translation on one side and Spanish on
the other. The first infographic will focus on
health services, such as highlighting clinics that
accept Medicaid and Medicare patients. It will
also emphasize the benefits of seeking care
locally. For instance, health care services
provided by Chatham Hospital will be
promoted, and the infographic will discuss how
available doctors include those from UNC
Health Care. The second infographic will focus
on transportation resources, such as providing
information on different ways a patient could
get from their home to an upcoming doctor’s
appointment. This infographic will highlight
resources for different targeted populations,
including elderly, low-income, Hispanic, and
chronic disease members. For example, the
Council on Aging will be listed as a resource
for elderly citizens. These infographics will be
linked on the local Department of Health and
Human Services (DHHS) website, and will also
be available in common community spaces,
such as the DHHS office, Chatham County
Public Health Department, Chatham County
Community College, and public schools
throughout the community. The goal of this
campaign is to rebrand health services, such as
showing residents that Chatham Hospital is an
effective place to receive care. An additional
goal is to encourage residents to stay in
Chatham County to receive health services.
Another strategy to implement in
Chatham County is increasing health services
and transportation coordination between local
providers, UNC Health Care, and Chatham
Hospital. This will be achieved by calling local
providers to build awareness of the problem, in
addition to talking to providers at UNC
Hospitals and Chatham Hospital to find ways to
improve care coordination within the Chatham
community. The goal of these conversations
will be to raise awareness of the current
medical transportation issues. Additionally, a
long-term goal will be to adjust the Electronic
Health Record system to notify patients when
they could receive the same type of care at a
closer location. Finally, to coordinate
transportation services, partnerships will be
formed with Chatham Transit and the Council
on Aging to help develop a fixed medical
transportation schedule.
Impact and Outcomes
The impact that is most desired from
implementing these strategies is increasing the
amount of medical transportation trips provided
to Chatham County residents. Increasing
medical transportation will provide many
beneficial outcomes to the Chatham
community. Primarily, more residents will be
able to make their medical appointments, which
reduces missed visits, improves continuity of
care, and keeps Chatham County residents
healthier and less likely to develop chronic
conditions. Secondly, as a result of more
residents utilizing medical transportation
services, revenue streams to these services
should increase, bolstering what the services
can offer.
The action plan introduced by the
Access to Healthcare Subcommittee expects a
five percent increase, from a baseline of 16,100
medical trips provided in 2013, in the amount
of medical transportation trips provided by
Chatham Transit by December 2016.79
This
would be a significant achievement that could
only be possible with cooperation from
community stakeholders, health care providers,
and transportation services.
Ideal System
There are many characteristics of an
ideal medical transportation system, which
should dictate the desired outcomes of
strategies related to health services and medical
transportation. Most importantly, transportation
offered should be reliable and flexible. In
particular, flexibility in trip planning and trip-

making is very important for transit services.
One hundred percent of participants in a Transit
Industry focus group mentioned “spontaneity”
as an important feature in an ideal
transportation system. They specifically said
they wanted the ability to request and receive
transportation for a medical appointment within
the same day.80
For instance, Mountain Empire
Older Citizens (MEOC), a rural public
paratransit system serving southwestern
Virginia, utilizes same-day scheduling to meet
any trip request. Through computer scheduling
and radio contact with drivers, MEOC can
attempt to fit in any trip request, regardless of
when it is made.81
In addition, dependability of transit
services is of paramount importance to citizens,
especially those from vulnerable populations. If
service does not operate on time in a
coordinated manner, appointments will be
missed, frustration will grow, and the fear of
being stranded will become a significant
concerns. As a result, people will be less likely
to utilize public transit to meet their travel
needs. To increase reliability of transportation
services, schedules can be reconfigured, and
the monitoring of on-time performance can be
increased. Moreover, technologies can be
implemented to provide real-time arrival
information for passengers. The
implementation of such practices is ideal for
improving health services and medical
transportation in Chatham County.82
Action Plan 2016
The Chatham County Health Alliance is
currently finalizing action plans to address non-
emergency medical transportation, identified as
a health priority within Chatham County's 2014
Community Health Assessment. Further, the
health department will work to share the
findings of the assessment with members of the
community.83
1
Social Determinants of Health for Rural People. (2015,
June 9). Retrieved November 19, 2015, from
https://www.raconline.org/topics/social-determinants-of-
health
2
Transportation to support rural healthcare. (2014,
October 13). Retrieved November 19, 2015, from
https://www.raconline.org/topics/transportation
3
Ibid.
4
Chatham County Public Health Department,. 2014
Community Health Assessment. Chatham County, North
Carolina: N.p., 2014. 17 Nov. 2015.
5
Ibid.
6
Ibid.
7
Zelek, M. (2015, October 10). Personal interview.
8
Carolina: N.p., 2014. 17 Nov. 2015.
9
Ibid.
10
Ibid.
11
Myers, A. (2015). Non-Emergency Medical
Transportation: A Vital Lifeline for a Healthy
Community. Retrieved from
http://www.ncsl.org/research/transportation/non-
emergency-medical-transportation-a-vital-lifeline-for-a-
healthy-community.aspx
12
Ibid.
13
Small Urban & Rural Transit Center,. Transportation,
Distance, And Health Care Utilization For Older Adults
In Rural And Small Urban Areas. Fargo: Upper Great
Plains Transportation Institute, 2010. Web. 7 Oct. 2015.
14
Ibid.
15
Arcury, T. (2005). Access to transportation and health
care utilization in a rural region . The Journal of Rural
Health , 21(1), 31–38.
16
Wallace, R., Hughes-Cromwick, P., Mull, H., &
Khasnabis, S. (n.d.). Access to Health Care and
Nonemergency Medical Transportation: Two Missing
Links. Transportation Research Record: Journal of the
Transportation Research Board, 76-84
17
Ibid.
18
Highlights of the 2001 National Household Travel
Survey. Publication BTS03-05. United States
Department of Transportation, Bureau of Transportation
Statistics, 2003
19
Small Urban & Rural Transit Center,. Transportation,
Distance, And Health Care Utilization For Older Adults
In Rural And Small Urban Areas. Fargo: Upper Great
Plains Transportation Institute, 2010. 7 Oct. 2015.
20
Bellamy, G., Stone, K., Richardson, S., & Goldsteen,
R. (2003). Getting From Here to There: Evaluating West
Virginia's Rural Nonemergency Medical Transportation
Program. The Journal of Rural Health, 19, 397-406.
21
Ibid.
22
Carolina: N.p., 2014. 17 Nov. 2015.

23
Community Action Plan 2014. (2012, October 1).
Retrieved November 19, 2015, from
http://www.chathamnc.org/modules/showdocument.aspx
?documentid=25352
24
Chatham County, North Carolina Rentals. (n.d.).
http://www.weichertrents.com/NC/Chatham/
25
Wallace, R., Hughes-Cromwick, P., Mull, H., &
Khasnabis, S. (n.d.). Access to Health Care and
Nonemergency Medical Transportation: Two Missing
Links. Transportation Research Record: Journal of the
Transportation Research Board, 76-84
26
Ibid.
27
Community Transportation Association of America.
(2005). Toolkit and Best Practices. Medical
Transportation, 3. Retrieved from
http://www.ctaa.org/webmodules/webarticles/articlefiles/
medtoolkit.pdf
28
Ibid.
29
Bernier, B. and Seekins, T. (1999). Rural
Transportation Voucher Program for People with
Disabilities: Three Case Studies. Journal of
Transportation and Statistics, 2(1), 61-70.
30
Samuel, P., Lacey, K., Giertz, C., Hobden, K., and
LeRoy, B. (2013). Benefits and Quality of Life
Outcomes from Transportation Voucher Use by Adults
with Disabilities. Journal of Policy and Practice in
Intellectual Disabilities, 10(4), 277-288.
31
Bellamy, G., Stone, K., Richardson, S., & Goldsteen,
R. (2003). Getting From Here to There: Evaluating West
Virginia's Rural Nonemergency Medical Transportation
Program. The Journal of Rural Health, 19, 397-406.
32
Bonita, R., Irwin, A., & Beaglehole, R. (2006).
Promoting Public Health in the Twenty-First Century:
The Role of the World Health Organization.
Globalization and Health, 3, 268-283.
33
Ibid.
34
35
Chatham County Safety Net Planning Council,.
Chatham County Safety Net Planning Council: 2009
Evaluation. Pittsboro: N.p., 2009.
36
Community Facts. (n.d.). Retrieved November 19,
2015, from
http://factfinder.census.gov/faces/nav/jsf/pages/communi
ty_facts.xhtml
37
Ibid.
38
U.S. DOT NHTSA. 2001. Older Road User Research
Plan. http://www.nhtsa.dot.gov/
people/injury/olddrive/OlderRoad/
39
Burkhardt, Jon, Adam McGavock and Charles Nelson.
2002. Improving Public Transit
Options for Older Persons. V.1. (TCRP Report 82).
Washington, DC: Transit Cooperative Research
Program.
40
Ibid
41
Long, L, and B Enders. 2014 Community Health
Assessment: Chatham County, NC. Pittsboro: Chatham
County Health Department, 2015.
42
Ibid.
43
The United States Census Bureau/American
FactFinder. (2013). Chatham County, NC. Retrieved
from
http://factfinder.census.gov/faces/nav/jsf/pages/index.xht
ml
44
FactFinder. (2013). Siler City town, NC. Retrieved from
ml
45
46
American Civil Liberties Union of North Carolina
(n.d.). Explanation of HB 318: Prohibition of Sanctuary
City Ordinances and Limitations on the Acceptability of
Certain Forms of Identification. Retrieved from
http://www.acluofnc.org/files/legislative/HB_318_Fact_
Sheet_10052015.pdf
47
Ibid.
48
Ibid.
49
Lampmann, E. (2015, October 8). How H.B. 318
attacks North Carolina's immigrants and working class.
http://www.scalawagmagazine.org/articles/hb-318-
nativism
50
Carolina: N.p., 2014. 17 Nov. 2015.
51
Ibid.
52
Chatham Transit Network - public transportation in
Chatham County. (n.d.). Retrieved November 20, 2015,
from http://www.chathamtransit.org/
53
Ibid.
54
Ibid.
55
Chatham Connecting. (n.d.). Retrieved November 20,
2015, from http://www.chathamconnecting.org/
56
Ibid.
57
Ibid.
58
Bucy, C. (2015, October 14). Personal interview.
59
North Carolina Department of Health and Human
Services,. Family And Children's Medicaid Manual:
Medicaid Transportation. Raleigh: Medicaid Eligibility
Unit, 2015.
60
Ibid.
61
The Hilltop Institute,. Emergency Medical
Transportation (NEMT) Study Report. Baltimore:
University of Maryland, 2008.
62
FactFinder. (2013). Chatham County, NC (Income).

Retrieved from
ml
63
FactFinder. (2013). Pittsboro town, NC (Income).
Retrieved from
ml
64
FactFinder. (2013). Siler City town, NC (Income).
Retrieved from
ml
65
FactFinder. (2013). Pittsboro town, NC (Income).
Retrieved from
ml
66
FactFinder. (2013). Siler City town, NC (Income).
Retrieved from
ml
67
Carolina: N.p., 2014. 17 Nov. 2015.
68
Ibid.
69
Girard, M. (2015, September, 11). Personal interview.
70
Testerman, A. (2015, September, 11). Personal
interview.
71
Serbaroli, F. (2008). Offering Free Patient
Transportation Poses Risks. New York Law Journal,
240(112).
72
73
interview.
74
75
interview.
76
77
Ibid.
78
Ibid
79
Community Action Plan 2014. (2012, October 1).
http://www.chathamnc.org/modules/showdocument.aspx
?documentid=25352
80
KFH Group, Inc.,. Mountain Empire Older Citizens
Transit Development Plan. Bethesda: Cambridge
Systematics, 2011.
81
Ibid.
82
Burkhardt, J., & McGavock, A. (2002). Improving
public transit options for older persons. Washington
D.C.: National Academy Press.
83

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