This essay gives the descriptive account of how Paratransit services are in need of better assessment criteria but it also highlights the expense of managing a program that caters to people who are disabled.

1. Running head: MEDICAL TRANSPORTATION BARRIERS 1
Paratransit Services: A Public Health Initiative for African Americans who are diagnosed
with Cognitive Disorders and End Stage Renal Disease
Anthony Wallace, BSc., M.A., ACHE, DrPHC
October 22, 2016
Abstract

2. Running head: MEDICAL TRANSPORTATION BARRIERS 2
In this literature review, we will explore the opinions of several research studies that will
outline the benefit and the cost of managing a Paratransit program for African American who
are diagnosed with End Stage Renal Disease (ESRD) and cognitive impairments. The
information provided may be use to challenge existing policies and procedures by exploring
new research within the area of concern and formulate new opinions in reserving existing
programs that are serving this population.
The goal of the research is to establish quality services at an affordable price. The
infrastructure of most Paratransit programs may differ in regards to contractual agreements
between the transportation companies and the federal government. Factors that may
determine how much it will cost to manage the program are due to the size and the potential
growth of the population. Researchers’ and executive stakeholders must forecast this
potential population growth as a focal point when incorporating census data into the budget
for those who are at risk for ESRD and/or cognitive impairments related to traumatic brain
injuries (TBIs) or biological origins.
Introduction

3. Running head: MEDICAL TRANSPORTATION BARRIERS 3
African Americans and other minorities in the United States may face some type of
hardship in accessing appropriate services that may provide a better quality of life. This
project may provide cultural specific health education to executive stakeholder and other
health providers in efforts to raise awareness of the urgency in providing access to public
transportation to receive quality health services. Access to public transportation is paramount
in promoting a health and wellness in the African American community. The target
population for which will be used for this study will focus on the African American with
ESRD who may exhibit cognitive impairments related to TBIs or due to biological disorder.
The project will not only highlight the struggles within the African American
community in accessing quality health care but it will highlight the older population within
the African American community who may be more at risk for health disparities due to age
and/or secondary to preexisting conditions. Contributing factors to common diseases found in
African American patients may be due to diet and stress. According to Jackson, Knight, &
Rafferty (2010), high rates of obesity are observed in black populations, particularly among
women and it is believed that consuming large amounts of comfort food may contribute to the
condition.
Educating communities regarding diet and exercise may reduce the risk factors for
ESRD and other secondary diseases such as strokes, diabetes or high blood pressure that
could contribute to stroke, kidney failure, other forms of arthritis. An interesting fact
according to Hall, Choi, Ping, Smith, & Boyko (2013), patients who eventually developed
ESRD were younger and more likely to be male, of black race, covered by Medicaid and
speak English as their primary language as compared with those who did not develop ESRD.
This alarming fact within the African American community may warrant public health
education to slow or prevent new cases of ESRD
According to the National Kidney Foundation (2015), 1 in 3 American adults is at risk
for kidney disease. Major risk factors include diabetes, high blood pressure, a family history
of kidney failure and being age 60 or older. Kidney disease often has no symptoms, and it
can go undetected until very advanced but a simple urine test can tell the patient if they have
kidney disease. It is very importance to get tested because early detection and treatment can
slow or prevent the progression of kidney disease.

4. Running head: MEDICAL TRANSPORTATION BARRIERS 4
The information that is provided by the kidney foundation may provide validity to the study
but incorporating quantitative research and practical application of prior protocol in detecting
chronic and End Stage Renal disease. The contributing factor that may pose danger to the
patient may be prevented by incorporating early detection and treatment by a qualified health
professional. Access to public transportation allows these individuals to access quality
healthcare within other neighborhoods, which will create a health community and competition
among health providers.
The Scope of the Issues
In the United States, each population of have a medical belief and a sect law or rule that
makes our country unique and well advanced in research that produces scientific discoveries
in medicine, nursing, and social services. For the sake of this proposal, we will discuss the
demographics in the United States. ESRD and secondary cognitive disorders may be
prevalent worldwide but this study will only cover US populations.
According the United States Census
Bureau (2015), Caucasians make up over
half of the population. The statistics did
not give a description of what population
were added to generalize the figures
shown above. For example, Hispanics are
considered a group of nationalities that do
not fit in other categories despite of their
origin i.e. Puerto Rico, Mexico, or South
American continents.
80%
14%
6% 0%
U.S. Population
White Black
Asian Native Hawaiian
Native American

5. Running head: MEDICAL TRANSPORTATION BARRIERS 5
The comparison between the US population and the minority population shows that there is
no difference in the demographic population. Caucasians still make up the majority of the
world’s population including Texas.
The goal of the research is to establish a
link of services to those who are in the
minority and not as much of the
majority.
Looking at the figures above, the
population may not represent the true
number of Texas as illustrated in the
figure. The current statistics may be
misinterpreted due to the lack of census
participation and population grouping as
previously discussed in the first figure. The study will enlighten these statistics within the US
and Texas population in efforts show how minorities maybe in danger of losing some benefits
such as public transportation that may provide better access to healthier foods, qualified
health providers, and continuous therapies necessary to promote healthy living.
State and federal regulators forecast their operation budgets based on the current
statistics of the population. As public health practitioners and social services professions, we
must advocate for the people who do not have a voice. We must obtain the latest research and
provider stakeholder with new criteria regarding the needs of the African American
population in effort to ensure that transportation is not a barrier in achieving ultimate health.
African-American patients, who are more likely to live in low-income neighborhoods
and to have multiple chronic conditions, are seen even less likely to follow medical
recommendations. Neighborhood disadvantage also predicts higher rates of poor diet and
lower physical activity. Neighborhood features that might contribute to such effects including
poor housing conditions, distance from stores selling healthy foods, and lack of recreation
facilities (Senteio & Veinot, 2014). Diet and exercise may not become the answer in the
treatment and curation of ESRD or secondary cognitive impairments but goring forward,
public health practitioners must take into account the amount services that are in existence
White
81%
Black
13%
Asian
4%
Native
Hawaiian
0%
American
Indian
2%
Texas

6. Running head: MEDICAL TRANSPORTATION BARRIERS 6
and formulate new policies in efforts to stabilize these services for potential population
growth.
Paratransit Programs
According to Wise (2012), government accountability office (GAO) reported that 80
federal programs in eight different agencies fund a variety of transportation services for
transportation-disadvantaged populations, which includes older Americans. Correlating
literature suggest that Paratransit transportation is mostly for older people but in essence,
Paratransit services are distributed among all age populations who fit the criteria according to
American Disabilities Act (ADA).
The potential growth within the population of older American including African
Americans who are diagnosed with ESRD may prompt more social workers to advocate for
these individuals to receive transportation assistance from their local city government office.
Several states and local offices expressed concern about their ability to adequately address
expected growth in elderly, disabled, low-income, and rural population (Wise, 2012). As
explain in the introduction, expected growth in the population and in disease disability may
drain city and county transportation resources prematurely. This may result in the loss of
jobs, increase in heath disparities due to the lack of stable transportation, and less physical
activity within the population.
Incorporating public transportation in low-income neighborhoods may increase physical
activity among African American renal and cognitive impaired patients. Activity modes of
transportation, including public transportation, can contribute substantially to total physical
activity (Webb, Laverty, Mindell, & Millett, 2016). Incorporating a Paratransit non-
emergency program within low-income neighborhoods may save many lives. Transportation
is the essential element in the relief of suffrage among minority-disadvantaged populations
such as African American.
Transportation barriers are often cited as barriers to healthcare access. Transportation
barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed
medication use. These consequences may lead to poorer management of chronic illness and
thus poorer health outcomes (Syed, Gerber, & Sharp, 2014). Patients who have ESRD may
visit a dialysis center at least three times a week. Without stable transportation, the state of
the patient population may be at stake.

7. Running head: MEDICAL TRANSPORTATION BARRIERS 7
According to Syed et.al (2014), transportation is a basic but necessary step for ongoing
health care and medication access, particularly for those with chronic disease. Chronic
disease care requires clinic visits, medication access, and changes to treatment plans in order
to provide evidence-based care. However, without transportation, delays in clinical
interventions results. Such delays in care may lead to a lack of appropriate medical treatment,
chronic disease exacerbations or unmet health care needs, which can accumulate and worsen
health outcomes. Restrictions in transportation may produce unwanted results that could
cripple the local economy with high cost emergency room visit in efforts in treating
symptoms of chronic disease such as ESRD.
Public transportation ridership in the United States is at its highest level in 57 years,
with 10.7 billion trips taken on public transportation in 2013. Transportation systems help
shape communities and affect safety, physical activity, healthcare access, and the environment
(James, Ito, Buonocore, Levy, Arcaya, 2014). The estimates in this article may exhibit the
need for more governmental funding for more Paratransit programs throughout the U.S.
According to the Texas
Workforce Investment Council
(2016), the most reported
disability among Texas is related
to a physical function that
impairs mobility. Paratransit
services may provide individuals
who have physical limitation to
get back and forth to their
doctor’s and therapy
appointments. The average
amount of patients that are
utilizing Paratransit services is
unknown but the discovery of
Ambulatory
Disability
28%
Independent
Difficulties
21%
Cognitive
Difficulties
17%
Hearing
Difficulties
13%
Self-care
Difficulty
12%
Vision
Difficulty
9%
Types of Diabilities in Texas

8. Running head: MEDICAL TRANSPORTATION BARRIERS 8
new criteria may be of interest to those who manage these services. The present criteria long
with low reimbursement rate may exhaust the resource that is set to provide low-cost or free
rides to those who are unfortunately disabled.
As a social services worker, the focus of my practice is to ensure that all client have
their needs met in a timely order which in this case is transportation to and from dialysis
appoints. However, most Paratransit services are suffering financially with strict budgeting
due to the frequent pass of individual who meet the criteria based on futuristic complications
due to ESRD and cognitive impairments.
Courtesy of DART.org, the fiscal years starting with 2012 to 2015 illustrates the need
for stronger assessment criteria when approving Paratransit benefits. The user statistics
appear to be rising and not stabilizing. This can become a problem in the future if Paratransit
administrators do not forecast the growth in ridership and recognize the growth in disability
claims
In 2012, the Paratransit ridership was at an all time high at 992,937 that is almost
100,000 riders with limited amount of fleet to serve them all. From 2013-2014 it appears that
the ridership acceptance rates were going downward, which may save the company money in
operational cost. However, on most Paratransit services, riders who are considered eligible
for the service may continue to use fixed bus routes. Looking at the statistics, the approval
rate for Paratransit programs are increasing at a rapid rate. Public health practitioners should
992,937
763,469
753,398
781,797
2012
2013
2014
2015
DART Paratransit Acceptance
DART Paratransit Acceptance

9. Running head: MEDICAL TRANSPORTATION BARRIERS 9
educate the Paratransit administrators about forecasting and setting criteria for ESRD and
cognitive impaired patients in efforts to reserve funding to manage the program while
providing services to those who are desperately in need.
Cost of the Program
The cost to manage a Paratransit program may impose higher taxes for participating
cities that permit Paratransit services. The cost in contracting government approved
contracting services to pick up the slack can be expensive. According to Smirnova & Leland
(2016), there is a level of competition in the bidding of services (among private vendors) and
the level of competition during the execution of a service contract. The bidding process for
transit services often takes place on a national scale, where large private companies bid for
different contracts, while service provision occurs at the local level by cities, counties, and
special-purpose governments.
The first important step in making corrections to the program, we must look at the way
how each vendor bids for a 5.5-year contract with the government to provide transportation to
disabled customers. One aspect that stood out was that once a contract has been awarded to a
particular company, the local agency may become locked into a particular arrangement, and
have no choice but to pay what the vendor demands for the service. Each local company must
look at the services in which the taxi/bus service can provide to existing customers. There
should also be some type of assessment criteria that measures the providers performance. The
factors should include on time performance ratio, customer service, and the safety measures
of the drivers.
Customer satisfaction surveys and face-to-face renewal interview should be
implemented to prevent high cost providers who cannot provide the standard service from
getting or renewing their contract. Smirnova & Leland (2016), emphasized that if government
agencies do not pay attention to the market power of vendors and understand how they
influence outcomes, information asymmetry may occur and the cost-effectiveness of
contracting out will fail to be realized, particularly when contracts are not frequently rebid.
Local entities must get more involved and seek incorporate competition as a criterion in
measuring quality services to existing customers that are accessing disability transportation.

10. Running head: MEDICAL TRANSPORTATION BARRIERS 10
Conclusions and Recommendations
ESRD is one of the most expensive diseases to manage due to the many complications
that a patient may exhibit during dialysis treatment. Cognitive impairments such as stroke,
high blood pressure, or TBI can become a burden for poor to low income African Americans.
Access to free or low cost transportation may be an option for those who cannot afford
transportation to and from medical appointments. However, this cost is transferred to the
stakeholders who receive limited grant money to host the program.
The focus agenda for the project was to look at the number of existing programs and
find ways on how to reserve those programs for future population. Correlating research
supports the idea that hosting a Paratransit program may encourage physical activity and
better health (Webb et. Al, 2016). Social service agencies that host Paratransit programs must
forecast potential grow in the general and disease population in effort to allow more services
to be offered.
Minority population may be at a more disadvantage due to the limited number of
practitioners within the area. This is the reason why it is important to have public
transportation as an essential part of community development. According to longitudinal
studies in this proposal, incorporating public transportation is a right and as much as a
privilege but as a social worker the cost of managing a Paratransit system may be quite
expensive. This project may educate stakeholders on how to serve the riders who need the
service while making the service more cost-effective to both the customer and the managing
company.
The need to service African American ESRD patient is at an alarming rate that if not
addressed, the population may experience more hardship in accessing proper health services
and receiving treatment for ESRD and cognitive impairments related to the disease.

11. Running head: MEDICAL TRANSPORTATION BARRIERS 11
References
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www.dart.org/about/dartfacts.asp
Hall, YN., Choi, AI., Ping, MS., Smith, NL., Boyko, EJ. (2013). Predictors of end-stage renal
disease in the urban poor . Journal of Health Care for The Poor and Underserved 24(4),
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Jackson, J. K. (2010). Race and unhealthy behaviors: Chronic stress, the HPA axis, and physical
and mental health disparities over the life course. American Journal of Public Health
100(5) , pp. 933-9.
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proposed public transportation service cuts and fare increase in Boston, Massachusetts
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2017/stateplanonaging15-17.pdf
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http://factfinder.census.gov/faces/nav/jsf/pages/community_facts.xhtml
United States Department of Justice . (2009). A guide to disability rights and laws . Retrieved
from US Department of Justice Civil Rights Division : Retrieved from:
http://www.ada.gov/cguide.htm#anchor64984

12. Running head: MEDICAL TRANSPORTATION BARRIERS 12
Webb, E., Laverty, A., Mindell, J., Millett, C. (2016). Free bus travel and physical activity, gait
speed, and adiposity in the english longitudinal study of ageing. American Journal of
Public Health 106(1), pp. 136-142.
Wise, D. . (2013). Transportation-disadvantage populations: Coordination efforts are underway,
but challenges continue. Washington, D.C.: The United States Government
Accountability Office .