Transportation for Older Adults: Measuring Results Could Help Determine If Coordination Efforts Improve Mobility
Released: 2014-12-10T00:00:00

Letter

Background

Older adults are considered among the transportation-disadvantaged population, or those millions of Americans who are unable to provide their own transportation or have difficulty accessing public transportation because of age, disability, or income. The total number of transportation- disadvantaged older adults is unknown, and groups of transit dependent riders can overlap because some older adults may also be disabled or low income, or both. However, the older adult population is growing more rapidly than any other age group in the United States. Specifically, according to 2010 U.S. Census data, the population aged 65 and older grew 15 percent from 2000 to 2010, compared to about a 10 percent growth in the overall population, and by 2030, older adults are expected to comprise about 20 percent of the overall population. In 2012, the estimated population of veterans 65 and older was 9.6 million. Although about 83 percent of older adults are licensed drivers, approximately 20 percent of older adults no longer drive, according to the Federal Highway Administration’s 2009 National Household Travel Survey.

A range of mobility options can allow older adults to maintain their independence and age in place in their communities. For example, for those older adults who no longer drive, some may walk, bike, or use public transportation to meet their mobility needs. Others, including those with disabilities, may require more specialized transportation, such as paratransit in order to access services. According to 2010 U.S. Census data, 50 percent of adults 65 and older had a disability. Paratransit service, broadly defined, is accessible, origin-to-destination transportation service that operates in response to calls or requests from riders. It is an alternative to fixed-route transit service, which operates according to regular schedules along prescribed routes with designated stops.

The Older Americans Act of 1965 (OAA) was enacted to provide services to older adults to help them remain in their homes and communities for as long as possible. authorizes federal funding for a variety of home- and community-based supportive services that allow older adults to maintain independence. For example, Part B of Title III provides funding for a variety of supportive services, including transportation for older adults with and without mobility impairments. In fiscal year 2014, about $1.2 billion in Title III grants were provided to states, of which $344 million were grants for supportive services. The OAA, as amended, established the Administration on Aging (AoA) within HHS as the chief federal advocate for older Americans and assigned responsibility for home- and community-based services to AoA. In 2012, HHS established the Administration for Community Living (ACL), which brought together AoA, the Office on Disability, and the Administration on Developmental Disabilities—within HHS—to better align the federal programs that address the community living service and support needs of both the aging and disability populations, among other things. AoA distributes funding through grants to state units on aging, which allocate these funds to AAAs that either directly provide services, or contract with local service providers.

42 U.S.C. §§ 3001 and 3003. include private nonprofit and government organizations; 244 tribal and Native American organizations; and 2 organizations serving Native Hawaiians. Nearly 20,000 local organizations provide services through this network. The state units on aging and AAAs are responsible for the planning, development, and coordination of an array of home- and community-based services within each state. In particular, the OAA requires state units on aging to submit plans to the AoA for 2, 3, or 4 years. Among other types of information, the plans must evaluate older adults’ needs for home- and community-based services, which may include transportation. In addition, the OAA requires that state units on aging develop a standardized process to determine the extent to which public or private resources (including volunteers and programs and services of voluntary organizations) are capable of meeting needs.

MAP-21, Pub. L. No. 112-141, § 20028, 126 Stat. 405, 726, codified at 49 U.S.C. § 5338 (a)(2)(D). include activities previously eligible under the New Freedom program and to public transportation projects that improve access to fixed-route service and decrease reliance by individuals with disabilities on complementary paratransit. In particular, Enhanced Mobility program funds can be used for capital planning and operations: 55 percent of all allocations for each grant recipient must be used for public transportation projects where traditional services are unavailable, inappropriate, or insufficient, while the remaining 45 percent can be used for other eligible services, including capital and operating expenses and projects previously eligible under the New Freedom program. States typically distribute these funds to local nonprofit human service agencies to buy vehicles that transport older adults and people with disabilities, and the agencies funded may provide transportation to support a range of activities, such as visiting friends.

The Enhanced Mobility program requires grantees to develop coordinated public transit-human services plans. development and approval process that includes seniors, people with disabilities, and transportation providers, among others, and is coordinated to the maximum extent possible with transportation services assisted by other federal departments and agencies. The program also allows other federal non-DOT funds, such as Title III Part B funds, to be used as matching funds in order to better meet the transportation needs of older adults and promote federal coordination.

Human-service transportation refers to transportation services provided by or on behalf of a human service agency to provide access to agency services and to meet the basic, day-to-day mobility needs of transportation-disadvantaged populations, especially individuals with disabilities, seniors, and people with low incomes. income individuals. Medicaid programs, which are administered by each state subject to the oversight of CMS, are required to assure that program beneficiaries—such as low-income children, people with disabilities, and older adults, among others—have access to necessary Medicaid providers when the beneficiaries cannot transport themselves to these providers. Under federal regulations, VA also provides transportation to medical services for those veterans who have service connected injuries or disabilities and meet certain eligibility criteria.

Our past work on transportation-disadvantaged populations has found that federal coordination has the potential to reduce federal transportation program costs by clustering passengers; using fewer one-way trips; and sharing the use of personnel, equipment, and facilities. Federal efforts to coordinate transportation for the disadvantaged, including older adults, began in 1986 when DOT and HHS formed what is now known as the Coordinating Council. The Coordinating Council is chaired by the Secretary of Transportation and is charged with improving the efficiency and effectiveness of human service transportation by coordinating related programs at the federal level and promoting the maximum feasible coordination at the state and local levels. In 2003, the Coordinating Council launched the “United We Ride” initiative to act as a forum for interagency communication and to help states and communities overcome obstacles to coordination. The Coordinating Council’s actions have included issuing publications such as policy statements and progress reports on efforts taken. However, our June 2012 report on transportation-disadvantaged populations concluded that insufficient federal leadership and a lack of guidance for furthering collaborative efforts might hinder coordination efforts among state and local providers. To promote and enhance federal coordination efforts, we therefore recommended in 2012 that the Secretary of Transportation, as the Chair of the Coordinating Council, along with the council’s 11 member agencies, should meet and complete and publish a strategic plan outlining agency roles and responsibilities and articulate a strategy to help strengthen interagency collaboration and communication. In response to our recommendations, the Coordinating Council’s member agencies issued a strategic plan for 2011 to 2013, which established agency roles and responsibilities and identified a shared strategy to reinforce cooperation.

Our prior work has shown that coordination can lead to improved quality and cost-effectiveness of transportation-disadvantaged services. In addition, we have previously identified key features and issues to consider when federal agencies collaborate and implement collaborative mechanisms, such as an interagency group or council. These key features include defining outcomes; monitoring progress to show accountability; establishing clear leadership; and determining key resources, such as funding. For example, various approaches can help enhance and sustain collaboration among federal agencies, such as developing a plan to identify short- and long-term outcomes and tracking progress toward those outcomes.

Transportation Funding Flows to Older Adults through Key Federal Programs, but Outcomes of Coordination Efforts Are Not Measured

Transportation Funding Can Flow to Older Adults through Two Targeted Federal Programs and Several Other Federal Programs That Serve Broader Populations

We identified two key federal agency programs, AoA’s Title III Part B Supportive Services and FTA’s Enhanced Mobility program, and six other federal agency programs that can provide funding or transportation services for older adults. These eight identified programs are not an exhaustive list of all existing programs, but rather we focused on programs administered by the three primary Coordinating Council member agencies that provide transportation funding or services that may benefit older adults. Not all of the programs we identified focus solely on the older adult population. (For additional information on how we identified these, see appendix I. Also, see appendix II for the complete program list, including program descriptions.) In addition, as we reported in 2012, total federal spending on transportation services for transportation-disadvantaged populations is unknown because in many cases federal agencies do not separately track spending for these services. As such, transportation spending for older adults is also unknown because the funds are used to provide transportation services for a broader population.

Of the eight federal programs we identified, the only programs that specifically provide funding exclusively for older adults were established in the OAA, which includes Title III Part B Supportive Services. Specifically, Title III Part B provides funds to 11 categories of supportive services for older adults, including transportation and assisted According to HHS officials, transportation can include a transportation.range of services such as shared rides and public transportation access, while assisted transportation serves eligible older adults who have difficulties using regular vehicular transportation and involves providing assistance, such as an escort, to those adults. Because this program targets services for older adults—including transportation—spending information for that population is available, as states are required to annually report their Title III Part B spending across the different supportive services. In fiscal year 2012, states reported spending a total of $68.8 million on transportation and $3.3 million on assisted transportation. Overall, states reported spending a total of $330 million on supportive services in 2012, making transportation and assisted transportation about 22 percent of total reported expenditures. This is similar to what states have previously reported spending on these two supportive service categories from 2010 and 2011 (see table 1). In addition, AoA collects information on the number of transportation service rides provided through Title III Part B, as well as both the number of rides and people receiving assisted transportation services through their programs.

FTA’s Enhanced Mobility program also targets older adults as one of its primary populations and is focused on improving the mobility of seniors and people with disabilities. According to FTA officials, the agency obligated about $180.6 million in Enhanced Mobility program funds in fiscal year 2013. FTA officials stated that they do not track the proportion of funds going to transportation projects and services for older adults versus those with disabilities, and said that in many cases, the project to be funded would benefit both populations by responding to the same functional needs, whether the need is derived from age or a disability. For example, the cost to ride in taxicabs that meet the Americans with Disabilities Act (ADA) accessibility requirements are an eligible expense under the Enhanced Mobility program. Accessible taxis offer communities flexibility, and cost savings, compared to traditional ADA paratransit service,disabilities regardless of age. and can benefit older adults and persons with The remaining programs within CMS and VA do not specifically target older adults, but provide funds for transportation services that qualified older adults could benefit from. These programs are primarily focused on nonemergency medical transportation (NEMT). Specifically, CMS’s programs such as Medicaid NEMT and 1915(c) Home and Community Based Services waiver programs can provide transportation to eligible older adults. The Medicaid program provided health services to NEMT eligible populations. For example, it provided service to more than 4.6- million low-income seniors, compared to 11-million non-disabled adults, 8.8-million individuals with disabilities, and more than 31-million children. In addition, VA programs, including Veteran’s Medical Care Benefits (Beneficiary Travel) and Veteran’s Transportation Program can benefit eligible older adult veterans. For example, in 2013, VA officials told us that the Beneficiary Travel program reimbursed approximately 5- million claims for mileage costs totaling about $168 million to veterans aged 65 or older.

Federal Coordination Efforts Vary and Outcome Measures Are Not Clearly Identified or Tracked

Federal agency involvement in the Coordinating Council varies, with coordination on older adult transportation primarily occurring between FTA and AoA, the two primary agencies involved in human services transportation planning activities. The Coordinating Council’s Executive Committee has not met since 2007, but Coordinating Council officials told us that the lack of meetings is not a sign of inactivity, as working groups comprised of staff-level program officials from some of the 11 member agencies have developed initiatives intended to further federal coordination efforts. According to Coordinating Council officials, working groups are activated in response to specific needs that arise for collaboration between partner agencies. For example, current working group initiatives have focused on mobility management tools, such as one-call one-click centers, to better connect transportation service providers and riders. In particular, Coordinating Council officials stated that the Health, Wellness and Transportation working group, which includes participation from DOT, VA, HHS, and the Department of Laboris the focal point for current coordination activities and has incorporated earlier initiatives, such as veterans transportation efforts, into this group.

This research and demonstration program also included contributions from the Community Transportation Association of America, Easter Seals, and the National Association of Area Agencies for Aging—industry associations representing transportation providers, older adults, and people with disabilities, as well as the aging services network, respectively. as well as new and innovative models for addressing the needs of older adults and those with disabilities. According to DOT officials, the Small Grants program was initially funded in fiscal year 2012 for $1 million, about $950,000 in fiscal year 2013, and $1 million in fiscal year 2014. The program has finished its first phase and is currently funding its second phase of grant projects. One such grant was awarded to Montgomery County, Maryland to help increase participation by older adults in a local transportation advisory committee, and to train high school and community college students to assist older adults and persons with disabilities in accessing and navigating public transportation systems. The second initiative was the Veterans Transportation and Community Living Initiative (VTCLI) grant, a coordinated effort by the Departments of Defense, HHS, Labor, DOT, and VA.help veterans and others identify and access locally available transportation services that connect them with work, education, health care, and other vital services in their communities. While the primary goal was to support veterans and military families, the grants are structured to fund transportation projects that will potentially benefit anyone living within the jurisdiction of a grant recipient—including older adults. The program only awarded grants in fiscal years 2011 and 2012. In that period, VTCLI awarded approximately $64 million for 119 grant projects for a wide range of activities and technology improvements, including mobility management tools, such as one-call or one-click centers.

VTCLI grants were intended to Mobility management was also identified as an objective in the Coordinating Council’s 2011 to 2013 strategic plan, with an emphasis on increasing the use of cost-effective and efficient mobility management principles, in part by expanding training for state and local officials. According to Coordinating Council officials, FTA’s Enhanced Mobility program, which includes allowing mobility management as an eligible expense, provides opportunities for innovative programs and practices at the state and local level, such as helping support mobility manager positions or other mobility management tools. According to these officials, mobility managers are seen as a key position that can help connect the various stakeholders in a coordinated transportation system.

In addition to supporting mobility management activities, the Coordinating Council’s strategic plan highlights the importance of providing technical assistance to support Coordinating Council coordination goals and strengthen state- and local-coordination efforts. Coordinating Council officials highlighted three national technical assistance centers that receive funding from FTA and are affiliated with other Coordinating Council agencies, and have been established to share coordination information and resources with state and local entities.

Easter Seals Project ACTION (Project ACTION) provides technical assistance related to accessible community transportation for persons with disabilities and older adults through research, online training, and outreach efforts to individuals or communities. For example, a Project ACTION white paper for FTA on access to public transit found that increased coordination of healthcare and transportation programs can produce reduced costs, increased accessibility to transportation options, and more positive health outcomes for older adults and persons with disabilities.

The National Center for Mobility Management provides support to FTA grantees, with a focus on direct technical assistance and sharing information with state and local entities. As a part of its efforts, the center is collecting data on transportation coordination plans and mobility management approaches from state and local providers for inclusion in a database and as case studies published on its website. For example, the center has developed publications identifying promising practices in mobility management areas, including coordinated transportation planning and technology use in transportation coordination.

The National Center for Senior Transportation facilitates local partnerships that help provide transportation to older adults, administers grant programs, and provides information and technical assistance support to communities. FTA is the primary funding agency, and according to center officials, AoA has been a primary partner in program development and activities. The center’s technical assistance activities have included administering a series of grants intended to encourage aging organizations and public and private transportation providers to involve older adults and people with disabilities in the public-transit planning process. For example, the center implemented a grant program under a cooperative agreement with FTA that focuses on person-centered mobility management. In 2012, NCST awarded 9 grants totaling about $500,000 to local communities, which included grants to provide travel training and counseling on travel options for older adults.

We found that some agencies are more engaged in coordinating transportation for older adults than others. In particular, AoA and FTA have shown continuing coordination through Coordinating Council working groups, initiatives, and technical assistance efforts as described above. Both agencies also help facilitate coordination through their respective programs. Specifically, the planning requirements and funding flexibility in both the Title III Part B and the Enhanced Mobility programs help involve stakeholders and coordinate federal resources for human service transportation by, for example, allowing Title III Part B funds to be used as the non-federal match for Enhanced Mobility program funds. However other agencies, such as VA and CMS, have not been as active in federal coordination efforts that affect the transportation- disadvantaged. For example, the Coordinating Council’s activities have been limited to staff-level working group activities that do not involve all member agencies, and lack participation by key players, such as those primarily involved in NEMT. As we previously found, agencies can use their strategic plans as tools to drive collaboration with other agencies and partners by ensuring consistent and complementary goals and strategies. Our concurrent report related to the coordination of NEMT services recommended that the Council update its strategic plan, which covered the period from 2011 through 2013. An updated strategic plan could be used to outline a strategy for coordinating NEMT across all federal agencies funding this type of service, which could benefit all transportation-disadvantaged populations, including older adults.

In addition, current federal coordination efforts do not identify or incorporate clear short- and long-term desired outcomes, a key issue to consider when implementing interagency collaborative mechanisms to ensure participation from all member agencies. The Coordinating Council identified high-level strategies, related objectives, and proposed performance indicators supporting these objectives in the 2011 to 2013 strategic plan as a guide for the council’s activities over the two-year period. However, the Coordinating Council did not clearly define desired outcomes, measures to track progress towards achieving its objectives, or timeframes for implementing its strategies and communicating results. For example, the strategic plan identifies deploying mobility management as one of the objectives for implementing the strategy to expand coordinated human-service transportation infrastructure in order to improve the capacity of communities to deliver integrated transportation and improved customer service. The objective identifies action steps and performance indicators, including tracking the number of mobility managers and the number of mobility managers receiving training and technical assistance. However, according to Coordinating Council officials, no data associated with these indicators are currently being collected that would help the council determine whether its efforts to deploy mobility management are resulting in an increased use of cost- effective and efficient mobility management principles in local communities. Additionally, because Coordinating Council officials said there are currently no plans to renew or revise the now-expired strategic plan, it is not clear which, if any, of the proposed objectives are applicable to current Coordinating Council activities or whether the performance indicators will be tracked. Coordinating Council officials said the objectives and performance indicators outlined in the strategic plan were intended to demonstrate potential outcomes and ways of measuring progress, and officials plan to explore specific measures and opportunities for data collection through the technical assistance centers in the future. However, the Coordinating Council has not yet established a specific time frame for doing so. We have previously found that monitoring and evaluating federal collaborative efforts to identify areas of improvement can help key decision makers within the agencies, as well as clients and stakeholders obtain feedback for improving both policy and Without clearly defined outcomes and related operational effectiveness.performance measures, it is difficult to assess the effectiveness of activities related to transportation for older adults currently under way in improving mobility options and access to transportation services or to make decisions about future coordination efforts. Additionally, without a clear method to collect and track information and data to demonstrate progress, it is difficult to show the benefits of coordination, and whether current Coordinating Council efforts are achieving the outcomes intended to improve transportation coordination for transportation-disadvantaged populations, including older adults.

State and Local Transportation Agencies and Aging Network Organizations Coordinate in Various Ways, but Challenges Continue

A Variety of State and Local Coordination Efforts Are Under Way

State and local transportation agencies and aging network organizations in the four states we selected used a variety of different mechanisms to coordinate transportation services for older adults. These mechanisms are similar to those we previously found are being used by a number of other regions, states, or localities for coordinating transportation. In our selected states, they were also being used to help older adults access transportation services (see table 2). For example, state level coordination councils may be created by statute, executive order, or governor initiative to oversee coordinated transportation for transportation-disadvantaged populations within a given state. In addition, mobility management efforts—which include individual level education and counseling on transportation options and systems level coordination among transportation and human service providers—are being promoted nationwide, including in our selected states.

Building from the efforts described above, some selected transportation and aging network organizations have implemented or are piloting more extensive or innovative approaches to coordination intended to help older adults access transportation services, such as offering a wide range of volunteer transportation and expanded mobility management services. For example, Ride Connection—a transportation provider operating in Oregon—relies heavily on volunteers and a network of service partners throughout the region to provide over 400,000 rides a year to older adults, people with disabilities, and those living in rural areas through a range of programs. These include travel training and coaches, community shuttles, a shared vehicle program, as well as fare assistance and relief programs. According to Ride Connection officials, approximately two thirds of the organization’s 600 drivers are volunteers, and the officials view the volunteer model as an important component of helping older adults age in place. Transportation organizations in other areas of the country are also seeking to leverage volunteer networks. The Independent Transportation Network America, an organization created to help expand the range of services available to older adults needing transportation, has explored innovative approaches and a volunteer network specifically targeted at serving older adults. Founded in Maine, this organization has 26 affiliate locations nationwide, offering rides 24 hours a day, 7 days a week, for any purpose. As members, the individuals also have the option to trade in their vehicles in exchange for credits that can be used to pay for future rides. The Independent Transportation Network also provides door- through-door service to better meet the mobility needs of frail older adults.

All of the states we selected were also pursuing pilot projects to refine long-standing services or conducting research to better assess unmet needs and potential additional coordination mechanisms. For example, the Pennsylvania Department of Transportation and stakeholders, including AAA officials, have begun a pilot project to explore adjustments and alternative approaches for the state’s lottery-funded Shared-Ride program. In part, this is an effort to use stakeholder input to address issues with many counties’ inability to cover the full cost of the senior transportation service. Other selected states have engaged in research and assessments to better identify unmet needs and potential approaches for furthering coordination efforts among transportation- disadvantaged groups, including older adults. For example, officials at the Florida Commission for the Transportation Disadvantaged worked with academic researchers to define the unmet and latent travel demand to better understand the mobility needs of the transportation-disadvantaged population in the state. Oregon and Texas have also undertaken initiatives to further explore opportunities for increased coordination. Both states completed reports in 2013 that included recommendations for developing performance metrics and both reports highlighted the need to collect and share information on gaps in service and unmet need, efforts that officials in these states continue to pursue. For example, the Texas coordination report proposed that state and regional stakeholders collaborate to develop statewide performance indicators for demonstrating that individuals throughout the state have improved access to an effective and efficient network of public transportation services, especially for seniors and people with disabilities.

Some of the transportation agencies and aging network organizations we met with described examples of areas where existing coordination efforts have been particularly helpful, but data or information quantifying the effects of coordination are lacking. For example, officials involved in regional coordination efforts in Texas told us that standard performance measures may not adequately capture the complexity of successful transportation coordination efforts, and they are working on developing performance measures to help identify geographic service gaps, which they know are issues in the region. Generally, examples of the benefits of coordination in our selected states, including those below, were limited to anecdotal examples.

Ride Solution officials in Florida noted their county-level coordinated system was designed to deliver any type of rider to any location— serving the general public, human service agencies, and transportation-disadvantaged populations with the same fleet of vehicles. Ride Solution officials also designed their own vehicle, which can accommodate 5 wheelchairs, 25 passengers, and has a low floor feature eliminating the need for stairs, which can be difficult for older adults to navigate (see fig.1). According to Ride Solution officials, the overall level of coordination resulting from their deviated-route format combining different types of riders has enabled them to provide over double the trips than the state paratransit average for many years.

Others noted that coordination can help improve the logistics necessary for coordination by offering, for example, one shared call center and scheduling system. One Oregon transportation provider we met with, Lane Transit District, described operational efficiencies and benefits to the customer resulting from coordination. For example, this provider established a one-stop call center for human service transportation, which handles requests for transportation for a variety of programs including ADA paratransit, Medicaid NEMT, as well as senior and disabled services community transportation. According to officials, this simplified one-stop access to transportation breaks down what was once a complex administration of programs, putting individuals in direct contact with resources to help identify transportation options available to them.

Challenges May Inhibit Coordination and Make It Difficult to Meet Older Adults’ Needs

We identified funding eligibility and reporting requirements for different programs, geographic boundaries, and limited data on the extent of need given the growing population of older adults as challenges at the state and local levels that may inhibit coordination in our selected states. For example, a number of state and local officials in each of our four selected states told us that it is difficult to co-mingle funds from different federal funding streams because of eligibility requirements, including both programmatic requirements on how funds can be used (i.e., certain beneficiaries) as well as perceptions about how funds can be used within those requirements. We previously found there is a disconnect between transportation providers and human service agencies. In other words, transportation providers are generally focused on making transportation services available for a wide population, including the general public, older adults, and people with disabilities. In contrast, human service agencies are often focused on meeting the specific needs of a narrower population (i.e., an eligible program beneficiary). For example, a transportation provider we met with in Florida said there is a perception in Northeast Florida, including the Jacksonville area, that OAA funding can only be used to provide a specific service, transporting older adults to congregate meal sites. These officials stressed that these perceptions need to be overcome so the region can pursue additional opportunities to coordinate transportation services and share resources. Similarly, in the locations we visited, VA officials were generally not involved in regional or local coordination efforts. In Pennsylvania, for example, VA NEMT programs operate outside the coordinated transportation planning process. According to VA officials we met with, from the agency’s perspective, if veterans are not eligible for VA-provided NEMT, they are essentially on their own in finding transportation. In certain circumstances for a specific patient, VA officials may reach out to local entities to try to identify transportation alternatives, but the officials said there is no formal structure or process in place for this type of activity. Pittsburgh’s VA Medical Center currently does not participate in any type of coordination with non-VA transportation planning or human service-transportation coordination, according to Medical Center officials.

Coordination among providers serving different geographic boundaries can be challenging in both rural and urban areas. Officials in Oregon and Florida identified transportation to medical centers in other counties as a transportation need. For example, transportation officials in Oregon told us that in areas outside the urban core or in more rural areas, a rider may need to access more than one transportation provider to make such a trip and cross county lines in order to access that service. This situation may be further complicated for older adults, because it can be more difficult to physically manage transfers or long waits. In addition, available service days and hours may be limited in rural areas, further affecting older adults’ ability to access different types of activities. Officials in all four of our selected states noted that rural areas often have very few transportation options available to serve older adults and other residents. For example, an AAA in rural Pennsylvania noted that the lack of transportation service options on Sundays has a direct impact on older adults’ ability to get to church, which can be a very important outing for some riders.

Another challenge that may hinder coordination is limited data on the extent of older adults’ transportation needs given the growing population of older adults. While recipients of Enhanced Mobility program funding are required to develop coordinated public transit-human service plans and aging network organizations are required to develop plans that include planned strategies and priorities to address the growing number of older adults, state and regional transportation and aging plans include limited systematically-collected data on unmet needs or projected future needs. For example, one selected state’s aging plan indicated that it does not have a formal needs-assessment process. According to the plan, other sources, such as focus groups and interviews with providers, helped identify transportation as a service need. Another plan we reviewed stated that satisfaction surveys and focus groups were used to help determine needs and ways in which services—including transportation—could be improved. AAA officials in Florida, Pennsylvania, and Oregon also told us there is very little concrete data identifying the extent of unmet transportation needs beyond anecdotal information, and there is no systematic data collection to identify unmet needs at the local level. As a result, limited data and information are available to help determine whether the coordination that is occurring is meeting additional needs or filling gaps in the provision of transportation services for older adults. For example, officials at an AAA in Florida explained that there is no repository of information for collecting data to identify the extent of all older adults’ needs, but noted that transportation is always raised as a major challenge in needs assessments and outreach conducted by the AAA.

Older adults may require certain types of service to meet their specific mobility and daily living needs as illustrated by examples from the states and localities we visited. For example, an AAA in Pennsylvania discussed working with the primary transportation provider in the region to find ways to better meet older adults’ mobility needs. In this case, door-to-door transportation assistance is available, but the officials are interested in exploring opportunities to provide door-through-door service to better serve the older adult community. In addition, examples from our selected states suggest that transportation for life-sustaining needs in those states are being met (e.g., to access medical and nutrition services), but there is a significant gap in transportation for social and recreational purposes. As a transportation provider in Florida explained, demand for older adult rides in its service area always exceeds available funding, and there are limits on how the existing funds can be used. For example, the transportation provider prioritizes its state Transportation Disadvantaged Trust Fund dollars for life-sustaining activities, such as transportation to congregate meal sites or medical trip appointments. As a result, this provider stated that very little funding remains for social outings like going to church or shopping with friends, which officials noted are very important components to helping older adults age in place and remaining connected to their community.

Conclusions

As the population of older adults continues to grow, having access to a variety of transportation options is critical to ensure older adults’ access to health care, social and recreational events, and other instrumental activities of daily living. When flexible transportation services exist and are accessible, older adults can more comfortably age in place in their homes and communities for as long as possible. Furthermore, when these transportation operations are coordinated, older adults may benefit from improved and more cost-effective services. A number of federal agencies provide funding that can be used for transportation for older adults, and FTA and AoA have been coordinating and are involved in facilitating initiatives, such as technical assistance efforts and community grants, to help meet older adults’ mobility needs. However, federal coordination efforts by the Coordinating Council lack clear, desired outcomes for its current coordination activities. In addition, there are no efforts under way to collect performance data that could help the Coordinating Council and its member agencies better plan and execute coordination strategies to ensure that its efforts are resulting in improved mobility and access to transportation services for transportation- disadvantaged populations, including older adults. In particular, defining desired outcomes could help the Coordinating Council determine whether its current activities are effective in facilitating coordination and help inform planning and decision-making about future coordination efforts. Furthermore, tracking performance data on its activities will help the Coordinating Council demonstrate the benefits of coordination and encourage more widespread participation.

As we concluded in 2012, a comprehensive strategy that outlines goals and desired outcomes for federal coordination efforts is needed to ensure that relevant stakeholders are actively engaged and participating in coordination efforts. While the Coordinating Council developed a strategic plan for 2011 to 2013, it is now out of date, and little else is in place to provide overall strategic guidance for federal efforts to coordinate transportation for older adults. Coordinating Council officials said that there are no plans to update or renew the existing strategic plan. We continue to believe that a current strategic plan, as recommended in our concurrent report on NEMT, could enhance coordination and collaboration among the federal agencies that provide funding that can be used to meet older adults’ transportation needs.

Recommendation

To promote and enhance federal, state, and local coordination activities, we recommend that the Secretary of Transportation, as the chair of the Coordinating Council, convene a meeting of the member agencies of the Coordinating Council and define and report on desired outcomes and collect related data to track and measure progress in achieving results, including the extent of coordination efforts that are under way, such as improved services for older adults. This effort could be conducted as a part of the Coordinating Council’s process to update its strategic plan, which we have also recommended in a concurrent report.

Agency Comments and Our Evaluation

We provided a draft of this report to DOT for review and comment. DOT partially concurred with our conclusions and recommendation in an email response. Specifically, DOT stated that the Coordinating Council’s working groups and affiliated technical assistance centers have ongoing activities related to coordination. DOT also stated that FTA is developing a 2-year implementation strategy for the Coordinating Council and will determine policy objectives and information that may be needed to measure progress and evaluate coordination efforts that are under way. While we agree that these are important steps toward improved coordination, we believe it is important that any framework FTA establishes for the Coordinating Council articulates clear, desired outcomes and measures that the Coordinating Council can use to collect data and assess the effectiveness of its coordination activities in improving access to and mobility options for transportation-disadvantaged populations, including older adults.

We also provided a draft of this report to VA and HHS for review and comment. VA commented that the agency welcomes opportunities to participate in additional coordination efforts and supports the establishment of performance measures among federal, state, and local agency coordination efforts. VA also commented that the agency’s priority for its transportation programs is to ensure timely access to medical care for veterans. HHS did not have any comments on the draft report.

We are sending copies of this report to the appropriate congressional committees and the Administrator of FTA, the Secretaries of the Department of Transportation, HHS, VA, and interested congressional committees. In addition, the report is available at no charge on GAO’s Web site at http://www.gao.gov.

If you or your staff members have any questions about this report, please contact me at (202) 512-2834 or wised@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are listed in appendix III.

Appendix I: Objectives, Scope, and Methodology

This report addresses the following questions: 1. What federal programs provide funding for transportation services for older adults, and to what extent are the programs that fund these services coordinated? 2. How do state and local transportation agencies and aging network organizations in selected states coordinate transportation for older adults and what challenges do they face in coordinating or providing these services?

To identify federal programs that provide funding for transportation services for older adults, we reviewed our 2012 report on transportation- disadvantaged populations, which identified federal programs that provide funding and services for transportation-disadvantaged populations, which includes older adults, a 2013 AARP report that that identified federal programs that provide funding for older adults, and conducted a search of the Catalog of Federal Domestic Assistance. These programs may fund infrastructure-related costs for transportation or transportation services. We limited our scope to federal agencies that are members of the Interagency Coordinating Council on Access and Mobility (Coordinating Council) because these agencies were identified by executive order to participate in coordination. Through these reviews, we identified three primary federal agencies—the Departments of Health and Human Services (HHS), Transportation (DOT), and Veterans Affairs (VA)—that administer programs that provide funds to older adults where transportation is an eligible expense or that target older adults among the eligible recipients for transportation funds. Other federal agencies may also have programs that provide funding for transportation for older adults. However, we did not systematically identify every program government-wide that could provide such funding as part of this review. We subsequently asked federal program officials from the three agencies to review and verify the programs identified and the program information collected, including if transportation for older adults was an allowable use of program funds, and program spending or obligations for fiscal 2013. For HHS’s Title III B program we asked for spending data from fiscal year 2010 to 2013. We also asked agency officials to include any relevant programs we may have missed in our search. Agency officials provided requested spending and obligation data when available, but we did not independently verify the data provided.

To determine the extent to which these federal programs are coordinated, we reviewed policy and other guidance established to promote coordination of transportation services at the federal level and interviewed officials from HHS, DOT, and VA about the level of interagency coordination on transportation for older adults. For example, we met with DOT agency officials involved with Coordinating Council activities. We also reviewed Coordinating Council documents, such as the 2011 to 2013 strategic plan and the Council’s progress report on recommended actions for human service transportation coordination. We also interviewed officials from relevant stakeholder groups, academic researchers, and technical assistance centers, such as the National Association of Areas Agencies on Aging, AARP Public Policy Institute, Center for Urban Transportation Research at the University of South Florida, Easter Seals Project ACTION, the National Center for Senior Transportation, and the National Center for Mobility Management. In addition, we reviewed literature since 2009 on the coordination of transportation services for older adults, and interviewed staff from federal technical assistance centers and other stakeholder groups involved in transportation coordination efforts about federal coordination of services to meet the transportation needs of older adults. For example, we reviewed National Center for Senior Transportation grant programs and initiatives. We also compared coordination efforts against leading practices GAO has identified for successful interagency collaboration and collaborative mechanisms, such as interagency groups and councils.

To determine how selected state and local transportation agencies and aging network organizations coordinate transportation for older adults and the challenges they face in coordinating or providing these services, we conducted site visits in four states—Florida, Oregon, Pennsylvania, and Texas—to discuss the coordination of transportation services between transportation agencies and aging network organizations. In particular, we interviewed officials from state and area agencies on aging, state transportation departments, metropolitan planning organizations, VA medical centers, and local transit providers about the coordination of transportation services for older adults, challenges to providing and coordinating services, and any gaps in the current services provided. We selected these four states as they were among those with the greatest overall population of and the largest proportion of older adults and received the largest amounts of DOT funding for transportation services that can be used for older adults. We also selected states with a mix of state coordination mandates and coordinating councils, and identified and visited metropolitan areas within the states that provided transportation services to older adults in both urban and rural portions of the states. Information obtained in the site visits is not generalizable to other states that coordinate transportation services for older adults. In addition, we interviewed federal agency officials within HHS, DOT, and VA as well as staff from the federal technical assistance centers about the challenges to coordination at the state and local levels. We also reviewed selected state and local aging plans and local and regional transportation coordination plans for selected sites. Table 3 provides more detailed information about the state and local entities we interviewed.

We conducted this performance audit from March 2014 to December 2014 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Appendix II: Identified Programs from the Department of Health and Human Services, Department of Transportation, and Department of Veterans Affairs That Fund or Provide Transportation for Older Adults

Older Americans Act of 1965; 42 U.S.C. § 3030d(a)(2)

Title III Part B is a formula grant program established in the Older Americans Act of 1965. Its purpose it to encourage state units on aging and area agencies on aging to concentrate resources to develop and implement comprehensive and coordinated community-based systems of service for older individuals via statewide planning and area planning and provision of supportive services. The program is intended to serve those aged 60 or older. There are a number of supportive services these funds can be applied to, including providing both transportation and assisted-transportation services. These funds are flexible and can be used for both medical and nonmedical transportation.

Older Americans Act of 1965; 42 U.S.C. §§ 3057, 3030d (a)(2)

Title VI Part A is a project grants program established in the Older Americans Act of 1965. Funds are available through grants to eligible Indian Tribal Organizations for services comparable to those provided under Title III. Services must include nutrition services and information and referral, and may include transportation and other services authorized under Title III. Grants also are available to private or nonprofit organizations having the capacity to provide services to older Native Hawaiians.

Social Security Act: 42 U.S.C. §§ 1396a, 1396n(e)(1)(A)

Federal law requires states to ensure that eligible Medicaid beneficiaries have transportation to and from health care services. The program is focused on those who cannot provide their own transportation to and from appointments. NEMT programs and ride scheduling procedures vary from state to state. Generally, beneficiaries must contact the Medicaid transportation provider in their area to arrange for rides. Medicaid NEMT rides can be provided through a number of methods such as through mass transit systems as well as taxis, cars, or vans.

Social Security Act: 42 U.S.C. § 1396n(c)(3)

The Medicaid Home and Community Based Services waiver program was authorized under Section 1915 (c) of the Social Security Act. Through this program, states can assist Medicaid beneficiaries by providing a wide array of services that permit them to live in their homes or community and avoid institutionalization in a nursing-home facility. Among the services that can be provided under the waiver are transportation services approved to help a beneficiary access a service that may not be a traditional Medicaid plan service.

Agency

The Enhanced Mobility program is a formula grant program established in 1975 to provide financial assistance in meeting the transportation needs of elderly persons and persons with disabilities where public transportation services are unavailable, insufficient, or inappropriate. Funds can be used for capital planning and operations. The Enhanced Mobility program is designed to supplement the Federal Transit Administration’s other capital assistance programs by funding transportation projects for elderly persons and persons with disabilities in all areas—urbanized, small urban, and rural. The program was renamed under the Moving Ahead for Progress in the 21st Century Act and modified to include New Freedom Program activities as eligible projects.

VA provides transportation funds and services to qualified veterans needing to access a VA medical facility. The program provides transportation through mileage reimbursement, purchase of transportation service contracts, or medically necessary specialized transportation.

VA provides grants to eligible recipients to assist veterans in highly rural counties through innovative transportation services to travel to VA Medical Centers, and to otherwise assist in providing transportation services in connection with the provision of VA medical care to these veterans.

VA provides funding for housing and services in the community to help veterans out of homelessness.

Medicaid transportation for older adults is provided under the Nonemergency Medical Transportation program benefit. The Centers for Medicare and Medicaid Services’ 1915 (c) Home an Community Based Services waivers is a program within Medicaid. For the purposes of our report, as this is a program focused on assisting older adults in living independently and provides transportation funding and services, we have presented it separately from Medicaid NEMT.

The Department of Transportation had other formula funding programs for transportation services, such as the Urbanized Area Formula program and formula grants for rural areas. These are general transit program funds that serve a number of populations, but they may also be applied to transportation for older adults.

Appendix III: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the individual named above, the following individuals made important contributions to this report: Lorelei St. James (Director), Nancy Lueke (Assistant Director), Lorraine Ettaro, Delwen Jones, Maria Wallace, Betsey Ward-Jenks, Cheryl Peterson, and Sarah Veale.