Transportation-Disadvantaged Seniors: Efforts to Enhance Senior Mobility Could Benefit from Additional Guidance and Information
Released: 2004-09-16T00:00:00

Letter

Background

Seniors are a heterogeneous group—many do not require assistance with transportation, and, in fact, most drive automobiles. However, according to data from the 2001 National Household Travel Survey conducted by DOT’s Bureau of Transportation Statistics, Federal Highway Administration, and National Highway Traffic Safety Administration, approximately 21 percent (6.8 million) of seniors aged 65 and older do not drive. The percentages are higher among minority populations aged 65 and older: approximately 42 to 45 percent of African-Americans and Asian-Americans do not drive, compared with 16 percent of Caucasians. Approximately 40 percent of Hispanics also do not drive. A person’s driving status is correlated with travel behavior. For example, one study found that drivers aged 75 and older made an average of six trips per week, compared with two trips per week for nondrivers. While some of this difference may be due to individual preferences or to other circumstances, such as an illness that prevents travel, some of the difference may be due to a lack of transportation alternatives.

Those seniors with poor health or a disability, or who have a limited income, may face more difficulty finding and accessing transportation. According to data from the 2000 Census, about 37 percent of persons aged 65 and older reported having at least one disability, and about 10 percent were below the federal poverty line. Although not all of these seniors need assistance with transportation, a sizable number are likely to need such assistance. According to senior transportation experts, the “oldest of the old” (those aged 85 and older) are especially likely to be dependent on others for rides, particularly if they are also in poor health. Figure 1 shows some of the factors that affect seniors’ transportation needs. The more of these factors that seniors have, such as a network of family and friends who can drive them and an available public transportation system, the more likely it is that their mobility needs will be met.

Transportation assistance is an important issue for all seniors. In 2001, approximately 26 percent of state units on aging surveyed by the Aging States Project identified transportation as a top health issue for older adults, and 38 percent identified inadequate transportation as a barrier to promoting health among older adults. Furthermore, transportation was among the top five information requests to the Eldercare Locator Service in 2001, 2002, and 2003. There is, however, a significant gender gap in the amount of time that seniors can expect to be dependent on alternative sources of transportation. A study published in August 2002 in the American Journal of Public Health estimated that men aged 70 to 74 who stopped driving would be dependent on alternative transportation for an average of 6 years, while women in the same age group can expect to have an average of 10 years’ dependence on alternative transportation modes.

Although there is no clear-cut definition of mobility need, the literature and the experts we consulted indicate that there are two main categories of mobility need, both of which are important to seniors: (1) “essential” or “life-sustaining” trips, which include medical trips and trips for employment, shopping, banking, and other necessary errands, and (2) “quality of life” or “life-enhancing” trips, which include recreational or social trips that enable a senior to fully participate and engage in the community, such as trips to concerts, theatre, visits with family members in nursing homes or with friends, religious activities, and volunteer activities. For the purposes of this report, we will use this two-fold definition of types of trips as our working definition of mobility need. Unmet need occurs when assistance from others is needed but is not provided or is inadequate. However, according to the experts we contacted, there is no agreed-upon standard or benchmark for the number of trips that an individual requires to take care of essential activities for living (for both life-sustaining and life-enhancing activities), although experts generally agree that government should be concerned with meeting both types of needs for transportation-disadvantaged seniors. The lack of a standard or benchmark makes it difficult to determine an appropriate way to measure the extent to which mobility needs are being met. Researchers have begun to identify and evaluate transportation-disadvantaged seniors’ unmet mobility needs by comparing the number of trips they make with those of nondisadvantaged populations. In addition, some researchers have used satisfaction ratings to measure seniors’ unmet mobility needs. In the absence of a standard measure of need, we will discuss need and unmet need by comparing the travel of disadvantaged seniors with the travel of nondisadvantaged seniors and by using other measures that federal and local officials have developed.

The federal government has traditionally provided some assistance in mobility, mostly for the purpose of accessing other federal program services. Federal agencies partner with local agencies, nonprofit organizations, and others that actually provide transportation services and also contribute their own funds. The federal agency that has a central role in providing all types of services to seniors is HHS’s Administration on Aging (AOA). With a total discretionary budget of more than $1.3 billion, AOA is the official federal agency dedicated to policy development, planning, and the delivery of supportive home and community-based services to older persons and their caregivers. AOA works through a national aging network of 56 state units on aging; 655 AAAs; 241 tribal and native organizations representing 300 American Indian and Alaskan Native tribal organizations, and 2 organizations serving Native Hawaiians; and thousands of service providers, adult day care centers, caregivers, and volunteers.

Federal Agencies Address Mobility Issues Mainly through 15 Programs That Help Make Transportation Available, Accessible, and Affordable

Five federal departments administer 15 programs that are key in addressing mobility issues of transportation-disadvantaged seniors. The programs are “senior-friendly” in that they help make transportation available, accessible, and affordable to seniors.

Fifteen Key Federal Programs Fund Services to Enhance Transportation- Disadvantaged Seniors’ Mobility

Working with experts and federal agency officials, we identified 15 key programs in five departments that provide senior transportation (see table 1) out of the many federal programs that are used to provide transportation services. Some of these programs specifically target seniors, such as HHS’s Grants for Supportive Services and Senior Centers (Title III-B). Other programs—including DOT’s Nonurbanized Area Formula Program (Section 5311)—target other groups, such as rural populations, of which seniors can be a part. About half of the 15 programs fund transportation for specific types of trips, including for medical services, employment-related activities, and other services (such as nutrition) that the programs provide. The other half of the programs can be used to provide general transportation for any trip purpose. The programs fund a variety of types of services, ranging from transit passes and training in the use of public transit to vehicle purchases or expansion of public transit service.

Funds from the 15 programs follow various paths in providing transportation services to seniors (see fig. 2). Many of the programs are block grants or formula programs through which funds are distributed to states on the basis of certain criteria, such as population. State agencies then provide services directly or distribute the funds to local agencies, nonprofit organizations, transit providers, and other organizations. For example, funds from DOT’s Capital Assistance Program for Elderly Persons and Persons with Disabilities (Section 5310) are allotted by formula to state agencies, which then distribute the funds to private nonprofit organizations or local public entities (such as transit providers) to purchase vehicles or other equipment. In another example, funds from HHS’s Grants for Supportive Services and Senior Centers (Title III-B) are distributed first to state units on aging according to the number of seniors residing in the state, and then to local AAAs, which generally contract for services with local transportation providers. In other programs, such as the Department of Labor’s Senior Community Service Employment Program, some funds go through the state while other funds go directly to nonprofit organizations or local service providers. Finally, other programs—such as HHS’s Rural Health Care Outreach Services Program—bypass state agencies altogether and go directly to local entities. Local entities can use funds from a variety of federal programs to provide transportation services to seniors. For example, AAAs can receive funds from the Title III-B program, DOT’s Capital Assistance Program for Elderly Persons and Persons with Disabilities (Section 5310), and other federal programs.

Federal Programs Enhance Senior Mobility by Addressing Certain Attributes of Senior-Friendly Transportation

The Beverly Foundation, a leading independent research organization on senior transportation issues, has identified the following “5 A’s” of senior-friendly transportation service: availability (service is provided to places seniors want to go at times they want to travel); accessibility (e.g., door-to-door or door-through-door service is provided if needed, vehicles are accessible to people with disabilities, and stops are pedestrian-friendly); acceptability (service is clean, safe, and user-friendly); affordability (financial assistance is provided to those who need it); and adaptability (service is flexible enough to accommodate multiple trip types or specialized equipment).

However, there are trade-offs involved in addressing any of the “5 A’s.” For example, improving the acceptability of service can increase the costs of providing service.

Our review of federal programs’ authorizing legislation and guidance, as well as interviews with federal program officials, indicates that most of the 15 key federal programs we identified in table 1 are generally designed to make transportation more available, accessible, and affordable to transportation-disadvantaged populations, such as seniors (see table 2). For example, HHS’s Medicaid Program provides transportation that is free or low-cost for seniors. Some of the programs address other attributes of senior-friendly transportation, such as acceptability. For example, the Department of Education’s Independent Living Services for Older Individuals Who Are Blind program can be used to train seniors in the use of the public transit system, making it both more accessible and acceptable to them.

In addition to the 15 key programs identified in tables 1 and 2, the federal government helps to make transportation more senior-friendly through other programs and policies that provide or ensure access to transportation services for all disadvantaged populations (including seniors). Although seniors are not the target population of these other programs and policies, they often benefit from them. For example, seniors are eligible for many of the programs we identified in a previous report on the coordination of services for the transportation-disadvantaged. In that report, we identified 62 federal programs that can be used to provide transportation services, including the 15 programs identified above. For instance, seniors can benefit from the Department of Housing and Urban Development’s Community Development Block Grant Program, which can be used to purchase and operate vehicles in low-income areas, and the Department of Labor’s Workforce Investment Act Adult Services Program, which can be used to provide bus tokens or reimbursement for mileage to access training opportunities.

Another federal program that does target seniors—Medicare, the federal health financing program covering almost all persons aged 65 and older and certain persons with disabilities—was not included in our list of 15 key programs because it funds only a very specific type of transportation service for seniors. Medicare covers medically necessary ambulance services when other means of transportation, such as a wheelchair van or a taxicab, are inadvisable, given the beneficiary’s medical condition at the time. Medically necessary ambulance trips include both emergency care, such as responses to 911 calls, and nonemergency care, such as transfers from one hospital to another. Medicare covers nonemergency transports—both scheduled and nonscheduled—if the beneficiary is bed-confined or meets other medical necessity criteria, such as requiring oxygen on the way to the destination.

Many programs and policies that address the mobility needs of persons with disabilities also benefit seniors. For example, the Americans with Disabilities Act (ADA) has resulted in changes to many transportation-related facilities, including transit vehicles and bus stops, that make transportation more accessible to seniors with disabilities as well as others. Other federal ADA-related activities can also benefit seniors. For example, the Department of Justice’s Civil Rights Division is responsible for enforcing federal statutes, including the ADA, that prohibit discrimination on the basis of race, sex, handicap, religion, and national origin. In addition, Justice has published rules governing the design of transportation facilities, such as bus stops, to make them accessible to people with disabilities. Finally, the U.S. Architectural and Transportation Barriers Compliance Board—an independent entity within the federal government devoted to accessibility for people with disabilities—develops and maintains accessibility standards for transit vehicles, provides technical assistance and training on these standards, and ensures compliance with accessibility standards for federally funded facilities.

Data Indicate That Some Types of Mobility Needs Are Not Being Met, but Information on the Extent of Unmet Needs Is Limited

The data on the nature of mobility needs that we obtained from research publications and interviews with federal officials, experts, and officials from 16 local AAAs indicate that federally supported programs are not meeting some of the mobility needs of transportation-disadvantaged seniors. In particular, (1) seniors who rely on alternative transportation have difficulty making trips for which the automobile is better suited, such as trips that involve carrying packages; (2) life-enhancing needs are less likely to be met than life-sustaining needs; and (3) mobility needs are less likely to be met in nonurban communities (especially rural communities) than in urban communities. However, there are few current or planned efforts to collect data for assessing the extent to which federally supported programs are meeting transportation-disadvantaged seniors’ mobility needs. In addition, AAAs’ methods for collecting and reporting data make it difficult to determine the extent to which transportation-disadvantaged seniors’ needs are being met, in part because of a lack of federal guidance on how to assess needs. According to experts and local officials, barriers to assessing the extent of unmet needs include the lack of consensus on how to define or measure needs, a lack of federal guidance, and the difficulties of measuring the unmet needs of seniors who are not attempting to access publicly funded services.

Federally Supported Programs Are Not Meeting Some Types of Mobility Needs of Transportation- Disadvantaged Seniors

Federally supported transportation services are meeting some, but not all, types of mobility needs of transportation-disadvantaged seniors. Although up to 75 percent of nondrivers aged 75 and older have reported being at least somewhat satisfied with their mobility, evidence from nationally published research and from interviews we conducted with federal officials, experts, and local aging professionals indicates that many of those seniors who are able to meet life-sustaining and life-enhancing needs are doing so because they have access to supportive family and friends who drive them or because they live in transit-rich cities. For those seniors who do not have access to these support structures or who live in nonurban areas, some mobility needs—especially those related to life-enhancing activities—may not be met.

Transportation-Disadvantaged Seniors Lack Alternatives to the Automobile That Provide Comparable Benefits

Data from nationally published research indicate that transportation-disadvantaged seniors prefer the automobile to other modes of transportation because it is readily available, can reach multiple destinations in the course of one trip, and can be used to access destinations that require carrying packages (such as shopping). In focus groups conducted by AARP, the general consensus among participants was that access to ready transportation provided by the private automobile is critical to overall life satisfaction. In comparison, seniors perceived other modes such as public transit, specialized transportation (such as senior vans), and walking as having inherent negative attributes—including time spent waiting, waits in bad weather, difficulty carrying items, scheduling requirements, infrequent service, and concerns about personal security and accessibility—that made them less attractive than driving or being driven. Consistent with this, a survey conducted by AARP found that senior nondrivers use automobile rides from family or friends more than other modes of transportation to get where they need to go (see fig. 3).

Even if seniors could overcome some of these negative perceptions of alternatives to the automobile, they may not be able to use the alternatives because the alternatives might be unavailable in their community or are inaccessible to seniors. In a survey by AARP, about 33 percent of senior nondrivers who reported that they did not use public transportation said that it was because public transportation was not available. In focus groups conducted for the Coordinating Council on Access and Mobility, HHS, and the National Highway Traffic Safety Administration, participants reported having trouble walking long distances, getting to the bus stop, getting on and off buses, and seeing street signs from the bus so that they knew where and when they should disembark. Similarly, more than one-third of the respondents in one study’s focus groups reported that they would be unable to walk one-quarter mile to a bus stop.

Transportation-Disadvantaged Seniors’ Life-Enhancing Needs Are Less Likely to Be Met Than Life-Sustaining Needs

Data from nationally published research indicate that difficulty in getting the transportation they needed interfered with transportation-disadvantaged seniors’ activities and trip-making, especially for life-enhancing needs such as social or recreational activities. For example, a report analyzing data from the 2001 National Household Travel Survey found that seniors who do not drive made 15 percent fewer trips to the doctor than drivers, but made 65 percent fewer trips for social, family, religious, and other life-enhancing purposes. In addition, although few seniors in an AARP survey reported that a lack of transportation interfered with their activities—such as getting to the doctor, their place of worship, the grocery store or drug store, or entertainment; shopping for clothes or household items; or visiting with friends—nondrivers were two to three times as likely as drivers to report that a lack of transportation interfered with such activities. Furthermore, a study that analyzed responses from seniors in focus groups reported that older adults who have stopped driving significantly curtailed their recreational activities. One participant who had stopped driving reported, “What I do now, my daughter tries to take me shopping once a week for heavy items, which is very helpful. But I’m accustomed to going from mall to mall and store to store to see things, you know, and I don’t get around like that. I’m very limited.”

Federal officials and experts we interviewed also said that the available transportation options are not meeting seniors’ mobility needs, especially for life-enhancing trips. Several experts said that, while mobility needs are being met for the majority of seniors who drive—and even for some transportation-disadvantaged seniors who live in transit-rich environments, who have access to supportive family and friends, or who have knowledge of and access to nonprofit or other organizations that provide transportation—the mobility needs generally are not being met for transportation-disadvantaged seniors without these options. Although a few officials and experts said that for most seniors, trips for life-sustaining needs (e.g., medical appointments) are likely being met, others said that such needs are not being met.

Finally, the majority of AAA officials we interviewed said that transportation-disadvantaged seniors’ needs were not being met. (Although 3 of the 16 AAAs said that needs were being met with the limited funding available, they also cited gaps in service.) Furthermore, although the AAA officials we interviewed were split in their perspectives on whether needs for travel to critical, life-sustaining activities were being met, nearly all said that needs for travel to life-enhancing activities such as church and shopping at the mall were not being met. In addition, all of the AAAs we interviewed imposed restrictions that limited or prioritized transportation services for life-sustaining activities. For example, many AAAs require advance notification (e.g., 24-hour notification) for service and most restrict service to approximately 9 a.m. to 5 p.m. on weekdays, which limits spontaneous travel and travel in the evenings when many cultural and social events take place. Furthermore, most AAAs offer transportation only within the counties or towns they serve, which limits access to activities. Finally, when we asked AAA officials about the destinations to which they provide transportation, most identified essential, life-sustaining sites, such as nutrition sites, medical facilities, grocery stores, pharmacies, public service agencies, and banks. Only a few AAAs offered transportation for life-enhancing activities, such as for recreational or cultural events, or for visits to spouses or other family or friends in long-term-care facilities, and some explicitly stated that they were unable to provide service for personal or life-enhancing activities. The AAA officials told us that all of these constraints were due to limited funding availability.

Transportation-Disadvantaged Seniors’ Needs Are Less Likely to Be Met in Nonurban Areas Than in Urban Areas

The travel of transportation-disadvantaged seniors living in nonurban communities is more restricted than the travel of transportation-disadvantaged seniors living in urban communities. A study analyzing 2001 National Household Travel Survey data indicated that older Americans living in small towns and rural areas who do not drive were more likely to stay home on a given day than their urban and suburban counterparts—63 percent of nondrivers in small towns and 60 percent of nondrivers in rural areas reported that they stayed home on a given day, compared with 51 percent of nondrivers living in urban and suburban areas. Alone, these data do not indicate that mobility needs are less likely to be met because of limited transportation options rather than other aspects that distinguish rural communities from urban ones, such as fewer activities and longer distances between destinations. However, data we obtained from other sources support the idea that the lack of transportation is a significant reason for these travel patterns. For example, in focus groups and interviews that AARP conducted in 2001 with seniors aged 75 and older, nondrivers living in the suburbs were less satisfied that their mobility needs were met than urban nondrivers. In addition to identifying feelings of lost freedom, diminished control, and altered self-image, several suburban participants noted that they make fewer trips and pursue fewer activities as nondrivers, whereas the urban nondrivers expressed more satisfaction with their ability to get around. In addition, in a survey by AARP, respondents living in cities reported that they were more likely to have public transportation available to them than respondents living in rural areas (see fig. 4).

In addition, several federal officials and experts we interviewed said that the needs of transportation-disadvantaged seniors are not being met with available transportation options, especially for those seniors living in rural communities. Similarly, when we asked AAA officials whether transportation-disadvantaged seniors’ needs were being met, nearly half offered the view that needs were not being met for those living in rural communities because of the long distances required to travel to facilities and the resulting need for the driver to wait to bring the senior back. In addition, some said there are geographic regions in rural areas that are not served at all by public transportation, taxicab, or other transportation providers.

Data Are Limited on the Extent to Which Mobility Needs Are Being Met

Because most of the federal programs that fund transportation for transportation-disadvantaged seniors do not focus specifically on seniors or transportation (instead, seniors may be one of several target populations, and transportation may be one of several supportive services provided by the program), federal agencies have minimal program data about the extent of seniors’ unmet transportation needs. Five of the 15 key federal programs that provide transportation to seniors—the Department of Education’s Independent Living Services for Older Individuals Who Are Blind program and HHS’s Social Services Block Grants, Community Services Block Grant Programs, Grants for Supportive Services and Senior Centers (Title III-B), and Program for American Indian, Alaskan Native, and Native Hawaiian Elders (Title VI)—collect some nonfinancial performance data related to senior transportation. Most of the data collected for these 5 programs provide only information on usage, such as the number of seniors receiving transportation services or the number of one-way trips provided to seniors. In addition, for transit programs that serve the general public, the Federal Transit Administration collects data on the number of rides and the number of people served, but these data are not broken out by federal program or by age. However, AOA officials told us that they are beginning to measure performance outcomes related to transportation services under the Title III-B program. On the basis of a national survey it conducted in 2004, AOA estimated that state and area agencies on aging provided transportation services to approximately 440,000 seniors in fiscal year 2003. AOA officials told us that most of the respondents rated the transportation services as good or excellent, and that many respondents reported that they relied on these services for all or nearly all of their local transportation needs. Although this information is useful in assessing the satisfaction of seniors who receive transportation services, it does not measure the extent of unmet needs. Officials from AOA and the Federal Transit Administration currently are assessing the state of data on seniors’ mobility needs to identify baseline data on needs and available resources.

Similarly, few AAAs use, or plan to use, data collection methods that enable them to determine the extent of seniors’ unmet mobility needs—that is, information on both the extent of need in the community and the capacity of services, including their own, to provide transportation to seniors to meet those needs. AAAs are required to determine the extent of need for supportive services (which could include transportation) provided through HHS’s Title III-B program and to evaluate how effectively resources are used to meet such need. However, several AAAs we interviewed reported that they do not collect this type of data at all. Of those AAAs reporting that they do collect data on the extent of unmet needs, most collect data on the number of seniors who called the AAA to request transportation services that the agency was unable to provide (including data such as the number of trip denials and the number of seniors on a waiting list). There are a number of limitations to this type of data. For example, a few AAAs reported that waiting list data were not reliable in measuring the unmet needs of seniors because the data allowed multiple-counting of seniors who are wait-listed by more than one transportation provider or who periodically call for rides and are added to the waiting list each time they call. In addition, AAAs reported that waiting list data were not entirely representative of unmet needs because these data include information only on seniors who call for service and not on seniors who do not call (because no services are available, because they do not know what services are available, because they are tired of being turned down, because they moved to an assisted living facility since they had difficulty obtaining transportation, or because of some other reason) but who may still need rides. Furthermore, the waiting list data do not allow for calculating the number of seniors who were referred to other transportation services and were able to get rides through these other services. Only 2 of the 16 AAAs (the Salt Lake County Aging Services and the Bear River Association of Governments, both in Utah) have a method for determining the gap in transportation service by calculating the difference between the number of seniors who are in need of transportation and the number of seniors who are receiving service through other providers, or through family and friends.

Finally, there is little information from national surveys and studies that addresses the extent to which transportation-disadvantaged seniors’ needs are being met; rather, those surveys and studies focus on the nature of needs, as discussed in the previous section of this report. For example, one report prepared by DOT’s Bureau of Transportation Statistics analyzes 2002 data from the Transportation Availability and Use Survey on the travel behavior of persons with disabilities, but the findings are not broken down by age. Another Bureau of Transportation Statistics report analyzing the same data source provides some insights on the types of travel problems encountered by seniors with disabilities, but it does not provide data that can be used to measure the extent of those seniors’ transportation needs or to determine whether those needs are being met.

There Are Several Barriers to Assessing the Extent of Unmet Need

Senior mobility experts told us that there is no clear-cut definition of mobility needs, making it difficult to determine the extent to which such needs are being met. Although many of the experts we contacted mentioned the distinction between life-sustaining and life-enhancing needs, they did not provide a more concrete definition. Many of these experts also said that they were not aware of an agreed-upon standard or benchmark for assessing seniors’ unmet mobility needs. One researcher said that the topic of seniors’ mobility needs is just beginning to be discussed in the literature, so a standard has not yet been developed.

In addition to the lack of consensus on definitions or measures of need, there is also little guidance on assessing mobility needs. Although some of the 15 key federal programs we identified require state or local agencies to assess the need for services, federal agencies provide little guidance on how to do this. As previously noted, HHS’s Title III-B and Title VI programs—through which AOA provides grants to states and Native American tribes for senior services—require AAAs to prepare a plan that includes an assessment of the needs of disadvantaged seniors, which could include transportation needs. Furthermore, the Older Americans Act, as amended, requires AOA to provide guidance to states on assessing needs, specifically “to design and implement [for program monitoring purposes]…procedures for collecting information on gaps in services needed by older individuals” and “procedures for the assessment of unmet needs for services....” Although AOA has developed general guidance for Native American tribes on conducting needs assessments for its Title VI program, the program guidance that the agency provides to states for its Title III-B program does not include guidance on how to assess and measure needs or on specific data collection methods. As a result of the lack of guidance on assessing need, most of the AAAs that we interviewed reported assessing seniors’ unmet mobility needs using a range of data collection methods that resulted in data not specific enough for planning purposes, and not indicative of the precise extent to which seniors’ mobility needs are being met. While some AAAs said they did not need additional data, other AAAs we spoke with said that more precise information on the extent of unmet need would be useful in designing services and getting political support and funding for services, but some do not have the staff, funds, or expertise to develop methodologies to do this. They said that guidance from the federal government in this regard would be very useful.

Officials at AOA said that, in the past, they have not provided guidance to state and local aging agencies on how to assess needs for the Title III-B program because they received feedback that state and local aging agencies had a more immediate desire for guidance on assessing the quality of service and collecting information on client characteristics. To this end, AOA is currently developing a plan for evaluating the various supportive services, including transportation, provided through its Title III-B programs. The evaluation effort will address the needs of states and communities for supportive services and the extent to which the Title III-B program is meeting the needs and preferences of the elderly for those services. As part of the evaluation, AOA plans to address questions about the role of AAAs in providing supportive services, how needs assessments are performed by state and local entities, and how the results of those assessments are used by states in implementing the Title III-B program. On the basis of the results of our interviews with AAA representatives, the AOA official responsible for the planned evaluation said that it would be useful to obtain some additional information during the evaluation to determine the need for services under the Title III-B program, including (1) identifying how needs should be defined and measured; (2) determining the range of methodologies that AAAs use for assessing seniors’ need for services, including transportation, and unmet needs; and (3) identifying the kinds of guidance that AAAs want from AOA and states to help them perform their required needs assessments. AOA plans to complete its evaluation of this program by January 2006.

Other federal program regulations also require or encourage local agencies to assess need to be eligible for funding. For example, DOT’s Capital and Training Assistance Program for Over-the-Road Bus Accessibility (which provides funds to bus operators to help make their services more accessible to persons with disabilities) lists “identified need” as one of the criteria for selecting grantees, and HHS’s Community Services Block Grant Program (which provides funds for services to address the needs of low-income individuals) requires grantees to assess need for services and report this information to the state. However, these agencies do not provide guidance for assessing need for most of these programs. DOT officials said that they allow local applicants for the Capital and Training Assistance Program for Over-the-Road Bus Accessibility to decide what measures to use to demonstrate need, and the measures vary accordingly. For example, some of these applicants have provided information on the number of trips that were denied for lack of an accessible vehicle, while other applicants demonstrate need on the basis of the number of trips provided using an existing lift-equipped vehicle. For its Job Access and Reverse Commute Program, DOT asks applicants to provide data on the percentage of low-income persons in the area as well as on transportation gaps between existing services and employment opportunities for these persons, and the agency provides some guidance on how to identify such gaps. HHS provides some guidance for assessing the need for services under the Community Services Block Grant Programs, but the guidance is for assessing a wide range of services, of which transportation is only one.

Federal officials report that it is difficult to measure unmet mobility needs largely because of difficulties in measuring the unmet needs of those transportation-disadvantaged seniors who are not trying to access transportation services (such as those who do not call for service because they have given up trying to get transportation or are not aware of services). Some AAA officials and federal officials said that collecting this type of data is time-consuming and expensive. In addition, there may be other difficulties in reaching these seniors. For example, they may have difficulty hearing questions posed over the telephone, may be wary of providing personal information, or may be reluctant to admit that they need assistance or that they can no longer safely drive themselves to activities they need or want to attend.

Transportation Service Providers Implement Practices That Enhance Senior Mobility with Some Federal Support, but Implementation Difficulties Remain

Transportation providers use a variety of practices—which we have grouped into three categories—to enhance the mobility of transportation-disadvantaged seniors and promote the cost-effective delivery of transportation services. These include practices that (1) improve service efficiency through increasing the use of technology and by coordinating services with other providers in the community; (2) improve customer service by providing training sessions for service staff and seniors, using vehicles that can accommodate seniors’ mobility challenges, and increasing the level of service provided; and (3) leverage existing resources by increasing volunteer involvement and forging financial partnerships with public and private entities in the community. According to the local service providers we interviewed, these practices, which were implemented with some federal support, resulted in more senior-friendly transportation services and more cost-effective service delivery. All 10 local transportation service providers we interviewed indicated that they had been able to use funds from 1 or more of the 15 key federal programs in implementing practices that enhance senior mobility. The most commonly used programs were DOT’s Capital Assistance Program for Elderly Persons and Persons with Disabilities (Section 5310) and HHS’s Title III-B and Medicaid Programs, followed by DOT’s Nonurbanized Area Formula Program (Section 5311), and HHS’s Community Services Block Grant Programs. However, according to the providers we interviewed, certain characteristics of federal programs may impede the implementation of practices that enhance transportation-disadvantaged-seniors’ mobility.

Certain Practices Enhance Transportation- Disadvantaged Seniors’ Mobility and Promote Cost-effective Delivery of Services

According to a 2002 report prepared by DOT’s Transit Cooperative Research Program (hereafter referred to as the TCRP report), local transportation providers have implemented a number of program practices to improve public transportation services for seniors. The 10 local service providers we interviewed in urban and rural areas have implemented some of these practices, as discussed below.

Improvements to Service Efficiency

Increasing the use of technology: According to the TCRP report, using advanced technology can improve efficiency, productivity, and cost-effectiveness. Global Positioning Systems (GPS) and other advanced technologies can provide real-time information about where vehicles are located, when they will arrive to pick up a senior, and how long the trip may take. Two of the 10 local service providers we interviewed are using advanced technology to improve their trip scheduling. For example, Sweetwater Transportation Authority in Rock Spring, Wyoming, is using GPS technology on board each bus, connecting the bus to software that will automatically schedule rides and provide an accurate estimated time of arrival to passengers. The Friendship Center, which offers door-through-door transportation services in Conroe City, Texas, is involved in the early stages of implementing a computerized dispatching and mapping system that will allow same-day scheduling to transport seniors to their destinations. In the past, all scheduling was done manually and seniors often had to call 48 hours in advance to schedule a ride. According to Friendship Center officials, the implementation of the computerized mapping system will increase efficiency and coordination of their transportation service, which will also improve the level of service provided to seniors.

Coordinating transportation services: According to the TCRP report and our previous work, coordination of transportation services can improve the overall efficiency of operations, increase the productivity of services, reduce service costs, and increase mobility. Our previous work indicated that the extent of coordination of transportation services varies. Several service providers we interviewed have implemented a coordinated transportation service, including Mountain Empire Older Citizens (MEOC), which is located in central Virginia. MEOC recognized that coordination was needed because each human service agency in the area was transporting its own clients exclusively, while other vehicles from other agencies were picking up passengers in the same area. Under its coordination contract, MEOC leases vehicles from other specialized transportation service providers and coordinates all aspects of transporting their clients (including other transportation-disadvantaged groups, such as people with developmental disabilities). As a result, MEOC has maximized the efficient use of vehicle fleet and realized cost savings in service delivery, according to an agency official. Another service provider, the Friendship Center, coordinates its transportation services with medical facility staff to schedule medical appointments for seniors. The dispatchers at the center work directly with the medical providers to schedule medical appointments for seniors when the center’s transportation services are available. In addition, the center’s hours for transportation services reflect those of the medical centers. By coordinating their services, the center helps ensure that seniors do not encounter transportation scheduling problems. Lastly, Medical Motor Service, which provides transportation and brokerage services to seniors in Monroe County, New York, coordinates with other nonprofit agencies to provide volunteers who serve as “shopping buddies” to help seniors carry packages or assist them with their groceries.

Improvements to Customer Service

Providing training to staff and seniors: According to the TCRP report and a brochure on innovative transit services for seniors developed by the Beverly Foundation and the Community Transportation Association of America (hereafter, Innovations Brochure), training for service staff—particularly drivers—and for senior riders is important in improving transportation services. The TCRP report states that staff training should address customer service issues, such as the need for polite and courteous interactions by drivers with passengers and the physical constraints seniors encounter while using public transportation. The TCRP report also indicates that customer service training should be part of an overall change in organizational focus, from just operating vehicles to serving customers. Several service providers we interviewed were implementing training to improve customer service by helping seniors feel more comfortable while being transported. For example, Altoona Metro Transportation, which provides public transit service to the general public in central Blair County in Pennsylvania, developed a driver-training sensitivity program through which drivers receive specialized training to recognize the diverse needs of seniors. In what is considered a “hands-on” session, drivers wear special glasses to distort their vision so that they can temporarily experience the physical limitations that some seniors face while riding public transportation. An Altoona Metro official also told us that drivers are encouraged to socialize with senior passengers and foster relationships to make seniors feel comfortable and welcomed. In addition to training for staff, providers are also implementing travel-training programs to teach seniors who are not accustomed to using transit services how to use public transportation. One service provider, North County Lifeline, Inc. (a curb-to-curb transit service located in the northern San Diego area), developed a travel-training program for seniors to learn about public transit and reduce any concerns they may have about personal safety when using transit. The program includes instruction in how to problem-solve, map out a trip, make transfers, and understand the rights and responsibilities they have while riding public transportation.

Using vehicles that can accommodate seniors’ mobility challenges: Using vehicles that accommodate the mobility challenges of seniors—such as purchasing low-floor buses, equipping vehicles with lifts, or modifying vehicles to make them identifiable and visually appealing (by using buses with distinctive colors to designate specific routes or with large see-through windows)—may help address some of the physical challenges (such as difficulties boarding a bus or van) and emotional challenges (such as concerns about boarding the wrong bus or personal safety) that seniors may face while using public transportation. For example, the TCRP report states that low-floor buses provide advantages over conventional buses because they shorten the distance between the first step on the bus and the curb (e.g., the first step on a conventional bus is approximately 9 to 12 inches above the curb, whereas the first step on the latest low-floor buses is less than 3 inches above the curb). However, there may be constraints in using such buses—one service provider we interviewed found them impractical for the provider’s service area, which contains hilly terrain and many narrow streets. The majority of service providers we interviewed use lift-equipped vehicles to transport seniors who use wheelchairs. Several of the service providers are also using vehicles that are easily identifiable and visually appealing to further address concerns seniors may have about using public transportation. For example, several of the service providers we interviewed said that they transport seniors in vehicles that are color-coded to designate specific routes or that have large, nontinted windows to limit the confusion that seniors face while trying to determine which bus to board, to provide a sense of personal security, and to “demystify” public transportation for seniors.

Increasing level of service: According to the TCRP report, increasing overall service levels is vital to meeting the mobility needs of a growing senior population. Some of the local service providers we interviewed said that the practices they implemented allowed them to improve their services by expanding service hours for life-sustaining trips (as much as their funding allows), accommodating all requests as they arise (even if that means temporarily modifying a route), and expanding services to include life-enhancing trips (e.g., field trips sponsored by senior centers and trips to a therapeutic warm-water pool program). For example, a MEOC official told us that the provider expanded its service from 8 hours to 12 hours per day on weekdays to provide transportation for life-sustaining trips (e.g., medical appointments), and that the agency plans to modify an existing route to provide service regardless of how little notice is given. MEOC’s computer scheduling system enables dispatchers to radio the nearest driver and ask him or her to modify the current route to fit in an extra pick-up or drop-off. In another example, Gold Country Telecare, a nonprofit agency that provides accessible specialized transportation in rural northern California, learned through interviews with others in the local community involved in senior transportation that seniors were often isolated on weekends, when transportation services were rarely available for them. To address this need, the agency increased its service level by implementing an all-day Sunday transportation service for seniors to get to church or other activities, such as grocery shopping.

Improvements to Leverage Available Funds

Increasing volunteer involvement: According to the TCRP report and the Innovations Brochure, volunteer involvement may lead to cost savings in delivering transportation services to seniors by reducing the need for paid staff. The local service providers we interviewed used volunteers in a variety of ways. For example, Gold Country Telecare implemented a volunteer driving program under which volunteers are reimbursed for mileage expenses incurred in using their personal vehicles to transport seniors to medical and health treatment facilities located in a nearby urban center. According to a Gold Country Telecare official, this program allows seniors to participate in health therapies or medical services not found in their rural community. OATS, Inc., a transportation service provider in Missouri, uses volunteers who act as dispatchers, taking calls in their homes from people in the community who need trips. The volunteers transfer requests to the driver, who then schedules the trips. The use of volunteers allows OATS to provide more cost-effective and more frequent service by avoiding the administrative expense of having an office in each of the 87 counties it serves. Furthermore, according to an OATS official, the value of the volunteer hours (including the in-kind allowance for the use of their personal telephones and space in their home) translates into approximately $1.6 million in cost savings per year.

Forging partnerships with private and public entities: The TCRP report suggests forging financial partnerships with public and private entities in the community to address funding concerns and to diversify funding sources. Several of the local service providers we interviewed developed private/public partnerships such as (1) contracts with private entities to engage in revenue-enhancing activities, such as using the service providers’ vehicles to transport other groups when the vehicles were not being used for senior transportation or transporting seniors to specific locations, such as shopping sites, or (2) joint agreements with human service agencies to provide specialized services for clients who need additional assistance. For example, the Friendship Center contracts with private entities to provide shuttle services from employee parking to employment sites, from overflow parking lots to special event venues, to community churches on Sunday mornings, and other similar transportation services. According to center officials, these additional contracts for shuttle services bring in approximately $140,000 in additional annual revenue, which is being used to provide additional senior transportation services and represents approximately 15 percent of the center’s annual budget for senior transportation. Another local service provider that diversified its funding sources, Medical Motor Service, developed a partnership with a regional private supermarket to supplement its fund-raising efforts. Under this arrangement, Medical Motor Service receives approximately $300,000 in annual funding from the supermarket to transport seniors to and from the grocery store. This sum represents 18 percent of the provider’s annual senior transportation budget. As a result of this arrangement, seniors residing in 55 housing complexes have transportation for grocery shopping or for renewing medical prescriptions at any of the 14 supermarkets located in Monroe County. However, one trade-off in having an exclusive partnership with one grocery store chain is that, unlike seniors (and others) who can drive, seniors who rely on such a service do not have a choice of where to shop. In that regard, Special Transit, a local service provider in Boulder, Colorado, identified a need to diversify its funding sources to reduce dependence on any one source of funds, helping to ensure continuity of service for all of its clients, including seniors. To do so, it hired an outreach coordinator to identify other service providers in the community (such as senior day care programs, senior centers, and local hospitals) that were interested in having Special Transit provide transportation services. In addition, the coordinator was tasked with identifying opportunities for generating private donations. Through its partnerships, Special Transit reduced its dependence on public funding (including federal and local government grants and matching funds) from more than 80 percent of its total revenue sources in the mid-1980s to approximately 65 percent in 2004. Presently, Special Transit’s service contracts and private donations account for approximately 30 percent of its total revenues.

Summary of Practices and Funding Sources

Table 3 provides examples of some of the practices and federal funding sources used by the local service providers we interviewed.

Local Practices Have Enhanced the Senior-Friendliness and Cost-effectiveness of Services

The implementation of these practices contributed to the improvement of senior transportation services by making them more senior-friendly, according to the 10 local service providers we interviewed. In particular, these practices collectively addressed the five A’s of senior-friendly transportation previously discussed—availability, accessibility, acceptability, affordability, and adaptability—as follows: The majority of service providers told us that they made transportation services readily available for seniors to get to needed medical locations.

The 10 providers said that their services are tailored to ensure that seniors can access the vehicles: that is, pick-up locations are easy for seniors to walk to, one-on-one escort service is available to seniors who need special assistance, or lift equipment is installed in the vehicles.

Several service providers stated that they use vehicles that are identifiable and visually pleasing to make sure their vehicles are acceptable to seniors.

Most of the service providers also indicated that their services are affordable because they are free to seniors or minimal donations are requested at the time of service.

More than half of the service providers said that their services are adaptable and flexible enough to accommodate the service requests and the mobility limitations some seniors may have.

In addition, the majority of the service providers we interviewed said that their organizations realized cost savings and increased the quality and quantity of service by implementing the practices. For example, as previously noted, the coordinated transportation service implemented by MEOC allowed lower per-unit costs, which also resulted in cost savings for all the agencies involved. According to a MEOC official, the cost savings allowed MEOC to increase the number of trips provided, increase the hours of operation, continue to afford dispatchers, hire more transportation managers, and provide adequate training for drivers—all of which translated into improvements in the quantity and quality of service to MEOC’s clients.

Federal Programs Support the Implementation of Practices That Enhance Transportation- Disadvantaged Seniors’ Mobility to Some Extent

According to the service providers we interviewed, the most common way in which federal programs support the implementation of practices that enhance transportation-disadvantaged seniors’ mobility is by providing funding. As previously noted, the 10 providers we interviewed use funds from at least 1 of the 15 key federal programs in implementing practices that enhance transportation-disadvantaged seniors’ mobility. (See table 3 for the federal funding sources associated with each service provider.) We found that DOT’s Capital Assistance Program for Elderly Persons and Persons with Disabilities (Section 5310) and HHS’s Grants for Supportive Services and Senior Centers (Title III-B) and Medicaid Programs are the federal programs most often used by the 10 providers we interviewed, followed by DOT’s Nonurbanized Area Formula Program (Section 5311) and HHS’s Community Services Block Grant Programs.

According to some of the service providers, the federal programs had both a direct and an indirect role in providing technical assistance for the implementation of practices to enhance transportation-disadvantaged seniors’ mobility. In some cases, federal programs provided direct technical assistance (by providing information on how to apply for program funding or how to implement the service or by providing contact information for other resources) through program representatives or through the program’s Web site. Several providers stated that, as grantees, they obtained technical assistance from DOT’s Intelligent Transportation Systems (ITS) program, which assigned consultants to their organizations to provide assistance in selecting software and hardware and developing requests for proposals. One service provider further added that he found DOT’s ITS program Web site to be useful in obtaining information on best practices and on other technology-related resources. Another service provider received technical assistance through both Federal Transit Administration representatives and the state’s transit association on how to obtain funding through the Job Access and Reverse Commute Program. In other cases, some providers stated that the federal government indirectly provided guidance or technical assistance. For example, guidance on implementing practices and marketing services to the senior community was provided through federally funded professional organizations, such as the Community Transportation Association of America and the National Academy of Sciences’ Transportation Research Board.

Other service providers we interviewed told us that the federal programs did not provide assistance (other than funding) or guidance on implementing practices to enhance transportation-disadvantaged seniors’ mobility, so they had to look to other state and regional transit agencies or other local transportation service providers to provide guidance or technical assistance. One service provider said that it researched and sought out other mobility management programs and travel-training programs to learn how to implement such programs, because this information was not available from federal or state agencies. Several providers told us that finding information on successful practices for enhancing transportation-disadvantaged seniors’ mobility required considerable staff time and other resources, and that a centralized source—particularly a Web-based source—for such information would be useful. Many of the providers suggested that providing such a Web site would be an appropriate role for the federal government. AOA, the lead federal agency for coordinating programs for seniors and the dissemination of information relevant to seniors, has some transportation information available on its Web site, but there are some limitations to this information, as discussed in more detail in the section below on senior mobility obstacles and strategies.

Local Transportation Service Providers Continue to Face Difficulties in Implementing Practices That Enhance Transportation- Disadvantaged Seniors’ Mobility

According to the local providers we interviewed, certain characteristics of federal programs can impede the implementation of practices that enhance transportation-disadvantaged seniors’ mobility. Although federal programs provide financial support for practices that enhance senior mobility, an expert in senior mobility and several service providers stated that receiving federal funds entails burdensome reporting requirements. Often, the local service providers receive funding from several federal programs with different reporting requirements and therefore have to submit several different reports calling for different data. One provider stated that submitting all of the required documentation for DOT’s Capital Assistance Program for Elderly Persons and Persons with Disabilities (Section 5310) and HHS’ Grants for Supportive Services and Senior Centers (Title III-B) Program necessitated the dedication of 720 administrative hours each year (equivalent to over $10,000), costing the provider more in administrative costs than the actual funding received through the federal programs. Another service provider we interviewed said it has designated about 1,690 administrative hours annually to complying with the reporting requirements of the Title III-B program, Medicaid, and DOT’s Congestion Mitigation and Air Quality Improvement Program, including doing such tasks as tracking the different data requested by each program, organizing documents, and following up on required information. The provider noted that the 1,690 hours (equivalent to about $60,000 in costs) represented a significant portion (14 percent) of the total federal program funding received under those programs. Federal officials have told us that the Coordinating Council on Access and Mobility—a federal body, consisting of representatives from 10 federal agencies, including the Departments of Education, Labor, Health and Human Services, Transportation, and Veterans Affairs, that is charged with coordinating transportation services provided by federal programs and promoting the maximum feasible coordination at the state and local levels—is examining possible ways to streamline reporting requirements of the various federal programs that fund transportation for disadvantaged populations. Council officials said that a paper addressing this issue will be developed and presented in 2004 or early 2005.

Some of the local providers said that federal guidance on how to apply for funding and comply with reporting procedures is limited. For example, one service provider stated that it has not received technical guidance from DOT that explains the funding process for the Urbanized Area Formula Program (Section 5307). Instead, the provider contacted other local nonprofit organizations to seek their technical assistance in understanding the funding process, but the funds were delayed in the meantime. The provider said that it contacted local DOT representatives but was unable to determine the cause of the delay in funds. As a result, the provider said that it had to convince its nonprofit board of directors to continue to provide services without the promised federal funds so that seniors would still have transportation services available.

Lastly, several of the service providers perceive that program guidelines are rigid and lack flexibility, although the federal officials we contacted disagreed with the providers’ interpretations. For example, one provider stated that the program guidelines for DOT’s Nonurbanized Area Formula Program (Section 5311) are very rigid in that the funds may only be used for transportation for the general public. The service provider stated that the Section 5311 guidelines require it to track the type of passenger who requests demand-response service and the trip destination. If a senior requests transportation to a senior center or any other human service program destination, the service provider told us it must find another funding source (e.g., Title III-B) for that trip because Section 5311 funding is designated for general rural transportation services and not specialized services. However, a DOT official told us that rural transit providers receiving Section 5311 assistance may transport a senior to a senior center if the service is also made available to the general public.

Experts and Stakeholders Suggested Strategies for Overcoming Mobility Obstacles

Through a review of the literature and interviews with experts on senior transportation and aging, representatives of pertinent professional associations and advocacy groups, local officials, and transportation service providers, we identified several obstacles to addressing transportation-disadvantaged seniors’ mobility needs and potential strategies that the federal government and other government levels, as appropriate, can consider taking to better address those needs and enhance the cost-effectiveness of the services delivered. We grouped these obstacles and strategies around three themes: (1) planning for alternatives to driving as seniors age to extend the lifespan of their mobility, (2) accommodating seniors’ varied mobility needs, and (3) leveraging federal and other government funding to better use limited resources. The suggested strategies for addressing obstacles to senior mobility involve certain trade-offs, and these obstacles, strategies, and trade-offs are discussed in each of the following sections.

Conclusions

As the senior population doubles over the next 25 years, it will become increasingly important to target resources to the areas of greatest need and to know whether current methods and programs are working to reduce transportation-disadvantaged seniors’ unmet needs and improve their mobility and access to services. The 655 local area agencies on aging that are required to gather data to assess seniors’ needs for services could serve as valuable sources of information for federal agencies to use in program planning, evaluation, and resource allocation. However, without guidance from the Department of Health and Human Services’ Administration on Aging on assessing needs for services, including transportation, these local agencies are using a variety of methods—some less comprehensive than others—to assess seniors’ mobility needs. As a result, it is not possible to determine whether current programs are reducing unmet needs and improving transportation-disadvantaged seniors’ mobility and access to services. The Administration on Aging is now embarking on a comprehensive assessment of seniors’ needs for services that affords a good opportunity for the administration to help state and local agencies conduct and use the results of improved needs assessments.

The experiences of other federal agencies, such as the Department of Transportation, that have developed guidance for assessing or demonstrating needs for some of the programs they administer, such as the Job Access and Reverse Commute Program, could be useful in designing guidance for area agencies on aging to assess needs. The Coordinating Council on Access and Mobility is uniquely positioned to provide a forum for such a coordinated effort because all of the federal agencies that administer the key programs we identified are members, and many of these agencies are involved in the council’s efforts to improve mobility for all transportation-disadvantaged populations. As the agency designated by the Older Americans Act as the lead for gathering information on seniors’ needs for services, and as one of the original members of the council, the Administration on Aging is well-situated to lead a coordinated effort to design guidance for assessing seniors’ needs.

Not having information on alternatives to driving is an obstacle to both seniors and service providers. Without such information, seniors do not plan for a time when they can no longer drive, and providers waste time and money “reinventing the wheel” and become frustrated with federal programs. Some federal efforts, such as the community awareness pilot project implemented by the Department of Transportation’s National Highway Traffic Safety Administration, have already begun to address this obstacle, but the expected growth in the senior population will require broader efforts. As service providers and representatives from the advocacy groups and professional associations we interviewed said, an important role for the federal government would be to provide a central forum for comprehensive information on transportation services, perhaps through a centralized Web site that could enhance seniors’ awareness of available services and improve providers’ ability to serve them. Such a Web site would also be useful for publicizing activities the various federal agencies are undertaking to improve transportation-disadvantaged seniors’ mobility. Although the Administration on Aging (the federal focal point and advocacy agency for seniors) has a Web site with information on transportation services, most of this information is aimed at service providers rather than at seniors or their caregivers. Furthermore, many of the service providers and representatives from advocacy groups and professional organizations we interviewed did not seem to be aware of the presence of such information on the administration’s Web site. In addition, although seniors are increasingly comfortable using the Internet, there are still many who do not have access to, or are not at ease with, such technology.

Recommendations for Executive Action

To help enhance transportation-disadvantaged seniors’ mobility by improving available information and guidance, we recommend that the Secretary of Health and Human Services direct the Administrator, Administration on Aging, to take the following four actions: To improve the value and consistency of information obtained from area agencies on aging on the extent to which transportation-disadvantaged seniors’ mobility needs are being met, the Administrator should develop guidance for assessing such needs by doing the following: Expand the scope of work in the administration’s planned evaluation of the Grants for Supportive Services and Senior Centers (Title III-B) program to include gathering and analyzing information on (1) definitions and measures of need; (2) the range of methodologies that area agencies on aging use for assessing seniors’ need for services, including transportation, and unmet needs; (3) leading practices identified in the needs assessments methodologies used by area agencies on aging; and (4) the kinds of guidance that area agencies on aging want from the administration and the states to help them perform their required needs assessments.

Use the results of the administration’s evaluation of the Title III-B program, and input from the Coordinating Council on Access and Mobility of other federal agencies that fund transportation services for seniors, to develop and disseminate guidance to assist state and local agencies on (1) methods of assessing seniors’ mobility needs and (2) the suggested or preferred method for collecting information on gaps in transportation services.

To help address the obstacles that seniors, their caregivers, and service providers face in locating information on available services and promising practices, the Administrator should do the following: Take the lead in developing a plan—in consultation with members of the Coordinating Council on Access and Mobility—for publicizing the administration’s Web site and Eldercare Locator Service as central forums for sharing information on senior transportation through workshops, annual meetings, and other outreach opportunities with seniors, their caregivers, and service providers. The plan should include steps for reaching out to seniors and providers who do not use or have access to the Internet to increase awareness of information available in hard copy or other format.

Work with members of the Coordinating Council on Access and Mobility to consolidate information about services provided through the participating agencies’ programs and to establish links from their programs’ Web sites to the administration’s transportation Web site to help ensure that other agencies (such as local transit agencies) are aware of, and have access to, such information.

Agency Comments

We provided the Departments of Education, Health and Human Services, Labor, Transportation, and Veterans Affairs with draft copies of this report for their review and comment. The Departments of Health and Human Services, Transportation, and Veterans Affairs agreed with the findings and conclusions in the report. The Department of Transportation also provided technical clarifications, which were incorporated as appropriate. The Department of Health and Human Services provided written comments on the draft of this report, which are presented in appendix IV. The department concurred with our recommendations. The Departments of Education and Labor said that they did not have any comments on the draft.

As arranged with your office, unless you publicly announce its contents earlier, we plan no further distribution of this report until 30 days after the date of this letter. At that time, we will send copies of this report to the appropriate congressional committees and to the Secretaries and other appropriate officials of the Departments of Education, Health and Human Services, Labor, Transportation, and Veterans Affairs. We will also make copies available to others upon request. In addition, the report will be available at no charge on the GAO Web site at http://www.gao.gov.

If you have any questions about this report, please contact me at siggerudk@gao.gov or at (202) 512-2834. Additional GAO contacts and staff acknowledgments are listed in appendix V.

Scope and Methodology

The scope of this report is limited to a review of the mobility needs of transportation-disadvantaged seniors, who we define as those who cannot drive or have limited their driving and who have an income constraint, disability, or medical condition that limits their ability to travel. In addition, because federal, state, and local programs have different age ranges for seniors (e.g., aged 55 and over, aged 65 and over), we do not use the term “senior” in this report to mean any specific age. We obtained statistics presented in the introduction and background of this report about seniors and their mobility from an article published in the American Journal of Public Health, the 2000 Census, the Aging States Project, and the Eldercare Locator Service; because this information is included as background only, we did not assess its reliability.

To identify federal programs that address transportation-disadvantaged seniors’ mobility issues, we asked experts who had participated in a senior mobility forum we moderated in July 2003 to identify those federal programs that they consider key for providing transportation services to seniors who cannot drive or have limited their driving. We verified the resulting list of 15 programs with federal program officials. To assess the extent to which the 15 federal programs address each of the five A’s of senior-friendly transportation (as identified by the Beverly Foundation), we reviewed program legislation and guidance and interviewed federal officials and senior mobility experts. We also reviewed prior GAO reports on the coordination of transportation services for disadvantaged populations and interviewed federal officials, senior mobility experts, and other stakeholders to identify additional ways in which the federal government addresses transportation-disadvantaged seniors’ mobility challenges.

To identify data that could tell us anything about the extent to which transportation-disadvantaged seniors’ needs are being met, we reviewed the literature on transportation, disability, and aging found in statistical databases and on agency, academic, and advocacy Web sites. In addition, we asked experts—including academics conducting research in the fields of aging, disability, and transportation; advocacy policy analysts knowledgeable about senior transportation; and federal officials responsible for senior transportation programs—to identify sources of data and relevant studies. We included in our review only nationwide surveys or focus groups (1) that were conducted in multiple states or types of communities, (2) that were conducted after 1995, (3) that had variables that analyzed transportation behavior of individuals aged 65 and older, and (4) that were reported in published or soon-to-be-published journals or reports. Also, we identified federal agency performance indicators and other data collected by federal agencies that have key transportation programs for seniors. For the performance indicators and data sources we identified, we assessed the extent to which they provided meaningful information about the extent to which seniors’ mobility needs are being met. To assess the reliability of research publications, we reviewed the studies’ overall designs and methodologies, including the selection processes for any participants, response rates, and measures used. A social science analyst at GAO was involved in each review of methodological soundness. Table 4 summarizes the limitations of the data sources we used in assessing the extent to which seniors’ mobility needs were being met.

To better understand the variety of methodologies that area agencies on aging (AAA) used to assess seniors’ unmet mobility needs, the reliability of data collected using these methodologies, the barriers to quantifying unmet mobility needs, and the perspectives of local officials on the extent to which seniors’ mobility needs are being met, we conducted semistructured interviews with officials from 15 of the 655 AAAs nationwide and 1 state unit on aging. To select the nonprobability sample of 15 AAAs that we interviewed, we asked the 42 state units on aging that have AAAs in their states (8 states—Alaska, Delaware, Nevada, New Hampshire, North Dakota, Rhode Island, South Dakota, and Wyoming—and the District of Columbia do not have AAAs and instead the state unit on aging is the single planning and service area under the Older Americans Act) to identify 1 urban, 1 rural, and 1 suburban AAA in their state, and for each, to identify the method by which the AAA collects data on seniors’ unmet mobility needs. Of the 42 states that have AAAs, 30 responded to our request. From these responses, we selected AAAs to ensure geographic dispersion (West, South, Northeast, and Midwest); representation of AAAs with different population density (urban, rural, and suburban); representation of different data collection methods (survey, focus group, census, or other); representation of input from community stakeholders (service providers, caregivers, seniors, and professionals); and representation of states with higher-than-average and lower-than-average percentages of seniors in their population. In addition to selecting 3 AAAs from each of 4 states—1 in the West, 1 in the South, 1 in the Midwest, and 1 in the Northeast—we also selected 3 AAAs in New York State because it had recently completed an audit of transportation for seniors that included an evaluation of AAAs’ procedures for conducting needs assessments. We also interviewed the state unit on aging from 1 of the 8 states that do not have AAAs (South Dakota). Using a semistructured interview, we asked senior-level management and staff that had responsibilities for assessing seniors’ unmet mobility needs at each of the AAAs (and 1 state unit on aging) to provide information on transportation services offered and restrictions to service; on their processes for collecting data on seniors’ unmet mobility needs, including information about how they ensure the reliability of the data they collect and their methodology for reporting and maintaining the data; on their perspectives on the extent to which seniors’ mobility needs are being met; and on the additional data that should be collected, if any. To assess the reliability of the data obtained from AAAs, we reviewed the data for obvious errors in accuracy and completeness and interviewed agency officials knowledgeable about the data. Specifically, we asked whether any tests were conducted to ensure that data were entered accurately and whether the quality of the collected data had been reviewed. In addition, we asked AAAs to identify limitations of the data and actions taken to correct any limitations. (See table 4 for information about limitations of the AAA data.)

To obtain the perspectives of experts on the extent to which needs are being met, possible barriers to determining the extent of unmet mobility needs, and their knowledge of any standards or benchmarks developed for assessing seniors’ unmet mobility needs, we interviewed federal agency officials that have responsibilities for senior transportation programs in the Departments of Education, Health and Human Services, Labor, Transportation, and Veterans Affairs, as well as representatives from research organizations, advocacy organizations, and academic institutions in the fields of aging, disability, and transportation (see table 5). We asked these experts to identify potential sources for data and information on seniors’ mobility needs as well as for their perspectives on the extent to which such needs are being met.

To identify practices that can enhance transportation-disadvantaged seniors’ mobility and local service providers that have implemented such practices, we interviewed experts and federal officials and reviewed the literature on senior mobility. We then contacted these local service providers and requested further information about the practices they employed and the funding sources they used to implement the practices. To learn about the practices and their results, obstacles to implementing the practices, and the role of federal programs in supporting them, we conducted semistructured interviews with officials from 10 of the 29 local transportation service providers that responded to our initial request for information. These 10 providers represented a nonprobability sample, chosen to include a diversity of geographic areas (i.e., 5 were in urban areas and 5 were in nonurban areas, from different regions of the country); types of practices (such as use of technology and coordination); and federal funding sources (to get representation of as many of the 15 key federal programs as possible and to include both providers that used many federal funding sources and those that used only one or two). To determine the extent to which federal programs support practices that enhance transportation-disadvantaged seniors’ mobility, we interviewed federal program officials, senior mobility experts, and local service providers and reviewed pertinent GAO reports.

To identify examples of obstacles to addressing transportation- disadvantaged seniors’ mobility needs and strategies the federal government could consider taking to improve the ability of federal programs to meet these seniors’ mobility needs and enhance the cost- effectiveness of the services delivered, we reviewed literature on transportation, disability, and aging and interviewed experts, professional associations, and advocacy groups (see table 6). We also interviewed federal officials and officials from the 16 AAAs and 10 local transportation service providers previously mentioned. We organized the obstacles and strategies identified in the literature and through our interviews into three categories: planning for alternatives to driving as seniors age, accommodating seniors’ varied mobility needs, and addressing federal and other governmental funding constraints. We presented the proposed strategies to federal program officials to obtain their comments on the potential trade-offs associated with implementing them. The trade-offs were included in the discussion on obstacles and suggested strategies.

We conducted our work from November 2003 through August 2004 in accordance with generally accepted government auditing standards.

Information on Transportation Provided by 16 Area Agencies on Aging

Service restrictions (age, day/hours, distance, number of trips)

Escort, fixed-route, and demand-responsive transportation is provided to grocery stores, medical appointments, nursing homes for spousal visits, congregate meal sites, senior centers for general nonmeal activities, hospitals for spousal visits, and provider agencies (such as the Social Security Administration)

Service restrictions (age, day/hours, distance, number of trips)

Restrictions on when service may be available, depending on distance; medical destinations are prioritized; may have to wait for trips other than medical Services for fixed route and demand response have restrictions on distance—for the most part within county boundaries (except for some medical services)

Aged 60 and older Most transportation is limited to 5 days per week, 8 a.m. to 5 p.m.

One county is more rural and limits transportation to three cities Varies by county (senior centers cannot accommodate everyone due to limited funds); providers tend to prioritize trips (medical appointments/pharmacy and food shopping are higher priorities)

Service restrictions (age, day/hours, distance, number of trips)

Most providers restrict service at least within the county Number of trips depends only on scheduling and availability (most providers operate on a first-come, first-served basis)

Fixed route to senior centers Assisted door to door for trips to doctor appointments, grocery stores, and recreational activities (funded by seniors)

Local Service Providers and Practices That Can Enhance Transportation-Disadvantaged Seniors’ Mobility

Type of practice (as described by the providers and in the literature)

Coordinates transportation service with “zero trip denial” policy and uses dedicated funding through state lottery program.

Provides fixed-route service using dedicated funding from the state lottery program, targets marketing efforts to increase senior ridership, offers a driver sensitivity training program, and uses senior volunteers to promote and teach seniors how to ride fixed-route service through the “bus-buddy” program.

Provides free rides for seniors throughout an eight-rural-county service area with a 48-hour call ahead using volunteers from the Retired Senior Volunteer Program. Provides senior volunteer companions for homebound seniors through Senior Companions Program.

Provides demand-response transportation service with volunteer drivers to transport seniors to medical appointments, grocery stores, pharmacies, senior centers, or other errands.

Provides free fixed-route service to seniors. Also provides free transportation to groups of 20 or more seniors during off-peak hours (late evening or weekends) to destinations within the service area (e.g., Senior Games, Senior Proms, Senior Nursing Home Games, Retired Senior Service Volunteer Program luncheons, and AARP events).

Implemented a volunteer-based transit ambassador program that allows a volunteer, who knows the local transit systems, to assist and provide information to other passengers or people using public transit for the first time. The ambassador program is available to all passengers. However, seniors often take advantage of the program to learn how to ride fixed-route services in Napa, CA.

Type of practice (as described by the providers and in the literature)

Provides specialized coordinated transportation services for medically fragile, disabled, and elderly to locations such as medical offices, hospitals, and other key destinations. Coordinates transportation services with consumer advocates, social service agencies, government offices, and transportation providers to best meet their clients’ needs. Secures transportation funding, takes telephone calls, schedules and assigns trips with subcontractors, provides rides, and reimburses providers.

Implemented a medical advocacy program that uses local volunteers to assist elders with medical transportation and advocacy. Program is targeted to all elders and spouses and to working and long-distance caregivers.

Implemented a mileage reimbursement program through which seniors find volunteer drivers who use their private vehicles to transport seniors to medical appointments, grocery shopping, church, or other recreational activities. The program was modeled after the Transportation Reimbursement and Information Program, which is listed below.

Coordinates with medical facility staff to schedule senior medical appointments to match with transportation availability and is involved in business enterprises with others in the community to generate additional program revenue. The implementation of a computerized mapping system to schedule same-day services is slated for the near future.

Provides low- or no-cost transportation to low- income seniors and persons with disabilities located in rural communities to healthcare services, provides all-day Sunday service for seniors to go to church and other activities, and offers a volunteer driver program through which volunteers who use their own vehicles to transport seniors are reimbursed for mileage.

Implemented a travel-training program through which volunteers teach seniors how to use public transportation.

Type of practice (as described by the providers and in the literature)

Offers a range of demand-responsive services (door-to-door, door-through-door, and hands-on assistance) to a broad spectrum of older riders using automobiles driven by both paid staff and volunteer drivers. Operates exclusively on a combination of fares and donations and does not depend on public subsidies. Customers (seniors) become “members” of Independent Transportation Network and prepay (through a variety of payment plans) into their own account in advance of travel.

Provides demand-response transportation services to seniors for grocery shopping, medical appointments, banking, daily nutrition, senior center activities, and other general travel trips.

Provides transportation and brokerage services by coordinating with other nonprofit agencies. Services are customized to meet the needs of seniors, using wheelchair accessible vehicles and providing shuttle services to rural areas of the county. Contracts with a private, regional grocery chain to supplement its fund-raising efforts. The grocery store contributes to Medical Motors in exchange for Medical Motors transporting seniors to the grocery store.

Provides transit services to the general public and door-through-door, one-on-one services to special-needs populations in a multicounty region through a coordinated system that is also consumer friendly and flexible to meet the needs of the community.

Targets a travel-training program to the senior population to encourage seniors to use the public transit system by teaching (one-on-one or through groups) and showing seniors how to use the system. Helped establish the Strides Web site, designed as a distribution center for other public transportation service providers as well as a referral service for seniors to learn about transit services in the San Diego area.

Provides transportation service for the general public, prioritizing its services on senior citizens and persons with disabilities within 87 rural counties in the state of Missouri. Uses volunteers to fulfill a number of functions, such as dispatching calls to drivers, fund-raising, and serving as liaisons to the community.

Type of practice (as described by the providers and in the literature)

Provides flexible transportation services for trips to senior centers, shopping, banking, and medical appointments. Drivers use pagers for efficient pick-up service. Night and weekend trips are available.

Transports older adults and persons with disabilities to medical facilities, grocery stores, meal sites, and adult day centers and for other personal needs.

Uses volunteers to provide door-through-door medical transportation services to seniors. Services are free to seniors.

Provides a variety of services, including demand-response, curb-to-curb transportation service offered to the general public; a circular shuttle route serving the entire community that is also senior friendly; a “family and friends” mileage reimbursement program; and a comprehensive, one-on-one training program developed to teach seniors how to use their community transit alternatives.

Coordinates its services with local transit authority and taxicab services. Provides a driver- training program that emphasizes safety and customer service. Uses brightly-decorated vehicles to attract senior ridership.

Helps provide vehicles and funding to local communities in the service area. Local communities that receive the vehicles and funding design and operate services independently according to local needs.

Provides coordinated demand-response transportation services using computerized scheduling. The computerized scheduling software will allow accurate and on-time scheduling through the use of Global Positioning Systems technology that tracks the location of vehicles.

Provides senior transportation services 7 days a week and serves approximately 40 designated senior nutrition and social center sites. Also implemented a community bus program that circulates within a specific community to encompass shopping areas, senior residences, and senior day programs.

Type of practice (as described by the providers and in the literature)

Reimburses volunteer drivers to transport individuals where no transit service exists or when the individual is too frail to use other transportation.

Operates a demand-response service for seniors who need transportation services to medical facilities. Also works with local senior centers to provide transportation services.

Provides free transportation using volunteers, who use their private vehicles to transport seniors to medical appointments, shopping, and errands.

Comments from the Department of Health and Human Services

GAO Contacts and Staff Acknowledgments

GAO Contacts

Staff Acknowledgments

In addition to the individuals above, Bert Japikse, Jessica Lucas-Judy, Kristen Sullivan Massey, Sara Ann Moessbauer, Elizabeth Roberto, and Maria Romero made key contributions to this report.

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