This blog post is the sixth of a seven-part series highlighting the achievements of the 2021 ACCC Innovator Award Winners before their in-depth sessions at the ACCC 38th National Oncology Conference. You can learn more about the innovations being recognized this year and the people who pioneered them by joining us live in Austin, Texas, October 20-22, 2021.
Greensboro, N.C., is a historic city known for igniting the sit-in movement of the 1960s, which included the infamous confrontation at a lunch counter in Woolworth that attracted national attention in 1960. Although these and other protests marked important milestones in the American civil rights movement, the city of Greensboro continues to face historically driven division and segregation along racial lines—including within the healthcare arena. Specifically, current residents in two ZIP codes (27405 and 27406) that were once in heavily segregated areas of the city continue to be more likely to suffer from adverse health outcomes due to chronic disease, with some Greensboro residents living approximately 18 years fewer than residents located in non-historically segregated areas.
While the Moses H. Cone Memorial Hospital in Greensboro played its own role in desegregating healthcare services in the 1960s, the Cone Health Cancer Center continues today to fight for health equity by addressing the barriers to care that unequally affect lower-resourced communities in the rural and urban setting. To that end, the cancer center has built a transportation program that provides free roundtrip rides to all patients from their homes to their medical appointments.
To better understand the impact of transportation barriers from the patient’s perspective, Rachel Marquez, MPH, director of Transportation Services at Cone Health Cancer Center, spent a day riding the Greensboro city bus. “It was cumbersome, and there were lots of stops,” she explains. “It wasn't very quick to get to any one place, and it doesn't cover our entire county, let alone our entire service area.”
Later that day, Marquez pondered on her bus ride about how it would feel to navigate the Greensboro bus system for patients with cancer traveling to a treatment appointment, particularly when they are not feeling well. “While the bus is a great resource and has a place in our community, it’s not something we want to hang our hat on completely as a solution to our patients transportation barriers," Marquez says.
Marquez used her bus experience to argue that Cone Health Cancer Center needed to look deeper into the transportation issues patients were facing. She did not want to simply provide patients with vehicle cards for fuel, especially if they were not feeling well enough to drive after treatment, nor did she want to rely on patients’ friends or family to offer rides to and from appointments. Marquez’s team knew traditional solutions did not meet all patients’ needs, and they could place more of a burden on the very patients who are at risk of noncompliance in the first place. “We all know that transportation is a social determinant of health,” Marquez says. “I thought this was the perfect opportunity to bring my lens from public health and mix it into the operational world, to address our transportation barriers to care.”
In first designing the Cone Health transportation program, Marquez faced a few hurdles. “I think with anything new, there's a little bit of winning over that needs to be done, especially when you say you're going to start offering something for free to patients,” she says. This was especially true to Cone Health’s compliance and risk department. Because providing free rides to patients poses some risk to the health system and its patients, Marquez collaborated with the health system’s compliance and risk staff to mitigate their concerns. They developed waivers for patients to sign in order to participate in the program, provided a safety tip sheet to patients, and created a system-wide policy to address regulations and follow anti-kickback and Stark clauses. “I really think that my persistence won them over,” Marquez explains. “I really understood what the concern was and then worked to find solutions to overcome it.”
Targeting and Meeting a Need
In a coordinated effort with Cone Health Cancer Center’s administration, nursing, social work, and radiation oncology staff, Marquez and her team developed a screening tool to determine patients’ need for transportation assistance prior to treatment and before noncompliance could become an issue. If a need for transportation services is identified, rides are coordinated and scheduled by the health system's transportation coordinator through an online platform serviced by a vendor. The program uses a range of resources, including ride services, such as Uber and Lyft, non-emergency medical transportation providers, and wheelchair-accessible vehicles.
A 2019 pilot study of the program conducted with its patient population proved the program’s efficacy. Providing free, reliable transportation services to their patient population decreased no-show appointments by 48 percent (from 6.1 percent to 3.2 percent), resulting in a return on investment of $63,391. This more than recovered the $69,557 in revenue the cancer center expected to lose that year due to no-shows.
The transportation program also had a large impact on patients living in the 27405 and 27406 targeted ZIP codes. In these under-resourced, typically Black communities in Greensboro, residents experience poorer health outcomes compared to other demographic groups. The 27405 and 27406 ZIP codes had a 12 percent and 15 percent no-show rate, respectively, before the transportation program was implemented. After the pilot study, no-shows dropped to 1.2 percent and 1.3 percent, respectively. To further expand transportation access to much-needed medical services, Cone Health Cancer Center now refers all patients, including those from the targeted ZIP codes, to the program when they first present for treatment.
Adapting to Patient Needs
Cone Health Transportation Services is now a permanent program at the cancer center, offering its services to the entire health system, including its ambulatory centers and hospitals. The service has proven to be adaptable to patients’ changing needs, as evidenced during the worst of the COVID-19 pandemic. Since many patients were no longer attending their appointments in person due to safety concerns, demand for rides decreased in early 2020. Instead, food security became an issue for many patients treated by the health system.
Using the available vehicles and drivers from the transportation program, Cone Health delivered meals to patients who were immuno-compromised due to ongoing treatment. Social workers used needs assessment tools to determine if patients qualified for this help, and the cancer center partnered with local restaurants to develop medically tailored meals and deliver them to patients’ homes.
Marquez says she’s learned a lot from her experience of the now system-wide program. “I think there's a complexity to being a rural health system, and we already know in rural areas that transportation needs are higher,” she says. “So when building a transportation network, you have to get a little creative. Your innovation has to be tailored to your patients, your community, and the resources that are available in your community.”
Marquez presented at the ACCC 47th Annual Meeting & Cancer Center Business Summit, breaking down the development and pilot study of the Cone Health transportation program. By attending the ACCC 38th National Oncology Conference, you can learn more about Marquez’s experiences, including updated data on the program’s impact on patients and Cone Health, as well as how the program was quickly adapted to address changing patient needs.
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