Transportation to Support Rural Healthcare
Transportation is an important social determinant of health in rural communities. The availability of reliable transportation impacts a person’s ability to access appropriate and well-coordinated healthcare, purchase nutritious food, and otherwise care for themselves. Rural populations most likely to need transportation services to maintain their health and well-being include:
- Older adults
- People with disabilities
- Low-income individuals and families
- People with special healthcare needs, who often must travel long distances to access care
This guide focuses on how communities can provide transportation services to support access to rural healthcare, which may also benefit healthcare providers by decreasing inappropriate use of EMS services, improving utilization of healthcare services, decreasing no-show rates, and increasing access to health-supporting services. The guide also highlights transportation as a community-based service that can allow the elderly and people with disabilities to live successfully in a community rather than entering a long-term care facility or leaving the community.
Frequently Asked Questions
- Where can I get help planning and funding transportation projects?
- Where can I get help finding local transportation programs and services?
- Do rural residents experience greater travel burdens in accessing healthcare?
- What are the health-related consequences of not having transportation for rural residents, including older adults and people with disabilities?
- What strategies can rural communities and healthcare facilities use to provide non-emergency medical transportation services?
- What issues should facilities and organizations consider when providing transportation?
- Can Medicaid be used to subsidize non-emergency medical transportation?
- What resources are available to assist my rural community in planning, developing or expanding public transit services that would help the elderly, disabled, and low-income individuals access healthcare services?
- What are the types of accommodations rural transportation providers must support to comply with the Americans with Disabilities Act (ADA), and who is eligible for these special accommodations?
- Are there programs or grant opportunities to help tribal communities improve transportation services?
- Are there grants or programs to assist veterans in rural areas with transportation to VA medical centers and other VA and non-VA facilities for medical care?
- What is FTA Section 5310, and how can it help provide transportation services in rural areas?
Where can I get help planning and funding transportation projects?
The following organizations provide resources and technical assistance related to rural transportation projects:
Community Transportation Association of America (CTAA)
Provides a wide variety of information on economic development, financing, technical assistance, and offers training related to rural and urban public and community transportation. Its Health Care and Transportation page offers resources, policy updates, and information focusing on the issues, opportunities, and challenges impacting non-emergency medical transportation professionals.
National Rural Transit Assistance Program (National
Provides training and technical assistance products and services that are developed nationally, for distribution and replication by the states to local transit agencies. Offers a National RTAP Resource Library with access to information and expertise, and an online list of State RTAP contacts.
National Aging and Disability Transportation Center (NADTC)
A cooperative agreement supported by the Federal Transit Administration (FTA), and assisted by Easterseals, USAging, and the Administration for Community Living (ACL). NADTC provides communities technical assistance, training, information and referral, and community grants focused on the availability and accessibility of transportation for seniors and people with disabilities.
Center for Mobility Management (NCMM)
Provides technical assistance, training, and community grants to help communities implement transportation policies and mobility opportunities that enable people to live independently, as well as promote health, economic vitality, and self-sufficiency. NCMM hosts a Health and Transportation Resources Center that provides resources to assist mobility management professionals and their communities in understanding the intersection among health care, public health, and transportation.
NCMM is funded through a cooperative agreement with the Federal Transit Administration, and is operated through a consortium of three national organizations, the Community Transportation Association of America, the American Public Transportation Association, and Easterseals.
National Center for Applied Transit Technology (N-CATT)
Offers technical assistance including practical and replicable resources for small-urban, rural, and tribal transportation agencies supporting innovative and technological solutions enabling communities to offer efficient, multi-modal, and on-demand transportation.
Where can I get help finding local transportation programs and services?
To learn about transit options in your area and help rural residents find transportation:
National Rural Transit Assistance Program Directory of State RTAP Managers
Provides a searchable directory of state Rural Transit Assistance Program managers by state, name, and keyword.
Transportation Association (APTA) – U.S. Local and State Transit Links
Provides a comprehensive list of links to transit agency websites by state, county, and city, and includes state department of transportation (DOT) websites.
National Volunteer Transportation Center Map of Volunteer Driver
Provides an interactive map allowing the user to search by location for volunteer driver programs in each state.
Community Action Partnership
Provides information, resources, and program models on a variety of topics including transportation that can help low-income persons and families move toward self-sufficiency and reduce poverty in rural and urban communities across the United States. Offers directories identifying Community Action Agencies or Associations at the state and local level.
Do rural residents experience greater travel burdens in accessing healthcare?
According to Rural-Urban Variations in Travel Burdens for Care: Findings from the 2017 National Household Travel Survey, rural residents experience greater travel burdens when accessing healthcare. This national survey of rural and urban populations demonstrated significant variations in travel burden in a variety of healthcare-related categories. Some of the highlights of the study found:
- Rural residents traveled more than twice the distance (17.8 miles) as urban residents (8.1 miles) for medical or dental healthcare.
- Time spent traveling was nearly 9 minutes longer for rural residents (34.2 minutes) than for urban residents (25.5 minutes). Travel time was the greatest in the rural West (41.7 minutes), followed by the rural South (35.4 minutes) and the rural Midwest (31.5 minutes).
- Rural residents' travel time occurring after midnight to receive healthcare were longer (67 minutes) and farther (38 miles) than for urban nighttime trips (42.6 minutes and 15.6 miles).
- Well over half of rural residents (55.8%) identified the cost of gasoline and the financial expense of travel as barriers, compared to 45% of urban residents.
It is important to recognize the factors of excessive distance and time spent on travel, and their link to reasons why rural residents delay healthcare or miss appointments resulting in reduced preventive care, greater disease burden, and poorer treatment outcomes.
What are the health-related consequences of not having transportation for rural residents, including older adults and people with disabilities?
Reliable transportation options can determine whether many people in rural areas have access to healthcare, which is critical for promoting and maintaining health, and preventing and managing disease. Often elderly individuals and individuals with disabilities have greater healthcare needs than other rural residents, and living in rural areas isolated from healthcare providers can have a significant impact on their quality of life, their health, and their safety.
According to the Transportation Cooperative Research Program (TCRP) some of the negative impacts of a lack of appropriate or available transportation services include:
- Reduced access to healthcare services
- Delayed or missed appointments to receive needed healthcare services
- Disruption in ongoing treatments and services for chronically ill patients
- Lack of accessible options may prevent individuals from using public or private transportation systems
- Increased potential for poorer health outcomes
- Higher overall costs for healthcare
- Travel distance to health services and the related costs affect patients' healthcare decisions
- Extended travel time to access healthcare can affect patients physically and cause stress
Studies have shown that providing transportation for medical treatment to low-income, elderly, and disabled patients is cost-effective and improves the quality of life. A 2005 study by the Transit Cooperative Research Program demonstrated the differences between the cost of poorly-managed and well-managed care, as well as the differences in quality of life. They found that the reduction in healthcare costs and improvement in quality of life would more than offset the costs required to provide non-emergency medical transportation (NEMT). Missing a routine or preventive care service because of transportation can lead to poorly managed care, a need for emergency care, and preventable hospitalizations.
Providing effective public transportation options to healthcare services for low-income, elderly, and disabled residents decreases hospitalizations and nursing home stays, allowing them to remain contributing members of the community and lead healthier lives while keeping health costs down. In addition, transportation allows rural residents to avoid social isolation, as discussed in the Rural Monitor article, Social Isolation and Loneliness: Insights from Rural Clinical Providers and Other Experts. The July 2020 report, The Role of Transportation in Addressing Social Isolation in Older Adults, recommends increasing collaboration between the transportation, health, and aging sectors at the state and local levels and conducting additional research on public transportation and meeting the social needs of older adults.
What strategies can rural communities and healthcare facilities use to provide non-emergency medical transportation services?
According to a 2010 study funded by the Federal Transit Administration (FTA):
“The greatest problems for people using public transportation for healthcare trips are inconvenient schedules, the need to match transit and medical schedules, and infrequent service.”
Many strategies have been implemented in rural communities across the country to provide non-emergency medical transportation services. Strategies for communities who have some kind of transportation service available may include:
- Hiring a mobility manager to streamline scheduling and dispatch efforts
- Creating a website and customer service contact center for direct trip requests
- Centralizing staff for trip eligibility determination and reservation requests
- Setting schedules for medical trips to specialty care centers to reduce travel times and to provide consistent service.
- Implementing an interactive voice response (IVR) system that calls the night before to confirm or allow a cancellation, as well as same day notification when the vehicle is near rider location
- Broadly disseminating information about the availability of transit services
- Forming partnerships between ridesourcing companies, healthcare providers, public health agencies, transit agencies, and insurers.
In some communities where formal transportation services are not available or are insufficient, healthcare facilities or community organizations have chosen to fill the healthcare transportation gap by:
- Offering transportation services for healthcare appointments using paid or volunteer drivers
- Coordinating a shared ride/cost transportation program (a door-to-door, advance-reservation, ride-sharing service)
- Brokering out coordinated trips to qualified vendors
- Using telehealth to decrease the travel required for local patients to access specialty care
- Starting a mobile clinic to take healthcare services to patients in remote areas
- Providing some services in local schools to reach low-income or high-needs children
- Having Community Health Workers or Community Paramedics visit people in their homes, which may decrease the frequency of trips for medical care
Examples of non-emergency transportation programs in rural areas include:
- HealthTran – A non-emergency transportation service that offers rides for patients demonstrating a transportation need for timely primary and preventive care access in South Central Missouri. HealthTran was also profiled in a 2016 Rural Monitor article.
- Angel Flight West – A network of more than 1,400 pilots donate their skills, aircraft, and all costs associated with flying to help families and individuals in need in the 13 western states of the United States. Angel Flight West was one of several charity flight services highlighted in a 2018 Rural Monitor article.
- Tri-Valley Opportunity Council Rural Transportation – A coordinated public transportation and volunteer driver system which serves a rural 8-county area in northwest Minnesota.
- Garrett County Regional Cancer Patient Navigator Program – A comprehensive cancer-centric program offering transportation to provide patients access to radiation treatment for residents within an 8-county, 3-state area in Appalachia.
For more information on the development of rural transportation programs, see the Rural Transportation Toolkit. Also, TCRP's Guidebook and Research Plan to Help Communities Improve Transportation to Health Care Services discusses selecting, developing, and modifying transportation services to meet the healthcare needs of a community.
What issues should facilities and organizations consider when providing transportation?
Screening and training of drivers
Whether using volunteer or paid drivers, care should be taken to screen the drivers to ensure the safety of patients. In addition, drivers should be adequately trained just like any other staff member, including topics such as safety, how to assist patients, and the necessity of confidentiality.
Before implementing a transportation program, liability issues must be fully investigated and considered, particularly when using volunteer drivers or personal vehicles.
Funding the program
How will the program be funded and maintained? Facilities might approach state transportation departments or local foundations regarding potential funding. In addition, facilities can explore partnerships with other organizations or agencies serving the community.
For additional information about volunteer driver programs, see the National Volunteer Transportation Center Map of Volunteer Driver Programs and the National Volunteer Transportation Center Resource Library.
Can Medicaid be used to subsidize non-emergency medical transportation?
Yes. States are required to cover non-emergency medical transportation (NEMT) to Medicaid beneficiaries who need transportation in order to access medically needed services. This includes both local providers of care and tertiary healthcare facilities. See the Kaiser Family Foundation's Medicaid Benefits: Non-Emergency Medical Transportation Services.
For further information on Medicaid coverage for NEMT, see the following resources:
- Medicaid Coverage of Certain Medical Transportation under the Consolidated Appropriations Act, 2021 (Public Law 116-260) – Offers states details of the Consolidated Appropriations Act concerning Medicaid coverage for specific medical transportation.
- Medicaid Coverage of Non-Emergency Medical Transportation – Describes the NEMT benefit, including models for using it and guidance on financing and spending.
- Handbook for Examining the Effects of NEMT Brokerages on Transportation Coordination – Provides background on NEMT as well as models for implementation and features a companion document with state-by-state profiles.
What resources are available to assist my rural community in planning, developing or expanding public transit services that would help the elderly, disabled, and low-income individuals access healthcare services?
Organizations that can assist rural communities with transit planning include:
- State departments of transportation
- Local councils of government
- Community based organizations
- Private transportation companies
- Economic and community development corporations
- Regional planning organizations
- Also, individual State Rural Transit Assistance Programs (RTAPs) provide workshops, on-site training, educational materials, and peer assistance. Contact National RTAP and your state's department of transportation for information on your State RTAP resources. National RTAP also provides a list of State RTAP website links.
The Community Transportation Association of America (CTAA), a national organization, offers a variety of technical assistance and guides for communities looking to initiate and/or expand transportation services and programs that link people to jobs, medical care and other destinations necessary for quality of life.
The Transportation Research Board (TRB) offers detailed information on selecting an appropriate approach to managing and operating transportation services including a continuum of solutions to consider when matching patients with transportation options.
In addition, SBA.gov provides assistance with the development of small businesses that could include a non-emergency medical transportation business.
Examples of transportation models that address the transportation inequities of elderly and low-income individuals in rural communities include:
- SMiles Senior Transportation – SMiles was implemented in Blount County, Tennessee to provide transportation to rural seniors who are no longer able to drive.
- Kid One Transport – Provides rides to medical appointments for children and expectant mothers who otherwise have no other means of transportation in rural Alabama.
- Age-Friendly and Dementia-Friendly Winnemucca and Humboldt County – Monthly community meetings are held to discuss topics around health, housing, transportation, social events, and how their rural community could be more inclusive for older adults.
What are the types of accommodations rural transportation providers must support to comply with the Americans with Disabilities Act (ADA), and who is eligible for these special accommodations?
Rural transportation providers are not required to provide fixed-route service in any rural area. However, if they do provide a fixed-route service they are required to comply with ADA and be accessible. They must provide ADA complementary paratransit service for those individuals with disabilities who cannot use fixed-route service. If another type of transportation service is offered such as a taxi, shuttle, or ride-share, or any form of demand-response transportation, ADA regulations will apply and servicers are required to provide equivalent and reasonable accommodations. For additional information about compliance with federal requirements, see Federal Transit Administration's (FTA) Shared Mobility FAQs: Americans with Disabilities Act (ADA).
Regulations and technical assistance materials are available from the Americans with Disabilities Act website. Also, the FTA's Topic Guides on ADA Transportation provide detailed information on equipment maintenance, stop announcements, and route identification. National RTAP also provides an ADA Toolkit.
According to the section Eligibility for ADA Paratransit, individuals are eligible for paratransit service if they meet one of these criteria:
- Navigation of the transit system requires assistance
- Individual needs an accessible vehicle
- Bus routes or bus stops are inaccessible
- Travel is prevented if a reasonable person with the disability would be deterred from making the trip
Are there programs or grant opportunities to help tribal communities improve transportation services?
Yes, there are several programs that fund tribal communities' transportation needs, including:
Social and Economic
Development Strategies (SEDS)
This program from the Administration for Native Americans (ANA) funds projects to develop community transportation activities that support the needs of the elderly, the disabled, and the local workforce.
Public Transportation on Indian Reservations (Section 5311c)
Available through the Federal Transportation Administration (FTA). Provides planning, capital, and operating assistance to designated tribal entities. For more information, contact your regional FTA office.
In addition, the majority of the funding opportunities for general rural transportation projects are applicable to tribal communities.
Are there grants or programs to assist veterans in rural areas with transportation to VA medical centers and other VA and non-VA facilities for medical care?
The U.S. Department of Veterans Affairs program, Highly Rural Transportation Grants (HRTG), awards grants to veterans service organizations that use innovative approaches to assist veterans in rural areas with transportation to VA medical centers and other VA and non-VA facilities for medical care. For information about this program and other programs that may assist veterans in accessing medical care, see RHIhub’s Rural Veterans and Access to Healthcare – Funding & Opportunities.
Also, the Disabled American Veterans (DAV) Hospital Service Coordinator Directory provides a state-by-state list of Hospital Service Coordinators (HSCs), their affiliated VA Medical Centers, and contact information. HSCs manage DAV transportation programs for veterans needing medical care.
What is FTA Section 5310, and how can it help provide transportation services in rural areas?
FTA Section 5310 (49 U.S.C. 5310) is a program that funds projects for enhanced mobility of older adults and people with disabilities. Section 5310 funding is allocated to states based on the population for the two target groups in rural and urban areas. States then have flexibility in deciding how the funds are distributed to sub-recipients, which may be formula-based, competitive, or discretionary. Sub-recipients may be private nonprofit organizations, state and local government authorities, and operators of public transportation. Each state must publish a management plan for how sub-recipient funding decisions are made.
Traditional uses of funds include:
- Buses and vans
- Wheelchair lifts, ramps, and securement devices
- Transit-related information technology systems, including scheduling/routing/one-call systems
- Mobility management programs
- Acquisition of transportation services under a contract, lease, or other arrangement
Examples of less traditional projects include:
- Travel training
- Volunteer driver programs
- Building an accessible path to a bus stop, including curb-cuts, sidewalks, accessible pedestrian signals, or other accessible features
- Improving signage, or way-finding technology
- Incremental cost of providing same day service or door-to-door service
- Purchasing vehicles to support new accessible taxi, ridessharing, and/or vanpooling programs
- Coordinating with other programs and assisting in regularly providing meal delivery service for homebound individuals
Additional information about FTA Section 5310 funding is available from the National Aging and Disability Transportation Center.
To learn more about how Section 5310 funds are distributed in your state, contact your Regional FTA Office.
Last Reviewed: 3/29/2022