PROJECT LEAD(S): Jane Jih, MD, MPH, MAS and Atrejo "Trey" Patridge, NP, UCSF Health Mount Zion Division of General Internal Medicine General Medicine (DGIM) Practice

EXECUTIVE SPONSOR(S): Adele Anfinson, Eric McNey

ABSTRACT: The overall health of our patients is linked to their social and economic conditions, and access to transportation is integral to well-being and delivery of patient-centered primary care. By providing some of our most vulnerable patients with reliable transportation, we believe we will advance the health of our patients by improving continuity of care with their primary care team and could reduce the need for unnecessary visits to the ER, reduce avoidable hospital readmissions, and improve patient satisfaction with the healthcare system. Leading up to this project, our team has been iterating on an approach to implement a transportation voucher program for patients that have a high no show rate and transportation barriers to engage in primary care. The main goal of this proposal is to implement a ride share voucher pilot for a subset of DGIM patients that have a high no show rate, screen positive for transportation barriers and have medical complexity that require follow up in the UCSF Health Mount Zion Division of General Internal Medicine General Medicine Practice every 2-3 months. This work would provide the proof-of-concept and allow us to assess if the ride share voucher results in increased follow up, reduced no shows and improved patient experience as well as the financial implications of this work for UCSF Health that could make a persuasive case to UCSF Health Primary Care Services administrative leaders to extend this program beyond the proof-of-concept pilot.

TEAM:
* Jane Jih, MD, MPH, MAS co-project lead, general internist, Associate Professor of Medicine, Co-Director of UCSF Multiethnic Health Equity Research Center, Physician Champion for Social Determinants of Health in UCSF Primary Care Services
* Atrejo "Trey" Patridge, NP, co-project lead, nurse practitioner at UCSF Health Division of General Internal Medicine
* Tiffany Chinn, project coordinator
* Sara Abrahams, MD, UCSF Primary Care Resident (PGY-2) who is conducting her Resident Scholarship Project as part of this proposal

PROBLEM: In our pilot work leading to this application, 13% of DGIM patients screened for transportation barriers self-identified as having transportation issues that affect their ability to obtain medical care. Transportation barriers greatly impact patient access to healthcare and impact their health. Many patients surveyed report missing medical appointments due to transportation barriers. The downstream effects to patients of missing primary care visits can result in increased utilization of the ER, after hours calls to the clinic, worsening health conditions, and reductions in overall health status. Increased utilization of healthcare beyond the primary care setting often leads to increased health care costs for the patient and the health care system.

Transportation barriers disproportionately affects people of color, those that do not speak English (particularly Spanish-speakers), older adults, individuals with less education, and those with lower incomes. These are also individuals with the worse healthcare outcomes, and therefore, in greatest need of intervention to address transportation challenges. Currently, there are very limited resources and solutions available for patients with transportation barriers to have this need addressed, particularly for patients that do not meet the strict eligibility criteria for Paratransit. When it comes to public transportation, many of our patients choose not to rely on it for reasons like personal safety concerns with riding crowded buses, having to take more than one bus/train to clinic, or trouble navigating directions due to language barriers.

TARGET:
1) Can providing ride share vouchers reduce no shows? We will use quantitative data by looking in the electronic health record to determine the number of in-person visits completed in the pilot and the number of visits that utilized round trip ride share vouchers. We will also use the electronic health record to assess any changes in chronic disease care (including blood pressure, hemoglobin A1c, medication adherence) and any pre- and post-changes to healthcare utilization including emergency room visits and urgent/acute care visits.

2) Does providing ride share vouchers improve patient experience? We will use a blended quantitative and qualitative approach. For all patients, we will conduct a brief pre- and post-pilot survey to assess their impressions of the pilot project including questions from the patient-oriented Press Ganey UCSF Health Survey including:
-Our practice's sensitivity to their needs
-How well staff cared about patients as a person
-How well everyone at UCSF Health worked together to care for patients
-Likelihood of recommending our practice to others
At the end of the pilot project, we will also conduct brief interviews with a subset of patients in the pilot to ask about how the ride share affected their chronic disease care and how it impacted their experience as a patient in the practice as well as areas to improve or work on.

3) How does a ride share voucher pilot for patients with high no show rate, high medical complexity and transportation barriers affect the clinician experience? We will conduct brief interviews with a subset of clinicians who had their patients participate in the pilot to gather their impressions of ride share program and its impact on delivering primary care to a vulnerable population of patients.

4) What is the financial impact of providing ride share vouchers on the clinical revenue generated? To support our proof of concept, we will determine if it is to the financial benefit of Primary Care Services to have a patient complete a primary care visit and receive the revenue that visit generates, minus the costs incurred to supply a roundtrip ride share for a patient, vs the revenue lost when a patient no-shows to a visit.

GAPS: Qualitative interviews of DGIM patients with transportation barriers identified a number of issues including lack of automobile access, transportation costs, safety concerns with public transportation, and unreliability of arranging taxi rides using taxi vouchers, to name a few, many resulting from structural inequities and racism. Transportation barriers disproportionately affect older adults, non-English speaking patients, and those with multiple complex medical conditions. Paratransit has strict eligibility criteria based on disability and functional status and is therefore limited to only a small portion of patients. Patients have expressed dissatisfaction with public transportation for reasons that include safety concerns, having to take more than one bus/train to get to a medical appointment, and unpredictable schedules. Patients have also expressed frustration with taxi vouchers, with some reporting challenges scheduling rides due to language discordance, scheduled rides that never show up, and even an inability to get an operator on the phone when calling to schedule. Rideshare apps have also traditionally relied on the user to have a smartphone, and to interface in English.

INTERVENTION: The main goal of this proposal is to implement a ride share voucher proof-of-concept pilot for a subset of DGIM patients that have a high no show rate, screen positive for transportation barriers and have medical complexity that require follow up in DGIM every 2-3 months. This work would provide the proof-of-concept and allow us to assess if the ride share voucher results in increased follow up, reduced no shows and improved patient experience as well as the financial implications of this work for UCSF Health that could make a persuasive case to UCSF Health Primary Care Services administrative leaders to extend this program beyond the proof-of-concept pilot.
Working with clinicians and clinic leadership including practice and nurse managers, we will enroll 60-70 medically complex adult patients into the pilot project and offer then ride share vouchers for all DGIM visits over 6-9 months (anticipate up to 3 visits per patient on average). The eligibility criteria for patients to participate are: a) high no show rate (25%+) to DGIM General Medicine Practice visits in the last year; b) screened positive for transportation barriers (screening question in APeX in the social determinants of health wheel: in the past 12 months, has lack of transportation kept you from medical appointments or from getting medications?); and c) have chronic disease burden necessitating follow up every 2-3 months as identified by trend of prior visits and/or primary care clinician referral. Patients will also be ineligible or unable to use Paratransit services.

Potential barriers to implementation include patient buy-in. Leading up to this application, we conducted a pilot randomized controlled trial of 46 patients who had a higher no-show rate at DGIM. Patients in the intervention group received a mailed reminder letter of their upcoming visit and a taxi voucher with the letter explaining the purpose of the voucher and how to use it. Only two individuals in the intervention group used the taxi voucher. Follow-up calls of the patients in the intervention arm of the pilot trial informed us that many that received a taxi voucher by mail were suspicious – even though we explained in the letter why we had mailed the taxi voucher, they hadn't expected their doctor's office to mail them a taxi voucher. We expect to avoid this skepticism with our proposed project as our administrative colleagues, internal staff members who our patients interface with regularly, will be the ones to call patients and arrange rides using the UberHealth rideshare platform. Language discordance may also pose a potential barrier to some patients, which is why we have opted to partner with UberHealth, which offers notifications to riders in 14 different languages. And patients who have traditionally found technology to be a barrier to accessing transportation will find that, unlike traditional rideshare apps, having a smartphone is not a requirement to using the service, as the feature allows patients with any cellular phone that receives text messages to participate, and those without a mobile device can use a landline phone that accepts incoming calls.

Adverse outcomes are likely few. Patient safety throughout the duration of a patient's rideshare trip is of the utmost concern to us. Our staff will have the ability to track rides, share rides alerts with a patient's trusted contacts, and we will survey patients about their experience with the ride.

PROPOSED EHR MODIFICATIONS: An APeX dashboard/indicator that shows the number of missed and completed visits at DGIM for a chosen time period would help us identify patients with the higher no show rates to achieve the goals of this project and support future work to address no shows. Currently, APeX provides us a patient's percent no-show rate for all visit types across all of UCSF for the patient's entire time of care at UCSF.

COST: The cost savings of this pilot is unclear. A goal of this proposal is to evaluate the financial impact of providing ride share vouchers on the clinical revenue generated. As part of the project, we will calculate the clinical revenue generated from a completed visit, minus the costs incurred to supply a roundtrip ride share for a patient versus the revenue lost when a patient no-shows to a visit.

SUSTAINABILITY: This project will provide proof of concept and the potential financial model to make such a program permanent and supported by UCSF Health. In speaking to administrative leadership of UCSF Health Primary Care Services, UCSF Health Primary Care Services is very interested in learning if this type of intervention could be cost neutral or generate revenue that would be otherwise lost if patients no showed for their visit as well as the patient satisfaction and potential for downstream health outcomes and clinician satisfaction. Primary Care Services has expressed support in this work and potentially scaling up the intervention if it is cost neutral or revenue generating.

BUDGET:
Salary support
• Project co-lead Jane Jih, MD, MPH, MAS. $9,617 (0.3 calendar months)
• Project co-lead Atrejo "Trey" Patridge, NP. $9,600 (stipend)
• Project coordinator: Tiffany Chinn, BS. $11,464 (1.2 calendar months)
• Practice Coordinator Champions (To Be Named): $4,000 to support 2-3 practice coordinators. Since these activities are not yet part of the job description for a practice coordinator, we will offer quarterly gift cards in appreciation of the added role and responsibilities.

Uber Health Ride Share Rides. $14,819. For up to 70 patients, we estimate to $70 for each round-trip ride share per patient per visit and estimate up to a total of 210 round trips (up to 3 round trips per patient).

Patient participant incentives. We request funds in the amount of $500 to be used to as an incentive to recruit 25 patients ($20/patient) for in-depth post-project interviews to evaluate the project and its effect on patient experience and chronic disease care.

UCSF Data Network Recharge (if required) $53.
Computing and Communication Device Support (CCDSS Premium Rate) (if required) $66.