Continuity of Care for Chronic Conditions

Continuity of Care for Chronic Conditions

Six in ten U.S. adults live with at least one chronic condition, and four in ten live with two or more chronic conditions. The ability to attend medical interventions and follow-up care for these diseases is crucial to their successful management. 

One study showed that patients with a propensity to miss appointments  were significantly more likely to have incomplete preventive cancer cancer screenings as well as worse results on indicators of chronic disease, such as hemoglobin A1c and low-density lipoprotein (LDL) levels.

The most common chronic diseases include the following:

This short NCMM video shows the importance of creating a business relationship with dialysis providers.

  • End-stage renal disease. More than half a million people in the U.S. live with end-stage renal disease (ESRD) and require renal replacement therapy to sustain life. Approximately 90% of these patients travel to a dialysis center three times a week for treatment; during dialysis a machine does the work that their now non-functioning kidneys used to do. Missing even one dialysis treatment can cause severe complications and jeopardize patient health. Many dialysis patients are dependent on public transportation or contracted medical transportation services in order to get to the dialysis facility.
  • Cancer. Treatment for cancer may begin with surgery and post-surgical appointments, often followed by some type of chemotherapy. Most chemotherapy treatments are given in repeating cycles lasting from 2 to 6 weeks each. The American Cancer Society offers a volunteer-based transportation program to patients.
  • Chronic heart and lung disease. Patients attend regular appointments with health care providers for disease education, medication management, and disease monitoring.
  • Diabetes. Patients attend regular appointments with health care providers for disease education, medication management, and disease monitoring.
  • Alzheimer’s disease and other debilitating old age-related diseases. When an individual reaches the stage where they need continual care, and they are not in a residential setting that provides that care, they and their family may turn to adult day care centers. These services are designed to provide care and companionship for older adults who need assistance or supervision during the day. There are two types of adult day care: adult social day care and adult day health care. Adult social day care provides social activities, meals, recreation, and some health-related services. Adult day health care offers intensive health, therapeutic, and social services for individuals with serious medical conditions and those at risk of requiring nursing home care. In all states, Medicaid pays for adult day care and/or adult day health care; Medicare does not, although a Medicare Advantage plan may. Adult day centers usually operate five days/week, and many provide their own transportation.

For further investigation . . .

National Center for Chronic Disease Prevention and Health Promotion

We know that most chronic diseases can be prevented by eating wellbeing physically active, avoiding tobacco and excessive drinking, and getting regular health screenings. CDC’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) helps people and communities prevent chronic diseases and promotes health and wellness for all.

Needham Community Council Rides to Health Care

Needham Community Council – Needham, MA
In 2017, the Needham Community Council began supplementing its volunteer driver medical transportation program with trips provided through the ridehailing company, Lyft. Lyft rides were funded through the Needham Community Council operating budget and a donation from Beth Israel Deaconess Hospital – Needham.

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Engaging Older Adults in Mobility Management

Brookline Council on Aging – Brookline, MA
Transportation Resources Information Planning and Partnership for Seniors (TRIPPS) is an initiative of the Brookline Council on Aging. TRIPPS launched in 2015 with initial funding through a grant from the Massachusetts Department of Transportation using federal 5310 funding. We provide information, resources, and support to older adults in Brookline who are looking for transportation options. Our focus has been on older adults who are either not driving or are transitioning from driving to other modes. About 70 percent of our older adults who we work with do not own a vehicle.

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Seniors on the GO

Gloucester Health Department – Gloucester, MA
Cape Ann Seniors on the GO launched in October 2019 across the communities of Gloucester, Rockport, Essex and Manchester by-the-Sea to meet an identified need of improving access to healthy food and opportunities for physical activity among low income older adults through increased transportation access. This pilot grew out of the work of the Cape Ann Mass in Motion coalition, a part of the Massachusetts Department of Public Health’s Municipal Wellness & Leadership Program. The need for food and physical activity access was identified through root cause analysis and examining high rates of chronic disease among older adults in our Cape Ann communities. Over half of older adults who reside in Gloucester have four or more comorbidities.

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RideLink-Transportation for Older Adults​

Dakota County Community Services, “The Rapid” – Dakota County, MN
RideLink is a network of five area transportation providers that together provide older adults (age 60+) with door-to-door transportation as a complement to the fixed route bus. RideLink can be utilized for medical appointments, shopping trips, and recreational trips, which sets it apart from other options in the area that limit rides for older adults for specific purposes. RideLink’s providers have multiple types of vehicles that provide service to those who use a wheelchair accessible, and also accommodate service animals and caregivers.

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In-House Microtransit in Rural Massaschusetts

Franklin Regional Transit Authority – Greenfield, MA
In 2019, FRTA launched the FRTA Access microtransit program. In contrast to many microtransit programs that are contracted out to a third-party company, FRTA operates its microtransit in house: FRTA upgraded its scheduling software to allow riders to book on-demand rides, and uses its existing demand-response vehicles to make the trips. Eligible demand-response riders have priority when they reserve in advance, and then any remaining capacity is open to the general public through the FRTA Access app. Initially, riders could only summon rides through the app, but over time FRTA also added an online reservation as some parts of the region lack good cell coverage.

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Taxi-Based Employment Program in Partnership with WIB

Franklin Regional Transit Authority – Greenfield, MA
In April 2021, the Franklin Regional Transit Authority (FRTA), which provides transportation in 41 communities in rural Western Massachusetts and fixed-route services in the small city of Greenfield, added a new pilot to expand mobility for workers needing to commute to late night and early morning shifts. In partnership with the local Workforce Board, FRTA received a grant to fund taxi rides for workers needing to get to second and third shift jobs during hours when public transit was not operating. In addition to getting a ride to work, participants could also stop at a childcare facility if they needed to drop off or pick up their children on the way.

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SeniorCare Inc. Medical Transportation Program

SeniorCare Inc. – Gloucester, MA
Recognizing that they would not be able to fill all trip requests with just their volunteer driver program, they also set out to become knowledgeable about other transportation options in the region, and to share that information with their riders. SeniorCare began by reaching out to area Councils on Aging and the local transit authority to learn about their transportation services. They compiled a town-by-town listing of transportation resources, posted on the SeniorCare website. To keep the information up to date, SeniorCare does regular outreach. When a new caller requests a ride, SeniorCare’s Transportation Coordinator discusses all transportation options appropriate for them and mails them a welcome packet with that information.

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Franklin County Access Pilot for Nonprofits

Franklin Regional Transit Authority – Franklin County, MA
In November 2021, Franklin Regional Council of Governments (FRCOG) a new program, entitled the Franklin County Access Pilot for Nonprofits. It was created for a coalition of local health and social service agencies. FRCOG had funding from a state legislative earmark that they originally planned to use to subsidize Lyft rides. The Lyft pilot was delayed due to lack of Lyft drivers in the rural area, and in the meantime, FRTA’s in-house ride-hailing program, Access, launched. , so FRCOG pivoted to subsidize microtransit rides instead of Lyft rides. FRTA’s Advisory Board met in May 2022 to discuss the future of these initiatives and voted to make the FRTA Access a permanent program.

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Public & Senior Transportation

OCCK Public Transportation – Salina, KS
On the Go: Enticing Seniors to Try Salina’s Public Transportation program began in 2022 as a partnership between the Salina Senior Center, OCCK Transportation and the Mobility Manager for North Central Kansas. The goal of the program is to increase the number of senior citizens using Salina’s public transportation system.

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Long-distance Medical Transportation

Cape Cod Regional Transit Authority – Hyannis, MA
To promote access for Cape Cod residents to specialty medical appointments in Boston, the Cape Cod Regional Transit Authority (CCRTA) has run a Boston Hospital shuttle since 2001. The shuttle starts on the Outer Cape and picks passengers up at seven stops in different Cape towns, and then drives into Boston and drops passengers off at their appointments. In the early afternoon, the shuttle picks riders back up for the return trip to the Cape. Prior to the pandemic, service ran one daily round trip five days a week; since the pandemic, the shuttle runs Monday through Thursday. In order to serve as many residents as possible, the shuttle is open to the general public.

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