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Out of Reach for Access to Care

Telehealth was perhaps the most positive outcome of COVID-19. When cities and states announced stay-at-home mandates, telehealth became a critical path to maintaining our nation’s health. Still, telehealth could not answer such in-person medical needs as dialysis, cancer treatment, surgical treatment, and even some  behavioral health therapy, including substance use treatment. This became particularly true for residents of rural areas, who might postpone care until a crisis point, then struggled with locating access to care.

Envida (right) is pictured with two of its partners in rural Teller County, Cripple Creek Transit and Ute Pass Health Services District.

Rural Communities in Crisis

When COVID-19 hit, Envida, a nonprofit in Colorado Springs, Colorado, that specializes in transportation and homecare, was expanding its new program on behavioral health rides under an FTA Innovative Coordinated Access and Mobility (ICAM) grant to rural Teller County. Almost overnight, behavioral healthcare providers turned to telehealth, and Envida wondered if its innovative service might become obsolete. But social isolation, anxiety, depression, and substance use disorders under COVID impacted rural communities hard.  In 2021, Teller and Park counties, with rural, highly rural, and frontier populations experienced some of the highest suicide rates in the U.S. at 36.88 and 50.25 people per 100,000, respectively, according to the Colorado Department of Public Health & Environment. Envida was in the right place at the right time to help.

Questions to Answer When Addressing Behavioral Health Rides in Rural America

The simple act of a ride to a medical appointment can de-escalate a health crisis, lower anxiety, and ultimately lead to better physical and mental health outcomes. Based on Envida’s experience, there are a number of steps rural agencies might take to address access to care for rural residents who are dealing with behavioral health and substance use disorders.

Who Needs Care? Key stakeholders in both Teller and Park counties were already aware of their burgeoning behavioral health crises. Envida joined existing cross-sector mental health alliance meetings comprised of representatives from police and sheriff, fire and ambulance, schools, behavioral health, local government, public health and healthcare, human service agencies, and more. They learned that transportation services must serve the following:

  • Older adults who are unable to drive themselves long distances to care
  • People with disabilities who may need wheelchair-accessible rides
  • Those who live in areas without any transportation and people whose driver’s license has been suspended/revoked
  • Young people

Young people or students may sound surprising, but they are often left vulnerable when family members depart their communities daily for their jobs. In fact, lack of a trusted adult, pressure to perform well in school, and bullying are leading factors that contribute to youth suicide, according to a 2019 Colorado Health Access Survey.  Crisis Point, a project that examines youth suicide in Colorado, reports that the pandemic, economic downturn, and racial injustices nationally have led to increased anxiety, loss of social connections, and a rise in domestic violence affecting the mental health of youth.

A regular convening of stakeholders is critical to determining who in the rural community needs help.

What Does Assisted Transportation Mean? To address behavioral health needs, Envida found it necessary to redefine assisted transportation. In addition to ensuring its services were ADA-compliant, the agency hired a behavioral health professional who established relationships with rural organizations and agencies, trained drivers, and assisted with individual mobility issues. For example, since cancellations and no-shows are endemic to behavioral health rides, they waste scarce resources in rural areas. It takes a higher level of staff involvement to ensure rides are scheduled correctly and riders follow through.

When Are Services Provided? A behavioral health crisis or even appointment doesn’t always occur neatly within scheduled weekday transit hours. Envida hired drivers from the local area who were flexible and available for delivering rides outside posted hours. For example, one behavioral health rider has regular, late afternoon appointments in Colorado Springs, more than an hour from his mountain home. By the time the driver finishes the route, it is close to 7 p.m.

Where Are They Going? Even without COVID, demand for behavioral health services in rural Colorado outpaces supply; there simply are not enough providers. So Envida accepted rides that went beyond its typical geographic area. Drivers transported individuals from Woodland Park to an in-patient drug and alcohol treatment center nearly 150 miles away. As CEO Gail Nehls often says, “We do the right thing, and we figure it out.”

Why Is Coordination Important? One van, bus, or transportation service alone cannot adequately support a rural region. Volunteer programs, senior transportation, fixed routes, and even first responders must work together. For example, Envida found that police, sheriff, and fire and ambulance services (sometimes known as health service districts in underserved areas) welcomed a transportation partner they could call who would provide a lower-cost ride and free up scarce resources for true emergencies. Consider ALL possibilities in the local area for coordination. Talk with the town hall, churches, schools, social service agencies, service clubs, the rural electric association, and other nontraditional partners to find out who is available to help and how best to maintain ongoing communication. Likewise, find out where people need to go and coordinate with services and organizations at those destinations, e.g., grocery stores, Walmart, banks, and healthcare facilities. They may have ideas for your routes; healthcare providers, in particular, may be interested in contracted transportation services for their patients.

The success stories of working with rural transportation outweigh the challenges. You will discover how creative your solutions can be, which can inform your work in urban and suburban settings and how you reach other populations. It is valuable, life-giving work.


Dave Somers recently joined NADTC as Senior Research Associate, Transportation. He previously served as director of operations and development for Envida, a nonprofit transportation and homecare agency serving an area of nearly 750,000 people in Southern Colorado, where he created and launched rural transportation services.


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