Ride to Care Ambulance Service Capacity Challenges

This story map presents highlights of interview findings about non-emergency medical transportation (NEMT) ambulance capacity challenges affecting the  Ride to Care  benefit program. These are challenges that affect Health Share members who need to use a non-emergency ambulance for transport to and from health care appointments. People need ambulance rides when it's not an emergency if they have to travel in a reclined or prone position and need medical care during the trip. The difference between an emergency (911) use of ambulance and a non-emergency ambulance ride (NEA) is that the condition is not a sudden, unexpected situation that creates a medical crisis requiring emergency medical services and immediate transportation (see  410-136-3000 ).

This story map is a companion summary to the full NEMT ambulance capacity interview findings report (download report here: Ho and Cicolani, 2024 ). The aim of this story map is to support dialogue about ongoing changes to improve the Ride to Care program's ambulance service. The first version was released on April 30, 2024 and was up for three weeks to give people time to fill out a survey at the end. This final version includes feedback interviewed stakeholders provided through the survey at the end. Please share it with colleagues who help make decisions that affect non-emergency or emergency medical transportation.

In the summer of 2023,  Ride Connection  (RC) analysts sought a clearer understanding of barriers to on-time and available ambulance rides in the Ride to Care program that have been happening for a long time but became more prominent during the covid19 shut down of 2020. Ride Connection is the  network manager  and handles administration of member reimbursement and public transit fare distribution in the Ride to Care program. This role includes addressing challenges with capacity in any of the different transportation services, including ambulance service. NEMT involves many decisions from many different actors, each with an understanding of their unique role. Ride Connection analysts conducted interviews in the winter of 2023 to 2024 to gather these different perspectives. Ride Connection analysts asked stakeholders to confirm and expand understanding of challenges in providing non-emergency ambulance rides in the Ride to Care program. Ride Connection analysts conducted confidential interviews of forty four stakeholders from 22 teams, of 21 organizations with expertise in one or more areas of NEMT. Interviewed groups included:

1. "Direct" stakeholders - the people who order, schedule, dispatch, receive, and provide ambulance rides in the Ride to Care program. This includes hospitals, dispatch, ambulance providers, skilled nursing facilities, etc.
2. "Brokerage" stakeholders - representatives from nearby OHP transportation networks that send folks to the tri-county region who may face similar, or different, related challenges.
3. "Government" stakeholders - government agency staff who understand state and local policies that affect ambulance and non emergency transportation
4. "Workforce" stakeholders - people from organizations that train EMTs and Paramedics who work in ambulance transport.
5. "Advocate" stakeholders - Ride Connection analysts were unsuccessful in finding advocacy organizations, or self advocates, that could talk about their experience of delayed or unavailable ambulance rides among the eight organizations we contacted.

This summary shares how many teams brought up an issue out of the total who were asked a specific question about it. The summary focuses in on five of the question areas from the interviews. It also includes feedback from survey responses gathered in the first version of this story map. We heard from thirteen of the original 44 participants; a 29% response rate. We requested that Ride Connection staff not fill out the survey to ensure results were focused on input from colleagues. Ride Connection analysts conducted interviews alongside ongoing ambulance trip data analysis, and a literature scan of strategies used to address ambulance delays in the emergency and non-emergency medical transportation fields, to delve into the issue. This story map includes some related findings from those efforts as well. If you have questions or see glaring errors, please contact tho@rideconnection.org.

This exploration involved talking to people with expertise about NEMT and ambulance service. The data is limited from potential missing information as analysts did not speak to all representatives of all actors in the Ride to Care program's transportation network and related health care facilities. Nonetheless, the information provides a more complete and whole picture of what is happening in NEMT ambulance service than the analyst team, or colleagues at Ride Connection, had prior to the exploration. There may have been misunderstandings or misinterpretations by analysts when interpreting what people said, or among interview participants themselves. Interviewed stakeholders may have prioritized some topics differently than the analysts. The interview data included areas of "information drift" where discussion of one topic unintentionally shifted to another. For example people talking about ambulances but meaning stretcher cars, or talking about Medicaid coverage but meaning Medicare, and so on. Ride Connection analysts recommend pairing this content with additional sources as part of decision making in this field.

Ride to Care is a benefit program that provides non-emergency ambulance service as part of the Medicaid NEMT benefit through the Oregon Health Plan. The Oregon Health Authority receives Medicaid funds, combined with state dollars, to provide medical coverage for individuals who qualify for the Oregon Health Plan, including transport to that care. Medicaid recipients can be low income individuals, children and teens under 19, seniors at or above 65 years of age, or those with disability status. These populations can be considered economically disadvantaged, and they may face systemic inequities in transportation access and other health supports that can lead to negative health effects for these populations (see for example the analysis by  MACPAC, 2021 ). For many years the Ride to Care program, and the Portland tri-county region, has encountered limited ambulance capacity, prompting Health Share of Oregon, CareOregon, and Ride Connection to invest in solutions. The Ride to Care program's service area are members of Health Share of Oregon who live in one of the three counties in the tri-county region. However, patients may still be enrolled in Health Share of Oregon when they move to a neighboring county and continue to receive care from the same coordinated care organization (CCO), and therefore NEMT rides from the Ride to Care program. These are called "out of service area" rides. The map below reveals Ride to Care program non-emergency Basic Life Support ambulance trips from 2022 as displayed in a commissioned report by the Cambridge Consulting Group (2024). All dots outside of the tri-county region, for example those in Salem, Silverton, McMinnville, Newberg,Woodburn, or Vancouver, WA, would be considered out of the service area, although they were still completed trips.

Non emergency ambulance providers must follow multiple levels of policy at the federal, state, and local levels in order to be a licensed ambulance provider and to complete non-emergency ambulance rides. The local policies can also vary from county to county. The table below provides context on intersecting regulations that affect non-emergency ambulance rides provided in the Ride to Care program because we asked stakeholders to share if any of these were related to ambulance capacity challenges. See the  Interview Findings report  for more in-depth description of each policy's language specific to NEMT ambulance service.

Ride Connection analysts identified a number of barriers affecting both emergency and non-emergency ambulance service capacity across the country through conducting a literature scan of interventions to address late and unavailable ambulances. The literature in the scan included news reports, academic literature, and organizational research. Regional differences could make barriers in another state less of an issue in Oregon. Analysts selected a sub-set of areas that came up frequently in the literature as a starting point and put them in a concept map, shown on the left side of slider 1 below. There were many more areas analysts identified in the literature scan, however few of them seemed to be something the Ride to Care program partners could specifically influence, such as inflation or pandemic-related workforce burnout.

Analysts asked stakeholders to share what they agreed or disagreed with, what needed clarifying, and what was missing in the diagram in terms of what was specifically affecting the Ride to Care program's ambulance capacity. Analysts also asked representatives from two NEMT transportation networks in other parts of the state about what was affecting ambulance capacity in their brokerage. Other brokerages send patients to the tri-county region for care and may have intersecting challenges. Additionally, analysts asked a separate, related question about barriers to on-time ambulance rides to see where there was overlap and unique challenges with delays. The right side of slider 1 indicates the changes analysts made to the diagram based on interview feedback.

Most stakeholders (15 of 20 interviewed teams) agreed that Ride to Care program ambulance capacity is affected by a limited number of ambulance providers and ambulances vehicles, as well as needing more qualified people to staff them. Ambulance service on the emergency medical side has been suffering from a paramedic shortage that is regularly featured in the news, and appears to be a nationwide issue (see for example the NAEMT 2023 National Survey ). Echoing capacity challenges, eight of thirteen interviewed teams described a limited number of ambulance providers, a limited number of vehicles with specialized equipment, and not enough vehicle drivers as contributing to ambulance trip delays. Three teams brought up that there are not enough bariatric ambulance vehicles specifically. Bariatric is a term to describe medical care for people experiencing obesity. Bariatric ambulance vehicles include a gurney that can hold over 700 lbs and body width beyond a 36 inch wheelchair, as well as other necessary equipment to transfer members in and out of the vehicle, and a higher level of staffing.

Of the fourteen teams who spoke about ambulance delays, eight felt that limited capacity in the region contributes to ambulance trip delays, even in the Ride to Care program. There were also mixed views about elements of the diagram, including whether or not the Ride to Care program's transportation provider network is facing actual ambulance capacity limits and how policy affects ambulance capacity, as the quotes below indicate.

Below is an outlined summary of the main areas people described being in agreement with in the diagram above shown in slider 1. Participants described clarifications in their discussions.

Policy– Eleven of twenty teams brought up that policy confusion adds either effort or costs that affect ambulance capacity for providers. Beyond this, there were specific areas of policy that emerged.

• State policy - Four of twenty teams specifically named fee for service vs brokerage rules in NEMT​ as confusing. In Oregon, there are two primary types of NEMT transportation networks. Fee for service network (FFS), also called "open card" brokerages are those that are in contract directly with the Oregon Health Authority when Oregon Health Plan members are not yet connected to a CCO. Coordinated care organizations also contract with transportation network brokerages to complete NEMT. The Ride to Care program is a unique structure where the CCO, Health Share of Oregon, delegated management and provision of NEMT to CareOregon. CareOregon deviated from the traditional and historical structure of a single brokerage entity responsible for managing NEMT medicaid benefit programs. CareOregon contracted with Ride Connection, ComTrans, and Transdev, to form a collaborative framework that prioritized partnership and operational expertise. Ride Connection is contracted for transportation network management and administration of member reimbursement and public transit fare distribution. The two additional partners, ComTrans and Transdev, are contracted with CareOregon to provide dispatch, scheduling (same day and future) of all types of NEMT services and rides. CareOregon retains oversight of the Ride to Care program related to Health Share of Oregon's Medicaid and Oregon Health Plan regulatory obligations. All four partner entities collaborate to share decision making on NEMT benefit services and operations beyond each partner's contracted role. Ambulance providers who work with the Ride to Care program may also have contracts with other brokerages, with hospitals, and other organizations that need ambulance service. These providers have to keep track of which regulations they follow for which transport, in which areas, as part of their overall service and business model, as described below.

The next quote illustrates how state policy, this time on the EMS ambulance licensing side, can intersect with county policies leading to confusion.

• County policy – Ten of twenty interviewed teams brought up county-level policies, with specific confusion on two sub-areas. ​Note that in Oregon, the ambulance provider must follow the county rules of where the ride originates instead of where the ride ends or the various counties a provider travels through before arriving at their destination. Counties may update their ambulance rules every five years, so a provider also has to keep track of new changes.
  • Stretcher cars - Stretcher cars are vehicles that can transport a client in a prone or supine position without medical personnel (Emergency Medical Responder [EMR], Emergency Medical Technician [EMT], Paramedic, etc.) providing medical care or observation. Some counties in Oregon allow stretcher car use for transporting patients in NEMT. Some counties restrict stretcher car use and other counties prohibit their use completely. Teams brought up that in counties where stretcher cars are prohibited, providers are required to provide an ambulance and therefore a higher level of medical care than in a county where stretcher cars are allowed. Some participants expressed that ambulance services should be reserved for those who absolutely need them because they are a limited resource. The perspective is that when a person is lacking the capacity to sit up and otherwise does not need medical monitoring or intervention, they are better served by a stretcher car.
  • Exclusive, or closed, Ambulance Service Areas -In neighboring counties to the tri-county region, closed ambulance service areas (ASAs) emerged as a potential second county-level policy barrier to ambulance capacity. An ASA is a geographic area that a county designates as being served by one or more ambulance providers as part of an Ambulance Service Area Plan (ASA Plan). An ASA Plan is required by the state for establishing a county-level emergency medical services system (see  OAR 333-260  and  OHA FAQ ). Sometimes counties give an EMS provider the first right of refusal, or an exclusive contract, to provide both emergency and non-emergency transportation inside the ASA (such as  Marion County ). In these counties, other ambulance providers cannot provide those rides. Some counties don't choose to regulate non-emergency ambulance provision beyond the trips the EMS provider is given access to in an ASA franchise agreement (for example Yamhill county ). In a county using a right of first refusal, an NEMT provider who is not assigned an ASA has to ask the EMS provider if they can provide the non-emergency ride. Contracted EMS providers have to prioritize their 911 contractual obligations first, before they can address NEMT rides.

• City policy – Three of twenty teams brought up that City of Portland licensing requirements of stretcher cars, wheelchairs, and/or driving age for drivers of NEMT vehicles as affecting ambulance capacity because some providers do all 3 types of modes​. Efforts in one service area may affect efforts in another within one vendor.
• Ambulance & Workforce Capacity - Ten of twenty stakeholder teams agreed that Ride to Care's transportation network needs a bigger workforce and more ambulances. A few stakeholders disagreed either because they weren't sure if it was staffing related or because they felt Ride to Care was fine and it's the region that's experiencing the challenge.

• Communication challenges – Nine of twenty stakeholder teams confirmed that manual data entry in trip tracking software can lead to inadequate communication or miscommunication. Teams also brought up related miscommunication elements such as broad ETAs or lack of communication about changes of plans related to unavailable ambulances.

Stakeholders also shared that there were two areas missing from the diagram, describe next. The first one analysts recognized as an issue but didn't think it was an area the Ride to Care program partners could influence, and the other may be unique to Oregon and the region's medical infrastructure context.

• Financial Limitations: Regulation-related service costs - Eleven of twenty interviewed teams shared that the diagram's biggest gap is that reimbursement for ambulance rides has been, and continues to be, inadequate. Stakeholders emphasized that Medicaid and other payers have not covered the costs of ambulance services in the past, contributing to the low number of NEMT ambulance providers in the region and in the Ride to Care program. Both hospitals and ambulance providers face difficult choices of providing services that may not be compensated by various health insurance payers. The region’s medical facilities, hospitals, clinics, and brokerages are also competing for a set of limited ambulance providers.

Low Medicaid reimbursement is part of a larger issue of insufficient funding generally of public services that the recent COVID pandemic made more visible (see  TFAH 2022 ,  Weber et al., 2020 ;  Orr et al.,2023 ). The EMS literature highlights this when considering the inadequate funding of emergency medical services. For example, a 2023 survey of Medicaid reimbursement rates from the American Ambulance Association revealed that the average Medicaid base-rate reimbursement for an emergency advanced life support (ALSE) response is $232.72, which is 9.9% of the average cost of service and 43.7% below the Medicare Fee Schedule ( NAEMT, 2023 ). One provider analysts interviewed shared that most of the people they serve are on Medicare, which may be why Medicaid rates are compared to Medicare rates. State Medicaid programs have different levels of reimbursement because each state program is administered differently.

Bunched Discharges - Six out of twenty interviewed teams also explained that a factor that affects ambulance capacity is the demand mismatch with supply. Among the fourteen teams that were also asked about barriers to on-time ambulances, five felt that peak hours where the region's and hospitals simultaneously discharge patients contributes to late ambulances. One team described this situation as creating temporary ambulance scarcity and a need for "controlled capacity." Stakeholders gave a range of times that they view as the "peak" time where many discharges happen simultaneously: 1pm, 11 am to 2pm, 2pm to 4pm and 11am to 5 pm.

Stakeholder perspectives on bunched discharges in the middle of the day matches data analysis of Basic Life Support (BLS) ambulance trips from Ride to Care's 2022 trip data. In image 2 below consultants found that for 2022 the Ride to Care program would have needed between two and three dedicated ambulance units for these specific trips to meet demand. Ride to Care currently has three dedicated units which were hired in the fall of 2023 based in part on this data analysis. What isn't taken into account by the heat map is that the four ambulance transportation providers serving the Ride to Care program have other contracts and are meeting regional need at the same time that they are addressing the Ride to Care program's trip demand. While the three dedicated ambulance units can address some of the demand for the Ride to Care program among the four providers currently serving the network, there may be additional rides during the peak hours that would require even more units than were encompassed by the 2022 analysis. Ride to Care partners do not have data on the entire region's NEMT demand to have a better sense of how many ambulances would be needed to address regional ambulance capacity.

This situation may be unique to the region and state. There are only 65 licensed hospitals in all of Oregon. Thirty-seven of them have a general acute care license where unless they receive a waiver they are required to provide emergency, maternity, and surgical services (see OHA information under "Fiscal and Economic Impact" of OAR Proposed Rules ). Oregon is ranked nearly last in the nation, 49th, for the per capita number of acute care beds with only 1.66 hospital beds for every 1,000 people ( Templeton, 2024  and  Health Forum, LLC, 2022 ). If patient need increases for acute care then more people have to be served without additional bed capacity. This means that hospitals face volume pressure to both provide care and to discharge people when they are medically ready. Three of twenty interviewed teams brought up limited acute care bed resources as a component of limited ambulance capacity.

Patient readiness and broad estimated times of arrival - Coordination of patient readiness at pick up and drop off affects ambulance timeliness. Ambulance timeliness also affects how hospitals plan to ready patients to arrive or depart. When communication falters on either end, both may contribute to ambulance delays.

Five of fourteen teams who spoke to barriers to on time ambulance rides brought up that communication about payer coverage, miscommunication about the necessary level of care, and missed notes on needed equipment can result in delays. If hospitals don't receive updates on trip delay notifications or case managers don't communicate further in advance, both can result in ambulance delays. Image 3 below walks through a cycle of how communication on either patient readiness end or transportation provider broad estimated time of arrival end can feed into each other.

Analysts spoke with two representatives from schools that train EMTs and Paramedics as part of understanding why there is a lack of adequate staffing for ambulances - whether that's for the emergency or non-emergency medical services. Participants gave a range of reasons. We provide the two areas that they emerged in both interviews. Both teams agreed that ensuring students gain necessary clinical practice is a limitation because hospitals (which Oregon does not have many of) do not have capacity.

A second challenge, affecting retention, are workforce environment conditions. For EMTs and Paramedics in NEMT, people want to use and maintain a skillset they were trained in and they may not stay in an position where they don't use their skills. One interview participant mentioned this can be a challenge when hospitals hire EMTs to fill the role of medical assistants - the training and investment is different and the skillsets do not match.

Additional environment conditions include low pay, burnout, exposure to trauma, low company investment, work hours being a mismatch with the life people want to have (e.g. "bad" hours), and an expectation that these are short-term positions.

In addition to the already vulnerable population the Ride to Care program serves, there is a sub population of individuals whom experience the negative impacts of this ambulance issue more acutely. Below are the main groupings of factors listed in order of most frequent mentioned by stakeholders. The first two were named by seven of sixteen interviewed teams and areas three through five were named by three to four teams each. The last two reasons were named by one team each.

1. People with specialized needs, or who need special skill medical services such as people who need a bariatric ambulance, the use of chair stairs, people who are on ventilators, children who are moved in special equipment such as those involved in neonatal intensive care units (NICU).
2. People with time sensitive appointments such as surgery, checking into a skilled nursing facility, returning home from hospice.
3. People who live in rural areas or are out of the Ride to Care program's service area
4. Anyone needing an acute care bed
5. People who experience social isolation
6. Additional reasons included people who have multiple payers or who need care management advocacy because they face multiple determinant of health barriers.

Analysts asked all twenty two teams what efforts are already underway to address ambulance capacity challenges, including workforce development, in the region, or in the Ride to Care program. It was apparent in responses that people care deeply about this challenge and most are engaged in efforts to address a component of ambulance capacity they could directly influence. Below are the most frequently mentioned categories of efforts. See the  full report  for more detail.

Resource adjustments - Eight teams described organizations making resource adjustments. Five teams described expanding resources to support more ambulance capacity. For example, purchasing or needing to purchase more ambulances, acquiring specialty equipment such as a ventilator, investing in communication and staff for coordinating NEMT or seeking more ambulance vendors to bring to the region. Ride Connection had already brought on two dedicated ambulance units as well as worked with Ride to Care program partners to develop and implement different communication methods while analysts were completing interviews. Seven teams described hospitals or brokerages hiring dedicated ambulance vehicles for their specific use. While hiring dedicated ambulances supports the specific hospital or brokerage using them, it may lower regional capacity.

Increased Communication, Collaboration and Planning - Seven teams brought up different approaches to address ambulance delays. Examples include increased communication for aligning scheduling and timing of trips, internal process planning, collaboration among different agency teams to improve both NEMT efforts and EMS efforts related to efficiencies.

Proposed or Completed Policy Changes - Ten of twenty-two teams described advocating for, or already making policy changes to address limited ambulance capacity or workforce development. Government agency staff spoke about policies that affect both the EMS and NEMT sides such as state regulations to support more paramedics see  333-265-0027  and  OHA FAQ.  

Programs - Seven teams described workforce development programs, usually led by ambulance provider companies. Three teams brought forward pilot programs or testing out new procedures.

An overarching theme that emerged across interviews is that no one organization knows, or can change, ambulance capacity alone. One stakeholder described Non-Emergency Medical Transportation as a specialized sector between two major disparate commercial (e.g. for profit) and public (e.g. not for profit / publicly funded) sectors. Beyond these two sectors, non-emergency ambulance provision has less transparency because it is adding in the impact of policy focused on an emergency response system applied to non-emergency scenarios (see Ho and Cicolani, 2024).  Shifts in the system will require multiple efforts over time by multiple actors. It was also apparent that the emergency medical service is interconnected with the non-emergency medical ambulance service and they influence each other, as the image below reveals. Communicating and sharing information will benefit both sides.

The following set of short term and long term recommendations are based on interview findings, an initial literature scan of interventions to address ambulance capacity, and recommendations from a commissioned analysis of Ride to Care's 2022 ambulance data. The lists are not exhaustive. In this version of the story map we've included additional columns to indicate results from survey responses that provided feedback on the April 30th working draft version of this story map. Out of the forty-four interviewed participants, thirteen filled out the survey (29% response rate). The thirteen respondents included representation from all four ambulance providers in the Ride to Care program, three hospital system staff members, one educational facility representative, one public agency staff member, one neighboring brokerage representative, and from Ride to Care program decision making partners other than Ride Connection (we requested that Ride Connection staff and leadership *not* fill out the survey), see Ho and Cicolani, 2024.

In the table below, the fourth column includes survey responses to the question “Imagine we could only do four of the proposed short-term strategies. Please choose which four you think would best address the multiple limits on ambulance capacity described in interviews with stakeholders.” See the source  interview findings document  for more information.

The first set of short term strategies involves continuing efforts Ride Connection has been taking by hiring additional direct service for the network from the four existing ambulance service providers. Whether that's a competitive bid for additional units, a contract with a provider to focus in on trips that other providers are having challenges addressing such as out of area, trips that are for the same day called "ready now" which is to arrive as soon as possible for pick up, or bariatric trips. A third idea would be for Ride Connection to purchase additional ambulances that could be leased to the network, assuming that providers had sufficient staff to fill them. The first two strategies would potentially reduce regional capacity because all providers are working for multiple brokerages and contracts. The third strategy is uncertain because analysts don't know if the existing vendors would feel comfortable leasing a vehicle for NEMT ambulance service.

The second set of short term strategies in table 4 involve larger scale efforts that could address both ambulance capacity within Ride to Care and the region. The first one would be for Ride Connection in its role as network manager to launch a non-profit ambulance organization to increase capacity in the region. Based on a commissioned report, Cambridge Consulting group considered this potentially not financially sustainable. Stakeholders noted that one of the challenges is managing bunched hospital discharges that occur in the middle of the day. One interviewed transportation provider explained that the challenge of bunched discharges needs more communication support, more staffed vehicles may not adequately address it. The fifth short term strategy originates in the EMS literature where community paramedicine programs have supported efficiency in use of ambulance and related emergency medical services. Analysts would need a better understanding of Ride to Care's existing ambulance service clientele to determine what proportion of patient's care needs would have been addressed by a home visit, instead of a trip to a health care facility. NEMT is in the business of non-emergency medical transportation, not medical care, so this may be considered beyond the scope of Ride to Care's current efforts.

Two short term communication strategies that could address bunched discharges are presented in table 5. The first is a broad category as stakeholders shared various methods that teams are already working to address this from a hospital or ambulance provider perspective. Ride Connection partners have been working on communication strategies already to improve real time updates for hospitals. Both strategies would support managing existing capacity, neither would added physical new staffed ambulances to the network or region.

In the follow up survey we also asked people to rank the short term strategies based on which ones we should do first. The next table displays the strategies in order of where the averaged rankings. The three most immediate efforts include technological communication strategies, dedicated ambulance service contracts during peak hours, and expanding live chat threads with more hospitals for improved communication and trip planning. Ride to Care partners have been working on these strategies already in 2023 and will continue to expand on these efforts.  

A handful of issues are beyond the Ride to Care program partner's direct level of decision making because they involved regulations. If these are pursued the efforts would need to come from a coalition of actors collaborating together. Table 6 describes policy advocacy, table 7 covers related research and table 8 involves supporting collaborative work as well as workforce development in the region.

The first long term policy strategy in table 6 is focused on understanding the feasibility of Oregon revising its Medicaid reimbursement formula to increase ambulance rates for rides. Because Medicaid covers many different services beyond transportation to that health care, it's unclear how changes in the formula for a finite set of funds would affect other programming. It would be important to not negatively affect OHP member health further than ambulance delays potentially do. The second strategy is focused on increased funding for Emergency Medical Services in Oregon as part of being an essential service. While this indirectly affects NEMT, this exploration made it clear that NEMT and EMS are linked in multiple ways and capacity on one can affect the other. Policy strategy three is focused around understanding how to best support EMS providers in each county through exclusive contracts without creating a barrier to NEMT ambulance provision. The fourth policy strategy in table is related to reducing confusion transportation providers shared about variations across fee for service and CCO brokerages in how the state administers the OHP NEMT benefit.

Table 7 suggests researching how providing NEMT through the use of stretcher cars in counties across the state is related to health outcomes versus using ambulance trips in counties that require them for similar health conditions and circumstances. This would require access to data sets that are beyond Ride to Care's purview. Related to this is looking at how ambulances are required to be licensed as though they are all going to perform emergency medical services, rather than NEMT services. It's not clear if other states in the nation all apply the same EMS protocols to NEMT or if there are ways to support NEMT ambulances while maintaining adequate medical care during transport.

Table eight focuses on two different collaborative strategies. Strategy seven is around requests of agency staff at the state and county levels to revisit stretcher car use from the perspective of limited ambulance capacity. It may be that policies do not need changing, their interpretation needs further guidance. Strategy eight would build on existing transportation provider efforts to increase EMTs and Paramedics in the region through a collaborative grant or other initiative.

When asked to rank the long term strategies for the ones people would be most willing to work on in a coalition, the results were similar as how the priorities emerged in the tables above.  The two areas are Medicaid/OHP ambulance reimbursement funding and better alignment between CCO and FFS rules for ambulance service. The next two are workforce development and better funding for the EMS system. The grouping of strategies related to investigating how stretcher car use may be related to better, or worse, health outcomes as compared to ambulance service participants were third, see the table below.

As described in the  findings report , this set of strategies is limited to ones analysts felt most matched what came up frequently in interview findings and/or are connected to interventions that emerged in the literature scan. Many behavioral intervention strategies are not included here. Ride Connection leadership will work with Ride to Care program partners to consider the feedback shared here as part of the decision making process for next steps on short-term and long-term strategies.

Thank you for your time, attention, care and expertise.