Access to transportation can present major obstacles in providing optimum continuity in rural practices. Not only must patients find a way to get to their initial visit, but they must also negotiate repeat visits for follow-up laboratory work, X-rays, etc. In addition, scheduling clinic visits to coincide with orders for fasting laboratory or other tests can present further dilemmas.

Residents of rural areas who are elderly, poor, or have handicaps have even more of a disadvantage than their urban and suburban counterparts. For instance, poor residents of urban and suburban areas can reach clinics through a combination of public transportation and walking. An urban resident with a handicap can often find accommodation on public transportation equipped with special devices. This is not an option for rural residents with handicaps, or who do not have their own transportation or support from family or friends. These patients are truly homebound.

Transportation = Better Health

One 2005 study1 examined the relationship between transportation availability in rural North Carolina and access to healthcare, using a sample of 1,059 households in the area. The researchers found that patients who owned their own vehicles had 2.29 more chronic care visits per year compared to individuals who did not own vehicles. Patients who had family or friends who could drive them to clinic visits had 1.58 more completed appointments per year compared to respondents who lacked such support.

This study resonates in my own daily practice and supports my own experiences. After the initial physical examination and testing of one male patient, I became suspicious of a possible hepatic mass. I wanted him to return for additional laboratory tests to clarify my findings before referring him to gastroenterology. Unfortunately, this patient was wheelchair-bound, had chronic pain from severe spinal stenosis, and lived in a very rural area without family or neighbor support. The closest magnetic resonance imaging facility was located in a neighboring state, which was a 380-mile ride (one-way) via government van. Because of chronic pain, this patient would have never been able to tolerate such a long trip. His situation posed a referral dilemma for which I could find no immediate solution.

A second male patient was recently hospitalized for severe gastrointestinal bleeding. He could not obtain transportation to the clinic for follow-up hemoglobin and hematocrit tests, and he did not qualify for nursing homebound services.

Calling On Volunteers

In both situations, I was eventually able to make community connections with local volunteer organizations. A local Meals on Wheels driver offered to drive the first patient to the clinic.The local grange organization provided my second patient with transportation to his visit. By tapping into the volunteer potential of existing local services, NPs can initiate transportation assistance. In a rural practice, NPs may also need to combine clinic visits with other supplemental testing to maximize access to services.

Nurse practitioners in rural areas must make every effort to meet the needs of patients and deliver a satisfactory standard of care. Sometimes, transportation needs for patients in underserved rural areas can only be met by the creative means of the NPs who provide healthcare to them.

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