1. Implementation of an Advanced Connected Transportation Network (ACTiN), a novel, collaborative multinetwork transportation model for small cities and rural areas.
2. Evaluation of effectiveness in improving transportation assets for clients of a community-based nonprofit specializing in addressing social determinants of health (Lighthouse Community Health Services in Lynchburg, VA).
3. Simultaneous evaluation of wellness metrics based on the standards of the CMS Annual Wellness Visit and metrics associated with common chronic diseases.

1. Implementation of a community transportation solution The project will be managed by Unified Potential, Inc., a 501c3 tax-exempt organization for transportation.

   • The solution requires implementation of four separate transportation "networks"
   • Public / Contracted / For-Hire Transportation
   • Workforce Transportation Network
   • Community Rideshare Network
   • Volunteer Transportation Network

2. Assessment of Personal Transportation Assets

   • Subjects asked to complete a survey upon intake, at six months, and at one year
   • Digital survey:
   • Can be completed by individual using provided smartphone app or at onsite desktop kiosk
   • Can be facilitated by a caregiver or other provider not involved in data analysis

3. Assessment of health and wellness metrics and chronic disease metrics if applicable

   • Dataset based on metrics assessed in the Center for Medicare and Medicaid Services (CMS) Annual Wellness Visit
   • All metrics quantified via either binary (yes/no) or through use of a validated scale (see below)
   • Data collected electronically at onsite or in-home provider visits at intake, six months, and one year

Inclusion Criteria:

• Adult resident of the City of Lynchburg, Virginia
• Under-resourced at trial entry as defined by meeting eligibility for welfare, food stamps/SNAP, Medicaid, Housing Choice Voucher program, or income at or below 200% of the Federal Poverty Threshold.

Exclusion Criteria:

• None

Deidentified data from all three datasets

Available July 2024 (2 years)

Government entity; Healthcare system