Department of Veterans Affairs’ Transportation System: Stakeholder Perspectives on the Current and Future System, Including Electric Autonomous Ride-Sharing Services

Abstract

The Department of Veterans Affairs’ (VA’s) transportation system plays an important role in ensuring access to transportation services for veterans, particularly those in rural or underserved areas. However, concerns remain regarding the effectiveness of collaboration among the various VA transportation stakeholders. Persistent transportation challenges hinder veterans’ access to essential healthcare services and resources. Electric autonomous ride-sharing services (ARSSs) offer a promising opportunity to enhance transportation access; however, their current limitations and the perspectives of VA transportation personnel must be considered. This study explored the current perspectives of the VA transportation system and assessed ARSSs as an innovative and sustainable alternative through interviews with eight VA transportation stakeholders representing seven transportation sectors. Our findings revealed the VA’s strengths, including personalized service, flexible accommodations, and collaborative care models, but also identified challenges, including limited funding, staff shortages, volunteer constraints, and restrictive eligibility criteria. The introduction of ARSSs was identified as an opportunity to alleviate some of these constraints by reallocating human resources and improving access to essential services, although concerns remain regarding ARSSs’ ability to accommodate veterans with disabilities and address rural route complexities. Effective communication strategies and streamlined coordination were key recommendations for improving service delivery and expanding transportation access for veterans.

1. Introduction

VA transportation services are available to approximately 9 million veterans who are enrolled in the VA healthcare system and require transportation assistance to attend medical appointments at VA facilities or authorized non-VA healthcare providers [1]. The Veterans Transportation Program (VTP) comprises multiple stakeholders, including the Veterans Health Administration (VHA), which offers shuttle services and travel vouchers, and the Veterans Transportation Service (VTS), which assists in scheduling transportation and coordinating specialized services, such as wheelchair-accessible vehicles [2]. Additional programs, such as the Beneficiary Travel Program, reimburse travel expenses, while the Highly Rural Transportation Grants fund initiatives for veterans in remote areas [3]. The Office of Rural Health (ORH) and Veterans Service Organizations (VSOs) support access through telehealth services and partnerships with local transportation providers [4]. However, challenges remain, including limited availability, regional disparities, and funding constraints, with VHA medical transportation expenses reaching USD 750 million in FY 2010 [5,6]. Challenges in coordination among stakeholders may result in missed appointments and unreliable services, particularly for rural veterans or those with disabilities [7]. Addressing these barriers requires policy interventions, enhanced resource allocation, and improved collaboration to ensure equitable transportation access and better healthcare outcomes for veterans.

The integration of ARSSs within the veterans’ transportation system presents promising future opportunities. Autonomous ride-sharing services are defined as shared transportation services that utilize self-driving vehicles operating at the Society of Automotive Engineers (SAE) Level 4, i.e., capable of performing all driving functions within specific operational design domains without human intervention [8]. While electrification is common, it is not a required feature of ARSSs, and vehicles may be electric or gasoline-powered depending on the deployment context. Autonomous ride-sharing services offer the potential to enhance the flexibility, efficiency, and cost-effectiveness of ARSS platforms [9], which may help to overcome geographical barriers, reduce transportation costs, and provide veterans with greater autonomy and convenience in scheduling their travel to VA facilities and community-based services. More specifically, veterans residing in rural or underserved areas with limited public transportation options could benefit from ARSS by gaining access to reliable transportation services when traditional options are scarce. Additionally, such services have the potential to reduce transportation costs for veterans, particularly those facing financial constraints, by offering competitive pricing and eliminating the need for vehicle ownership and maintenance [10]. Moreover, ARSS platforms may provide veterans with greater autonomy and convenience in scheduling their travel to VA facilities and community-based services, allowing for personalized transportation solutions tailored to their specific needs and preferences.

Despite these potential benefits, several drawbacks and limitations of ARSS technology currently exist. First, while these platforms offer convenient and flexible transportation options, they may not yet be suitable for all veterans, particularly those with special mobility needs or disabilities. Veterans with mobility impairments may require specialized vehicles equipped with wheelchair ramps or other accessibility features, which may not be readily available through ARSS providers [11]. Second, the reliability and availability of ARSSs are currently limited due to the technology being in the development and testing phases. Such services are currently operating on fixed routes with restricted speed limits, typically at 10 mph [12,13]. As such, the availability of ARSSs may be limited to specific areas and times, with service disruptions and delays possible due to technical challenges and testing limitations. In rural or remote areas, ARSSs may be particularly challenging, as the technology is still being refined and tested in more urbanized environments [14]. Factors, such as weather conditions and road infrastructure, may further impact the reliability of ARSS [12,13]. Additionally, concerns about data privacy and security may arise with the use of these platforms, as personal information, such as pickup and drop-off locations, is often shared with third-party companies [14].

Given these limitations, a key question remains, namely “how feasible and appropriate is the integration of ARSSs into the VA’s transportation system?” While automation is increasingly prioritized in public and private mobility initiatives, there is a lack of research examining its alignment with the unique needs and operational constraints of federal veteran transportation services. Although the VA has made substantial investments in its transportation infrastructure, traditional models struggle to meet the evolving needs of a geographically dispersed and demographically diverse veteran population. Existing systems are often inflexible, resource-intensive, and limited in scope, particularly in rural or underserved areas where access to care remains a persistent barrier. Autonomous ride-sharing services may offer a novel, technology-driven opportunity to reimagine how veterans access care, but their implementation must be informed by real-world insights from those who manage, deliver, and coordinate VA transportation.

The purpose of this study is to identify and understand the VA transportation system’s strengths and weaknesses and explore the potential of ARSS as an innovative transportation alternative for veterans. This study is the first to assess the potential feasibility and perceived value of ARSS within the VA transportation system and applies a socioecological framework to organize and interpret stakeholder perspectives. By capturing the insights of VA transportation planners, service coordinators, and operational staff, this research provides early-stage evidence that may inform policy decisions, demonstration projects, and resource allocation aimed at enhancing veterans’ access to transportation and the VA healthcare system.

2. Methods

2.1. Ethics

The study obtained approval from the University of Florida’s Institutional Review Board (UF IRB-01), the North Florida/South Georgia Veterans Affairs Human Research Protection Office, and the ORH. The study was conducted as part of a VA ORH grant submission for FY23-24 (IRB#: 202202386; Title: Benefits of Autonomous Ride Sharing Services for Florida Veterans). All participants provided their consent by signing IRB- and VA-approved documentation, including the informed consent form (ICF), indicating their agreement to participate in the study.

2.2. Study Design

This study used a basic qualitative research design, also referred to as a generic qualitative approach [15], to explore how VA transportation personnel interpret and give meaning to their experiences related to service delivery and innovation. Unlike phenomenology, which seeks to capture the essence of lived experience, or grounded theory, which aims to build theory from data, a basic qualitative approach focuses on descriptive and interpretive understanding without being limited by the philosophical assumptions of traditional qualitative methodologies.

This methodology was chosen because the study’s objective was not to generate theory or examine deeply personal experiences, but to understand stakeholder perspectives within the organizational context of the VA. Its flexibility made it particularly well-suited to examining the feasibility and perceived value of ARSSs—a relatively new and under-explored area within the VA transportation system [16]. In this study, the approach was applied through semi-structured interviews with key internal stakeholders, followed by thematic analysis to identify recurring patterns across the data. This allowed the research team to derive insights grounded in participants’ own language and experiences, while maintaining analytical rigor without the constraints of more traditional qualitative methodologies.

2.3. Participants

To gain a broader understanding of VA transportation services, this study interviewed a diverse group of stakeholders, including those in leadership, service providers, and representatives from key programs. Leadership provided insights into strategic planning, budgeting, and policy implementation, while service providers shared perspectives on daily operations. Participants included representatives from the VTP, VTS, Facilities Management—Transportation, ORH, and Highly Rural Transportation Grants, offering perspectives on policies, budgeting, strategies, coordination of services and rural transportation efforts. A VSO representative provided insights into veterans’ experiences, access barriers, and operational challenges, while a Veteran Experience Officer contributed insights on stakeholder communication and veteran satisfaction.

Participants were recruited through purposeful and snowball sampling, leveraging recommendations from key leaders within the ORH, to identify individuals with valuable insights into VA transportation services [17,18,19]. A community-based recruitment strategy involved connectors—trusted individuals who spread awareness—and champions, influential figures passionate about the research topic [20,21]. The eligibility criteria required participants to be actively involved in VA transportation services, to be proficient in English, and to have access to a secure Internet connection for Microsoft Teams videoconferencing. Those with less than one year of experience were excluded due to limited knowledge.

2.4. Procedure

The research team screened participants via phone or email using a predetermined script to explain the study, interview procedures, eligibility criteria, time commitments, and contact information. Eligible participants received the ICF and a demographic questionnaire by mail. After returning the ICF, they were contacted to schedule their interview via Microsoft Teams. Participants received instructions on accessing Microsoft Teams, and those unfamiliar with the platform were offered a brief training session to ensure ease of use [22]. The research team developed a semi-structured interview guide based on the strengths, weaknesses, opportunities, and threats (SWOT) framework [23] to identify key factors affecting veterans’ transportation services and the role of ARSS.

The semi-structured interviews were conducted online using VA HIPAA-compliant Microsoft Teams [24]. Online interviews provided scheduling flexibility, convenience, and access to a broader participant pool [25]. Microsoft Teams ensures data security through multifactor authentication and encryption, making it suitable for VA research. Each interview, lasting 30–60 min, was conducted from a VA office in Gainesville, FL. Sessions began with a brief period for technical adjustments before the interviewer formally welcomed the participant and proceeded with the interview. Questions focused on service effectiveness, COVID-19-related barriers, and ARSS opportunities and challenges. A qualitative expert reviewed and refined the guide. Interviews began with an overview of the study, followed by predetermined prompts that allowed for open discussion [26]. At the end of each session, participants were given the opportunity to share additional insights, and they were thanked for their time.

2.5. Strengths, Weaknesses, Opportunities, and Threats (SWOT) as a Framework

The SWOT analysis, a strategic planning tool used to assess organizational strengths, weaknesses, opportunities, and threats, has been widely applied in various fields, including transportation [23,27]. While this study did not conduct a formal SWOT analysis, the research team used it as a framework to develop the semi-structured interview guide. This ensured a structured yet flexible exploration of transportation services for veterans. Strengths and weaknesses focused on internal factors, such as resources and organizational capabilities, while opportunities and threats addressed external influences specifically related to ARSSs. This approach, while structured by the SWOT framework, maintained the inductive principles inherent in the generic qualitative methodology.

2.6. Data Collection and Data Management

Each interview was audio-recorded using the VA Microsoft Teams functions. Upon completion of each interview, Microsoft Teams automatically transcribed the recording using Microsoft’s speech-to-text technology. Subsequently, the research team promptly initiated the review process of the transcript for accuracy and completeness, cross-checking it against the recording. Transcript accuracy took place concurrently with data collection to ensure early detection and correction of any inaccuracies. The research team took several steps to ensure the security and confidentiality of the data collected from participants. Specifically, participant responses to ICFs, demographic questionnaires, and interview recordings were stored in password-protected systems or locked cabinets in a secured VA research office in compliance with the VA and the University’s information security policies. Additionally, the interview data used for analysis were deidentified to protect the privacy of the participants. Only certain project team members indicated on the IRB had access to the deidentified data for analysis purposes. This ensured that the data were only used for the intended research purposes and that the confidentiality of the participants was maintained throughout the research process.

2.7. Data Analysis

The demographic questionnaire was analyzed using descriptive statistics via RStudio using R 4.3.1 [28]. The semi-structured interviews were recorded, transcribed verbatim, and deidentified for confidentiality. Transcripts were reviewed for accuracy before being analyzed using NVivo software version 12 [29]. Two research team members conducted a thematic analysis by allowing categories to emerge inductively from the data [30,31]. The analysis process involved repeated reading for immersion, coding key concepts, and categorizing codes into meaningful groups, typically between 10 and 15 clusters [32]. Coders collaborated to refine the coding scheme, and disagreements were resolved with input from a third researcher.

Findings were structured using the socioecological model to explore transportation challenges across individual, relational, community, and societal levels. Initial coding was conducted inductively, allowing themes to emerge directly from the data, while the socioecological model was applied in the later stages to structure and interpret those emergent themes. This framework was used analytically rather than prescriptively, supporting thematic organization without constraining the inductive process. To ensure rigor and trustworthiness, investigator triangulation enhanced credibility by verifying participants’ original perspectives through regular discussions on coding, themes, and interpretations [33,34]. An audit trail documented key research decisions, supporting confirmability and transparency throughout data collection, analysis, and reporting [35].

3. Results

3.1. Demographics

Eight participants completed the semi-structured interviews, aged between 35 and 56, with 63% being men and 75% identifying as White. All participants were full-time VA employees, with varying levels of experience within the VA transportation system. Half of the participants had 1–5 years of experience, one had 6–10 years, and four had over 10 years of experience. Participants were from diverse locations including Florida, Georgia, New York, and Wyoming, though the majority (five out of eight) were from Florida. Their roles within the transportation system included being a director, analyst, manager, specialist, chief, assistant chief, and coordinator, with expertise in administrative, planning, funding, logistics, operations, and mapping solutions. The participants represented various transportation sectors and departments, such as VTP, VTS, Facilities Management—Transportation, ORH, Highly Rural Transportation Grants, Volunteer Transportation Services, and Patient Services.

3.2. Semi-Structured Interview Data

Table 1. Main qualitative themes and subthemes and respective operational definitions.

Themes/Subthemes	Operational Definitions of Themes and Subthemes
Complex system	The VA transportation system consists of multiple interconnected components, including the various modes of transportation, regulatory frameworks, diverse stakeholders, processes of change, and access to care. Each element contributes to the system’s complexity and functionality.
Different modes of transportation	Includes special mode transport for wheelchair- and stretcher-bound patients, Uber/Lyft and volunteer services for ambulatory veterans, and beneficiary travel for travel reimbursement. MAS outsources to vendors for trips to veterans that require a special mode of transportation. Each mode of transportation addresses different needs.
Regulations and policy	The regulatory structure is complex, involving multiple layers of rules and guidelines that influence funding, programs, and standard operating procedures for day-to-day operations. This complexity often leads to challenges in service provision, requiring flexibility and adaptation by transportation services.
Diverse stakeholders	The system involves veterans, caregivers, healthcare personnel, the ORH, the Veterans Experience Office, and community partners, such as the Disabled American Veterans (DAV). Stakeholders have a unique role in determining transportation needs, organizing services, managing complaints and working toward service improvements.
Process of change	The VA is integrating new technologies and piloting new services to improve accessibility. Challenges include technology reliance, coordination issues, and engagement difficulties. Efforts focus on identifying transportation deserts, expanding resources, and overcoming barriers to enhance service provision.
Access to care	Reliable transportation impacts veterans’ health outcomes by providing access to primary, specialty, and mental health services. High outsourcing costs emphasize the need to bring care back to VA facilities. Strict eligibility criteria and limited service availability pose significant barriers, especially in rural areas.
Transportation strengths	Strengths include the NFLSGA unique ability to provide a wide range of flexible and adaptive transportation services, strong collaboration between various transportation departments and external contractors, and personalized, high-quality services facilitated by trained and dedicated drivers, many of whom are veterans themselves.
NFLSGA-unique	NFLSGA is unique due to its geographic reach and the range of services it offers. It is flexible and adaptable and transports those who may not qualify under beneficiary travel criteria. The integration of services under one umbrella allows NFLSGA to cater to a wide array of needs, making it distinct from other facilities.
Collaborative approach	Collaborative efforts with various stakeholders, such as social workers, nurses, and external contractors. This integrated approach ensures coordinated care and addresses the social determinants of health by working closely with all stakeholders involved in veterans’ healthcare.
Better customer service product	The VA transportation services are tailored to veterans’ needs, providing door-to-door service, better tracking, and higher safety standards. This personalized approach enhances veterans’ overall experience.
Drivers working for the VA	The employment of veterans as drivers, who share a unique bond and understanding with their passengers. This veteran-to-veteran interaction provides comfort and encouragement to veterans. The high training standards and commitment to service further enhance the reliability and quality of the transportation provided.
Transportation weaknesses	Limited resources, such as insufficient funding, manpower, and vehicles. Reliance on volunteer transportation presents challenges, including inconsistency, and restrictions on the types of patients that can be transported. Strict eligibility criteria further complicate access to transportation services.
Limited resources	Insufficient manpower, vehicles, and funding to meet the transportation demands of veterans. This impacts the ability to provide timely and effective transportation services, as highlighted by the constraints of staffing and vehicle availability due to budget cuts and funding limitations.
Volunteer transportation limitations	Challenges in relying on volunteers for transportation services, including inconsistency of volunteer availability, lack of medical training, and restrictions on the types of patients they can transport.
Eligibility	Strict criteria that veterans must meet to qualify for certain transportation services. The criteria often exclude veterans who do not meet specific administrative or clinical requirements, thereby limiting their access to transportation services and impacting their access to healthcare.
ARSS opportunities	Potential advantages and strategic recommendations for deploying ARSSs. Perceived benefits include increased efficiency, resource reallocation, and improved accessibility for underserved populations. Suggestions for deployment include its integration in urban areas and hospital campuses.
Perceived benefits	Perceived benefits include the potential for increased efficiency and resource allocation within transportation services. By automating aspects of transportation, human resources can potentially be reallocated to other tasks. ARSSs may improve accessibility for veterans by providing consistent and reliable transportation options.
Suggestions for ARSS deployment	Implementing fixed routes, focusing on short trips, and providing transportation services in small communities. Serving able and ambulatory veterans and deployment in urban areas as a last leg of trip. Incorporating ARSS in hospital campuses and parking lots may benefit both veterans and employees.
ARSS threats	The ARSS threats are the potential challenges and barriers that could impede the effective implementation and operation of ARSS. These threats encompass logistical, accessibility, and adoption issues.
ARSS logistics	Limited application for rural veterans due to varied trips and geographical components. Funding limitations, connectivity issues, road conditions, operational constraints and the suitability of vehicles for different terrains and weather conditions, and limited reach due to reliance on fixed routes.
Serving PWDs	Serving PWDs in the context of ARSS involves ensuring that these services are accessible and accommodating to individuals with mobility challenges. This includes having personnel available to assist, which may be challenging with ARSSs that lack onboard staff to help with wheelchairs, scooters, or other assistive devices.
ARSS adoption	Factors influencing adoption include trust in the technology, comfort levels with driverless vehicles, and the perceived reliability of these services. This is particularly challenging for older veterans, those living in rural areas, homeless veterans and those with no access to technology or limited technological proficiency.
Communication	Encompasses the methods and effectiveness of information exchange between staff members and between staff and veterans. It involves ensuring that all parties are informed about transportation options, eligibility criteria, scheduling processes, and service availability.
Staff to staff communication	Effective communication is important for coordinating transportation for veterans. Challenges include timely communication between inpatient teams and social workers, which can delay discharges. Regular and structured communication among departments is needed to ensure smooth operations and timely transportation services.
Veteran and staff communication	Clear communication between veterans and VA staff ensures that veterans are aware of the transportation services available to them and understand the eligibility criteria. This involves disseminating information through various channels and ensuring veterans are connected to the right personnel for scheduling transportation.
Suggestions for improvement	Streamline services by integrating departments under a unified system. The focus is on reducing redundancy, improving coordination, and ensuring that veterans have better access to transportation options through clear eligibility criteria and efficient scheduling processes.
Streamline services	Consolidate departments and services under a unified system to reduce redundancy and improve efficiency. By centralizing services, the VA can enhance coordination, reduce operational delays, and better manage resources. This also includes hiring more drivers and transportation staff and reducing reliance on external vendors.
Communication strategies	Enhancing communication strategies includes improving internal communication within the VA and external communication with veterans. Developing a centralized communication hub and utilizing public affairs to disseminate information about transportation eligibility and services can improve awareness and access.

illustrates the qualitative themes, subthemes, and their respective operational definitions. A thematic analysis revealed seven major themes and ten subthemes. The seven major themes included complex system, transportation strengths, transportation weaknesses, ARSS opportunities, ARSS threats, communication, and suggestions for improvement. Direct quotes from participants are provided throughout the results section below. Complex system had five subthemes, as follows: different modes of transportation, regulations and policy, diverse stakeholders, process of change, and access to care. Transportation strengths encompassed four subthemes, namely North Florida/South Georgia Veterans Health System (NFLSGA)-unique, collaborative approach, better customer service product, and drivers working for the VA. Transportation weaknesses comprised three subthemes, namely limited resources, volunteer transportation limitations, and eligibility. ARSS opportunities included two subthemes, namely perceived benefits and suggestions for ARSS deployment. ARSS threats had three subthemes, namely ARSS logistics, serving PWDs, and ARSS adoption. Communication comprised two subthemes, namely staff to staff communication and veteran and staff communication. Suggestions for improvement included two subthemes, namely streamline services and communication strategies. The themes that emerged from the coding are synopsized as follows.

3.2.1. Complex System

The complex system theme encompasses five subthemes that highlight the multifaceted nature of VA transportation, namely different modes of transportation, regulations and policy, diverse stakeholders, process of change, and access to care.

Different modes of transportation. This subtheme involves a variety of transportation options available to veterans based on eligibility and need (see Figure 1). Special modes of transportation provide door-to-door services for wheelchair- and stretcher-bound patients, while volunteer and ride-share services (e.g., Uber, Lyft) support ambulatory veterans, who can walk and self-assist. Beneficiary travel, managed by the Medical Administrative Service (MAS), provides mileage reimbursement to veterans who meet specific criteria, such as being service-connected or falling below a certain income threshold. When the demand exceeds internal capacity, trips are outsourced to vendors and contractors, but only for special mode transportation.

“Special mode, part of the medical administration service, handles wheelchair and stretcher-bound transport…providing door-to-door service…special mode has the secondary option of vending (ID: 1010).”

“[Volunteer Services] I can’t allow non-ambulatory individuals on the vehicle. We don’t have a ramp, lifting device, or any moving equipment, and my volunteers are certainly not medical staff (ID: 1012).”

“We partnered with Uber to provide transportation for ambulatory veterans—those who can walk and self-assist. Before that, they only had mileage reimbursement. [Beneficiary Travel] To qualify, you have to meet certain criteria, you got to be service connected, at least 30% pension, and have an income below $16,500. Not every Veteran qualifies (ID: 1004).”

“Everything else is vented out to a contractor. Trips cannot be vended if the individual does not meet special mode criteria (ID: 1006).”

Regulations and policy. This subtheme addresses the regulatory complexities and policy constraints that impact the delivery of transportation services. The numerous and layered regulations governing transportation services create challenges in service delivery and eligibility. Additionally, one participant emphasized the stringent adherence required for participation in the VTS program. Accepting VTS funding and resources mandates strict compliance with established protocols, which may not align with the operational realities of certain regions. The participant pointed out that local leadership often adopts a pragmatic approach, prioritizing the immediate transportation needs of veterans over rigid regulatory adherence. In some instances, VA transportation services operate outside the established system or regulations to ensure effective transportation solutions, demonstrating the importance of flexibility and adaptability in service provision.

“There are so many regulatory components to transportation that oftentimes there’s more services available than is known. And there’s different requests for adjustments of regulations to open coverage that’s going through the congressional process (ID: 1000).”

“If you join VTS and sign up 100%, take their money and their vehicles, then you have to do everything exactly as they say. That doesn’t work for our area. Our leadership is more like, ‘do what you got to do to get these folks in and take them home’ (ID: 1006).”

Diverse stakeholders. This subtheme highlights the range of stakeholders involved in the transportation services, including hospital personnel, social workers, and VA offices. The clinical team, including nurses and physicians, determines and communicates transportation needs for veterans. Social workers facilitate transportation for veterans who do not qualify for special modes of transportation, often handling discharge transportation needs. The ORH partners with the VTP to support VTS at rural sites, providing funding and resources to enhance service delivery. The Veterans Experience Office handles complaints and ensures service recovery related to transportation.

“The clinical inpatient team determines whether a Veteran is ambulatory or requires a wheelchair or stretcher. This information is then communicated to the social worker, who completes a trip ticket specifying the transportation needs—such as requiring oxygen, a stretcher, or a wheelchair (ID: 1014).”

“[Office of Rural Health] We help provide the funding and the VTS provides vehicle support for the personnel to get them up and running (ID: 1000).”

“[Veterans Experience Office] Drills down on all transportation complaints and issues (ID: 1006).”

Overall, the involvement of diverse stakeholders is important for the effective operation and continuous improvement of VA transportation services. Stakeholders interact not only for basic functions, such as arranging rides, but also at higher levels during planning, evaluation, prioritization of services, problem-solving, and as part of the change process. Participants emphasized the importance of coordinated efforts, data-driven decision making, and strategic engagement with leadership.

“It comes down to stakeholders sitting down with leadership at the division or facility level and making the case—being able to show, based on data, the resource impact both financially, by reducing spending on third-party contractors and ambulances, and operationally, by improving access to care for Veterans in high-need areas (ID: 1008).”

Process of change. This subtheme involves the ongoing efforts to adapt and improve transportation services in response to emerging needs and challenges. Additionally, the integration of services, like Uber Health, is discussed, though technological barriers, such as smartphone requirements, pose challenges.

“We piloted a rural shuttle based on identified need in Levy, Gilchrist, and Dixie counties. After six months of outreach and advertising, we received only one (non-legitimate) call. It never really got off the ground. I know there’s a need, but when it comes down to it, it’s hard to get folks to do it (ID1006).”

“One barrier with Uber and Lyft is that Veterans need a smartphone, and that’s not always the case with older generations (ID: 1006).”

Access to care. This subtheme emphasizes the critical role of transportation in ensuring that veterans can access necessary medical care, highlighting barriers to access.

“If a Veteran is very poor, has a car that doesn’t work, or lives 3 h away from a specialty care appointment without a friend or family member to assist, they might not be eligible for mileage reimbursement or Uber if they’re not ambulatory. And that can potentially cause further health concerns for that Veteran if they’re not getting the care they need. I would love it if the VA could say every Veteran gets a ride to every appointment, but some of our areas are very rural. Even if the Veteran is eligible for Beneficiary or special mode travel, there might not be a vendor who’s available to go to those more rural areas (ID: 1014).”

3.2.2. Transportation Strengths

Participants highlighted several strengths of the VA transportation system, including the unique aspects of the North Florida/South Georgia (NFLSGA) transportation system, a collaborative approach to care, better customer service, and the value of having veterans as drivers. Four subthemes emerged, namely NFLSGA-unique, collaborative approach, better customer service product, and drivers working for the VA.

NFLSGA-unique. The NFLSGA transportation system subtheme was repeatedly noted for its distinct capabilities and operational flexibility. Participants emphasized the flexibility of the transportation services offered. This flexibility allows the VA at NFLSGA to accommodate needs that might fall outside their usual support parameters.

“The NFLSGA is like no other facility and should be its own service because we’re that big (ID: 1006).”

“We are very flexible. If a need arises that we wouldn’t typically support, we reassess and find a way to help, considering the long-term impact. For example, if a patient from the Panhandle had surgery in Gainesville and initially had transportation but now needs it for a follow-up appointment, we may classify it as a one-time or until the need is over (ID: 1010).”

Collaborative approach. The VA’s integrated care model fosters significant collaboration between various departments, enhancing the coordination and quality of care for veterans. This collaboration includes working with the ORH to support rural transportation programs, integrating with social work services, and maintaining effective communication across different sections to meet diverse needs.

“Because of the integrated nature of VA care, the collaboration between the transportation program and social work provides better coordinated care, especially in terms of identifying and addressing the social determinants of health (ID: 1002).”

“The ORH and the VTP work really well together. We both recognize how important the other is, and that’s a real strength (ID: 1000).”

Better customer service product. The VA transportation service is noted for its personalized approach, including door-to-door service and close monitoring of transport. This high level of service ensures that veterans receive tailored transportation, contributing to better overall satisfaction. Additionally, there is a diversity within the system itself, with availability of staff-operated systems, volunteer-operated systems, and third-party operating systems. This diversity in coverage is considered a strength.

“Provides door-to-door service, offering one-on-one support between the Veteran and VA staff. It is also probably tracked better (ID: 1006).”

“Many of our Veterans are disabled, and not all disabilities are visible. It’s great that we have resources for both seen and unseen disabilities, something not always available to non-Veterans (ID: 1014).”

“There is diversity within the system, with staff-operated, volunteer-operated, and third party-operated systems providing coverage (ID: 1012).”

Drivers working for the VA. The employment of veterans as drivers was seen as a significant strength, fostering a strong connection and sense of camaraderie between the drivers and veteran passengers. This connection was considered inspirational and provided additional comfort to veterans attending appointments. Additionally, the VA drivers are held to higher standards, which helps ensure a high level of service quality.

“The program is primarily staffed by Veterans. They have a commitment to service and to other Veterans, and because they are Veterans, they bring military experience in transportation, logistics, program management, and personnel management. It’s unique—it’s truly a Veteran-owned and Veteran-operated entity within the VA (ID: 1002).”

“The support of Veterans as drivers—by connecting and being the inspiration for a Veteran to get to an appointment or providing added comfort for them to go—is really impressive and impactful (ID: 1000).”

“We monitor all training and driver physicals; they’re held to a higher standard (ID: 1006).”

3.2.3. Transportation Weaknesses

Participants identified several weaknesses within the VA transportation system, particularly focusing on limited resources and operational challenges. These were organized into the following three subthemes: limited resources, volunteer transportation limitations, and eligibility.

Limited resources. Participants noted significant funding constraints that impact the sustainability and expansion of services. Budget freezes and the high costs associated with outsourcing care to community providers were major concerns. These financial pressures are particularly important given the preference of veterans to receive care within the VA system, where relationships and understanding of veterans’ unique needs are stronger. Another significant limitation identified by participants is the shortage of staff and drivers within the VA transportation system. This issue exacerbates the operational challenges and strains the ability to provide timely and efficient transportation services to veterans. The insufficient number of drivers means that each driver must cover a large area, often leading to delays and logistical difficulties. Participants emphasized that their daily schedules are frequently adjusted based on patient appointments, which can be unpredictable and vary widely, further complicating the management of available drivers.

“We always need more resources—manpower, vehicles—because the demand is overwhelming. Right now, we’re in a budget crunch, and everything is pretty much frozen. Part of the reason is community care—if a Veteran can’t be seen within 30 days, we have to outsource it, and the VA covers the cost. That’s gotten very expensive—just in NFLSGA, it’s about $700 million (ID: 1004).”

“It comes down to staffing. Each morning, we get a list of 25–35 Veterans needing rides, but we only have two drivers. They can manage four to six trips a day, with three passengers each…and people have to understand that schedule changes daily, it’s driven by patient appointment (ID: 1006).”

“One of the biggest weaknesses is staffing. Due to a neutral FTE policy and limited funding, transportation often gets overlooked in the broader healthcare conversation. Leadership may prioritize hiring 25 doctors, but without drivers, patients can’t get to their appointments—and personnel is usually the first area cut (ID: 1008).”

Volunteer transportation limitations. The inconsistency of volunteer drivers was frequently cited as a significant challenge. Volunteers, while appreciated, often lack the reliability needed to ensure timely and dependable transportation for veterans’ appointments. Additionally, the limited number of drivers available to cover large areas means that scheduling is often strained, leading to potential delays and logistical difficulties in meeting daily transportation demands. The impact of COVID-19 has further exacerbated this issue, as explained by a participant.

“The problem with volunteers is consistency. I love them all and plan to volunteer myself, but when they’re unreliable, it disrupts patient appointments (ID: 1006).”

“If a volunteer goes on vacation for three months, which happens quite regularly, we don’t have a built-in backup (ID: 1012).”

“DAV offers a great shuttle service, but it’s not run through us. It used to be robust—vans ran daily between Jacksonville and Gainesville—but after COVID-19, volunteer numbers dropped significantly. Most volunteers are 60+, and once COVID-19 came through, I think it spooked them. Now, they don’t always have the people to keep the vans running daily, and gaps are starting to show in our coverage (ID: 1010).”

Eligibility. Participants also pointed out that the eligibility criteria for transportation benefits are restrictive, preventing many veterans from accessing necessary services. There is a need for better communication regarding these criteria and potential flexibility to accommodate more veterans.

“There’re administrative and clinical criteria that have to be met for Veterans to be eligible for that program, and that can sometimes affect a Veteran’s access to care (ID: 1014).”

“We can do a better job communicating the criteria of what makes a Veteran eligible for certain programs within the VA, specifically regarding transportation (ID: 1014).”

3.2.4. Autonomous Ride-Sharing Service Opportunities

Participants identified several promising opportunities associated with the potential deployment of ARSSs within the VA transportation system, focusing on perceived benefits and specific suggestions for effective implementation. ARSS opportunities included two subthemes, namely perceived benefits and suggestions for ARSS deployment.

Perceived benefits. One major benefit highlighted by participants was the potential for ARSSs to expand the pool of available employees who can assist with transportation, thereby alleviating some of the staffing constraints currently faced. Additionally, the service offers a consistent and reliable point of access within cities or towns, where veterans simply need to arrive at a designated stop to begin their journey. Furthermore, another benefit of ARSS is its potential to assist rural veterans. For instance, one participant noted that ARSS could provide a standardized, stress-free final leg of the journey for rural veterans traveling to urban centers for care.

“It would open up the pool of employees that could successfully help with the transportation, so that would be helpful (ID: 1000).”

“It would provide a better resource for Veterans to have that consistent point of access in a city or town…all they have to do is show up to one of the stops, get on and away they go (ID: 1008).”

“It would be good if it could help rural Veterans get to their final urban track of their ride to make that standardized and less stressful (ID: 1000).”

Suggestions for ARSS deployment. Participants suggested various deployment strategies to maximize the benefits of ARSS, particularly for short trips and in urban communities. Another participant proposed using ARSSs within large, walkable developments designed specifically for veterans. Such communities could leverage ARSSs to facilitate not only medical appointments but also access to grocery shopping, dining, entertainment, physical activities, parks, and other essential services, effectively addressing multiple social determinants of health within a self-contained environment.

“On a smaller scale, we could use it within the hospital. Our campus is large, and we have many Veterans—some with disabilities, others just running late—who could benefit from quick hop-on, hop-off routes. It could also support parking access and even help employees navigate the hospital and nearby locations more easily (ID: 1004).”

“Knowing they can be geofenced, ARSS would be especially beneficial in large metropolitan areas where maintenance is easier and connectivity is stronger due to widespread cell tower coverage (ID: 1008).”

“In large, walkable developments or Veteran communities, ARSS could go beyond medical appointments to support trips for groceries, dining, physical activity, and access to parks—addressing broader social determinants like food, education, and healthcare access (ID: 1002).”

3.2.5. Autonomous Ride-Sharing Service Threats

Participants expressed concerns regarding the logistical challenges and limitations of ARSSs, particularly in serving people with disabilities (PWDs), and adoption barriers. Autonomous ride-sharing service threats had three subthemes, namely ARSS logistics, serving PWDs, and ARSS adoption.

Autonomous ride-sharing services logistics. One significant logistical threat identified is the variability and complexity of routes in rural areas. Participants noted that rural veterans often have unique and diverse travel needs, making it difficult to implement a standardized ARSS route. The geographical components and varied road conditions present additional challenges for ARSS deployment in these regions. Additionally, concerns were raised about the reliance on satellite or tower control for ARSS operations, which might face connectivity issues in rural areas.

“Their trips are so varied that it’s hard to establish a shuttle on a standardized route. For Level 4, it would need to stay close to the VA, with specific geographical constraints. Rural Veterans have such varied road conditions, distances, and terrain… it’s going to be the topography that impacts distance (ID: 1000).”

“It’s being run on satellites or some kind of tower control—is that going to be an issue in rural areas? (ID: 1010).”

“Their primary concern would be safety and connectivity. Our drivers use tablets that connect via satellite and cell towers, and we still encounter issues—sometimes losing connection and trip data. That’s a concern for ARSS, especially since there’s no one physically present to troubleshoot in real time (ID: 1008).”

Serving PWDs. Another major threat relates to the ability of ARSSs to adequately serve veterans with disabilities. Participants highlighted that many veterans rely on wheelchairs, scooters, and other mobility aids, which necessitate accessible vehicles equipped with wheelchair lifts. The absence of a driver in ARSS vehicles could significantly impede the ability to assist these veterans.

“I could see ARSS working for fixed routes with ambulatory riders only. But all my fixed-route vehicles have wheelchair lifts. What happens the first time someone shows up in a wheelchair? More riders use rollators, scooters, or power chairs than are fully ambulatory (ID: 1006).”

“I can’t imagine a vehicle without a person in it—our drivers often go above and beyond to assist Veterans and help them access higher-level care. I’d strongly advocate for someone to always be present in the vehicle (ID: 1000).”

ARSS adoption. Participants expressed concerns about the adoption of ARSS by veterans, especially regarding trust and technology acceptance. Veterans might experience anxiety or stress about using a vehicle without a driver, especially given their unique experiences and needs. There might be resistance from older veterans, who may not be comfortable with new technology. Additionally, veterans who may not have access to a cell phone, including homeless veterans, might face challenges in accessing and using ARSS.

“If there’s no driver, it could cause anxiety or added stress for any Veteran, regardless of age. Many have experienced trauma, and getting into a vehicle without a person present may raise concerns—like whether they’ll get to the right place or arrive on time. There are just too many unknowns (ID1014).”

“We have more older Veterans than younger. We have younger Veterans who might think, oh, this technology is amazing. However, most of our Veterans who require assistance with transportation are older, and I believe many of them wouldn’t be completely comfortable with a Level 4–5 ARSS because they have a lot of old-school thinking. Most prefer paper surveys over computer surveys, many don’t have access to email, and they don’t use My HealtheVet secure messaging. So even if the technology is great, they’re not utilizing it. Our larger Veteran population that uses transportation wouldn’t be on board with a Level 4–5 ARSS (ID: 1014).”

“There’s probably a link the Vet has to click to approve the ride—some kind of manifest system. But not everyone is tech savvy, and many Vets here are homeless, so you’re assuming they even have a phone (ID1010).”

3.2.6. Communication

Effective communication is essential to the success of the VA transportation system, as it ensures that veterans and staff are well-informed and coordinated. This theme encompasses communication between veterans and staff, as well as internal staff communication to facilitate transportation services. Communication included two subthemes, namely staff to staff communication, and veteran and staff communication.

Veterans and staff communication. Efforts to inform veterans about transportation services and eligibility criteria were highlighted by participants. Specifically, participants emphasized the importance of educating both veterans and VA providers about the transportation services available. While veterans are often aware that they can access transportation services, they may not always know the best point of contact for scheduling. Ensuring that veterans are connected to the appropriate person is crucial for providing timely and effective transportation support. Another participant emphasized the importance of providing clear guidance and criteria for qualifying for transportation services. This includes disseminating information through various channels, such as Facebook, websites, flyers, and brochures. Despite these efforts, there are still challenges in ensuring effective communication. One participant pointed out that the transportation services they provide are primarily support functions, meaning they rely on internal VA systems and referrals rather than direct outreach to veterans.

“The transportation program has done a fantastic job at the local level of educating Veterans, providers, and administrative staff that transportation services are available. Often, the issue isn’t that Veterans don’t know they can get a ride—it’s that they don’t know who to contact to schedule it. Almost 99% want to speak to someone on the phone. So, it’s more about making sure they’re connected to the right person to help identify what benefits they’re eligible for and ensure they get to their appointments (ID: 1002).”

“We try to get the guidance out to Veterans first, so they understand the criteria to qualify. Once they know, we share updates on Facebook, post them on websites, and provide flyers and brochures so they’re aware of the services (ID: 1004).”

“We don’t have many direct conversations with Veterans. Sometimes they find our number, but everything we do is behind-the-scenes support. Realistically, our name isn’t out there. When Veterans call, it can feel like a carousel—being bounced around from one place to another—which is frustrating, especially since our department doesn’t have the tools to verify their eligibility (ID: 1010).”

Staff to staff communication. Internal communication among staff was also noted as important, particularly in terms of logistical coordination. Effective communication and collaboration across different sections and regions are needed to ensure that the transportation needs of veterans are met, regardless of the demand. However, there are notable barriers to effective communication that can impact service delivery. One significant issue is the lack of timely communication between the inpatient team and social workers regarding veterans’ discharge schedules.

“One of our current strengths is communication. Logistically, we coordinate and collaborate across different sections to meet demand, no matter what it is. There’s strong communication with other sites, even outside our region, to ensure we take care of our patients (ID: 1004).”

“The biggest barrier is when the inpatient team doesn’t notify the social worker in time about a Veteran’s discharge. We may get a last-minute request for a trip that could take up to six hours. Our catchment area spans 14,000 square miles—50 counties across NFLSGA—so if we don’t get timely notice, it may be too late in the day to arrange same-day transportation, causing delays (ID: 1014).”

3.2.7. Suggestions for Improvement

Improving the VA transportation system involves addressing various logistical, operational, and communication challenges. Suggestions for improvement were organized into two subthemes, namely streamline services and communication strategies.

Streamline services. One recommendation was to implement the VTS program at all VA facilities to streamline services. Another suggestion focused on consolidating transportation-related departments into a single, centralized unit. Consolidating various departments into a single unit would enhance communication and reduce redundancy. This one-stop shop model would help optimize the care and services provided to veterans by ensuring all transportation needs are coordinated from one place. Additionally, by hiring more drivers, the VA could save money compared to contracting out services to vendors. This would also allow for greater control over transportation services, ensuring that veterans’ needs are met more effectively.

“It would be really helpful to have the VTS program at all facilities. It’s available to all Veterans—regardless of service connection—which makes things more streamlined. There’s one place to go for rides, and if demand exceeds capacity, it becomes immediately clear (ID: 1000).”

“From a transportation standpoint, I think it would help to have a one-stop shop. Even though communication is good, it could be better if we were all in one area. There’s a lot of redundancy we could reduce to optimize care and services. Also, with VA drivers, it’s more cost-effective to hire and retain our own staff to meet Veterans’ needs, rather than paying vendors significantly more under contract (ID: 1004).”

Communication strategies. Improving communication about eligibility criteria and available services would help veterans understand what benefits they qualify for. Public affairs should actively disseminate information about travel reimbursement and ride-share programs to ensure that veterans are well-informed. An additional strategy included streamlining internal communication by building a centralized communication hub where staff can interact directly. This approach would reduce the need for multiple phone calls and emails, leading to quicker decision making and better service delivery. Expanding communication to include third-party services and staff operations would ensure seamless coordination when there are gaps in transportation resources. This would help maintain consistent service levels and meet transportation needs effectively.

“We can do a better job communicating eligibility criteria for VA programs, especially transportation. It would help if public affairs shared clearer messages—like letting veterans know they might qualify for travel reimbursement or ride-share services. Most issues come down to a lack of communication, and we could improve how we educate veterans about their options (ID: 1014).”

“There are too many phone calls, emails, and Teams messages—it wastes time. If everyone were in the same space, we could just ask quick questions and get answers faster than making multiple phone calls or teams messages (ID: 1010).”

“We need broader communication with alternate stakeholders—like staff services or third-party providers. If we’re short a driver, it would help to share a manifest and points of contact so they can step in when needed (ID: 1012).”

In summary, the qualitative analysis of the VA transportation system reveals a complex interplay of strengths, weaknesses, opportunities, and threats (see

Table 2. Key themes organized by the SWOT framework with respective take-home messages.

SWOT Framework	Theme	Take-Home Messages
Strengths (internal factors)	(1) Complex system (2) Transportation strengths (3) Communication (4) Suggestions for improvement	The VA transportation system is multifaceted, involving a variety of transportation options across diverse stakeholders, which reflects the richness and adaptability of the system. Strengths include the unique aspects of the NFLSGA system due to its geographical size and transportation flexibility; a collaborative care model; personalized customer service; and the employment of veterans as drivers, which enhances satisfaction and service quality. Effective communication among staff and with veterans is a system strength that supports coordination and user satisfaction. Although forward-looking, many of the proposed improvements (e.g., hiring more drivers, centralizing departments, enhancing communication) depend on internal restructuring and policy change, aligning them with internal strengths that can be developed.
Weaknesses (internal factors)	(1) Complex system (2) Transportation weaknesses (3) Communication	Certain aspects, like regulatory burdens and fragmented access, expose internal inefficiencies that complicate service delivery. Weaknesses include funding constraints, a shortage of staff and drivers, inconsistency and reliability issues with volunteer drivers, and restrictive eligibility criteria. Addressing staffing shortages and budget constraints is essential for improving service delivery. Communication is a double-edged theme, which also includes organizational inefficiencies and access barriers (e.g., veterans not knowing the correct point of contact, last-minute discharge notices, limited direct outreach, and redundant communication workflows).
Opportunities (external factors)	(1) ARSS opportunities	ARSS may expand the pool of transportation employees, provide reliable access points in urban areas, and assist rural veterans by standardizing and easing final leg journeys. They may also alleviate staffing constraints and offer a scalable solution for short trips.
Threats (external factors)	(1) ARSS threats	Threats include logistical challenges in rural areas, limited connectivity, safety concerns, difficulties in serving veterans with disabilities, and adoption barriers due to trust and technology acceptance issues. Threats need to be addressed to support ARSS implementation.

). The analysis identified seven major themes, which offer a comprehensive view of the current state and potential future of VA transportation services.

3.3. Findings Related to the Socioecological Model

The qualitative data, organized within the socioecological model, present a detailed view of the various factors influencing the VA transportation services (see Figure 2). This approach encompasses the seven main themes and associated subthemes, along with additional findings. The socioecological model captures the layered and interconnected influences at the individual, relational, community, and societal levels.

The individual level focuses on factors, such as knowledge, perceptions, and experiences, that influence the use of transportation services. Themes that fall under this level include interviewee-related factors (perspectives of ideal transportation system, background/role, and ARSS perspectives and knowledge), veteran experiences (how individual access to transportation affects their ability to receive timely medical care), veterans satisfaction (satisfaction levels with transportation services provided), and Transportation eligibility (how criteria affects access). These themes reflect the importance of understanding individual perspectives and experiences to improve service delivery. For instance, one participant described how they started using Uber for ambulatory veterans. However, they encountered challenges with driver availability in certain areas, particularly in the north catchment area of the NFLSGA region. This led to missed appointments, sometimes resulting in a six-month wait for the next available slot (ID: 1004). This indicates the need for a system that meets veterans’ expectations and needs, with clear transportation eligibility criteria to enhance accessibility for more veterans.

The relational level examines the role of communication and interpersonal connections in influencing veterans’ access to and satisfaction with transportation services. Themes that fall under the relational level include VA drivers (veterans serving veterans), and communication (staff to staff communication, and staff to veteran communication). The involvement of veterans as drivers or support staff fosters trust and satisfaction, creating a more relatable and supportive transportation experience. Effective communication is important for ensuring that veterans properly understand and utilize transportation services. Participants highlighted the importance of clear and efficient communication in enhancing service delivery and ensuring veterans receive the support they need. For instance, one group has been working on a project with stakeholders from the VTS to develop a decision support tool. This tool is designed to help clinicians and administrators identify eligibility criteria, match them with veterans’ needs, and track these interactions within EPRS for better care coordination (ID: 1002).

The community level focuses on transportation organization, logistics, capacity, planning and evaluation processes, stakeholder collaboration, and specific challenges faced in different community settings. This level encompasses how community infrastructure, local policies, and community-specific needs and resources impact the VA transportation. These themes include VA transportation system goals, different modes of transportation, stakeholders, physical environmental factors, facility leadership, the NFLSGA transportation system, system capacity, logistics (drivers, vehicles, and routes), VA transportation planning process, the evaluation process, the collaborative approach, volunteer transportation limitations, suggestions for improvement, and suggestion for ARSS deployment. For example, one of the VA transportation system goals is to increase access to care by fostering stakeholder collaboration and understanding veterans’ needs (ID: 1010). However, achieving this goal requires careful assessment of each case to avoid setting unrealistic expectations and ensuring that transportation solutions are sustainable. In terms of physical environmental factors, one participant highlighted the challenges of workforce recruitment and retention in rural areas, identifying the difficulty of keeping drivers within the program (ID: 1002).

The societal level encompasses broad factors, such as policies, federal funding, and organizational structures that shape the availability, quality, and accessibility of transportation services. These themes include the importance of transportation, social determinants of health, innovation (including concerns and technology access), regulations and policies, no one-size-fits-all approach, return on investment, limited resources (federal funding), VA organization structure (in-house care vs. care in the community), the impact of COVID-19, suggestions for improvement, ARSS threats, and ARSS benefits. One participant emphasized the importance of transportation in meeting the social determinants of health for veterans, noting that it contributes significantly to veterans’ health and well-being by ensuring they can attend primary care, specialty care, and mental health appointments, thereby preventing poor health outcomes (ID: 1002). Others noted how COVID-19 reduced the availability of DAV volunteer drivers (often older drivers), even after the pandemic, which has led to missed appointments for many veterans and an increase in expenditure (ID: 1006 and 1004). Suggestions for improvement appeared at both the community and societal levels. Suggestions at the community level included adding more drivers, streamlining services (creating a one-stop shop and eliminating redundancy), covering more rides, and transporting more veterans. At the societal level, improvements involved adjusting regulations, bringing veterans’ care back to VA facilities, and securing increased federal funding for transportation programs.

The levels of the socioecological model are interconnected, with changes at one level affecting outcomes at another. For instance, individual experiences (individual level) can influence communication (relationship level), which, in turn, can impact community logistics and stakeholder involvement (community level), ultimately shaped by federal policies and funding (societal level). Three main examples are illustrated below.

Impact of delays in care on veterans’ health and the need for improved stakeholder collaboration and communication. Transportation delays have a profound impact on veterans’ health, with effects observable across multiple levels of the socioecological model. At the individual level, participants reported that transportation delays are particularly detrimental to veterans who lack reliable transportation and live far from medical facilities, which may exacerbate existing health conditions due to missed or delayed care (ID: 1006, 1004, 1014). Confusion over eligibility criteria further limits access to services and may lead to gaps in care (ID: 1014). At the relational level, effective communication is important for coordinating timely transportation, yet breakdowns in coordination prolong delays. Clear guidance on eligibility, shared through multiple channels, may mitigate these issues (ID: 1004). At the community level, the availability and reliability of transportation options play a significant role in either mitigating or exacerbating delays. This is particularly critical in rural areas where transportation infrastructure may be lacking. Stakeholders, including social workers, transportation coordinators, and leadership, must work together to develop tools and processes that improve service delivery, such as the decision support tool for identifying eligibility criteria and matching them with veterans’ needs (ID: 1002). At the societal level, policies and funding allocations are needed to create a robust transportation system capable of meeting veterans’ needs. Overall, by enhancing communication and coordination at the relational level, improving transportation infrastructure and planning at the community level, and securing robust policies and funding at the societal level, the VA can better support veterans’ access to timely medical care (individual level).

Veterans’ satisfaction and interactions with VA drivers. Veterans’ satisfaction and trust in VA transportation services are significantly influenced by the personal connections and understanding exhibited by VA drivers. At the individual and relational levels, veterans often express a preference for VA drivers over contractors due to their deeper personal connections and familiarity with their specific needs (ID: 1010, 1006, 1008). Veterans often feel more comfortable and understood when transported by another Veteran who shares similar experiences, fostering a sense of trust and enhancing their overall satisfaction with the transportation services (ID: 1000, 1002, 1006, 1008). At the community level, ensuring that VA drivers are well-trained, adequately compensated, and available to meet the transportation needs of veterans is important to maintaining customer satisfaction. At the societal level, policies and funding should prioritize hiring and training veterans as drivers to sustain veterans’ trust and satisfaction. By prioritizing the employment of VA drivers and ensuring they are well-trained and supported, both at the community and societal levels, the VA can maintain high satisfaction levels and trust among veterans.

Addressing system capacity and exploring ARSS opportunities in VA transportation. Addressing system capacity and integrating ARSS in VA transportation is important for improving service efficiency. At the community level, a shortage of drivers significantly impacts the ability to meet demand (ID: 1000, 1002, 1004, 1006, 1008, 1010, 1012). Challenges, such as workforce recruitment and retention, particularly in rural areas, indicate the need to consolidate transportation-related departments into a centralized unit to enhance communication and reduce redundancy (ID: 1002, 1004). At the societal level, government funding and policies play a key role in resource allocation to ensure adequate staffing and vehicle procurement. Additionally, leveraging ARSS may alleviate staffing constraints and enhance transportation capacity, especially in urban areas where potential reliable access points may help streamline services (ID: 1008, 1004). However, ARSSs faces challenges in rural areas due to complex routes, connectivity issues, and limited accessibility for veterans with disabilities. To address these concerns, shuttle attendants, such as social workers, could assist passengers and foster trust among veterans resistant to new technology. Deployment should focus on short trips and urban communities where infrastructure supports ARSS, with potential applications for shuttle services within hospital campuses and large VA facilities to enhance intra-campus mobility.

4. Discussion

The research team conducted semi-structured interviews with eight VA transportation stakeholders to understand the strengths and weaknesses of the current system and explore future plans for ARSS. All participants were full-time employees with extensive experience in the VA transportation system, which ensured that the insights gathered were well-informed by years of practical expertise. However, the relatively small sample size may not encompass the full diversity of experiences and viewpoints present within the VA transportation workforce. Geographically, the participants were spread across diverse locations, including Florida, Georgia, New York, and Wyoming, although a significant majority (five out of eight) were based in Florida. The concentration in Florida might have skewed the findings towards issues and solutions more pertinent to that state, potentially overlooking those from other regions. Overall, participants held a range of roles and responsibilities across various transportation sectors and departments, which helped capture a broad view of the transportation system’s operational landscape and the interconnectedness of its various components.

The complex system theme identifies the multifaceted nature of the VA transportation services, shaped by diverse transportation modes, regulatory constraints, various stakeholders, ongoing processes of change, and access to care. This complexity aligns with the current literature which identify challenges in providing transportation services to veterans due to varying needs, such as medical conditions, geographical location, socioeconomic status, and systemic constraints, including regulatory policies and resource limitations [36,37]. While the availability of different transportation modes benefits veterans, coordinating these across numerous stakeholders remains challenging. The study identified the complexities and rigidities of the regulatory environment, which often hinder the flexibility needed to address local transportation needs. Although programs, like rural shuttles and Uber Health, signal progress, barriers, such as low uptake and technological challenges, persist. Access to care remains a key issue, with eligibility restrictions and vendor limitations exacerbating transportation-related healthcare barriers, particularly for those in rural areas [38,39].

The transportation strengths theme identifies key advantages of the VA transportation system, including flexibility, collaboration, superior customer service, and the benefits of employing veterans as drivers. The NFLSGA region exemplifies adaptability by accommodating unique transportation needs, aligning with calls for personalized healthcare transportation solutions [37]. Collaboration between VA transportation and social work services, along with partnerships, like those with the ORH, enhances coordinated care and helps bridge service gaps in rural areas, a strategy that has been shown to be effective in improving access to care in underserved regions [40]. The VA’s personalized, door-to-door service and diverse transportation options enhance service flexibility, particularly for veterans with disabilities who require special attention. Employing veterans as drivers fosters camaraderie, empathy, and trust, while high training standards ensure consistent service quality, making them a valuable asset [6].

The transportation weaknesses theme identified challenges within the VA transportation system, including limited resources, volunteer transportation limitations, and restrictive eligibility criteria. Limited resources identified included funding constraints and staffing shortages, which impact service sustainability and expansion [6]. These issues are exacerbated by the high costs associated with outsourcing care to community providers, which diverts funds that could otherwise enhance in-house transportation capabilities. These financial pressures are particularly concerning given veterans’ preference for receiving care within the VA system, where relationships and understanding of their unique needs are stronger. Participants also noted the inconsistency and unreliability of volunteer drivers, especially post-COVID-19, due to reduced availability and lack of backup, which affects the dependability of transportation for veterans’ appointments. While volunteers provide a valuable service, their unreliability compared to paid staff poses a persistent challenge. Additionally, the restrictive eligibility criteria for transportation benefits prevent many veterans from accessing necessary services. Thus, the need for better communication regarding these criteria and potential flexibility to accommodate more veterans underscores the importance of education and adaptability in service provision [38].

The ARSS opportunities theme identified the potential benefits and deployment strategies of ARSSs within the VA transportation system. Participants identified ARSSs as a solution to alleviate staffing shortages by expanding the pool of available employees for transportation. While ARSSs cannot fully replace drivers in complex or rural routes, they may reduce demand for staffing on more standardized or low-risk routes, particularly in urban or campus settings. ARSSs are currently being deployed or tested in urban centers and controlled environments, such as university campuses or healthcare districts. These systems typically operate at Level 4 autonomy within geofenced areas, with oversight from remote operators and/or onboard assistants. While early pilots have demonstrated technical feasibility and moderate rider satisfaction, widespread deployment remains limited by technological, regulatory, and infrastructural barriers [8,9,10]. ARSSs may streamline transportation logistics by providing consistent and reliable access points in cities, with shorter delay times, less variation in expected delays per trip, and reduced vehicle miles traveled [41]. For rural veterans, ARSSs may offer a standardized, stress-free final leg to urban centers for care [40,42]. By reducing the stress and uncertainty associated with long-distance travel, ARSSs may enhance the overall transportation experience for rural veterans. However, as noted by participants, rural deployment must be approached cautiously due to infrastructure limitations and limited connectivity, which can reduce the operational efficiency of ARSSs. Deployment strategies include using ARSSs for short trips, hospital campus mobility, and metropolitan areas where existing infrastructure supports geofenced Level 4 autonomy [43,44]. Additionally, deploying ARSSs within Veteran communities may support transportation for medical appointments, grocery shopping, and recreational activities, addressing multiple social determinants of health.

While ARSSs offer potential benefits, their implementation faces threats, including logistical challenges, limitations in serving PWDs, and adoption barriers. ARSS technology is often optimized for structured urban environments, meaning it struggles with unpaved roads, irregular address systems, or areas lacking clear mapping—conditions more typical in rural regions [43,45]. In rural areas, complex routes and diverse travel needs make standardizing ARSSs difficult, compounded by concerns about satellite or tower connectivity [43]. However, as improving rural Internet connectivity remains a political and economic priority, these challenges may diminish over time [45]. Thus, leveraging 5G and satellite Internet expansion could improve ARSS functionality in rural areas by enhancing vehicle-to-infrastructure communication and enabling real-time route adjustments [46].

Additionally, most ARSSs are not yet universally designed, and accessibility modifications, such as wheelchair lifts, visual–auditory prompts, or space for service animals, are not consistently standard [46,47]. These issues are compounded by the VA’s high concentration of elderly veterans and those with disabilities who may need human assistance during boarding or navigation [46]. Moreover, veterans may experience anxiety or stress about using a driverless vehicle, which could hinder the adoption of ARSSs, particularly among older adults and PWDs [48,49]. To potentially solve this problem, participants strongly recommended ARSS models that include onboard assistants or trained personnel at key hubs to ensure safe boarding, facilitate assistance with mobility aids, and enhance user trust. ARSS fleets should also integrate universally accessible vehicle designs with automated ramps, wider doorways, and multisensory alerts tailored for veterans with hearing, visual, or cognitive impairments. However, equity issues still persist for veterans lacking smartphones, particularly those experiencing homelessness, indicating challenges in digital inclusion and technology access [50].

These findings are consistent with lessons learned from other pilot projects testing ARSS in public transportation. For example, in Columbus, Ohio, the Linden LEAP project demonstrated the feasibility of low-speed autonomous shuttles on fixed routes but identified challenges around weather reliability, ADA accessibility, and community trust [47]. More recently, Golchin et al. (2024) evaluated an autonomous shuttle pilot at UNC Charlotte that completed over 800 trips in mixed traffic [51]. Their analysis showed system performance and operational reliability, while also pointing to the importance of human supervision and the need for accessible boarding infrastructure [47]. In another recent pilot, Shen et al. (2018) conducted a simulation study evaluating ARSS deployment as a first-mile solution in Singapore’s public transit system [9]. Their work demonstrated the potential of ARSSs to reduce transfer times and enhance network accessibility, while also indicating the importance of integrated planning and infrastructure readiness to ensure effective coordination with fixed-route transit systems. Their findings support the scalability and relevance of ARSSs in bridging transportation service gaps, especially for populations with limited access to conventional transit.

Compared to these municipal or campus-based use cases, our study expands the application of ARSS to the federally managed and medically focused context of the VA, showcasing additional complexity in regulatory alignment, service coordination, and user population vulnerability. Thus, while ARSS deployment strategies may be technically scalable, successful adoption in healthcare systems, like the VA, will depend on operational customization and human-centered implementation. Moreover, our findings indicate important gaps in the literature, particularly around the adaptability of ARSSs in rural settings. Prior research has largely focused on urban or academic environments with robust infrastructure, while our study demonstrates how ARSSs must adapt to resource constraints, geographic disparities, and diverse veteran populations. These insights contribute to emerging discussions about equitable AV deployment, digital inclusion, and transportation access within national healthcare systems [11,12,50,52].

The communication theme identified the important role of effective communication, both between veterans and staff and among internal staff. While veterans may be aware of transportation services, they often struggle to identify the correct point of contact for scheduling. Ensuring clear connections to the appropriate personnel is important for providing timely and effective transportation support [51]. Participants stressed the need for clear, accessible guidance on eligibility through multiple channels, consistent with public health communication best practices [53]. Overreliance on internal systems and referrals—rather than direct outreach—can leave veterans feeling bounced between departments. Streamlining communication strategies and expanding outreach efforts may help to ensure that veterans are fully aware of available transportation services and eligibility criteria. Internally, delays in communication between inpatient teams and social workers—particularly regarding discharges—lead to last-minute trip requests that are hard to fulfill, especially in large regions, like NFLSGA. Strengthening collaboration and reducing communication gaps is key to improving service delivery and ensuring timely transportation support.

The suggestions for improvement theme addressed logistical, operational, and communication challenges within the VA transportation system. Participants recommended implementing the VTS program at all VA facilities to create a uniform service accessible to all veterans, simplifying access and ensuring consistency. Another key suggestion was consolidating transportation-related departments into a centralized unit. The current decentralized approach leads to inconsistencies [6], and a “one-stop shop” model could improve communication, reduce redundancy, and enhance service delivery for veterans. Participants recommended hiring more drivers instead of relying on contracted services to reduce costs and improve control over transportation. With VHA medical transportation expenses rising—USD 750 million was spent on beneficiary travel in FY 2010—cost-effectiveness is a growing concern [6]. However, these proposals require significant resource investments and face feasibility constraints, including budget limitations, interdepartmental resistance to structural change, and staffing shortages. Prioritization may begin with expanding the VTS program system-wide, as this has proven to be an effective and scalable VA-led initiative already in operation at many sites. Additionally, consolidating transportation-related departments into a centralized structure should be explored as a medium-term goal due to its potential to enhance efficiency and reduce redundancies. Hiring more drivers may require phased implementation contingent upon facility-specific budget assessments and regional workforce availability, with priority given to sites experiencing the most acute driver shortages or reliance on inconsistent contractor services. These recommendations align with the VA’s high performing integrated infrastructure strategy, which emphasizes coordinated, veteran-centered service delivery and operational efficiency [54]. Additionally, enhancing communication about eligibility criteria and available services was also suggested, with public affairs playing a key role in disseminating information on travel reimbursement and ride-share programs. Streamlining internal communication through a centralized hub could reduce redundant calls and emails, leading to faster decision making. Expanding communication to third-party vendors and VA transportation departments would also improve coordination and address gaps in transportation resources.

The qualitative data, organized within the socioecological model, provide a comprehensive view of the factors influencing VA transportation services at individual, relational, community, and societal levels. The interconnections between the levels of the model show the complexity of the VA transportation system and indicate the necessity for a holistic approach to service improvement. Relational dynamics—such as communication and trust between veterans and staff—directly impact individual experiences, while also influencing broader community logistics and stakeholder coordination. These, in turn, are shaped by societal-level factors, like policies and funding. Addressing transportation challenges requires coordinated efforts across all levels, ensuring that individual needs are met through strong communication, efficient logistics, and supportive policies. This approach is necessary for improving veterans’ access to timely and reliable transportation services, ultimately enhancing their overall satisfaction and health outcomes.

5. Conclusions

This study explored key VA transportation stakeholders’ perceptions through semi-structured interviews, identifying strengths and weaknesses of the VA transportation system, as well as the opportunities and threats of the potential implementation of ARSSs. Using the socioecological model, the study identified factors across individual, relational, community, and societal levels that influence veterans’ transportation access. Strengths included personalized service, flexibility, veteran drivers, and collaborative care, while challenges, such as funding constraints, staff shortages, volunteer limitations, and restrictive eligibility criteria, were identified. ARSSs present opportunities to alleviate some of these issues, particularly by freeing up human resources and addressing social determinants of health in urban areas, though logistical complexities and accessibility for veterans with disabilities remain concerns. Suggestions for improvement included streamlining and consolidating transportation-related departments, hiring more drivers, and enhancing communication strategies to ensure that veterans are well-informed and connected to appropriate services. Priority areas for initial ARSS deployment include urban hospital campuses and short-distance transportation within metropolitan regions where geofenced Level 4 autonomy is most feasible. Targeting these environments aligns with veterans’ needs for accessible transportation to and from medical appointments while minimizing operational challenges associated with rural or unstructured settings.

This study offers a novel contribution by providing a system-level, stakeholder-informed examination of the VA transportation network—an area underexplored in the existing transportation literature. It is one of the first studies to use the socioecological model to structure an analysis of transportation accessibility and modernization within the VA, a uniquely complex federal healthcare system. By capturing the perspectives of internal VA transportation professionals across states, this work surfaces operational challenges and system improvement opportunities that are typically absent from evaluations centered only on veteran users. It also introduces new insight into the feasibility and policy implications of deploying ARSS within a federal healthcare environment, bridging gaps between innovation, infrastructure, and public service delivery. These findings provide an overview of the VA transportation system’s current state, indicating areas for improvement and offering recommendations for leveraging the identified opportunities. By addressing the weaknesses and capitalizing on the strengths and opportunities, the VA may enhance its transportation services to better meet veterans’ needs. This study offers insights for VA decisionmakers, transportation planners, and industry partners to advocate for policy adjustments and collaborative efforts to optimize service delivery.

Limitations, Strengths, and Future Directions

Some participants may have been hesitant to respond due to concerns about professional implications; however, confidentiality was assured, and open-ended questions allowed discretion in answering [26]. An inherent bias of participants may be present, as those who agreed to participate might have had more positive attitudes and perceptions towards ARSSs. The absence of representatives from the Beneficiary Travel Program and Veterans Transportation and Community Living Initiative may have limited insights into these programs. Additionally, the geographic concentration of participants in Florida may have skewed findings toward state-specific issues. The small sample size may have also limited the diversity of perspectives, and the study could have benefitted from additional interviews, particularly with representatives from the aforementioned programs that were not included. Although the study included participants serving as directors, analysts, managers, specialists, chiefs, assistant chiefs, and coordinators—covering administrative, planning, funding, logistics, operations, and mapping expertise—the perspectives gathered leaned toward managerial and administrative viewpoints. Insights from front-line staff, such as drivers or dispatch personnel, may be underrepresented. As a result, some relevant themes or divergent perspectives may not have been fully captured, which may limit the comprehensiveness and generalizability of the findings.

A key strength of this study is the knowledge and experience of participants in VA transportation, representing various roles, sectors, and departments. The semi-structured interview format enabled in-depth discussions, while Zoom facilitated participation across six areas in four states. These qualitative insights, although limited to the geographic regions as previously stated, may provide initial guidance for decision-makers and stakeholders seeking to enhance transportation services for veterans. However, caution should be exercised in broadly applying the recommendations for ARSS implementation, particularly in rural areas, until additional pilot data are available. Future research should incorporate quantitative measures, such as surveys or operational metrics, to complement and validate the qualitative findings.

The integration of ARSSs presents an initial promising avenue for addressing transportation gaps, particularly in underserved areas. Our research team piloted an AS in a rural area to evaluate its benefits and effectiveness. Strengths and opportunities identified in the pilot suggest that AS deployment warrants further consideration, especially for first-mile–last-mile service. Weaknesses and threats were noted, some are being addressed in the next generation of the AS, including a redesigned chassis for improved on-road performance, enhanced accessibility and comfort features, and operational refinements, such as routine foliage trimming and optimized satellite antenna placement to improve communication. A longer, stable deployment may further enhance these elements while providing additional insights into feasibility and scalability. Based on the findings of this study, a practical next step would be to propose an ARSS pilot framework for VA settings that prioritizes deployment at urban hospital campuses with controlled environments, followed by phased rural expansion contingent on connectivity improvements and accessible vehicle design standards. Pilot testing within VA facilities, rural communities, and urban settings may provide insights into feasibility, scalability, and effectiveness in reducing transportation-related healthcare barriers. A broader, geographically representative sample and inclusion of participants across a wider range of frontline roles will be important in future ARSS assessments to refine recommendations for deployment across diverse VA contexts. Future research should also address the integration of ARSSs with broader smart infrastructure systems, particularly energy grids and cybersecurity frameworks. Given that ARSS fleets are likely to be electric, reliable integration with vehicle-to-grid services and protection against cybersecurity threats related to battery management systems will be essential for maintaining system stability and ensuring veteran safety.