Caring for Rural Veterans
Overview of the Office of Rural Health
Thomas F. Klobucar, PhD
Deputy Director
#/Month 2015
Today’s presentation
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Overview of the U.S. Department of Veterans Affairs
Rural Veterans
Office of Rural Health
Environment
VHA ORH Activities and Projects in Region A
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Overview
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Mission of the U.S. Department of Veterans Affairs (VA)
“…to care for him who shall have
borne the battle and
for his widow and orphan…”
- Abraham Lincoln, 1865
Photo by Jeff Kubina
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What is the U.S. Department of Veterans Affairs (VA)?
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Established in 1930
Elevated to Cabinet level in 1989
United States government’s 2nd largest department after the Department of
Defense
Three components:
– Veterans Health Administration (VHA)
– Veterans Benefits Administration (VBA)
– National Cemetery Administration (NCA)
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Organization of the U.S. Department of Veterans Affairs
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Organization of the Veterans Health Administration (VHA)
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Veterans Health Administration “Footprint”
167 Medical Centers
14 VA Health Care Centers
749 Community Based
Outpatient Clinics
272 Other Outpatient Services Sites
(including Mobile Clinics, Outreach Clinics)
370 Veterans Centers (including Mobile Veterans Centers
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VETERANS HEALTH ADMINISTRATION (VHA) OFFICE OF RURAL HEALTH (ORH) - 7
21 Veterans Integrated Service Networks (VISN)
IN JANUARY 2002
VISNS 13 AND 14
WERE INTEGRATED AND
RENAMED VISN 23
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Office of Rural Health Policy Regions
ORHP Region A overlaps with:
• VISN 1
• VISN 2
• VISN 3
• VISN 4
• VISN 5
• VISN 6
• VISN 9
And contains
• 45 VA Medical Centers
• 160 VA Community Based
Outpatient Clinics
• 58 VA Outreach and Mobile
Clinics
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Definition of Veteran for VA Purposes
• Veteran is a person who:
– Served in the active military, naval or air service
– Was discharged or released under conditions other than
dishonorable
• Former or current Reservists, if they served for the full period
for which they were called (excludes training purposes)
• Former or current National Guard members if
activated/mobilized by a Federal order
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Rural Veterans
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Eligibility for VHA Healthcare
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Eligibility for VHA health care services depends on a number of qualifying factors,
including:
– The nature of a Veteran’s discharge from military service (e.g., honorable, other than
honorable, dishonorable)
– Length of service
– VA adjudicated disabilities (commonly referred to as “service-connected disabilities”)
– Income level
– Available VA resources
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As VA’s Rural Veteran Population Grows, VA Continues to
Address Their Unique Needs
• 22 million Veterans in the United States,
5.2 million or 24 percent live in rural areas
• Rural minority populations (of 5.2 million)
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7% Women
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4.7% African American
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2.2% Hispanic
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1.2% American Indian/Alaska Native
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0.3% Asian American and Pacific Islanders
• 33 percent, or 3.0 million, are enrolled in
VA’s health care system
• 58% of all rural Veterans rely on VHA for
health care
• 36% of all urban Veterans rely on VHA
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The most common
outpatient diagnoses
among rural Veterans are:
 High blood pressure
 Post-traumatic Stress
Disorder (PTSD) and other
mental health diagnoses
 Type II Diabetes
 Tobacco use disorder
 High blood cholesterol
 At least one serviceconnected disability
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VA Patient Population and over 20 General Population
by Age Group
The VA Patient Population is Older than the General
Population
The age differential is more pronounced among Rural
and Highly Rural Veterans
57%
53%
46%
Highly Rural
Rural
Urban
Adult General Population 28%
26%
26% 27%
36%
19%
18%
15%
9%
11%
11%
8%
<40
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9%
40-49
50-64
65+
VHA Office of Rural Health
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VA’s Office of Rural Health (ORH)
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In 2006, Congress created the Office of Rural Health (ORH) by enacting Public Law
109-461, Sec. 212
As the VA’s lead proponent for rural health, ORH works to see that America’s
Veterans thrive in rural communities
Mission: Improve the health and well-being of rural Veterans by increasing their
access to care and services
Works across VA and with external partners to develop policies, best practices and
lessons learned to improve care and services for rural and highly rural Veterans
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Office of Rural Health components
• Office of Rural Health (ORH) Central Office
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Provides national leadership on issues pertaining to rural veterans
Administers special purpose appropriation and resources
Provides technical assistance, project monitoring and performance analysis functions
Coordinates Indian Health Service /VA Memorandum of Understanding (MOU) to promote access for American
Indian/Alaska Native Veterans
• Veterans Rural Health Resource Centers (VRHRC)
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Three regional centers: Togus Maine; Iowa City, Iowa; Salt Lake City, Utah
Serve as rural health experts
Field-based clinical and education laboratories for VA demonstration projects/pilot projects
Provide programmatic support and technical assistance to funded VA partners
• Veterans Integrated Service Network (VISN) Rural Consultants (VRC)
• Serve as primary interface between ORH and VISN rural activities and projects
• Develop rural health service plans based on VISN-wide needs assessments
• Perform outreach to develop community relationships
• Veterans’ Rural Health Advisory Committee (VRHAC)
• Federal advisory committee to advise the Secretary of Veterans Affairs on health care issues affecting enrolled
Veterans residing in rural areas
• Chartered by VA Secretary in 2008 to bring the voice of rural Veterans and their supporters to the national stage
• The appointed 16 person group’s recommendations inform priorities, policies and the focus of health care delivery
projects in rural communities in service to Veterans
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Organization of the Office of Rural Health (ORH)
VHA Assistant Deputy Under Secretary for Health
for Policy and Planning
Gina L. Capra, MPA
Director
Veterans Rural Health
Resource Centers
(VRHRC)
Thomas F. Klobucar,
PhD
Deputy Director
Secretary’s Veterans’
Rural Health
Advisory Committee
(VRHAC)
Strategic
Planner
Staff
Assistant
Byron Bair, MD
Director
VRHRC Western Region
Michael Ohl, MD
Acting Director
VRHRC Central Region
21 VISN Rural
Consultants (VRC)
6 Analysts /
HSS
Budget
Analyst
Program
Support
Assistant
Paul Hoffman, MD
Director
VRHRC Eastern Region
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Veterans Rural Health Resource Center,
Iowa City, Iowa
Veterans Rural Health Resource
Center, Salt Lake City, Utah
Veterans Rural Health
Resource Center,
Gainesville, Florida
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2015-19 Rural Health Strategic Plan
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The interagency supported
FY15-FY19 Rural Health Strategic
Plan strives for healthy rural
communities that support healthy
Veterans
ORH works across VA and with
external partners to develop
policies, best practices and lessons
learned to improve care and
services for rural and highly rural
Veterans
The top five states with the highest
numbers of enrolled rural Veterans
are Texas, North Carolina, Ohio,
Pennsylvania and New York
The top five states with the highest
number of enrolled rural women
Veterans are Texas, North Carolina,
Florida, Georgia, California
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ORH Five-Year Strategic Goals 2015-2019
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Environment
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Veterans Access, Choice and Accountability Act of 2014
• VA officially launched the Veterans Choice Program on November 5,
2014 in accordance with Public Law 113-146 , August 7, 2014
• The Choice Act provides $10B for community care if
• VA cannot appoint within 30 days of the Veteran’s preferred date, or;
• The Veteran resides more than 40 miles from their closest VA medical
facility, or;
• In cases of medical necessity
• Choice Act allows VA to expand the availability of community care for
Veterans through agreements with non-VA entities and providers
• This authority sunsets in three years or when Veterans Choice Fund is
expended
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Veterans Choice Act Rural Provisions
Contained in HR 5404 and negotiated by VA with Congress (passed House & Senate):
• Continued Project Access Closer to Home (ARCH) Pilot (Maine)
• Enhanced collaboration with IHS to increase access, quality and coordination
• Distinctions between use of mobile medical clinics and mobile vet centers
Contained in the Omnibus (passed in December 2014):
• Alaska and Maryland special payment provisions (beyond Medicare rates)
• Additional $209M for Choice Act medical staff hiring, facility expansion and
Caregivers-providing stipends to families of seriously wounded Veterans
• Inclusion appropriations for mandatory benefits (C&P; Readjustment; Indemnities)
• 14.98M for Health Resources and Services Administration’s (HRSA) small, rural
hospitals and $1M for tele-health pilots
• $10.3M for Dept. of Agriculture’s broadband expansion to rural areas for
telemedicine and distance learning
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Veterans Choice Act in Region A
All of Region A lies within Choice Act Region 1
VHA’s Third Party Administrator is Health Net
Except for a small part of Western West Virginia which falls in Region 3
Third Party Administrator is TriWest
Interested Providers can use this link:
http://www.va.gov/opa/choiceact/for_providers.asp
to get started
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Patient Centered Community Care (PC3): A Community
Contract Opportunity
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PC3 provides eligible Veterans access to health care through a comprehensive
network of community-based, non-VA medical professionals
Providers must meet VA quality standards when VA must supplement care outside
its own facilities
Provides eligible Veterans access to:
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Primary care
Inpatient specialty care
Outpatient specialty care
Mental health care
Limited emergency care
Limited newborn care for enrolled
female Veterans following birth of a child
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VA’s Contractor Third Party Administrator Geographic
Assignments
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Increasing Collaborations = Implications for Care
Coordination and Health Information Exchange (HIE)
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Veterans have more opportunities to formally receive care outside VA
Greater “dual-use” will increase demand for care coordination and HIE between
VA and community providers
– Dual-use is when Veterans use VA and non-VA health care services
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VA has a responsibility to ensure patients receive high quality care even when that
care occurs outside VA facilities
VA seeks to engage with community providers to deliver direct, query based
and/or patient driven HIE or electronic care coordination
How can we build off successes to date?
What must we keep in mind for future?
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VHA ORH Activities and Projects in Region A
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VHA Virtual Lifetime Electronic Record (VLER) Electronic
Health Information Exchange Partners
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http://www.va.gov/vler/
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Veteran Health Information Exchange Products
The Veteran (HIE)/VLER Health Program includes 2 options for sharing health data
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Exchange (Provider to Provider Direct) – allows VA providers and community providers
to query and retrieve health information with each other’s organizations
– Standards Based Exchange of relevant clinical information
– 42 Partners in production, in 40 communities
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Direct Secure Messaging– allows VA patients to send and receive health information to
community partners via secure email through a trusted Network
– Access through enterprise-wide web application and there is no installation or
support required by the VA healthcare System
– 18 Partners in production
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http://www.va.gov/vler/
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What Does Exchange Look Like?
Health Bank or
PHR Support Organization
State and
Local Gov
Community
Health Centers
Community #1
Acronym Key
-CMS – Centers for
Medicare & Medicaid
Services
-DoD – Department of
Defense
-PHR – Personal Health
Record
-SSA – Social Security
Administration
-VA – Department of
Veterans Affairs
Shared trust framework and rules
of the road
Labs
Powered by
Integrated
Delivery
System
The Internet
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Pharmacies
• Healtheway DOES NOT
maintain any data
• Healtheway IS NOT a
gateway or connection
point
Common standards, specifications and policies enforced through Data Use & Reciprocal Support Agreement
(DURSA)
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Direct Secure Messaging
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Direct leads to greater workflow efficiencies by providing a low cost alternative to
faxing and scanning
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Direct is a simple and secure way to send messages and medical information to
other providers, enhancing VHA clinicians ability to collaborate for Veteran patient
care
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Direct is built on well-established Internet standards, commonly used for secure
email communications
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Direct is required for Meaningful Use 2014 Certification which is facilitating
national adoption
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http://www.va.gov/vler/
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Veteran Initiated Electronic Care Coordination (VIECC) Pilot
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Goal 1: Improve quality and care coordination for rural Veterans receiving VA care
and care outside of VA (dual use) by using VA’s My HealtheVet Blue Button
capability to facilitate transfer of health information to non-VA providers for
healthcare
Goal 2: Evaluate if availability of VA health information at non-VA points of
care/appointment impacts care received (medication discrepancies, duplicative
tests)
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VIECC Agencies and Sites
National multi-site, multi-agency
collaboration
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My HealtheVet and VA Blue Button
• My HealtheVet- VA’s personal health record portal ww.myhealth.va.gov
• VA Blue Button – Veterans can download, view, and transmit (in testing) their
health information from My HealtheVet
• VA Health Summary – Interoperable document available in both machine (xml)
and human (pdf) readable formats
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VIECC Community Provider Feedback
“90 percent endorsed that information
from the Continuity of Care Document
improved my ability to have an accurate
medication list and make treatment
decisions about medications.” (n=71)
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“50.8 percent of providers endorsed “I
did not
order some laboratory tests or other
Procedures because of information
available on the VA Continuity of Care
Document.” (n=65)
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ORH Collaborative Workforce Initiatives
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Specialty Care Access Network – Extension for Community Healthcare Outcomes (SCANECHO)
– Program leverages telehealth technology to equip rural VA providers to manage
patients with chronic conditions closer to home
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Geri Scholars
– Aided geriatric health care providers in treating the special needs of older Veterans
– Served 185 facilities and 1,356 staff (e.g., primary care providers and pharmacy,
social work, psychology staff that support the care of older Veterans)
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Rural Provider and Staff Training Initiative (RPSTI)
– 21 VHA clinical sites serving rural Veterans where innovative training and educational
programs were developed for existing health care providers and clinic staff
– Training topics included palliative care, dementia, polypharmacy and substance use
disorders
– As of FY 2014, 4,962 clinicians and staff have been trained
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ORH Collaborative Workforce Initiatives (continued)
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The Rural Health Training Initiative (RHTI)
– Clinical education program launched in 2012
– 420 clinicians have trained at 22 VHA rural sites of care
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Telehealth projects
– ORH partners with Office of Telehealth Services to fund telehealth projects
such to provide services to rural Veterans where provider shortages or access
to care may be a challenge
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Requests for Proposals
– ORH funded more than 1,850 providers and non-clinical service providers in
rural communities (FY 2015)
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VA-Indian Health Service Partnership and National
Reimbursement Program
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October 2010: the VA Under Secretary for Health, and the IHS
Director signed a Memorandum of Understanding
Goals:
– Increase access and quality of care for American Indian/Alaska
Native (AI/AN) Veterans
– Improve health-promotion & disease-prevention
– Encourage patient-centered collaboration and communication
– Consult with tribes at the regional and local levels
– Ensure appropriate resources for services for AIAN Veterans
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December 2012: VA-IHS National Reimbursement
Agreement signed
August 2015: Veterans Access, Choice, and Accountability
Act Section 102 requires increased outreach, improved
metrics and further study of reimbursement agreements
across IHS programs and VA
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The MOU and
Agreements:
 Promote quality health
care through
collaborative
relationships and
agreements
 Focus on increasing
coordination,
collaboration, and
resource-sharing for
eligible AI/AN Veterans
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Tribal Health Program and Indian Health Service Facilities
Participating in the Reimbursement Program, FY 2014
Source: VA Chief Business Office Reimbursement Reports, FY 2014
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VHA’s Rural Veterans in SORH Region A
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513,000 total rural Veterans enrolled in VA in SORH Region A
28 percent of enrolled Veterans in SORH Region A live in rural or high rural areas
– Largest enrolled rural Veteran population: Pennsylvania (118,383)
– Smallest enrolled rural Veteran population: Rhode Island (2,069)
58 percent of the rural enrolled population is >65 years old
– 53 percent of the enrolled urban Veteran population is >65 years old
36 percent of enrolled rural Veterans have a service connected disability
– Same rate in urban population
11 percent served in the recent Iraq or Afghanistan conflicts
– 13 percent in the urban Veteran population
6 percent are female
– 7 percent in urban areas
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ORH Initiatives in SORH Region A
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218 funded initiatives since FY 2014
$91 million invested to increase rural Veteran access to care
180,000 total Veterans impacted
– 160,000 rural Veterans impacted
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Projects increased access to the following services:
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Mental health
Home based primary care
Pharmacy
Women’s health services
Nutrition and wellness
Geriatrics
Telehealth
Chronic pain treatment
Audiology
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Noteworthy ORH Initiatives in SORH Region A
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Project Access Received Closer to Home (ARCH) (ME)
– Legislatively mandated community care program active in 5 states that
includes care coordination
– Partnered with Cary Medical Center
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Maternity Care Coordination for Rural Women Veterans (MA)
– Network wide maternity care support including collaboration with community
providers
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TeleQuit Tobacco Cessation Program (NY)
– Increase access to tobacco cessation services through personalized telephonebased interventions
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Noteworthy ORH Initiatives in SORH Region A (continued)
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Rural Provider and Staff Training Initiative (RPSTI) (VT)
– Providers are trained to improve posttraumatic stress disorder care for Veterans
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Home Based Cardiac Rehabilitation (NH,CT)
– “Promising practice” where Veteran receives personal telephone-based cardiac
rehabilitation services in the home
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Telemental Health at Staunton, Wytheville, and Lynchburg Clinics (VA)
– Provides mental health care to rural Veterans at the most accessible point of contact
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Where are We Headed?
Eye on the Current…and Future Environment
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Affordable Care Act
– Medicaid expansion
– Health Insurance Marketplace Outreach and Enrollment
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Veterans Access, Choice and Accountability Act of 2014 (VACAA, “Veterans
Choice Act”)
– Geographic access: 40-miles or more
– Health care access point expansion mechanisms
– Leveraging federal health partners: Indian Health Service/Tribal Health Programs, Native
Hawaiian Health
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Rural Issues and Trends
– Population Migration and Demographics
– Workforce Development
– Technology Impact & Effective Use of Resources
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Thank you. Discussion/questions?
For additional information, please contact:
Thomas Klobucar, PhD
Deputy Director, Office of Rural Health
Thomas.Klobucar@va.gov
Adam Bluth
Senior Analyst, Office of Rural Health
Adam.Bluth@va.gov
Visit
ruralhealth.va.gov
Watch
http://youtu.be/yyIjKAa-kv0
Subscribe
http://www.ruralhealth.va.gov/news
VHA Office of Rural Health – 90K Street Room 703, Washington, DC 20002
Phone: 202.632.8615
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Supplement
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Definition of Urban, Rural and Highly Rural
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VHA uses the Rural Urban Commuting Area (RUCA) system to determine rurality
– Developed and used by the US Department of Agriculture (USDA) and the US
Department of Health and Human Services (HHS)
– Widely accepted and adaptable, very precise
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RUCA “tiers” determine rurality
– RUCA tiers are grouped into urban (U), rural (R) and highly rural (H) categories
using the scheme suggested by Washington State Department of Health.
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Map 2. Approved Urban, Rural and Highly Rural Areas
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