Increasing Access: Reaching Out to Rural Veterans

Nearly 40 percent of enrolled Veterans live in rural areas of our country. This includes men and women Veterans of all ages, races and ethnic groups.  Like other individuals living in rural areas, Veterans have difficulty in obtaining access to quality health care. The reasons for this are multiple and varied, but mainly stem from the need to travel long distances to health care facilities, lack of health insurance, and lack of specialty care providers working in rural areas. As a result, rural populations tend to be in poorer health; in fact, a study by the Office of Health and Human Services estimates that half of the adults living in rural areas suffer from a chronic health condition. With regard to rural Veterans, there are the unique health complications associated with combat exposure such as PTSD, depression, and traumatic brain injury.

Over the past decades, VA has transformed itself from an in-patient tertiary care system to an out-patient health care system with an emphasis on prevention and patient-centered care using the electronic health record and patient aligned care teams. The Office of Rural Health was created in March 2007 to  bring this model of care to Veterans in rural and highly rural areas. It’s a model that can provide not only the specialty care that can meet the unique health needs of Veterans, but one that can also provide care to meet the needs associated with chronic illness and aging.

ORH has established six strategic goals and associated initiatives to accomplish their mission of increasing access to quality health care for Veterans living in rural areas. They include improved communications and outreach to rural areas, building and staffing community based outpatient clinics and outreach clinics, enhancing  tele-health capabilities such home-based tele-health and tele-mental health in rural areas, funding transportation systems to VA facilities from rural areas, and collaborating with non-VA clinicians to provide health care for women Veterans.  ORH is making great strides on all of our strategic goals. Using VA data sources, ORH can report the following progress:

  • From FY08 to FY10, over 217,000 Veterans from rural areas were enrolled through ORH outreach and communication efforts
  • Fifty-one VA community-based outpatient clinics were opened in rural areas
  • Thirty-seven VA Outreach clinics have been opened in rural areas
  • Within a new telehealth-based program that focuses on obesity, the number of services provided to rural Veterans rose 60% in the past year to 13,035.
  • The number of rural Veterans receiving mammograms, by both VA and non VA providers, increased 17% (20,447 in FY10)
  • The number of rural veteran outpatient primary care visits increased 18% to 5.5 million in FY10
    From FY09 to FY10, the number of rural Veteran telemental health encounters increased 23%

Although we are proud with our progress, there is still much to be done to provide rural Veterans with the care they deserve. ORH is committed to fulfilling our mission and will report back here on our progress as well as the impacts our programs and initiatives have made to improve the health and well-being of rural Veterans.

Mary Beth Skupien, PhD, MS, RN, is the Director of the Office of Rural Health for the U.S. Department of Veterans Affairs.

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24 Comments to “Increasing Access: Reaching Out to Rural Veterans”

  1. Jerry Pfannenstiel says:

    This a very well written and honest account of how the VA healthcare system has and is delivering services to our rural veterans. The VAHCS deserves a pat on the back for realizing the need and acting on that realization.

    Now if we can get VASH vouchers in our rural counties, that would be a huge help. If the VA would look at working with the local community action agency and housing authorities as partners in administering the program we could help house our homeless rural veterans.

    Thank you VAHCS for all of you hard work.

    • Thank you for your comments and suggestions. ORH is currently updating our strategic plan and we will look into this. In addition, ORH is partnering with the VA Office of Mental Health in a National initiative to expand outreach services for homeless Veterans living in rural and highly rural areas across the VA system. This initiative is an expansion and integration of VA’s existing Rural Access Network for Growth Enhancement (RANGE) program, the Healthcare for Homeless Veterans programs, and where applicable, the collaborative Department of Housing and Urban Development and VA Supportive Housing (HUD-VASH) Supported Housing program.

  2. Dan Flynn says:

    I live in a rural area that has a CBOC located about 25 miles from my home. The only problem is that the services are very limited. If you have more than a cold, it requires another appointment at the VAMC which is a 140 mile round trip for me.

    A recent issue I had caused me to go to the CBOC. I had a diagnosis of the problem and tests done by a private physician two years prior to bringing this up to the VA. My PCP referred me to the VAMC to a specialist. Upon seeing the specialist, I was told he couldn’t help me as they do not have the facilities for the test I needed (which I already had, even though they were two years old) . He referred me to the controlling VISN hospital which is a two hour drive.

    Of course, the first visit there ended up with just an evaluation and another appointment for the test. At the next appointment the test was performed by a resident outside the direct supervision of the Attending Physician. He caused further injury because of his lack of expertise.

    All in all, I wasted four days of traveling to have them tell me something I already knew. Of course, this left me with no confidence in the VA’s ability to perform successful surgery. To make a long story short, I ended up going to a private physician and had an operation done under medicare (which cost me $3,200 out of pocket). To me, it was the best $3200 I have ever spent.

    Is it any wonder that vets feel they get jerked around? For me, even though I am 100%, I would rather pay medicare deductibles and co-pays then to go jumping through hoops by minimally qualified health care providers. My PCP has agreed to work with a private physician I have to provide medications and that is all I will use the VA for from now on.

    The whole VA system should be torn down and a system of medicare type reimbursement made to private physicians. Although I have met a few caring individuals, the system is ripe with people covering their butt and more concerned about what to enter in a computer.

    I doubt that you will publish this. However, I get sick of reading that everything is getting better. It is hard to believe it could get worse.

    • David McCullough says:

      Aloha Dan,

      My name is David McCullough and I am an Emergency Room Nurse at the San Francisco VA Hospital. I was checking out my pay online and started following the links and saw your letter. Sounds like you had a bad experience brother and I want to apologize to you from my end – its not official since I am not authorized to speak for the VA but let me tell you something – if you ever walk through my doors in my ER you will get the best service I and the rest of our staff is capable of giving.

      I’m not a RA RA kind of guy either Dan. I am also a volunteer fire fighter on my days off in a very rural area about 2 1/2 hours drive North of San Francisco. I get what it means to live far away.

      I am not trying to change your mind about coming back but I hope you give us a try. Only if you write this letter, contact the patient advocate and make us work to improve the system will things get better. We work very hard to earn your trust and I tell you this now, I want to earn it back. I make no excuse – we can always do better – but we do blow it like everyone else at times and all we can do is work hard to improve.

      I Strongly and Completely disagree that the ‘the system is ripe with people covering their butt and more concerned about what to enter in a computer’. Yes, of course any system has that going on to an extent but let me tell you this . . . I don’t tolerate that in my ER (and I don’t own it but I take ownership and I am proud of what we do). The VA system is huge – way bigger then even I know since I have only been on board for two years. So to ascribe this fault to the whole system is not right – but I get the frustration and anger, I really do.

      Don’t be too quick to discount me because I work for the ‘man’ – for the VA. No one knows I am going to push the publish button and I hope the site moderator lets my email through! But check out this book, bought it from Amazon.com – Best Care Anywhere – Why VA Healthcare is Better Than Yours. The author is Phillip Longman. It reads pretty easily – my brother turned me onto it.

      And I tell you this – it can get better and it will . . . it is every day. A lot of you sacrificed so much in service to your country – even when your country was WRONG. So it is my job, OUR job to see that you are provided the best service possible with all that good stuff we call sensitivity, caring attitude, dedication and an unflagging discipline to see that we do it right by all those who have served.

      My powers are limited but if you live in Northern California please look me up. Look, we both know the system is not perfect but a lot of these guys love this darn place, the staff and the service. The book has a lot of hard numbers about the quality of the medicine and hell, you and I could argue about that till the end of time but the VA is leading the way in how to do medicine in so many ways. Check the book out.

      Last but not least – there are not enough private physicians available to suck all you guys up into their care! I welcome your attitude, we need people to push the system to be better. You are welcome to look me up so you can learn I am not just some guy who shills for the VA!

      Thanks for your service in the past Dan and in writing your letter. I’ll throw the gauntlet down to you – help us make it better. You took that step already by writing that letter. I wish you the best and you are always welcome the VA sir. I will be proud to meet and take care of you.

      Best Regards,

      David McCullough, RN
      San Francisco VA Emergency

  3. Thank you for your comments. We appreciate your feedback.

  4. Mike McLeod says:

    I am excited about VA’s desire to help rural vets. Our round trip is over 155 miles and an all day affair. As the local VSO, I am trying hard to coordinate efforts between our local private rural clinics and the RO. I think for some of the simpler procedures, this would greatly reduce the burden on the VAMC and expenditure while assisting our local vets. I appreciate the outreach and efforts.

    • Christopher Barry says:

      I must agree with Mike. I drive over 200 miles to the nearest VA Facility. I also have private health insurance. If the VA would pay a fee basis it would only cost the VA 30 dollars rather than to pay the 58 dollars for my gas and mileage. That is over a 20 dollar savings for the VA and multiply that by the 24 drives I make per year. Sadly the politicians are more worried about spending money on building a parking garage to over pack a hospital rather than building a better plan on saving money by allowing veterans to see either private doctors or having a new hospital built closer to the rural areas.

  5. Richard Clinton says:

    Just what is considered rural. I live 45 minutes from the Charlottesville Clinic which is great for routine checkups but, if I attempt to make an appointment for an illness the wait is 2-3 weeks and I’m sent to McQuire “emergency” in Richmond which is an hour 15 one way. How about getting some support at the Clinics, they are understaffed if the wait to see a Dr. is 2-3 weeks. This was not a one time occurrence, it’s every time…
    The sad part is I like my Dr. in Charlottesville a lot and I’ve had good experiences at McQuire as well.

  6. Jolene Michaels says:

    I am stuck between two V. A. hospitals, each about 200 miles in opposite directions from me. I have no idea why I can’t go to a civilian hospital that is only 25 miles away in order to get the MRI and x-ray tests that I need for my knee. I am going to have to take a whole day (maybe more) off of work in order to go to the appointment.

    I am thankful the V.A. system doesn’t have any mammography machines because I can at go to a closer facility (of my choosing) for those. As it is, I have to drive fifty miles to get to a V.A. clinic. I have to say that the doctor and staff are great and they really seem to care about us.

    Thank you for working so hard. I know the problems can’t all be fixed in a short time.

    • Jolene Michaels says:

      Update:
      I just got my appointment notification in the mail and have to go to Milwaukee for an MRI. This is an 8 hour drive each way and I would have to take two days off of work plus pay for gas, food and a night in a motel. If I was going to the appointment, that is. I am cancelling it and will live with my problem for now.

  7. Don Lathrop says:

    Today I left my house at 8 am for a 3 hr drive to do an MRI…I understand that this is necessary if you have no insurance and need things at VA but
    why not go to local hospital and have tests done and VA pay bill. I live between 3 hospital choices from VA…like 2 of them and saying that of those 2 only 1 has parking at time of arrival…this morning spent 30 min in the parking lot at buffalo and still thought i was going to have to say the heck with this…I have handicap parking but never has a handicap spot in all my visits there…Let us go to local hospital and have VA pay…

    • The local hospitals do NOT like Tri-Care, CHAMPVA or VA since they pay low and slow and have no cross communication between VISN’s. Part of the problem is at
      the local hospitals whose billing staff do NOT know where to send the bill or how to bill the VA and usually screw up even when you leave clear written instructions for them. But even if they do it right the VA sends the money when they send it and seldom does so before the hospital sends the bill to collections.

  8. Cindy Miller says:

    I am a registered nurse, BSN, and have been trying to get a job at the VA outpatient clinic in Hickory, NC ever since it opened. Sometimes I get a response regarding my application and sometimes I don’t. I have been recommended for a job there by current employees who know me but the hiring is done through the Salisbury VA. I would like to know if there are special qualifications they are looking for. I am a certified wound care nurse and have 12 years experience in home health and most recently,more than 10 years experience in a hospital outpatient clinic. I also have experience in acute care.
    My husband recently returned from a year’s deployment to Afghanistan and will be deploying to Kuwait next year. My son will be deploying to Afghanistan in a few months. I would like to do my part to support our military and feel I could do that best with my nursing skills. Any suggestions?

  9. Ron Norton says:

    Most people would look at your suggestion and say one thing, “There’s a problem in your thinking, it’s logical.” I have a neurological impairment which is Service Connected. It caused me to have a long history of different types of seizures and many people had no idea what was going on inside of me. This includes me. I had silent seizures, first. People would see me and I was staring out at nothing. I don’t blame or I’m not angry at them because we both didn’t know. Many people are confident when they understand the situation, when they don’t, they’re scared of you. But anytime I went to get a job, it would last only as long as the next episode. When he came to the subject of driving something inside of me said no. I’m glad I listened what would’ve happened if I had a seizure while driving? With the help of my family, I survived. I was like a leper, when I began to think about getting a job. In the mid-90s I was certified as, “Unemployable my the VA and the issues with the seizures caused by encephalitis causing ear drum rupture in one ear and total loss ear drum w/ ossicles (2 small bones in the inner ear). As in anything with medications, there are the side effects. But the condition itself has caused a real problem with travel. How to we define travel? For me, there was always the question of mode of transportation. This is not about driving, is about riding in a car, van or bus. These are the things that are a very real threat to my survival. For a long time, I always figured, “if I have a problem, I can only walk home.” Well, my body has put a new requirement, stay near the house!

    Now, let me get back to the article written by Ms. Skupien, she makes an excellent point, the VA is trying to find new ways to help the Veterans. As we look at the VA clinics over the past, I would suggest everybody talk with their primary care provider if there having a problem. With this new concept of “E-Consult”, this is showing a foundational shift in VA’s concept of both the clinic and the hospital and the relationship between the two, three, four or whatever. From one, Very Grumpy old Vet, this sounds like a good idea. Don’t tell anybody, but I believe over the long haul, it will save money and make the nurses at the clinic’s feel more secure.

    Ron Norton “Grumpy”

  10. Tom Lacombe says:

    Although I am very well pleased with the VA, I have a comment in regards to the placement of the clinic I visit. I was served by a clinic in Stephens City, VA, which is 27 miles from my home. A couple years ago it was moved to Kernstown, VA which is a 31 mile trip for me. They moved 4 miles farther from me and 4 miles closer to the Martinsburg VA Hospital, which is about 51 miles from me. Maybe that makes sense to someone, but not to me.

  11. Rick Wheaton says:

    I’ll admit I’ve been spoiled by having the pleasure of being only a few miles from the Cheyenne VAMC. A real hospital in a relatively small town. Soon I’ll be moving to Northern Minnesota, 175 miles from Minneapolis VAMC. I can only hope the clinics on the Iron Range and the new technologies being implemented will be adequate for my needs. At the very least I know my records will be available when I get there.

    I’ve been happy with the VA so far, I hope it continues.

  12. Shari Thomas says:

    Hello, I read with interest the establishment of an Office for Rural Health Care.

    I am a Vietnam Era Veteran, and have only recently (2009) requested assistance from the VA for my health issues.

    I live in a very rural valley in SW Utah, with the nearest Veterans clinic being 65 miles one way (about a 1.5 hour drive each way). I don’t drive, so must have someone drive me to any appointments. Once a month, the Senior Citizen van may or may not be available to go to St. George.

    So far, I’ve had a mammogram with follow-up ultrasound, which the VA tried to tell me wasn’t covered. They were trying to make my breast “service connected” to which I reminded them that yes, they (my breasts) were with me every step of the way during my three years of active duty. It only took a year to get that settled.

    I will say that the VA has been very cooperative with requests for Physical Therapy at a non-VA funded location. In fact, the PT clinic prefers VA to either Medicare or Medicaid when it comes to billing and payment.

    Over the two years, all of my providers in St. George (I had open heart surgery at Dixie Regional Medical Center) have bent over backwards to work with the VA, only to be told that “no”… if I need specialized care or tests, I’ll have to go to Salt Lake City. For me, that is a 5 hour ride one way.

    There is a van that goes from St. George to Salt Lake City, but I would have to get a ride to Cedar City at 4 AM in order to meet the van. I would then return to Cedar City the same day, at sometime after 11 PM.

    I understand that I have chosen to live where I do. I also remember that my contract with the government was that I serve you, you take care of me. You didn’t tell me I had to live in a big city, or be willing to put up with all kinds of billing errors, run arounds, etc.

    Now, I also understand you really can’t put a clinic in this valley, as there are less than 100 vets in a population of about 1000 over about the same square miles. However, there is a very good clinic in Enterprise (south end of the valley) where we can at least get initial diagnosis before having to go either to Cedar City, or to St. George.

    I don’t buy the idea that private physicians (including clinics or hospitals) don’t like to deal with the VA. Please, allow those of us with very good non-VA facilities to use them and reimburse them for our care. That could save thousands… maybe millions of dollars.

    Can you imagine how simple it would be for a veteran to simply make an appointment with the health care provider of choice, and have a VA card, a Medicare card, and any other insurance, allowing the provider to choose the method of payment.

    Thanks for allowing my input,
    Shari Thomas
    Beryl, UT

  13. Kelly Green says:

    I am in the center of two VA Medical Centers both 3 to 4 hrs away – 2 other VA Medical Centers 5 to 6 hours away and 1 CBOC right here. The problem in which I am seeing is that resourcing out to local medical care or specialist is not being done. We currently have no mental health professional(s) at the clinic and who knows when and instead of resourcing out they are telling patients to wait for maybe a once a month visit. I don’t know of many mental health issues that wait for a once a month session to help with issues. VA needs to allow more resourceing out patients with they say their biggest concern.

  14. James Scott says:

    I live 200 miles round trip from the va hospital. I am an OIF veteran that is waiting for my disability to get processed. The va will not pay travel pay until I get a disability rating. With gas at $4, it makes it very hard to get to an appointment. The va needs to pay travel for OIF veterans that are waiting for their rating and need medical treatment due to injuries from their service or the va needs to let us use our rural health clinic right here in town. I realize that rual health clinics cannot provide all the necessary treatment, but, as it is now, a recent OIF/OEF vet has to wait 6 months+ to get a rating from the VA and for many not having the ability to get to treatment is the same as not providing treatment at all for the recently returned combat vets when they need it the most–right when they get home.

  15. Joe Owens says:

    I am the VA Liaison for Operation Outreach. VA is trying to reach out to rural veteran. At least in Northern Maine. This is just some of what we provide to our veterans. God Bless each and everyone of them
    OPERATION OUTREACH is a new healthcare services program developed collaboratively by AMHC and the VA Maine Health Care System (VA Maine HCS) for Veterans in Aroostook and Washington Counties. The first of its kind in Maine. OPERATION OUTREACH offers Veterans access to substance abuse and mental health treatment closer to home, without having to first go to the VA clinic or to the medical center at Togus. Under OPERATION OUTREACH, AMHC offers: 1) substance abuse treatment to any Veteran eligible for VA Maine health care services; and 2) peer support, mental health, and readjustment counseling services to Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) Veterans.

  16. Tom Caldwell says:

    I am a OIF vet living in Rural North Dakota. Being a rural vet I travel long distance over 300 miles round trip twice a month. The VA works well in resourcing out major medical issues to my local Hospital to avoid driving to my closest CBOC which is 200 miles round trip. I hope that other VA facilities will follow the lead of the Black Hills VA system it rocks.

  17. Simmering says:

    This isn’t something that needs to happen ‘eventually’, it needs to happen NOW. It’s absurd for anyone in the VA upper-echelon to delay ‘outsourcing’ medical care to private facilities in rural areas. Most physicians and clinics will happily work with ANY entity who will pay them for their services. The model for doing this already exists with MediCare/MediCaid. The VA doesn’t need to ‘invent’ anything in that regard. Simply make it possible for private medical care providers to bill the VA at the time of service to the vets.

    Instead, the VA sticks to its slow, lumbering nature and rationalizes and justifies every lagging step. Ideas are not enough. The idea needs to be IMPLEMENTED. Also, IF services are already in place – such as mobile PTSD units to rural areas etc etc – the VA needs to do mass mailings to all vets, put up posters everywhere ( public libraries, colleges, etc ) and not just inside the VA hostpitals and clinics about these services INCLUDING detailed instructions on how to access them.

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