VA Rural Health Initiatives: Improving Access to Care for Veterans in Rural Communities

1. VETERANS HEALTH ADMINISTRATION Office of rural Health Iowa City VA Health Care SysteM Carolyn Turvey, Ph.D. Bryant Howren, Ph.D.

2. Rural health Legislative mandate

3. Office of Rural Health’s Goals

4. ORH Program Overview - 2019 • 2019 portfolio includes more than 45 national access initiatives adopted at 97 percent of VA medical centers across the country • All are designed to increase access to care for rural Veterans • Rural Promising Practices are field-tested, innovative projects that meet ORH criteria demonstrating increased access to care for rural Veterans • Six in mentored implementation spread to more than 100 sites across VA • Enterprise-Wide Initiatives enable VA to rapidly address systemic health care and access challenges experienced by Veterans in rural communities and expand national program office access efforts to sites serving rural Veterans • ORH leverages resources to study, innovate and spread Enterprise-Wide Initiatives through local and national partnerships

5. Enterprise-Wide Initiative highlights • Teleprimary Care • establishes teleprimary care hubs with spoke sites to ensure access to primary care in rural areas where providers are unavailable • Telemental Health Hubs • connect mental health specialists with rural-serving sites where Veterans require same-day or urgent access to mental health services and where access is limited due to provider shortages or other barriers • TeleIntensive Care Unit (ICU) • connects VA facilities that do not have intensivists on staff with VA intensivists nationwide via telehealth to increase access to ICU services and specialty inpatient care for rural Veterans • Telerehabilitation Services • expands an integrated network of specialists who are specifically trained in delivering physical and rehabilitative therapy to rural Veterans using telehealth technology • National Telestroke Program • provides emergent telehealth care by qualified stroke neurologists in a timely manner to Veterans presenting symptoms of stroke at rural-serving VAMCs that do not have stroke neurologists on site

6. Brief Overview • VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 • Five titles, both amending and creating new sections of law • Title I – Caring for Our Veterans Act of 2018 • Subtitle A – Developing an Integrated High Performing Network • Subtitle B – Improving Department of Veterans Affairs Health Care Delivery • Subtitle C – Family Caregivers • Title II– VA Asset and Instructure Review (AIR) Act of 2018 • Subtitle A – Asset and Infrastructure Review • Subtitle B – Other Infrastructure Matters • Title III – Improvements to Recruitment of Health Care Professionals • Title IV – Health Care in Underserved Areas • Title V – Other Matters

7. Quick Facts • Expands and amends the current VA program structure for more effective care across VA and community care providers • Community Care Program streamlines the process for Veterans to receive community care • Sets stricter guidelines for VA payment to community providers • Expands medical education through residencies, scholarships, and education debt reduction • Provides for more medical resources to underserved facilities in rural areas • Requires VHA to report market area assessments, performance reviews, and VA standards for care to congress between every one to four years

8. New Portfolio domains: Care in the community • Identification of Reoccurring and Systematic Issues of VA Choice Implementation Among FQHCs- Mengeling • Pilot and Feasibility Program to Link Veterans in FQHCs with Mental Healthcare in VHA- Howren and Abrams LONG TERM GOAL: Define role of VHA in the context of the US health care system based on veteran preference and VHA strengths. Identify the most effective clinical, technical, and administrative processes to support that role.

9. New portfolio domains: Mental Health Developing systematic screening and referral for Veterans seen in psychiatry at academic affiliate- Turvey Exploring community data bases that include information on Veteran substance abuse treatment seeking LONG TERM GOAL: Develop identification and referral processes between VHA and community care to ensure timely high quality mental health care for all Veterans

10. Expanding portfolio domains: Substance Abuse VET-MAT-IA for Veterans with Opioid Use Disorder Developing a collaborative care model to improve access to medication assisted treatment for rural Veterans with substance abuse and opioid use disorders • Alison Lynch, M.D. • Tony Miller, M.D. LONG TERM GOAL: Improve access to evidence based care for Veterans struggling with substance use disorders and provide comprehensive wrap-around services to ensure full recovery.

11. Office of Rural Health Director’s Meeting Promising Practices • Home-Based Cardiac Rehabilitation • Bonnie Wakefield, PhD, RN (Iowa City VA) • HIV Telehealth Collaborative Care (TCC) • Michael Ohl, MD, MSPH (Iowa City VA) • Using Clinical Video Telehealth (CVT) to Provide Comprehensive Care to Rural Veterans with MS • Amy Kunce, MS, BSRS (Baltimore VA)

12. Office of Rural Health Director’s Meeting Home-based Cardiac Rehabilitation • Cardiac rehabilitation (CR) provides significant benefit to those with cardiovascular disease • Access to CR services is often limited due driving distance, travel cost, and time away from work • 12-week telephone based program counsels patients on exercise, nutrition, smoking cessation, stress management, and medication adherence

13. Office of Rural Health Director’s Meeting Home-based Cardiac Rehabilitation Note: In total HBCR is in 28 VA sites including 9 spoke sites (served by 4 VAs)

14. Office of Rural Health Director’s Meeting Home-based pulmonary rehabiltation • Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality • Optimal outpatient care for this disease includes a complex set of interventions including pulmonary rehab • However, less than 50% of patients receive this outpatient care • Modeled after Home-Based Cardiac Rehabilitation, this program brings pulmonary rehabilitation services closer to the patient’s home

15. Office of Rural Health Director’s Meeting HIV Telehealth collaborative care (TCC) • Rural Veterans living with HIV travel long distances to reach the specialty clinic, bypassing nearer primary care clinics • This program addresses this issue through four main activities: • Clinical video telehealth to deliver HIV specialty care closer to home • Shared-care relationships with local clinics • Nurse care manager to coordinate care • Registry to facilitate population management

16. Office of Rural Health Director’s Meeting HIV Telehealth collaborative care (TCC) • Five sites are participating in the implementation of this program in FY18 • Atlanta, GA • Dallas, TX • Dayton, OH • Houston, TX • Indianapolis, IN

17. Office of Rural Health Director’s Meeting Expansion of Comprehensive Telemedicine-Based Diabetes Care for Rural Veterans • Diabetes contributes to renal failure, lower-limb amputation, blindness, heart attacks and strokes • Controlling diabetes helps limit these complications • This program specifically targets improvement in HbA1c • Evidence-based telemedicine intervention • Combines telemonitoring with self-management support & medication management

18. Office of Rural Health Director’s Meeting Expansion of Comprehensive Telemedicine-Based Diabetes Care for Rural Veterans • Adapted for rural Veterans and pilot tested in FY17 • Pilot largely successful & initial site continues to deliver the ACDC maintenance intervention to 15 rural Veterans • Site also enrolled 10 additional Veterans during FY18 • Expansion to additional site in FY18 • Enrolled 12 Veterans to date with plans to serve an additional during Q4 • Began qualitative evaluation on program delivery & implementation late in FY18 • Results expected during FY19 • Additional expansion of the program in FY19 includes a third site • Denver VA

19. Rural Health Community Coordinator Program

20. Community Provider perspectives • “With VA, we get nothing...[W]e need something we have to call the VA or have the patient acquire it...Nothing is ever sent automatically from VA...and most of the time I don’t even know that they see the VA...” (non-VA) • “What would be really ideal is if there were an interface between the community and the VA system where if a patient gets lab work done at the VA, or diagnostic studies done at the VA, or a colonoscopy done at the VA, right? Then, that stuff would come in and integrate with my system.” (non-VA)

21. Veterans Lifetime Information Exchange VHIE- formerly VLER Bi-directional exchange that gives VA and non-VA health care providers secure access to certain parts of the Veteran’s electronic health record through the eHealth Exchange. TO DATE: VA patients must opt in to sharing their information by signing VA Form10-0485 (includes sensitive health data, ie. Sickle Cell Anemia, Drug Abuse/Alcohol Abuse, treatment/testing for HIV)

22. Rural Health Community Coordinators • Promote patient awareness and authorization for the program • Promote provider adoption and “meaningful use” of VLER/JLV – electronic health information exchange • All is overseen by Joseph Nelson, Lead Program Specialist- Pittsburgh

23. VA Direct Messaging Vital Signs VA Direct Messaging Vital Signs # Direct Messages Month to Month (2 years)

24. VA Direct Messaging: Validated Partners/ Community Care Providers (CCPs) by VAMC To view the interactive map, click here (My EES- inside VA network) or here(Google- outside VA network) Community care partners/ providers connected with VA Direct Messaging VAMCs with Direct Messaging partners VAMCs with no Direct Messaging partners yet

30. Office of Rural Health Director’s Meeting Pilot and Feasibility Program to Link Veterans in FQHCs with Mental Healthcare • VA has developed extensive expertise in delivering evidenced-based PTSD care to Veterans • However, many still receive care from outside providers including FQHCs with little interaction with VA

31. Office of Rural Health Director’s Meeting Pilot and Feasibility Program to Link Veterans in FQHCs with Mental Healthcare • This program is a partnership with a FHQC in Burlington focused on: • Screening for Veteran status at the clinic • Screening for mental health symptoms and unmet care needs • Linking Veterans with symptoms to a VHA mental health care navigator • Delivering VA mental health care using a CVT or home telehealth device • Coordinating VA mental health care with rural community-based primary care

32. Office of Rural Health Director’s Meeting Identification of Issues with VA Choice Implementation Among FQHCs • The Veterans Access, Choice, and Accountability Act (VACAA) implemented to improve access to timely, high-quality healthcare for Veterans • Aim of this project is to explore common & reoccurring issues in administration of community-purchased care • Method of evaluation is a survey with FQHCs, Rural Health Clinics, and Critical Access Hospitals

33. Office of Rural Health Director’s Meeting Rural Veterans’ Access to VA and Non-VA Health Care Providers • The Choice Program was designed to become the vehicle by which Veteran patients seek non-VA care • Success of this initiative is dependent on the availability & capacity of providers • Purpose of this study is to quantify geographic access to community providers and describe the use of VHA “in-house” and community-purchased care among rural Veterans • Analysis also focused on creating regional scenarios for community provider availability

34. Office of Rural Health Director’s Meeting Improving OEF/OIF/OND Veterans’ Mental Health and Functioning • ~40% of OEF/OIF/OND Veterans meet diagnostic criteria for depression, posttraumatic stress, and/or other anxiety disorders • However, these Veterans often face significant barriers to seeking and engagement in treatment • Rural and highly rural Veterans specifically face both distance barriers & additional perceived barriers related to stigma of mental health treatment in small communities

35. Office of Rural Health Director’s Meeting Improving OEF/OIF/OND Veterans’ Mental Health and Functioning • Program will use existing partnerships with Veteran-centered organizations to identify OEF/OIF/OND Veterans who may not otherwise seek help • Collaborations with United Way, Hope for Warriors and Combined Arms • Deliver a 1-day Acceptance and Commitment Therapy (ACT) workshop in rural community-based settings and CBOCs • Goals are to establish feasibility and acceptability, obtain preliminary data on effects of the workshop, and engage key VA and community stakeholders in the development of a toolkit

36. Office of Rural Health Director’s Meeting Harnessing Community IT Infrastracutre to Implement a Population Health Model • Project aims to identify how VA works with these community providers for rural Veterans seeking mental health or substance abuse treatment • Identify clinical workflow and underlying information technology support • Understand the overall effectiveness of treatment • Develop protocols for referral or consult with VHA Mental Health Services

37. Questions