[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
CLOSING THE HEALTH GAP OF VETERANS
IN RURAL AREAS: DISCUSSION OF
FUNDING AND RESOURCE COORDINATION
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
MARCH 19, 2009
__________
Serial No. 111-8
__________
Printed for the use of the Committee on Veterans' Affairs
----------
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas VERN BUCHANAN, Florida
JOE DONNELLY, Indiana DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida HENRY E. BROWN, JR., South
VIC SNYDER, Arkansas Carolina, Ranking
HARRY TEAGUE, New Mexico CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas JERRY MORAN, Kansas
JOE DONNELLY, Indiana JOHN BOOZMAN, Arkansas
JERRY McNERNEY, California GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
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of converting between various electronic formats may introduce
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further refined.
C O N T E N T S
__________
March 19, 2009
Page
Closing the Health Gap of Veterans in Rural Areas: Discussion of
Funding and Resource Coordination.............................. 1
OPENING STATEMENTS
Chairman Michael Michaud......................................... 1
Prepared statement of Chairman Michaud....................... 26
Hon. Cliff Stearns............................................... 2
Prepared statement of Congressman Stearns.................... 26
WITNESSES
U.S. Department of Veterans Affairs:
Adam Darkins, M.D., Chief Consultant, Care Coordination,
Office of Patient Care Services, Veterans Health
Administration............................................. 16
Prepared statement of Dr. Darkins........................ 34
Kara Hawthorne, Director, Office of Rural Health, Veterans
Health Administration...................................... 19
Prepared statement of Ms. Hawthorne...................... 36
______
Disabled American Veterans, Joy J. Ilem, Assistant National
Legislative Director........................................... 3
Prepared statement of Ms. Ilem............................... 27
National Rural Health Association, Graham L. Adams, Ph.D., State
Office Council Chair, and Executive Director, South Carolina
Office of Rural Health......................................... 5
Prepared statement of Dr. Adams.............................. 31
SUBMISSION FOR THE RECORD
Brown, Henry E., Jr., Ranking Republican Member, Subcommittee on
Health......................................................... 40
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Hon. Eric K. Shinseki,
Secretary, U.S. Department of Veterans Affairs, letter
dated March 30, 2009, and VA responses..................... 42
CLOSING THE HEALTH GAP OF VETERANS
IN RURAL AREAS: DISCUSSION OF
FUNDING AND RESOURCE COORDINATION
----------
THURSDAY, MARCH 19, 2009
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:11 a.m., in
Room 334, Cannon House Office Building, Hon. Michael Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Teague, Rodriguez,
Donnelly, McNerney, Halvorson, Perriello, Stearns, and Moran.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. I would like to call the Subcommittee on
Health back to order.
I would like to thank everyone for participating in the
hearing. I would ask, while I give my opening remarks, for our
first two witnesses to please come forward.
The purpose of today's hearing is to provide oversight of
U.S. Department of Veterans Affairs' (VA's) rural health
funding, spending, and resource coordination. The hearing will
explore whether resources are used efficiently to narrow the
health disparity of veterans living in rural areas.
In general, we know that nearly two million veterans reside
in rural areas. This includes nearly 80,000 veterans who live
in highly rural areas.
According to the VA Health Services Research and
Development Office, rural veterans have worse physical and
mental health-related issues.
I commend the VA for their efforts in improving rural
health. This includes building new Community-Based Outpatient
Clinics (CBOCs), rural outreach clinics, and Vet Centers in
rural and highly rural areas. It also includes pilot programs
such as the Traveling Nurse Corps, the mobile health care
pilots, which are in place in four mobile clinics and 24
predominantly rural counties in Colorado, Nebraska, Wyoming,
Maine, Washington, and West Virginia.
I also applaud the advances made in telehealth through the
numerous pilot programs that have been implemented today.
To help the VA efforts, the Appropriation Committee
provided $250 million in September of 2008 to establish and
implement new rural health outreach and delivery initiatives.
Through today's hearing, we seek to better understand how
the VA has allocated and plans to allocate this $250 million.
The hearing will also address concerns about the lack of
coordination and duplicative efforts by various offices in the
VA that deal with rural health.
On today's first panel, we have the Disabled American
Veterans who will share their thoughts on VA's progress in
improving rural health. We also will hear from the South
Carolina Office of Rural Health about local challenges and
recommendations for closing the rural health gap.
Finally, the VA Office of Care Coordination and the Office
of Rural Health (ORH) will report on the Department's current
efforts on rural health.
I look forward to hearing your testimony on both panels.
And now I would recognize Mr. Stearns for an opening statement.
[The prepared statement of Chairman Michaud appears on
p. 26.]
OPENING STATEMENT OF HON. CLIFF STEARNS
Mr. Stearns. Thank you, Mr. Chairman.
I ask unanimous consent for my colleague, Congressman Henry
Brown, who is the Subcommittee Ranking Member, his opening
statement be made part of the record.
Mr. Michaud. Without objection, so ordered.
[The prepared statement of Congressman Brown appears on
p. 40.]
Mr. Stearns. Okay. I am here today on Mr. Brown's behalf. I
am pleased to be here this morning for our Health Subcommittee
hearing on ensuring that our veterans living in rural areas are
receiving the quality health care they certainly deserve.
Today's hearing affords us the chance to examine how the
Department of Veterans Affairs is spending some of the funds
allocated to them in the fiscal year 2009 Appropriations Act.
Specifically, we are focusing on funds that were marked to
help further the VA's rural health initiative in areas such as
mobile health clinics and telemedicine.
My colleagues, we are all aware of the health care gaps
that exist for veterans that reside in the rural areas. We know
that almost 40 percent of veterans enrolled in VA health care
live in rural or highly rural areas and that 44 percent of our
veterans returning from Iraq and Afghanistan also reside in
these rural areas.
Veterans living in rural America are statistically shown to
have lower quality of life scores and are more likely to suffer
from treatable diseases. Clearly this is an issue we must
address and monitor very closely.
I applaud the VA's current outreach efforts to recruit and
retain more health care providers to serve in rural areas and
to pursue innovative health care methods such as telemedicine.
We are moving in the right direction, but we must stay the
course and VA must fulfill the goals it has set.
I welcome our panel of witnesses and look forward to
hearing more about how VA has and intends to further distribute
the funds allocated to them under the fiscal year 2009
Appropriations Act so that we can truly, truly begin closing
the health care gap for our Nation's rural veterans.
Also, on behalf of Mr. Brown, my colleague, I would like to
extend a special welcome to one of our witnesses on the first
panel, Dr. Graham Adams. He serves as the Chief Executive
Officer and provides overall supervision and direction for the
South Carolina Office of Rural Health.
Thank you, Mr. Chairman.
[The prepared statement of Congressman Stearns appears on
p. 26.]
Mr. Michaud. Thank you very much, Mr. Stearns.
I will apologize up front. I do have to leave for another
meeting shortly, so I want to apologize up front. We will start
the first panel.
On the first panel, we have Joy Ilem who represents the
Disabled American Veterans (DAV), as well Dr. Graham Adams who
is the Chief Executive Officer (CEO) of the South Carolina
Office of Rural Health.
Once again, I want to thank both of you for coming here
this morning. I look forward to hearing your testimony as well
as working with you as we move forward to do what we have to to
make sure that our veterans in rural areas get the adequate
health care in the timely fashion that they need.
So without any further ado, Ms. Ilem.
STATEMENTS OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS; AND GRAHAM L. ADAMS,
PH.D., EXECUTIVE DIRECTOR, SOUTH CAROLINA OFFICE OF RURAL
HEALTH, AND STATE OFFICE COUNCIL CHAIR, NATIONAL RURAL HEALTH
ASSOCIATION
STATEMENT OF JOY J. ILEM
Ms. Ilem. Mr. Chairman and Members of the Subcommittee,
thank you for inviting DAV to testify today. We value the
opportunity to discuss our views on funding and coordination of
care for rural veterans.
We recognize that rural health is a difficult national
health care issue not isolated to VA. We also appreciate that
many sick and disabled veterans in rural areas face multiple
challenges in accessing VA health care services, even private
services under VA contract or fee basis.
We deeply appreciate the due diligence of this Subcommittee
and Congress by enacting legislation, which authorized VA to
establish the Office of Rural Health and the resources it has
provided to carry out its mission.
It appears VA is reaching across the Department to lay the
foundation for improving the delivery and coordination of
health care services to rural veterans. And DAV is pleased and
congratulates VA on its progress to date.
VA's appointment of rural care consultants in all its
Veterans Integrated Service Networks (VISNs), establishment of
three rural health resource centers, and a number of new rural
outreach clinics harnessing telehealth and other technologies
to reduce barriers to care are all positive steps forward.
In VA's 2009 Appropriations Act, Congress approved $250
million to support new and existing rural health care
initiatives and $200 million to increase fee-basis services. It
appears that VA has distributed $22 million to its VISNs for
rural health care improvements with an additional $24 million
being used to establish the pilot programs, new outpatient
clinics, provide outreach to rural veterans returning from the
wars in Iraq and Afghanistan, and activate a number of mobile
health clinics, including a fleet of 50 mobile Vet Centers.
We appreciate the Subcommittee's interest in conducting
this oversight hearing and we are interested in learning more
from VA about the specific instructions issued to the field
guiding the use of these new funds for rural care, what
monitoring is being conducted related to the use of those
funds, and the degree and type of reporting requirements that
have been imposed related to the number of veterans served as
well as the information on access, quality of care, and
workforce issues.
Although VA is off to a good start, we believe it faces a
number of challenges. In our testimony, we have offered a
series of recommendations we hope the Subcommittee will
consider as it continues its work in this important area.
Initially we suggest VA be required to provide more
thorough reporting to this Subcommittee to enable meaningful
oversight of the use of the funds provided and to properly
evaluate the implementation phase of rural health initiatives.
Without this type of oversight, we are concerned that the
funds Congress provides may simply be melded into VA's
equitable resource allocation system without the means of
measuring whether these new funds will be allocated in
furtherance of Congress' intent, specifically to enhance health
care services and health outcomes for rural and highly rural
veterans and particularly our newest generation of war
veterans.
Reports to Congress should include standardized and
meaningful measures of how VA rural health care capacity has
changed with workload changes reported on a quarterly or semi-
annual basis and disclosure of other trends that reveal whether
the rural health initiatives and funds allocated for them are
truly achieving their purposes.
Health workforce shortages and recruitment and retention of
health care personnel are also a significant challenge to rural
veterans' access to VA care and the quality of that care.
The Institute of Medicine recommended that the Federal
Government initiate a comprehensive effort to enhance the
supply of health care professionals working in rural areas.
We believe VA's Office of Academic Affiliations in
conjunction with ORH should develop a specific initiative aimed
at taking advantage of VA's affiliations to meet clinical
staffing needs in rural locations.
Finally, DAV is concerned about the organizational
placement of the Office of Rural Health within Veterans Health
Administration's (VHA's) Office of Policy and Planning and
recommends it be placed closer to the operational arm of VA
management.
We also suggest increasing staffing levels for the office
and urge Congress to continue to provide appropriate financial
support to ensure VA sustains these new activities without
diminishing resources for VA's specialized medical programs in
accordance with DAV Resolution 177.
In summary, DAV believes VA is working in good faith to
improve access and medical services to veterans living in rural
areas and we are hopeful that with continued oversight from
this Subcommittee, supported by appropriate resources, rural
veterans will be better served by VA in the near future.
That concludes my statement and I am happy to answer any
questions you or Members may have. Thank you.
[The prepared statement of Ms. Ilem appears on p. 27.]
Mr. Michaud. Thank you very much for your testimony.
Dr. Adams.
STATEMENT OF GRAHAM L. ADAMS, PH.D.
Dr. Adams. Thank you, and I appreciate the opportunity to
speak this morning.
I am Graham Adams, CEO of the South Carolina Office of
Rural Health, Past President of the National Organization of
State Offices of Rural Health, and a Trustee on the Board of
the National Rural Health Association, the NRHA.
The NRHA is a national nonprofit organization whose mission
is to improve the health of the 62 million Americans who call
rural home. The NRHA has long focused efforts on improving the
physical and mental health of our rural veterans and I
appreciate this opportunity to testify once again.
Since our Nation's founding, rural Americans have always
responded when our Nation has gone to war. Simply put, rural
Americans serve at rates higher than their proportion of the
population. Nineteen percent of the Nation lives in rural
areas, yet 44 percent of U.S. military recruits are from rural
America.
And sadly, according to a 2006 study, the death rate for
rural soldiers is 60 percent higher than the death rate for
soldiers from cities and suburbs.
Mr. Chairman, because of this great level of service, it is
incumbent upon each of us to do more for our rural veterans.
There is a national misconception that all veterans have
easy access to comprehensive care. Unfortunately, this is
simply not true. Access to rural veterans can be extremely
difficult and access for rural veterans in need of specialized
mental or physical care can be daunting.
In brief, because there is a disproportionate number of
rural Americans serving in the military, there is also a
disproportionate need for veterans' care in rural areas.
Program expansion and resource coordination are critical to
improve the care of rural veterans. We must be mindful of long-
term costs and needs because the wounded veterans who return
today will not need care for just the next few fiscal years.
They will need care for the next half century.
The National Rural Health Association supports the five
following recommendations.
One, access must be increased by building on current
successes. Community-based outreach centers or CBOCs and vet
outreach centers open the door for many veterans to obtain
primary care within their home community. The NRHA applauds the
success of these programs, but there are simply too few of
these centers.
In my State of South Carolina, there are only eleven CBOCs
and three vet outreach centers despite the fact that South
Carolina is one of the top 20 States in which veterans reside.
Two, access must be increased by collaborating with non-VHA
facilities. Because rural VA facilities are too few and far
between, many rural veterans simply forego care. If critical
preventative care or follow-up treatment is not received, a
veteran will undoubtedly become sicker and in need of more
costly care. This must change.
The NRHA's goal is not to mandate care to our rural
veterans, but to provide them a choice, a local choice.
The NRHA strongly supports ``The Rural Veterans Access to
Care Act,'' which was signed into law last October. The Act
establishes a 3-year pilot program which will allow some of the
most under-served rural veterans the choice to access their
care from a local provider. Despite the limitations of this
program, it is a strong and important step in the right
direction, but more must be done.
Linking the quality of VA services with rural civilian
services can vastly improve access to health care for rural
veterans. As long as quality standards of care and evidence-
based treatment for rural veterans is adhered to, the NRHA
strongly supports collaboration with community health centers,
critical access hospitals, and other small rural hospitals and
rural health clinics.
Three, access must be increased to mental health and brain
injury care. Currently it appears that traumatic brain injury
or TBI will most likely become the signature wound of the
Afghanistan and Iraqi wars. Such wounds require highly
specialized care. The current VHA TBI case manager's network is
vital, but access to it is extremely limited for rural
veterans. Expansion is needed.
Additionally, 85 percent of mental health shortages are in
rural America. Vet Centers do offer mental health services, but
the services are not consistently available at a local rural
level.
Four, care for rural veterans must be better targeted.
Returning veterans adjusting to disabilities and the stresses
of combat need the security and support of their families in
making their transitions back into civilian life.
The Vet Centers do a tremendous job in assisting veterans,
but their resources are limited. Additionally, because more
women serve in active duty than in any other time in our
Nation's history, better targeted care is needed for rural
women veterans.
And, five, improvements must continue with the VA Office of
Rural Health. The National Rural Health Association calls on
Congress and the VA to fully implement the functions of the VA
Office of Rural Health.
Efforts to increase service points have not always been
embraced by the VA. It is our hope that the Office of Rural
Health and the newly formed VA Rural Health Advisory Committee
will work to eradicate previous barriers and expand access
options for the betterment of our rural veterans.
The NRHA also strongly encourages greater coordination
between the rural health coordinators housed in each VISN and
State level officials in each State Office of Rural Health.
Mr. Chairman, thank you again for this opportunity. The
NRHA's full recommendations can be found in my written
testimony. I look forward to working with you and this
Committee to improve the rural health care access for millions
of veterans who live in rural America, and I ask that my full
statement be submitted into the record.
Thank you.
[The prepared statement of Dr. Adams appears on p. 31.]
Mr. Teague [presiding]. Yes. Thank you.
Hearing no questions, it is so ordered.
First, thank you for sharing your concerns about the
organizational placement of the Office of Rural Health. You
recommend that the office be moved from the VA's Office of
Policy and Planning to an operational arm of the VA system.
Please explain how you think moving the Office of Rural
Health to an operational arm would improve the planning and
coordination capabilities of the Office of Rural Health.
Ms. Ilem. Thank you for the question.
I think that we are concerned that there is a number of
bureaucratic levels that the office is required to go through
to the implementation phase under probably Mr. Feely's office.
Direct access to that office with, and talking to the VISN
directors and the local Medical Center directors directly is
going to be, I think, critical during the implementation phase
of this program.
I think they need to coordinate with Office of Policy and
Planning and continue--I mean, there are a number of
initiatives that they are starting which, you know, cross
throughout the departments. At the same time, we would like to
see the office have that direct access to make sure that these
things get implemented in a very expeditious manner.
Mr. Teague. Okay. Also, as you know, the VA received $250
million in the 2009 appropriation. What are your views of the
types of services and programs that the VA should support with
this funding and do you agree with how the VA has spent it so
far?
Ms. Ilem. Just in reviewing very briefly this morning, the
VA's testimony, I have not had a chance to look at it
thoroughly, but it appears that they have a number of programs
that have been initiated, many of them just at the very
beginning stages, trying to establish many of these clinics,
probably working with their coordinators in each of the VISNs
and a variety of other functions.
So I think that they have a tall task ahead of them in
terms of the things that they have scheduled to do.
So I think that they need to just continue to keep working
on the programs that they have set forth as indicated in their
testimony and I think many of those are the right direction. It
is just a tall order and it seems like a lot of things are just
at the very beginning stages.
Mr. Teague. Dr. Adams, in your testimony, you highlighted
the need for rural providers to be trained because of the
unique needs of rural, minority, and female veterans.
I'm from a large rural district in New Mexico and we have a
lot of the same needs that you were discussing.
I was just wondering if you might be able to expand a
little bit on this and tell us a little more about the needs.
Dr. Adams. Yes, sir. So often in a physician or a
provider's medical training, they receive excellent clinical
training, but they do not have the other cultural competency
trainings that are so key when you work with disadvantaged
populations, be it women, minorities, others. And I think
especially when working with these populations, you do need to
have special sensitivity to those issues.
I also think that in States and regions that have a high
minority population, where possible, the providers serving
those populations need to be reflective. So trying to achieve
greater diversity in ethnicity and race among those providers
that are providing care would be a good thing and could be
accomplished through contracting or cooperative arrangements
with other non-VHA facilities such as community health centers,
rural health clinics, and critical access hospitals.
Mr. Teague. I would just like to say that, coming from the
2nd District of New Mexico, which is bigger than the State of
Pennsylvania, and has almost 200,000 veterans, I am encouraged
to hear how you are addressing similar concerns across the
country.
Mr. Rodriguez from Texas.
Mr. Rodriguez. Thank you very much. First of all, thank
you, Mr. Chairman.
Let me point out that my district is one of the largest in
the Nation. I have 785 miles along the Mexican border. I have
two major cities, but within my district, I do not have any VA
clinics or facilities.
We have had a serious problem with the ones that the VA has
contracted out in the past who are not willing to work with the
VA now because of the fact that they had not gotten paid the
way they should.
And now they have gotten some new contracts, but one of
them came, and this is probably not to this panel, but to the
other, is that there is some other contractor in between that I
guess is getting 15 percent from the top before the other
person even gets paid, which does not make any sense
whatsoever.
And I still have not seen any results in my district in
terms of the efforts of some of the pilot programs and trying
to get some mobile units out there. That has not happened.
I have a large number of veterans in my district. It has
extremely rural areas where people have to go a long ways. A
straight shot on I-10 is 550 miles between one side of the
district and the other. And the major facilities are in San
Antonio and El Paso, but my district is in between.
I have problems with the contracting that has gone on with
some of the local providers. In one case, they actually stopped
providing services because the VA was not timely in reimbursing
them. They just said, ``look, I have had enough, I am not going
to deal with this.''
And the other, we had two groups, two community-based
outpatient clinics that they used to work with that are
unwilling to work with them now because of past experiences
with them.
I just wanted to see if you might comment as to how do we
get past some of the things that have happened in the past and
how do we make sure that they deliver in the future.
Dr. Adams. I believe that creating incentives, financial
and other, for VA facilities, be it CBOCs and vet outreach
centers, to coordinate and to work with non-VHA facilities will
go a long way to creating those partnerships.
And in some cases, veterans are being seen in these
facilities already. And the non-VHA facilities that I
mentioned, rural health clinics, community health centers, and
critical access hospitals, these are all fully qualified, fully
staffed facilities that are providing care at the local
community, all of which receive some kind of enhanced
arrangement from Medicare to provide services, but
unfortunately not for veterans.
So if that linkage could be put in place, I think that you
will see care increased dramatically and there will certainly
be things that have to be worked out, but you have folks that
are in the field right now that are willing to see veterans if
only a mechanism existed to do so.
Mr. Rodriguez. That mechanism that you are referring to,
would that require any form of additional legislation or is
that something that is already in place that we could just
require them to do?
Dr. Adams. I cannot speak exactly as to what authority the
VA has. But if the authority would allow and if the intent were
there, there are partners on the provider side that are more
than willing to see these veterans as long as they are
reimbursed fairly and they are in these communities. There is
no sense in reinventing the wheel, building another facility,
investing additional taxpayer dollars when you have points of
access already there.
Mr. Rodriguez. Thank you very much.
Thank you, Mr. Chairman.
Mr. Teague. Next I need to apologize to the gentleman from
Kansas. I am sorry. This was my first time to Chair this
Subcommittee and I guess it is showing in going out of order
here. I would like to present, at this time, Congressman Moran
from Kansas.
Mr. Moran. Because you are new to the Committee, you do not
know how offended I am, how difficult I am to get along with.
Mr. Chairman, I am delighted to be here and I am happy to
be able to visit with these witnesses at your leisure, at your
convenience.
I thank Mr. Michaud and this Subcommittee for having this
hearing. The pilot program is a piece of legislation that I
have worked on really since I came to Congress and I am
delighted that Mr. Michaud has indicated a willingness to have
a hearing.
My staff met with folks from the VA and others yesterday
for the beginning implementation conversation and we are
generally pleased that the VA is paying a lot of attention to
this topic. And I think it is important for all of us to stay
on point to make sure that it is implemented in a way that
demonstrates the value of this pilot program.
Dr. Adams, in the testimony of the Disabled American
Veterans, in Ms. Ilem's testimony, she indicated concerns about
veterans who may seek health care for convenience with a
private provider, that they may not receive the protections of
the VA system, patient safety and other protections that are
indicated in the VA system.
Do you have any concerns about how a veteran would be
treated in the private system with their hometown doctor and
hospital as compared to being treated more directly in the VA
system with a VA provider? And if you do have those concerns,
do you have suggestions of what it is that we ought to be
paying attention to in order to make sure those concerns are
addressed? Dr. Adams.
Dr. Adams. Thank you.
I do not have concerns. Certainly the VA with the system
that they have, they provide excellent care in those
facilities. The problem is there just are not enough of those
facilities.
So if we can create linkages where there is reasonable
requirements for electronic medical records (EMRs) for quality
of care, then there is no reason that those veterans cannot
receive high quality care in non-VA facilities.
All these facilities meet every quality requirement of the
Federal Government that is put upon them. So these are highly
trained folks doing the work that they need to do and they do
not currently have to abide by all the VA rules. But as long as
there were reasonable, and I stress reasonable, requirements in
place, I do not know why those partnerships could not exist.
Mr. Moran. In my early days in Congress, our outpatient
clinic was staffed by a physician in her private practice. She
ultimately left the system and no longer provided services to
veterans through her clinic as an outpatient clinic of the VA.
The concern, the criticism, and the difficulty was related
to medical records, to technology, and the inability to connect
in getting answers from the VA and, in our case, in Wichita.
At least my sense is that much of that has been resolved.
Am I missing something or are we headed--the VA seems to be
probably one of the better utilizers of technology in the
entire medical delivery system.
Dr. Adams. I think that is correct. The VA has an excellent
electronic medical record system. All the dollars that are
contained within the American Recovery and Reinvestment Act
(ARRA) are going to allow even more facilities in rural
communities, non-VHA facilities that do not have EMR now, that
do not have electronic medical records now, to have that in
place.
So I think that the ability for information to be exchanged
in a Health Insurance Portability and Accountability Act
(HIPAA) compliant, safe way is going to be less and less of an
issue once all of these facilities have some form of electronic
medical records.
Mr. Moran. Has anyone in the VA's Office of Rural Health
ever contacted you? Do they reach out to people in your
position to seek advice and suggestions?
Dr. Adams. I do have to say the Office of Rural Health has
been very supportive and very helpful with entities like the
National Rural Health Association. I think from a staff
perspective, they have done a great job of creating good will
and seeing where those partnerships could exist.
I get the sense it might be a little bit higher up the food
chain, if you will, within the VA that some of this resistance
occurs.
And from my perspective at a State level, each of the VISNs
has, I believe it is called a rural health coordinator. I do
not know who that person is. I have never been contacted by
that person. I have tried to go on the VA Web site and identify
that person. I cannot do that.
So I would strongly urge for those rural health
coordinators, if that is the correct term, that are located
within each VISN to be more proactive reaching out to the State
level rural health officials in each State.
Mr. Moran. I will try to ask Ms. Hawthorne a similar kind
of question when she is our witness.
There is a Rural Veterans Advisory Committee commissioned
now and I want to hear about how it is interacting with the VA
and what difference it is making.
My time has expired. I thank the Chairman for his
indulgence and appreciate your consideration.
Mr. Teague. Well, once again, I would like to apologize to
Congressman Moran and I appreciate his patience with me in my
learning process here.
And next is the Congressman from California, Jerry
McNerney. Do you have a question, please, sir?
Mr. McNerney. Thank you, Mr. Chairman.
First of all, I would like to thank the witnesses for
coming forth today.
Mrs. Ilem, is that correct?
Ms. Ilem. Ilem.
Mr. McNerney. Ms. Ilem. You suggested more oversight by the
Committee and I think that is probably a good idea. But I was
wondering if you had--and you also mentioned standardized
reporting.
Do you have specific recommendations or specific ideas for
standardizing the interchange between the Committee and the
witnesses or the reporting entities?
Ms. Ilem. I think VA would be able to do that fairly
easily. I think if there is a request from the Committee to do
that, I am sure they would be willing to provide that.
And I think the main thing would be not just a data dump,
but something that you could really read and be able to make a
true assessment to see, is capacity improving, what are the
workloads, what are they doing.
In briefly looking at their testimony, I think they have a
number of reporting requirements that they are requiring from
the field. And if they can tally up that information in a very
sensible way that would be easy for the Committee to review, I
think would just be just another opportunity to really have the
oversight that is needed.
Mr. McNerney. Okay. Well, thank you.
Any ongoing suggestions you have on standardizing that
would be appreciated by the Committee.
Ms. Ilem. Sure.
Mr. Mcnerney. You also mentioned more physicians as one of
the major problems. Do you see that as the major problem or are
there other related problems to the shortage of physicians in
rural areas?
Ms. Ilem. I think that is one of the issues. I mean, there
are so many factors involved in rural health care issues that
the Nation is grappling with in general, including VA.
I think that is just obviously one of the keys to have the
willingness for qualified people to be in the rural areas and
available to these veterans, but I think it is one of many
things that are necessary.
Mr. McNerney. Thank you.
Dr. Adams, I want to say I have both rural and suburban
areas in my district and I appreciate your mentioning
disproportionate share of active-duty members and veterans from
rural areas.
I was just at a funeral in a town of mine, about a 60,000-
person town, and it is their eighth fatality in the War on
Terror. So they certainly are paying their share or more than
their share.
And I also appreciate your suggestion to let non-VA
organizations partner up with VA organizations to provide the
best possible care to our servicemembers.
I would like to see, speaking of standardized, I would like
to see a standardized approach to that so that we can move
forward aggressively and provide those services in a way that
would benefit everyone.
One of the questions I have is, do you see the telenet
being helpful in filling the gap between rural and urban
service capabilities?
Dr. Adams. I think telemedicine, telehealth is a great tool
to provide some services in more isolated rural communities.
Specifically things like telepsychiatry, it can be fairly
effective with.
I think that while telemedicine and things like a mobile
clinic are great steps in the right direction, they do not
nearly provide the continuity of care that a full-time provider
or a facility would in those rural communities.
And, again, we have a very robust network throughout the
country of folks that are already in place to serve the
underserved and to serve vulnerable populations. And I think we
all could agree rural veterans are a vulnerable population.
So providing linkages with those folks, I think, again will
increase access to care dramatically. Telemedicine is a
wonderful thing and I think it can be used in conjunction with
some additional agreements in place at the local level.
Mr. McNerney. Thank you.
Ms. Ilem, do you have any comments on telemedicine?
Ms. Ilem. We agree telemedicine is another great
opportunity to be used in the arsenal of ideas looking at all
of these issues that can help to improve services in those
communities.
Mr. McNerney. Thank you.
I am going to yield back, Mr. Chairman.
Mr. Teague. Thank you, Congressman McNerney. I appreciate
those comments.
At this time, I would like to call on the lady from
Illinois, Congresswoman Deborah Halvorson.
Mrs. Halvorson. Thank you, Mr. Chairman.
And I would like to start with Dr. Adams. In your
testimony, you highlighted the need for rural providers to be
trained to meet the unique needs of the rural minority and
female veterans.
Everywhere and every panel that comes before us, they talk
about the need for women veterans and the fact that more and
more are coming back and there is going to be a huge need. This
is going to really complicate a complicated issue even more.
What do you suggest we do when there is already a need for
more rural services and now we are going to need more help with
the women population coming back?
Dr. Adams. I think that can largely be addressed through
increased mental health and behavioral health services. Every
veteran that comes back has issues potentially with combat
situated problems. And the females who come back often have
family burdens. They have children. They have different roles
than a male typically plays in our society and they have
different expectations when they come home.
So I think a lot around family counseling, marital and
other family counseling being available for the family as a
whole, not just for the veteran, is key. So often when it was
just a male veteran population, they did not have some of those
expectations when they returned home. I think you are finding
that more and more with returning female veterans.
Mrs. Halvorson. And if I could ask both of you to comment
on this one. So you feel that we should be treating the entire
family because I know that there has been some discussion,
which has completely caught me off guard, about women who have
children while a veteran and how these children are not
veterans, but, yet, we have to find a way to take care of them.
And there has been a lot of discussion about that.
What are your views on these are veterans, they have served
our country, and now we are debating whether to even take care
of their children?
Ms. Ilem. I would just start out by saying thank you for
the question on women veterans and bringing it up. And I think
it is great that Dr. Adams included that in his statement.
This is an issue that VA is working very hard to address
right now through their Office of Women's Health Program and
the Center for Women Veterans.
VA indicates an increasing number of women veterans
returning from war and high rates of use among this Operation
Enduring Freedom/Operation Iraqi Freedom population coming to
VA with the changing demographic.
I think that it will be really important in the next year
for the Office of Rural Health to also reach out to Dr. Patty
Hayes' office at VA to really make sure that within the rural
health question and initiative that these issues are addressed
with respect to women veterans. I think that is great.
Some of the programs that VA has specifically for women
veterans are really important in terms of post-deployment
issues and some of the things that Dr. Adams has referred to in
their post-deployment readjustment. So we want to be able in
the rural health communities for those veterans to have that
access to VA's unique specialties and providing those types of
services or training local people that are seeing them to be
able to do that.
And with respect to the child care issues, this has been a
longstanding issue in the women's community that this is a
barrier, but we see it not only as a barrier for now just
women, there are so many single veterans in general other than
just women. Both men and women can have child care issues and
primary care responsibilities.
And I think you are referring to the pilot program
recommended by Congresswoman Stephanie Herseth Sandlin.
Mrs. Halvorson. Yes.
Ms. Ilem. We think that when we look at all the research
that is put out there, that this is one of the big barriers. So
certainly if there is an opportunity to provide, not VA
directly providing child care, but providing some sort of chit
for them to access child care so that they can attend their
appointments, especially if they have post-deployment issues
that require extensive mental health sessions. You know, it
really would not be appropriate for them to bring their
children.
So we just hope that that is a consideration, that the
Subcommittee will take up as it looks at that bill further.
Mrs. Halvorson. Did you have anything to add, Dr. Adams?
Dr. Adams. Beyond child care, I do think that the
counseling resources should be available to the families as
well because so often if the veteran returns home with either
psychosocial or severe physical issues, the family are the
caretakers and they are the ones that are bearing the burden 99
percent of the time.
So I think resources should be available to them because so
often in our rural communities, mental health and behavioral
health services are just not available. They are not available
for the general population.
And at least in my State, our local community mental health
centers will not see veterans. They will not see them because
they feel that, first of all, they are overburdened, but,
second, they feel like they should be seen at the VA
facilities.
So, again, creating a linkage and incentives for that to
occur, I think, is vital in providing veterans and their
families the services that they need locally.
Mrs. Halvorson. Thank you.
Mr. Teague. I thank the Congresswoman from Illinois for
those questions because they needed to be asked and I thank the
witnesses for addressing them.
And now at this time, I would like to recognize the
gentleman from Indiana, Congressman Donnelly.
Mr. Donnelly. Thank you, Mr. Chairman.
In regards to TBI, Dr. Adams, you had mentioned that
earlier, and this is for both you and Ms. Ilem, there are
approximately four centers throughout the country, polytrauma
centers to help with this through the VA system. And if you get
in a very rural area, it is hard to get treatment for this.
Would you fully support the opportunity for our vets to
receive treatment at either one of our centers in the VA system
or to go to a place like the Chicago Rehabilitation Institute
where they can go and receive very intensive additional care
for this injury?
And there are similar facilities throughout the country. I
wanted to find out what you think of expanding the range of
places where our vets can go.
Dr. Adams. I absolutely think that creating additional
access points makes sense. And, yes, we all want the quality of
the VA system to be held intact and we want to make sure that
the veteran's health information is kept private, but all these
things can occur in private settings. And it is of little
solace to those that need the care who cannot get it knowing
that there are four centers that do this and do it excellent if
they cannot get there.
Accessing additional facilities, as you mentioned, that
have the expertise, to me makes great sense and it is really
just a matter of choice and access, making sure that these
veterans get care no matter where it is as long as it is of
high quality and it meets reasonable standards.
Ms. Ilem. I would just mention, obviously for the most
critical cases that are just coming back, the major polytrauma
centers, the way they are going, the VA has established also in
each of their VISNs a level two. So it would depend, you know,
certainly on the level of the injury and the needs of that
veteran. And I know that they have options to outsource that
care if necessary and working with the family.
Of course, we want, you know, veterans to have the best
care and for those that are really working with these very
unique injuries and the polytraumatic injuries they are seeing
from the wars in Iraq and Afghanistan. So I do not think, you
know, we are opposed to in certain circumstances, you know,
making that available.
Certainly the family, there is a lot of family issues, we
want the families to be available and to be with them. And we
know that many have had to relocate, giving up, you know, jobs
and a variety of other things that have made it very difficult
or leave one parent at home and not be able to stay in their
local area.
So I think those things should be taken under consideration
for VA with the unique circumstance of the family.
Mr. Donnelly. Okay. And, again, this would be for both of
you. In terms of listing here is the problem with outsourcing
some care for veterans when you have local doctors or local
facilities, what do you find the biggest barriers, cost, the
technology in the health clinic? What are the kind of things
that make it most difficult for rural vets to be able to
receive assistance locally as opposed to having to get in a van
and travel 3 hours to the VA clinic?
And the VA clinics are extraordinary places, but if you can
save yourself a 3-hour trip, it would be a lot better off. What
are the kind of things preventing it from happening?
Dr. Adams. From my perspective, the largest barrier is that
except for in a few isolated pilots, the VA will not pay for
care at these local facilities. So----
Mr. Donnelly. Excuse me. Will not pay at all or at an
appropriate level, what you consider an appropriate level?
Dr. Adams. Well, to my knowledge, unless a veteran resides
in one of these areas where they have a rural pilot, a veteran
cannot go to, say, a community health center or just a private
doctor, be seen, and have that care reimbursed by the VA.
Mr. Donnelly. So it is not that the doctor or the clinic
itself will not meet a payee number set by the VA, the VA just
will not participate?
Ms. Ilem. My understanding is that VA has the option
through its fee-basis program to, if there are geographic
barriers and a number of certain circumstances, they can
authorize fee-basis care based on the individual circumstances
of the veteran and location and a variety of other factors. But
they do that on an individual basis.
So VA does currently have that authority. The problem we
have heard is that through the distribution of the dollars for
fee-based programs, they oftentimes are only allotted a certain
amount of money for those fee-basis programs.
So they are very judicious in how they allow veterans to
use that program. And if there is an opportunity to get them to
the nearest clinic, even though it may be several hours away,
that is where they want them to go.
But I think looking as part of the establishment of the
Office of Rural Health, there was a request to look at the fee-
basis program and I know there has been some increased funds in
the 2009 appropriation for increasing fee basis. And I would
assume that the Office of Rural Health is really looking at the
fee-basis issue and to use it appropriately when necessary,
especially when you have some very elderly veterans or somebody
with TBI that it would be very difficult for them to make
extensive trips to and from a facility and a number of trips if
required by their medical condition.
Mr. Donnelly. Okay. Thank you very much.
Thank you, Mr. Chairman.
Mr. Teague. Thank you, Congressman from Indiana. I
appreciate that.
And, also, Joy Ilem and Dr. Adams, thank you for your
participation. I think that the information and knowledge that
we received from you today will be helpful as we make the
decisions that we have to make down the road. I really do want
to thank you for participating.
Dr. Adams. Thank you.
Ms. Ilem. Thank you.
Mr. Teague. Now, at this time, I would like to call panel
number two to come to the table. We have Dr. Adam Darkins who
is the Chief Consultant, Office of Care Coordination, Veterans
Health Administration, U.S. Department of Veterans Affairs, and
Kara Hawthorne, Director of the Office of Rural Health,
Veterans Health Administration, U.S. Department of Veterans
Affairs.
Once again, thank you for being here today and taking a
part in this. Dr. Darkins, we will start with you, please.
STATEMENTS OF ADAM DARKINS, M.D., CHIEF CONSULTANT, CARE
COORDINATION, OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND KARA
HAWTHORNE, DIRECTOR, OFFICE OF RURAL HEALTH, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF ADAM DARKINS, M.D.
Dr. Darkins. Good morning, Mr. Chairman. Thank you for the
opportunity to testify before the Committee today.
My testimony covers funding and resource coordination
issues associated with the expansion of telehealth programs
within the Department of Veterans Affairs or VA and how they
help meet the health needs of veterans in rural areas.
Health care delivery in rural areas is a challenge as we
have just heard, one that the VA is confronting directly.
Telehealth involves the use of information telecommunications
technology to increase access to care and reduce travel.
In fiscal year 2008, VA's telehealth programs provided care
to over 100,000 veterans in rural areas. These telehealth-based
services involve real-time videoconferencing, store-and-
forwards telehealth, and home telehealth.
Real-time videoconferencing services in VA known as care
coordination and general telehealth provide specialty services
to veterans in both VA medical centers and in community-based
outpatient clinics.
The main focus of this program is in providing mental
health services in rural areas and in 2008 provided services to
20,000 veterans at over 171 sites of care. These services
included provision of care to 2,000 returnees from Operations
Enduring Freedom and Operation Iraqi Freedom.
Store-and-forwards telehealth, care coordination, store-
and-forwards known in VA, involves the acquisition,
interpretation, and management of digital imaging screening and
assessment purposes of patients.
These services were provided to over 62,000 veterans in
rural areas in 2008 and were predominantly to provide care for
diabetic eye disease screening and for skin diseases.
To enable veterans with chronic diseases to live
independently in their own homes and in local communities, VA
provides home telehealth services. In financial year 2008,
these services known as care coordination home telehealth
services in VA supported 35,000 veteran patients to remain
living independently in their own homes. Forty percent of these
patients were in rural areas.
VA is very sensitive to the increasing need for services in
the home, particularly in rural areas, and is preparing for the
future demand by expanding the range of these services it
provides as well as other telehealth services.
And I am going to describe briefly some ways in which this
is happening in the next year.
Firstly, we are formalizing and implementing a national
program using telehealth to help support the 41,096 veterans
with amputations who receive care from VA.
Secondly, we are instituting a program to expand the use of
telehealth in both home telehealth and in general telehealth to
support spinal cord injury and disorder services and to make
this renowned specialist care more available, especially in
rural areas.
Thirdly, we are completing the necessary work to implement
VA's Managing Overweight and/or Obesity for Veterans Everywhere
Program known as MOVE. And this is going to be incorporated
with home telehealth and will help it expand into rural areas.
Fourthly, we are completing a home telehealth technologies
program for supporting veterans challenged by substance abuse
issues.
And the last one I would like to focus on is establishing a
national telemental health center which will coordinate
telemental health services nationally. Its particular emphasis
will be on bipolar disorders and on post-traumatic stress
disorder and on making those services widely available.
In implementing telehealth solutions to serve veteran
patients in rural areas in the ways I have described,
collaborations with colleagues within and outside VA is vitally
important. We collaborate with mental health, medical surgical
services, rehabilitation, prosthetics, spinal cord injury, and
spinal disorders amongst many other offices who provide
invaluable expertise that ensures VA's telehealth services are
appropriate, safe, effective, and cost effective.
Telehealth is a marriage between clinical care and
technology and another key ongoing collaboration is that we
have with information technology colleagues in order to
underpin a robust and sustainable infrastructure to deliver
care nationwide.
In financial year 2009, VA is piloting an extension of its
preexisting polytrauma telehealth network to create a clinical
enterprise videoconferencing network. This will facilitate the
extension of polytrauma, post amputation, spinal cord injury
care and specialists mental health services to rural areas.
These efforts combined with VA's personal health record, my
healthy vet, leverages new technologies to benefit our
patients.
VA's Office of Rural Health provides a focus we welcome to
address the needs of veteran patients in rural areas and
dovetails services into the spectrum of health care provision
necessary to support these veterans.
VA has a longstanding relationship with the Joint Working
Group on Telehealth, an interagency group. Cross-fertilization
of telehealth practices with other Federal partners assists us
in developing services, for example, those we deliver to meet
the needs of populations such as those in American Indian,
Alaska native, and Pacific Islander communities.
VA has three telehealth training centers and has trained
over 6,000 staff to ensure workforce is competent using those
modalities wherever possible that are virtual.
The safety and efficacy of VA's telehealth programs is
substantiated by a national quality management program that
reduces utilization and shows high levels of patient
satisfaction with the telehealth programs.
Key to the development of telehealth in VA is the energy,
expertise, and dedication from various staff from different
backgrounds. They are united in their commitment to serve
veteran patients.
It is a privilege to work with such colleagues throughout
VA and engage in implementing ground-breaking services for
those who served our Nation and for whom we are committed to
serving, whether they live in rural, highly rural, or urban
locations. This remains VA's mission and one we gladly accept.
Mr. Chairman, that concludes my prepared statement. I am
pleased to address any questions the Committee may have for me.
[The prepared statement of Dr. Darkins appears on p. 34.]
Mr. Teague. Okay. Thank you.
Next, Kara Hawthorne, please.
STATEMENT OF KARA HAWTHORNE
Ms. Hawthorne. Thank you.
Good morning, Committee Members. Thank you for the
opportunity to discuss VA's work to enhance the delivery of
health care to veterans in rural and highly rural areas.
I would like to request that my written statement be
submitted for the record.
VA's Office of Rural Health referred to as the ORH is
empowered to coordinate policy efforts across to promote
improved health care for rural veterans.
VA has embraced a national strategy of outreach to ensure
veterans, regardless of where they live, can access the
expertise and experience of one of the best health care systems
in the country.
In partnership, Congress and VA can do even more. We
appreciate Congress' support and interest in this area and we
are happy to report that portions of the $250 million included
in this year's appropriation have already been distributed to
the field to support new and existing projects.
Specifically, the ORH has allocated $24 million to sustain
fiscal year 2008 programs and projects, including the rural
health resource centers, mobile health care clinics, outreach
clinics, the VISN Rural Consultant Program, and mental health
and long-term care projects.
In December 2008, VA provided almost $22 million to VISNs
across the country to improve services for rural veterans. This
funding is part of a 2-year program and will focus on projects
in line with the ORH strategic vision to increase access and
enhance quality, education, and training, information
technology use, workforce recruitment and retention, and to
strengthen collaboration with our non-VA partners.
VA distributed resources according to the proportion of
rural veterans within each VISN. VISNs were provided program
guidance and directed to identify programs or projects that
would support the ORH vision to enhance care delivery and
outreach for veterans in rural areas, and also that they are in
line with guidelines provided in Public Law 110-329 to increase
the number of access points, to accelerate telemedicine
deployment, to explore collaborations with non-VA partners, and
to fund innovative pilot projects.
The Office of Rural Health instructed VISNs to include
funding, validation, and reporting with a breakdown by target
to facilitate distribution and tracking, as well as execution
and evaluation plans. VISNs are required to report their
accomplishments based on these factors to us quarterly.
In February 2009, the ORH distributed guidance to the VISNs
and program offices concerning allocation of the remaining
funds as early as May to enhance rural health care programs.
A cross-sectional group of VA program offices came together
to develop a process and a method to allocate the additional
funds.
Together we developed a request for proposal. VISNs and
program offices were each eligible to apply for this funding.
And, again, we focus on the ORH's six key areas, access,
quality, technology, workforce, education and training, and
collaboration strategies.
We also required proposals include an evaluation component
with specific measures to explain how the proposed work will
increase access and the quality of care to our rural veterans.
ORH, along with the other program offices in the panel and
other relevant program directors across VA, will be reviewing
these proposals in early April. Proposals that recommend new
technologies or those that sought to extend current enterprise
programs needed to justify how these alternative solutions
would be interoperable and embody the essential clinical,
technology, and business processes to ensure compatibility with
existing programs.
Affected program offices will be involved in the review of
these applications to ensure that continuity and consistency
within the program areas.
VA's ORH during its short existence has produced a number
of programs that are actively improving the delivery and
coordination of health care services to rural veterans. Some
examples include expanding the existing home-based primary care
and the medical foster home programs into rural VA facilities,
developing the Geri Scholars Program to support geriatric
providers in rural areas, supporting expansion of community-
based supports for veterans with severe mental illness, opening
ten new rural outreach clinics, and also establishing the
mobile health care pilot in 24 predominantly rural counties.
The VA's Office of Rural Health is reaching across the
Department to coordinate and support programs aimed at
increasing access for veterans in rural and highly rural
communities.
And thank you once again for your support to appear today
and I am prepared to address any additional questions that you
may have.
[The prepared statement of Ms. Hawthorne appears on p. 36.]
Mr. Teague. I do have some questions, but due to the fact
that we are fixing to go vote, I will submit my questions in
writing and defer to the Congressman from Kansas, sir.
Mr. Moran. Mr. Chairman, thank you very much. You have more
than overcome your slight earlier in the morning.
Thank you both for being here.
One of the things that seems so clear to me as we have
finally begun the process of increasing the funding for
veterans' health care is that the challenge we now face within
the VA system is hiring and retaining health care
professionals.
So as we add additional resources that make health care
perhaps more accessible and higher quality, what is the VA able
to do, what do you need from Congress in regard to the
employment of people who perform health care services?
There is a shortage, generally. My hospitals, my
communities all struggle to hire necessary health care
professionals, from physical therapists to psychologists to
psychiatrists to nurses.
My question is and my guess is and certainly my experience
is that this is a more difficult challenge in rural communities
than it is in urban or suburban settings, and is there a
concerted effort at the VA to overcome the health care
professional shortage, particularly in rural areas, but just
generally?
Ms. Hawthorne. Thank you for your question.
You are correct. It is a national problem getting rural
providers and the VA is addressing this. We have begun some
initiatives to help recruit providers in the rural areas. We
are linking in with non-VA entities to help advertise to entice
them to come to VA.
Let me tell you specifically about one exciting new
initiative that we are undertaking with the Office of Academic
Affiliations.
We are expanding the rural residency for physicians into
more rural facilities. So what we are doing is we are able to
now provide supportive services so that the physicians can
practice in rural areas because what we have learned is that
providers who do their residencies in rural areas are more
likely to stay and work in rural areas. So that is one of the
examples.
The other one, as I mentioned in my oral testimony, is the
Geri Scholars Program. Finding specialists that concentrate on
geriatric services is difficult in urban and rural areas. So we
are providing some extra training to the gerontologists about
our rural veterans and I am hoping that they will disseminate
that information among their peers in the rural communities
where they practice.
Mr. Moran. Is the VA capable of compensating health care
providers in a way that we are not at a disadvantage to the
private sector?
Ms. Hawthorne. I am not able to answer that question
directly, but I can take it back and get a more thorough answer
for you.
[The VA subsequently provided the following information:]
Yes, with the flexibilities VHA has and the addition, several
years ago, of market pay for physicians we can be competitive.
However, salaries alone don't do this. It is the flexibility
and use of incentives that makes VHA successful in remaining
competitive.
Mr. Moran. Please do. I thank you for that. And if so, is
there a request to Congress that we do something about how we
allocate the resources, the increased resources in a way that
actually allows the VA to hire more providers?
Dr. Darkins. Could I just----
Mr. Moran. Absolutely, Doctor.
Dr. Darkins. Certainly salary is one of the factors in
terms of recruitment and retention of staff. Equally well, my
understanding is, preferentially people from different
disciplines are working within VA because the culture is very
attractive. There is the training, which my colleague just
commented on, VA provides substantial training for all health
care professionals.
We are also finding, certainly in the area that I work in,
telehealth, the benefits from our ability to link some of these
rural practitioners into their specialist colleagues and the
educational aspects that go with this. To be able to link
practitioners directly into training and keep them up-to-date
helps prevent that isolation.
So the cost is certainly something. These other factors
really, I think, make VA a place where people are very proud to
work in terms of the services they are now delivering.
Mr. Moran. That is, you know, a very accurate description.
Communities that have only one physician find it very difficult
to retain that physician. You want colleagues. Doctors do not
want to be on call 7 days a week, 24 hours a day. There is a
collaboration and just a professional necessity of having
colleagues in your presence.
The comment by our earlier panelist about not being able to
find out who the--apparently each VISN has a rural coordinator
and, yet, unable to find out who that person is. Do we have
those rural coordinators in every VISN? Are they accessible?
What are they doing? What is the status of that program?
Ms. Hawthorne. Sure. Yes, sir. We do have a VISN rural
consultant in each VISN and this was actually something that
the Committee had foresight to put into the Public Law that
established the Office of Rural Health.
Some of the VISNs have full-time positions and some of them
are not full time, but part of their responsibility is not only
to facilitate information exchange between the fields and the
VACO Central Office of Rural Health, but also to collaborate
with the community, with community partners.
So they are seeking out potential collaborations for direct
care, for education and training, and building those
relationships.
I will look into your specific VISN and find out who that
VISN coordinator is and make sure that they are in touch with
the State Office of Rural Health and actually urge all of our
VISN rural consultants to reach out to the State Offices of
Rural Health.
Mr. Moran. Thank you for that.
And point out that a couple of instances over a long period
of time, we have tried, I have been involved in efforts, this
Committee has been involved in efforts, to encourage the VA to
employ the services of certain health care providers,
chiropractic care, physical therapy. It always seems like there
is a push to get the VA to accept certain segments of the
medical profession.
And I just would remind you that in both those instances,
physical therapy, chiropractic care, that in rural America,
those professionals are very important. They fill a real need.
And I would encourage your efforts on behalf of rural health
care to recognize this, not to be narrow in the way that we
define who can be a provider.
I think there is some reluctance to pursue the
opportunities that I see there with a wide array of services
that are more available in rural America in certain
subcategories of professionals than there are just--than
sometimes what we look for.
Let me finally, and, again, my time has expired, the
Chairman has been very kind, but let me just thank you, Ms.
Hawthorne, for your meeting with my staff.
Implementation of the legislation that we have been talking
about is a high priority of this Committee. Many Members come
from rural areas. It is a high priority with me.
You were very gracious and it appears to me that you are
very interested in seeing that this occur in a timely and
appropriate fashion and I am very grateful for your attitude
and approach and look forward to working with you.
Thank you, Mr. Chairman.
Mr. Teague. Thank you, sir, for those very pertinent
questions and appropriate issues that needed to be addressed.
At this time, I would like to ask the Congressman from
California, Mr. McNerney, if he has some questions.
Mr. McNerney. Well, I do, Mr. Chairman. Thank you for
giving me the gavel here.
And I want to follow-up a little bit on some of the
questions by my colleague from Kansas. I certainly recognize
the shortage, critical shortage of health care professionals in
rural areas. And it is not just for VA services. It is a
general problem. So we need to look at how to entice
physicians, health care professionals of all kinds to come into
rural areas.
One of the problems we are facing in California is that our
prisons are severely overcrowded resulting in poor health care
for prisoners. And now they are suggesting, the courts are
about to mandate that we open up health care facilities in our
area that will pay far more than the VA can and that will draw
physicians further away from VA use and applications to prison.
And that is very controversial. I am sure you can imagine. So
it is an area that we need to look at and maybe address at this
level.
One of the things that struck me about your testimony, Dr.
Darkins, was the sort of difference in tone about telehealth
from the prior panel. They certainly acknowledged the need for,
the value of telenet, but your testimony was a little bit
farther than that. It was not just the value, but how it could
be used in several areas, vets with amputations, vets with
spinal cord injuries, weight problems, post-traumatic stress
and so on.
One of the things I am concerned about with telenet is the
lack of personal touch. I mean, you have a screen in front of
you and you can see the physician.
How effective is that in terms of reaching a veteran with
these sorts of problems as opposed to having someone that can
actually touch their hands and look them straight in the eye?
You know, how much difference is there in terms of the
effectiveness of the treatment if we go that way because it is
clear to me that telehealth is a very effective tool? We are
not going to be able to get all the physicians we need no
matter how hard we try. So how effective is this treatment?
Dr. Darkins. Thank you very much.
In terms of the VA's use of telemedicine, let me just say
it is not a panacea to be able to provide all services.
Absolutely it has to fit into a spectrum of care in which it is
there with face-to-face services as well. So it is part of a
spectrum of services.
VA's experience makes it a nationwide leader if not in
certain areas, an international leader. There are certain
benefits the VA has to make sure happens and develop very large
networks. VA has had an ongoing commitment from leadership
toward telehealth. It has been seen as a way to deliver
specialist services, particularly out into rural communities.
Secondly, we do not have barriers from State licensure
which allow us to develop large networks and to put these
enterprise services into place. So it is very much the scale at
which it is being done in VA that is so important. I think VA's
experience is much higher than elsewhere because we have really
an integrated health care system and are doing telehealth on an
enterprise level.
In terms of your specifics, that has been something of
enormous importance as we have taken telehealth forwards to be
able to be quite clear that this is the right care for
patients, it is what they want.
What we find is that telehealth services are really seen
across the board by patients as being really directly
equivalent in many cases to delivering face to face. We find
sometimes people prefer to have face to face, but if you take
into consideration the travel, sometimes the inconvenience, we
are finding that people say they really enjoy the telehealth
services.
It is not enough to be able to say anecdotally. We have
good evidence from surveys we have done. Our home telehealth
patients show an 86 percent satisfaction score with these
services. They help them live independently in their own homes.
We have 37,000 patients currently who otherwise might be in
nursing homes if it were not for these services.
Mr. McNerney. What sort of equipment is needed for home
telehealth that a person might not ordinarily have?
Dr. Darkins. Well, we are very sensitive to the fact that
we are dealing with an aging population and may not be the most
technology savvy. So we use simple technologies, which are push
button.
The current connectivity is largely through telephone land
lines, simple to use and communicate backward and forwards. And
we are seeing a 20-percent reduction of utilization, so
reducing hospital visits, and reducing hospital admissions
using these technologies. They are really helping people with
chronic disease to be able to stay living independently in
their own homes and communities.
Mr. McNerney. Do they need like a big screen TV or, I mean,
what physical equipment do they need in the house?
Dr. Darkins. They are small, little, unobtrusive boxes.
There are three different ways in which this is generally done.
One way is to do videoconferencing into the home so
somebody can directly see that provider. It means they get much
more of that face-to-face contact. Obviously a physical
examination cannot be done.
Mr. McNerney. Right.
Dr. Darkins. Second is to be able to monitor people's vital
signs, pulse, weight, blood pressure, temperature. It is
possible, thereby, to be able to remotely care for conditions
like heart failure. Very simply, if somebody puts on weight and
gets symptomatic, it is possible to intervene early and prevent
hospital admission.
And the third area really is to be able to use what are
known as disease management dialogs, to ask the kind of
questions of a patient each day that they might be asked of
their provider if they came into a clinic.
So we are finding this is really targeting care. We can
expedite admission of people to hospital or referral to clinics
based on this personal care each day which takes place from a
VA provider back in the VA Medical Center.
Mr. McNerney. Thanks.
If the Chairman will indulge me one more question, what do
we need to do here to make sure that the VA can provide these
sort of home-based services, make them available? Do we need to
provide equipment or people, service people to come in and
install, or what do we need to do here?
Dr. Darkins. Well, I would say in this area at the moment,
VA is very much on the leading edge of being able to take this
forward. These are emerging technologies that have been used
elsewhere but not as widely in the VA.
Patients are very accepting. Patients show high scores of
satisfaction. We are working with the vendors that provide the
technologies to standardize the systems, which is very
important to be able to standardize the data, and thereby, data
exchange.
There is not an issue in terms of our use of equipment or
having equipment to be able to do this. I think our main issues
as we go forward are really just those human being issues. You
touched on earlier is it as good to be able to be using
telehealth technologies as face to face.
So paradoxically we find a lot of the work is actually on
relationships because in the end, it comes down to
relationships. So I think the things I would say is one
limiting factor is being absolutely sure we have a robust
information technology backbone. We are working very hard with
our information technology colleagues and the outside vendors
to ensure that they are in place.
And the second is relationships, helping veteran patients
to be accepting, which they are, of this technology, but also a
provider population for whom this is a new way of delivering
care as well. So those are really our main challenges are those
human challenges rather than the technology.
Mr. McNerney. Thank you, Mr. Chairman.
Mr. Teague. Thank you, Congressman McNerney from
California, for that.
Dr. Darkins and Kara Hawthorne, I want to thank you again
for coming and testifying before our Subcommittee and thank you
for the input that you have had. There will be some other
questions submitted in writing.
And with that, that concludes the hearing this morning.
Thank you.
[Whereupon, at 11:27 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud,
Chairman, Subcommittee on Health
The Subcommittee on Health will now come to order. I thank everyone
for attending this hearing. The purpose of today's hearing is to
provide oversight of the VA's rural health funding spending and
resource coordination. The hearing will explore whether resources are
used efficiently to narrow the health disparities of veterans living in
rural areas.
In general, we know that Americans living in rural areas tend to be
in poorer health and are more likely to live below the poverty level
compared to the rest of the country. This is magnified by the shortage
of health professionals. In fact, while a quarter of the U.S.
population lives in rural areas, only 10 percent of physicians practice
in rural areas.
Focusing on the rural veteran population, we know that among all VA
health care users, 40 percent of nearly 2 million veterans reside in
rural areas. This includes nearly 80,000 veterans who live in highly
rural areas. And according to the VA Health Services Research and
Development Office, rural veterans have worse physical and mental
health related to quality of life scores compared to their urban
counterparts.
I commend the VA for their efforts to improve rural health. This
includes building new CBOCs, Rural Outreach Clinics, and Vet Centers in
rural and highly rural areas. It also includes pilot programs such as
the traveling nurse corps, and the mobile health care pilot which
places four mobile clinics in 24 predominantly rural counties in
Colorado, Nebraska, Wyoming, Maine, Washington, and West Virginia. I
also applaud the advances made in telehealth through the numerous pilot
programs which have been implemented to date.
To help the VA's efforts, the Appropriations Committee provided
$250 million in September of 2008 to establish and implement a new
rural health outreach and delivery initiative. Through today's hearing,
we seek a better understanding of how the VA has allocated and plans to
allocate the $250 million. The hearing will also address concerns about
the lack of coordination and the duplicative efforts by the various
offices in the VA that deal with rural health.
Today, the Disabled American Veterans will share their thoughts on
VA's progress in improving rural health. We will also hear from the
South Carolina Office of Rural Health about local challenges and
recommendations for closing the rural health gap. Finally, the VA's
Office of Care Coordination and the Office of Rural Health will report
on the Department's current efforts on rural health. I look forward to
hearing their informative testimonies.
Prepared Statement of Hon. Cliff Stearns
Thank you, Mr. Chairman.
I'm pleased to be here this morning for our Health Subcommittee's
hearing on ensuring our veterans living in rural areas are receiving
the quality health care they deserve.
Today's hearing affords us the chance to examine how the Department
of Veterans Affairs is spending some of the funds allocated to them in
the FY2009 Appropriations Act. Specifically, we are focusing on funds
that were marked to help further the VA's rural health initiatives in
areas such as mobile health clinics and telemedicine.
We are all well aware of the health care gaps that exist for
veterans residing in rural areas--we know that almost 40 percent of
veterans enrolled in VA health care live in rural or highly rural
areas, and that 44 percent of our veterans returning from Iraq and
Afghanistan also reside in rural areas. Veterans (and people in
general) living in rural America are statistically shown to have lower
quality of life scores and are more likely to suffer from treatable
diseases. Clearly, this is an issue we must be addressing and
monitoring closely.
I applaud the VA's current outreach efforts to recruit and retain
more health care providers to serve in rural areas and to pursue
innovative health care methods such as telemedicine. We are moving in
the right direction, but we must stay the course and the VA must
fulfill the goals it has set.
I welcome our panel of witnesses and look forward to hearing more
about how the VA has and intends to further distribute the funds
allocated to them under the FY09 appropriation so that we can truly
begin closing the health care gap for our Nation's rural veterans.
Prepared Statement of Joy J. Ilem
Assistant National Legislative Director,
Disabled American Veterans
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV) to
testify at this oversight hearing of the Subcommittee. We value the
opportunity to discuss our views on funding and resource coordination
as related to health care gaps for veterans residing in rural and
highly rural areas. This is an issue of significant importance to many
DAV members and veterans in general.
Approximately 40 percent of veterans enrolled for Department of
Veterans Affairs (VA) health care are classified by VA as rural or
highly rural. Additionally, 44 percent of current active duty military
servicemembers, who will be tomorrow's veterans, list rural communities
as their homes of record. Research shows that when compared with their
urban and suburban counterparts, veterans who live in a rural setting
have worse health-related quality-of-life scores; are poorer and have
higher disease burdens; worse health outcomes; and are less likely to
have alternative health coverage. Such findings anticipate greater
health care demands and thus greater health care costs from rural
veteran populations.
Over the past several years through authorizing legislation and
additional appropriations Congress has attempted to address unmet
health care needs of veterans who make their homes in rural and remote
areas. With nearly half of those currently serving in the military
residing from rural, remote and frontier areas, access to VA health
care and other veterans services for them is perhaps VA's most
perplexing challenge. We recognize that rural health is a difficult
national health care issue and is not isolated to VA's environment. We
also appreciate that many service-connected disabled veterans living in
rural areas face multiple challenges in accessing VA health care
services, or even private services under VA contract or fee basis.
Shortage of health care providers, long travel distances, weather
conditions, geography and financial barriers all negatively impact
access and care coordination for many rural veterans, both the service-
connected and nonservice-connected.
Section 212 of Public Law 109-461 authorized VA to establish the
Veterans Health Administration (VHA) Office of Rural Health (ORH). We
deeply appreciate the due diligence of this Subcommittee and Congress
as a whole in exerting strong support for rural veterans by enacting
this public law.
As required by the Act, the function of the ORH is to coordinate
policy efforts across VHA to promote improved health care for rural
veterans; conduct, coordinate, promote and disseminate research related
to issues affecting veterans living in rural areas; designate in each
Veterans Integrated Service Network (VISN) rural consultants who are
responsible for consulting on and coordinating the discharge of ORH
programs and activities in their respective VISNs for veterans who
reside in rural areas; and, to carry out other duties as directed by
the Under Secretary for Health. In the Act, VA also was required to do
an assessment of its fee-basis health care program for rural veterans
to identify mechanisms for expanding the program and the feasibility
and advisability of implementing such mechanisms. There were also a
number of reports to Congress required including submission of a plan
to improve access and quality of care for enrolled veterans in rural
areas; measures for meeting the long term care and mental health needs
of veterans residing in rural areas; and, a report on the status of
identified and opened community-based outpatient clinics (CBOCs) and
access points identified from the May 2004 decision document associated
with the Capital Asset Realignment for Enhanced Services (CARES) plan.
Finally, the Act required VA to conduct an extensive outreach program
to identify and provide information about VA health care services to
veterans of Operations Iraqi and Enduring Freedom (OIF/OEF) who live in
rural communities for the purpose of enrolling these veterans into the
VA health care system prior to the expiration of their statutory
eligibility period (generally, 5 years following the date of military
discharge or completion of deployments).
In addition to establishing the ORH, in 2008 VA created a 13-member
VA Rural Health Advisory Committee to advise the Secretary on issues
affecting rural veterans. This panel includes physicians from rural
areas, disabled veterans, and experts from government, academia and the
non-profit sectors. We applaud former VA Secretary Peake for having
responded to our recommendation in the Fiscal Year (FY) 2009
Independent Budget (IB) to use VA's authority to form such a Committee.
Recently, this new Committee held its second scheduled meeting. We hold
high expectations that the Rural Veterans Advisory Committee will be a
strong voice of support for many of the ideas we have expressed in
previous testimony before Congress, and joined by our colleagues from
AMVETS, Paralyzed Veterans of America, and the Veterans of Foreign Wars
of the United States, in the IB.
We are pleased and congratulate VA on its progress to date in
establishing the necessary framework to begin to improve services for
rural veterans. It appears that ORH is reaching across the Department
to coordinate and support programs aimed at increasing access for
veterans in rural and highly rural communities. We note, however, that
the ORH has an ambitious agenda but only a minimal staff and limited
resources. The ORH is still a relatively new function within VA Central
Office and it is only at the threshold of tangible effectiveness, with
many challenges remaining. Given the lofty goals of Congress for rural
health improvements, we are concerned about the organizational
placement of ORH within the VHA Office of Policy and Planning rather
than being closer to the operational arm of the VA system. Having to
traverse the multiple layers of VHA's bureaucratic structure could
frustrate, delay or even prevent initiatives established by this
office. We believe rural veterans' interests would be better served if
the ORH were elevated to a more appropriate management level in VA
Central Office, with staff augmentation commensurate with its stated
goals and plans.
We understand that VA has developed a number of strategies to
improve access to health care services for veterans living in rural and
remote areas. To begin, VA appointed rural care designees in all its
VISNs to serve as points of contact in liaison with ORH. While we
appreciate that VHA designated the liaison positions within the VISNs,
we expressed concern that they serve these purposes only on a part-time
basis. We are pleased that VA is conducting a pilot program in eight
VISNs to determine if the rural coordinator function is apropos of a
part-time or a full-time position.
VA reported that its approach to improving services in rural areas
includes leveraging existing resources in communities nationwide to
raise VA's presence through outreach clinics, fee-basis, contracting,
and use of mobile clinics. Additionally, VA testified it is actively
addressing the shortage of health care providers through recruitment
and retention efforts; and harnessing telehealth and other technologies
to reduce barriers to care. Also, in September 2008 VA announced plans
to establish new rural outreach clinics in Houston County, Georgia,
Juneau County, Alaska, and Wasco County, Oregon. VA plans to open six
additional outreach clinics by August 2009 in Winnemucca, Nevada,
Yreka, California, Utuado, Puerto Rico, Lagrange, Texas, Montezuma
Creek, Utah, and Manistique, Michigan.
VA also reported that it has conducted other forms of outreach and
developed relationships with the Department of Health and Human
Services (HHS) (including the Office of Rural Health Policy and the
Indian Health Service), and other agencies and academic institutions
committed to serving rural areas to further assess and develop
potential strategic partnerships. Likewise, VA testified it is working
to address the needs of veterans from OIF/OEF by coordinating services
with the HHS' Health Resources and Services Administration community
health centers, and that these initiatives include a training
partnership, technical assistance to community health centers and a
seamless referral process from community health centers to VA sources
of specialized care.
In August 2008, VA announced the establishment of three ``Rural
Health Resource Centers'' for the purpose of improving understanding of
rural veterans' health issues; identifying their disparities in health
care; formulating practices or programs to enhance the delivery of
care; and, developing special practices and products for implementation
VA system-wide. According to VA, the Rural Health Resource Centers will
serve as satellite offices of ORH. The centers are sited in VA medical
centers in White River Junction, Vermont; Iowa City, Iowa; and, Salt
Lake City, Utah.
Given that 44 percent of newly returning veterans from OEF/OIF live
in rural areas, the IB veterans service organizations believe that
these veterans, too, should have access to specialized services offered
by VA's Readjustment Counseling Service, through its Vet Centers. In
that regard we are pleased to acknowledge that VA plans to roll out a
fleet of 50 mobile Vet Centers this year to provide access to returning
veterans and outreach at demobilization sites on military bases, and at
National Guard and Reserve units nationally.
The issue of rural health is an extremely complex one and we agree
with VA that there is not a ``one-size-fits-all'' solution to this
problem. To make real improvements in access to the quality and
coordination of care for rural veterans, we believe that Congress must
provide continued oversight, and VA must be given sufficient resources
to meet its many missions, including improvements in rural health care.
In regard to funding for rural health, VA acknowledged in 2008 that
it had allocated almost $22 million to VISNs to improve services for
rural veterans. VA noted this funding is part of a two-year program and
would focus on projects including new technology, recruitment and
retention, and close cooperation with other organizations at the
federal, state and local levels. These funds are being used to sustain
current programs, establish pilot programs and establish new outpatient
clinics. VA distributed resources according to the fraction of enrolled
veterans living in rural areas within each VISN. It is DAV's
understanding that VISNs with less than three percent of their patients
in rural areas received $250,000, those with between three and six
percent received $1 million, and those with six percent or more
received $1.5 million.
The ORH has testified VA allocated another $24 million to sustain
these programs and projects into 2009, including the Rural Health
Resource Centers, mobile clinics, outreach clinics, VISN rural
consultants, mental health and long-term care projects, and rural home-
based primary care, and has convened a workgroup of VISN and Central
Office program offices to plan for the allocation of the remaining
funds. In February 2009, ORH distributed guidance to VISNs and program
offices concerning allocation of the remaining funds as early as May to
enhance rural health care programs.
Concurrently, Public Law 110-329, the Consolidated Security,
Disaster Assistance, and Continuing Appropriations Act, 2009, approved
on September 30, 2008, included $250 million for VA to establish and
implement a new rural health outreach and delivery initiative. Congress
intended these funds to build upon the successes of the ORH by enabling
VA to expand initiatives such as telemedicine and mobile clinics, and
to open new clinics in underserved and rural areas. Notably, the bill
also includes $200 million for fee-basis services.
Health workforce shortages and recruitment and retention of health
care personnel are also a key challenge to rural veterans' access to VA
care and to the quality of that care. The Institute of Medicine of the
National Academy of Sciences report ``Quality through Collaboration:
The Future of Rural Health'' (2004) recommended that the Federal
Government initiate a renewed, vigorous, and comprehensive effort to
enhance the supply of health care professionals working in rural areas.
To this end, VA's deep and long-term commitment to health profession
education seems to be an appropriate foundation for improving these
situations in rural VA facilities as well as in the private sector.
VA's unique relationships with health profession schools should be put
to work in aiding rural VA facilities with their human resources needs,
and in particular for physicians, nurses, technicians, technologists
and other direct providers of care. The VHA Office of Academic
Affiliations, in conjunction with ORH, should develop a specific
initiative aimed at taking advantage of VA's affiliations to meet
clinical staffing needs in rural VA locations. While VA maintains it is
moving in this general direction with its pilot program in a traveling
nurse corps, VA's pilot program in establishing a ``nursing academy,''
initially in four sites and expanding eventually to 12; its well-
founded Education Debt Reduction Program and Employee Incentive
Scholarship Program; and, its reformed physician pay system as
authorized by Public Law 108-445, none of these programs was
established as a rural health initiative, so it is difficult for DAV to
envision how they would lend themselves to specifically solving VA's
rural human resources problems. We do not see them as specific
initiatives aimed at taking advantage of VA's affiliations to meet
clinical staffing needs in rural VA locations.
The DAV has a standing resolution from its membership, Resolution
No. 177, fully supporting the right of rural veterans to be served by
VA, but insists that Congress provide sufficient resources for VA to
improve health care services for veterans living in rural and remote
areas. We thank VA and this Subcommittee for supporting this specific-
purpose funding for rural care without jeopardizing other VA health
care programs. Furthermore, we appreciate the Subcommittee's interest
in conducting this oversight hearing to learn more from VA about the
specific instructions issued to field facilities guiding the use of
these new funds, what Central Office monitoring is being provided over
the use of those funds, and the degree and type of reporting
requirements that have been imposed. Such information would serve
everyone's interest in ascertaining how many additional veterans
received care at VA's expense that otherwise would not have received
care were it not for the new resources made available for rural
veterans, as well as gathering data on how their health outcomes have
been affected as a measure of the quality of that care.
VA's previous studies of rural needs identified the need for 156
priority CBOCs and a number of other new sites of care nationwide. A
March 30, 2007, report submitted to Congress also required by Public
Law 109-461, indicates 12 CBOCs had been opened, 12 were targeted for
opening in FY 2007, and five would open in FY 2008. In June 2008, VA
announced plans to activate 44 additional CBOCs in 21 states during FY
2009. Of the over 750 CBOCs VA operates, 353 CBOCs are doing real-time
video conferencing (predominantly tele-mental health), while 130 CBOCs
are transmitting tele-retinal imaging for evaluation by specialists in
VA medical centers. Such services greatly enhance patient care, extend
specialties into rural and highly rural locations, and drastically cut
down on long-distance travel by veterans. VA directly staffs 540
clinics, and the remainder of these CBOCs are managed by contractors.
At least 333 of VA's CBOCs are located in rural or highly rural areas
as defined by VA. In addition, VA is expanding its capability to serve
rural veterans by establishing rural outreach clinics. Currently 12 VA
outreach clinics are operational, and more are planned. These are major
investments by VA and we appreciate both VA and Congress for supporting
this level of extension of VA services into more and more communities.
While we applaud the VHA for improving veterans' access to quality
care and its intention to spread primary and limited specialty care
access for veterans to more areas, enabling additional veterans access
to a convenient VA primary care resource, DAV urges that the business
plan guiding these decisions generally first emphasize the option of
VA-operated and staffed facilities. When geographic or financial
conditions warrant (e.g., highly rural, scarceness, remoteness, etc.),
we do not oppose the award of contracts for CBOC operations or leased
facilities, but as a contributor to the IB for FY 2010 we do not
support the general notion that VA should rely heavily or primarily on
contract CBOC providers to provide care to rural veterans.
We understand and appreciate those advocates on this Subcommittee
and in Congress in general who have been successful in enacting
authority for VA to increase health care contracting in rural areas
through a new multi-VISN pilot program enacted in Public Law 110-387.
However, in light of the escalating costs of health care in the private
sector, to its credit VA has done a remarkable job of holding down
costs by effectively managing in-house health programs and services for
veterans. While some service-connected and nonservice-connected
veterans might seek care in the private sector as a matter of personal
convenience, they may well lose the safeguards built into the VA system
by its patient safety program, prevention measures, evidence-based
treatments, national formulary, electronic health record, and bar code
medication administration (BCMA), among other protections. These unique
VA features culminate in the highest quality care available, public or
private. Loss of these safeguards, ones that are generally not
available in private sector systems or among individual practitioners
or group practices (especially in rural areas), would equate to
diminished oversight and coordination of care, lack of continuity of
care, and ultimately may result in lower quality of care for those who
need quality the most.
For these reasons, we urge Congress and VA's ORH to closely monitor
and oversee the development of the new rural pilot demonstration
project from Public Law 110-387, especially to protect against any
erosion or diminution of VA's specialized medical programs and to
ensure participating rural and highly rural veterans receive health
care quality that is comparable to that available within the VA health
care system. We are pleased that the ORH reported it is coordinating
with the Office of Mental Health Services to implement this pilot
program. We ask VA, in implementing this demonstration project, to
develop a series of tailored programs to provide VA-coordinated rural
care (or VA-coordinated care through local, state or other Federal
agencies, as VA has previously claimed it would be doing) in the
selected group of rural VISNs, and to provide reports to the Committees
on Veterans' Affairs of the results of those efforts, including
relative costs, quality, satisfaction, degree of access improvements
and other appropriate variables, compared to similar measurements of a
like group of rural veterans in VA health care. To the greatest extent
practicable, VA should coordinate these demonstrations and pilots with
interested health profession academic affiliates. We recommend the
principles outlined in the Contract Care Coordination section of the FY
2010 IB be used to guide VA's approaches in this demonstration, and
that it be closely monitored by VA's Rural Veterans Advisory Committee,
with results reported regularly to Congress.
We also recommend that VA be required to provide more thorough
reporting to this Subcommittee to enable meaningful oversight of the
use of the funds provided and the implementation of the authorizing
legislation that serves as a foundation to this work.
We urge the Subcommittee to consider legislation strengthening
recurring reporting on VA rural health as a general matter. We are
concerned that funds Congress provided to VA to address shortages of
access in rural areas will simply be dropped into the VA ``Veterans
Equitable Resource Allocation'' (VERA) system, absent means of
measuring whether these new funds will be obligated in furtherance of
Congress's intent--to enhance care for rural and highly rural veterans,
with an emphasis on outreach to the newest generation of war veterans
who served in the National Guard and hail from rural areas. Reports to
Congress should include standardized and meaningful measures of how VA
rural health care capacity or ``virtual capacity'' has changed; VA
should provide recorded workload changes on a quarterly or semi-annual
basis, and disclose other trends that reveal whether the rural health
initiatives and funds allocated for them are achieving their designed
purposes.
In closing, DAV believes that while VA may be working in good faith
to address its shortcomings in rural areas, it clearly still faces
major challenges and hurdles. In the long term its methods and plans
may offer rural and highly rural veterans better opportunities to
obtain quality care to meet their specialized health care needs.
However, we caution about the trend toward privatization, vouchering
and contracting out VA health care for rural veterans on a broad scale.
As VA's ORH develops its policies and initiatives, DAV cannot stress
enough the importance of communication and collaboration between this
office, other VA program offices and field facilities, and other
Federal, State or local organizations, to reach out and provide VA
benefits and services to veterans residing in rural and highly rural
areas. As noted above, we are concerned that the current staffing level
assigned to ORH will be insufficient to effectively carry out its
mission. Moreover, DAV believes ORH's position in VHA's organizational
structure may hamper its ability to properly implement, guide and
oversee VA's rural health initiative. Also, Congress should monitor
VA's funding allocation to ensure rural health needs do not interfere
with other VA medical obligations. Finally, we are hopeful with
continued oversight from this Subcommittee and, with these principles
in mind; rural veterans will be better served by VA in the future.
Mr. Chairman, this concludes my statement. I would be happy to
address questions from you or other Members of the Subcommittee.
Prepared Statement of Graham L. Adams, Ph.D.,
Executive Director, South Carolina Office of Rural Health, and
State Office Council Chair, National Rural Health Association
I am Graham Adams, CEO of the South Carolina Office of Rural
Health, a Past-President of the National Organization of State Offices
of Rural Health and a trustee on the Board of the National Rural Health
Association. The NRHA provides leadership on the issues that affect the
health of the 62 million Americans who call rural home and has long
focused efforts on improving the physical and mental health of our
rural veterans. I appreciate the opportunity to speak before you today
to discuss this very important issue.
Since our Nation's founding, rural Americans have always responded
when our Nation has gone to war. Whether motivated by their values,
patriotism, or economic concerns, the picture has not changed much in
230 years. Simply put, rural Americans serve at rates higher than their
proportion of the population. Though only 19 percent of the Nation
lives in rural areas, 44 percent of U.S. Military recruits are from
rural America. And, sadly, according to a 2006 study of the Carsey
Institute, the death rate for rural soldiers is 60 percent higher than
the death rate for those soldiers from cities and suburbs. Given this
great commitment to service on behalf of rural communities, we need to
do more to closely examine the health care barriers that face rural
veterans. Developing solutions specific to rural veterans and their
unique needs must be a priority.
There is a national misconception that all veterans have access to
comprehensive care. Unfortunately, this is simply not true. Access to
the most basic primary care is often difficult in rural America. Access
for rural veterans can be daunting. Combat veterans returning to their
rural homes in need of specialized care due to war injuries (both
physical and mental) likely will find access to that care extremely
limited. What this means, is that because there is a disproportionate
number of rural Americans serving in the military, there is a
disproportionate need for veteran's care in rural areas.
Veterans that live in rural communities face great challenges when
trying to receive care. Lack of an adequate number of Community Based
Outpatient Clinics (CBOCs), Outreach Health Centers or other approved
sources of care make it difficult for rural veterans to receive timely,
appropriate care. According to the VA website, my home state of South
Carolina only has 11 CBOCs, and 3 Vet Outreach Centers. This is
especially concerning given that South Carolina is one of the top
twenty states in which veterans reside. Scarcity of mental health and
family counseling services is also a problem for rural veterans in need
of these services.
The NRHA believes that both program expansion and resource
coordination is critical to improve the care of our rural veterans and
makes the following recommendations:
1. Increase Access by Building on Current Successes
Community Based Outreach Centers (CBOCs) open the door for many
veterans to obtain primary care services within their home communities.
Additionally, Outreach Health Centers meet the needs of many rural
veterans. NRHA applauds the success of these programs and supports
their expansion.
2. Increase Access by Collaborating with Non-VHA Facilities
Approximately 20 percent of veterans who enroll to receive health
care through the VHA live in rural communities. With an ever-growing
number of veterans returning home to their rural communities after
military service, these rural health care systems must be prepared to
meet their needs. While CBOCs and Veteran Outreach Centers provide
essential points of access, there are not enough of these facilities in
rural communities. Furthermore, CBOCs do not provide a full range of
care and the low volume of veterans in some communities may never be
able to support one of these centers. Simply put, more providers are
needed to serve the increasing number of rural veterans. Collaboration
with existing rural health care facilities provides an effective and
timely solution to this problem.
Linking the quality of VA services with rural civilian services can
vastly improve access to health care for rural veterans. Our goal is
not to mandate care to our veterans, but to provide them a choice, a
local choice. As long as quality standards of care and evidence-based
medicine guide treatment for rural veterans, the NRHA supports
collaboration with:
Federally Qualified Community Health Centers (FQHCs).
These centers serve millions of rural Americans and provide community-
oriented, primary and preventive health care. More importantly, FQHCs
are located where rural veterans live. A limited number of
collaborations between the VHA and Community Health Centers already
exist and have proven to be prudent and cost-effective solutions to
serving eligible veterans in remote areas. These successful models
should be expanded to reach all of rural America.
Critical Access Hospitals and other small rural
hospitals. These facilities provide comprehensive and essential
services to rural communities and are specific to rural states. If
these facilities are linked with VHA services and models of quality,
access to care would be greatly enhanced for thousands of rural
veterans.
Rural Health Clinics. These clinics serve populations in
rural, medically underserved areas and comprise a vital piece of the
safety-net system. In many rural and frontier communities, RHCs are the
only source of primary care available. Furthermore, many RHCs are more
than willing to see these rural veterans if only a mechanism existed to
do so.
The above rural health facilities are the cornerstone of primary
and preventive quality health care in rural America. Each is required
to meet Federal requirements for quality, provider credentialing and
the use of health information technology. Current collaborations with
the VHA in Wisconsin, Missouri and Utah are strong examples of success.
Expanding the levels of collaboration will vastly increase access to
care in a cost-effective manner.
The NRHA is pleased that the Rural Veterans Access to Care Act was
signed into law last October. This act establishes a 3-year pilot
program in several rural regions of the country to allow the most
underserved rural veterans to take advantage of existing quality rural
health providers, such as Critical Access Hospitals, community health
centers and rural health clinics. The pilot project is relatively small
and requirements to qualify are rigid--a veteran must live at least 60
miles from a VA primary care facility like an outpatient clinic, 120
miles from a VA hospital or 240 miles from a VA specialized-care
facility when seeking that care. Despite these defects, this
legislation is a strong and important step in the right direction, but
so much more must be done.
3. Increase Access to Mental Health and Brain Injury Care
Currently, it appears that Traumatic Brain Injury (TBI) will most
likely become the signature wound of the Afghanistan and Iraqi wars.
Such wounds require highly specialized care. The current VHA TBI Case
Managers Network is vital, but access to it is extremely limited for
rural veterans--expansion is needed.
Additionally, mental health needs of combat veterans deserve
special attention and advocacy as well. Access to mental health
services is a problem in many small rural communities. In fact, 85
percent of all mental health shortages are found in rural America. A
lack of qualified mental health professionals, shortage of psychiatric
hospital beds and the negative stigma of mental illness, often result
in many rural residents not getting the care they so desperately need.
These problems are exacerbated for veterans who live in rural
communities.
Although Vet Centers provide mental health services, they are not
consistently available at the local, rural level. More resources are
needed in order to contract with local mental health providers, hire
additional mental health providers and/or contract with Critical Access
Hospitals (CAHs) and other small rural hospitals.
4. Target Care to Rural Veterans
A. Needs of the Rural Family. Rural veterans have an especially
strong bond with their families. Returning veterans adjusting to
disabilities and the stresses of combat need the security and support
of their families in making their transitions back into civilian life.
The Vet Centers do a tremendous job in assisting veterans, but their
resources are limited. The NRHA supports increases in funding for
counseling services for veterans' and their families.
B. Needs of Rural Women Veterans. More women serve in active duty
than at any other time in our Nation's history. And more women are
wounded or are war casualties than ever before in our Nation's history.
Targeted and culturally competent care for today's women veterans
is needed. Rural providers should also be trained to meet the unique
needs of rural, minority, and female veterans.
5. Improving Office of Rural Veterans
The NRHA calls on Congress and the VA to fully implement the
functions of the newly created Office of Rural Veterans to develop and
support an on-going mechanism to study and articulate the needs of
rural veterans and their families.
Additionally, efforts to increase service points for rural veterans
have, in large part, not been fully supported by the VA Administration
itself. The VA has not consistently supported attempts to collaborate
with rural health. It is my hope that with a new Administration and the
newly formed VA Rural Health Advisory Committee, previous barriers will
be eradicated and the Office of Rural Veterans will lead the way in
expanding access options for rural veterans. Furthermore, the NRHA
strongly encourages greater coordination between the Rural Health
Coordinators housed in each VISN and state-level rural health officials
in their region. Specifically, quarterly meetings with State Office of
Rural Health and State Rural Health Association officials would be
prudent.
6. Explore ways to coordinate benefits for dual eligible veterans
As the veteran population ages, a growing number of veterans are
eligible for both VHA health benefits and Medicare. The combination of
two partial benefits packages should ensure the best possible care for
our veterans, but the copayments and Medicare Part D requirements may
not be affordable for many veterans. Coordination of benefits would
allow veterans to utilize the different resources offered to them
effectively to receive high quality care close to home.
7. Increase research on defining the rural veteran population
Without good research about the rural veteran population, we cannot
possibly expect to ensure their good health. Epidemiological studies
are needed to identify the locations and populations of veterans in
various rural areas of the country. These studies must provide
information about race, gender, place of residence, health care needs,
service-related health issues and service utilization. Only about 39
percent of veterans are enrolled in VA health care benefits; quality
research would provide information about how to best serve the veteran
population who are currently not enrolled. The NRHA would encourage the
VA to collaborate with the six Federal Office of Rural Health Policy/
HRSA-funded Rural Health Research Centers to explore this research.
Conclusion
While many opportunities for improvement exist in providing care to
veterans in rural communities, the VA is to be commended for the
excellent service provided in many of its facilities. However, we must
never forget that many veterans forgo care entirely because of access
difficulties to VA facilities. Providing health care in rural
communities requires unique solutions, whether it is to veterans and
their families or the general population. Adopting some of the
strategies referenced in this written testimony would aid in addressing
these rural needs.
Additionally, we must all be mindful of long-term needs and costs
of our sailors and soldiers. The wounded veterans who return today
won't need care for just the next few fiscal years, they will need care
for the next half century.
Thank you again for this opportunity. The NRHA looks forward to
working with you and this Committee to improve rural health care access
for the millions of veterans who live in rural America.
Prepared Statement of Adam Darkins, M.D.
Chief Consultant, Care Coordination,
Office of Patient Care Services, Veterans Health Administration,
U.S. Department of Veterans Affairs
Good morning, Mr. Chairman. Thank you for the opportunity to
testify before the Committee about addressing the health care needs of
Veterans in rural areas. This initiative recognizes our continuing
commitment to provide services to Veterans no matter where they live.
My testimony today covers issues associated with funding and resource
coordination with respect to how the Department of Veterans Affairs
(VA) is implementing telehealth programs at the enterprise level to
meet the needs of Veterans in rural areas.
Health care delivery in rural areas challenges all health care
systems, including VA, but we are not discouraged by this challenge,
and we are confronting it directly. Telehealth, which involves the use
of information and telecommunications technologies to deliver services
in situations where the patient and the provider are geographically
separated from one another, offers one solution to this challenge.
Telehealth provides health care to underserved rural areas and involves
35 clinical specialties in VA. In Fiscal Year (FY) 2008, VA's
enterprise telehealth programs provided care to over 100,000 Veterans
in rural and highly rural areas. These telehealth-based services
involve real-time video conferencing, store-and-forwards telehealth and
home telehealth.
VA provided real-time video-conferencing, also known as Care
Coordination/General Telehealth (CCGT), to 32,000 Veterans in rural
areas and 2,000 in highly rural areas in FY 2008. Of these, 1,900
Veterans from rural areas served in Operation Enduring Freedom or
Operation Iraqi Freedom (OEF/OIF) and 112 OEF/OIF Veterans live in
highly rural areas. The majority of CCGT services were for mental
health conditions. The responsiveness and availability of mental health
care services for our clients is a priority. In FY 2008, 19,000
Veterans received tele-mental health services in rural areas and 1,500
in highly rural areas. CCGT services were available to Veterans at 171
sites in rural or highly rural areas.
Store-and-forwards telehealth, known as Care Coordination/Store-
and-Forwards (CCSF), involves the acquisition and interpretation of
clinical images for screening, assessment, diagnosis and management.
These services were provided to 61,776 Veterans in rural areas and
2,911 in highly rural areas during FY 2008. CCSF services were
predominantly delivered to screen diabetic eye disease (tele-retinal
imaging) and prevent avoidable blindness in Veterans, 50,908 of whom
were in rural areas and 2,536 in highly rural areas. Of the 219 sites
at which tele-retinal screening took place in FY 2008, 54 of these
sites were in rural or highly rural clinics. The remainder of CCSF
activity mainly covered tele-dermatology.
To help Veterans continue living independently in their own homes
and local communities, VA provides home telehealth services, known as
Care Coordination/Home Telehealth (CCHT). CCHT services cover a range
of chronic conditions including diabetes, chronic heart failure,
hypertension and depression. In FY 2008, over 35,000 Veterans received
home telehealth-based care. More than 16,000 Veterans received these
services for non-institutional care. VA recognizes we treat an older
population, one that will have increasing need of home-based primary
care, and we are preparing now for future demand. Currently, 37,000
Veterans receive CCGT for non-institutional care, chronic care
management, acute care management and health promotion or disease
prevention. Thirty-eight percent of these patients in VA are in rural
areas and 2 percent are in highly rural areas. All together, between 30
and 50 percent of telehealth activity in VA supports Veterans in rural
and highly rural areas, depending upon the area of telehealth. Data
from the first quarter of FY 2009 show ongoing growth in all areas of
telehealth with commensurate growth in rural and highly rural areas.
VA is undertaking a range of initiatives in FY 2009 that are
targeted at sustaining this growth of telehealth services and expanding
access in rural and highly rural areas. These initiatives focus on the
clinical, technology and business processes that are underpinning the
safe, effective and cost-effective implementation of telehealth in VA
to support Veteran care. For example, Care Coordination Services (CCS)
is collaborating with the Office of Rehabilitation Services to
formalize the clinical processes necessary to use telehealth to support
the 41,096 Veterans with amputations receiving care from VA. Telehealth
enhances access to care in rural areas as close to Veterans' homes and
local communities as possible, if the Veteran wishes to use the
services. CCS is also working with our colleagues in the Spinal Cord
Injury and Disorder Service to implement CCGT services to make
specialist care more widely available, including in rural areas. We
have recently completed the necessary work to implement VA's Managing
Overweight and/or Obesity for Veterans Everywhere (MOVE!) program
within CCHT programs. This development will expand the reach of this
successful and groundbreaking program for weight management to Veterans
in rural and highly rural areas. We anticipate making a program for
supporting Veterans with substance abuse issues via home telehealth
available during FY 2009.
CSS is collaborating with the Office of Mental Health Services to
establish a national Tele-mental Health Center. This center will
coordinate tele-mental health services nationally with an emphasis on
making specialist mental health services, such as those for post-
traumatic stress disorder and bipolar disorder, available in rural
areas. CSS is also proposing an innovative approach for consideration
by our colleagues in VA's Office of Rural Health to directly fund VISNs
in support of enterprise-wide telehealth programs to expand their reach
into rural areas and to increase the number of Veterans served. CSS is
working with VA's Medical/Surgical Service to further extend tele-
retinal imaging. CSS is seeking funding from the Office of Rural Health
to support five additional sites in rural areas. We are currently
implementing a pilot program we hope to expand nationally for tele-
dermatology in five Veterans Integrated Service Networks (VISNs) in 35
sites, 20 of which are in rural areas.
VA is known for its significant work in creating and
institutionalizing an award winning electronic medical record that has
propelled VA into the 21st century. VA is very fortunate to have a
workforce of clinicians who are so receptive to new technology and who
readily embraced the use of VA's electronic health record (EHR). The
EHR underpins all that we do in telehealth in VA. With telehealth, as
with the implementation of the EHR, it is necessary to ensure
clinicians and patients are educated and accepting of a new approach to
health care. VA has three training centers for telehealth located in
Boston, MA; Salt Lake City, UT; and Lake City, FL. These centers have
trained over 6,000 staff to. ensure we have a workforce competent in
telehealth and to develop and sustain these services. Always cognizant
of the issues involved in training staff in rural areas, our training
centers have partnered with VA's Employee Education System to use
virtual training modalities wherever possible, including bi-monthly
national satellite broadcasts that can be viewed remotely, an annual
virtual national meeting, and web-based courses that cover our
enterprise telehealth applications.
Telehealth technologies are constantly developing as new
functionalities become available. VA is working in this evolving
environment to improve usability of the technologies for both patients
and clinicians. VA has developed robust interoperable national IT
platforms to support the commercial-off-the-shelf (COTS) telehealth
devices that interface with patients. In FY 2009, VA is piloting an
extension of its pre-existing Polytrauma Telehealth Network to create a
clinical enterprise videoconferencing network (CEVN). The CEVN will
facilitate the extension of polytrauma, post-amputation, spinal cord
injury care and specialist mental health care to rural areas. These
efforts, combined with My HealtheVet, which offers Veterans access to
their personal health record any time, anywhere, leverage new
technologies to benefit our clients.
VA is also extending its enterprise telehealth programs to American
Indian/Alaskan Native and Pacific Islander communities. VA currently
operates seven such programs, with four more awaiting connectivity and
11 in deployment for 15 Tribes in four VISNs. VA is one of several
agencies working to improve care in these areas through telehealth. We
have maintained a longstanding relationship with other Federal partners
through the Joint Working Group on Telemedicine, which is an excellent
forum for sharing practices and concepts for expanding care.
In order to substantiate the safety and efficacy of care delivery
through its enterprise telehealth networks, we have introduced quality
management programs for CCHT, CCGT and CCSF. In FY 2009, these quality
management programs are being combined for all three areas of
telehealth to create a single assessment process in which the policies
and procedures of telehealth programs are assessed biannually in each
VISN. In addition, VA collects routine outcomes data for program
management purposes. These systems allow us to quantify, validate and
monitor the benefits of these approaches to clinical care. The data
indicate VHA's enterprise telehealth programs are associated with
substantial reductions in hospital admissions (more than 20 percent
reductions compared to non-telehealth users) and high levels of patient
satisfaction (mean scores above 85 percent).
Many areas of telehealth are still emerging technologies that we
are committed to mastering. Our focus will always remain on the needs
of Veterans. VA's strategy has been to adopt a systematic enterprise
approach with the aim of providing the right care in the right place at
the right time to Veterans in rural, highly rural and urban settings.
This approach of developing VA's telehealth network has resulted in
sustained growth. By remaining client-centric, we provide dynamic,
flexible, and responsive specialist care to underserved areas. Key to
the development of telehealth in VA is the energy, expertise and
dedication of staff from various backgrounds who resolve the ongoing
clinical, technology and business issues that arise. Given the
commitment of VA to serving the needs of Veterans and meeting the
challenges of those requiring care in rural and highly rural areas, the
development of telehealth is not solely a technical exercise; we are
driven to deliver caring, compassionate and appropriate care in the
least restrictive and most accessible manner possible.
In drawing to a close, I would like to acknowledge the challenges
of providing health care services in rural areas, particularly with
respect to meeting specialist care. Telehealth is part of a spectrum of
services that includes obligate needs for in-person provision of
ambulatory care and clinical procedures. It is a privilege to work with
colleagues throughout VA and engage in implementing telehealth to
provide groundbreaking services to those who have served our Nation and
to whom we are committed to serving, whether they live in rural, highly
rural or urban locations where access to care presents a challenge for
them. This remains VA's mission and it is one we gladly accept.
Mr. Chairman, this concludes my prepared statement. I am pleased to
address any questions the Committee may have.
Prepared Statement of Kara Hawthorne,
Director, Office of Rural Health,
Veterans Health Administration, U.S. Department of Veterans Affairs
Good morning, Mr. Chairman. Thank you for the opportunity to
discuss the Department of Veterans Affairs' (VA's) work to enhance the
delivery of health care to Veterans in rural and highly rural areas. VA
continues our commitment to provide service to Veterans in remote
geographic areas, and we look forward to working with the Committee to
better promote services and care.
VA's Office of Rural Health (ORH) was authorized in December 2006
by Sec. 212 of Public Law 109-461 and is empowered to coordinate
policy efforts across VHA to promote improved health care for rural
Veterans. Development of this office started in early April 2007, and a
Director was named in October 2007. As the Secretary has said, rural
health is a difficult national health care issue, but one that we will
meet directly, with an eye toward becoming the leader in this field.
Veterans and others who reside in rural areas face a number of
challenges associated with obtaining health care. VA has embraced a
national strategy of outreach to ensure Veterans, regardless of where
they live, can access the expertise and experience of one of the best
health care systems in the country. In partnership, Congress and VA can
do even more. We appreciate Congress' support and interest in this
area, and we are happy to report portions of the $250 million included
in this year's appropriation have already been distributed to the field
to support new and existing projects.
ORH has allocated $24 million to sustain Fiscal Year 2008 programs
and projects, including the Rural Health Resource Centers, Mobile
Clinics, Outreach Clinics, VISN Rural Consultants, mental health and
long-term care projects, and rural homebased primary care. ORH worked
with representatives throughout VA and the Veterans Health
Administration (VHA), including VISN Directors, Program Chiefs, the
Office of General Counsel, the Office of Information Technology, VHA's
Chief Business Office, and the VHA Chief Financial Office, to develop
strategy, guidance and measures for allocating the remaining funds. ORH
has adopted an inclusive approach that reaches across business lines
throughout the organization.
In December 2008, VA provided almost $22 million to VISNs across
the country to improve services for rural Veterans. This funding is
part of a 2-year program and will focus on projects including new
technologies, recruitment and retention, and close cooperation with
other organizations at the Federal, State and local levels. VA will use
funds to sustain current programs, initiate pilot programs and
establish new outpatient clinics. VA distributed resources according to
the proportion of Veterans living in rural areas within each VISN;
VISNs with less than three percent of their patients in rural areas
received $250,000, those with between three and six percent received $1
million, and those with six percent or more received $1.5 million.
VISNs were directed to identify programs or projects that would
develop innovative strategies, care delivery models, educational
initiatives, technology uses and other approaches to enhance health
care service delivery and outreach for rural Veterans. ORH provided
examples, including programs or projects that: a) assess and anticipate
the current and future health care needs of rural Veterans; b) address
solutions that may be adapted for use by, or have value for, all VA
facilities; c) emphasize collaborations with other VHA facilities, as
well as public and private entities; or d) programs that would meet the
legislative requirements of the Consolidated Security, Disaster
Assistance, and Continuing Appropriations Act, 2009 (Public Law 110-
329) or the Veterans' Mental Health and Other Care Improvements Act of
2008 (PL 110-387). ORH instructed VISNs to include funding validation
and reporting with a breakdown by target (e.g., medical administration,
medical services, medical facilities, information technology, etc.) to
facilitate distribution and tracking. VISNs are required to report
their accomplishments based upon this funding quarterly. This report
must include a description of the program, the purpose and objectives,
and supporting documentation (including the demographics of the service
area, the execution plan and the evaluation plan). ORH supplied
evaluative criteria to VISNs, including how objectives compare to
legislative requirements, how significant the potential and likely
impacts of the program are for rural Veterans, whether there is
programmatic relevance and adherence to the award's intent, and whether
the budget is appropriate for the proposal. These measures allow us to
validate the benefits of our services to Veterans.
In February 2009, ORH distributed guidance to VISNs and Program
Offices concerning allocation of the remaining funds as early as May to
enhance rural health care programs. Both program offices and VISNs were
eligible to apply for this funding, which would support programs in six
key areas of focus, including access, quality, technology, workforce,
education and training, and collaboration strategies. Projects could
include leveraging existing, proven initiatives, such as increasing
access points in rural and highly rural areas (i.e., establishing
outreach clinics in areas not meeting VA's drive time standards, or
developing mobile clinics), structured initiatives to expand feebasis
care, developing collaborations with Federal and non-Federal partners,
accelerating telemedicine deployment or funding innovative pilot
programs. ORH, along with the program review panel consisting of
relevant program directors across VA, will be reviewing these proposals
in early April 2009 by considering their capacity for meeting
legislative requirements, their relevance for rural and highly rural
populations, their ability to assess and anticipate current and future
health care needs of rural Veterans, their potential for adaptation or
use by all VA facilities, their collaborations with other VHA
facilities, the evidence-base to support the program, their clear
articulation of potential impacts, and their definition of Veterans'
needs being addressed. Proposals that recommended new technologies or
those that sought to extend current enterprise programs needed to
justify how these alternative solutions will be interoperable and
embody the essential clinical, technology and business processes to
ensure compatibility with existing programs. Affected program offices
will be involved in the review of these applications to ensure
continuity and consistency within the program area.
Proposals must include a clearly defined purpose and objectives,
implementation strategies (including Veteran populations affected,
service area demographics, and collaborators), specific program
evaluation measures (including cost, quality, access, outcomes, policy
effectiveness, and other criteria, such as measures established by VA's
Office of Quality and Performance) and budget justifications. ORH will
review proposals based on the following criteria: the program's
objectives, feasibility, innovation, budget, personnel, service area
environment, evaluation, and the recommendations of relevant program
offices. All programs receiving funding will be required to submit
either monthly or quarterly reports that assess the number of Veterans
served, the funded amounts for all initiatives, program evaluation
measures, and additional evaluation measures as defined by ORH. ORH
will notify award recipients by May and begin disbursing funds at that
time.
At the start of this Fiscal Year, VA opened three Rural Health
Resource Centers: one in White River Junction, Vermont; another in Iowa
City, Iowa; and the last in Salt Lake City, Utah. These centers develop
special practices and products for use by facilities and networks
across the country. Each Resource Center is identifying disparities in
health care for rural Veterans within their regions. These Centers
essentially serve as field-based clinical laboratories capable of
experimenting with new outreach and care models. They also serve a
crucial function in enhancing academic affiliations with nursing and
medical schools and support direct outreach to Veterans.
As an example of the work the Centers are doing, the Eastern Rural
Health Resource Center in White River Junction hosted a conference with
nearly 100 participants on March 13-14 titled, ``New Horizons in Human
Health: Bringing Leading-Edge Medicine to Rural Communities.'' This
conference was a collaborative effort between the Togus VA Medical
Center, Eastern Maine Health Care, the Maine Institute for Human
Geriatrics and Health, and the University of New England. The Resource
Centers are also working with ORH to develop an evaluation methodology
for the Maine Mobile Health Care Clinic to answer questions about the
effectiveness of mobile clinics and their impact on Veteran enrollment
and use. The Central Region's Rural Health Resource Center is
conducting a telephone-based survey designed to assess structural and
functional capabilities of community-based outpatient clinics (CBOCs)
in urban and rural settings. Finally, the Western Region has hired a
Native Consultant to help the Center examine the current health care
policies for rural American Indian/Alaskan Native and rural Native
Hawaiian Veterans. The report produced for each population will discuss
next steps for policy development and prioritize recommendations for
further work.
VA's ORH, during its short existence, has produced a number of
programs that are actively improving the delivery and coordination of
health care services to rural Veterans. VA is actively expanding the
existing Home-Based Primary Care and Medical Foster Home programs (part
of VA's Community Residential Care Program) into rural VA facilities
with startup funding for Fiscal Year 2008 and partial funding for
Fiscal Year 2009. Home-Based Primary Care provides comprehensive,
interdisciplinary care to Veterans with chronic, complex diseases that
worsen over time. This is a cost effective program for providing
primary care services in the home, including palliative care,
rehabilitation, disease management and coordination of care. Home-Based
Primary Care can reduce Veteran travel time, which can avoid
exacerbating chronic conditions.
ORH has also helped develop the ``Geri'' scholars program, in
collaboration with VHA's Office of Geriatrics and Extended Care, to
target VA geriatric providers in rural areas and provide them with an
intensive course in geriatric medicine and a tailored training program
on providing geriatric medicine in rural VA clinics with curricula and
supportive activities based on a needs assessment of each participant.
Currently, there is a severe shortage of VA physicians with training or
certification in geriatric medicine, and VA currently lacks training
for primary care clinicians in key aspects of geriatrics and extended
care to older Veterans living in rural areas. This new training program
consists of intensive didactic training in core issues related to the
health care needs of older patients, mentoring curricula to support a
model quality improvement process at each participating rural CBOC, and
web-based education for interdisciplinary health care teams at CBOCs.
Graduates of this program will disseminate this work within their home
facility.
ORH is supporting expansion of the Mental Health Care Intensive
Care Management-Rural Access Network for Growth Enhancement (MHICM-
Range) Initiative to provide community-based support for Veterans with
severe mental illness. VA has been adding mental health staff to CBOCs,
enhancing our capacity to provide telemental health services and using
referrals to Community Mental Health Services and other providers to
increase access to mental health care in rural areas. ORH collaborated
with the South Central Mental Illness Research, Education and Clinical
Center in VISN 16 to fund four research studies investigating clinical
policies or programs that improve access, quality and outcomes of
mental health and substance abuse treatment services for rural and
underserved Veterans.
VA has also taken the lead in opening new rural health care
facilities, such as Rural Outreach Clinics. Last September, VA
announced the opening of ten new Rural Outreach Clinics this Fiscal
Year; four of these are currently operational, including sites in
Houlton, ME; Perry, GA; Juneau, AK; and The Dalles, OR. VA utilizes
Rural Outreach Clinics to offer services on a part-time basis, usually
a few days a week, in rural and highly rural areas where there is
insufficient demand for full-time services or it is otherwise not
feasible to establish a full-time CBOC. Rural Outreach Clinics offer
primary care, mental health services, and specialty referrals. Each
Rural Outreach Clinic is part of a VA network and meets VA's quality
standards. Veterans use Rural Outreach Clinics as an access point for
referrals to larger VA facilities for specialized needs.
VA recently announced a Mobile Health Care Pilot Project in VISNs
1, 4, 19, and 20. The vans associated with this program will be
concentrated in 24 predominately rural counties, where patients would
otherwise travel long distances for care. VA is focusing on counties in
Colorado, Maine, Nebraska, Washington, West Virginia and Wyoming. This
pilot will collaborate with local communities in areas our mobile vans
visit to promote continuity of care for Veterans. It will also allow us
to expand our telemedicine satellite technology resources and is part
of a larger group of mobile assets. ORH is developing evaluation
methodologies and measures to determine the effectiveness of this
program and to identify areas for improvement.
Vet Centers also provide services and points of access to Veterans
in rural communities. Vet Centers welcome home Veterans with honor by
providing quality readjustment counseling in supportive, non-clinical
environments. By the end of FY 2009, VA will have 271 Vet Centers and
1,526 employees to address the needs of Veterans; any county in the
country with more than 50,000 Veterans will have services available
through a Vet Center. A fleet of 50 Mobile Vet Centers are also being
put into service this year and will provide access to returning
Veterans and outreach to demobilization military bases, National Guard
and Reserve locations nationally.
Recruiting providers in rural areas is a challenge for VA as well
as the civilian community. ORH is working with VHA's Office of Academic
Affiliations to develop a program expanding health profession training
in rural VA facilities. The Rural Health Training Initiative selection
process will be implemented this spring, with trainees scheduled to
matriculate at rural health care access points beginning July 1, 2010.
VA is expanding the use of Internet-based venues for health care
related job postings in addition to recruiting from the VA job board
(VA Careers), which links to USAJobs.gov, and other job boards. The VHA
Healthcare Retention & Recruitment Office is hiring recruiters who will
concentrate on recruitment of health care providers for rural areas and
as well as establishing a national contracts with search firms that
target physician recruitment. This Office is developing other
collaborative relationships with organizations focused on rural
recruitment such as the National Rural Recruitment & Retention Network
(www.3Rnet.org), increasing training courses specifically for practices
related to rural recruitment issues, and hiring recruiters whose
primary aim will be recruitment of physicians.
Similarly, VA has conducted outreach and developed relationships
with the Department of Health and Human Services (including its Office
of Rural Health Policy and the Indian Health Service), other agencies
and academic institutions committed to serving rural areas. VA has also
reached out through ORH to government and nongovernmental
organizations, including the National Rural Health Association, the
National Organization of State Offices of Rural Health, the National
Institute of Mental Health Office of Rural Mental Health, the National
Cooperative Health Networks, the Rural Health Information Technology
Coalition, the Rural Assistance Center, the Rural Health Resource
Center, the Georgia Health Policy Center, various rural health research
centers, and other organizations to further assess and develop
potential strategic partnerships. ORH is working in close collaboration
with the Department of Health and Human Services to address the needs
of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF)
Veterans to coordinate services with the Department of Health and Human
Services' Health Resources and Services Administration Community Health
Centers. These initiatives include a training partnership, technical
assistance to Community Health Centers, and a seamless referral process
from Community Health Centers to VA medical centers.
Importantly, VA is conducting ``in-reach'' within VA to identify
needs and services relevant for rural Veterans. ORH works closely with
the following offices and groups within the Veterans Health
Administration (VHA): the Office of Mental Health Services, the Office
of Care Coordination, the Office of Geriatrics and Extended Care, the
Readjustment Counseling Service, the VHA Business Office, the VHA
Finance Office, the Office of Academic Affiliations, the Healthcare
Recruitment and Retention Office, the Office of Health Information, the
National Center for Patient Safety, the Office of Public Health and
Environmental Hazards, the Office of Quality and Performance, the
Office of Research and Development, the Employee Education System, and
the Office of Operations and Management. ORH also works closely with
the Department's Office of Policy and Planning, Office of Information
and Technology and Office of General Counsel.
Last year, Congress passed Public Law 110-387, the Veterans' Mental
Health and Other Care Improvements Act of 2008. Section 107 of Public
Law 110-387 directs VA to conduct a pilot program in at least three
VISNs to evaluate the feasibility and advisability of providing OEF/OIF
Veterans with peer outreach and support services, readjustment
counseling services, and other mental health services through
arrangements with, among others, community mental health centers. VA's
Office of Mental Health Services and ORH are in the process of
implementing this pilot program. The pilot will be conducted in a
number of stages evaluating:
the identification of rural areas that are beyond the
reach of VA's mental health services for Veterans but have other mental
health providers capable of providing high quality services;
the willingness and capability of these entities for
providing outreach and treatment services for returning Veterans;
the feasibility of developing performance based
contracts with these entities that meet the requirement of Section 107;
and
the use of services and the outcomes of care provided
through these contracts.
Section 403 of the law requires VA to conduct a pilot program that
would provide non-VA care for highly rural enrolled Veterans in five
VISNs. VA is working to implement this pilot while resolving two
questions. First, VA must develop a regulation to define the ``hardship
provision'' in Section 403(b)(2)(B). Second, we must reconcile how VA
has traditionally defined ``highly rural'' (based on Census data as
discussed above) and how the statute defines it. VA's next steps
involve identifying qualifying communities, identifying local providers
willing and able to participate, and beginning with acquisition and
exchanges of medical information as well as addressing pharmacy
benefits and performance criteria for contracts and care. However, it
is important to note VA already has the authority to contract with the
most appropriate provider when VA is unable to provide necessary
services. During FY 2008 VA expended $248 million for inpatient and
outpatient services, including long term and home health care,
purchased by contract in rural areas. An additional $1.04 billion was
expended on a fee-for-service basis in rural areas for Veteran health
care.
Mr. Chairman, VA's Office of Rural Health is reaching across the
Department to coordinate and support programs aimed at increasing
access for Veterans in rural and highly rural communities. We work
closely with the Office of Care Coordination and our colleague, Dr.
Darkins, in this regard. Thank you once again for the opportunity to
discuss VA's continuing efforts for rural Veterans. We are prepared to
address any additional questions you might have.
Statement of Hon. Henry E. Brown, Jr.,
Ranking Republican Member,
Subcommittee on Health
Thank you Mr. Chairman.
I appreciate your holding this hearing to take a close look at how
the Office of Rural Health is working and being funded.
Congress took a significant step in 2006 when we created a new
Office of Rural Health within VA to address the unique needs of
veterans living in rural areas. And, I appreciate your holding this
hearing to take a close look at how this new office is working and
being funded.
It is important that new and emerging technologies are being
considered to help effectively bridge the distance gap. The expanded
use of telehealth, while not a cure-all, can alleviate some of the
distance-based challenges in the areas of primary care, mental health
and even long-term or home-based care. I expect that our VA witnesses
will provide us with details on what is currently being accomplished in
this area and what we can anticipate in the future.
Equally important to the use of new technologies, we must also
expand partnerships with the local health care community to provide
care closer to the veteran's home. Last year, the Rural Veterans Access
to Care Act, legislation sponsored by my good friend and colleague,
Jerry Moran, was enacted into law as a pilot program in Public Law 110-
387. Although this hearing is not focused on this important measure,
Chairman Michaud has assured me that we will have a future hearing
dedicated to the implementation of the law later in the year.
In closing, I would like to extend a special welcome to one of our
witnesses on the first panel, Dr. Graham Adams. He serves as the CEO
and provides overall supervision and direction for the South Carolina
Office of Rural Health. Dr. Adams has consistently worked
collaboratively with clinicians, administrators, educations,
legislators, community and civic leaders and state and Federal agencies
to improve access to quality health care in rural communities.
I am looking forward to listening to and learning from his
experiences and that of all of our witnesses.
And, with that, Mr. Chairman, I yield back.
MATERIAL SUBMITTED FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
March 30, 2009
Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, D.C. 20240
Dear Secretary Shinseki:
Thank you for the testimony of Dr. Adam Darkins, Chief Consultant
to the Office of Care Coordination, Veterans Health Administration, and
Ms. Kara Hawthorne, Director of the Office of Rural Health, Veterans
Health Administration, at the U.S. House of Representatives Committee
on Veterans' Affairs Subcommittee on Health Oversight Hearing on
``Closing the Health Gap of Veterans in Rural Areas: Discussion of
Funding and Resource Coordination'' that took place on March 19, 2009.
Please provide answers to the following questions by May 11, 2009,
to Jeff Burdette, Legislative Assistant to the Subcommittee on Health.
1. To date, the VA has awarded about $46 million of the $250
million appropriated for the rural health initiative. Why did the VA
choose to phase the grant award instead of fully allocating the $250
million up front?
2. Of the $46 million awarded to date, $22 million was awarded to
the VISNs based on the number of rural veterans living in the VISN. The
VISN awards ranged from as little as $250,000 to $2.5 million. How did
the VA determine the size of the grant award? Is $250,000 sufficient
funding for the VISNs to accomplish what you outlined in your
testimony?
3. The VA will require the VISNs to submit a quarterly report to
track the funding use and to report on their accomplishments. When is
the next quarterly report due? Will this information be provided in the
required quarterly report to the Appropriations Committee on the uses
of $250 million?
4. Of the $46 million awarded to date, $24 million went to sustain
FY 2008 Office of Rural Health programs and projects. Please submit for
the record the funding amounts associated with the programs that
received this money.
5. To allocate the remaining funds from the appropriated $250
million, the VA has set up a program review panel consisting of
relevant program directors across the VA. Please identify the panel
members.
6. Please also walk us through the timeline for awarding funding.
Please explain how the VA will determine its success or shortcomings in
meeting the original intent of the appropriated funding or establish
and implement a rural health outreach and delivery initiative.
7. How will the VA ensure that local VISNs and program offices
leverage this funding to help close the rural health gap?
8. How does the Office of Rural Health ensure that its efforts do
not duplicate that of other offices in the VA, such as the Office of
Care Coordination?
9. In your testimony, you highlighted the outreach and the ``in-
reach'' the Office of Rural Health has conducted. Please expand on this
and explain the specific nature of the collaboration and coordination
that has resulted from these relationships.
In addition, please answer the following questions for
Representative Ciro Rodriguez.
1. Your testimony reported that VISNs with less than 3 percent
rural veterans received $250,000, VISNs with 3 to 6 percent received $1
million, and VISNs with more than 6 percent received $1.5 million to
sustain current programs, initiate pilot programs, and establish new
outpatient clinics. Please provide any details available on how much
VISN 17 and VISN 18 received and what specific programs in those VISNs
are to receive portions of these allocated funds.
2. What were the recommendations for enhancing rural veteran
access to health care resulting from the March 13-14 conference in
White River Junction entitled ``New Horizons in Human Health: Bringing
Leading Edge Medicine to Rural Communities''? Which recommendations are
being considered for Department-wide implementation?
3. Are there any plans to open a Rural Outreach Clinic in Texas
District 23 (VISNs 17 and 18), such as the ones mentioned in your
written testimony?
4. Why was VISN 18 not selected for the Mobile Health Care Pilot
Project mentioned in your testimony?
5. To what degree has the VA considered or used mobile surgery
units and screening units, such as those provided by Mobile Medical
International, for operational/surgical, ambulatory, or medical
screening in remote rural areas? Are these types of units being
considered for use in VISN 18?
6. Based on your statements about the section 403 Pilot Program,
when do you expect these issues to be resolved and the pilot program
actually implemented?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by May 11, 2008.
Sincerely,
MICHAEL H. MICHAUD
Chairman
CW/jb
______
Prepared Questions for the Record
Hon. Michael Michaud,
Chairman, Subcommittee on Health,
House Committee on Veterans' Affairs
Closing the Health Gap of Veterans in Rural Areas:
Discussion of Funding and Resource Coordination
March 19, 2009
Question 1: To date, VA has awarded about $46 million of the $250
million appropriated for the rural health initiative. Why did VA choose
to phase the grant award instead of fully allocating the $250 million
up front?
Response: The Department of Veterans Affairs (VA) chose to disburse
funds from the $250 million included in this year's budget
appropriation in phases to ensure the funds were allocated properly to
achieve the greatest possible advances in reducing the health care gap
for rural Veterans. VA recognized there were immediate needs in rural
and highly rural areas across the country and provided initial seed
money (approximately $22 million) with specific guidelines on
allocation to Veterans Integrated Service Networks (VISN) to support
their rural health programs in compliance with Public Law (P.L.) 110-
329, the Consolidated Security, Disaster Assistance, and Continuing
Appropriations Act, 2009.
On March 19, 2009, VA testified that $24 million of the $250
million allocated to VA for a rural health initiative in P.L. 110-329
was being used to support continuing programs from fiscal year (FY)
2008 into FY 2009. VA has since decided to fund these programs out of
the Office of Rural Health's (ORH) base budget. Consequently, of the
$250 million included in this year's appropriations bill, VA has only
allocated approximately $22 million. The remaining funds will be used
to support programs proposed by program offices and VISNs; these
proposals have been reviewed for merit and feasibility by a panel and
have been approved by Veterans Health Administration (VHA) leadership.
ORH has informed the recipients of these funds and disbursements are
underway.
As rural solutions are market driven, VA wanted to provide VISNs
and program offices more planning time and the opportunity to compete
for the remaining funds to support their initiatives that resolve local
health issues and hold promise for regional or national adoption. These
proposals would support programs in six key areas of focus including
access, quality, technology, workforce, education and training, and
collaboration strategies.
Additionally, projects could include leveraging existing proven
initiatives (such as increasing access points in rural and highly rural
areas by establishing outreach clinics in areas not meeting VA's drive
time guidelines or deploying mobile clinics); structuring initiatives
to expand fee-basis care; developing collaborations with Federal and
non-Federal partners, accelerating telemedicine deployment, or funding
innovative pilot programs.
Question 2: Of the $46 million awarded to date, $22 million was
awarded to the VISNs based on the number of rural Veterans living in
the VISN. The VISN awards ranged from as little as $250,000 to $2.5
million. How did VA determine the size of the grant award? Is $250,000
sufficient funding for the VISNs to accomplish what you outlined in
your testimony?
Response: ORH worked with the Deputy Under Secretary for Health for
Operations and Management to ensure the unique interests of rural
Veterans were considered. In December 2008, VA provided $21.75 million
directly to VISNs to help them immediately implement programs to
improve services for rural Veterans. This funding is part of a 2-year
program focusing on initiatives such as new technologies, provider
recruitment and retention incentives, and cooperation with other
organizations at the Federal, State and local levels. Facilities are
using these funds to sustain current programs, initiate pilot programs,
and establish new outpatient clinics.
VA distributed the initial resources according to the proportion of
Veterans living in rural and highly rural areas within each VISN: VISNs
with less than 3 percent of their patients in rural areas received
$250,000; those with between three and 6 percent received $1 million;
and those with 6 percent or more received $1.5 million. VISNs were
directed to identify programs that could develop innovative strategies,
care delivery models, educational initiatives, technology uses and
other approaches to enhance health care service delivery and outreach
for rural Veterans in compliance with P.L. 110-329.
For the three VISN's that received $250,000, the initial seed money
was adequate based on their unique rural health needs. If more funds
are required, those VISNs can apply for additional funds under the
February 2009 ORH Funds Distribution Program Guidance.
Question 3: VA will require the VISNs to submit a quarterly report
to track the funding use and to report on their accomplishments. When
is the next quarterly report due? Will this information be provided in
the required quarterly report to the Appropriations Committees on the
uses of $250 million?
Response: Senate Appropriations Report No. 110-428, which
accompanied the Military Construction and Veterans Affairs and Related
Agencies Appropriations Act, 2009, directed VA to report quarterly to
the House and Senate Committees on Appropriations on new rural health
initiatives implemented as a result of the funding. The current report
is nearing final clearance through VA leadership and VA expects to
furnish it by May 30, 2009. This report will contain additional
information on the VISN funding allocations.
Question 4: Of the $46 million awarded to date, $24 million went to
sustain FY 2008 Office of Rural Health programs and projects. Please
submit for the record the funding amounts associated with the programs
that received this money.
Response: ORH, in conjunction with VHA program offices, supported a
range of initiatives in FY 2008, and VA has allocated funds to sustain
those programs in FY 2009 out of ORH's base budget. VA originally
testified that a portion of the $250 million included in P.L. 110-329
would be used to fund these efforts. The chart below provides specific
amounts for each initiative.
------------------------------------------------------------------------
ORH Funded Initiatives FY 2009 Funding
------------------------------------------------------------------------
Veterans Rural Health Resource Centers $6,600,000
------------------------------------------------------------------------
VISN Rural Consultants $1,200,000
------------------------------------------------------------------------
Veterans Rural Health Advisory Committee $300,000
------------------------------------------------------------------------
Rural Outreach Clinics $3,600,000
------------------------------------------------------------------------
Rural Mobile Health Care Clinics $2,100,000
------------------------------------------------------------------------
Home Based Primary Care Rural Expansion $1,500,000
------------------------------------------------------------------------
Medical Foster Home Expansion $600,000
------------------------------------------------------------------------
Geri Scholars Program $500,000
------------------------------------------------------------------------
Idea Award Funding $2,000,000
------------------------------------------------------------------------
Contract Support $5,000,000
------------------------------------------------------------------------
Veterans Sessions Educational Sessions $600,000
------------------------------------------------------------------------
TOTAL FUNDING $24,000,000
------------------------------------------------------------------------
Question 5: To allocate the remaining funds from the appropriated
$250 million, VA has set up a program review panel consisting of
relevant program directors across VA. Please identify the panel
members. Please also walk us through the timeline for awarding funding.
Response: ORH requested that both VISNs and program offices submit
proposals to fund additional initiatives to support rural and highly
rural Veterans within their areas of operations. The deadline for
proposals was March 20, 2009. A panel with representatives from program
offices across VA is reviewing proposals for compliance with P.L. 110-
329 and prioritizing them based on merit and feasibility. ORH presented
its final selection to VHA leadership on April 14, 2009, and submitted
selected proposals to the appropriate program offices for review and
concurrence to ensure the project(s) were consistent with the program
office mission and plans. Based on the overwhelming response from the
VISNs and program offices, ORH projects the remaining funds will be
fully allocated during the third quarter of FY 2009.
The ORH P.L. 110-329 Review Panel membership includes rural health
resource center directors, VISN rural consultants, key program office
representatives, senior VA staff professionals (including chief
officers, deputy chief officers, network directors, and deputy
directors), and other subject matter experts.
Question 6: Please explain how VA will determine its success or
shortcomings in meeting the original intent of the appropriated funding
or establish and implement a rural health outreach and delivery
initiative.
Response: A key requirement of the ORH funding guidance is that
project objectives must be consistent with ORH's mission and that they
adhere to the legislative requirements of P.L. 110-329. In addition to
the stated primary requirements, ORH will evaluate project development
and execution through review of the periodic project reports.
All programs receiving funding will be required to submit quarterly
reports that assess the number of Veterans served, key program
indicators, and additional evaluation measures as defined by ORH.
Specifically, all funded projects are required to adhere to the
reporting requirements detailed below:
a. Quarterly reports that present a summary of issues and
accomplishments, the numbers of Veterans served, funded amounts for all
initiatives, and program evaluation measures (specific to each project)
as proposed in each project proposal using a standard format;
b. A final report that summarizes the entire period of
performance, due at the end of the performance period;
c. Stated deliverable(s) from proposal; and
d. Additional reports, which may be required as stipulated during
award negotiations.
Question 7: How will VA ensure that local VISNs and program offices
leverage this funding to help close the health care gap?
Response: ORH is working with VISNs and program offices to identify
projects and programs that will develop innovative strategies and care
delivery models to enhance health care delivery and outreach to rural
Veterans. VISN and program office initiatives are expected to support
projects in six key areas of focus: access, quality, technology,
workforce, education and training, and collaboration strategies. To
support their efforts ORH has supplied evaluative criteria to VISNs,
including how objectives compare to legislative requirements, how
significant the potential and likely impacts of the program are for
rural Veterans, whether there is programmatic relevance and adherence
to the award's intent, and whether the budget is appropriate for the
proposal. Additionally, each project is required to submit a list of
measures that they will be monitoring to determine program
effectiveness.
Question 8: How does the Office of Rural Health ensure that its
efforts do not duplicate that of other offices in VA, such as the
Office of Care Coordination?
Response: ORH is conducting ongoing ``in-reach'' within VA to
identify needs and services relevant for rural Veterans. Soon after ORH
was created, VA conducted an assessment to determine the most
challenged areas in terms of drive time access. ORH also spent time
developing and building a robust infrastructure to continue to learn
about rural Veterans and how best to serve this population through the
development and execution of pilot projects, promotion of rural health
issues through education, training and information dissemination,
engagement in VISN level strategic planning, and relationship building
with community partners.
ORH also immediately began collaborating with, and learning from,
the already established VHA program offices and VA staff. ORH sought to
learn what services were already provided and to use the input and
guidance to assist ORH in identifying necessary actions and how best to
deploy ORH funds. ORH recognized there were successful programs already
in place and did not want to use resources to duplicate services.
ORH continues working with offices and groups across VA to ensure
efforts are unique and consistent with program offices' goals and
missions.
Question 9: In your testimony, you highlighted the outreach and the
``in-reach'' the Office of Rural Health has conducted. Please expand on
this and explain the specific nature of the collaboration and
coordination that has resulted from these relationships.
Response: ORH has collaborated with other offices within VA to
identify current or emerging solutions for rural Veterans. For example,
by working with the Deputy Under Secretary for Health for Operations
and Management, ORH was able to fund 10 additional rural outreach
clinics, while cooperation with the Readjustment Counseling Service
helped deploy 4 mobile health clinics in rural areas. ORH's work with
the Office of Patient Care Services resulted in plans to expand
telehealth, geriatrics and extended care initiatives, and mental health
initiatives. Specifically, VA is actively expanding the existing home-
based primary care and medical foster home programs into rural VA
facilities with start-up funding for FY 2008 and partial funding for FY
2009. ORH has also helped develop the Geri Scholars program, in
collaboration with the VHA Office of Geriatrics and Extended Care, to
target VA geriatric providers in rural areas. ORH is also supporting
expansion of the Mental Health Care Intensive Care Management-Rural
Access Network for Growth Enhancement initiative to provide community-
based support for Veterans with severe mental illness. VA has added
mental health providers to community based outpatient clinics (CBOC),
enhancing capacity to provide tele-mental health services and using
referrals to community mental health services and other providers to
increase access to mental health care in rural areas.
Recognizing rural communities have limited capital for health
information technology investment, the likelihood for rapid changes in
technology, and the absence of national technical standards pose
additional challenges; ORH has worked closely with the VHA Chief
Information Office to expand My HealtheVet, which offers Veterans
access to their personal health record any time, any where. ORH is also
investing in health information exchanges and regional health
information organizations that have been created in many localities to
test the electronic exchange of protected health information, and VA is
establishing connections with these successful networks.
Most importantly, ORH has used the expertise and guidance of
representatives throughout VA--including VISN directors, chief officers
of different programs, the Office of General Counsel, the Office of
Information Technology, VHA's Chief Business Office, and VHA's Chief
Financial Office--to develop strategies, guidance, and measures for
allocating ORH's appropriated funds. This inclusive approach reaches
across business lines throughout the organization.
Hon. Ciro Rodriguez
Question 1: Your testimony reported that VISNs with less than three
percent rural Veterans received $250,000, VISNs with three to six
percent received $1 million, and VISNs with more than six percent
received $1.5 million to sustain current programs, initiate pilot
programs, and establish new outpatient clinics. Please provide any
details available on how much VISN 17 and VISN 18 received and what
specific programs in those VISNs are to receive portions of these
allocated funds.
Response: VISN 17 received $1 million in initial funding. Of this,
$333,334 has been obligated to three initiatives. The first is the
expansion of home health services. This initiative will expand services
using existing contracts with home health agencies and includes the
Southern Oklahoma counties of Bryan and Choctaw and the Northern Texas
counties of Cooke, Delta, Fannin, Grayson, Hopkins, Hunt, Lamar and Red
River. The second initiative expands telemedicine access for mental
health compensation and pension (C&P) exams for rural Veterans in the
Central Texas Veteran Health Care System. This project will install
additional telemedicine equipment for C&P exams at the CBOC in
Brownwood and Palestine, TX. The third initiative expands contract
nursing home care to rural Veterans who do not have access to VA
nursing homes and will cover a service area of 15 rural counties
through contracts with 20 non-VA nursing homes. VISN 18 received $1
million in funding to be used to support fee-basis programs that
provide care to rural and highly rural Veterans who are eligible for
fee-basis care. These programs will strive to decrease the drive time
for rural and highly rural Veterans.
Question 2: What were the recommendations for enhancing rural
Veteran access to health care resulting from the March 13-14 conference
in White River Junction entitled, ``New Horizons in Human Health:
Bringing Leading Edge Medicine to Rural Communities''? Which
recommendations are being considered for Department-wide
implementation?
Response: The following recommendations were discussed at the New
Horizons in Human Health: Bringing Leading Edge Medicine to Rural
Communities meeting and are being considered for broader
implementation:
Considering the use of existing medical resources in
remote locations rather than attempting to build new VA facilities in
these areas;
Expanding telehealth presence in rural areas to overcome
transportation barriers;
Integrating VA rural health efforts with other Federal
rural initiatives (such as partnering with federally qualified health
centers and rural health centers);
Reducing VA administrative barriers to private sector
partnership (for example, contracting regulations); and
Making VA more of a two-way player when it comes to
sharing medical information across systems.
Question 3: Are there any plans to open a Rural Outreach Clinic in
Texas District 23 (VISNs 17 and 18), such as the ones you mentioned in
your written testimony?
Response: VHA has not developed plans to open a Rural Outreach
Clinic in Texas District 23. However, VISN 17 awarded a contract to
LifeLine Mobile for a mobile clinic, based out of Laredo and McAllen,
TX which will visit designated cities every other week. The mobile
clinic will provide primary care, mental health care, immunizations and
education services to Veterans living in Texas in Rio Grande City
(Starr County), Roma (Starr County), Zapata (Zapata County), Falfurrias
(Brooks County), Hebbronville (Jim Hogg County), and Port Isabel
(Cameron County). Veterans living in the southern end of District 23
including the counties of Kinney, Maverick, Uvalde, Medina, Zavala,
Dimmit and Bexar are proximate to the contract awarded for the LifeLine
Mobile Clinic, and may have opportunities to use these services. South
Texas Veterans Health Care System (VAHCS) has done a market analysis of
the 11 counties they support and the West Texas VAHCS (VISN 18)
continues to review care services support opportunities within its area
of Congressional District 23.
Question 4: Why was VISN 18 not selected for the Mobile Health Care
Pilot Project mentioned in your testimony?
Response: In FY 2008, a mobile fleet strategic plan workgroup was
established to assess VHA assets and to develop ORH pilot project
initiatives. ORH worked in collaboration with the workgroup to draft a
request for proposals to initiate a rural mobile health care clinic
pilot project to enhance the delivery of care for Veterans in rural
areas. ORH received applications from VISNs 1, 4, 10, 17, 18, 19, 20,
and 21 requesting funds for both purchases and operations. The process
was competitive and an interdisciplinary team scored and ranked
applications. The application process focused on three critical issues:
the geographic area to be served, the projected impact, and operational
plans. The application rating criteria covered five areas:
Improving access to services in rural area;
Soundness of operational plan;
Collaborations with community and other partners;
Use of telemedicine;
Innovation and program uniqueness; and
Veteran population.
The four-member review panel recommended VISNs 19, 1, and 4, in
rank order, to receive funding for purchase and operations. Based on
this competitive process, VISN 18 did not rank high enough relative to
the other VISN applicants to be considered for funding.
Question 5: To what degree has VA considered or used mobile surgery
units and screening units, such as those provided by Mobile Medical
International, for operational/surgical ambulatory, or medical
screening in remote areas? Are these types of units being considered
for use in VISN 18?
Response: Rural health mobile clinics funded by ORH provide primary
and mental health care, screening and limited specialty care. They are
not designed to provide higher intensity care such as surgical
procedures. Currently, VISN 18 is not pursuing such units.
Question 6: Based on your statements about the section 403 Pilot
Program, when do you expect these issues to be resolved and the pilot
program actually implemented?
Response: Section 403 of Public Law 110-387 requires VA to conduct
a pilot program that would provide non-VA care for highly rural
enrolled Veterans in five VISNs. VA is working to implement this pilot
while resolving two issues: 1) VA must develop a regulation to define
the ``hardship provision'' in Section 403(b)(2)(B); and 2) VA must
reconcile how it has traditionally defined ``highly rural'' and how the
statute defines it. VA's next steps involve identifying qualifying
communities, identifying local providers willing and able to
participate, and beginning with acquisition and exchanges of medical
information, as well as addressing pharmacy benefits and performance
criteria for contracts and care.
On March 17, 2009, VA met with staff from both the House and Senate
Committees on Veterans' Affairs to provide an update on the pilot
program. VA and the Committees staffs discussed the hardship provision
from (b)(2)(B) and the statute's definition of ``highly rural''. VA
proposed potential approaches to resolve these concerns and we are
awaiting guidance from both Committees. In the interim, VA continues to
work on this pilot program in accordance with the statute.