1. VA Office of Rural Health
Gina L. Capra, MPA
Director, Office of Rural Health (ORH)
Office of the Assistant Deputy Under Secretary for Health (ADUSH) for Policy and Planning
Veterans Health Administration (VHA)/Department of Veterans Affairs (VA)

2. Today’s Presentation Mission and Overview Demographics and Needs
Focus and Resources
Environment and Collaborations

3. Mission of the Department of Veterans Affairs (VA)
“…to care for him who shall have borne the battle and
for his widow and orphan…”
- Abraham Lincoln, 1865
Photo by Jeff Kubina

4. Department of Veteran Affairs (VA) Mission, Core Values & Characteristics
“…to care for him who shall have borne the battle and
for his widow and orphan…”
VA Core Values:
“I CARE” - Integrity, Commitment,
Advocacy, Respect & Excellence
VA Characteristics:
Trustworthy, Accessible, Quality, Innovative, Agile and Integrated

5. What is the Department of Veterans Affairs (VA)?
Established in 1930
Elevated to Cabinet level in 1989
Federal government’s 2nd largest department after the Department of Defense
Three components:
Veterans Health Administration (VHA)
Veterans Benefits Administration (VBA)
National Cemetery Administration (NCA)

6. Veterans Health Administration (VHA) Mission
Honor America’s Veterans
Provide Exceptional Health Care
VETERANS HEALTH ADMINISTRATION (VHA) MISSION STATEMENT Honor America’s Veterans by providing exceptional health care that improves the their health and well-being.
VETERANS HEALTH ADMINISTRATION VISION STATEMENT VHA will continue to be the benchmark of excellence and value in health care and benefits by providing exemplary services that are both patient-centered and evidence-based. This care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery and continuous improvement. It will emphasize prevention and population health and contribute to the Nation’s well-being through education, research and service in national emergencies.
Improve Health and Well-being

7. VHA is the Largest Integrated Health Care System in the United States
151 Hospitals
995 Outpatient Clinics (Hospitals, Community, Independent and Mobile )
135 Community Living Centers
300 Readjustment Counseling Centers Vet Centers
103 Domiciliary Resident Rehabilitation Treatment Programs

8. 21 Veterans Integrated Service Networks

9. Eligibility for VHA Healthcare
Eligibility for VHA health care services depends on a number of qualifying factors, including:
The nature of a veteran’s discharge from military service (e.g., honorable, other than honorable, dishonorable)
Length of service
VA adjudicated disabilities (commonly referred to as “service-connected disabilities”)
Income level
Available VA resources

10. Who is eligible for VHA Healthcare?
Veteran eligibility for VA healthcare is based on category group (“Priority Enrollment Group”)
Category Group 1
Veterans with service-connected disabilities rated 50% or more disabling
Category Group 2
Veterans with service-connected disabilities rated 30% or 40% disabling
Category Group 3
POWs, Purple Heart recipients, those rated 10% or 20% disabled, or those eligible under Title 38, U.S.C., Section 1151
Category Group 4
Veterans who receive aid and attendance or housebound benefits or are catastrophically disabled
Category Group 5
Veterans whose income and net worth are below established VA thresholds of $31K - $46K annually, (depending on family size), those on VA pension and/or are eligible for Medicaid benefits
Category Group 6
WW I, Mexican Border War Veterans, disorders associated with exposure to herbicides (Agent Orange) while serving in Vietnam, exposure to ionizing radiation in Hiroshima and Nagasaki, Gulf War illness.
Category Group 7 Veterans who pay co-payments with income and/or net worth above the VA threshold
Category Group 8 Veterans who agree to pay specified co-payments with income and/or net worth above the VA threshold and HUD geographic index who were enrolled before January Income requirements may change
from year to year.

11. Population Served
U.S. Population Density, 2011
■ Rural Area: Any non-urban or non-highly rural area.
■ Highly Rural Area: Any areas in counties having < 7 civilians per square mile.
Of 8.3 million enrolled Veterans, 3.1 million enrolled Veterans live in rural/highly rural areas
22 million Veterans nationwide6.1 million Veterans living in rural areas
36% of total enrolled Veteran population live in rural/highly rural areas
About one-third (31 percent) of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) users of the VA Health Care System in FY12 reside in rural or highly rural areas.
Enrolled Veteran
Population Density, FY 2010
While 84% of U.S. inhabitants live in suburban and urban areas, cities occupy only 10% of the country and rural areas occupy the remaining 90%.
19% of Americans live in rural areas  9% of physicians practice in rural areas
Reflections on User Demographics: enrolled vs non-enrolled; cultural competency in all dimensions; ancillary and support needs/social determinants of health; service delivery models
Providers: recruitment and retention; multidisciplinary teams/PACT; use of technology/telehealth; quality and care coordination; collaboration with non-VA
Diagnosis: disability support and related ancillary services vs general primary/specialty care; age bands and related health care needs
Health Outcomes: quality indicators; goals and benchmarks; impact on overall health of individual, family, community

12. How are rural communities (and Rural Veterans) unique?
Status/Health Equity
Older, sicker, and poorer population
Options for integrated health care and coordination
Primary and Specialty Care
Mental Health Care
Healthcare Workforce
Geography/Transportation
Longer travel distances to receive care
Lack of public transportation
Limited internet/broadband connectivity
According to a Health and Human Services report, half of the adults living in rural areas suffer from a chronic health condition.
While many rural Veterans receive their Primary Care at one of over 400 rural community-based outpatient clinics (CBOCs) in the VA health care system, they have fewer options for local VA specialty care such as:
Audiology, Neurology, Cardiology, Oncology, and Surgery
AND
Mental health services
Long distance travel can be difficult, especially for Veterans with mobility issues.
Travel can be complicated by a lack of transportation.
Rural health care options are also limited by the difficulty in recruitment and retention of health care providers to rural areas.

13. Rural Veterans’ Most Common Outpatient Diagnoses
High Blood Pressure
Post-Traumatic Stress Disorder (PTSD)
Type II Diabetes
Depressive Disorder
High Blood Cholesterol
At least 1 service-connected
disability
The five most common diagnosis in rural Veterans seen as an outpatient include:
High Blood Pressure
PTSD
Type II Diabetes
Depressive Disorder
High Blood Cholesterol
Diabetes, Arthritis, Hearing Loss, Hypertension, Mental Health Disorders (?)
Source: VA National Center for Veterans Analysis and Statistics

14. VHA Office of Rural Health (ORH)
The VHA Office of Rural Health (ORH) was created by Congress in 2007 under Public Law , Sec 212
Mandated to work across VA to develop policies, best practices and lessons learned to improve care and services for enrolled rural and highly rural Veterans
ORH falls under the VHA Assistant Deputy Under Secretary for Health (ADUSH)for Policy and Planning

15. Office of Rural Health (ORH) Mission
Improve access and quality of care for enrolled rural and highly rural Veterans by developing evidence-based policies and innovative practices to support their unique needs.
3-Pronged Approach:
Promote best practices for maximum impact: Innovative pilots  study and analyze  spread best practices.
Build parternships and collaborations: Engage with VA program offices, Federal and state partners, Veteran Service Organizations and rural health communities to effectively utilize resources.
Bridge operations and policy: Leverage lessons learned to inform policy and contribute to measurable impacts.

16. Office of Rural Health (ORH)
VHA Assistant Deputy Under Secretary for Health
for Policy and Planning
ORH Director
Secretary’s Veterans’ Rural Health
Advisory Committee
(VRHAC)
Veterans Rural Health Resource Centers
(VRHRCs)
ORH Deputy Director
Budget
Analyst
VRHAC Program Analyst
Staff Assistant
VRHRC
Western Region
VRHRC
Central Region
VRHRC
Eastern Region
Office of Rural Health (ORH) Central Office
Provides coordination, monitoring, analysis and national leadership
Veterans’ Rural Health Advisory Committee (VRHAC)
Federal advisory committee to advise the Secretary of Veterans Affairs on health care issues affecting enrolled Veterans residing in rural areas.
Veterans Rural Health Resource Centers (VRHRCs)
Three regional centers: Gainesville, FL; Iowa City, IA; Salt Lake City, UT.
Function as field-based clinical laboratories for demonstration projects/pilot projects.
Serve as rural health experts.
Act as educational and clinical repositories.
Provide programmatic support to ORH.
Veterans Integrated Service Network (VISN) Rural Consultants (VRCs)
Serve as primary interface between ORH and VISN rural activities.
Develop rural health service plans based on VISN-wide needs assessments
Facilitate information sharing across the VISNs.
Perform outreach to develop community relationships.
VISN Rural Consultants
(VRCs)
4 Program Analysts
Health Systems
Specialist
Staff
Assistant
Full-Time
10 Positions Funded
VISNs 6, 7, 9, 11, 12, 15, 16, 17, 19, 21
Part-Time/ Collateral Duties
11 Positions
VISNs 1, 2, 3, 4, 5, 8, 10, 17, 18, 20, 22, 23 16

17. Office of Rural Health Components
Veterans’ Rural Health Advisory Committee (VRHAC)
Federal advisory committee to advise the Secretary of Veterans Affairs on health care issues affecting enrolled Veterans residing in rural areas
Veterans Rural Health Resource Centers (VRHRCs)
Three regional centers: Gainesville, FL; Iowa City, IA; Salt Lake City, UT
Serve as rural health experts
Field-based clinical and education laboratories for VA demonstration projects/pilot projects
Provide programmatic support and technical assistance to funded VA partners
Veterans Integrated Service Network (VISN) Rural Consultants (VRCs)
Serve as primary interface between ORH and VISN rural activities and projects
Develop rural health service plans based on VISN-wide needs assessments
Facilitate information sharing across the 21 VISNs
Perform outreach to develop community relationships
Office of Rural Health (ORH) Central Office
Provides national leadership on issues pertaining to rural veterans
Administer special purpose appropriation and resources
Provides technical assistance, project monitoring and performance analysis functions
Coordinates IHS-VA MOU to promote access for American Indian/Alaska Native Veterans

18. Location of ORH Veterans Rural Health Resource Centers
Eastern Region Resource Center’s focus
Clinical Telehealth, workforce development, GIS
Central Region Resource Center’s focus
Big Data Analysis, Women’s Health, Treatment adherence
Western Region Resource Center’s focus
Native American Veterans, Geriatric Care VA and Community Outreach 3 2 1
Central Region Iowa City, IA
Eastern Region, Gainesville, FL
ORH Washington, DC
Western Region Salt Lake City, UT
Region 1 (East): VISN 1-10
Region 2 (Central): VISN 11-12, 15-17, 23
Region 3 (West): VISN 18-22

19. ORH STRATEGIC FOCUS AREAS
Collaborate to increase service options
Measure, evaluate, and document impact of best practices
Identify, recruit and retain rural health care professionals
Use emerging studies and analyses to improve care
Educate and train VA and non-VA providers
Improve access and quality of care through measurement, evaluation, & documenting impact of best practices in rural health.
Optimize use of available and emerging health information technologies.
Maximize use of existing and emerging studies and analyses to improve care delivered to rural Veterans.
Improve availability of education and training for VA and non-VA providers by increasing distance learning and developing new education resources for health care professionals.
Enhance existing and implement new strategies to improve and begin new collaborations and increase service options for rural Veterans.
Develop innovative methods to identify, recruit and retain health care professionals and expertise in rural communities
Use emerging health information technologies
ORH STRATEGIC FOCUS AREAS

20. ORH Priorities – FY 2013 Category
Project ARCH - Public Law , Section 403
VA must conduct a pilot program to provide non-VA care for eligible, highly rural enrolled Veterans in five VISNs (VISNs 1,6,15, 18 & 19)
SCAN-ECHO RFP
Specialty Care Access Network-Extension for Community Healthcare Outcomes
Rural Health Training and Education Initiative (RHTI)
Inter-professional, team-based models of training to deliver care to rural Veterans at 7 sites
New, sustained/existing, and expansion projects for FY13
Approved projects address many VHA and ORH priorities such as Telehealth, Women veterans, Mental Health, Homelessness, and Access & Quality

21. Project Focus Areas – FY 2013
Category
# of ORH Projects
Rural Telehealth, including Home Telemonitoring, Store and Forward Image Transmission, and Clinic Based Video Telemedicine 30
Rural Primary Care / Patient Aligned Care Teams (PCMH) 16
Rural Specialty Care: Cardiology, Audiology, Prosthetics, Optometry, Radiology, Dermatology 69
Rural Community Based Outpatient Clinics, Outreach Clinics, Mobile Clinics 57
Rural Education Initiatives 14
Rural Facilities Improvement 3
Rural Home Based Primary Care 50
Rural Homelessness 5
Rural Mental Health, including Post Traumatic Stress Disorder 35
Other Categories 21
Rural Outreach Activities 15
Projects Focused on Rural Special Populations, including Women, American Indians/Alaska Natives, and Asian American/Pacific Islanders 31
Rural Veteran Transportation Programs, including ground and air transportation
TOTAL
361

22. ORH Communications ORH Publications Dissemination Strategies
“The Rural Connection” Quarterly Newsletter
Research Briefs
Monthly Fact Sheets
Website,
Dissemination Strategies
“Push” dissemination to contacts (> 3,000 internal and external to VA)
Publish articles in VA, Veteran Service Organizations (VSO), and other rural health publications (ex. National Rural Health Association e-newsletter and Rural Roads magazine)
Leverage the VA social media channels and VAntage Point blog
Present at national meetings
Conduct ORH-sponsored webinars and broadcasts through My VeHU (VA eHealth University)

23. FY14: Eye on the Environment
Population Migration, Demographics and Definitions
Affordable Care Act Implementation
Rural Economies and Service Markets
Outreach, Coordination and Collaboration
Workforce Development
Technology Impact
Effective Use of Resources

24. Affordable Care Act and VA
Since the Affordable Care Act’s (ACA) enactment, VA has been proactive in working to understand the law’s impact on Veterans, other beneficiaries, and VA’s health care system and in preparing for implementation of the law.
The most significant provisions of the ACA are the individual mandate requirement, which requires most individuals to have health insurance coverage and the Medicaid expansion provision, which expands Medicaid eligibility to up to 138% of the Federal Poverty Level.
The individual mandate is a provision that requires all individuals to have minimum essential insurance coverage or face a tax penalty.
Enrollment in VA health care, CHAMPVA or Spina Bifida programs meet the minimum essential coverage requirement.
Veterans or other beneficiaries currently enrolled in VA health care do not have to take any additional steps to comply with the health insurance requirement outlined in ACA.
Veterans and other eligible beneficiaries not currently enrolled in VA health care can apply for enrollment at any time.

25. Collaboration and Communication
Leverage collaborations, communications and coordinated efforts to seize strategic opportunities and improve efficiencies in service to rural Veterans and their families.

26. Additional Resources: ORH Website

27. Thank You for Your Service
Upon their discharge from active duty, many OEF/OIF and Operation New Dawn (OND) Veterans are returning to their rural communities.

28. Gina L. Capra, MPA Director, Office of Rural Health
Questions? Ideas? Contact Information
For additional information, please contact:
Gina L. Capra, MPA Director, Office of Rural Health
(202) (direct)
(202) (main line)
VHA Office of Rural Health 1722 Eye St, NW, Suite GL16 Washington, DC