1. Caring for Rural Veterans and the Smart Rural Community
Rural Broadband Workshop
March 19, 2014
Thomas F. Klobucar, PhD, VHA Office of Rural Health
17 April 2013

2. 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

3. 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)
Third leg on Federally Funded healthcare stool

4. Veterans Health Administration “Footprint” (end-of-fiscal-year 2013)
151 Medical Centers
985 Outpatient Clinics (Hospitals, Community, Independent and Mobile )
135 Community Living Centers
300 Readjustment Counseling Centers Vet Centers
103 Domiciliary Resident Rehabilitation Treatment Programs

5. 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

6. Rural Population Served
■ Rural Area: Any non-urban or non-highly rural area.
■ Highly Rural Area: Any areas in counties having < 7 civilians per square mile.
Of 8.9 million enrolled Veterans, 3.2 million (36%) enrolled Veterans live in rural/highly rural areas*
21.9 million Veterans nationwide, 5.2 million Veterans living in rural areas
Approximately 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.
25 VA medical centers are designated as rural or highly rural facilities
52 VA medical centers serve more than half rural Veterans
340 VA community based outpatient clinics are considered rural or highly rural
Data sources: *VHA enrollment files as of end-of-fiscal-year 2013, US Census Bureau American Community Survey Population Estimates 2012
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

7. About Rural Veterans 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
The Segmented Audience Study & Analysis, which I will explain further on the next slide, together with two Veteran focus groups, has provided the foundation for strategic VHA Communications planning and the development of two separate communications plans (and supplemental materials).
The VHA Integrated Strategic Communications Plan provides a path to build a comprehensive infrastructure and functional capacity to execute the VHA Communications program. The VHA Brand Identity & Style Guide will provide the framework for all communications materials to be produced under the VHA brand.
The VHA Health & Healing Communications Plan was developed as a sub-strategy of the overarching communications plan, and seeks to deliver messages that encourage Veterans to be actively engaged in their own health, healing and health care. The plan places particular emphasis on messages regarding healthy living, disease prevention, and chronic disease management. This effort aims to reach Veterans at every stage of health and promote healthy behavioral choices. A Health & Healing Brand Identity & Style Guide is currently in development.

8. Rural Veterans’ Most Common Outpatient Diagnoses
High Blood Pressure
Posttraumatic Stress Disorder (PTSD)
Type II Diabetes
Depressive Disorder
High Blood Cholesterol
At least 1 service-connected
disability

9. Telehealth and Health Information Technology
Getting Health care to rural Veterans
Telehealth Technology
Store and Forward Telemedicine
Forwards Images to specialists for reading and interpretation
Clinical Video Telehealth
Face to face, provider to patient, real time health care delivery
Home Telehealth (monitoring with Case Management)
Monitoring Veterans with conditions in their homes
Innovative models of care using telehealth
Virtual Intensive Care Unit
Home Telerehabilitation for Multiple Sclerosis
Telemental Health Care for Veteran Students
Virtual HIV Care teams
Mobile Teleretinal Imaging for rural Veterans with Diabetes

10. VHA Technology Infrastructure
Inside the VA firewall
VA has built a technology infrastructure that supports broadband Video Conferencing
VHA Office of Telehealth Services has overseen the creation of more than 4,000 video endpoints, all of which can link up via direct dial via Internet Protocol (IP)
Over this infrastructure VA delivers virtual care
Mental Health Care
Primary Care
Specialty Care
Provider to Provider Consultation
Multi-endpoint provider exchanges are in place using the New Mexico Extension for Community Healthcare Outcomes (ECHO), model to help providers in rural locations all over the country learn more about specialty care for specific conditions
2013 VA had 542,628 Video Telehealth Visits, 56% Rural

11. VHA Technology Infrastructure (II)
A current major VA initiative
IP video directly to Veterans homes
Will link VA video resources from VA hospitals, through the firewall, to Veterans’ computers or laptops in their homes
Uses application that encrypts the video signal based on Cisco Jabber
Minimum Requirement is 1.2 Mbps up and down

12. Broadband Access and the Rural Veteran
VHA’s plans to extend telehealth services over IP into Veterans homes requires that rural Veterans have access to broadband
This will allow delivery of in-home health care services including
Mental Health Care
Monitoring home-bound Veterans in our Home Based Primary Care program
New methods of in-home monitoring of chronic conditions
But if BROADBAND does not reach rural Veterans, these options are not be available
Based on data supplied by our Federal Partners at the Federal Communications Commission (FCC), United States Department of Agriculture (USDA), The Department of Commerce (National Telecommunications & Information Administration), ORH created a national broadband coverage map that shows broadband’s current reach and how many rural Veterans live outside of areas with broadband service

13. Broadband National Coverage Overview with VHA Networks

14. Broadband Coverage in Veterans Integrated Service Network 19 with Overlay of Veteran Population Concentrations Outside of Broadband Coverage

15. Broadband Coverage Analysis
Rural Veterans and Broadband Coverage
Currently 557,560 VHA enrollees aren’t reached by broadband
388,018 active Veteran patients are outside of coverage
This translates to roughly 7% of VHA enrollees and active patients outside of a broadband coverage area
Since members of the Armed Forces in Afghanistan and Iraq reside disproportionately in rural areas when they return home, a continued lack of broadband coverage in areas where they live may have long term implications for their access to in-home health care services

16. Thank You
ORH stands firmly behind our Federal partners’ continuing efforts to expand broadband coverage in rural areas
Federal Communications Commission
Department of Commerce/National Telecommunications and Information Administration
US Department Of Agriculture

17. Contact Us Our website Our rural health mailbox inquiry
Our rural health mailbox inquiry
Join the ORH mail list to receive updates and our Quarterly Newsletter
Thomas F Klobucar, Ph.D.
VHA Office of Rural Health
Department of Veterans Affairs
Veterans Health Administration
1100 First St. NE
Washington, DC