Office of Rural Health (ORH) NRHA Rural Health Policy Institute January 24, 2011 Mary Beth Skupien, PhD, MS Assistant Deputy Under Secretary for Health for Policy and Planning Director, Office of Rural Health

2 Agenda Office of Rural Health Rural Veterans Demographics Programs and Initiatives Future Direction

3 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  Collaborate with VA program offices, other Federal and state partners and rural health communities to build partnerships  Engage in studies and analyses and promulgate best practices  Translate research and best practices into policy and measurable impacts

Areas of Focus  Access and Quality  Technology and Telehealth  Studies and Analyses  Education and Training  Building Collaborations  Workforce Recruitment and Retention

ORH Organizational Structure ORH Director (SES) Mary Beth Skupien, Ph.D., MS, RN ORH Director (SES) Mary Beth Skupien, Ph.D., MS, RN Veterans’ Rural Health Advisory Committee Chairman James Ahrens Veterans’ Rural Health Advisory Committee Chairman James Ahrens Veterans Rural Health Resource Centers VRHRC-Eastern Acting Director Paul Hoffman, M.D. VRHRC-Eastern Acting Director Paul Hoffman, M.D. VRHRC-Central Director Peter Kaboli, M.D. VRHRC-Central Director Peter Kaboli, M.D. 1. Jackie Morales (V9) 2. Sherri Deloof (V11) 3. Mary O’Shea (V15) 4. Deanna Jackson-Moore (V16) 5. Ron Schmidt (V19) 6. Jodie Waters (V20) 7. Colette Alvarez (V21) 8. Katie Dziak (V23) Program Analyst Anthony Achampong, MBA, MHSA Program Analyst Anthony Achampong, MBA, MHSA Program Analyst Christina White Program Analyst Christina White Program Analyst Serena Chu, Ph.D. Program Analyst Serena Chu, Ph.D. Staff Assistant Alta Jones Staff Assistant Alta Jones Program Analyst Nancy Maher, Ph.D. Program Analyst Nancy Maher, Ph.D. Budget Analyst Mike Privman, MHSA Budget Analyst Mike Privman, MHSA ORH Deputy Director Sheila Warren, MPH, RN ORH Deputy Director Sheila Warren, MPH, RN VRHRC-Western Director Byron Bair, M.D. VRHRC-Western Director Byron Bair, M.D. Contractor Support 1. Doug Edwards (V1) 2. Christopher Petteys (V2) 3. Bertha Fertil (V3) 4. Anthony Behm (V4) 5. Alvis Hargrove (V5) 6. Talbot Vivian (V6) 7. Kristin Pettey (V7) 8.Pat Ryan (V8) 9.Joe Kohut (V10) 10. Joseph Zimmerman (V12) 11. Shenita Washington (V17) 12. Kenneth Browne (V18) 13.Laurie Traylor (V22) Clinical Liaison Lynn McQueen, DrPH, RN Clinical Liaison Lynn McQueen, DrPH, RN VISN Rural Consultants Part-Time / Collateral Duties 13 Positions Part-Time / Collateral Duties 13 Positions Full-Time 8 Funded Full-Time 8 Funded

ORH Infrastructure Veterans Rural Health Resource Centers (VRHRCs)  ORH has three regional VRHRCs. The VRHRCs:  Provide programmatic support to ORH  Conduct policy-oriented studies and analyses  Operate as field-base clinical laboratories for demonstration projects  Serve as regional rural health experts  Act as educational and clinical repositories of expertise  The VRHRCs are located in:  Eastern Region (White River Junction, Vermont)  Central Region (Iowa City, Iowa)  Western Region (Salt Lake City, Utah)

7 Central Region Iowa City, IA Eastern Region, White River Junction, VT ORH Washington, D.C. Western Region Salt Lake City, UT Map of VRHRCs and Veteran Integrated Service Networks (VISNs)

ORH Infrastructure (cont.) VISN Rural Consultants (VRCs)  Serve as the primary interface between ORH and the VISN in which they operate  Meet semi-annually to discuss ORH programs and policies that impact the provision of VA health care  There are 8 full-time VRC positions and 13 part-time VRC positions that have collateral responsibilities  Responsible for executing a needs assessment, developing a rural health service plan, facilitating information sharing within and across VISNs and with ORH  Perform outreach to develop strong relationships and communications within the community at large and within VA

ORH Infrastructure (cont.) Veterans Rural Health Advisory Committee (VRHAC)  VRHAC is a 12 member committee that advises the Secretary of VA  Has two ex officio members representing other Federal agencies, to ensure coordination with other federal agencies involved with rural health issues  Meets semi-annually to discuss ORH programs and policies that impact the provision of VA health care  Examines ways to improve and enhance VA service for Veterans residing in rural and highly rural areas by evaluating current program activities and identifying barriers to providing service

10 Agenda Office of Rural Health Rural Veterans Demographics Programs and Initiatives Future Direction

11 Rural Veterans Demographics There are almost 8 million Veterans enrolled in the VA Health Care System. Approximately 3 million live in rural and highly rural areas. (1) (2) Rural: 3,414,983 Highly Rural: 120,334 Urban: 8,288,077 (1)Definitions: Urban - areas defined by U.S. Census as urbanized areas; Rural - all other areas excluded in U.S. Census defined as urbanized areas; Highly Rural - any rural area within a county with less than 7.0 civilians per square mile. (2)FY 2010 data

12 Agenda Office of Rural Health Rural Veterans Demographics Programs and Initiatives Future Direction

Over 300 ORH Projects and Programs VA National Programs Rural CBOCs, Tele-health, Mental Health, Women Veterans Health, Homeless, HBPC, Outreach Clinics, Behavioral Health, PACT, transportation, other. VISN/VRC Projects Tele-health, optometry, podiatry, diabetes, case management, mental health, women’s health, homeless, transportation, communications improvement, substance abuse treatment, social services, mobile clinics, etc. Rural Health Resource Center Projects HIV/AIDS, Rural Health Provider Training, Neuro-rehab consultation, Tele- rehab, VA Outreach clinic evaluation, Veteran’s Healthcare and Needs Survey, Geographic access assessment, others. Studies Tobacco Cessation, Suicide-related mortality analysis, rural surgery needs and strategies, transportation needs assessment, others. 13

ORH Funding Fiscal Year (FY) 08  ORH allocated $24 million to establish initial ORH programs and projects FY 09  Public Law provided $250 million to support service expansion and outreach:  December 2008: ORH distributed $22 million to the VISNs as seed money  February 2009: ORH provided $215 million to 74 projects across the VISNs and Program Offices

Fiscal Year 2009 CategoryFunding VISN Initiatives$21,700,000 Telehealth/Telemedicine Expansion$66,193,322 Home Based Primary Care Expansion$36,323,645 Mental Health Programs$11,340,480 Health Care Service Expansion$14,011,988 Outreach Initiatives$28,946,984 Education and Training$9,093,375 Other$12,794,488 Total:$200,404,282 ORH Funding 15 Funding as of August 31, 2010

ORH Funding Fiscal Year CategoryFunding Telehealth/Telemedicine Expansion$4,718,846 Home Based Primary Care Expansion$953,640 Mental Health Programs$1,124,514 Health Care Service Expansion$10,395,908 Outreach Initiatives$63,290,751 Education and Training$3,374,694 Fee Care$200,000,000 Other$28,675,121 Total:$312,533,474 Funding as of August 31, 2010

Fiscal Year 2011 ORH Funding Fiscal Year 2011-$250 Million-Operating Plan (Submitted for approval) 17 CategoryFunding Sustainment Projects$109,500,000 Community-Based Outpatient Clinics (CBOC) $70,500,000 Public Law Section 403 $70,000,000 Total:$250,000,000

Programs and Initiatives: Access Outreach Clinic Expansion  Provide primary care services, case management and mental health services in rural and highly rural areas  ORH has funded 40 Outreach Clinics Rural Mobile Health Clinics (RMHCs)  Expand access to primary care, mental health, and specialty referral into rural areas where it is not feasible to establish a fixed access point and impacted Veterans are not able to easily travel to fixed locations such as VA Medical Centers and Community-Based Outpatient Clinics (CBOCs)  ORH has four operational RMHCs serving rural counties in Maine, West Virginia, Washington, Colorado, Nebraska and Wyoming

19 Home Based Primary Care (HBPC) Expansion  Provide comprehensive longitudinal primary care by an interdisciplinary team in the homes of Veterans with complex chronic disease and disability for whom routine clinic-based care is no longer effective Medical Foster Home Expansion (MFH) Expansion  I mprove access and enhance delivery of health care to Veterans residing in rural and highly rural areas Programs and Initiatives: Geriatrics and Extended Care

Programs and Initiatives: Geriatrics and Extended Care (cont.) Geri-Scholars Program  Support geriatric health care providers in rural and highly rural areas by aiding them in treating the special needs of older Veterans  Through intensive coursework and training, VA disseminates the most current and effective methods in rural and highly rural geriatric medicine to rural and highly rural health care providers

Programs and Initiatives: Mental Health South Central Illness Research Education and Clinical Center (MIRECC) Pilot Studies  The study will be used to develop clinical policy or program that improve access, quality, and outcomes of mental health and substance abuse treatment services for rural and underserved Veterans. Community-Based Mental Health Services for Veterans in Rural Areas  Expands intensive case management services for Veterans with serious mental illness and outreach services and expansion and integration of VA’s existing Rural Access Network for Growth Enhancement (RANGE) program

Programs and Initiatives: Women Veterans Health Delivery of Care to Women Veterans  Improves the care for women Veterans by enhancing the practice and culture of the VA to be more inclusive of women Veterans  Expand access for women Veterans  Engage in outreach with women Veterans through communication and advocacy  Engage women to be partners in managing their health

23 Agenda Office of Rural Health Veteran Demographics Initiatives Future Direction

Future Directions Improving knowledge base  Continue improving ORH understanding of rural and highly rural Veterans and their needs  Implementing best practices and program evaluations of current initiatives  Implementing evidence-based strategies and innovative care delivery models Improving capacity to care for rural and highly rural Veterans  Lessons learned from each year’s experience  Growing infrastructure; emphasizing local innovation with national focus  Building community collaborations  Working in partnership with other rural partners for policy development

ORH Strategic Plan Refresh “ Refreshing” the ORH Strategic Plan ORH has formed 6 workgroups to review and update programmatic goals and objectives 1.Improve access and quality for rural Veterans 2.Optimize use of technology to enhance health care services 3.Maximize utilization of studies & analyses to impact health care delivery 4.Improve availability of education and training for VA and non- VA service rural providers 5.Increase collaborations and increase service options for rural Veterans (Top Priority) 6.Develop innovative methods to identify, recruit and retain medical professionals in rural communities 25

VRC & VRHRC Activities Geographic Assessments Health Need Assessments Objective Measures Development, Implementation Reporting and Training Communication Improvement Alignment of VISN projects with National Programs (e.g. VISN Telehealth projects with OTS measures and standards). Identifying and establishing new partnerships Strategic Planning alignment, development and implementation. 26

Developing Relevant Measures for ORH Programs and Projects How we’ve established measures Through research and from literature review of national rural health measures to identify evidence-based measures. Through evaluation and review of existing VA, non-rural measures To compare VA rural and non-rural health care, service and outcomes To identify and work to prevent disparities 27

What will be measured? 1.Access Measures – All ORH projects and Programs will report: Number of rural veterans impacted Number of newly enrolled rural Veterans Number of rural women Veterans impacted Number of rural OEF/OIF Veterans impacted Number of rural homeless Veterans impacted Number of rural AI/AN Veterans impacted 2.All ORH projects related to established National Programs (Tele-health, Mental Health, Other) Will come into alignment with related National Program measures. 28

What will be measured (continued) 3. Quality of Care and Service Hypertension recorded, Wait times, courtesy, move (exercise) projects 4. Preventive Care Flu shots, Mammograms, Colorectal screening 5. Satisfaction/Perception Veteran, Staff and Provider 6. Outcome Measures: HB A1C, etc. 29

How will Measures be collected and tracked? Through the development and national deployment of an electronic, web-based data collection, and tracking system. Through Passive and Active data collection methods Collaboration with VSSC and OQP Development of a Rural Health Briefing Book – in pilot now and target release date 12/31/10. Rural Health Dashboard – target date for completion 3/2011. OQP is continuing to expand ability to pull out rural health data from EPRP and SHEP 2/

31 Questions? We look forward to partnering in the future! Thank you.