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

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

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

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

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

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

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.

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

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

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

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

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

Broadband National Coverage Overview with VHA Networks

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

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

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

Contact Us Our website Our rural health mailbox inquiry www.ruralhealth.va.gov Our rural health mailbox inquiry rural.health.inquiry@va.gov Join the ORH mail list to receive updates and our Quarterly Newsletter http://www.ruralhealth.va.gov/subscribe.asp Thomas F Klobucar, Ph.D. VHA Office of Rural Health Department of Veterans Affairs Veterans Health Administration 1100 First St. NE Washington, DC 20002 Thomas.Klobucar@va.gov