“Answering the Call: Caring for Rural Veterans” National Rural Health Day: Devils Lake, North Dakota Thomas Klobucar, PhD Deputy Director, Office of Rural Health (ORH) Veterans Health Administration (VHA) U.S. Department of Veterans Affairs (VA) 19/November 2015

VETERANS HEALTH ADMINISTRATION Presentation Topics 2 Topics 1. U.S. Department of Veterans Affairs Overview 2. Rural Veterans Snapshot 3. Community Collaborations & Strategic Drivers for Health Care Delivery 4. Veterans Choice Program Overview 5. Key Resources

VETERANS HEALTH ADMINISTRATION Overview of the Department of Veterans Affairs

VETERANS HEALTH ADMINISTRATION 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

VETERANS HEALTH ADMINISTRATION What is the Department of Veterans Affairs? Established in 1930 Elevated to Cabinet level in 1989 Federal government’s 2 nd largest department after the Department of Defense Three components: 5 Veterans Health Administration National Cemetery Administration Veterans Benefits Administration

VETERANS HEALTH ADMINISTRATION 6 VA Strategic Goals Goal 1: Empower Veterans to Improve their Well-Being −Give Veterans more information and choices for health care Goal 2: Enhance and Develop Trusted Partnerships −Create relationships between VA and community partners to provide care for Veterans Goal 3: Manage and Improve VA Operations to Deliver Seamless and Integrated Support −Improve the coordination of care between VA and community providers

VETERANS HEALTH ADMINISTRATION Who is a Veteran? Definition of a Veteran for VA purposes Veteran is a person who: −Served in the active military, naval or air service −Was discharged or released under conditions other than dishonorable Former or current Reservists, if they served for the full period for which they were called (excludes training purposes) Former or current National Guard members if activated/mobilized by a federal order 7

VETERANS HEALTH ADMINISTRATION Overview: Which Veterans Use the VA Health Care System? 8 ~22 million U.S. Veterans ~9 million enrolled in VA health care ~6 million VA Patients Not every VA-enrolled Veteran receives VA health care services in a given year. Some Veterans opt to not seek care, and/or others receive care outside the VA system, paying for care using other health insurance, Medicare, Medicaid, TRICARE, private insurance or other means. In order to receive VA health care benefits, a Veteran must be eligible for care (usually determined by the presence of a service-connected disability, period of military service, or income level).

VETERANS HEALTH ADMINISTRATION DoD and VA Health Care Systems: Quick Look 9 Provides care to those who serve in uniform (plus families and retirees) through the TRICARE program 57 hospitals and ~400 clinics worldwide Fiscal year 2015 budget = $47.4 B Provides care to those who serve in uniform (plus families and retirees) through the TRICARE program 57 hospitals and ~400 clinics worldwide Fiscal year 2015 budget = $47.4 B Department of Defense Military Health System (MHS) Department of Veterans Affairs Veterans Health Administration (VHA) Provides care to those who served in uniform More than 1,500 sites of care, including 167 medical centers, 14 health care centers and 757 Community Based Outpatient Clinics Fiscal year 2015 budget = $59.5 B Provides care to those who served in uniform More than 1,500 sites of care, including 167 medical centers, 14 health care centers and 757 Community Based Outpatient Clinics Fiscal year 2015 budget = $59.5 B ~10 million MHS beneficiaries ~9 million VHA enrollees ~1 million dual-eligibles

VETERANS HEALTH ADMINISTRATION Veterans Health Administration “Footprint” 167 VA medical centers (VAMC) 771 Community Based Outpatient Clinics (CBOC) and health care centers 287 Other outpatient and/or residential service sites (includes mobile medical and telehealth units) 300 readjustment counseling centers (Vet centers) 80 mobile Vet centers 10

VETERANS HEALTH ADMINISTRATION Snapshot of the Rural Veteran

VETERANS HEALTH ADMINISTRATION 12 Snapshot of the Enrolled Rural Veteran 5% increase of enrolled rural women Veterans since fiscal year % are 65+ years old 12% served in Iraq or Afghanistan and typically have multiple medical and combat-related issues 22M Veterans in the United States, 5.3M live in rural areas (24%) 9.1M enrolled in VA health care (41%) 3M rural Veterans enrolled in the VA health care system (57%) 33% (of 9.1M) enrolled Veterans live in rural areas 43% earn an annual income of less than $26,000 6% are women 8% are minorities (African-American, Asian, Native Hawaiian or Pacific Islander, American Indian or Alaska Native) 25% of rural Veterans live below the poverty line (fiscal year 2013) 36% do not access the Internet at home (fiscal year 2013)

VETERANS HEALTH ADMINISTRATION 57,395 Veterans (10% of 18+ population) 24,793 rural Veterans (43% of ND Veteran population) 28,511 Veterans enrolled in VHA for care (50% of ND Veterans); 5 th in the U.S. for percent of Veterans enrolled 44% enrolled Veterans are rural Highest percentage of highly rural Veterans in the U.S. (16%) 73% of enrolled Veterans 50+ years old, 51% are 65+ years old 13 69% rural Veterans enrolled in VHA for health care (56% nationally) 35% urban Veterans enrolled in VHA for health care (36% nationally) 6% of ND Veterans are women The number of ND Veterans enrolled in VHA for health care increased nearly 10% from 2009 to 2014, from 26,000 to 28,500 North Dakota Veterans

VETERANS HEALTH ADMINISTRATION Snapshot of VA’s Rural Care Delivery ,000+ rural Veterans used telehealth to access VA health care in FY ,000+ one-way trips provided for Veterans to receive VA care 41% of rural enrolled Veterans have at least one service connected disability 80.4% of rural enrolled Veterans have other health insurance (e.g. Medicare, Medicaid, Tricare, Private Insurance) in addition to their VA benefits $1+ billion increase in VHA spending on health care for rural Veterans between 2012 and 2014, from $17.4 billion in 2012 to $18.4 billion in 2014, which represents 32% of all VHA health care expenditures 43% of VA patients who received care via telehealth were rural 443 VA sites of care are located in rural areas of the country 35% VA Medical Centers have greater than 50% rural Veterans enrolled for VA health care

VETERANS HEALTH ADMINISTRATION “Caring for Rural Veterans” 15 ORH Video: Caring for Rural Veterans The VA Office of Rural Health video Caring for Rural Veterans was filmed in a VA Community Based Outpatient Clinic in Cumberland, Maryland. Take a three-minute trip to Cumberland to learn how VA helps meet the needs of rural Veterans across the country. Link:

VETERANS HEALTH ADMINISTRATION Does Veteran Status Impact Health Status? Rural health requires a community-based approach that provides health care and support services that foster Veterans’ and their families’ well-being Veterans and their families are assets in rural communities 16 The most common outpatient diagnoses among rural Veterans are: High blood pressure Post-traumatic Stress Disorder Type II Diabetes Depressive Disorder High blood cholesterol At least one service-connected disability

VETERANS HEALTH ADMINISTRATION Traditional Challenges of Rural Health Care Delivery Health care delivery in a rural setting faces ongoing challenges: – Provider and specialist shortages – Hospital closings due to financial instability – Population health factors/“social determinants of health” Access to health care services and wellness promotion efforts Housing Education Employment Transportation – Limited broadband coverage – Geographic and distance barriers Rural health requires a community-based approach that provides health care and support services that foster Veterans’ well-being 17

VETERANS HEALTH ADMINISTRATION Community Engagement and Collaborations

VETERANS HEALTH ADMINISTRATION VA Efforts to Engage Community Providers 19 November 2014 VA launches Veterans Choice Program (VCP) February 1995 VA begins to establish Community Based Outpatient Clinics (CBOCs) CBOCs established to improve Veterans’ geographic access to and use of primary care services Shifts focus of care from inpatient to outpatient setting Most CBOCs owned and staffed by VA, but some contracted to private sector CBOCs established to improve Veterans’ geographic access to and use of primary care services Shifts focus of care from inpatient to outpatient setting Most CBOCs owned and staffed by VA, but some contracted to private sector Lack of access for Veterans seeking specialist care PC3 established to expand care options for Veterans Lack of access for Veterans seeking specialist care PC3 established to expand care options for Veterans Barriers to accessing care due to long wait times and geographic distance Choice Act established the VCP to increase accessibility to care for eligible Veterans Barriers to accessing care due to long wait times and geographic distance Choice Act established the VCP to increase accessibility to care for eligible Veterans January 2014 VA establishes Patient Centered Community Care (PC3) Contracts The VCP provides greater access to community health care for eligible Veterans Coordinated Care Choice Improvement Act The VCP provides greater access to community health care for eligible Veterans Coordinated Care Choice Improvement Act

VETERANS HEALTH ADMINISTRATION Health Care Programs Used by Veterans 20 Source: 2013 American Community Survey

VETERANS HEALTH ADMINISTRATION Current Use of the VA Health Care System 21 Source: 2014 Survey of Enrollees AgeGenderIncome

VETERANS HEALTH ADMINISTRATION Veterans, Enrollees and Patients: Fiscal Years

VETERANS HEALTH ADMINISTRATION Overview of the Veterans Choice Program

VETERANS HEALTH ADMINISTRATION Overview: Veterans Choice Program (VCP) Veterans who are enrolled for VA medical care OR recently discharged combat Veterans (within the five-year enrollment window) AND: Live >40 miles driving distance, Wait time >30 days from medically appropriate date or clinically necessary Reside in state without VA Medical facility, OR Unusual or excessive burden for travel to nearest health care facility Veterans who are enrolled for VA medical care OR recently discharged combat Veterans (within the five-year enrollment window) AND: Live >40 miles driving distance, Wait time >30 days from medically appropriate date or clinically necessary Reside in state without VA Medical facility, OR Unusual or excessive burden for travel to nearest health care facility VCP allows eligible Veterans the choice to receive pre-authorized health care in their communities from community VCP providers, rather than waiting an extended time for a VA appointment or traveling a significant distance to a VA medical facility In order to be a VCP provider, you must be an approved provider through a third party administrator VCP allows eligible Veterans the choice to receive pre-authorized health care in their communities from community VCP providers, rather than waiting an extended time for a VA appointment or traveling a significant distance to a VA medical facility In order to be a VCP provider, you must be an approved provider through a third party administrator 24

VETERANS HEALTH ADMINISTRATION 25 How does a Veteran Access Services via Veterans Choice Program? Care in VCP is activated by the Veteran calling the Third Party Administrator (TPA) at the number on the Veterans Choice Card Health care through the VCP is authorized (Veteran may incur some cost if condition is non-service connected) Medical documentation return: 1) 30-day requirement for both in and out patient care 2) New cancer diagnosis must be reported within 48 hours

VETERANS HEALTH ADMINISTRATION 26 Requirements for Veterans Choice Program Providers Accept Medicare rates and meet all Medicare conditions of participation and conditions for coverage Be in full compliance with federal and state regulatory requirements Have unrestricted license in state where services are delivered

VETERANS HEALTH ADMINISTRATION 27 Veterans Choice Program - Provider Participation Complete information on respective Third Party Administrator (TPA) website TPA sends authorization package for Veteran’s medical appointment Return medical documentation and claim to TPAClaims payment by TPA

VETERANS HEALTH ADMINISTRATION Third Party Administrator (TPA) Geographic Assignments 28 Role Geographic Coverage - Health Net (yellow) and TriWest (blue)

VETERANS HEALTH ADMINISTRATION What VCP Means for Rural Health Systems, Medical Practices and Providers In line with mission to provide rural access Provides a venue for connecting with Veterans in the community Additional source of revenue Community impact and opportunity for partnership with Veteran Service Organizations, Officers and nonprofits 29

VETERANS HEALTH ADMINISTRATION Take Aways 30 1.Sign up as a VCP provider—you have nothing to lose and lots to gain 2.Know your local Veterans and their needs – At the end of this presentation is a list of organizations that can help with this 3.Contact your local VA medical facility leadership and staff to build a relationship that can evolve in service to vets As the VA evolves into its "future" state of closer community collaborations where regional health care planning and patient care coordination is paramount

VETERANS HEALTH ADMINISTRATION Thank You! 31 Photo credit: Jose Gil “… to care for him who shall have borne the battle and for his widow and orphan…” - Abraham Lincoln, VA mission Thomas Klobucar Office of Rural Health Visit: ruralhealth.va.govruralhealth.va.gov Watch: -kv0 -kv0 Subscribe to The Rural Connection: Photo credit: Jose Gil

VETERANS HEALTH ADMINISTRATION Key Resources

VETERANS HEALTH ADMINISTRATION Key Resources 33 Tom Grahek, Chief, Non-VA Purchased Care, Chief Business Office, VHA – or Veterans Choice Program overview "How to Become a Veterans Choice Program and/or Patient-Centered Community Provider" fact sheet – Choice_Program_508c_Internet.pdf Choice_Program_508c_Internet.pdf VHA Choice Locator PC3 Provider Map –

VETERANS HEALTH ADMINISTRATION 34 How to Become a VCP Provider Health Net contact information: – Provider customer service phone: – – Website: – Point of contact: Jim Jones, Director, Provider Network Management, Health Net Federal Services, TriWest contact information: – Provider services contracting phone: – – Website: – Point of contact: Hal Blair, Deputy Program Manager, TriWest Healthcare Alliance,

VETERANS HEALTH ADMINISTRATION Veterans Choice Program Providers: Making Yourself Known to Veterans in Your Community Engage with Veteran Community Marketing and Outreach Partner with Community VSOs Provide Fact Sheets Partner with Nearest VA 35

VETERANS HEALTH ADMINISTRATION Key Resources (continued) Military Culture Training Course Training for community providers on treating the unique Veteran patient community PTSD Consultation Program Post-traumatic stress disorder training offered for health care professionals who treat Veterans Veterans Choice Program Toolkit Outreach materials (e.g., fact sheets, FAQs) designed to make it easy to share information and spread awareness about VCP 36