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Improving Access and Quality of Care for Rural Veterans -- An Imperative

Understanding and addressing the needs of rural Veterans requires complementary perspectives including VA Central Office and local administration, policymakers, clinicians, researchers, and most importantly, the patient. For example, one of the fundamental challenges in the care of rural Veterans is distance. However, distance can mean different things to different people with a variety of ways to overcome it. For some Veterans, traveling two hours for a clinic visit can be a welcome social event; for others, it is a barrier to obtaining care. Policies and programs exist to bring care closer to the Veteran including Home Based Primary Care (HBPC), a group effort between the Veteran, family caregiver, VA, and the community. Other policies and programs include telehealth, mobile clinics, and fee-basis care. Yet each of these and other programs has their pros and cons: HBPC may not be cost-effective in highly rural settings; not all Veterans have adequate connectivity for telehealth; mobile clinics have distance, weather, and other limitations; and fee-basis care in the community may contribute to fragmented care.

Access

Even defining "access" is challenging. From a patient perspective, traveling two hours for a simple blood test can be onerous, especially if the service is available close to home. Yet two hours of travel for highly specialized care like a neurosurgeon may not be a barrier if these services are not available closer to home. Thus, different access standards can exist for different services. Access barriers can manifest in other ways such as waits and delays for care, health professional shortages, limits in specialty services such as mental health, and even identifying eligible benefits.

Once access barriers have been defined, the next step is overcoming these barriers with strategies to meet the patient-centered needs of the Veteran. One size does not fit all and thus these strategies need to be combined with adequate both program effectiveness and barriers to implementation.

Quality

Another aspect of rural health is determining whether disparities in quality of care exist for rural Veterans. To date, results of studies appear to be mixed. VA-based research has suggested that rural Veterans have lower health-related quality of life, yet clinical outcomes for a condition like acute myocardial infarction appear to be no different for rural versus non-rural Veterans. Further, studies and analyses are critical to help define quality disparities and then to propose interventions to overcome them.

Addressing the Issues

In an effort to understand the challenges of access and quality, and test strategies to improve these, the Office of Rural Health established three field-based Veterans Rural Health Resource Centers (VRHRC). The VRHRCs bring together rural health experts, clinicians, researchers, administrators, and the patient to evaluate the care of rural Veterans and perform pilot studies to address issues identified. The VRHRCs work collaboratively to identify access and quality gaps and best practices to overcome them, and then disseminate the findings throughout VA.

SOTA Conference

The recent September 2010 State of the Art (SOTA) conference examined issues related to access. This HSR&D sponsored conference brought together VA and non-VA experts in health care access to better define the problem and identify proven and potential future interventions to overcome access barriers for all Veterans--whether urban or rural. Please see accompanying text box with information regarding the SOTA conference.

As outlined by Dr. Skupien, ORH has the charge and the resources to improve access and quality of care for rural Veterans. It is thus the responsibility of the VRHRCs, program offices, researchers, clinicians, and facilities to understand how we are meeting the real and perceived needs of rural Veterans. The imperative is to then test and implement the most cost-effective strategies to improve access and quality of care for all Veterans.