Response to Commentary
Partnered Research to Improve Health of Rural Veterans
The health and health care of rural Veterans is a major priority for the VA Health Services Research and Development Service (HSR&D). The VA research community has undertaken highly partnered, rigorous work to develop and test innovative implementation strategies that help ensure delivery of evidence-based care for rural Veterans. Indeed, several HSR&D-funded centers, known as Centers of Innovation (COINs), focus on strategies for optimizing care among rural Veterans.
COINs: Optimizing Care for Rural Veterans
The COIN located in Salt Lake City, Utah (Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0)) partners with the Veterans Rural Health Resource Center, Western Region, and includes a significant focus on rural health. Recent work from IDEAS 2.0 found that women Veterans in rural areas identified access to local dental, mental health, and gender-specific care options as important health care needs.1
The COIN located in West Haven, Connecticut, (Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center) partners with at least nine VA and non-VA entities. One goal of PRIME is development of strategies that will reduce ethnic, racial, geographic, gender-and agerelated disparities in access to and delivery of effective pain care. PRIME investigators have examined geographic variations in the use of telementoring as a means to improve pain management for Veterans.2
In 2014, HSR&D funded the Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) Initiative. CREATEs consist of interrelated research projects to produce deliverables and new knowledge that offer a distinct advantage over pursuing individual projects separately. The CREATE hosted by the VA HSR&D COIN (Center for Mental Healthcare and Outcomes Research (CeMHOR)) in North Little Rock, Arkansas focuses on the delivery of high-quality mental health care to rural Veterans. Four projects are in progress in partnership with the VA Office of Mental Health Services, the VISN 16 Mental Health Service Line, and the VA Office of Rural Health. The projects address access to, engagement in, and quality of care through a coordinated set of initiatives that target the community-based outpatient clinic setting. An important preliminary finding from these projects is that rural Veterans include systems of care, and experiences of care and treatment in how they think about access to health care. This finding suggests that these concepts should be considered in future interventions for access to care among rural Veterans.
QUERI: A Strong Commitment to Rural Veterans
Like HSR&D, the VA Quality Enhancement Research Initiative (QUERI) has a strong commitment to partnered projects that improve access to health care for rural Veterans. For example, the Virtual Specialty QUERI is evaluating the use of clinical video-telehealth with home-based cardiac rehabilitation (CR) for Veterans who live far from CR services. Key partners for this initiative include the Office of Rural Health, VA Telehealth Services, and the VA Office of Connected Care. In 2015, QUERI and the VA Office of Rural Health funded a partnered evaluation center known as the National Rural Evaluation Center (NREC). NREC is in the process of conducting a nationwide needs assessment for rural Veterans and examining the relationship between social determinants of health and domains of access to health care.
To understand the barriers to accessing care among rural Veterans, the NREC is conducting geospatial analyses that examine variations in access to care among rural Veterans across the United States. The NREC leveraged existing VA and non- VA data including the Survey of Enrollees (SOE) and the Survey of Healthcare Experiences by Patients (SHEP). To better understand the views of Veterans themselves, NREC investigators have conducted over 200 qualitative interviews with Veterans living in rural areas across the country. Early findings suggest that access to care among rural Veterans is a function of the number of barriers rather than a specific access domain. Interestingly, many Veterans who live in areas with poor geographic access (i.e., living more than 40 miles from VA health care), report that they perceive themselves as having good access to care.
Despite progress through these partnered, innovative projects, the research timeline is a major challenge in conducting highly partnered research that impacts rural health care. It typically takes one to two years to obtain funding for a given project. Once funded, the research project typically takes place over one to three years meaning that, at minimum, three years elapse before the average project has results to share with the clinical and administrative communities. Rural Veterans need real time solutions that move more quickly through this timeline.
Current research initiatives to improve health and health care of rural Veterans are critical and are expected to yield actionable outcomes. However, it is essential that new, innovative funding mechanisms are identified that can enhance partnerships between researchers and VA program.