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Medicine off the battlefield

VA hospitals, community-based clinics meet special challenges in trying to provide care to veterans living in rural areas

By Jessica Zigmond
Posted: November 5, 2007 - 12:01 am ET

When Elmer “Buzz” Ours travels the roughly 100 miles from his rural West Virginia home to the nearest full-service veterans’ hospital for counseling services, the smell of diesel fumes and asphalt takes him back to Vietnam.

That’s why the 58-year-old veteran, who suffers from post-traumatic stress disorder, or PTSD, prefers to receive care at the Veterans Affairs’ community-based outpatient clinic, or CBOC, in his hometown of Petersburg.

“I think the clinics are good things for veterans in rural areas,” said Ours, who said he earned a Silver Star for valor after serving as an Army sergeant near the Cambodian border in the Vietnam War from 1969 to 1970. “I can run over and get some help.”

But because the lone social worker on staff at the Petersburg clinic does not specialize in PTSD, Ours endures the psychologically difficult journey—never alone—to the 559-bed Martinsburg VA Medical Center once every three to four months for treatment.

Meanwhile, as wars continue in Iraq and Afghanistan, the U.S. is faced with a host of complicated problems back home, including how to care for the growing number of wounded—physically, mentally or both—from these conflicts. In the past six years, the Defense Department designated more than 29,000 service members involved in Operation Iraqi Freedom and Operation Enduring Freedom as wounded in action, according to a September report from the Government Accountability Office. And a March 2006 article in the Journal of the American Medical Association reported that 35% of Iraq war veterans accessed mental health services in the year after returning home, while 12% per year were diagnosed with a mental health problem.

Against this grim backdrop is an issue that has ignited debate among veterans, government officials and civilians in the healthcare industry: how the Veterans Affairs Department could improve access to healthcare services for rural veterans, who account for about 40% of the VA’s patient population.

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Looking for options

Among the service members who have returned from the Middle East to rural America is Adam Fultz, a former Marine corporal who served as a helicopter mechanic at Al Taqaddum Airbase in Iraq. Fultz, 26, said he returned to Mount Storm, W.Va.—a rural town tucked inside the Appalachian Mountains—about four months after he was spared any physical injuries when a missile landed on the base near Fallujah where he worked in late January 2005.

Since he has been back in the U.S., Fultz has had frequent nightmares and said his “temperament went up” easily over little things, such as the time he tried to assemble a shelf from Wal-Mart and broke it out of frustration. According to Fultz, a physical late this past summer determined that he suffers from PTSD. He received medication to manage it, and he learned from the VA that counseling is another option—and one he is eager to try. But to do that, he would have to take time off from work (although he said his boss at a local power plant supports his efforts) and travel more than two hours from his home in Mount Storm to Martinsburg, given that the drive is not on an expressway.

Both Ours and Fultz said they would be interested in receiving mental-health treatment through the use of telehealth services if the Petersburg CBOC offered it. A VA spokesman said that clinic does not offer telehealth services because the patient load does not warrant it at this time. The Martinsburg VA Medical Center has six CBOCs under its direction, including Petersburg. Telehealth is available at the CBOC in Cumberland, Md., about 90 minutes away. The VA has plans to expand the service in Hagerstown, Md., more than two hours away, and Stephens City, Va., also about 90 minutes away from Petersburg.

“I just wish they had more options in rural areas,” Fultz said. “There are only a few big communities in West Virginia.”

That’s exactly the message that the National Rural Health Association promoted when Andy Behrman, an NRHA member and president and chief executive officer of the Florida Association of Community Health Centers, testified at a hearing of the House Committee on Veterans Affairs in April of this year. Behrman, a Navy veteran, said that increasing the number of CBOCs, as well as veterans’ centers and outreach health centers, can improve access to healthcare for rural veterans. But the VA should also “fully implement the contracting of services from the VA to federally qualified health centers in rural areas, and develop approaches to link VA services and quality to existing rural health providers … including critical-access hospitals, rural health clinics and mental health providers,” Behrman said in written testimony.

At the same hearing, the VA described what it has done—and is doing—to improve access for rural veterans. That testimony came from Gerald Cross, the acting principal deputy undersecretary for health at the Veterans Health Administration—which, together with the Veterans Benefits Administration and the National Cemetery Administration, compose the VA. Cross reported that of the 5.4 million patients the VA served in 2006, 39% resided in rural areas and 2% resided in highly rural areas. Highly rural refers to counties with fewer than seven citizens per square mile, according to a VA spokesman.

The high percentage of rural veterans led Congress to pass legislation in August 2006 that called for an Office of Rural Health within the VA, which was established in March. Cross also said the VA has improved home-based care programs for veterans. Care-coordination, home-telehealth programs have been established in all 21 veterans integrated service networks, and provide care for nearly 25,000 patients, which Cross said is a 25% increase from fiscal 2006. And with a requested budget of $36.6 billion for fiscal 2008, including $3.6 billion for medical facilities, the VHA continues to develop more clinics.

“We have been successful in creating greater access to quality services” by expanding the CBOCs, Cross said in his written testimony. “Over 92% of enrollees reside within one hour of a VA facility, and 98.5% are within 90 minutes.”

To date, the VHA oversees 719 CBOCs with more than 50 planned for 2008. But more of the same isn’t always better, according to Bill Sexton, former president of the NRHA and chief executive of Providence Health & Services’ North Coast Service Area. The region includes Providence Seaside (Ore.) Hospital, a critical-access facility located between the Pacific Ocean and the Coast Mountain Range in Seaside.

“I think the CBOCs are beneficial,” said Sexton, who retired as a lieutenant colonel in the U.S. Air Force in 1990. “But in many cases, they duplicate services in the community,” he said, adding that there is a CBOC in Camp Rilea near Warrenton, Ore., which is between Seaside and the town of Astoria. “Before the VA comes into a community and puts in resources, they should be talking with the communities.”

Sexton said perhaps there is a philosophy within the VA that “nobody can do it as well as we can,” which could be a result of the military’s esprit de corps. But demographic studies would be useful, he said, to understand what resources are available so the VA could focus on filling gaps rather than reproducing existing services.

The same is true in Nebraska, where the VA will add more CBOCs in the towns of Bellevue and Holdrege next year. Dennis Berens, director of the state’s office of rural health in Lincoln, said a CBOC in Holdrege would not be a wise use of taxpayer dollars.

“In my rural state, I have 122 certified rural health clinics,” Berens said. “We have four community health centers. I have 65 critical-access hospitals, about 20 mental-health centers,” he said, adding that the state also established the Nebraska Statewide Telehealth Network for video consultations in 2005.

To make the most of these existing services for Nebraska’s rural veterans would require the VA to change its linear way of thinking to a way that is “organic,” allowing the agency to be more flexible in its approach and connect with existing services, according to Berens.

“Why do we have to run parallel systems?” he said. “Can’t we link those safety net providers?”

One way to do this is through contracting services, an option the VA has chosen in some regions. That is the case for the VA’s CBOC in Petersburg, which has had a contract with local 57-bed Grant Memorial Hospital since April 1999. Although the arrangement was somewhat of a financial struggle in its early years, the hospital’s contract with the VA is filling a need and has enrolled more than 1,000 veterans, said Mary Beth Barr, chief operating officer at Grant Memorial and program coordinator for the Petersburg CBOC.

“Our frustration is (in) understanding that they have to be admitted to a VA facility,” Barr said. “We’re not used to working under the bureaucracy,” she said, adding that if patients need to be admitted to the hospital, Grant Memorial has to arrange for the transfer to the Martinsburg VA Medical Center. Sometimes Grant Memorial receives permission to admit a patient at its own facility if the Martinsburg facility is at capacity. As soon as a bed becomes available, however, the patient is transferred to the VA hospital. And then there is the issue of lab work, sent daily to Martinsburg by courier. At times, the blood samples have hemolyzed in the process, resulting in a false reading.

“If the VA system could contract with us for inpatient care, we could take care of their needs here. It’s just a financial issue,” Barr said, adding that although not contracting with Grant Memorial for inpatient services allows the VA to contain costs, it is an “access problem and transportation problem for vets in this area.”

In addition to contracting with hospitals such as Grant Memorial, the VA should broaden its scope and extend its outreach capabilities to other rural healthcare providers, said Hilda Heady, executive director of the West Virginia Rural Health Education Partnerships and former president of the NRHA. She said that means arranging a contract with a community health center if a community does not have a hospital.

In July, the U.S. House of Representatives passed a bill that includes a provision supporting this approach. Part of the Veterans’ Health Care Improvement Act of 2007 would require the VA secretary to contract with community mental health centers in areas not adequately served by the VA, according to a summary from the House Veterans Affairs Committee. That legislation is one of several bills pertaining—in all or in part—to healthcare for rural veterans that the House introduced this year. Another, which the House passed in May, encourages the VA to improve treatment for those who have suffered traumatic brain injury. Part of that bill would require the VA secretary to establish an advisory committee that would provide reports and studies pertaining to rural veterans and their medical, mental and long-term-care needs. Both bills have moved to the Senate for consideration.

Then there are two bills that were introduced in the House but haven’t been brought to a vote. One would require the VA secretary to contract with non-VA facilities to furnish primary-care, nontherapeutic medical and other services, and acute or chronic symptom management for those whom VA facilities are geographically inaccessible, while the other would permit an enrolled eligible veteran to elect to receive healthcare services through a non-VA provider.

The text of the latter bill, introduced by Rep. Jerry Moran (R-Kan.) in March, requires the VA secretary to consult with HHS Secretary Mike Leavitt to “establish a partnership to coordinate care for rural veterans conducted at critical-access hospitals, community health centers and rural health clinics, and expand the use of fee-basis care through which private hospitals, healthcare facilities and other third-party healthcare providers are reimbursed.”

‘May simply be unworkable’

For its part, the VA is concerned that these two bills would create administrative issues and “may simply be unworkable,” according to a written statement from the VA’s Gerald Cross.

In an interview at the VA’s Washington, D.C., offices in October, Cross emphasized the first-rate care and innovative programs that the VHA has produced in home-based care, telehealth, traumatic-brain-injury and mental-health screenings, and CBOC development. The issue, though, is not the quality of care the VA provides, but how the department could improve access to that care for rural veterans and returning service members who do not yet have veteran status.

“We’ve made this tremendous progress with CBOCs,” Cross said. “Why change directions?”

For Adam Fultz, Elmer Ours and millions of rural veterans, the answer is because a new direction would allow them to receive healthcare services without the additional burden of traveling long distances, being apart from their families or taking time off from work for an extended period.

“It’s home to me,” Fultz said of rural Mount Storm. “I was born and raised in these mountains. I’ll probably die in these mountains.”

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