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Office of Rural Health

Office of Rural Health. Advisory Committee on Geriatrics and Gerontology April 14, 2011. Mary Beth Skupien, Ph.D. Director, Office of Rural Health. Office of the Assistant Deputy Under Secretary for Health for Policy and Planning Veterans Health Administration. ORH Establishment.

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Office of Rural Health

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  1. Office of Rural Health Advisory Committee on Geriatrics and Gerontology April 14, 2011 Mary Beth Skupien, Ph.D. Director, Office of Rural Health Office of the Assistant Deputy Under Secretary for Health for Policy and Planning Veterans Health Administration

  2. ORH Establishment • In 2006, Congress created Office of Rural Health (ORH) by enacting Public Law 109-461 (also known as the Veterans Benefits, Health Care, and Information Technology Act of 2006). • By March 2007, ORH was established within the Office of the Assistant Deputy Under Secretary for Health (ADUSH) for Policy and Planning, Veterans Health Administration (VHA), Department of Veterans Affairs (VA). 2

  3. ORH Mission & Major Goals • ORH Mission: Improve access and quality of care for enrolled rural and highly rural Veterans by developing evidence-based policies and innovative practices to support the unique needs of enrolled Veterans residing in geographically remote areas. • ORH Major Goals: • Improve access and quality of care for rural and highly rural Veterans. • Optimize the use of available and emerging technologies to enhance services to Veterans residing in rural and highly rural areas. • Maximize the utilization of existing and emerging studies and analyses to impact care delivered to rural and highly rural Veterans. • Improve availability of education and training for VA and non-VA service providers to rural and highly rural Veterans. • Enhance existing and implement new strategies to improve collaboration to increase service options for rural and highly rural Veterans. • Develop innovative methods to identify, recruit and retain medical professionals and requisite expertise in rural and highly rural communities.

  4. ORH Organizational Structure ORH Director (SES) Mary Beth Skupien, Ph.D., MS, RN Veterans’ Rural Health Advisory Committee Chairman James Ahrens ORH Deputy Director Sheila Warren, MPH, RN Budget Analyst Mike Privman, MHSA Program Analyst Judy Bowie, MA Staff Assistant Alta Jones Staff Assistant Elmer Clark Program Analyst Anthony Achampong, MBA, MHSA Program Analyst Christina White Program Analyst Serena Chu, Ph.D. Program Analyst Nancy Maher, Ph.D. Clinical Liaison Lynn McQueen, DrPH, RN Health Systems Specialist Katie Dziak, MHSA,, MBA Veterans Rural Health Resource Centers VISN Rural Consultants Full-Time 8 Funded Part-Time / Collateral Duties 13 Positions VRHRC-Western Director Byron Bair, M.D. VRHRC-Central Director Peter Kaboli, M.D. VRHRC-Eastern Director Paul Hoffman, M.D. 1. Jackie Morales (V9) 2. Sherri Deloof (V11) 3. Mary O’Shea (V15) 4. Deanna Jackson-Moore (V16) 5. Ron Schmidt (V19) 6. Jodie Waters (V20) 7. Colette Alvarez (V21) 8. Katie Dziak (V23) • 1. Doug Edwards (V1) • 2. Christopher Petteys (V2) • 3. Bertha Fertil (V3) • 4. Anthony Behm (V4) • 5. Alvis Hargrove (V5) • 6. Talbot Vivian (V6) • 7. Kristin Pettey (V7) • Pat Ryan (V8) • Joe Kohut (V10) • Joseph Zimmerman (V12) • Shenita Washington (V17) • Kenneth Browne (V18) • Laurie Traylor (V22) Contractor Support

  5. ORH Resources • Veterans Rural Health Resource Centers (VRHRCs) • Three regional centers: White River Junction, VT; Iowa City, IA; Salt Lake City, UT. • Function as field-based clinical laboratories for demonstration projects/pilot projects. • Serve as rural health experts. • Act as educational and clinical repositories. • Provide programmatic support to ORH. • VISN Rural Consultants (VRCs) • Serve as primary interface between ORH and VISN rural activities. • Develop rural health service plans based on VISN-wide needs assessments. • Facilitate information sharing across the VISNs. • Perform outreach to develop community relationships. • Veterans’ Rural Health Advisory Committee (VRHAC) • Federal advisory committee to advise the Secretary of Veterans Affairs on health care issues affecting enrolled Veterans residing in rural areas. • Evaluate current program activities and identify barriers to providing rural health care services. • May adopt recommendations to enhance or improve VA rural health care services.

  6. ORH Funding Fiscal Year 2009 Funding as of August 31, 2010

  7. ORH Funding Fiscal Year 2010 Funding as of August 31, 2010

  8. Fiscal Year 2011 ORH Funding Fiscal Year 2011-$250 Million-Operating Plan

  9. ORH Accomplishments • FY ‘11- ORH has allocated $22,825,892 to Home Based Primary Care initiatives and $3,582,764 to GEC. • They are very important partners to ORH and we support the efforts. • The partnership is making a difference in the lives of rural Veterans!

  10. ORH Accomplishments • ORH has executed over $500 million in support of over 300 national and local-level rural health initiatives and is now working to gather metrics and other outcome data for these initiatives. • ORH led the VA-Indian Health Service (IHS) Memorandum of Understanding (MOU) Work Group and activities and updated the current interagency MOU from 2003. This was signed October 1, 2010.

  11. VA Geriatric Scholars Program: A collaboration of 9 GRECCs to improve care of older Veterans at rural VA CBOCs • Intensive education and on-going educational opportunities, practica, mentoring, coaching. • Learners since pilot program in FY08: 140 staff from 109 CBOCs, 21 VISNs, 41 states/territories: • 76% primary care providers (MD, DO, NP, PA) • 8% pharmacists and 16% social workers • Evaluation includes Scholars’ QI projects to apply state-of-the-art geriatrics in CBOC setting.

  12. Fighting immObility in Rural Veterans with Exercise and Technology(FOR VETs) • 38 % of all Veterans live in rural communities and 75% of rural Veterans are over 55 years of age. • Heart disease and stroke rank first and third, respectively, as the leading causes of death in the United States and are the most frequently first-listed diagnosis in VAMCs nationwide. • The image of a physically active rural lifestyle is no longer accurate. • Elderly rural Veterans have an increased risk of cardiovascular disease. 12

  13. Fighting immObility in Rural Veterans with Exercise and Technology(FOR VETs) • Exercise can fight both cardiovascular disease and osteoarthritis. • Remotely implemented pilot in-home exercise training program. • State-of-the-art empirical pre and post testing of vascular function, skeletal muscle fatigability, mobility, and joint function. 13

  14. Providing Rural Veterans Access to Proactive Memory Services: Targeting Wyoming and Southeast Idaho Collaboration with Pocatello ID and Afton WY CBOCs for: • 1. Phone screening for memory loss • 2. Brief cognitive assessment at CBOCs • 3. Neurobehavioral exams at CBOCs • 4. Comprehensive cognitive assessments • 5. Teleneuropsychological assessments • 6. Family management education • 7. Unified family plan for progressive support

  15. Providing Rural Veterans Access to Proactive Memory Services: Targeting Wyoming and Southeast Idaho • Collaborative cognitive specialty team to serve Veterans has been established at St. John’s Hospital in Jackson, WY: • Team includes: cognitive specialist physician, social worker/health educator, nurse also trained as a neuropsychology technician, and outreach coordinator • Since May 2010, 81 Veterans identified for program enrollment • 50 Veterans from Idaho and Wyoming have received 114 units of services • Services provided: Comprehensive cognitive assessments, neurobehavioral examinations, neuropsychological testing, health education for Veterans and their families, and proactive social work services to develop unified plans of progressive support for patient cognitive problems • Teleneuropsychological assessments for 5 Veterans • Reports of assessments have been provided to primary care providers, patients and their families

  16. Advancing Geriatric Education through Quality Improvement in Rural CBOCs AGE QI is an innovative program of team-based education and practice improvement. Three sessions: on site, case-based interactive teaching; QI project planning; project evaluation. Award 20 AMA PRA Category 1 Credits™ Participation to date: 33 clinics; 128 providers and 252 clinic staff members with 91% involvement rate. Fall risk screening QI program in five Wyoming CBOCs successfully meeting > 90% screening goal. In FY11, expanding to Montana CBOCs.

  17. New Initiatives with Office of Rural HealthHome Based Primary CareFY 09-10 Funding Received - $28,540,350 HBPC Expansion via 25 CBOCs HBPC Expansion via Indian Health Service and 14 Reservations Medical Foster Home Expansion – 3 Geriatrics Scholar Program Expansion

  18. Goals of Rural HBPC Initiative Improve Access to Non-Institutional Care in Rural Areas via Community Partnerships. Increase Provision of Cost-Effective Long Term Care. Respect Veteran’s Preferences to Remain in a Home Setting. Improve Quality and Safety of the Care Provided at Home.

  19. HBPC Project Goals Bring Interdisciplinary Home Care to Frail Medically Compromised Veterans Expand HBPC into Rural Areas Increase Number and Percent of Rural Veterans Enrolled in HBPC Expand Services to Native American (NA) Veterans

  20. Rural Health and Indian Country Partnership with Indian Health Service and Tribes Expansion of HBPC onto 14 Reservations HBPC Staff to Mentor Tribal Staff Tribes Providing in-kind space, IT, staff GEC and IHS to convene mentoring conference calls with projects

  21. Successes with HBPC & ORH Asheville – initiating 2nd Project with Cherokee Nation Richmond – mobile HBPC van serving 6 non-federally recognized tribes (concept being copied in Prescott AZ) Use of Telehealth equipment to solve manpower shortages in rural areas and to reassure Veterans and caregivers

  22. ORH Field Accomplishments • Rural Health Community Low Literacy Program (VISN 6) • Increasing rural Veteran enrollment, MyHealtheVet utilization, assessing health literacy levels, and improving self health management to over 500 Veterans. • Utuado, Puerto Rico Rural Outreach Clinic (VISN 8) • Provided services to over 200 unique Veterans in rural communities. The clinic has received a high demand for services and outreach resources. • Rural Health Professions Institute (VISN 9) • Completed 8 of 9 workshop sessions to over 200 providers on the complexities of rural health care. • Received strong enrollment response and positive feedback from participants across VISNs. • Wilmington, Ohio Outreach Clinic (VISN 10) • Since August 2010, the outreach clinic has provided primary care, mental health, and telehealth services to rural Veterans.

  23. ORH Field Accomplishments • Northern Michigan (Saginaw) Rural Health Transportation Network (VISN 11) • Scheduled over 400 transportations for rural Veterans to appointments, who on average live 176 miles away from their appointment locations. • Collaborative Discharge Planning for Veterans Returning to Rural Areas (VISN 15) • Over 80 rural Veterans received discharges from psychiatric care to outpatient care as a result of collaborative teleconferencing with inpatient and outpatient providers. • ACCESS: Assisting Communities to Collaborate for Expanded Soldier Support (VISN 16) • Implemented and evaluated programs to enhance access for mental health and substance abuse care for OEF/OIF Veterans using the latest technology. • Completed a Student Veteran Outreach Program implementation tool-kit; held an orientation in August 2010 on education to administrators and student services personnel in 4 rural college campuses. • Veterans Treatment Court (VTC) provided outreach services (eligibility evaluations, education, and counseling) to rural Veterans, and certified six Veterans in the VTC Mentor Program.

  24. ORH Field Accomplishments • Successful rural services support and expansions, including Home-Based Primary Care (HBPC) Expansion (VISNs 2, 7, 10, 21 and 22) • Enhanced access and expansion of services for rural Veterans in Northern Pennsylvania (VISN 2). • Implemented HBPC expansion at the Jasper, Mississippi community-based outpatient clinic (CBOC) resulting in improved access to services and decreased emergency room and inpatient stays (VISN 7). • Expanded optometry and podiatry services to 10 rural CBOCs (VISN 10). • Implemented HBPC on Molokai, Hawaii, resulting in increased access to services and completed a town hall meeting with rural stakeholders in July 2010, to discuss service needs (VISN 21). • Implemented the Veteran medical motel model, Medtel, used to coordinate Veteran health care, transportation, and follow-up services (VISN 22).

  25. ORH Major Telehealth Projects • Successful implementations of Telehealth and Tele-specialty services in rural areas (VISNs 1, 3, 4, 10, 12, 19, 20, and 23) • Improved access to care via Care Coordination Home Telehealth by implementation of best practices for home based primary care & geriatric services. • As of June 2010, completed 150 rural clinical video telehealth encounters. • Increased access to specialty services for rural Veterans through E-consults and telehealth. • Developed & supported telehealth sub-specialty pre- and post-operative services for the most rural medical centers for: surgery, endocrinology, cardiology; TBI; pain management; podiatry; PTSD; mental health/behavioral health conditions. • Implemented the Tele-audiology pilot program & TeleMOVE! Program. • Established 10 telehealth specialty clinics (VISN 19). • Implemented VISN-wide (15 & 20) Tele-dermatology services reaching over 2,400 Veterans and diagnosing over 3,700 conditions.

  26. ORH Major Telehealth Projects • Implemented a Care Coordination Home Telehealth renal project for chronic kidney disease for 20 Veterans (VISN 23). • Implemented Northern Plains PTSD Telehealth services on rural reservations. • Treatment services used innovative VA Telehealth technologies. • Currently 14 clinics serving over 11 Tribes in Montana, Wyoming, Nevada, North & South Dakota, and Utah from the Denver VA Medical Center with a rural funded psychiatrist. • Opening additional PTSD Tele-mental health clinics in VISNs 19 & 23. • Implemented a collaborative discharge planning model using tele-conferencing serving rural Veterans and 100% surveyed reported their health care needs were met and barriers to care were addressed. • Implemented and valuated programs VISN-wide that will enhance access for mental health and substance abuse care for OEF/OIF Veterans using Tele-health technologies.

  27. Rural Women Initiatives • VISN 5 – Women Veterans Health Program – Conducted women-specific needs assessment. Hired 3 nurse practitioners to provide clinical, training, education, and outreach services to rural women Veterans. Evaluate new and expanded programs. • VISN 6 – Rural Women Veterans Health Care Program – Conducted women-specific needs assessment. Trained physicians and nurses to provide services to rural women Veterans. Purchased specialized OB/GYN equipment for CBOCs. • VISN 10 – Women’s Diagnostic Coordinator – Nurse coordinates Mammography and Pap tests for all Veterans utilizing the Chillicothe VAMC and its 5 CBOCs. Order, track, and follow-up with the community providers. • VISN 16 – Women’s Health Pilot – Use biofeedback to regulate pain and anxiety.

  28. Other Rural Women Veteran Activities • Focus on Education activities: • Collaborate with The Women Veterans Health Strategic Health Care Group to provide Rural Women’s Health programs (e.g., presentation at Women Veterans Program Manager Conferences). • Participate in regular conference calls with the Rural Women Veterans Steering Committee. • Partner with VA Health Services Research and Development to develop initiatives. Share data in order to develop policy recommendations.

  29. Priorities of the Office of Rural Health • Web-based reporting system developed with all projects listed with access for all ORH staff. • Monitoring and Tracking all ORH projects quarterly. • Communications Plan developed for ORH. • Strategic Plan Update in FY 2011 with involvement of Stakeholders. • Increase collaboration & communication with existing and new partners. • Monitor and track the activities of the VA/IHS MOU Subgroups. • Regular site visits to the field.

  30. Priorities of the Office of Rural Health • Complete a Comprehensive Needs Assessment of Veteran’s with VRCs & VRHRCs participation. • Realignment of VRHRCs under ORH (Direct Supervision effective 10/1/2010). • Collaboration and Education Symposia planned and managed by ORH staff (focus Rural Mental Health and Barriers to Care). • Filled all 12 positions in ORH to strengthen infrastructure and field support. • Support our partnerships with GEC and HBPC! 

  31. Contact Information For further information please contact: Mary Beth Skupien, Ph.D. Director, Office of Rural Health Department of Veterans Affairs Veterans Health Administration 810 Vermont Avenue, NW Washington, DC 20420 (202) 461-1884 MaryBeth.Skupien@va.gov 31

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