MANAGEMENT BRIEF

Number 13 Overviews of Health Care Topics for VA Senior Managers January 2000

Rural Health – Improving Access to Improve Outcomes

“The availability of health care resources for veterans who live in rural settings is

extremely important to the health and well-being of those veterans. HSR&D is working to

identify ways to provide quality, cost-effective care in rural settings.”

John G. Demakis, MD

Director, Health Services Research and Development

What is rural health?

A rural setting is usually defined as a town or

county with fewer than 2,500 residents.1 Rural health

refers to health care provided for people who live in a

rural setting. Many veterans live in such a setting and,

depending on how far away they are from medical

facilities, may have difficulty accessing adequate

health care. Health care access is an individual's

ability to obtain the health care they need or want in

an appropriate timeframe. Access to adequate health

care for rural veterans can be affected by several

factors such as proximity to health care facilities

and/or providers, and availability of services. There

are many ways that health care for rural veterans

can be improved. Some of these are adjusting the

proximity between patients and providers; establishing alternative communication links (such as telecommunication) between patients and providers when

distance factors cannot be changed; community

outreach; implementing the use of mobile services;

and integrating VA and non-VA health care. These

are just some of the approaches that may be considered when planning improved health care for veterans

in rural settings.

How does rural health impact veterans’ health care?

VA medical centers tend to be located in urban

settings.2 Approximately 23% of all veterans live in

rural areas3 and thus may experience problems accessing treatment facilities and services. The degree

of difficulty rural veterans have in accessing treatment depends on several factors that may include the

distance the patient needs to travel to obtain health

care and any obstacles to travel, such as the veteran’s

physical and financial status. For instance, if a veteran

is in poor health, disabled and/or indigent, as are

many rural veterans,4

 getting to a medical facility,

much less a specialist, may be extremely difficult.

Because of the difficulties in obtaining care, many

veterans may put off preventive as well as necessary

treatment, which results in poorer health and ultimately increased costs in health care.

Why is rural health important for VA managers?

Because most VA medical centers are located in

urban settings, rural distance has become a crucial

determinant in veterans’ choices between VA and nonVA hospitals. HSR&D research shows that distance or

travel time between the patient’s home and the hospital is the most important determining factor affecting

that choice.5

 Therefore, access to care is not only

crucial to the health of veterans, it’s important to the

health of VA’s health care system. However, health

care interventions to improve access require careful

evaluation by managers. It is important to determine

whether interventions actually do improve access,

and whether improved access results in improved

outcomes. For example, while improving access

might improve a range of patient- and system-level

VA HSR&D Management Brief January 2000 Page 1 of 3
VA HSR&D Management Brief Number 13, January 2000 Page 2 of 3

outcomes (i.e., improved health status and patient

satisfaction, control costs, promote quality, assure

equity), these outcomes, at times, compete. Policy

makers and managers seeking to monitor and improve

health care need to have valid and reliable information about the multiple effects of decisions and

programs that alter access.

Below are findings from some of the

HSR&D studies that focus on rural health.

Impact of travel distance for health care

on patients with mental illness

Studies have shown that veterans are less willing

to travel for outpatient psychiatric care than they are

for outpatient medical care.2

 The problem of access

to appropriate mental health care would be particularly important during acute illness episodes that

require immediate and, perhaps, frequent crisis

interventions. A study supported by HSR&D and the

National Institute of Mental Health Center for Rural

Mental Healthcare Research tested the hypothesis that

patients with poor geographic accessibility to ambulatory mental health services would be more likely to

be hospitalized.

Study subjects included 109 patients who

presented multiple times for care to the Psychiatric

Evaluation Clinic in the Emergency Medicine Service

of the VAMC in Little Rock, AR. Patients in the

study were, in general, middle-aged, unmarried,

unemployed, and Caucasian or African American.

Just over a quarter of the subjects (27.5%) lived

farther than 60 miles from the Little Rock VAMC.

While only 17% of those living less than 60 miles

from the VAMC were admitted, 43% of those living

more than 60 miles away were admitted. On average,

patients who were admitted lived nearly twice as far

from the VAMC as did those patients who were not

admitted. These findings suggest that VA may need to

consider its efforts to substitute intensive outpatient

care in place of expensive inpatient treatment for rural

veterans with emergent mental health problems.

Fortney JC, Owen R, Clothier J. Impact of travel

distance on the disposition of patients presenting for

emergency psychiatric care. Journal of Behavioral

Health Services and Research, 26(1):104-8, 1999.

Study supported by HSR&D (HFP90-019) and the National

Institute of Mental Health Center for Rural Mental

Healthcare Research (NIMH P50 MH48197).

Mobile clinics improving the health status

of rural veterans

Between 1992 and 1994, VA operated six

mobile clinics in areas that were at least 100 miles

from a VA health care facility. The objective of this

program was to assess the health status of rural

veteran patients using mobile clinics compared

with patients receiving care in VA hospital-based,

or standard, clinics. Because ascertaining the type

of patients likely to be treated is a prerequisite for

effective health planning, comparative data on

these two groups of veterans is very valuable.

This HSR&D study showed that most patients

in the program sought care for the management of

chronic disease, and patients in both the mobile

clinic and standard clinic groups had similar types

of diseases. It was originally hypothesized that

mobile clinic patients would be healthier than

patients seen at VA standard clinics for several

reasons: many patients seen at standard clinics

are there for follow-up after hospitalization; and

most standard clinics operate at near capacity thus

limiting their service to those in greatest need.

In contrast, the mobile clinics had just begun

and did not limit patients by any set of selection

criteria.

However, study findings showed that despite

the similarities in presenting illness, mobile clinic

patients’ health status was statistically lower on all

scales except emotional. For example, of the more

than 6,000 patients seen at mobile clinics 64.2%

reported fair or poor health, nearly 80% reported

that their general health status limited their ability

to work, and 46.5% believed their health had

deteriorated over the previous year. Findings also

showed that 56% had not used the parent (or

closest) hospital in the previous two years. This

may reflect the degree of illness in veterans living

in rural America who do not have access to care.

This study represents VA’s continuing efforts to

ascertain the needs of this large, underserved

population.

Wray NP, Weiss TW, Christian CE, et al.

The health status of veterans using mobile clinics

in rural areas. Journal of Health Care for the

Poor and Underserved, 10(3):338-348, 1999.

HSR&D study #SDR 91-015.
For more information about this issue of

MANAGEMENT BRIEF, or to send comments, contact:

Gerry McGlynn, M.Ed., MDRC, Manager, Information

Dissemination Program, 150 S. Huntington Avenue, Boston,

MA 02130. Phone: 617-278-4433. Fax: 617-278-4438.

Visit the Research and Development web page at

http://www.va.gov/resdev or the Intranet site at

http://vaww.va.gov/resdev, or utilize the MDRC Fax-onDemand system by calling 617-278-4492 to see additional

MDRC publications and reports.

This is our thirteenth MANAGEMENT BRIEF. Please give us your

suggestions and comments:

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The MANAGEMENT BRIEF is produced by the Management Decision

and Research Center, a program within VA’s Office of Research &

Development, Health Services Research & Development Service. The

purpose of the MANAGEMENT BRIEF is to provide VA senior management

with a concise and timely overview of a specific health care topic that

includes topic definition, benefits, VA research activities, and resources

for further information.

Travel distance is a barrier for rural veterans’

use of VA medical/surgical care

As stated earlier, distance to providers is important when choosing a health care provider. This study

assessed the relationship between travel distance and

utilization rates of VA’s medical/surgical inpatient

care. Specifically, investigators set out to determine

whether the variability in VA hospital usage rates

indicates inequitable access to VA hospitals, and to

estimate how usage is related to travel distance to a

VA hospital, veterans’ characteristics, and access to

non-VA alternatives. Results of the study showed:

1) use of VA decreases with travel distance only up to

about 15 miles, after which use is relatively insensitive to further increases in distance; 2) use rates and

users’ travel distances vary considerably among VA

hospitals; 3) usage rates for eligible veterans who are

older than 65 years are less sensitive to distance than

younger veterans even though the over 65 group is

Medicare eligible and therefore has other choices; and

4) non-VA hospitals are generally closer to veterans’

residences than VA hospitals. Study investigators

suggest several reasons for these findings, such as

variability in population density and geographic

distribution of VA hospitals that result in lengthy

travel distances. Since VA’s health system is organized into 22 networks, or VISNs, that provide both

ambulatory and inpatient care to veterans, this research may help each network address concerns about

the distribution of services for rural veterans.

Mooney C, Zwanziger J, Phibbs CS, et al.

Is travel distance a barrier to veterans’ use of VA

hospitals for medical surgical care? Social Science

& Medicine. In press, 2000.

HSR&D study #IIR 92-042.

References:

1. Wray NP, et al. The health status of veterans using mobile

clinics in rural areas. Journal of Health Care for the Poor

and Underserved 1999;10(3):338-348.

2. Fortney J, et al. The effects of travel barriers and age on

the utilization of alcoholism treatment aftercare. Journal of

Behavioral Health Services & Research 1998;25:108-116.

VA HSR&D Management Brief Number 13, January 2000 Page 3 of 3

3. 1990 US Census Data from: Demographics Division.

Analysis and Statistics Service, National Center for

Veterans Analysis and Statistics, Office of Policy and

Planning, DVA.

4. Wray NP, et al. Case Study: Evaluation of the VA Mobile

Clinics Demonstration Project. Journal of Health Care

Management 1999;44(2):133-147.

5. Health services research: advancing veterans health care.

Washington DC: Health Services Research & Development

Service. Office of Research & Development. VHA, 1997.