Of the 23 million Veterans in this country, 

roughly 8 million are enrolled in the Veterans 

Health Administration (VHA), and approximately 40 percent of these Veterans live in 

rural and highly rural areas. Rural Veterans face 

unique health care challenges for a variety of 

reasons, including disparate access to higher 

quality services, shortages in qualified health 

professionals, and limited transportation options. On average, these rural Veterans travel 

between 60-120 minutes for inpatient care, and 

30-90 minutes for primary care. This population also has fewer financial resources compared to urban Veterans. One-third of OEF/

OIF Veterans live in rural or highly rural areas; 

three-fourths of rural Veterans are over the age 

of 55.

Office of Rural Health

The health needs of rural Veterans receive 

more attention now due to greater commitment and new resources within the VHA. The 

Office of Rural Health (ORH) was established 

in March 2007 in response to The Veterans 

Benefits, Health Care and Information Technology Act of 2006. ORH is part of the Office 

of the Assistant Deputy Under Secretary for 

Health (ADUSH) for Policy and Planning 

(10A5), led by Patricia Vandenberg. ORH’s 

mission is to improve access to and quality of 

care for enrolled rural Veterans by developing 

evidence-based policies and innovative practices that support the unique needs of those 

residing in geographically rural areas. ORH 

carries out its mission by working closely with 

internal VA program offices, field units, rural 

health experts, and partners to develop new 

methods to provide the best possible solutions 

to the challenges faced by Veterans living in 

rural areas. 

In fiscal year 2009, Public Law 110-329 appropriated $250 million for new rural health 

initiatives. Key major initiatives for this funding 

include: national and local telehealth expansion, Home Based Primary Care, local outreach clinic expansion, community outreach, 

rural provider outreach and education, rural 

Veteran education, geriatric care, mental health 

programs, women’s health initiatives, and local 

transportation programs. Many of these initiatives are designed at the local level to target the 

needs of specific rural and highly rural Veteran 

populations. Also in 2009, Public Law 110-387 

contained provisions for the development of 

rural health pilot programs to further focus 

on peer outreach and support for Veterans, 

improved access to community mental health 

centers and Indian Health Service facilities, 

and enhanced contract care authority to better 

involve private providers in the care of highly 

rural Veterans. 

Access and Quality for 

Rural Veterans

An additional $250 million in rural health appropriations was provided to ORH in fiscal 

year 2010 to continue improving access to and 

quality of care. These funds support a wide 

variety of existing and new initiatives, including 

the hiring of much needed health care professionals in underserved areas, evaluating new 

models and sites of care, purchasing telehealth 

FORUM

Translating research into quality health care for Veterans

Commentary

The Health Needs of Rural Veterans

Mary Beth Skupien, Ph.D., M.S., R.N., Director, Office of Rural Health, Washington, D.C.

 November 2010

Contents

Director’s Letter 2

Response to Commentary 3

SOTA Conference: Improving

Access to VA Care 3

Research Highlight

• Health Care Access and

Quality for Rural Veterans 4 

Research Highlight

• Access to VA Health Care in 

the Digital Age 5

Research Highlight

• Telehealth Technologies for 

the Delivery of Mental 

Health Services 6

Organizational Profile

• VA’s New Women’s Health

Research Consortium 7 

A publication of the VA Office of Research & Development, 

Health Services Research & Development Service, Center 

for Information Dissemination and Education Resources, in 

conjunction with AcademyHealth. 
and other equipment, initiating new mobile 

care units, providing education sessions for VA 

and non-VA health professionals on local rural 

Veteran needs, fee-based and contracted care, 

and new rural Community-Based Outpatient 

Clinics (CBOCs). 

To assist in the implementation, maintenance, 

and oversight of these initiatives, a network 

of 21 regionally based VISN Rural Health 

Consultants (VRCs) works directly with ORH 

staff to support each VISN in managing their 

rural health funded projects. In addition to the 

VRCs, ORH established three Veterans Rural 

Health Resource Centers located in Salt Lake 

City, Utah; Iowa City, Iowa; and White River 

Junction, Vermont. The Centers’ goals include 

conducting, coordinating, and disseminating studies and analysis related to issues that 

impact Veterans living in rural areas. Finally, a 

16-member Veterans’ Rural Health Advisory 

Committee evaluates program activities, identifies barriers to receiving services, and offers 

recommendations for ORH policies that impact rural Veteran care. 

National Rural 

Measurement Strategy

In order to demonstrate the impact of ORH 

funding, in conjunction with other VA program offices, ORH staff members are finalizing a nationwide rural measurement strategy 

that will include national measures and 

VISN-level project measures. Links with relevant HSR&D Centers of Excellence and 

Quality Enhancement Research Initiative 

(QUERI) groups will be an important part of 

this process.

In my new role as Director of ORH, I plan to 

continue these collaborative efforts by building on 28 years of federal service at the Indian 

Health Service (IHS) and with Tribal programs, where I most recently served as Deputy 

Director of the Office of Public Health Support. I also worked in a variety of rural settings 

as a nurse practitioner and public health nurse, 

and had progressive leadership roles in the 

field as well as at IHS headquarters. I received 

my doctoral degree from The Johns Hopkins 

University, with an emphasis in public health 

management and policy. In addition to my 

recent arrival, Sheila Warren, M.P.H., joined 

ORH as Deputy Director this fall, and additional staff members are coming on board to 

help implement the goals and activities of the 

office to meet the mission of ORH. 

Our nation’s rural and highly rural Veteran 

population is large, dispersed, and racially, 

ethnically, and culturally diverse. ORH will 

continue to collaborate with numerous areas 

of the VA, along with other government offices and private organizations and partners, 

to increase access to safe, effective, efficient, 

and compassionate health care for this unique 

group of Veterans. 

FORUM — Translating research into quality health care for Veterans 2

Director’s Letter

Veterans choose VA as their primary source of health care largely 

because it provides high quality, comprehensive, integrated care 

at relatively little or no cost. Access to health care, however, can 

be a vexing issue for Veterans, since the approximately 1,000 

hospitals and free-standing outpatient clinics and other facilities 

do not nearly cover Veterans’ health services needs across the 

expanse of the United States. This explains, in part, why a substantial majority of 

VA patients currently receives at least some health care from non-VA providers. 

The implementation of health care reform during the next several years will facilitate access for all Americans (including Veterans) to a broad array of health services. VA patients may therefore find non-VA care increasingly attractive, reinforced 

by the convenience of Veterans’ family members receiving services from those 

same non-VA sources. 

In September 2010, some of the nation’s leading VA and non-VA investigators 

participated in a State of the Art (SOTA) conference that addressed access to 

VA care for Veterans. Access was defined broadly, including directly observable 

and measurable access, and more difficult to measure patient perceived access. 

Research issues that were discussed included defining and measuring access; 

identifying access issues for special populations; characterizing the impact of access on utilization, quality, outcomes, and satisfaction; challenges associated with 

matching medically appropriate levels of access to patient perceptions of access 

needs; the impact of policy and organization on access; and identifying, evaluating, 

and implementing innovative approaches to improving access (emphasizing roles 

of computer technology and informatics). Manuscripts addressing access related 

topics commissioned as background papers for the SOTA or developed as a result 

of SOTA deliberations will be published in a special issue of the Journal of General 

Internal Medicine by summer 2011.

Investigators interested in pursuing access related issues are encouraged to 

thoughtfully align their research with VA objectives. Equally important, investigators must engage clinical, operations, and policy leadership in research concepts 

to help ensure that research objectives being addressed are likely to be relevant not 

only today, but several years in the future when results will be available. 

Seth Eisen, M.D., M. Sc.

Director, HSR&D

VA Office of Research & Development, Health Services Research & Development Service November 2010
VA Office of Research & Development, Health Services Research & Development Service November 2010

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 

evaluation and analyses to better understand 

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. 

Response to Commentary

Improving Access and Quality of Care for 

Rural Veterans – An Imperative

Peter J. Kaboli, M.D., M.S., Director, Veterans Rural Health Resource Center—

Central Region, Iowa City VAMC 

FORUM — Translating research into quality health care for Veterans 3

SOTA Conference: Improving Access to VA Care

The “Improving Access to VA Care” State of the Art (SOTA) conference was held in 

Arlington, Va., from September 21 to September 22, 2010. Access to care is one of 

VA’s priority transformational initiatives, making this SOTA particularly timely. While 

access to care is a consideration for all Veterans, it is particularly important given the 

needs of Veterans returning from the conflicts in Iraq and Afghanistan, many of whom 

are returning to rural areas and/or returning with severe injuries that will require longterm care. Both Under Secretary for Health, Dr. Robert Petzel and Principal Deputy 

Under Secretary for Health, Robert Jesse, M.D., Ph.D., spoke at the SOTA, providing 

an overview of VHA’s priorities and challenges regarding access and the importance 

of improving access to VA health care for Veterans. With the advent of health care 

reform, one particular challenge for VA will be to successfully compete with the many 

non-VA health care options that will become available to Veterans.

The 70 invited attendees, including VA and non-VA clinicians, researchers, and policymakers with special expertise in access to health care, worked to identify what we 

know and what we need to know to improve access to health care for Veterans. SOTA 

participants discussed resources, relationships, policies, and infrastructure related to 

accessing quality health care.

continued on page 7
About two in five VA health care enrollees are 

rural residents (including the 1.5 percent that 

VA defines as “highly rural”). Rural enrollees 

are slightly more likely than urban ones to 

use VA care (68 percent vs. 65 percent), and 

from 2006 through 2009 the number of rural 

enrollees grew faster (by 11 percent) than the 

number of urban enrollees (2 percent). Overrepresentation of rural residents among OEF/

OIF troops, and casualties, will likely increase 

rural Veterans’ health care needs further.

Rural Veterans’ Use of VA and 

Non-VA Health Care

Fully understanding Veterans’ access to health 

care requires much more nuance than utilization alone can reveal. Nevertheless, utilization 

sheds light on major aspects, such as the availability of financial resources to pay for services 

and the burden of traveling to reach them. 

VA provides a “safety net” of health care that 

many Veterans might not otherwise obtain for 

financial reasons. But because VA’s specialized 

and high-technology treatment is centralized, 

many rural Veterans must travel far to reach 

it. Many current VA patients obtain much 

of their health care from non-VA providers. 

Comparing rural and urban enrollees on their 

use of VA services, and to other Veterans and 

non-Veterans on the use of non-VA health 

care, provides contextual information on 

rural Veterans’ medical needs as well as their 

provider options, travel demands, insurance 

coverage, out-of-pocket medical expenses, and 

reliance on VA and other government support 

such as Medicare/Medicaid. 

Total medical expenditures incurred by male 

Veterans, rural or urban, who use VA for any 

of their health care, are much higher, on average, than for other health care using men. Most 

of the treatment received by these VA users, 

however, is non-VA care: for those 65 or older, 

the largest payer is Medicare, and for those 

younger, it is commercial insurance; in either 

age group, average out-of-pocket payments 

for services also are substantial. Despite similar 

co-morbidities and worse health self-ratings, 

adjusted medical expenditures for working-age 

rural VA users average 20 percent lower than 

for urban users; the difference is largely due to 

rural users receiving less inpatient care and having less private insurance coverage and lower 

incomes.1

For a current HSR&D-funded project, we 

have acquired administrative data for all VA 

and non-VA hospitalizations obtained in recent years by any VA enrollees living in eight 

states (Arizona, Iowa, Louisiana, Florida, Tennessee, South Carolina, Pennsylvania, and New 

York). These data permit analyses of regional 

variations in urban-rural VA/non-VA utilization for common medical conditions and 

procedures. The eight states vary greatly in “ruralness,” from Florida, where one in five enrollees is rural, to Iowa, where two in three are 

rural. The states also vary in how much rural 

enrollees relied on non-VA care: non-VA hospitalizations outnumbered VA Medical Center 

(VAMC) admissions by 2 to 12 times for those 

65 or older (mostly paid by Medicare), and by 1 

to 3 times for younger enrollees. In either agegroup, reliance on the VA was less for rural 

than urban enrollees in six states, but greater in 

Florida and Louisiana. In the more rural states 

(Iowa, Louisiana, Tennessee, South Carolina), 

rural and urban enrollees were hospitalized 

at similar rates; for elderly rural enrollees in 

Florida there was a trade-off—these enrollees 

use non-VA care less and VAMCs more than 

expected. In Arizona, Pennsylvania, and New 

York, however, rural enrollees had fewer admissions, either VA or non-VA, than might be 

expected from their numbers alone. This finding suggests that rural residents in states with 

concentrated population centers might have 

less referral access to urban hospitals in addition to greater travel burden. 

Travel Distances for 

Rural Veterans 

Across the eight states, most urban patients 

lived within a half hour and most rural patients 

lived within an hour of the nearest non-VA 

hospital. For VAMC inpatients the nearest 

VAMC averaged more than a half hour away 

if they were urban residents, and one to one 

and a half hours if rural. For enrollees who 

used non-VA hospitals instead, driving to the 

VAMC would have averaged at least one half 

to one and a quarter hours for urban residents 

and one and a quarter to two hours for rural. 

Patients with multiple admissions over time 

who used VAMCs exclusively lived about a 

half hour closer to those hospitals than those 

who used non-VA hospitals only. Such findings suggest that greater distance to VA inpatient care has some dampening effect on its 

use by both urban and rural enrollees; average 

travel time, however, is considerably higher 

for rural than urban residents, in effect establishing a different threshold for normative, 

perhaps acceptable, distances. Rural Veterans 

must travel a long way to hospitals anyway, so 

quality considerations should outweigh relative convenience in their treatment choices; 

we have shown elsewhere,2 for example, that 

those who need high-risk surgeries could be 

redirected from lower to higher performance 

non-VA hospitals with minimal impact on 

their travel burden. 

References 

1. West AN, Weeks WB. Health Care Expenditures for 

Urban and Rural Veterans in Veterans Health Administration Care. Health Services Research 2009; 44, 1718-34.

2. West AN, Weeks WB, Wallace AE. Rural Veterans and 

Access to High-Quality Care for High-Risk Surgeries. 

Health Services Research 2008; 43, 1737-51.

FORUM — Translating research into quality health care for Veterans 4

VA Office of Research & Development, Health Services Research & Development Service November 2010

Research Highlight

Health Care Access and Quality for 

Rural Veterans

Alan West, Ph.D., Deputy Director, Veterans Rural Health Resource Center—

Eastern Region, White River Junction VA Medical Center, VT

“Over-representation of rural 

residents among OEF/OIF 

troops, and casualties, will likely 

increase rural Veterans’ health 

care needs further.” 

The 28th National Meeting of VA’s 

Health Services Research and Development Service (HSR&D) has been 

approved and is being planned for 

February 2011 (dates and location are 

pending). To check for the most current meeting information go to: 

http://www.hsrd.research.va.gov/

meetings/2011/
VA Office of Research & Development, Health Services Research & Development Service November 2010

FORUM — Translating research into quality health care for Veterans 5

The U.S. health care system has been characterized as fragmented, delivering acute 

episodic treatment with little information 

sharing across providers and minimal care 

coordination over time.1 The U.S. health 

care system also relies predominantly on 

face-to-face encounters between patients 

and providers, with hardly any communication in between encounters. In contrast, the 

VHA health care system is an integrated 

system of care that has an assortment of 

e-health technologies that promote patientprovider communication outside the context of a face-to-face clinical encounter, and 

an electronic medical record that facilitates 

provider-to-provider communication.2 VHA 

is also embracing the patient centered medical home model with its emphasis on care 

teams and enhanced patient access through 

digital channels of communication.3 One 

can envision a future VHA health care system that relies less on the episodic delivery 

of treatment during face-to-face encounters 

between Veterans and their providers, and 

more on proactive non-encounter-based 

digital communications between Veterans 

and their care teams. With access being one 

of Secretary Shinseki’s three major themes, 

the VHA health care system should be an 

exemplar for how to deliver continuous and 

coordinated health care in the digital age. 

Digital Health Care Utilization

Digital communication modalities include 

cell phones, smart phones, interactive voice 

response, text messages, emails, clinic-based 

interactive video, home-based webcams, 

personal monitoring devices, kiosks, dashboards, electronic medical records, personal 

health records, Web-based portals, social 

networking sites, secure chat rooms, and 

online forums. There are at least five categories of digital health care utilization that 

use these communication modalities as 

an alternative to face-to-face interactions. 

Synchronous digital patient-to-provider encounters

include encounters in real time where the 

Veteran and the provider are located in different geographic locations. Asynchronous digital 

patient-to-provider communications include interactions between the Veteran and the provider 

where there are time lags in communication. 

Digital provider-to-provider communications include 

synchronous and asynchronous discussions 

between the members of a virtual caregiver 

team (including informal caregivers). Digital 

peer-to-peer communications include synchronous 

and asynchronous discussions among Veterans to share information and practical advice, 

and to provide mutual support. Synchronous 

digital interactions between patients and computers

include personal computer- and smart-phonebased applications that present information or 

deliver therapeutic treatments.

Digital Access 

The traditional conceptualizations and measures of access (e.g., providers per population, 

travel times, usual source of care, out-ofpocket costs) focus exclusively on face-toface, patient-to-provider encounters and are 

not well suited to measuring access to digital 

encounterless communications. As the paradigm of VHA health care delivery evolves, it 

is imperative that our conceptualization of access undergoes a concurrent paradigm shift to 

make it more relevant for the digital age. For 

the digital age, access to care should be redefined more broadly as the opportunity and 

potential ease of having face-to-face and virtual interactions among a care team (including 

a patient and their formal providers, informal 

caregivers, peers, and computer applications). 

Access is a multidimensional concept that 

includes the following domains: geographical, temporal, financial, cultural, and digital. 

Digital access represents the connectivity 

that enables synchronous or asynchronous 

digital communications with providers, 

peers and computerized health applications, 

and the connectivity that enables communications among the caregiver team and the 

sharing of relevant clinical information.

Improvements in digital access could drastically diminish the geographical, temporal, 

and cultural access problems faced by many 

Veterans. Synchronous digital communications can alleviate the travel burden associated with utilizing many—but not all—types 

of health care services. Asynchronous digital communication can diminish the time 

burden, as Veterans upload and download 

clinical information at times that are convenient to them. Computer applications can 

be designed to educate Veterans in order 

to help them better understand their treatment options/plans, thereby improving the 

cultural acceptability of treatment. On the 

other hand, a growing digital divide for low 

income, minority, rural, and elderly Veterans 

could create greater access disparities for 

these Veteran populations. 

Access Research 

To address these important issues, the 

2010 VA State of the Art (SOTA) conference focused on Veterans’ access to the 

VHA health care system. The objectives 

of the conference were to synthesize the 

literature on access in order to summarize 

accumulated knowledge and make policy 

recommendations, and to identify gaps in 

knowledge and make recommendations 

about HSR&D research priorities. Just as 

improving access is a priority for Secretary 

Shinseki, enhancing access research must be a 

priority for HSR&D. HSR&D investigators 

need to develop and evaluate interventions 

that improve digital access to care, including 

programs designed to improve connectivity 

and the usability of digital communication 

modalities. In addition, HSR&D 

investigators need to develop and validate 

access measures that are relevant in the 

Research Highlight

Access to VA Health Care in the 

Digital Age

John Fortney, Ph.D., Central Arkansas Veterans Healthcare System, 

North Little Rock, Arkansas

continued on page 8
Over the past decade, rural health disparities and 

access to quality health care in rural settings have 

been major priority areas in both Veteran and civilian populations. Persons in rural settings generally have fewer health care options and face a 

number of barriers to care, such as limited financial resources and long travel distances relative 

to their urban counterparts. Disparities in rural 

communities are particularly problematic with 

regard to the receipt of mental health care services. Recent research demonstrates that, relative 

to those in rural areas, residents in metropolitan 

areas are 47 percent more likely to receive general mental health services and 72 percent more 

likely to receive specialized services (Richardson 

et al., 2009). In response to these and similar 

data, a number of initiatives have been launched 

within the VA and other large health care agencies to address disparities in access to mental 

health care.

Use of Telehealth Technology to 

Overcome Barriers to Treatment

One proposed method to overcome barriers to 

mental health care access in rural settings is with 

the use of telehealth technologies to provide 

assessment and treatment services from metropolitan areas to patients in underserved rural 

or geographically remote areas. Telehealth has 

several advantages for patients over traditional 

treatment approaches, including decreased 

patient cost (e.g., lower cost of transportation, 

travel time, and missed work), decreased provider costs, and increased system coverage area. 

In addition, telehealth may be useful in overcoming several other barriers to mental health 

treatments, such as perceived stigma associated 

with mental health care in active military service 

personnel and Veterans, by providing services 

directly in patients’ homes. 

Preliminary Findings

Telehealth has received preliminary support in a 

number of treatment settings and with a range 

of patient populations, including patients in 

rural areas, older adults, racial/ethnic minorities, 

patients adjudicated by the courts, and Veterans 

(for review, see Richardson et al., 2009). In addition, there is strong evidence for both high 

patient and moderately high provider satisfaction with mental health services delivered via 

telehealth. Of particular relevance to mental 

health services in the VA, recent studies support the effectiveness of telehealth for delivering 

evidence-based psychotherapies to rural Veterans with post-traumatic stress disorder (PTSD) 

(Tuerk et al., 2010). Similar beneficial effects of 

mental health care delivered via telehealth also 

have been demonstrated for other psychiatric 

conditions (e.g., obsessive compulsive disorder, 

panic disorder, and anger management).

Ongoing Research

To better understand the effectiveness of mental 

health services delivered via telehealth to rural 

Veterans, HSR&D, the U.S. Department of 

Defense (DoD), and other agencies have recently funded several treatment outcome studies 

within the Charleston Veterans Affairs Medical 

Center (VAMC) and its associated VA Health 

Services Research and Development Research 

Enhancement Award Program (REAP). These 

studies include: 1) a randomized controlled trial 

(RCT) of Behavioral Activation for depression 

delivered via telehealth or in-person in elderly 

Veterans (n=224 ) (Egede et al, 2009); 2) a RCT 

of Behavioral Activation and Therapeutic Exposure delivered via telehealth or in-person in 

OEF/OIF Veterans with PTSD (n=220); and 

3) a RCT of Prolonged Exposure delivered via 

telehealth or in-person in OEF/OIF Veterans 

with PTSD (n=226). In addition to the above, 

the Charleston VAMC recently received funding from the Office of Rural Health to initiate a 

two-year clinical treatment program to provide 

evidence-based psychotherapies and pharmacotherapies to rural VAMCs and their associated 

community-based outpatient clinics across three 

states. The program provided funding for five 

psychiatrists, five psychologists, and two support staff in addition to telehealth equipment. 

Together, these projects will greatly improve and 

expand our understanding of use of telehealth 

services in the treatment of a wide range of 

mental health conditions for rural Veterans or 

Veterans who may simply prefer telehealth services over face-to-face care. 

Conclusions

Telehealth services can overcome many of the 

current obstacles to quality mental health care 

in rural settings, including lack of local providers, transportation barriers, lost time from work, 

and stigma. Preliminary findings suggest that 

telehealth services are both effective and are received favorably by patients and providers alike. 

Together with ongoing research and clinical 

initiatives of the VA, telehealth services stand to 

bridge longstanding gaps in access and mental 

health care delivery to rural and underserved 

Veterans, ultimately resulting in improved 

mental health outcomes, health care-related 

costs, and overall quality of life in our 

nation’s Veterans.

References

Richardson LK, et al. Current Directions in Videoconferencing Tele-mental Health Research. Clinical Psychology: Science and 

Practice 2009; 16, 323-38.

Tuerk PW, et al. A Pilot Study of Prolonged Exposure 

Therapy for Posttraumatic Stress Disorder Delivered via 

Telehealth Technology. Journal of Traumatic Stress 2010; 23, 

116-23.

Egede, LE, et al. Rationale and Design: Telepsychology 

Service Delivery for Depressed Elderly Veterans. Trials 2009; 

10, 22.

FORUM — Translating research into quality health care for Veterans 6

VA Office of Research & Development, Health Services Research & Development Service November 2010

Research Highlight

Telehealth Technologies for the Delivery 

of Mental Health Services

Daniel F. Gros, Ph.D., Ron Acierno, Ph.D., Kenneth J. Ruggiero, Ph.D., Anouk L. 

Grubaugh, Ph.D., and Leonard E. Egede, M.D., M.S., all with the Ralph H. 

Johnson VA Medical Center and the Medical University of South Carolina, 

Charleston, South Carolina, and B. Christopher Frueh, Ph.D., University of 

Hawai’i at Hilo, Hilo, Hawaii “...there is strong evidence for 

both high patient and moderately 

high provider satisfaction with 

mental health services delivered 

via telehealth.”
VA Office of Research & Development, Health Services Research & Development Service November 2010

Because many more women are serving 

in the military, being deployed to Iraq and 

Afghanistan, and enrolling in VA care, VA 

clinicians are treating twice as many women 

Veterans as they did a decade ago. This increase poses challenges for a system historically designed to see predominantly men. 

VA is responding by accelerating changes in 

practice and policy initiatives, such as the recently revised VHA Handbook on Care for 

Women Veterans.

In response to the demand for research 

to inform evidence-based approaches to 

improving access to high quality care for 

women Veterans, the VA HSR&D Service 

has funded a new VA Women’s Health Research Consortium (WHRC, pronounced 

“WORK”). WHRC is designed to build 

capacity in women Veterans’ health services 

research, with an emphasis on accelerating 

movement to interventions, quality improvement, and implementation research. 

A cornerstone of this effort was the establishment in 2004 of the first-ever national 

VA Women’s Health Research agenda and 

the publication of a systematic review that 

demonstrated that the women Veterans’ 

health literature is principally descriptive and 

observational rather than evidence-based.1, 2 

Since 2004, the number of VA investigators 

explicitly interested in Women’s Health Research has tripled, with more than 150 M.D. 

and Ph.D. researchers expressing interest in 

tackling research in a wide array of critically 

important areas relevant to VA operational 

concerns. Further, the number of women 

Veterans’ research peer-reviewed papers 

published in the past five years outstrips 

the volume published in the previous 25 

years combined, and has both dramatically 

extended our knowledge and simultaneously 

identified important knowledge gaps.

The goals of the Consortium are therefore 

to systematically arm this burgeoning and 

motivated cadre of VA investigators with 

knowledge, skills, and collegial VA leadership relationships necessary to generate 

relevant scientific knowledge regarding 

evidence-based care models, interventions, 

and strategies for transforming VA care for 

women Veterans. The Consortium will provide: (1) methodological and content-related 

education and training through Web-based 

and other seminars; (2) technical consultation and mentorship through one-on-one 

consults and building collaborative communities of practice around key topical areas 

(e.g., access to care, reproductive health); 

and (3) accelerated dissemination and implementation of VA women’s health research 

into evidence-based practice and policy. A 

special focus of the Consortium’s efforts will 

be on fostering investigators’ capabilities and 

readiness to translate current and emerging 

evidence into testable interventions among 

women Veterans.3 The Consortium, led by 

Elizabeth Yano, Ph.D. (VA Greater Los 

Angeles & UCLA) and Susan Frayne, M.D. 

(VA Palo Alto & Stanford), is also partnering with the VA Quality Enhancement 

Research Initiative (QUERI) Center for Implementation Practice & Research Support 

(CIPRS) to promote implementation of women’s health research into routine practice.

The Consortium recently organized a VA 

Women’s Health Services Research Conference in Arlington, VA, which attracted not 

only a large number of researchers but also 

senior VA leaders from almost every major 

office. The Conference also drew representatives from the U.S. Departments of Defense, Health & Human Services and Labor, 

the Institute of Medicine, and National 

Institutes of Health among other agencies 

(for more information go to www.research.

va.gov/programs/womens_health/default.

cfm). The Consortium is also coordinating 

a special VA Supplement to the journal, 

Women’s Health Issues, with manuscripts due 

November 15, 2010 (see call for papers on 

same website). For more information about 

the VA Women’s Health Research Consortium please contact Dr. Ruth Klap, VA 

WHRC Program Manager, at 

ruth.klap@va.gov. 

FORUM — Translating research into quality health care for Veterans 7

Organizational Profile

VA’s New Women’s Health Research Consortium

Seth Eisen, M.D., M.Sc., HSR&D Director and Linda Lipson, M.A., Scientific Program Manager, both from HSR&D Central 

Office, Washington, D.C. 

Conference participants were divided into work groups focusing on the 

following topics:

• Defining access and constructs; 

• Identifying access issues for special populations; 

• Impact of access on utilization, quality, outcomes, and satisfaction; 

• Impact of policy and organization of care on access; and 

• Adoption and implementation of information technology.

Each of the groups worked to develop recommendations for policy strategies to 

assist VA and the larger health care community to improve access to care. They 

also developed research questions to target strategies that will improve access for 

Veterans, which will be refined for several SOTA products. The research agenda 

and policy recommendations will be reviewed and synthesized for presentation to 

VA leadership as appropriate. Also, a supplement to the Journal of General Internal 

Medicine is planned for publication in the summer of 2011. Papers are due to the 

journal for peer review by December 1. In addition, the SOTA planners will discuss 

and plan for other possible SOTA products which might include an RFA, a white 

paper(s) for leadership, and one or more cyber seminars to inform the research 

community about access research priorities.

continued on page 8

SOTA Conference: Improving Access to VA Care continued from page 3
Peter L. Almenoff, M.D., 

FCCP, Assistant Deputy 

Under Secretary for Health for 

Quality and Safety, VA Central 

Office, Washington DC

David Atkins, M.D., M.P.H.,

QUERI Director,

VA Central Office, 

Washington DC

Cynthia Caroselli, Ph.D., R.N.,

Associate Director for Patient 

Services & Chief Nurse 

Executive, VA New York 

Harbor Health Care System, 

New York, NY

Martin P. Charns, D.B.A., 

Director, VA HSR&D Center 

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc., 

Director, HSR&D

VA Central Office, 

Washington DC

Joseph Francis, M.D., M.P.H., 

Chief Quality and 

Performance Officer, VA 

Central Office, Washington DC 

Rodney A. Hayward, M.D., 

Co-Director, VA HSR&D 

Center of Excellence, 

Ann Arbor, MI

Alan S. Perry, M.P.A., M.H.A., 

FACHE, Director, VA 

Central California Health Care 

System, Fresno, CA

Frances Weaver, Ph.D.,

Director, VA HSR&D Center 

of Excellence, Hines, IL

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

Access to VA Health Care in the Digital Age 

continued from page 5

VA’s New Women’s Health Research 

Consortium continued from page 7

FORUM

Translating research into quality health care for Veterans

Center for Information Dissemination and Education Resources 

VA Boston Healthcare System (152C) 

150 South Huntington Avenue, Boston, MA 02130-4893

Organization

U.S. Postage

PAID

Permit No. 3999

Washington, DC

digital age so that the VHA can monitor 

and adapt itself to better accommodate 

the needs of Veterans in the 21st century. 

References 

1. Bashshur RL, Shannon GW. National Telemedicine Initiatives: Essential to Healthcare Reform. 

Telemedicine and e-Health 2009; 15(6):600-10.

2. Naditz A. Telemedicine at the VA: VistA, MyHealtheVet, and other VA programs. Telemedicine 

Journal and e-Health 2008; 14(4):330-32.

3. Rosenthal TC. The Medical Home: Growing 

Evidence to Support a New Approach to Primary Care. Journal of the American Board of Family 

Medicine 2008; 21(5):427-40.

References

1. Yano EM, et al. Toward a VA Women’s Health 

Research Agenda: Setting Evidence-based Priorities to Improve the Health and Health Care of 

Women Veterans. Journal of General Internal Medicine 2006; 21(Suppl 3):S93-101.

2. Goldzweig C, et al. The State of Women Veterans’ Health Research: Results of a Systematic Literature Review. Journal of General Internal Medicine 

2006; 21(Suppl 3):S82-92.

3. Yano EM, et al. Integration of Women Veterans 

into VA Quality Improvement Research Efforts: 

What Researchers Need to Know. Journal of General 

Internal Medicine 2010; 1:56-61.