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S. HRG. 111–133 

CARING FOR VETERANS IN RURAL AREAS 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

FEBRUARY 26, 2009 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate 

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

DANIEL K. AKAKA, Hawaii, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

PATTY MURRAY, Washington 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JIM WEBB, Virginia 

JON TESTER, Montana 

MARK BEGICH, Alaska 

ROLAND W. BURRIS, Illinois 

ARLEN SPECTER, Pennsylvania 1

RICHARD BURR, North Carolina, Ranking 

Member 

LINDSEY O. GRAHAM, South Carolina 

JOHNNY ISAKSON, Georgia 

ROGER F. WICKER, Mississippi 

MIKE JOHANNS, Nebraska 

WILLIAM E. BREW, Staff Director 

LUPE WISSEL, Republican Staff Director 

1 Hon. Arlen Specter was recognized as a majority Member on May 5, 2009. 

(III) 

C O N T E N T S 

FEBRUARY 26, 2009 

SENATORS 

Page 

Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii ........................... 1 

Burr, Hon. Richard, Ranking Member, U.S. Senator from North Carolina ....... 3 

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 6 

Prepared statement .......................................................................................... 7 

Brown, Hon. Sherrod, U.S. Senator from Ohio ..................................................... 6 

Tester, Hon. Jon, U.S. Senator from Montana ...................................................... 2 

Begich, Hon. Mark, U.S. Senator from Alaska ..................................................... 5 

Burris, Hon. Roland W., U.S. Senator from Illinois ............................................. 4 

Johanns, Hon. Mike, U.S. Senator from Nebraska ............................................... 32 

WITNESSES 

Hawthorne, Kara, Director, Office of Rural Health, Veterans Health Administration, U.S. Department of Veterans Affairs .................................................... 8 

Prepared statement .......................................................................................... 10 

Response to request arising during the hearing by: 

Hon. Patty Murray ........................................................................................ 20 

Hon. Jon Tester ............................................................................................. 22,32 

Hon. Roland W. Burris ................................................................................. 27 

Response to post-hearing questions submitted by: 

Hon. Patty Murray ........................................................................................ 34 

Hon. Bernard Sanders .................................................................................. 37 

Darkins, Adam, M.D., Chief Consultant for Care Coordination, Veterans 

Health Administration, U.S. Department of Veterans Affairs ......................... 15 

Prepared statement .......................................................................................... 17 

Response to post-hearing questions submitted by Hon. Bernard Sanders .. 37 

Flippin, Reverend Ricardo C., Project Coordinator, West Virginia Council 

of Churches, CARE-NET: Caring Beyond the Yellow Ribbon .......................... 40 

Prepared statement .......................................................................................... 41 

Watson, Alan, Chief Executive Officer, St. Mary’s Medical Center of Campbell 

County, LaFollette, TN ........................................................................................ 42 

Prepared statement .......................................................................................... 44 

Loftus, Thomas, Commander, The American Legion, Post 45, Clarksville, VA .. 45 

Prepared statement .......................................................................................... 47 

Kuntz, Matthew, Executive Director, Montana Chapter, National Alliance 

for Mental Illness ................................................................................................. 48 

Prepared statement .......................................................................................... 49 

APPENDIX 

Sanders, Hon. Bernard, U.S. Senator from Vermont; prepared statement ........ 59 

Spoehr, Hardy, Executive Director, Papa Ola Lokahi, Honolulu, HI; prepared 

statement .............................................................................................................. 61 

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CARING FOR VETERANS IN RURAL AREAS 

THURSDAY, FEBRUARY 26, 2009 

U.S. SENATE, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 10:06 a.m., in room 

SR–418, Russell Senate Office Building, Hon. Daniel K. Akaka, 

Chairman of the Committee, presiding. 

Present: Senators Akaka, Murray, Brown, Tester, Begich, Burris, 

Burr, and Johanns. 

OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 

U.S. SENATOR FROM HAWAII 

Chairman AKAKA. This hearing on Caring for Veterans in Rural 

Areas will come to order. 

Good morning and aloha to all of you. I want to extend my 

warmest welcome to our Committee Members—it is good to see 

Senator Tester here early—and also to welcome our witnesses visiting the Nation’s capital from small communities as close as southern Virginia and as far away as Montana. Today’s hearing brings 

together small communities with VA to discuss the health care 

problems our newest veterans face when they return to homes in 

rural areas. 

Many of our veterans live in small towns and communities. This 

includes a large number of Guard members and Reservists, who 

have been such a big part of the wars in Iraq and Afghanistan. 

Members of the Guard and Reserve face challenges different from 

their active-duty counterparts, who return to military bases with 

the support of their unit with programs geared toward reacclimating them to life outside of the combat zone. 

When a Guardsman or Reservist returns home, he or she can be 

isolated from their unit and must reintegrate without a strong VA 

or DOD presence or support system. Frequently, these servicemembers live up to and beyond, 50 miles from their home base. 

When health care is needed, a rural community may not have 

providers who offer mental health services like group counseling or 

therapy. The doctors may not be familiar with treating combat-related disorders. 

Nevertheless, we have an obligation to care for all our veterans 

in need, regardless of location. We must ensure that adequate resources are available in our small communities, and that VA engages fully with local health care providers. Every resource must 

be united in the effort to care for our wounded warriors, be it a 

community hospital or VA clinic. When there is no VA presence 

2 

available, this may mean paying community providers for the reasonable costs of care. 

As a Committee, we will be focusing much effort on improving 

veterans’ health care in rural areas, and I welcome any new approaches to meet this goal. 

I also want to tell you that I just had a conversation with Secretary Shinseki before coming into the room. We discussed the proposed VA budget. I must say that with the little detail we do have, 

it is positive. I can tell you that there will be an increase in the 

veterans’ budget that will be proposed by the President to the VA 

and to Secretary Shinseki. And let me say that it is a step in the 

right direction. It is an increase. We are looking at about 15 percent, but it is a step in the direction of the needed resources. 

The President’s budget and its discretionary authority increases health care funding by $5 billion over last year’s budget, so that 

is a good step. And I am looking forward to seeing more of the 

President’s proposal in the days and weeks to come. And we do, of 

course, have VA’s budget hearing scheduled for March 10th. 

So let me call on Senator Tester for his opening statement. 

STATEMENT OF HON. JON TESTER, 

U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Chairman Akaka. I appreciate your 

holding this hearing today, and I want to thank the distinguished 

witnesses who are here today to discuss health care and the challenges faced by veterans living in rural communities. 

I also want to recognize Matthew Kuntz. Matthew is an attorney 

from Helena, Montana. He gave up his practice as an attorney to 

serve as Executive Director of the National Alliance on Mental Illness, NAMI, in Montana, and this happened after his step-brother 

committed suicide. I have been very, very fortunate over the last 

couple of years to get to know Matt, and I believe he adds a very 

important voice to this story. 

Matt’s brother was an Iraqi war veteran suffering from combatrelated PTSD, and I want to thank him personally for his leadership and his advocacy on this issue. His outreach has been a lifeline for Montana veterans and their families. We appreciate your 

courage, Matt, and the perspective that you will bring to this Committee today. 

This is not an easy topic, but we must continue to address combat-related mental illness and the devastating effects that it can 

have on veterans, because if it is not properly identified and expeditiously treated, the problems do not get better. They get worse. 

Again, I want to thank you for coming and thank you for bringing awareness from a Montana perspective. 

Montana has a large population of Native American veterans. 

This is a special group of veterans that is disproportionately affected by service-connected health conditions. Their access to primary and mental health care is further limited by distance, it is 

underfunded and often provided by inadequate community health 

care services through the IHS. We need to do better there. 

Next month, I intend to reintroduce the Rural Veterans Health 

Improvement Act. I will work with my colleagues and the Chairman on this Committee to be sure that this bill includes a section 

3 

on improving the VA’s work with IHS, because I think we all know 

that the relationship as it stands is not working properly. We did 

not have anything on the VA-IHS relationship last time, but I believe we need to address it. 

Veterans who reside in frontier communities like Montana are at 

greater risk of adverse health outcomes. They cannot wait weeks 

for a VA appointment in a city hundreds of miles away with a doctor that they have never seen or who has no knowledge of their 

medical history. In many instances, the primary care setting, 

whether it is in the CBOCs or some kind of private provider in the 

local community, becomes the de facto mental health care delivery 

system for these individuals. 

More than 40 percent of the patients with mental health concerns initially seek care in the primary care setting, and I believe 

we have to take a look at this because the primary care setting provides a valuable opportunity to improve access to mental health 

services. 

I believe there is a greater opportunity for the VA to collaborate 

and support primary care settings in local communities. If the VA 

cannot provide timely, targeted access for veterans in rural areas, 

whether for mental health or for physical injuries suffered in service to our Nation, then they must expand and build upon resources 

in the local community with an eye toward improving access, communications, and follow-up. 

Again, I appreciate, Mr. Chairman, your calling this hearing, and 

I appreciate the opportunity to hear from the witnesses as we 

progress today. Thank you. 

Chairman AKAKA. Thank you very much, Senator Tester. I want 

to mention that you are regarded as a leader here on rural health, 

so we are so glad to have you as a Member of this Committee. 

Let me call on Senator Burr for his opening statement. 

STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 

U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Aloha, Mr. Chairman. 

Chairman AKAKA. Aloha. 

Senator BURR. I think it is evident to all of us that Senator 

Tester got his hair cut while he was gone. He desperately needed 

it at the last hearing. I just want to point that out. [Laughter.] 

Mr. Chairman, I want to thank you for this hearing and good 

morning to our witnesses. 

About one-third of all veterans enrolled for VA health care live 

in rural communities as defined by the Census Bureau. Many of us 

can point to large portions of our States that have limited access 

to health care, and North Carolina is no exception to that. I am 

convinced we must tackle this problem, and I am eager to hear 

what the witnesses from VA are doing to solve it. 

I am pleased that in recent years the VA has continued to expand its presence of outpatient clinics in rural communities. VA 

has opened over 100 new community-based outpatient clinics in the 

past 5 years. I have had the pleasure of attending several VA clinic 

openings in North Carolina over the last couple of years. We have 

four more that will open within the next 2 years. These clinics will 

cut down on lengthy travel times and hopefully encourage veterans 

4 

to get the essential primary care and basic mental health services 

that they might not otherwise seek. 

Let me add at this point, Mr. Chairman, it is my intention to 

bring to this Committee, hopefully, a new model program for rural 

markets where we consider collocating VA outpatient clinics in 

with federally chartered community health centers, where we share 

the footprint of a delivery point and, potentially at least, share the 

technology components of X-ray, copiers, the things that we do not 

need to duplicate; and we will work out the professional staff if 

there is any sharing along those lines. But I think it is time that 

we begin to think outside of the box for how we increase the number of points that deliver health care—facing the reality that if we 

are unsuccessful at doing that, we will never accomplish the level 

of primary care that is needed to make sure that our veterans are 

not, in fact, inpatient fatalities within the system. 

Along with these new clinics is the opportunity to expand our use 

of telemedicine. That technology now permits remote consultations 

and even some medical procedures or examinations to occur in the 

comfort of a patient’s own home, which I would say we have done 

with great success thus far. 

As this technology continues to improve, it will open the doors 

to deliver more care to more veterans in remote areas. 

Finally, access to care for rural veterans raises the potential to 

work in coordination with health care providers in rural areas, as 

I have said, and this is a tremendous area of interest to veterans 

who live in these rural areas and are faced with the decision of how 

to get from where they live to a delivery point when travel seems 

to be their number 1 concern. 

Last year Congress passed legislation to test this concept with a 

pilot program allowing the VA to team up with community providers for the care of veterans who live far away from VA facilities, 

and I look forward to hearing how those pilot programs are going. 

Mr. Chairman, again, I thank you again for calling this important hearing. I do not believe that there is any area of greater concern than how we address the delivery of health care in rural 

America, particularly as we continue to see the demographic shift 

that is happening in this country. I go into this with the realization 

that many of those retired veterans are choosing North Carolina to 

be their home and that we cannot possibly, without the right 

amount of attention in rural markets, understand how we are 

going to service this population, regardless of which State they 

choose, unless we are willing to tackle new ways to deliver health 

care in the rural areas of this country. 

I thank the Chair. 

Chairman AKAKA. Thank you very much, Senator Burr. 

Let me call now on Senator Burris for his opening statement. 

STATEMENT OF HON. ROLAND W. BURRIS, 

U.S. SENATOR FROM ILLINOIS 

Senator BURRIS. Thank you, Mr. Chairman, and I want to thank 

the witnesses for appearing here as well. 

Mr. Chairman, over the break I was not able to go to a rural VA 

hospital, but I visited the most modern one up in Great Lakes in 

northern Illinois, and I was impressed with the move to combine 

5 

the medical services from the naval base over at Great Lakes with 

the veterans hospital. They are doing this as the only program in 

the country that is trying to do complete service with DOD and 

with the VA. The hospital administrators are all excited about it. 

The Navy leadership is all excited about it. But it is not getting 

to our rural communities, and we have rural communities in Illinois as well. 

As you all may know, there was that one incident in Illinois 

where that one doctor created a lot of problems for some veterans, 

and I understand that that has really been taken care of. But we 

have to be concerned about how they get access to health care. And 

when you see that 39 percent of the veterans enrolled in the VA 

health care system reside in rural areas, the model we have for 

providing care to veterans via large hospitals and clinics does not 

make sense in areas of low population density. We must find new 

ways to serve our rural veterans. And I hope a newly created Office 

of Rural Health and those clinics will find ways to eliminate the 

discrepancies in the care between urban, suburban, and rural veterans. 

There are some urgent issues right now that we must face, and 

we must solve them on behalf of the members who gave their all 

for us to be safe in this great democracy. We cannot forget them. 

We cannot let them suffer. We must take care of them. 

Thank you very much, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Burris. 

Senator Begich, your opening statement, please. 

STATEMENT OF HON. MARK BEGICH, 

U.S. SENATOR FROM ALASKA 

Senator BEGICH. Thank you, Mr. Chairman. I am going to be, as 

usual, brief, and say thank you. I am looking forward to your commentary. There is no State more rural than Alaska, and how you 

deliver health care systems up there causes grave concerns. 

I appreciate Senator Burr’s comment regarding delivery to rural 

communities. 

I like pilot ideas, but I like aggressive approaches. I think the 

system has to change dramatically, especially in Alaska, in how we 

partner with, for example, some of the best health care that is offered in regards to our Native health care systems that are all 

throughout the State of Alaska. And I know there are a couple 

ideas that are being kicked around. They are kind of jammed up 

a little bit, from what I understand. I am looking forward to seeing 

a long-term, aggressive approach in especially what I would consider the most rural of rural States in this country and how you 

deliver health care systems. 

So, I am looking forward to your testimony. I know we are going 

to be voting at 10:30. I do not know how this will all work, but I 

am looking forward to it. If I miss it, I am anxious to hear from 

both of you at a later time. 

Chairman AKAKA. Thank you, Senator Begich. 

Senator Brown? 

6 

STATEMENT OF HON. SHERROD BROWN, 

U.S. SENATOR FROM OHIO 

Senator BROWN. Thank you, Mr. Chairman, and thank you to the 

witnesses for being here and for your public service. Thank you. 

In my State of Ohio, of 11 million people, there are more than 

1 million veterans, and that number is growing rapidly, of course, 

as men and women return from Iraq, Afghanistan, and other deployments. These brave men and women were made a solemn 

promise that if they defended our country, we would provide them 

with services they have earned and they deserve. 

Veterans in rural America and rural Ohio face barriers, as others 

have pointed out, to healthy transition to civilian life. From a lack 

of access to VA facilities to a lack of VA reimbursement for community hospitals, rural veterans are struggling to regain a healthy 

life. That is why this hearing is so important, and I thank the 

Chairman for doing this. 

Last year I held a joint field hearing with Congressman Zack 

Space—now a two-term Member from Ohio—which examined 

issues facing veterans in Appalachia, Ohio. During the hearing I 

heard from Terry Carson, the CEO of Harrison Community Hospital, a 25-bed community hospital that serves the small village of 

Cadiz—the boyhood home of both Clark Gable and General George 

Custer, I might add. I asked Mr. Carson to testify after receiving 

a letter from him describing the enormous financial strain that 

small community hospitals experience when they provide urgent 

care for veterans, despite knowing the hospital may not receive VA 

reimbursement. 

After hearing Mr. Carson’s story and that of other community 

hospitals treating rural veterans, I introduced and this Congress 

enacted the Veterans Emergency Care Fairness Act of 2007 that 

requires the VA to reimburse community hospitals for all care a 

veteran receives before that veteran is transferred to another VA 

facility. 

But that act addresses just one issue that confronts veterans in 

rural areas. Today’s hearing examines important issues of recruitment of physicians in rural communities, strengthening telemedicine resources to compensate for the shortage of providers in rural 

communities, and other ways to ensure a concerted effort to provide adequate health care for our veterans. 

Much work needs to be done. Veterans, whether living in Cadiz 

or Cleveland, deserve access to the quality health care that honors 

their sacrifice. 

Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Brown. 

Senator Murray? 

STATEMENT OF HON. PATTY MURRAY, 

U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. We do have a vote in just a couple minutes, so 

I will put my opening remarks into the hearing record. And I would 

just say that I think this is a critical, critical hearing, and I look 

forward to your testimony and the opportunity to talk to all of our 

witnesses today about how we are going to address these needs. 

7 

Mental health is something that I have talked about for a long 

time. Concerning mental health needs, it is very hard in rural communities when we expect people to drive miles and miles, hours at 

a time, to get the help they need. It just does not happen. 

So, we have a lot of work ahead of us, and I am concerned 

about—as all of our colleagues have talked about—what we can do 

to make sure that we are taking care of our veterans wherever 

they live. I look forward to this hearing. 

Thank you very much. 

[The prepared statement of Senator Murray follows:] 

PREPARED STATEMENT OF PATTY MURRAY, U.S. SENATOR FROM WASHINGTON

Mr. Chairman, Senator Burr, thank you very much for holding today’s hearing to 

assess how well the VA is caring for veterans in rural areas. 

Before I begin, I want to thank today’s witnesses for coming here to testify. And 

I look forward to hearing from them shortly. 

Mr. Chairman, as you know, about 40 percent of all veterans who use the VA 

health care system today live in rural areas. And that’s true of nearly half of the 

servicemembers in Iraq and Afghanistan now. 

But making sure those veterans can access care is one of the many problems we’re 

still struggling to address. 

The VA has done a tremendous amount of work to increase access in rural areas 

by establishing: 

• new Community Based Outpatient Clinics—or CBOCs, • Vet Centers, and • Mobile Medical Units. 

But we still have gaps in our ability to reach veterans who need care. And I can 

tell you that it’s one of the most common complaints I hear from veterans from my 

home state of Washington. 

Many tell me they have to drive several hours—through snowy and icy conditions 

in the winter time—just to see their doctor and get basic care. 

As you know, many of our veterans are getting up there in age, and this is a real 

strain on their health—and on their finances. Unfortunately, the result is that many 

of them end up putting off preventive—and sometimes even necessary—treatment. 

And that’s taking a real toll on their health. 

The VA’s studies have found that rural veterans are in poorer health than those 

living in urban areas where care is more accessible. 

Congress and the VA have recognized the problem, and we’ve taken some 

proactive steps to correct this injustice: 

• We created an Office of Rural Health within the VA to improve the delivery of 

care to rural veterans. • We increased the mileage reimbursement to 41.5 cents per mile so that travel 

is more affordable. • We increased outreach efforts to make sure more veterans are informed about 

their health care and benefits. • We’re taking advantage of new technology, like telemedicine, to compensate for 

the shortage of providers in rural areas. • And we’ve created more CBOCs. The CBOCs in my home state have made a 

big difference for veterans on the Olympic Peninsula and in the city of Wenatchee. 

And we’re looking forward to the permanent opening of the Northwest Washington 

CBOC as well. 

But while each of these steps has been a significant improvement over the past, we 

still have work to do. Among other things, I want to make sure the VA’s Office of 

Rural Health has the resources to meet its full potential. And I also want to ensure 

our rural veterans can get access to the best mental health care possible. 

As many of us from rural states know, it can be very difficult to access to mental 

health care when you live miles from the nearest big city. 

And so from recruiting and retaining health care providers in rural VA facilities— 

to monitoring and managing the quality of care provided in non-VA facilities—the 

challenges are complex. 

And, while I realize there simply is not a silver bullet solution, we need to keep 

thinking about creative solutions to this serious problem. 

So today, I look forward to hearing from our witnesses about their experiences 

and the steps they’re taking to improve the care of our veterans living in rural 

8 

areas. I hope this discussion will help us develop new ideas to make sure all of our 

veterans can get the care they have earned. 

And again, I thank you, Mr. Chairman, for holding this hearing. 

Chairman AKAKA. Thank you very much, Senator Murray. 

As you know, we are expecting a roll call on the floor, but in the 

meantime, let me welcome our first panel of witnesses. We will 

hear first from Kara Hawthorne, Director of the Office of Rural 

Health for Virginia. The Office of Rural Health was created by 

Public Law 109–461 to address the needs of our rural veterans. We 

will hear today how her office has been addressing these needs. 

Second, we will hear from Dr. Adam Darkins, who runs VA’s 

telehealth program. 

I want to thank you all for joining us today. Your full statements 

will appear in the record, and, Ms. Hawthorne, before we have the 

vote on the floor, please proceed with your statement. 

STATEMENT OF KARA HAWTHORNE, DIRECTOR, OFFICE OF 

RURAL HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. 

DEPARTMENT OF VETERANS AFFAIRS 

Ms. HAWTHORNE. Good morning, Mr. Chairman and Members of 

the Committee. I am delighted to be here today to talk to you about 

the very important work that VA is doing to enhance the care delivery to veterans who live in rural and highly rural areas. I would 

like to request that my written statement be submitted for the 

record. 

Let me begin by saying that we know rural health is a difficult 

national health care issue. Veterans and other citizens face a number of challenges. But VA has aggressively pursued a national 

strategy of outreach to ensure that veterans, regardless of where 

they live, can access the expertise and experience of one of the best 

health care systems in the Nation. In partnership, I know that 

Congress and VA can do even more. We do deeply appreciate your 

support and interest in this area, and we are happy to report that 

portions of the $250 million included in this year’s appropriation 

have already been distributed to the field to support new and existing projects. 

In January, VA provided almost $22 million to VISNs across the 

country to improve services for rural veterans. VA’s Office of Rural 

Health, or ORH for short, has allocated another $24 million to sustain fiscal year 2008 programs and projects, including the Rural 

Health Resource Centers, Mobile Health Care Clinics, Rural Outreach Clinics, VISN Rural Consultants, mental health and longterm care projects, and rural home-based primary care. 

Another project supported by Congress is Section 403 of Public 

Law 110–387. This section requires VA to conduct a pilot project 

that would provide non-VA care for highly rural enrolled veterans 

in five VISNs. VA is working to implement this pilot while resolving two questions. 

First, we must reconcile how VA has traditionally defined ‘‘highly 

rural’’ and how the statute defines it. VA’s data has been structured based upon our definitions using drive times, and we are currently analyzing that data to develop a new baseline assessment 

using mileage. 

9 

Second, VA must develop a regulation to define the ‘‘hardship 

provision’’ in Section 403(b)(2)(B). We have been active in our development of an implementation plan, and once that assessment 

and the regulatory process are complete, VA will identify qualifying 

communities and local providers willing and able to participate. VA 

staff is available to meet with Members of the Committee or staff 

to discuss additional ways forward. 

ORH’s primary mission is to address the needs of rural veterans 

and improve access and quality of care, and its mission is in our 

mind at all times. VA understands that veterans can only use our 

services if they know about them, so VA has initiated a Veterans 

Call Center that has been reaching out to OEF/OIF veterans from 

all parts of the country to inform them of their benefits and ask 

if they need any help. ORH will be reviewing the Call Center’s 

work to determine what more we can do for rural veterans. 

We are also in close collaboration with HHS to address the needs 

of the OEF/OIF veterans by coordinating seamless referrals from 

community health centers to VA medical centers and sharing VA’s 

wealth of educational material. 

One of the most significant health care challenges in rural and 

highly rural areas is the shortage of health care providers, particularly specialty care providers. VA is working diligently to develop 

and implement creative solutions that will provide incentives and 

opportunities to bring qualified health care providers to these 

areas. 

For example, we are currently 1 year into a 3-year pilot for VA’s 

Travel Nurse Corps, which is designed to improve recruitment, decrease turnover, and maintain high standards of patient care. Additionally, VHA Office of Health Care Retention and Recruitment is 

establishing a national contract for retained search firms and is 

hiring recruiters who will focus on rural areas. VA also continues 

to grow education debt reduction and recruitment, retention, and 

relocation programs. 

The Office of Rural Health embraces technology as an essential 

component for expanding care and increasing access for rural veterans, and we are identifying new ways to collaborate with the 

community. In coordination with VA’s Office of Information and 

Technology and VHA’s Office of Health Information, we are exploring opportunities to exchange information with non-VA providers 

through the use of the Nationwide Health Information Network. 

Another innovative approach that has been piloted uses text 

messaging to help veterans send their home-based blood pressure 

readings to their clinicians. Researchers found that veterans who 

use this method achieve their blood pressure goals 2 weeks sooner 

than those using other methods. 

My HealtheVet is another example of technology at work. It offers veterans access to the personal health record anytime, anywhere. Veterans access My HealtheVet through an Internet-based, 

secure, and convenient portal that allows veterans to renew and refill prescriptions online, review medical information, self-report 

their clinical data, schedule and view appointments, and view 

wellness reminders. ORH will ensure that My HealtheVet meets 

the needs of rural veterans and directly supports their care. 

10 

My colleague Dr. Darkins will discuss the important role that 

telehealth plays in harnessing technology for improved access for 

rural veterans as well. 

Mr. Chairman and Committee Members, the VA’s Office of Rural 

Health is working with every available partner to coordinate and 

support programs aimed at increasing access for veterans in rural 

and highly rural communities. Let me conclude by assuring you 

that we share your passion for this effort, and we are prepared to 

address any questions that you may have. 

[The prepared statement of Ms. Hawthorne follows:] 

PREPARED STATEMENT OF KARA HAWTHORNE, DIRECTOR, OFFICE OF RURAL HEALTH, 

VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS

Good morning, Mr. Chairman. Thank you for the opportunity to discuss the Department of Veterans Affairs’ (VA’s) work to enhance the delivery of health care to 

Veterans in rural and highly rural areas. This is an issue of significant importance 

to the Department and we look forward to working together with the Committee in 

the coming session to ensure Veterans in geographically remote areas receive the 

care they have earned through service to our country. 

On behalf of the Secretary and the Under Secretary for Health, I’d like to welcome the newest Members of the Committee: Senator Mark Begich, from Alaska; 

Senator Roland Burris, from Illinois; and Senator Mike Johanns, from Nebraska. 

Each of you represents a state that is home to rural Veterans and I know this hearing will cover a topic of great import to you. We are very interested in hearing your 

ideas and concerns on this issue today and on others on future occasions. 

As the Secretary has said, rural health is a difficult national health care issue. 

Veterans and others who reside in rural areas face a number of challenges associated with health care. The published literature suggests that greater travel distances and financial barriers to access can negatively impact care coordination for 

many rural Veterans. VA has pursued a national strategy of outreach to ensure Veterans, regardless of where they live, can access the expertise and experience of one 

of the best health care systems in the country. In partnership, Congress and VA can 

do even more. We deeply appreciate Congress’ support and interest in this area, and 

we are happy to report portions of the $250 million included in this year’s appropriation have already been distributed to the field to support new and existing 

projects. 

VA’s rural health strategy reflects the insight and counsel of experts both inside 

government and out. Our approach is four-fold: 

• First, we have created an Office of Rural Health that coordinates efforts in programs across the Veterans Health Administration to reduce redundancy and disseminate best practices; 

• Second, we are leveraging existing resources in communities across the land to 

raise VA’s presence through Outreach Clinics, fee-basis and contracting, and mobile 

vans; 

• Third, we are actively addressing the shortage of health care providers through 

recruitment and retention efforts; and 

• Finally, we are harnessing technology to remove barriers to care and bring the 

best experts in the world to every corner of the country, and to empower Veterans 

as active participants in their health care through telehealth, which my colleague, 

Dr. Darkins, will address in his statement. 

Before I begin discussing these issues in greater detail, I would like to share with 

you how VA defines urban, rural, and highly rural as categories. Our definitions are 

based on the U.S. Census Bureau’s definition, which designates areas down to the 

census block level. The Census Bureau defines urban as all territory, population, 

and housing units within an urbanized area or an urban cluster. An urbanized cluster consists of a core census block group or blocks that have a population density 

of at least 1,000 people per square mile and surrounding census blocks that have 

an overall density of at least 500 people per square mile. Urban clusters are found 

in small towns surrounded by a lower density population. Urbanized areas consist 

of contiguous densely settled block groups that along with adjacent densely settled 

census blocks together encompass a population of at least 50,000 people. VA defines 

urban enrollees as any enrollees who are located within a Census-defined urbanized 

area. Rural enrollees are any enrollees not designated as urban (including those 

who live within urban clusters), while highly rural enrollees reside in counties with 

11 

fewer than seven civilians per square mile. Based on VA’s definitions, approximately 

60 percent of enrolled Veterans reside in urban areas, while approximately 37 percent reside in rural areas. Fewer than two percent reside in highly rural areas. 

OFFICE OF RURAL HEALTH

VA’s Office of Rural Health (ORH) was authorized by § 212 of Public Law 109– 

461 and empowered to coordinate policy efforts across VHA to promote improved 

health care for rural Veterans. One of the mandated functions of ORH includes the 

designation in each Veterans Integrated Service Network (VISN) of Rural Consultants who are responsible for consulting on and coordinating the discharge of ORH 

programs and activities in their respective VISN for veterans who reside in rural 

areas. These consultants are enhancing service delivery to Veterans residing in 

rural areas and will lead activities in building an ORH Community of Practice, 

which will facilitate information exchanges and learning within and across VISNs, 

while providing a crucial link between ORH and VISNs. The authorizing legislation 

required each VISN identify a Consultant; VA is currently conducting a pilot program in eight VISNs with full-time consultants to determine if this staffing level 

is more appropriate than a part-time position. The VISN Rural Consultant Pilot 

Project facilitates information exchanges and learning across VISNs and to VA Central Office. The Pilot collaborates with local communities through outreach, education and other activities to ensure Veterans’ access to quality care reflect local 

needs and conditions; each rural area is different and there is no ‘‘one size fits all’’ 

strategy we can adopt. Consequently, our Pilot is focused on engaging the VISNs 

in rural planning efforts to properly allocate resources and to support complementary efforts. 

In addition, VA has created a 13-member VA Rural Health Advisory Committee 

to advise the Secretary on issues affecting rural Veterans. This panel includes 

strong advocates for the needs of Veterans in rural areas. It includes physicians 

from rural areas, Veterans, and experts from government, academia and the nonprofit sectors. Earlier this month, Secretary Shinseki appointed Dr. Susan Karol, 

from the Indian Health Service, as an ex officio member on the Advisory Committee. 

We welcome Dr. Karol’s appointment and the expertise she will bring. The Advisory 

Committee will meet in Phoenix on March 3 and 4. A primary focus is to support 

collaborations with non-VA organizations, and in this regard, VA is making remarkable progress. VA has conducted outreach and developed relationships with the Department of Health and Human Services (including the Office of Rural Health Policy 

and the Indian Health Service), other agencies and academic institutions committed 

to serving rural areas. VA has also reached out through ORH to other government 

and non-governmental organizations, including the National Rural Health Association, the National Organization of State Offices of Rural Health, the National Institute of Mental Health Office of Rural Mental Health, the National Cooperative 

Health Networks, the Rural Health Information Technology Coalition, the Rural Assistance Center, the Rural Health Resource Center, the Georgia Health Policy Center, various rural health research centers, and other organizations to further assess 

and develop potential strategic partnerships. ORH is working in close collaboration 

with the Department of Health and Human Services to address the needs of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans to coordinate 

services with the Department of Health and Human Services’ Health Resources and 

Services Administration Community Health Centers. These initiatives include a 

training partnership, technical assistance to Community Health Centers and a 

seamless referral process from Community Health Centers to VA medical centers. 

VA opened three Rural Health Resource Centers at the start of this Fiscal Year. 

These centers develop special practices and products for use by facilities and networks across the country. The eastern Center is located at the White River Junction 

VA Medical Center in Vermont; the Central Center is at the Iowa City VA Medical 

Center in Iowa; and the Western Center is at the Salt Lake City VA Medical Center 

in Utah. Each Resource Center is appropriately staffed with administrative and 

clinical personnel who are identifying disparities in health care for rural Veterans. 

They are also developing processes and measures of health care outcomes to evaluate and pursue the most effective programs and direct resources accordingly. These 

Centers essentially serve as field-based clinical laboratories capable of experimenting with new outreach and care models. They also serve a crucial function in 

enhancing academic affiliations with nursing and medical schools and help promote 

direct outreach to Veterans. 

In January, VA provided almost $22 million to VISNs across the country to improve services for rural Veterans. This funding is part of a two-year program and 

will focus on projects including new technology, recruitment and retention, and close 

12 

cooperation with other organizations at the Federal, state and local levels. Funds 

will be used to sustain current programs, establish pilot programs and establish 

new outpatient clinics. VA distributed resources according to the proportion of Veterans living in rural areas within each VISN; VISNs with less than three percent 

of their patients in rural areas received $250,000, those with between three and six 

percent received $1 million, and those with six percent or more received $1.5 million. ORH has allocated another $24 million to sustain Fiscal Year 2008 programs 

and projects, including the Rural Health Resource Centers, Mobile Clinics, Outreach 

Clinics, VISN Rural Consultants, mental health and long-term care projects, and 

rural home based primary care. ORH convened a workgroup of VISN and Program 

Office representatives to plan for the allocation of the remaining funds. Earlier this 

month, ORH distributed program guidance to VISNs and Program Offices concerning allocation of the remaining funds as early as May to enhance rural health 

care programs. 

VA’s ORH, in its short time in existence, has produced a number of programs that 

are actively improving the delivery and coordination of health care services to rural 

Veterans. Some examples include: 

• Expanding VA’s existing Home Based Primary Care and Medical Foster Home 

programs (part of VA’s Community Residential Care Program) into rural VA facilities with startup funding for Fiscal Year 2008 and partial funding for Fiscal Year 

2009; • Developing the ‘‘Geri’’ scholars program, in collaboration with VHA’s Office of 

Geriatrics and Extended Care, to target VA geriatric providers in rural areas and 

provide them with an intensive course in geriatric medicine and a tailored training 

program on providing geriatric medicine in rural VA clinics with curricula and supportive activities based on a needs assessment of each participant; • Developing the ‘‘Idea Award’’ to reach beyond the Veterans Rural Health Resource Centers so additional staff and program offices can participate in pilot 

projects, studies and analyses, as appropriate; and • Building relationships with complementary Federal or non-Federal programs 

and organizations, as described above. 

One area of particular importance to ORH is American Indian/Alaska Native, Native Hawaiian and Pacific Island Insular Area Veterans. The VISN Tribal Veterans 

Representative Program is an inter-agency initiative between the Indian Health 

Services, Tribal Health Services, Community Health Centers, and Veterans Service 

Organizations. The Program was developed to provide outreach and open communication to Veterans in extremely rural and underserved areas, especially the American Indian/Alaska Native, Hawaiian Native, and Pacific Island Insular Area populations. The Program trains individuals on outreach techniques to assist, facilitate 

and encourage Veterans to access the full range of VA benefits they earned through 

service. There are approximately 185 Tribal Veterans Representatives throughout 

the Nation working with Veterans and their families. 

While Dr. Darkins will address telehealth and its unique benefits for rural Veterans, other technologies are also paving the way for easier access and better quality care. Rural communities have limited capital for health information technology 

investment, and the likelihood for rapid changes in technology and the absence of 

national technical standards pose additional challenges. Health information exchanges or regional health information organizations have been created in many localities to test the electronic exchange of protected health information, and VA is 

establishing connections with these successful networks. 

Possibly VA’s most promising expansion is My HealtheVet, which offers Veterans 

access to their personal health record any time, anywhere. This program was first 

launched in 2003. Veterans access My HealtheVet through an internet-based, secure 

and convenient portal that allows Veterans to improve their individual health 

through direct access. Access to this information helps the Veteran and the Veteran’s providers, whether in VA or elsewhere. 

Veterans can renew and refill prescriptions online, review medical information, 

self-report clinical data, schedule and view appointments and view wellness reminders. My HealtheVet reduces duplicate testing and increases our ability to prevent 

conditions from becoming worse by managing chronic diseases and adhering to evidence-based practices for quality care. ORH is working to ensure My HealtheVet 

meets the needs of rural Veterans and aids in their coordinated care. 

COMMUNITY RESOURCES

VA recognizes that local problems require local solutions, and by identifying the 

resources already available, we can work together with each community to tailor solutions to their needs. We also understand Veterans can only use our services when 

13 

they know about them. To that end, VA began a Veteran Call Center Initiative in 

May 2008 to reach out to OEF/OIF Veterans from all parts of the country who separated between FY 2002 and July 2008. The Call Center representatives inform Veterans of their benefits, including enhanced health care enrollment opportunities and 

to see if VA can assist in any way. This effort initially focused on approximately 

15,500 Veterans VA believed had injuries or illnesses that might need care management. The Call Center also contacted any combat Veteran who had never used a 

VA medical facility before. Almost 38 percent of those we spoke with requested information or assistance as a result of our outreach. The Call Center Initiative continues today, focusing on those Veterans who have separated since September 2008. 

ORH will be reviewing the work of this and other Call Centers to determine what 

VA can do to reach out more effectively to rural Veterans. 

Community based outpatient clinics (CBOCs) have been the anchor for VA’s efforts to expand access to Veterans over the last ten years. CBOCs have proven to 

be instrumental in greatly improving access to high quality care in a cost-effective 

manner. Our most recent strategic planning guidance focused specifically on underserved areas, which are defined as those where less than 70 percent of enrollees are 

within the access drive time guidelines for primary care; these guidelines are within 

30 minutes for urban and rural Veterans and within 60 minutes for highly rural 

areas. 

Beyond our CBOCs, VA utilizes rural outreach clinics that offer services on a 

part-time basis, usually a few days a week, in rural and highly rural areas where 

there is insufficient demand or it is otherwise unfeasible to establish a full-time 

CBOC. The clinics offer primary care, mental health services and specialty referrals. 

Each rural outreach clinic is part of a VA network and maintains VA’s quality 

standards. Veterans can use rural outreach clinics as an access point for referrals 

to larger VA facilities for specialized needs. Last September, VA announced the 

opening of 10 new Rural Outreach Clinics this Fiscal Year. 

Vet Centers also provide services and points of access to Veterans in rural communities. Vet Centers welcome home Veterans with honor by providing quality readjustment counseling in a supportive, non-clinical environment. By the end of FY 

2009, VA will have 271 Vet Centers and 1,526 employees to address the needs of 

Veterans; any county in the country with more than 50,000 Veterans will have services available through a Vet Center. A fleet of 50 Mobile Vet Centers are being put 

into service this year and will provide access to returning Veterans and outreach 

to demobilization military bases, National Guard and Reserve locations nationally. 

VA recently announced a Mobile Health Care Pilot Project in VISNs 1, 4, 19, and 

20. These vans will be concentrated in 24 predominately rural counties, where patients would otherwise travel long distances for care. VA is focusing on counties in 

Colorado, Maine, Nebraska, Washington, West Virginia and Wyoming. This Pilot 

will collaborate with local communities in areas the vans visit to promote continuity 

of care for Veterans. It will also allow us to expand our telemedicine satellite technology resources and is part of a larger mobile asset work group. ORH is developing 

evaluation methodologies and measures to determine the effectiveness of this program and to identify areas for improvement. 

Section 107 of Public Law 110–387 directs VA to conduct a pilot program in at 

least three VISNs to evaluate the feasibility and advisability of providing OEF/OIF 

Veterans with peer outreach and support services, readjustment counseling services, 

and other mental health services through arrangements with, among others, community mental health centers. VA’s Office of Mental Health Services and the ORH 

are in the process of implementing this pilot program. The pilot will be conducted 

in a number of stages evaluating, in turn, the identification of rural areas that are 

beyond the reach of VA’s mental health services for Veterans but have other mental 

health providers capable of providing high quality services; the willingness and capability of these entities for providing outreach and treatment services for returning 

Veterans; the feasibility of developing performance based contracts with these entities that meet the requirement of Section 107; and the use of services and the outcomes of care provided through these contracts. 

Section 403 requires VA to conduct a pilot program that would provide non-VA 

care for highly rural enrolled veterans in five VISNs. VA is working to implement 

this pilot while resolving two questions. First, VA must develop a regulation to define the ‘‘hardship provision’’ in Section 403(b)(2)(B). Second, we must reconcile how 

VA has traditionally defined ‘‘highly rural’’ (based on Census data as discussed 

above) and how the statute defines it. VA’s next steps involve identifying qualifying 

communities, identifying local providers willing and able to participate, and beginning with acquisition and exchanges of medical information as well as addressing 

pharmacy benefits and performance criteria for contracts and care. 

14 

HEALTH CARE PROVIDERS

Everyday, almost 60 million Americans in rural and highly rural areas face numerous challenges regarding health care, but one of the most significant in this area 

is a shortage of providers—particularly specialty providers. Recruitment and retention of health care professionals in rural areas is a national problem, not a VA-specific problem. However, VA is working diligently to develop and implement creative 

solutions that will provide incentives and opportunities to bring qualified health 

care providers to these areas. 

For example, we are currently one year into a three-year pilot program for VA’s 

Travel Nurse Corps. This program was created in response to a nationwide shortage 

of nurses and places nurses in medical centers and clinics across the country on a 

temporary basis. These nurses reduce wait times and the reliance upon contractors 

while bringing with them high-skill services and valuable knowledge of procedures. 

The program is designed to improve recruitment, decrease turnover and maintain 

high standards of patient care. Nurses are compensated for their time on duty and 

their travel, while also receiving per diem allowances, making it competitive with 

the private sector. The Travel Nurse Corps has the added benefit of establishing a 

potential pool of skilled and experienced nurses capable of responding in the event 

of a national emergency. 

One key incentive VA offers is the Education Debt Reduction Program, which provides for reimbursement of payments made to recently appointed Title 38 and Hybrid Title 38 employees on qualifying educational loans. The maximum award 

amount is $52,298 (as adjusted) over a total of five years of participation, but it carries an added value because of the tax exempt status of the award. As of January 

2009, there were over 7,500 health care professionals participating in EDRP. The 

average amount authorized per student, for all years, is $19,596. While employees 

from 34 occupations participate in the program, 75 percent are from three mission 

critical occupations—registered nurse, pharmacist, and physician. Resignation rates 

of EDRP recipients are significantly less than non-recipients. The EDRP incentive 

may be used in addition to other Federal incentives such as the recruitment incentive (hiring bonus), relocation incentive, or retention incentive—as hiring priorities 

dictate. While not exclusively used to recruit in rural areas, VA authorized over $66 

million for non-EDRP hiring incentives for employees in Title 38 occupations. The 

recipients included physicians, nurses, and others. In each category, 93 to 95 percent of the funding was authorized for nurses and physicians as follows: 

Recruitment (29%) Relocation (5%) Retention (66%) 

Physicians – 27% Physicians – 72% Physicians – 27% 

Registered Nurses – 66% Registered Nurses – 23% Registered Nurses – 66% 

From a recruiting perspective, VA is expanding the use of internet-based venues 

for health care related job postings in addition to recruiting from the VA job board, 

USAJobs.gov, and other niche job boards. The VHA Healthcare Retention & Recruitment office is hiring recruiters who will focus on recruitment of health care providers for rural areas and as well as establishing a national contract for retained 

search firms targeting physician recruitment. They are also developing collaborative 

relationships with organizations focused on rural recruitment such as the National 

Rural Recruitment & Retention Network (www.3Rnet.org), increasing training 

courses specifically for practices related to rural recruitment issues, and hiring recruiters whose primary focus will be recruitment of physicians. 

More than 100,000 health professions trainees come to VA facilities each year for 

clinical learning experiences. Many of these trainees are near the end of their education or training programs and become a substantial recruitment pool for VA employment as health professionals. The annual VHA Learners’ Perceptions Survey 

shows that, overall, following completion of VA learning experiences, trainees were 

twice as likely to consider VA employment as before the experience. This demonstrates that many trainees were not aware of VA employment opportunities or the 

quality of VA’s healthcare environment prior to VA training but became considerably more interested after VA clinical experiences. 

In an effort to initiate proactive strategies to aid in the shortage of clinical faculty, VA launched the VA Nursing Academy to address the nationwide shortage of 

nurses. The purpose of the Academy is to expand the number of nursing faculty in 

the schools, increase student nursing enrollment by 1,000 students, increase the 

number of students who come to VA for their clinical learning experience, and promote innovations in nursing education and clinical practice. Four partnerships were 

15 

established for the 2007–2008 school year. Six additional partnerships were selected 

in 2008. 

Both a recruitment and retention tool, the Employee Incentive Scholarship Pro- gram (EISP) pays up to $35,900 for academic health care related degree programs. 

The average scholarship awarded is $12,392 for the duration of the academic program. Since the program began in 1999, approximately 7200 VA employees have received scholarship awards for academic education programs related to Title 38 and 

Hybrid Title 38 occupations. Over 4000 employees have graduated from their academic programs thus far; many are still in progress. Scholarship recipients include 

registered nurses (93 percent), pharmacists, and many other allied health professionals. Focus group market research shows that staff education programs offered 

by VHA are considered a major factor in individuals selecting VA as their choice 

of employer. A five year analysis of program outcomes demonstrated positive employee retention. Less than one percent of nurses leave VHA during their service 

obligation period (from one to three years after completion of degree). As of October 

28, 2008, scholarship funding for this program since 1999 through FY 2012 is $88.3 

million. This figure includes future funds for those who have received scholarships 

for academic years extending through 2012. 

The implementation of the physician pay statute (Public Law 108–445) has been 

very successful for VHA. The pay of VHA physicians and dentists consists of three 

elements: base pay, market pay, and performance pay. Between the implementation 

of the pay bill and the beginning of February 2009, we have increased the number 

of VA physicians by over 2,748.3 full time employee equivalents. This statutory authority has helped VHA’s ability to recruit physicians and dentists. Additionally, 

section 5 of Public Law 108–445 authorizes the Chief Nurse of VHA to set Nurse 

Executive Pay to ensure we continue to successfully recruit and retain nursing 

leaders. 

CONCLUSION

Mr. Chairman, VA’s Office of Rural Health is reaching across the Department to 

coordinate and support programs aimed at increasing access for Veterans in rural 

and highly rural communities. We work closely with the Office of Care Coordination 

and our colleague, Dr. Darkins, in this regard and it is our pleasure to sit with him 

before you today. Thank you once again for the opportunity to discuss VA’s continuing efforts for rural Veterans. We are prepared to address any additional questions you might have. 

Chairman AKAKA. Thank you. Thank you very much, Ms. Hawthorne. 

Now we will hear from Dr. Darkins. 

STATEMENT OF ADAM DARKINS, M.D., CHIEF CONSULTANT 

FOR CARE COORDINATION, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS 

Dr. DARKINS. Aloha, Mr. Chairman. Thank you very much for the 

opportunity to be here and to the Committee for highlighting the 

issues related to delivering care to veterans in rural areas. It is a 

privilege to work for the VA, to be involved in addressing those 

problems, and using telehealth to do so. 

I would like to request that my written statement be submitted 

for the record. 

Chairman AKAKA. It will be included in the record. 

Dr. DARKINS. Thank you. 

Telehealth uses information and telecommunications technologies 

to support clinical care where a patient and practitioner are separated by geographical distance. It increases access to specialist 

services and reduces both patient and provider’s travel, thereby reducing one of the major barriers to care in rural areas, where recruiting of health care professionals can be problematic. 

However, I should just say at the beginning that telehealth is not 

a panacea in the sense that there are obligate needs for face-to-face 

delivery of services, and telehealth has to fit into a spectrum of apVerDate Nov 24 2008 15:27 Dec 01, 2009 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6601 H:\ACTIVE\022609.TXT SVETS PsN: PAULIN
16 

propriate care requirements in any particular locality. But it can 

fit into that when the requirements are met for safe, effective, and 

efficient care when we address the clinical technology and also the 

business processes associated with telehealth. 

The cost and complexity of managing chronic disease in rural 

areas challenges all health care organizations—hence, telehealth’s 

focus on these conditions in VA. VA’s vision for telehealth is providing veteran patients with the right care in the right place and 

at the right time. The VA goal is to make the home the preferred 

place of care wherever this is possible to do so. And in order to 

achieve this, VA has established three enterprise-wide telehealth 

programs that serve veterans in urban, rural, and in highly rural 

locations, as well as the special circumstances of addressing the 

challenges for American Indian/Alaskan Native, Hawaiian Native, 

and Pacific Islander communities. VA has seven telehealth programs supporting these various communities, and further deployments are in progress to serve 15 more tribes. 

The first enterprise program that I would like to cover is Care 

Coordination/Home Telehealth, or CCHT. This uses a national VA 

telehealth technology platform that collects vital sign data, disease 

management responses, and conducts video consultations into the 

home. This platform supports standardized clinical processes that 

care currently for 36,400 veteran patients, 20,000 of whom are receiving non-institutional care. Thirty-eight percent of these patients are in rural areas and 2 percent are in highly rural areas— 

proportions that show no urban bias in the deployment of this technology. CCHT data shows a 25-percent reduction in hospital stays 

and a 19-percent reduction in hospital admissions with CCHT, 50- 

percent reduction in highly rural areas, and a 17 percent in rural 

areas associated with the use of this telehealth technology. These 

services are provided from 140 VA medical facilities and 28 rural 

or highly rural clinics. 

The second program I want to mention is Care Coordination/General Telehealth. It is another enterprise program that uses clinical 

videoconferencing systems to deliver services between VA medical 

centers and community-based outpatient clinics. In fiscal year 

2008, over 48,000 veterans received these services, covering 35 clinical specialties, mainly mental health, of which 29,000 received this 

care. These services are provided to 171 sites in rural or highly 

rural areas. 

Patients receive their tele-mental health care as part of VA’s 

mental health universal service care plan, which is certainly addressing a focus on primary care—to deliver these services and the 

importance of increasing this. And they have shown a 24.6-percent 

reduction in hospital admissions and a 24.4-percent reduction in 

bed days of care, which is really associated with people receiving 

care more rapidly and thereby reducing the need for travel to care. 

VA established a Polytrauma Telehealth Network in fiscal year 

2007 which connects VA’s polytrauma sites of care and links them 

back also to Walter Reed Army Medical Center and Bethesda 

Naval Hospital. In fiscal year 2009, we are planning to expand this 

network into a national infrastructure, which we are calling the 

Clinical Enterprise Videoconference Network. The intent of this is 

17 

ultimately to lead to any site being able to connect to any other VA 

clinical site for the delivery of care. 

We are also establishing a national tele-mental health center for 

the delivery of specialist mental health services via this network, 

and we will seek to address particularly issues in rural delivery of 

care. 

The third enterprise program I want to mention is that of Care 

Coordination/Store-and-Forwards. It involves capture and storage 

of digital images from patients’ and their transmission to health 

care providers to report. Twenty percent of the veteran patient population receiving health care has diabetes, and this program 

screens for diabetic eye disease. Last year, 98,000 veteran patients 

received this care and it helped prevent avoidable blindness by 

doing so. In addition to this, we are expanding care in the area of 

CCSF into areas of tele-dermatology. 

VA is training staff to use telehealth technologies and to ensure 

their adherence to the associated clinical and business processes. 

We have three designated telehealth training centers: one in Lake 

City, Florida; a second in Salt Lake City, Utah; and a third which 

is in Boston, Massachusetts. These centers have trained over 6,000 

staff to provide VA with a tele-mental health competent workforce. 

The associated training curricula are standardized and utilize virtual training modalities wherever possible. 

VA has an internal system in place to assess the quality and consistency of its telehealth programs that is conducted biannually in 

each one of the VISNs. A fundamental underpinning for all areas 

of telehealth we are implementing is the use of our VA electronic 

health record. 

In closing, I would like to recognize the VA staff that develops 

these groundbreaking services. Our staff is driven by a commitment to support independence of the veterans we serve in all locations by providing access to high-quality care. The successful marriage of people and technology that I have just described is enabling VA to sustain a rapid pace of telehealth expansion and makes 

us a recognized leader in the field. 

Mr. Chairman, that concludes my prepared statement. I would 

like to take the opportunity to demonstrate this technology to you 

at an appropriate future time, and I am now pleased to answer any 

questions that you may have. 

[The prepared statement of Dr. Darkins follows:] 

PREPARED STATEMENT OF ADAM DARKINS, MD, CHIEF CONSULTANT, CARE COORDINATION OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH ADMINISTRATION, 

DEPARTMENT OF VETERANS AFFAIRS

Good morning, Mr. Chairman. I appreciate the interest of the Committee in the 

Department of Veterans Affairs’ (VA’s) telehealth programs and welcome the opportunity to brief you on their current status. Telehealth involves the use of information and telecommunications technologies to deliver services in situations in which 

patient and health care provider are separated by geographical distance. The benefits to Veteran patients that accrue from VA’s implementation of telehealth include 

increasing access to specialist care and reducing travel times for patients and health 

care providers. These benefits make telehealth of particular relevance to service delivery in rural areas where recruitment of health care providers can be problematic 

for all health care organizations, not just VA. Telehealth also reduces the need for 

travel which can be costly, inconvenient and may act as a barrier to care. 

In this context, it is important to note that telehealth is not a panacea that addresses all the challenges of health care delivery in rural areas. There is a real need 

18 

for face-to-face services in many instances. Therefore, given the necessary clinical, 

technological and business processes that underpin safe, effective and efficient care, 

telehealth services fit into a continuum of appropriate services for meeting the 

health care needs of the enrolled Veteran population. 

VA is predominantly targeting chronic disease in the Veteran population through 

our telehealth programs. Care of patients with chronic disease is a major challenge 

that all health care organizations face and which telehealth can help address. VA’s 

vision for telehealth is to provide the right care in the right place at the right time 

with a goal of making the home and local community the preferred place of care 

when it is possible and when it is the Veteran’s preference. In pursuit of this goal, 

VA has implemented three large, standardized telehealth programs that are available for urban, rural and highly rural Veterans. VA’s telehealth programs also extend to American Indian/Alaskan Native, Native Hawaiian, and Pacific Island Insular Area communities. VA currently operates seven such programs that include Hawaii and the Pacific Island Insular Area and Alaska. Four more await connectivity 

and 11 others are in various stages of deployment for 15 Tribes in the continental 

United States. 

The first major program is Care Coordination/Home Telehealth (CCHT). This program uses telehealth devices to connect enrolled Veterans with a VA practitioner, 

usually a nurse or social worker, who can routinely monitor vital sign data, disease 

management responses and engage in video consultations. VA has implemented a 

national technology platform to support standardized clinical and business processes. Through the adoption of this systematic approach to CCHT, VA has built a 

program that provides care to 36,400 patients, 20,000 of whom are receiving noninstitutional care. Thirty eight percent of CCHT patients in VA are in rural areas 

and two percent are in highly rural areas. These proportions of rural and non-rural 

patients mirror the proportions in the Veteran population as a whole. This is important because CCHT is equally useful and available in rural and urban settings. Routine clinical outcomes data from VA’s CCHT program published in December 2008 

showed an 25 percent reduction in the average number of days patients enrolled in 

CCHT are hospitalized and a 19 percent reduction in hospital admissions. The data 

also reveal a 17 percent reduction in hospital admissions for rural Veterans using 

CCHT and a 50 percent reduction for highly rural Veterans. Currently over 140 VA 

medical centers provide CCHT in addition to 28 CCHT clinics located in rural and 

highly rural areas. 

The second major area of telehealth in VA is Care Coordination/General Telehealth (CCGT), which uses real-time clinical videoconferencing systems to deliver 

services between VA medical centers (VAMCs) and community-based outpatient 

clinics (CBOCs) over VA’s telecommunications networks. In Fiscal Year (FY) 2008, 

more than 48,000 Veterans received care nationally through this program. Over 35 

clinical specialties in VA participate in the delivery of services via CCGT. CCGT 

mainly addresses care related to mental health and rehabilitation. In FY 2008, VA 

provided mental health care to 29,000 Veterans through tele-mental health. Patients received care at 171 sites in rural or highly rural areas. Tele-mental health 

is part of the overall framework of the mental health universal service plan. Routine 

outcomes data for tele-mental health in VHA have shown a 24.6 percent reduction 

in hospital admissions and 24.4 percent reduction in bed days of care. 

In FY 2007 VA implemented a Polytrauma Telehealth Network to link VA’s sites 

of care for polytrauma patients and offers CCGT tele-rehabilitation services and provide access to Walter Reed Army Medical Center and Bethesda Naval Hospital. In 

FY 2009, VA is seeking to extend this concept of networked services further by developing a national CCGT technology infrastructure called the Clinical Enterprise 

Video-conferencing Network. This Fiscal Year VA plans to establish a national telemental health center to coordinate delivery of specialist mental health services via 

tele-mental health for conditions such as bipolar disorder and Post Traumatic Stress 

Disorder. Part of this initiative will focus on delivery of these services in rural 

areas. 

The final major area of telehealth is Care Coordination/Store-and-Forwards 

(CCSF), which involves the capture and storage of digital images that are transmitted to a remote location where a health care provider can report the image and 

return it to the patient site for use in the diagnosis and management of various conditions. VA’s most significant advances in this area involve screening Veterans for 

diabetic eye disease. Twenty percent of the Veteran patient population has diabetes. 

Screening for diabetic eye disease is important because if it is recognized and treated before complications arise, we can prevent avoidable blindness. In other specialty 

areas, VA made tele-retinal imaging services available to 98,000 Veterans last year 

and 54 of the 219 sites at which this care took place were in rural or highly rural 

clinics. The remainder of the CCSF was for was tele-dermatology. Currently VA is 

19 

working toward a standardized approach to tele-dermatology with the intent of future enterprise-wide adoption. 

Training is an essential component of any successful new technology or service. 

VA staff is trained to use CCHT technology and adhere to clinical and business 

processes through courses developed and instituted by a VA home telehealth training center in Lake City, Florida. This training draws, wherever possible, on technologies that enable virtual participation. VA has a training center for CCGT in Salt 

Lake City, Utah and a CCSF training center in Boston, Massachusetts. Training 

center curricula are standardized and we emphasize virtual training whenever practical and possible. The three VA telehealth training centers have enabled over 6,000 

staff to be trained and have helped sustain a rapid pace of telehealth expansion that 

makes VA a recognized national leader in the field of telehealth. VA has also implemented an internal system to assess the quality and consistency of its telehealth 

programs at a VISN level that is conducted in each VISN biannually. 

In conclusion I would like to recognize the dedication of staff throughout VA in 

developing these ground-breaking services. Their energy and enthusiasm supports 

the independence of the Veterans we serve by providing access to high quality care 

via telehealth. Fundamental to our success is VA’s electronic health record system. 

Without an electronic health record, telehealth systems are of limited benefit because without clinical information, laboratory results and clinical images, it is impossible to change the location of care and proactively address many health issues. 

Mr. Chairman, this concludes my prepared statement. I would like to take this 

opportunity to offer my services to you to demonstrate this technology at a future 

time. I would be pleased to answer any questions you may have. 

Senator MURRAY [presiding]. Thank you very much to both of you 

for your testimony. We do have Members coming back and forth. 

I will ask a couple questions and turn it over to Senator Burr. 

I think you talked a lot about the importance of telehealth, but 

I was very disappointed to learn from the staff of this Committee 

that telehealth use is actually decreasing in some rural communities, and a lot of that is attributed to lack of space or trained personnel. Can you comment, Dr. Darkins, on how the VA is overseeing these programs so that they are utilized? 

Dr. DARKINS. Certainly, bringing these programs together depends on having the clinical staff. It also requires the facilities and 

the telecommunications bandwidth to do it. We are expanding 

these enterprise programs and as we do so, we have to make sure 

that these requirements are taken into consideration. 

The enterprise programs that we are rolling out are taking over, 

in many cases, previous pilot programs that did not have this kind 

of infrastructure to back them. 

Senator MURRAY. Do you have the resources to do this? 

Dr. DARKINS. I believe there are. These decisions about using 

telehealth service provision are made at a local level, and what we 

are seeing is transition of services which were previously delivered 

face-to-face toward ones that are now are using telehealth to deliver services. These decisions are made very much at a local level 

in bringing those requirements together. 

Senator MURRAY. I am told that a lot of the health care providers 

who use telemedicine to deliver telehealth have to be credentialed 

and privileged at each and every facility that gets the care as well 

as at the site that the provider provides the service. Can you help 

me understand whether this credentialing or servicing presents a 

challenge to our ability to—— 

Dr. DARKINS. It certainly does so. It does for us in VA as it does 

for all health care organizations providing telehealth services. 

State licensure for a VA practitioner in any State allows them to 

cross State lines, which is a benefit we have above those in private 

20 

sector organizations. However, one of the requirements that we as 

all providers face is that staff need to be credentialed at sites delivering care, and in many cases have to be privileged. 

Senator MURRAY. So this is a real challenge. 

Dr. DARKINS. It is a challenge because there is an administrative 

burden, particularly in some of those rural sites, where there may 

be quite a turnover of staff. And we are seeking ways that we can 

address this actively because of the burden to delivering services. 

Senator MURRAY. All right. And then very quickly—and I have 

to leave to vote—Ms. Hawthorne, the VA IG’s May 2007 assessment of VHA’s Suicide Prevention Initiative said that some of the 

data suggested that we are seeing higher suicide rates in rural 

areas. Are we seeing that among the veterans population as well? 

Ms. HAWTHORNE. I am not the expert in this subject matter area, 

so I would like to take that question for the record so I could provide you a more accurate reply. 

Senator MURRAY. If you could, because I am concerned about 

whether or not that is accurate; and if it is, what we are doing to 

provide outreach and better access for our servicemembers in more 

rural areas. 

[The information requested follows:] 

RESPONSE TO QUESTIONS ARISING DURING THE HEARING BY HON. PATTY MURRAY TO

KARA HAWTHORNE, DIRECTOR, OFFICE OF RURAL HEALTH, VETERANS HEALTH

ADMINISTRATION

Question. What is the rate of suicides for rural Veterans compared to non-rural 

Veterans? 

Response. The rates of suicide were 39.7/100,000 person years for patients whose 

last VA use (in FY05 or FY06) was at a facility in a rural area (based on classifications from the Office of Rural Health) and 35.0/100,000 person years for patients 

in urban areas. 

Senator MURRAY. I am going to turn it over to Senator Burr for 

his questions, and thank you very much. 

Senator BURR. Thanks, Senator Murray. I am only going to ask 

one, and then I am going to turn it to Senator Tester, and I am 

going to go vote, and I will save the majority of my time for when 

I come back. I just want to try to clarify a question you were asked 

and how you answered. It dealt with the credentialing issue. 

Credentialing, as I understand it, is one’s ability to practice a particular specialty. Am I correct? 

Dr. DARKINS. Credentialing verifies that the qualifications a 

practitioner requires to practice in a clinical area are indeed the 

qualifications that they have. So it is a way to check their licensure, their professional training. 

Senator BURR. But we do not—— 

Dr. DARKINS. Telemedicine in the private sector outside VA requires a license in every State a practitioner delivers care to. 

VA does not have a licensing issue in terms of needing a license 

in every State where telehealth is delivered. However, one of the 

things I ought to point out is that it is important to ensure that 

a practitioner is indeed licensed and qualified to provide the services required. Credentialing is the process that makes sure that the 

person is appropriately qualified and licensed and ensures the patient that the person they see for care is qualified and competent 

to deliver the care. 

21 

VA has a national system called VetPro, which is very beneficial. 

So credentialing is less of a problem for us. 

Senator BURR. I will get into more of this when I get back. I am 

going to turn it over to the Chairman now. 

Chairman AKAKA [presiding]. Senator Tester? 

Senator TESTER. Yes, thank you, Mr. Chairman. I apologize for 

not being able to hear all of your testimony. I think I got most of 

yours, Ms. Hawthorne, and if questions were asked previously 

along the same lines I am asking, I apologize ahead of time. 

As I was reading over your testimony, Ms. Hawthorne, you said 

that highly rural areas are seven people per square mile or less, 

and that 2 percent of veterans live in those kind of areas. Did you 

do anything differently for folks that live in the highly rural 

areas—and that question could go to either one of you—over folks 

who live in rural areas or urban areas? 

Ms. HAWTHORNE. Veterans who live in highly rural areas obviously have some unique challenges that neither their urban nor 

rural counterparts have. So, as far as delivery of care, we are looking at specific ways that we can increase that, and we will be 

leveraging some of the same service modes, such as telehealth. And 

we are also looking at partnering with our community providers to 

see if this is an appropriate way to expand care in those highlyrural areas, as well as utilizing mobile clinics. Could this be another opportunity to get into those more remote and highly rural 

areas? And then outreach clinics are a little less feasible, but, 

again, by partnering with our community providers, we may be 

able to expand access in that way as well. 

Senator TESTER. Have you started those endeavors yet as far as 

partnering up with folks? Is that actually happening in the highly 

rural areas yet? 

Ms. HAWTHORNE. We have initiated a pilot project for mobile 

vans and have four. One is currently operational; as for the other 

three, they have purchased the equipment and hope to be within 

operation in a few months. 

As far as partnering with the communities, we are actively engaged in seeking out ways to do this. We recognize, though, that 

continuity of care is very important. So before we move forward, we 

want to address all the quality issues, ensure that we are measuring properly, so that we can make a determination that our veterans are receiving the highest quality of care. 

Senator TESTER. OK. Speaking from a mental health perspective, 

in rural or highly rural areas, for instance, in eastern Montana, 

right now I do not think we have a mental health professional east 

of Billings, Montana, and there are several hundred miles east of 

Billings, Montana, before you hit the North Dakota line. 

If you partner with primary care settings and it is a mental 

health issue, how is that handled? 

Ms. HAWTHORNE. If I could first share with you that my background is of a clinical social worker, so I am very aware of mental 

health issues. I have directly worked with the mental health population. 

Senator TESTER. That is good. 

Ms. HAWTHORNE. And, again, continuity of care is extremely important—even more so in this case. So if we work with non-VA proVerDate Nov 24 2008 15:27 Dec 01, 2009 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6601 H:\ACTIVE\022609.TXT SVETS PsN: PAULIN
22 

viders, we have to have to ensure that the VA clinicians are getting 

their medical records and that there is proper case management 

following up with their care, and that we monitor the control points 

to ensure that if care is exasperated and the veteran needs a higher level of care, that we have in place a method to ensure that that 

happens. 

Senator TESTER. I do not have an answer to this question. Most 

questions you ask you have an answer for, but I do not. If you have 

got a situation where the nearest mental health professional is several hours away—maybe as far as 8 hours away—and you have got 

a person that is ready to commit suicide; they have called the hotline, and there is no doubt about it, we have got a problem. How 

is that handled? Either one of you can speak to that. That would 

be fine with me. 

Ms. HAWTHORNE. I will have to take that question for the record 

because our Office of Mental Health Services is actually coordinating the suicide prevention hotline, and I am sure that they have 

some things in place that would address that question. 

Senator TESTER. OK. 

[The information requested follows:] 

RESPONSE TO QUESTIONS ARISING DURING THE HEARING BY HON. JON TESTER TO

KARA HAWTHORNE, DIRECTOR, OFFICE OF RURAL HEALTH, VETERANS HEALTH

ADMINISTRATION

Question. How would VA handle a suicidal Veteran in a rural area who is acute 

and needs help today? 

Response. VA’s response to Veterans with suicidal risk is to intervene as necessary to support safety, whether the veteran is in an urban, rural, or highly rural 

area. When Veterans call the VA Suicide Prevention Hotline, they are evaluated for 

risk by clinician-responders in the call center. If they are found to be at imminent 

risk, the responders call police, ambulances or other emergency personnel who can 

make contact with the caller as soon as possible, and arrange for hospitalization as 

needed. Since the time the Hotline was established, there have been over 2,600 rescues of this type. Other Veterans may speak with providers at VA facilities, rather 

than the Hotline. However, the response is the same, emphasizing rapid access to 

care for those who are at imminent risk, regardless of where they live. 

Dr. DARKINS. Again, I think obviously it depends, services being 

local, exactly what—for the particular situation. But as an extreme 

urgency for the VA—as you know, everything the VA is currently 

doing is very much aimed at mental health services toward addressing those kinds of issues. From my particular remit, I can give 

you the issues around the use of tele-mental health, which, as I 

say, is not a panacea. In some sense, in some cases, it is possible 

to use telehealth for those kind of urgent interventions. It is also 

possible to use telehealth directly in the home to be able to obviate 

people getting into that circumstance. 

Connection with local services and the ability to access local—so 

telehealth fits into those wide areas of care. And the VA’s universal 

service plan for mental health, other work in mental health is certainly aimed at addressing those issues. 

From my point of view and my particular expertise, telehealth 

can lend a hand, can be useful in some of those circumstances, and 

certainly is part of that continuum of services that needs to be provided to help that person in that kind of distress. 

Senator TESTER. All right. I know the VA has been hiring a 

bunch of folks to deal with mental health issues, to the point 

23 

where—I actually talked to some folks in the private sector, saying 

they cannot hire anybody because the VA is hiring them all. And 

I commend them on that, you know, making a solid attempt to address that. 

Are there incentives offered to get them into rural America, into 

highly rural areas? Because that also is a big issue. And the conundrum is—as you are talking about, only 2 percent of the vets are 

living in the highly rural areas, which means 98 percent live somewhere else. How big of a priority is it to get mental health professionals into those areas and are there incentives? 

Ms. HAWTHORNE. Getting providers into rural areas is one of the 

primary focuses of the Office of Rural Health and part of our core 

initiatives. So we are working very closely with the VHA program 

offices that oversee this. We do offer an education debt reduction 

and other services currently, and we are initiating some new, innovative recruiting methods as well. Specifically, 3RNet seeks rural 

providers, and we have teamed up with them. 

Also, the Office of Rural Health is working with our Office of 

Academic Affiliations, and we are looking at how we can expand 

physician residency into rural areas, knowing that when providers 

train in rural areas, they are more likely to stay in rural areas. 

Senator TESTER. What about the highly rural areas? Are we 

doing anything different from rural areas as far as getting people 

into them? 

Ms. HAWTHORNE. Not specifically at this time. 

Senator TESTER. Do you think there should be something done? 

Ms. HAWTHORNE. I cannot answer that directly right now. I 

think they are two very tough populations. It is even more difficult 

in the highly rural areas because you are less likely to have the 

academic affiliations and the resources to—— 

Senator TESTER. Thank you very much. I will check off. If there 

is another round, I have got some more questions. Thank you, Mr. 

Chairman. 

Chairman AKAKA. Thank you very much, Senator Tester. 

Senator Begich? 

Senator BEGICH. Thank you very much, Mr. Chairman; and I 

apologize, we had to slip out. But I am looking at the testimony— 

Dr. Darkins, I think this is from you—in regards to the VA telehealth programs extended, and you talk about the Indian/Alaska 

Native community, the Hawaiian community, Alaska. Can you just 

expand a little bit on that? Then I have some specific questions. 

But can you expand on how you see that working or how that has 

been working, and what kind of volume of response? I am not sure 

who could answer that, but I saw it in your testimony, so I would 

look to both of you. 

Dr. DARKINS. Yes, I can certainly address that. There are telehealth programs in both Alaska and in Hawaii and serving the islands as well. The three enterprise programs I mentioned are all 

present there. 

There is the home telehealth programs. I think on the order of 

230 patients are currently being served for home telehealth out of 

Anchorage. So, it has become established. We also have teleretinal 

imaging which is taking place in Anchorage, plus the telehealth 

real-time videoconferencing that is taking place. 

24 

There are close associations between the VA and the other Federal agencies through the Afghan Project, which is there to be able 

to provide access to multiple sites throughout Alaska. 

We have variations around the country in terms of how telehealth is being implemented. We have enterprise systems, as I 

mentioned, which are readily available to implement. We are 

gradually rolling forward now. 

One of the salutary things about technology is that it is very 

much in the end down to relationships, so what we are finding is 

extending the use of this technology is very much centered around 

relationships—relationships between individual clinicians and their 

patients, being comfortable on both sides doing it, but also the relationships between the Federal agencies and then working and 

partnering in this way of taking it forward. 

So what I would like to say is I think that the infrastructure, the 

various components are there to do this. Moving it forward is very 

much a sense of that organizational change. But as we are seeing, 

I certainly look back over these last 2–3 years, of what has been 

happening in Alaska with the home telehealth, what has been happening with the teleretinal imaging, and I am seeing pleasing increases in the results with patients and would hope to look forward 

to that being even more rapid. 

If there are any suggestions either from yourself or other Members of the Committee of things that we can do to address your 

population or for the population of the Hawaiian Islands, then that 

is certainly a huge priority for us. Given what we are addressing, 

given what we have heard of returning military, to go the extra 

mile to be able to serve those people, we will do anything that is 

necessary. 

Senator BEGICH. Great, because as we talk about rural, you 

know, and you talk about drive miles, they are not drive miles in 

Alaska. That is why in your comment that you said about mileage 

versus how many miles away by road, you know, we measure by 

air because that is how we can get to locations. And then telemedicine in Alaska—education through technology and others has been 

pioneered in a lot of ways in Alaska because of the uniqueness of 

it; in rural communities especially, where you may have a hub that 

you can fly to, but you may have a village you cannot get to because of weather conditions, as well as many other factors. I absolutely will look at some ideas we would like to pass on to you. 

I do not know which of you would answer this, but in regards 

to the extensive Native medical care system that we have in Alaska, that is continuing to be developed, and we announced Monday 

there will be a facility in Nome, Alaska, about a $150 million facility starting construction this year, again, offering enormous quality 

health care. I know you have a couple of partnerships you are in 

the midst of trying to develop, and there is some lag time on that, 

but it just seems so logical. Senator Tester and I have talked about 

this when I had him up to Alaska, that is, to allow these veterans—because we do not have a VA hospital in Alaska—why not 

just allow the veterans to utilize the services of any hub medical 

facility—in this case, Native Hospital, which is run by a consortium 

of Native tribes, but also is funded by a Federal agency anyway. 

It is all Federal money. So, why not figure out a way that that sysVerDate Nov 24 2008 15:27 Dec 01, 2009 Jkt 000000 PO 00000 Frm 00028 Fmt 6633 Sfmt 6601 H:\ACTIVE\022609.TXT SVETS PsN: PAULIN
25 

tem can be utilized much more aggressively than just a couple of 

pilot programs, to just use them and then have VA reimburse. 

I know there is an argument that, well, VA does not have a 

budget line for that, and then there is this other argument. But 

building a hospital would be a huge expense, and yet we have these 

beautiful hospitals and clinics being built all throughout Alaska. 

I do not know who can answer that, and I know there are one 

or two—I cannot remember which ones right off the bat, but—pilots that you are looking at. But it just seems for an Alaskan veteran who lives in a village like Kwethluk and has to spend $1,500 

in airline tickets to get to a location and then know they have to 

go back there is not a very good way to deliver health care. 

Dr. DARKINS. Soon after I joined the VA, I went to Alaska. I went 

to Bethel and I went up river; actually saw the—— 

Senator BEGICH. Did you go in an open boat? That is the way to 

go. 

Dr. DARKINS. I did. I went in an open boat, yes. 

Senator BEGICH. That was the test. They tested you. Very good. 

Dr. DARKINS. And the boatmen, when they came back—— 

[Laughter.] 

Senator BEGICH. That is the test. He survived. Good. 

Dr. DARKINS. When the boatmen came back, they took us for 

some salmon strips in the shed. But it was possible to see exactly 

as you describe the tremendous health needs throughout, and I was 

enormously impressed to see how locally it is possible to deliver 

through the health aides the care that is taking place. 

There are already, I know, really good relationships for certain 

services between the VA, the DOD, and the Indian Health Service 

where they do share relationships. Senator Burris mentioned in 

North Chicago the relationship that is taking place there and how 

that is growing. So I think there are models of both how it is being 

done, and I think things like North Chicago show the way forward 

for how it can be done further. 

It is somewhat outside my remit or my piece of the world to be 

able to say overall, but I think certainly there is encouragement in 

ways in which, exactly as you say, it is going forward, and it is a 

very high priority for VA. 

Senator BEGICH. Very good. Thank you. 

Ms. Hawthorne, did you have anything? 

Ms. HAWTHORNE. I would like to follow by saying we also recognize that leveraging our community partners and the infrastructure already in rural areas is a direction that we do need to consider. 

I would like to point out that our Veterans Rural Health Resource Center, based out of Salt Lake City, has developed infrastructure to specifically look at these populations; and we are looking at it from a policy perspective and also testing out ideas. So we 

have some pilots and those are going well, and we hope to take 

those pilots that are successful and distribute eventually them 

through the larger health care system. 

Senator BEGICH. Very good. I will leave it at that for now, Mr. 

Chairman. Thank you very much. 

Chairman AKAKA. Thank you very much. 

Now let me call on Senator Burris for his questions. 

26 

Senator BURRIS. Thank you, Mr. Chairman. 

Dr. Darkins, how does telehealth facilitate the care if an issue 

is discovered in the teleconsultation that requires a veteran to seek 

direct care? How does that telecare operate? 

Dr. DARKINS. It addresses a lot—there are two pieces to delivery 

of health care. There is a direct delivery of care itself, which is 

often hands-on in terms of being able to intervene, to be able to diagnose, to be face to face with a patient. The second piece is to be 

able to make sure the right patient has got to the right place at 

the right time. So there is a piece about health care decisionmaking 

and then the actions associated with it. 

What telehealth can do is to make sure that those health care 

decisions can be made as close to the patient as possible, so let me 

give you a hypothetical case. 

You have the situation where somebody has had a stroke. Having 

had a stroke, the issue is what should be done. What kind of urgent treatment might be used to be able to help that person and 

make sure that they get the maximum chance of success and survival? So the ability of telehealth is to be able to take a specialist 

who might be elsewhere and to be able to help address in primary 

care or even in a smaller community hospital, so you can get absolute special expertise right to where that decision needs to take 

place. And often having that kind of decisionmaking in the acute 

stage can make the difference between life or death to somebody. 

So telehealth is something really beneficial even in the very acute 

stage. 

We manage, as I said, 36,700 patients. I mentioned the reduction 

in travel times—sorry, the reduction in hospital admissions. What 

we are doing is instead of somebody who may have chronic heart 

failure having to come along to the hospital regularly for outpatient 

treatments—where there is the travel, there are the wait times, et 

cetera—what we are doing is monitoring them on a daily basis, so 

if they start to get into trouble, so if their weight starts to go up, 

if they start to get symptomatic, such as breathless—— 

Senator BURRIS. Or blood pressure going up, yes. 

Dr. DARKINS [continuing]. Yes. What we can do is contact them. 

Usually a nurse will contact them by telephone, can adjust their 

medications under orders they have been given, and can actually 

prevent their deterioration. 

So telehealth is very much about changing the location of 

decisionmaking, also trying to stop people from getting into trouble, 

supporting their own understanding of their own health care and 

self-management. 

Senator BURRIS. Thank you very much. 

Ms. Hawthorne, what are we doing to make community providers 

more willing to treat vets on a fee basis? I am aware that many 

vets are not being reimbursed and providers are only receiving a 

percentage of the payments. Can you help me out there? 

Ms. HAWTHORNE. I cannot speak to specifics of the fee basis program, but can take that back for an answer. 

Senator BURRIS. OK, please. 

[The information requested follows:] 

27 

RESPONSE TO QUESTIONS ARISING DURING THE HEARING BY HON. ROLAND W. 

BURRIS TO KARA HAWTHORNE, DIRECTOR, OFFICE OF RURAL HEALTH, VETERANS

HEALTH ADMINISTRATION

Question. What are the fee basis rates for reimbursement in rural areas? Are they 

sufficient? 

Response. In the absence of a formal contract or negotiated agreement, VA payment for acute inpatient care and outpatient professional, laboratory, and dialysis 

services is the same as the full Medicare reimbursement. In the absence of a Medicare rate, VA payment is based upon the usual and customary (U&C) billed charges. 

VA payment for non-acute inpatient care is based upon a cost-to-charge methodology 

determined by information provided to Medicare in the cost reports submitted by 

the hospitals. The cost-to-charge ratio is determined annually and the payment 

amount for non-acute inpatient care is determined by multiplying the billed charges 

by the ratio. Special payment rates are applied to facilities and providers in the 

state of Alaska due to scarce medical resource availability, and in the state of Maryland for institutional providers in receipt of waivers granted by Medicare. 

Both Medicare and VA payment rates are geographically adjusted. The majority 

of payments based upon U&C charges are made using the 75th percentile methodology (8 highest billed charges received for the specified medical service the previous 

year ranked in order from highest to lowest). If there is not a 75th percentile rate 

available, VA payment for the service is the U&C charge. VA will pay the lesser 

of the above rate, the billed charge, or the amount negotiated with the provider via 

repricing agreement. 

There is an exception to VA payment methodology for emergency care not previously authorized before services are rendered. Reimbursement for claims authorized under 38 U.S.C. 1725, which is the statutory authority used to pay for unauthorized emergency care provided to certain Veterans for the treatment of nonservice-connected conditions, is reimbursed at the lesser of 70% of the applicable 

Medicare Fee Schedule or the amount the veteran is financially liable. A separate 

statutory authority is used to pay for unauthorized emergency care provided to certain service-connected Veterans; payment methodology used to pay for this care is 

the same as described above. Regardless of the statutory authority used for payment 

of unauthorized emergency care the payment is limited to the point of stabilization 

where the Veteran may be transferred to a VA or other Federal facility. 

VA pays in a manner very similar to other payments community providers receive. VA is not aware of concerns raised by community providers on these payment 

rates. 

Ms. HAWTHORNE. I would like to point out that the Office of 

Rural Health is looking at, though, when we engage in contracts, 

how we can best ensure that our providers are willing to work with 

us by making contracts amenable to both parties and ensuring that 

there are quality standards within those contracts. 

Senator BURRIS. Because pretty soon even the rural doctors will 

not come to these communities because of the low ability to get any 

type of compensation. And then, if they cannot get compensated for 

their reasonable services, it is going to make it even harder for 

them to do it if they cannot even get paid on a fee basis. 

Ms. HAWTHORNE. Correct. 

Senator BURRIS. Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Burris. 

A consistent question has been: are we meeting the needs of our 

veterans? VA is spending billions of dollars buying care in the community, and Congress appropriated another quarter billion dollars 

for specific rural health care and projects as well. 

Given all of this effort and funding, my question to both of you: 

Are we meeting the needs of rural veterans? Ms. Hawthorne? 

Ms. HAWTHORNE. Thank you. As I stated, increasing access to 

good quality health care is the focus of the Office of Rural Health 

and is how we will meet the needs. So I believe we are meeting 

the needs of our rural veterans. We, of course, can always improve 

and look to the Committee and to you, Mr. Chairman, for ideas on 

28 

how to do that. But for now we are proceeding to develop new innovative ideas that are going to address the uniqueness of the rural 

and the high rural populations, and we will continue to focus on 

that as we move forward. 

Chairman AKAKA. Dr. Darkins? 

Dr. DARKINS. From the perspective of the services I am responsible for—telehealth services—I believe we are. I believe we are on 

a trajectory to increasingly do so. My evidence for saying that really is the expansion that we are seeing in rural areas, seeing the 

home telehealth growth in rural areas, seeing the services delivering out to rural locations. Our plans are to expand this—both expand in terms of numbers, but also expand in terms of the breadth 

of it. 

The delivery of specialist care, expanding that scope of specialist 

care delivery: I think, is something we can increasingly do more of. 

I think the needs of rural patients is something all health care organizations have problems with, and everybody could do more. I 

certainly believe in telehealth. With the developments we are making and the trajectory we’re on, we will be able to increasingly meet 

the needs that you have addressed. 

Chairman AKAKA. Yes. Well, there is no question telehealth services need to be expanded. 

Dr. Darkins, in my State of Hawaii, we still have VA operations 

lacking telemedicine equipment, namely, on the island of Molokai. 

As you know, Hawaii has separate islands. Is this just an isolated 

instance, or are there other VA spots where the equipment has not 

been purchased? 

Dr. DARKINS. There are certainly sites in the VA where there is 

no equipment currently. The equipment, as I mentioned before, is 

only part of the equation. So having the equipment does not guarantee the service is going to be provided. So the issues that we face 

as we roll out these programs around the country is the sites at 

which care has to take place must be private and have sufficient 

space for the patient to be able to have a consultation conducted 

with privacy and those concerns taken care of. There needs to be 

the telecommunications bandwidth. 

Also, crucially, as I mentioned, it is about relationships. It really 

has to be that there are clinicians at the local sites and the services 

to be able to be provided. 

So I can’t—my apologies—comment on one individual site, but 

this tends to be the reason why we are not seeing necessarily something in every single site. Having equipment which is there but not 

functioning equally well is not what I would like to see either. My 

goal and what we are pushing toward is that we get all three 

pieces of this equation: the clinical service delivery, the right environment for the patient to be able to have the care, and the equipment to be able to do so. 

Chairman AKAKA. Ms. Hawthorne, quality assurance is always a 

goal of VA. How can VA be sure that the non-VA doctors who see 

veterans in the community know how to treat combat-related illnesses like PTSD? 

Ms. HAWTHORNE. I would like to address that first at the broader 

level. It is important for us to ensure that veterans receiving nonVA care are getting the top quality for all services. So when we 

29 

partner with non-VA providers, we are implementing a set of core 

quality measures that the VA is looking at. We are working with 

the Office of Quality and Performance to identify outcome measures so we will know specifically if they are providing adequate 

care or not based on these measures. 

Regarding PTSD and other mental health services—likely the 

same with Office of Rural Health—the Office of Mental Health 

Services has specific outcome measures that they look at to ensure 

that care is being provided as the VA sees fit. 

Chairman AKAKA. Thank you. I am going to start on a second 

round and ask Senator Burr for any more questions. 

Senator BURR. Thank you, Mr. Chairman. I would just point out 

to the Chairman I cheated myself on the first round, so I may go 

over. 

I want to go back to the telemedicine issue, doctor, just real 

quick for the purposes of trying to sort this out for all the Members. 

The Asheville VA Hospital, as an example, services a population 

out of Tennessee. Today, if telemedicine is done out of Asheville 

and they monitor a Tennessee patient, that doctor, not licensed in 

Tennessee, licensed somewhere else, enters the VA system, has no 

trouble with providing that service in Tennessee, though he is 

physically in North Carolina. Correct? 

Dr. DARKINS. From the point of legality, he or she can practice 

across State lines absolutely with their licensure. However, in 

order to do so, there are still requirements that regulatory bodies 

require. One of those requirements is that in Tennessee, it is necessary to check the credentials. So, in other words, to safeguard the 

patient, it is necessary to make sure that that physician who is in 

North Carolina indeed has his or her medical license, has got the 

professional training to be able to deliver those services. That is a 

requirement for VA, as other organizations. 

In addition to that, there are two pieces to the competency of a 

clinician: first, is what you can do by virtue of your training; and, 

second, is that the environment is right to do it in. 

So, to give you an example of a cardiac surgeon, somebody may 

be a fully licensed, professionally trained cardiac surgeon whose 

credentials are fully up to date and there is no issue with their 

practice. However, he or she would not be able to practice in a 

small hospital which did not have access to the necessary support 

to provide cardiac surgery. So that privilege is somebody at the 

site, so it is something related to the site. 

Senator BURR. I agree. It is more of a privileging issue that you 

are talking about. 

Dr. DARKINS. It is a privileging issue. So because of that privileging issue that relates back to the physical delivery of services, 

it is necessary for us to privilege at these various sites, and that 

is a considerable administrative burden in terms of establishing 

these services, particularly as we look toward what we would like 

to see in the future—establishing national services. 

Let me give you the hypothetical example of a woman veteran 

who is pregnant who is on antipsychotic medication. The ability to 

be able to provide access to expertise that is very specialized is 

something that potentially could be done around the country. HowVerDate Nov 24 2008 15:27 Dec 01, 2009 Jkt 000000 PO 00000 Frm 00033 Fmt 6633 Sfmt 6601 H:\ACTIVE\022609.TXT SVETS PsN: PAULIN
30 

ever, determining the site at which the person is going to be and 

the site it is going to be delivered and making sure all that privileging is done is a logistic issue I hope I have well enough described. 

Senator BURR. You have, and it is the point I wanted to make 

for the Members. If we want the ideal, most efficient, highest quality of the delivery of care utilizing telemedicine, then we have got 

some barriers to overcome. And it should be of great interest to us 

to help try to facilitate that in a way that assures us of the high 

quality. 

Let me, if I could, take the services provided in telemedicine and 

group three in a category: congestive heart failure, diabetes, and 

blood pressure monitoring. Share with me today, of the services we 

provide through telemedicine, what percentage do those three 

health conditions make up, and what makes up the rest? 

Dr. DARKINS. I mentioned the three areas of health care delivery 

enterprise systems: the home telehealth; the videoconferencing between clinic and hospital; and the store, and, forward—the taking 

of digital images to share. 

For the home telehealth, about two-thirds are taken up by the 

conditions that you mentioned. These are supporting people with 

chronic conditions in their own homes. It provides non-institutional 

care, is helping veterans live in their own homes who would otherwise potentially be in nursing home care. So, a very high focus on 

those high areas of need which are very expensive, as you know. 

In terms of videoconferencing, the major areas we are doing 

videoconferencing between rural sites is mental health and rehabilitation. We are moving toward doing more in those areas of congestive heart failure, but our concentration has been much more in 

this proactive approach with home telehealth. 

And I mentioned diabetes: 20 percent of the veteran population 

we serve has diabetes—who have seen the Veterans Health Administration—and so diabetic retinopathy screening, preventing avoidable blindness, is a very high priority. 

So, mainly the home telehealth and the store and forward, but 

certainly an increasing amount we are going to see specialist care 

being delivered by these services as well. 

Senator BURR. In your testimony on page 2, you said, ‘‘Currently 

over 140 VA medical centers provide’’—telemedicine—‘‘CCHT’’—— 

Dr. DARKINS. Yes. 

Senator BURR [continuing]. ‘‘In addition to 28 clinics located in 

rural and highly rural areas.’’ Can I interpret that to mean that 

of those 28 clinics, they actually initiate the telehealth from that 

clinic, or are you referring to that clinic is a service point for one 

of the medical centers? 

Dr. DARKINS. They initiate care from that clinic. 

Senator BURR. So they would do home telehealth from that rural 

clinic. 

Dr. DARKINS. They do. 

Senator BURR. OK. 

Dr. DARKINS. There is no requirement—sorry, the 140 medical 

centers I mentioned, they can deliver services hundreds of miles 

from the medical center. So, the fact that they are in VA medical 

centers does not mean, by any means, they are not delivering rural 

31 

services. There are logistic issues around issuing the technology, 

refurbishment of the technology, that make it easier at the moment 

to do so from a medical center. However, in terms of expanding 

these services, what we have been doing is looking toward also 

making them available from local clinics such as I mentioned. 

In some instances, patients travel to the hospital or to the clinic 

to be enrolled in the program and get the technology. In other instances, the staff go out to the patients home. But certainly it is 

something that has been very pleasing for us to see what we 

thought was going to be more difficult, to go into clinic settings, 

has been rolling into the clinic settings in rural and highly rural 

areas, and something I am encouraging and want to push very 

much more for. 

Senator BURR. Let me just turn to Ms. Hawthorne for one question. Last year’s legislation that was enacted directed the VA to establish a pilot program for collaboration with non-VA providers to 

deliver health care services to veterans specifically in rural areas. 

Real quickly, are these programs fully underway? And what, if any, 

obstacles to timely implementation have we run into? 

Ms. HAWTHORNE. Sure, good question. The Office of Rural Health 

has always had the vision to partner with community providers, so 

we welcome this piece of legislation to facilitate this. 

We took swift action in developing an implementation plan to 

execute this pilot, and we will be ready to present that at the end 

of April. And we are still dealing with two technical issues right 

now. One is the statute’s definition of ‘‘highly rural’’ differs from 

ours. And the second is a regulatory issue with the definition of 

‘‘hardship.’’ Once those two issues are resolved, I am going to be 

happy to work with the Chairman and the Committee Members on 

that, and we will be able to promptly move forward. 

Senator BURR. Thank you very much. 

Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you very much, Senator Burr. 

Senator Tester? 

Senator TESTER. Real quick—just kind of dovetailing off of Senator Burr’s question—in areas that you are going to contract with 

local communities, how do you envision accuracy of medical records 

when the health care is being provided by those local folks? 

Ms. HAWTHORNE. When we identify the areas to specifically partner with, we will be working at the local level to execute this. So, 

the VISNs will help to identify the providers, and they will also be 

working to ensure that the medical records come back to the VA. 

And we will be asking them to use our electronic medical health 

records, and this will ensure the continuity of care and ensure that 

we do get a copy of the encounters. 

Senator TESTER. As you implement this program, has there been 

any resistance from the hospital using the VA’s medical records, 

the electronic version? 

Ms. HAWTHORNE. At this point in our implementation, we have 

not contacted individual providers. 

Senator TESTER. OK. 

Senator BURR. Could I ask one question? 

Senator TESTER. Sure. 

32 

Senator BURR. Where we have used non-VA contractors, which 

we currently do, part of the contracts, as I understand it, is a requirement that those records be supplied to the VA and electronically supplied. Am I right? 

Ms. HAWTHORNE. Correct. 

Senator BURR. So, currently that is in place where we are using 

contract care. 

Senator TESTER. Yes. I just did not know if there was resistance 

to that. There should not be, but one never knows. 

Senator BURR. It is part of the contract. 

Senator TESTER. Right. Exactly. 

One more question deals with mental health issues, and I guess 

the question is: Are there plans or how do you see us increasing 

mental health crisis beds to be available within a reasonable driving time? Or is that an issue you have talked about? 

Ms. HAWTHORNE. Increasing the availability of mental health inpatient beds is not something that I have worked with the Office 

of Mental Health Services on, and so I will be happy to go back 

and address that question with them. 

Senator TESTER. That would be good. All right. Thank you. 

Thank you, Mr. Chairman. 

[The information requested follows:] 

RESPONSE TO QUESTIONS ARISING DURING THE HEARING BY HON. JON TESTER TO

KARA HAWTHORNE, DIRECTOR, OFFICE OF RURAL HEALTH, VETERANS HEALTH

ADMINISTRATION

Question. What is the number of mental health beds available in rural areas? Are 

more needed? 

Response. In FY 08, VA had 633 mental health beds in facilities operating in 

rural areas, and 4,088 mental health beds in facilities operating in urban areas. 

Although the cumulative number of Veterans living in rural areas is high, the 

number living in any specific rural area is relatively low. The need for high intensity, low frequency health care services such as admission to an inpatient mental 

health unit is likely to be variable. From a clinical perspective, it would not be responsible to recommend any large scale increase in the number of VA mental health 

inpatient beds in rural areas. When a Veteran needs hospitalization for a mental 

disorder, it is important to arrange admission as soon as possible to a high quality 

facility that is staffed by clinicians with expertise in the Veterans’ condition that 

can ensure continuity of care after discharge, and is accessible to the Veteran’s family and support system. For Veterans living in rural areas, the best balance between 

these goals can be achieved by admission to the closest VA Medical Center. At other 

times, it can best be achieved by arranging for emergency admission to a local community-based facility. The best strategy is for individual, case-by-case evaluations. 

Chairman AKAKA. Thank you, Senator Tester. 

Now let me call on Senator Johanns for your questions. 

STATEMENT OF HON. MIKE JOHANNS, 

U.S. SENATOR FROM NEBRASKA 

Senator JOHANNS. Senator, thank you. 

If I could just follow up on questions by Senator Burr. I have 

very high hopes for this pilot program, because there is, in some 

cases at least, capacity in some rural areas. And it just seems to 

me that it would be a natural. 

But recognizing the difficulty of trying to match the VA system 

with that local hospital or medical provider in terms of the electronic system, how big of an impediment do you think that will be? 

33 

Because they cannot all have the system that would interconnect. 

And is that holding us back? 

Ms. HAWTHORNE. I do not believe it is holding us back because 

we already do it. 

Senator JOHANNS. OK. 

Ms. HAWTHORNE. So there are methods for the non-VA providers 

to link into our system without having full access to the entire 

medical records. 

So, to directly answer your question, no, I do not believe that will 

be an impediment, but it is something that we will, of course, have 

to address and be tracking. 

Senator JOHANNS. Then if I might follow up on a question by 

Senator Tester, I appreciate his question about mental health services, because I suspect in his State they have identical problems as 

we do: just a lack of services in the rural areas, just in some rural 

areas a complete lack of services. It is hard to get a psychiatrist 

to go to rural areas, et cetera, et cetera. 

Any idea on a novel approach? Because many veterans desperately need these services. They come home, they go back to the 

ranch or the farm, and all of a sudden things are falling apart for 

them. How do we deal with that? 

Ms. HAWTHORNE. You have identified a very real problem, and 

we have done some analysis looking at highly rural areas, and 

what you stated is exactly the fact. There are not always the nonVA providers to even fee out to or contract with. 

Senator JOHANNS. Right. 

Ms. HAWTHORNE. So we are looking at—well, telehealth is obviously one of the major ways we are going to increase access to 

those veterans. We are also looking at other methods, such as 

using the telephone lines for care management. And we will have 

to be even more creative in identifying other methods and look to 

you if you have any ideas you would like to share. 

Senator JOHANNS. I will just offer this thought: Telemedicine is 

a big resource here. It is an interesting thing. For example, on 

counseling services, people do not seem to be bothered communicating through that television set. And that offers at least the 

possibility to connect somebody in a very rural area with somebody 

in an urban area and, again, provide counseling services. I have 

seen it at work. 

Many hospitals now do have telemedicine. Do you see an opportunity to contract into that hospital, for example, using their telemedicine services if we do not have those services out in the rural 

area? 

Dr. DARKINS. Perhaps I could comment on that. Certainly, VA 

has very extensive experience in delivery of tele-mental health. The 

area you mentioned of counseling is extensively done throughout 

VA, not only in terms of individual counseling of patients, but as 

opposed to in terms of group counseling and group therapy, which 

is possible to do in locations. Also, treatment of PTSD, depression, 

and treatment of psychosis is all routinely done now. Not only is 

it done between hospital and smaller hospital, hospital and clinic, 

it is also being done directly into the patient’s home. So the VA has 

a very extensive experience of that. 

34 

We are working very closely in terms of addressing these issues 

because telehealth can provide part of the solution, but what it has 

to do is to fit into how you crisis manage, how you fit into that 

wider spectrum of care. And, therefore, I work enormously closely 

with my colleague Dr. Katz in the Office of Mental Health Services. 

VA has made incredible strides, I believe, over the last few years 

in terms of becoming, really, a model that other organization are 

looking to about the kinds of innovative approaches to delivering 

care that you have just mentioned. So, we have been looking toward how we move telehealth into rural areas; how we use it in 

the context of also physical bases of services. 

You asked about doing it with other organizations. Yes, that is 

possible. There are difficulties in terms of not having a really robust contracting system for telehealth in the world outside. There 

are issues about exchange of health information. There are privacy 

issues in terms of linking onto networks, and there are just, again, 

those barriers to delivery of care, something which we are very well 

aware of working actively and hard to do. So it is really not for the 

want of either enthusiasm or wish, but just as we work through 

those details to make it happen. And, again, we would be very glad 

for any suggestions from either yourself or other Members of the 

Committee on how you think we might address this more. 

Senator JOHANNS. I am out of time, but I will just wrap up with 

a suggestion. Having dealt with many of these issues as a Governor, one thing I would recommend—and I suspect you are doing 

it already—is to reach out to the Chief Medical Officer in the State. 

Every State has one. Some States have better public health networks than others, but that position is probably going to exist to 

some degree in every State, just simply because those personnel 

are traveling the same road you are. They are trying to figure this 

out, how do we get services out into rural areas, how do we deal 

with these very same issues. It could be a great partnership; certainly would be a resource that I would urge you to tap into. So 

thank you. 

Chairman AKAKA. Thank you, Senator Johanns. 

Senator JOHANNS. Thank you, Mr. Chairman. 

Chairman AKAKA. Senator Burris, for any second-round questions? 

Senator BURRIS. I am fine, Mr. Chairman. I am listening and 

learning. Thank you. 

Chairman AKAKA. Thank you. We will submit our questions for 

the record and dismiss the first panel. 

Thank you very much for your responses. You have been very 

helpful this morning. 

Dr. DARKINS. Thank you very much. 

[Questions from the Committee Members follow:] 

RESPONSE TO POST-HEARING QUESTIONS SUBMITTED BY HON. PATTY MURRAY TO

KARA HAWTHORNE, DIRECTOR, OFFICE OF RURAL HEALTH, VETERANS HEALTH

ADMINISTRATION

CONTRACT/FEE-BASIS CARE

Question 1. Ms. Hawthorne, as you expand your partnership with local community 

providers through fee-basis and contracting, can you tell me how VA will be able 

to retain its quality control measures and continuity of care for which it has become 

well-known for? 

35 

1 Bodenheimer, T. ‘‘Coordinating Care: A Perilous Journey through the Health Care System.’’ 

New England Journal of Medicine. 2008; 10; 358: 1064–1071. 2Gans, D et al. ‘‘Medical Groups’ Adoption of Electronic Health Records and Information Systems.’’ Health Affairs. 2006; 24;5: 1323–1333. 

Response. The Department of Veterans Affairs (VA) is committed to ensuring the 

highest possible quality of care for Veterans, regardless of how and where their care 

is delivered. This means care consistent with evidence-based practices and proper 

coordination to assure continuity. 

VA would like to point out that such challenges are not easily met, in part because of well-recognized barriers to coordination in community practices.1 Additionally, few community physicians have the infrastructure to electronically capture and 

report the clinical variables that VA relies on to ensure quality care.2 Finally, unless 

a community site meets certain minimal volume thresholds (the statistical rule of 

thumb is approximately 30 unique cases per reporting period), performance metrics 

will have too great an error margin to be usable. 

Recognizing these challenges, VA is developing quality measurement tools to be 

used for both fee basis and contracted care. Because community capabilities differ 

widely, and the needs for fee basis or contracted care similarly vary by locale, our 

approach has to be tailored to meet specific local constraints. Project HERO, which 

represents one of VA’s first efforts at managing and consolidating contracted care, 

has allowed us to develop and test combinations of metrics, such as facility accreditation, provider credentialing, access measures, patient safety incident evaluation, 

clinical documentation submission, and patient satisfaction. In addition, the parent 

VA medical center provides local quality management and peer review of selected 

clinical records, to ensure outside care meets our own standards. We note that several of the Models for Care Coordination outlined by Bodenheimer (reference 1), 

such as electronic referral and data capture, referral agreements, and investing in 

care coordination, are currently in the process of testing and adoption. Wider use 

of electronic health records by community practices, and greater diffusion of personal health record usage (My HealtheVet) among Veterans will further support the 

sharing of clinical information that will support both quality monitoring and continuity of care. 

ORGANIZATIONAL PLACEMENT OF OFFICE OF RURAL HEALTH

Question 2. The Independent Budget has raised concerns with the placement of 

the VA’s Office of Rural Health within the organization. Specifically, they are concerned that by placing ORH in the VHA Office of Policy and Planning—rather than 

closer to the operational arm of the VA system—could, ‘‘frustrate, delay or even cancel initiatives established by the Rural Health staff.’’ Would you respond to these 

concerns? 

Response. Placing the Office of Rural Health (ORH) in the Office of the Assistant 

Deputy Under Secretary for Health for Policy and Planning was a purposeful decision made by the Under Secretary for Health after carefully evaluating what office 

was best equipped with technical resources and leadership skills to assure the successful creation and operation of this critical new office. The Veterans Health Administrations’ (VHA) Office of Policy and Planning has well-established relationships with program offices engaged in developing services that meet the health care 

needs of Veterans in rural communities; it also works closely with the Office of the 

Deputy Under Secretary for Health for Operations and Management and Veterans 

Integrated Service Networks (VISN) leadership. 

VHA’s Office of Policy and Planning is responsible for several functions directly 

connected with access and care issues for Veterans in rural areas. For example, the 

Office is intimately involved with the annual strategic planning process, which 

works with local facilities and VISN to identify and address the need for community-based outpatient clinics (CBOC) in market areas across the country. ORH’s 

presence provides a voice for the needs of rural Veterans during this process. 

VHA’s Office of Policy and Planning is also responsible for forecasting projections 

and conducting geospatial analyses to identify communities of underserved Veterans. These are instrumental in helping ORH achieve its goals of addressing gaps 

in services, reducing drive times for Veterans and ensuring resources are provided 

to high-need areas. 

Moreover, ORH works closely with VHA’s Operations and Management to ensure 

the interests of rural Veterans are represented. VA recognizes that every local community is different, with unique challenges and opportunities. By working with Operations and Management, ORH supports local solutions. For example, in December 

2008, VA provided almost $22 million directly to VISNs to help them immediately 

36 

implement programs to improve services for rural Veterans. This funding is part of 

a 2-year program focusing on initiatives such as new technologies, provider recruitment and retention, and close cooperation with other organizations at the Federal, 

State and local levels. Facilities and networks are using these funds to sustain current programs, initiate pilot programs and establish new outpatient clinics. 

By positioning ORH under VHA’s Office of Policy and Planning, ORH can easily 

reach out not only to VISNs but to program offices within VHA. Most recently, in 

February 2009, ORH distributed guidance to VISNs and program offices regarding 

the allocation of the remaining funds to enhance rural health care programs. Program offices and VISNs are eligible to apply for this funding, which will support 

programs in six key areas of focus: access, quality, technology, workforce, education 

and training and collaboration strategies. Projects may include leveraging existing, 

proven initiatives, such as structured initiatives to expand fee-basis care; developing 

collaborations with Federal and non-Federal partners; accelerating telemedicine deployment; funding innovative pilot programs; and increasing access points in rural 

and highly rural areas (e.g., outreach clinics in areas not meeting VA’s drive time 

standards, or developing mobile clinics). ORH continues to ensure program offices 

and VHA’s Operations and Management are involved in all programmatic activities, 

and ORH’s placement under the VHA Office of Policy and Planning provides the appropriate vehicle for these collaborations. 

FUNDING FOR ORH

Question 3. Ms. Hawthorne, the Office of Rural Health was established only a few 

years ago and it was assigned the rather broad role of overseeing the health care 

services provided to millions of rural Veterans across the country. I want to make 

sure that your office has the resources it needs to ensure it performs its role as effectively as possible. In your opinion, does the Office of Rural Health have the resources it requires to achieve its full potential? 

Response. ORH is sufficiently funded to meet the needs of rural Veterans. Our 

funding in fiscal year (FY) 2009 is supporting important initiatives, such as the 

rural health resource centers, mobile clinics, outreach clinics, VISN rural consultants, mental health and long-term care projects. We have also been able to support 

new initiatives through direct funding to VISNs and by soliciting requests from program offices and facilities to support programs in six key areas of focus, including 

access, quality, technology, workforce, education and training, and collaboration 

strategies. Successful programs will be included in the base budget of ORH, the facility or network, or the program office in the future. 

MENTAL HEALTH STIGMA

Question 4(a). The wars in Iraq and Afghanistan present a twofold challenge 

when it comes to caring for our rural Veterans. As you know, nearly half of servicemembers deployed in Iraq and Afghanistan are from rural areas. On top of this, 

study after study has shown high rates of TBI and PTSD among returning servicemembers. Folded together, these facts present a real challenge for the Office of 

Rural Health and VA generally. I think all of us here recognize that VA will have 

to be smart about how it approaches rural health care for Iraq and Afghanistan Veterans. Have you found any evidence that the stigma of seeking mental health care 

is greater in rural areas than in more urbanized sections of the country? 

Response. VA is not aware of any research that directly addresses the question 

of whether there is a greater degree or prevalence of stigmatization of mental health 

care in rural areas compared to more urban locations. 

Question 4(b). If you have identified this as a problem, what steps is VA taking 

to decrease the stigma in rural areas? 

Response. VA is reducing the stigma of seeking mental health care in both urban 

and rural settings through several initiatives. First, VA has integrated mental 

health care into primary care settings. VA screens any patient seen in our facilities 

for depression, Post Traumatic Stress Disorder (PTSD), problem drinking and military sexual trauma. We have incorporated this screening and treatment into primary care settings. We further offer programs for Veterans at risk of suicide, Veterans who are homeless, and Veterans who have experienced military sexual trauma. We provide these services by conducting an initial evaluation of all patients 

with potential mental health issues within 24 hours of contact, and we provide urgent care immediately. We are close to meeting our new standard of care—to see 

all new patients seeking a mental health care appointment within 14 days of their 

requested date 95 percent of the time; the standard is 95 percent rather than 100 

percent to allow for the occasional Veteran who may prefer to delay this evaluation, 

37 

perhaps because of planned travel. Nationally, we see 95.3 percent of patients within the 14-day standard. 

VA provides mental health care in several different environments, including Vet 

Centers. There are strong, mutual interactions between Vet Centers and our clinical 

programs. Vet Centers provide a wide range of services that help Veterans cope 

with and transcend readjustment issues related to their military experiences in war. 

Services include readjustment counseling for Veterans, marital and family counseling necessary for the successful readjustment of the Veterans, bereavement counseling, military sexual trauma counseling and referral, demobilization outreach/services, substance abuse assessment and referral, employment assistance, referral to 

VA medical centers, Veterans Benefit Administration (VBA) referral, and Veterans 

community outreach and education. Vet Centers provide a non-traditional therapeutic environment where Veterans and their families can receive counseling for readjustment needs and learn more about VA’s services and benefits. By the end of 

FY 2009, VA will offer 271 Vet Centers with 1,526 employees to address the mental 

health and readjustment needs of Veterans. Additionally, VA is deploying a fleet of 

50 new Mobile Vet Centers early this year; they will provide outreach to returning 

Veterans at demobilization activities across the country and remote areas. 

Care Coordination/General Telehealth (CCGT) programs support the delivery of 

specialist care in the patient’s local community in urban, rural and highly rural settings. CCGT programs encompass 36 clinical specialties but currently focus on mental health and rehabilitation needs. In FY 2008, over 48,000 Veterans received care 

nationally through CCGT of which 29,000 Veterans received mental health care via 

tele-mental health. CCGT services are provided at 149 VA medical centers and 353 

community based outpatient clinics. In FY 2008 Veterans received this care at 171 

sites which were in rural or highly rural areas. 

RESPONSE TO POST-HEARING QUESTIONS SUBMITTED BY HON. BERNARD SANDERS TO

KARA HAWTHORNE, DIRECTOR, OFFICE OF RURAL HEALTH, VETERANS HEALTH ADMINISTRATION AND TO ADAM W. DARKINS, MD, CHIEF CONSULTANT FOR CARE COORDINATION, VETERANS HEALTH ADMINISTRATION

PARTNERING WITH FQHCS AND CMHC FOR TELE-MENTAL HEALTH

Question 1. Can you tell me what VA is doing in the area of tele-mental health 

counseling and what you think about the idea of using federally Qualified Health 

Centers and Community Mental Health Centers as satellite locations where VA patients can link up over the internet with VA doctors who can provide them with 

mental health counseling from a community-based outpatient clinic (CBOC) or VA 

medical center? Is this a way we can expand the reach of VA’s care into rural areas? 

Response. All services provided in VA’s routine delivery of care via tele-mental 

health can be considered to include ‘‘counseling.’’ In FY 2008, VA provided tele-mental health services to 29,000 Veterans. However, if a narrower definition of counseling is applied—that is, a specific session of individual or group psychotherapy, 

then VA conducted 2,400 individual sessions or group psychotherapy sessions with 

760 Veterans via tele-mental health in FY 2008. 

VA’s primary obligation is to meet the health care needs of Veterans. We prefer 

to do this within our own facilities because we have established common standards 

for quality care based upon objective measures and because of the benefits of a coordinated and comprehensive electronic health record. Moreover, VA screens any patient seen in its facilities for depression, PTSD, problem drinking, and military sexual trauma. In some situations, however, the patient’s needs will be better served 

by finding an alternate provider. 

VA supports the use of federally Qualified Health Centers and Community Health 

Centers as satellite locations where Veterans can access care. Such access over the 

Internet or other telecommunications media needs to ensure privacy and confidentiality of patient data. In addition, provision of care at these sites must adhere to 

VA policies and procedures, provide electronic access to the requisite patient data, 

and satisfy patient safety considerations. Services to Veterans accessed via telehealth from federally Qualified Health Centers and Community Health Centers 

would provide a mechanism to expand access to care for Veterans in rural areas. 

Access would include technological and contracting mechanisms to ensure safe, appropriate and cost-effective clinical services. Within VA, patients are routinely offered access to face-to-face services when this is their preference. 

Section 107 of Public Law 110–387 asks VA to conduct a rural pilot program in 

at least three VISNs to evaluate the feasibility and advisability of providing Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans (particularly 

38 

those who served as members of the National Guard or Reserve) peer services, readjustment counseling, and other mental health services. These services would be provided through a variety of arrangements with a group of community and Indian 

health organizations that deliver mental health services in rural areas. Tele-mental 

health may be one of the service delivery modalities tested in this pilot. VA’s Office 

of Mental Health Services is currently in the process of implementing the pilot in 

collaboration with the Office of Rural Health. 

PARTNERING WITH THE NATIONAL HEALTH SERVICE CORPS

Question 2. It is my understanding that VA is not currently partnering with the 

National Health Service Corps to help increase the number of high quality medical 

professionals in rural areas. Is that correct? Can you tell the Committee whether 

you think there would be some benefit in such a partnership? We obviously don’t 

want to take Health Service corps doctors away from the communities they serve, 

but could there be some kind of connection with VA? 

Response. VA does not currently have an active partnership with the National 

Health Services Corps (NHSC) in the development of medical professionals. Due to 

certain legal restrictions, VHA facilities do not meet Department of Health and 

Human Services (HHS) criteria to be designated as NHSC practice sites for fulfillment of service commitments. To be eligible under HHS’ criteria to participate, VA 

would have to accept Medicare, Medicaid and indigent patients. 

However, to develop health care professionals, VHA modeled the Health Professionals Educational Assistance Program, Employee Incentive Scholarship Program 

(EISP) after the programs sponsored by HHS’ National Health Services Corps. Since 

2000, VA has offered scholarship programs for VHA employees that assist in meeting staffing needs through academic degree training for health care occupations. 

Over 4,500 individuals have graduated from academic degree programs under EISP. 

Many employees returned to school to enhance their existing professional credentials, but approximately 500 of these graduates were newly licensed health care providers. The statute requires a VHA service obligation modeled after the NHSC program, but fulfillment of the service agreement is not limited to rural areas. The 

statute does provide the Secretary the flexibility to require that service obligations 

be performed in any VHA facility as needs dictate. To date the program has not implemented this relocation provision or specifically used scholarships as a mechanism 

to geographically distribute the workforce to rural areas. Many VA employees in 

rural areas have participated in EISP. 

From the late 1980s through 1998, VA had statutory authority for a scholarship 

program for individuals who were not VA employees; however authority for that 

program expired December 31, 1998 and has not been reauthorized. This provision 

would be most similar to the NHSC program in terms of providing scholarships to 

individuals in exchange for service in hard-to-recruit locations. Chairman Akaka has 

introduced legislation to extend the sunset provision in the current statute. 

CARE FOR FAMILIES LIVING IN RURAL AREAS

Question 3. We have spent a good deal of time at the hearing discussing the care 

for our Veterans and that is, of course, the top priority. But we also have to recognize that when a Veteran needs help, as many of our Veterans from Iraq and Afghanistan and other conflicts do, that also means the family needs assistance. What 

is VA doing to help connect to family members of rural Veterans, especially those 

from Iraq and Afghanistan, to let them know about counseling services, expanded 

through congressional action in the 110th Congress (Public Law 110–387), available 

for family members through VA? 

Response. VA appreciates that families are central to the readjustment process for 

combat Veterans. In response to the growing numbers of Veterans returning from 

combat in OEF/OIF, the Vet Centers initiated an aggressive outreach campaign to 

welcome home and educate returning servicemembers at military demobilization 

and National Guard and Reserve sites. Through its community outreach and referral activities, the Vet Center program also provides many Veterans and family 

members the means of access to other VHA and VBA programs. To augment this 

effort, the Vet Center program recruited and hired 100 OEF/OIF Veterans to provide the bulk of this outreach to their fellow Veterans and Veterans’ family members. The program’s focus on aggressive outreach activities has resulted in the provision of timely Vet Center, and other VA, services to significant numbers of OEF/ 

OIF Veterans and family members. Vet Centers also provide readjustment counseling services for Veterans, including marital and family counseling as necessary 

for the successful readjustment of the Veteran. 

39 

In another area, VA actively supports OEF/OIF transition through the Department of Defense (DOD) Yellow Ribbon Reintegration Program (YRRP). The National 

Defense Authorization Act for FY 2008 (Section 582) tasked the Secretary of Defense with establishing a national combat Veteran reintegration program to provide 

support and outreach to National Guard and Reserve members throughout the entire deployment cycle. VA plays a key role in the DOD YRRP office, which opened 

in March 2008, by providing a full-time VA Liaison to the office. The VA Liaison 

works closely with the program management and service liaison officers within the 

program office and provides technical expertise and guidance pertaining to VA benefits, services, and programs available to National Guard and Reserves and their 

family members. The YRRP is currently active in 54 States and territories, and engages servicemembers and their families in the pre-, during and post-deployment 

stages, including 30, 60, and 90 days after deployment. At the local level, VA supported 185 Guard and Reserve Yellow Ribbon Events in FY 2008 through the end 

of March 2009. A total of 25,993 servicemembers attended these events, and 17,809 

family members did, too. VA provides information, assistance, and referrals to servicemembers and helps them enroll in VA care. 

Preventing Veteran suicide is a paramount goal for VA. As part of VA’s Suicide 

Prevention Initiative, two public service announcements (PSA) have been developed 

to speak to Veterans and their families. The first PSA released features actor Gary 

Sinise and targeted Veterans directly. The second PSA features TV personality 

Deborah Norville and includes key messages designed to help families and loved 

ones of Veterans recognize warning signs of suicide. The PSAs also provide helpful 

information to aid in support and intervention. 

In addition, VA is developing healthy cooking videos as part of the HealthierUS 

Veterans initiative for Veterans and their families. These videos aim to promote a 

healthier life style by eating right and staying active. The cooking videos will help 

Veterans and their families make healthier choices in purchasing and preparing 

food to achieve a healthier diet. 

EFFORTS TO INCREASE PAY FOR VA EMPLOYEES

Question 4. I mentioned in my opening statement the challenges we are having 

recruiting and retaining VA employees in Vermont because of the low locality pay 

level in our areas compared to neighboring states. Is this a complaint you have 

heard in other parts of the country? What suggestions do you have to fix this problem? Does VA have any involvement in the Office of Personnel Management’s locality pay decisions? 

Response. VA recognizes there are pay disparities in some areas, specific to local 

occupations, and we are working aggressively to address these disparities within our 

current resources. VHA has the authority to adjust salary rates for hybrid title 38 

and title 38 occupations to remain competitive if there are difficulties recruiting or 

retaining employees in a given area. We continue to offer incentives, salary adjustments, scholarships and loan repayment assistance. VHA recently awarded a contract to a private consultant to gather current salary data specific to local labor 

markets to facilitate a comparison across all medical facilities, including rural areas. 

This analysis will assist VHA in adjusting salaries as needed. VHA does not specifically have input into locality pay decisions by the Office of Personnel Management, 

but we have the authority to adjust salaries for title 38 and hybrid title 38 positions. 

PEER-TO-PEER OUTREACH

Question 5. What does the Office of Rural Health think about using more peerto-peer outreach to help connect to our rural Veterans and their families to make 

sure they know about and can access VA services available to them? In Vermont, 

we have a program operated by the Vermont National Guard with assistance from 

VA called the ‘‘Vermont Veterans and Family Outreach Program.’’ This program 

uses VA-trained Veterans to conduct outreach to returning servicemembers and we 

have found it is quite an effective way to contact Veterans, who may normally be 

hesitant to seek out help, and connect them to needed services. Could Vermont’s 

program be eligible for inclusion in the pilot program required by Section 107 of 

Public-Law 110–387? 

Response. VA recognizes the importance of the Veteran-to-Veteran connections, 

and VA is proud that it is one of the leading agencies in the Federal Government 

in terms of employing Veterans. There is no better example of this commitment 

than in VA’s Vet Center program. By design, the Vet Center program promotes the 

value of Veteran-to-Veteran peer readjustment services, a time-honored lesson 

throughout the program’s 30-year history. The Vet Center experience teaches that 

combat Veterans strongly prefer to talk to other Veterans who understand the miliVerDate Nov 24 2008 15:27 Dec 01, 2009 Jkt 000000 PO 00000 Frm 00043 Fmt 6633 Sfmt 6621 H:\ACTIVE\022609.TXT SVETS PsN: PAULIN
40 

tary culture and who share similar combat experiences. Receiving outreach and readjustment counseling from a fellow warrior of the same age group and military experience establishes an immediate connection and facilitates trust between Veterans. This opens the door to care for many combat Veterans who would not otherwise be receptive to entering the health care system. The Readjustment Counseling 

Service initiated the Vet Center Global War on Terror (GWOT) Veteran outreach 

program in the wake of hostilities in Afghanistan and Iraq. VA has added 100 

GWOT Veterans to the Vet Center staff across the country. These newest members 

of the Vet Center staff are primarily involved in our outreach efforts to make contact with their fellow Veterans as soon as they return from combat. Their unique 

ability to understand and connect with each other allows these staff members to 

help servicemembers access VA services as soon as possible after returning. Vet 

Center GWOT outreach specialists conduct proactive outreach services for all returning warriors and their families at Active Military, National Guard, and Reserve 

sites, and at other community locations. Since 2004, the Vet Center Program has 

hired over 200 additional OEF/OIF combat Veterans into other staff positions at Vet 

Centers. 

Section 107 of Public Law 110–387 asks VA to conduct a rural pilot program in 

at least three VISNs to evaluate the feasibility and advisability of providing OEF/ 

OIF Veterans (particularly those who served as members of the National Guard or 

Reserve) peer services, readjustment counseling, and other mental health services. 

These services would be provided through a variety of arrangements with a group 

of community and Indian health organizations that deliver mental health services 

in rural areas. tele-mental health may be one of the service delivery modalities tested in this pilot. VA’s Office of Mental Health Services is currently in the process 

of implementing the pilot in collaboration with the Office of Rural Health. 

Chairman AKAKA. Now let me call on and welcome our second 

panel of witnesses to today’s hearing. 

We will hear first from Reverend Ricardo Flippin, a community 

leader on the front lines in West Virginia, describing the health 

problems of our veterans who live in rural areas. 

Then we have Alan Watson, who is Chief Executive Officer of 

two rural hospitals. He will describe some of the challenges in providing hospital care for veterans in communities where there are 

no VA hospitals. 

Next we will have Tom Loftus, Commander of an American Legion Post. Commander Loftus will tell the Committee about the 

problems that our veterans face when they are trying to obtain outpatient care in communities without a VA clinic. 

Finally, Matt Kuntz, Executive Director of the Montana Chapter 

of the National Alliance on Mental Illness, will share information 

on the particular problems faced by veterans with mental illness 

who need to obtain care in a rural community. 

Thank you all for joining us today. Your full statements will appear in the record. 

Reverend Flippin, will you please begin? 

STATEMENT OF REVEREND RICARDO C. FLIPPIN, PROJECT 

COORDINATOR, WEST VIRGINIA COUNCIL OF CHURCHES, 

CARE-NET: CARING BEYOND THE YELLOW RIBBON 

Rev. FLIPPIN. Chairman Akaka, Ranking Member Burr in 

absentia, and Members of the Senate Committee on Veterans’ Affairs, thank you for the honor and the opportunity to speak to you 

today about the health care needs of our rural veterans. 

My name is Reverend Ricardo Flippin from Charleston, West Virginia. I represent CARE-NET: Caring Beyond the Yellow Ribbon, 

a project of the West Virginia Council of Churches funded by the 

Claude Worthington Foundation and the Attorney General Office of 

the State of West Virginia. 

41 

The State of West Virginia supports a military complex of Army 

and Air National Guard, Army and Air Reserve Components, plus 

Navy and Marine Reserve Units. Many of our soldiers in these 

units are serving their second or third tour of duty in Iraq or Afghanistan. 

Unlike the regular active army member who returns to a permanent base with medical clinics, surrounded by other soldiers and 

soldier families for support, our military members—National 

Guard—return home to a civilian community where few understand their military experiences. West Virginia armories are scattered across the State, many hours’ drive from military or veteran 

health care facilities. 

CARE-NET: Caring Beyond the Yellow Ribbon works to connect 

communities and helping professionals in the community to our returning veterans. This is particularly important in the areas without VA facilities. CARE-NET identifies the needs of the veteran 

and his or her family—needs like: the tools to fight addiction; Post 

Traumatic Stress Disorder; Traumatic Brain Injury; and equipping 

their families with the skills to cope with these invisible wounds. 

And then we try to match those needs with the resources in our 

small communities. 

This is particularly important to our rural veterans. In West Virginia, more than half of our veterans live in rural areas. And we 

know that veterans living in those areas are more likely to suffer 

from PTSD or depression than our veterans in urban areas. Our researchers think the reason for this is a lack of mental health care 

providers in rural areas. The VA itself has done work showing that 

rural veterans have more serious and costly health care problems 

than urban veterans. 

Many believe that TRICARE, the military insurance that provides veterans with 6 months of coverage after discharge, solves 

this problem. However, many providers in rural communities will 

not take TRICARE because it does not reimburse at the community 

rate. Then when TRICARE runs out, our veterans must rely on the 

VA. Many of our community providers will not accept VA payments 

either. In West Virginia, this can mean that our veterans must 

travel for hours to get care at VA facilities. 

Organizations like CARE-NET across the country are trying to 

connect our community resources with our returning veterans in 

those areas without VA hospitals or clinics. We urge the Committee 

and the VA to work with community health care providers and organizations like CARE-NET to use all our resources in rural communities to care for our veterans. We must reach out to our wounded veterans wherever they live and guarantee that they can get the 

care they need—a promise should be a promise, no matter where 

the servicemember calls home. 

Thank you for this opportunity to speak on behalf of our rural 

veterans and their communities. 

[The prepared statement of Rev. Flippin follows:] 

PREPARED STATEMENT OF REVEREND RICARDO C. FLIPPIN, COORDINATOR, CARENET: CARING BEYOND THE YELLOW RIBBON, WEST VIRGINIA COUNCIL OF CHURCHES

Chairman Akaka, Ranking Member Burr, and Members of the Senate Committee 

on Veterans’ Affairs: thank you for the honor and the opportunity to speak to you 

today about the health care needs of our rural veterans. 

42 

My name is Reverend Ricardo Flippin from Charleston, West Virginia. I represent 

CARE-NET: Caring Beyond the Yellow Ribbon, a project of the West Virginia Council of Churches funded by the Claude Worthington Foundation and the Attorney 

General Office of the State of West Virginia. 

The state of West Virginia supports a military complex of Army and Air National 

Guard, Army and Air Reserve Components, plus Navy and Marine Reserve Units. 

Many of our soldiers in these units are serving their second or third tour of duty 

in Iraq or Afghanistan. 

Unlike the regular military member (active duty) who returns to permanent bases 

with medical clinics, surrounded by other soldiers and soldier families for support, 

our military members return home to a civilian community where few understand 

their military experiences. West Virginia armories are scattered across the state, 

many hours’ drive from military or veteran healthcare facilities. 

CARE-NET: Caring Beyond the Yellow Ribbon works to connect communities and 

helping professionals in the community to our returning veterans. This is particularly important in the areas without VA facilities. CARE-NET identifies the needs 

of the veteran and his or her family—needs like the tools to fight addiction, PTSD 

and TBI, and equipping their families with the skills to cope with these invisible 

wounds. And then we try to match those needs with the resources in our small communities. 

This is particularly important to our rural veterans. In West Virginia, more than 

half of all our veterans live in rural areas. And we know that veterans living in 

those areas are more likely to suffer from PTSD or depression than our veterans 

in urban areas. Our researchers think the reason for this is a lack of mental health 

care providers in rural areas. The VA itself has done work showing that rural veterans have more serious and costly health care problems than urban veterans. 

Many believe that TRICARE, the military insurance that provides veterans with 

six months of coverage after discharge, solves this problem. However, many providers in rural communities will not take TRICARE because it does not reimburse 

at the community rate. Then, when TRICARE runs out, our veterans must rely on 

the VA. Many of our community providers will not accept VA payments either. In 

West Virginia, this can mean that our veterans must travel for hours to get health 

care at VA facilities. 

Organizations like CARE-NET across the country are trying to connect our community resources with our returning veterans in those areas without VA hospitals 

or clinics. We urge the Committee and the VA to work with community health care 

providers and organizations like CARE-NET to use all our resources in rural communities to care for our veterans. We must reach out to our wounded veterans 

wherever they live and guarantee that they can get the care they need- a promise 

should be a promise, no matter where the servicemember calls home. 

Thank you for this opportunity to speak on behalf of our rural veterans and their 

communities. 

Chairman AKAKA. Thank you very much, Rev. Flippin. 

Now we will hear from Mr. Watson. 

STATEMENT OF ALAN WATSON, CHIEF EXECUTIVE OFFICER, 

ST. MARY’S MEDICAL CENTER OF CAMPBELL COUNTY, 

LAFOLLETTE, TENNESSEE 

Mr. WATSON. Thank you, Chairman Akaka, Ranking Member 

Burr in absentia, distinguished Members of this Committee. Thank 

you for the opportunity to speak to you today about the challenges 

small communities encounter when providing health care to our 

veterans. 

I am Alan Watson, Chief Executive Officer of St. Mary’s Medical 

Center of Campbell County in LaFollette, Tennessee. St. Mary’s 

Medical Center of Campbell County is located in a rural Appalachian community and provides 56 acute-care beds, 10 senior behavioral health beds, and 98 long-term-care beds. We offer a broad 

array of acute-care services including emergency care, general surgery, pulmonary medicine, cardiology, senior behavioral health, and 

imaging services. 

43 

In our county, almost one-fourth of the population is below the 

Federal poverty level. All of our health care providers provide care 

each day without the guarantee of reimbursement for that care, 

making it difficult for physicians to be recruited into this area. The 

National Health Service Corps has been a valued resource in recruiting providers; however, we still need more providers in the 

community. 

Many of the patients that we serve on a daily basis are veterans. 

Thirty-five hundred veterans live in the county where our hospital 

is located. I would first like to say that I believe the care that veterans receive in VA facilities is excellent if they are fortunate 

enough to have the means to travel to those facilities or live near 

them. Our concerns with the VA system are not with the care it 

delivers to veterans within the system, but with the access to that 

care and continuity of care for our rural veterans. 

Access to care for our veterans is limited by the distance to VA 

facilities and the number of providers available at those facilities. 

The closest outpatient clinic to LaFollette, Tennessee, is located 1 

hour away in Knoxville. This clinic provides primary care, pharmacy, and limited diagnostic services. Specialist care is not available to manage the many disease processes identified in our veteran population. Veterans who require hospitalization and/or specialist care must drive to the Veterans Administration Medical 

Center in Mountain Home, Tennessee, a 21⁄2-hour drive. The next 

closest VA Medical Center is located in Murfreesboro, Tennessee, 

31⁄2 hours by car. 

These distances present significant challenges to our veterans 

considering that many cannot drive and do not have family members available to drive them to either Mountain Home or Murfreesboro. In addition, it is reported that local ambulance services are 

reluctant to transport patients because payment by the VA has 

been denied in the past. 

The second limiting factor related to care access is the low numbers of providers at the various VA clinics. Appointments are 

scheduled weeks and sometimes months in advance. Acute patients 

can ‘‘walk in.’’ However, there is no guarantee that they will be 

seen that day. In many cases, the patients will be forced to seek 

care in our emergency department while waiting for appointments 

in VA clinics. 

The continuity of care that is provided to our veterans is the second area of concern for our community. Problems occur related to 

communication between providers, long-term-care placement, and 

the options for homeless veterans. 

First, follow-up communication between VA providers and local 

primary care physicians is non-existent. In addition, it is difficult 

to obtain records from the VA clinics regarding ancillary testing 

and current medication lists. 

Second, it is challenging for hospitals to place patients needing 

long-term care. Many local long-term-care facilities are reluctant to 

accept VA patients due to poor reimbursement and the volumes of 

paperwork required. This results in longer lengths of hospitalization while placement options are being explored. It has been well 

documented that longer-than-expected hospitalization stays are 

44 

considered to be a patient safety issue due to the potential for exposure to hospital-acquired infections. 

Third, there are no resources for homeless veterans who do not 

qualify for placement in long-term care but are too sick to return 

to the street. 

I leave you with a patient care story that we have experienced 

in our own community. 

A 50-year-old veteran entered our hospital with liver failure. He 

needed residential hospice care because his elderly mother could 

not care for him during his last days. The only options provided by 

the VA were transfer to the Mountain Home facility 21⁄2 hours 

away or admission to a local nursing home. All of our local nursing 

homes were either full or initially refused the patient due to payment concerns. The patient’s elderly mother sat at his bedside in 

tears due to fear that her son would be moved to Mountain Home 

and she would not be with him during his death. After 13 days of 

hospitalization, a local nursing home finally agreed to take the patient. 

Thank you for your time and concern for our veterans in rural 

communities. 

[The prepared statement of Mr. Watson follows:] 

PREPARED STATEMENT OF ALAN WATSON, CHIEF EXECUTIVE OFFICER, SAINT MARY’S

MEDICAL CENTER OF CAMPBELL COUNTY, LAFOLLETTE, TENNESSEE

Chairman Akaka, Ranking Member Burr, and Distinguished Members of this 

Committee, and all others attending, thank you for the opportunity to speak to you 

today about the challenges small communities encounter when providing health care 

to our veterans. 

I am Alan Watson, Chief Executive Officer of St. Mary’s Medical Center of Campbell County in LaFollette, Tennessee. St. Mary’s Medical Center of Campbell County 

is located in a rural Appalachian community and provides 56 acute care beds, 10 

senior behavioral health beds, and 98 long term care beds. We offer a broad array 

of acute care services including Emergency Care, General Surgery, Pulmonary Medicine, Cardiology, Senior Behavioral Health and Imaging Services. 

In our county, almost one-fourth of the population is below the Federal poverty 

level. All of our healthcare providers provide care every day without the guarantee 

of adequate reimbursement for that care, making it hard to recruit physicians in 

this area. The National Health Service Corps has been a valued resource in recruiting providers to our areas, but we still need more health care providers in our 

community. 

Many of the patients we serve are veterans. 3,500 live in the county where our 

hospital is located. And I believe that they get wonderful health care from VA facilities if they are fortunate enough to have the means to travel to them, or live near 

them. Our concerns with the VA system are not with the care it delivers to veterans 

within the system, but with access to that care and continuity of care for our rural 

veterans. 

ACCESS TO CARE

Access to care for our veterans is limited by the distance to VA facilities and the 

number of providers available at those facilities. The closest outpatient clinic is located 1 hour from LaFollette in Knoxville, Tennessee. This clinic provides primary 

care, pharmacy, and limited diagnostic services. Specialist care is not available to 

manage the many disease processes identified in our veteran population. Veterans 

who require hospitalization and/or specialist care must drive to the Veterans Administration Medical Center in Mountain Home, TN, a 2.5 hour drive. The next closest 

VA Medical Center is located in Murfreesboro, TN, a 3.5 hour drive. 

These distances present significant challenges to our veterans considering that 

many cannot drive and do not have family members available to drive them to 

Mountain Home or Murfreesboro. In addition, it is reported that local ambulance 

services are reluctant to transport patients because payment has been denied in the 

past by the VA. 

45 

The second limiting factor related to care access is the low numbers of providers 

at the various VA clinics. Appointments are scheduled weeks and sometimes months 

in advance. Acute patients can ‘‘walk in’’. However, there is no guarantee that they 

will be seen that day. In many cases, the patients will be forced to seek care in our 

emergency department while waiting for appointments in VA clinics. 

CONTINUITY OF CARE

The continuity of care provided to our veterans is the second area of concern for 

our community. Problems occur related to communication between providers, Long 

Term Care placement, and the options for homeless veterans. 

First, follow up communication between VA providers and local primary care physicians is minimal or non-existent. In addition, it is difficult to obtain records from 

the VA clinics regarding ancillary testing and current medication lists. 

Second, it is challenging for hospitals to place patients needing Long Term Care. 

Local Long Term Care facilities are reluctant to accept VA patients due to poor reimbursement and the volumes of paper work required. This results in longer lengths 

of hospitalization while placement options are being explored. It has been well documented that longer than expected hospitalization stays are considered to be a patient safety issue due to the potential for exposure to hospital acquired infections. 

Third, there are no resources for homeless veterans who do not qualify for placement in Long Term Care but are too sick to return to the street. In many cases, 

these patients remain in the hospital for long periods of time until their disease 

process can be managed in their homeless situation. Again, we have created a patient safety issue due to the longer than expected length of stay. 

I leave you with two patient care stories that we have experienced in our 

community: 

A 50-year-old veteran entered our hospital with liver failure. He needed residential hospice care because his elderly mother could not care for him during his last 

days. The only options provided by the VA were transfer to the Mountain Home facility 2.5 hours away or admission to a local nursing home. All of our local nursing 

homes were either full or initially refused the patient due to payment concerns. The 

patient’s elderly mother sat at his bedside in tears due to fear that her son would 

be moved to Mountain Home and she would not be with him during his death. After 

13 days of hospitalization, a local nursing home finally agreed to take the patient. 

An 84-year-old veteran was admitted to our facility after being seen at a VA Medical Center 3 days earlier for a large ulcer on his one leg. He was a blind amputee, 

with many other medical problems. The patient was informed by the VA that his 

condition did not warrant hospital admission. Adult protective services listed his living conditions as extremely poor. His wife was already in a nursing home and they 

had no children or other local family members to care for him. Our case managers 

worked with the VA system for 6 days before approval was granted for nursing 

home placement in another community. Our staff spent hours completing forms and 

placing phone calls to obtain this approval. After his placement, payment to the hospital for our care was denied by the VA for his entire length of stay because it was 

not deemed a medical emergency and VA facilities were ‘‘feasibly available’’ to provide his care. 

Thank you for your time and concern for our veterans in rural communities. 

Chairman AKAKA. Thank you very much, Mr. Watson. 

Mr. Loftus? 

STATEMENT OF THOMAS LOFTUS, COMMANDER, THE 

AMERICAN LEGION, POST 45, CLARKSVILLE, VIRGINIA 

Mr. LOFTUS. Chairman Akaka, Senator Burr in absentia, and 

distinguished Members of the Committee, thank you for the opportunity to speak today about veterans living in rural areas. 

My name is Tom Loftus. I work every day with veterans living 

in rural areas, trying to help them find health care. I am myself 

a veteran, a disabled veteran, having served in the Air Force Medical Service Corps during the Vietnam era and in the Public Health 

Service Corps as a commissioned officer, in the National Health 

Service Corps, and at the community health clinics. Having left the 

Air Force, I was also the Chief Operating Officer of the National 

46 

Health Service Corps, Region III. I was Chief Executive Officer of 

the Public Health Service’s Occupational Health Division, and Administrator of the Occupational Medicine Department at State. 

More recently, I have worked with a variety of community health 

centers on physician recruitment, physician retention, and staffing. 

What brings me here today is the situation in the community 

where I live—a small town in southern Virginia called Clarksville, 

population 1,200. The county has a population of 30,000. Prior to 

opening up this new command position at the American Legion, I 

was running a community health service clinic in Boydton, Virginia, population 400. So, I am very familiar with the issues of both 

where you are located and health care delivery. 

Many of the issues that I have about the veterans you have already heard. Many revolve around access to health care. Our particular catchment area is in VISN 6 out of Durham. We are approximately an hour and one-half to Richmond; we are an hour and 

one-half to Durham. 

The big problem is neurological problems. We are 4 hours to VA 

Medical Center Salem, 3 hours to VA Medical Center Hampton. 

Many of our patients who have PTSD have to go to group therapy 

either at Durham or in Richmond, or if they have profound psychotic diagnoses, which a lot of them do, they have to go Hampton 

or Salem. 

As a minimum, there should be community-based personnel who 

can assess Post Traumatic Stress Disorder and Traumatic Brain 

Injury, with the understanding that our veterans can get follow-up 

at VA Medical Center Hampton and VA Medical Center Salem if 

needed. The problem is access. Our particular part of the country 

has no intra-city bus service, no intra-city train service, and/or taxi 

service. The transportation situation does not offer an easy way for 

veterans and family members to travel. 

The second issue we have is we are part of a national network, 

Department of Health and Human Services’ Community Health 

Centers—and I was very impressed with Senator Burr’s comment 

that there is discussion going on between the Department of 

Health and Human Services, the Health Resources Service Administration, Bureau of Primary Care, and the Indian Health Service 

to address the access issue that was spoken about earlier. 

People forget that we have 10,000 federally qualified community 

health clinics in the United States. In my area alone, covering six 

counties, we have seven of them—all fully equipped, very modern, 

well equipped. I regret to say that one clinic in Boydton, Virginia, 

is losing its board-certified psychiatrist next month, and its trauma-trained counselor because they cannot make a living on Medicaid reimbursement—Southern Dominion Health System with its 

multiple clinics in Southside Virginia. 

Another issue is women’s health. A significant fraction of the 

staffing of the community health clinics are women. A significant 

fraction of students in medical school are women. A third of the 

graduates of medical school are women. So as a result, a significant 

fraction of women practitioners are in these community health 

services, and they should be utilized for veteran women health 

problems. Women have just as many problems as the men—PTSD/ 

TBI, family separation, relationship problems, et cetera. 

47 

One problem with the VA is voucher services. The only people 

that are allowed to get a voucher from the VA now is a 100-percent 

disabled vet. It is only good for $150 to $200. 

I will summarize by saying this: The simplest solution from the 

community health service is to put in a veteran medical center terminal—VA could put terminals into clinics. Most of these clinics 

have electronic medical records. I want to also compliment VARichmond and VA-Durham. They do a superb job in medical care. 

Thank you, Chairman. 

[The prepared statement of Mr. Loftus follows:] 

PREPARED STATEMENT OF THOMAS LOFTUS, COMMANDER, 

AMERICAN LEGION POST #45 

Chairman Akaka, Senator Burr, and Distinguished Members of this Committee, 

and all others attending, thank you for the opportunity to speak today on behalf 

of veterans who live in rural areas. 

My name is Tom Loftus, and I work every day with veterans living in rural areas, 

trying to obtain health care for them. I am myself a veteran, having served in the 

Air Force Medical Service Corps during Vietnam and in the Public Health Service. 

Since leaving the Air Force, I have also been the Chief Operating Officer of the National Health Service Corps, Chief Executive Officer of the Public Health Service’s 

Occupational Health Division, and Administrator of the Department of State’s Occupational Medicine program. More recently, I have worked with community health 

centers on provider recruitment and health care management services. 

What brings me here today is the situation in the community where I live, a small 

town in Southern Virginia, called Clarksville. As Commander of American Legion 

Post #45, I hear the concerns of our veterans daily. Many revolve around their access to health care. Veterans in my community must travel 3–4 hours to Salem or 

Hampton, Virginia for neurological care. A 3–4 hour trip can be overwhelming for 

some of our veterans with Traumatic Brain Injury. 

At a minimum, there should be community based personnel who can assess 

veterans for Post Traumatic Stress Disorder and Traumatic Brain Injury, with the 

understanding that our veterans can follow-up at the Hampton and Salem hospitals 

if needed. Even for our veterans needing routine care for conditions like diabetes 

and high blood pressure, or group therapy for mental health conditions, they must 

travel 1–2 hours to Durham, North Carolina, or Richmond, Virginia for these 

services. 

There are some who believe that the problems of rural veterans have been solved 

by reimbursing community providers under a fee-for-service system. Under this system, the VA gives the veteran a voucher that they can use to get a specific screening 

or test in the community. The voucher amounts vary but in our area are usually 

in the $150-$200 range. These are episodic payments for one time use. They are 

available only sporadically and not used for routine medical care. 

This creates a situation where veterans receive occasional care in the community, 

which is often poorly coordinated with the care they do receive in VA facilities because local providers do not have access to VA’s electronic medical record. While we 

understand that the VA could never construct a VA hospital or clinic in every community like ours in the country, we believe there are opportunities for the VA to 

work with community health centers to provide care where VA facilities do not 

exist. For example, there are over 20 Bureau of Primary Care centers funded by the 

Department of Health and Human Services in Southern Virginia alone. 

To solve this problem the VA could credential and privilege VA providers to work 

in our community health centers, allowing them to service our veterans without the 

expense of building separate VA facilities. As VA employees, they would have access 

to the electronic medical record, and be able to put health information gathered in 

the community directly into the VA’s electronic medical record, ensuring that any 

provider seeing the veteran would have access to all of his or her health information. If it is not feasible for the VA to hire these providers, then they might expand 

their fee basis voucher system to allow private providers and clinics to care for our 

veterans. 

In short, every veteran, no matter where they live, deserves the best care our 

country can give them. The only way that this can occur is if the VA and our communities work together to solve this problem. 

48 

I thank this Committee for the opportunity to share with you the challenges our 

veterans in rural Southern Virginia and elsewhere face as they return to communities without VA health care facilities. 

Chairman AKAKA. Thank you very much, Mr. Loftus. 

Now we will hear from Mr. Kuntz. 

STATEMENT OF MATTHEW KUNTZ, EXECUTIVE DIRECTOR, 

MONTANA CHAPTER, NATIONAL ALLIANCE ON MENTAL ILLNESS 

Mr. KUNTZ. Chairman Akaka, Ranking Member Burr in 

absentia, and Members of the Committee, as Executive Director of 

the Montana Chapter of the National Alliance on Mental Illness 

(NAMI), I appreciate your invitation to testify before this Committee. Also on behalf of the NAMI National Office, please accept 

NAMI’s collective thanks for this opportunity. 

Mr. Chairman, my formal statement submitted to the Committee 

included information about NAMI and its work and important 

issues relevant to veterans living with mental illness under VA 

care. In the interest of time, I am not discussing those issues, but 

they are policy matters that I hope you will consider. 

As a proud and grateful consumer of the VA, I thank you for 

your work on this Committee. I also want to thank Senator Jon 

Tester for identifying me to your staff as a potential witness today. 

Senator Tester is an incredible ally in the fight to secure adequate 

treatment for veterans with mental illness. After my step-brother’s 

death, I called politicians across Montana to get help on this issue. 

Senator Tester was the only who called me, and I cannot thank 

him enough for that. 

For my background, I came into this position the hard way. I lost 

my step-brother to a PTSD-induced suicide 15 months after he returned from Iraq. It was a tragic and utterly preventable situation. 

I started fighting for better care 1 week after Chris’ death, and I 

continue to this day, eventually giving up my law practice and taking over for NAMI. I will be addressing you from that position. 

Our main issue is geography. Plain and simple, Montana is the 

fourth biggest State in the country. We have over 147,000 square 

miles. That is 36 Big Islands, 31⁄2 States of Virginia, and 2 States 

of Washington. It is big. And we also have a high per capita need 

for these services. We have a high percentage of veterans. We battle Alabama for the highest illness rate in the country, and we also 

have the highest percentage of wartime injuries per capita, with 

over 22 per 100,000. So I think it is a logical assumption that we 

also have just about around the highest rate of wartime PTSD per 

capita. 

Our challenges are further complicated by our State mental 

health system. It is overburdened and underfunded. With all honesty, we just cannot expect that they will be able to pick up the 

veterans that get through the cracks. 

We also have challenges in serving our Native veterans. A significant portion of our warriors come from Montana’s Indian population. They have distinct and proud cultural backgrounds, and the 

VA must serve them in a culturally sensitive manner. While we 

take our enemy as we find them, we take our heroes as they find 

us. Our tribal veterans’ representatives are a critical tool in this efVerDate Nov 24 2008 15:27 Dec 01, 2009 Jkt 000000 PO 00000 Frm 00052 Fmt 6633 Sfmt 6601 H:\ACTIVE\022609.TXT SVETS PsN: PAULIN
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fort and making sure that the veteran does not become the ‘‘hot potato’’ between IHS and the VA. 

One of the most critical issues that we have is a lack of crisis 

beds in our community. Plain and simple, if a veteran in Scobey, 

Montana, wants to commit suicide, we have no humane solution to 

deal with that. It is an 8-hour drive to our State mental hospital, 

and that is a long time for one of our heroes to be stuck in the back 

of a squad car. 

We need to ensure that the VA has access to, or can arrange, 

geographically dispersed crisis beds to ensure that no veteran is 

made to travel more than 2 or 3 hours to a safe place of care. We 

are working on this at the Montana Legislature, but realistically, 

we cannot do it without your help. The lack of inpatient services 

is only making this worse. 

I will come to one last conclusion. I have been working with Senator Baucus on preparing a screening measure for the Department 

of Defense. The real way to tackle this problem is to screen them 

before they hit the VA. We cannot have them dumped on our system not having any treatment for their mental illnesses, and I ask 

you to support us in that fight. 

Thank you, Mr. Chairman. Mahalo and thank you for your 

ko ̄kua. 

[The prepared statement of Mr. Kuntz follows:] 

PREPARED STATE OF MATTHEW KUNTZ, EXECUTIVE DIRECTOR, MONTANA CHAPTER, 

NATIONAL ALLIANCE ON MENTAL ILLNESS

Chairman Akaka, Ranking Member Burr, and Members of the Committee—As the 

Executive Director of the Montana Chapter of the National Alliance on Mental Illness (NAMI), I appreciate your invitation to provide testimony to the Committee. 

Also on behalf of NAMI Executive Director Michael Fitzpatrick, our NAMI Board 

of Directors Veterans Committee Chairman Fred Frese, Ph.D., and our national 

grassroots Veterans Council Chairman, Ms. Sally Miller, a neighbor of mine from 

Bozeman, Montana, please accept NAMI’s collective thanks for this opportunity for 

me to testify before your Committee today. 

Mr. Chairman, as a proud and grateful consumer of services provided by the Department of Veterans Affairs (VA), I thank you for your work on this Committee 

to sustain and improve programs for veterans. I also want to thank Senator Jon 

Tester for identifying me to your staff as a potential witness today. Senator Tester 

has been an incredible ally through all of my experiences and involvement with veterans’ mental health issues. We are happy to have him represent God’s Country in 

the Senate of the United States. 

NAMI is the Nation’s largest non-profit organization representing and advocating 

on behalf of persons living with chronic mental health challenges. Through our 

1,100 chapters and affiliates in all 50 states and over 200,000 members, NAMI supports education, outreach, advocacy and biomedical research on behalf of persons 

with schizophrenia, bipolar disorder, major depression, severe anxiety disorders, 

Post Traumatic Stress Disorder (PTSD), and other chronic mental illnesses that affect children and adults. 

NAMI and its veteran members established a Veterans Council in 2004 to assure 

close attention is being paid to mental health issues in the VA and especially within 

each Veterans Integrated Services Network (VISN) and at individual facilities. We 

advocate for an improved VA continuum of care for veterans with severe mental illness. The council includes members from each of VA’s 21 VISNs. These members 

serve as NAMI liaisons with their VISNs; provide outreach to local and regional 

Veterans Service Organization units; increase Congressional awareness of the special circumstances and challenges of serious mental illness in the veteran population; and work closely with NAMI State and affiliate offices on issues affecting 

veterans and their families. Our members are deeply involved in consumer councils 

at almost 50 VA medical centers and we advocate for even more councils to be established throughout the VA system. 

50 

In respect to VA’s consumer councils, some of my NAMI colleagues have learned 

and have asked me to report to this Committee that some VA attorneys may be 

using the requirements of the Federal Advisory Committee Act (FACA) as a type 

of shield to prevent or obstruct the establishment by VA facilities of new consumer 

councils in the mental health area. This is a very worrying trend. A consumer council is not a Federal advisory committee in any sense of that concept. Participating 

in consumer councils is at the very heart of our involvement in the care of our family members who are veterans in VA treatment programs. VA’s own mental health 

strategic reform plan, adopted formally by the Veterans Health Administration almost four years ago, prominently calls for the establishment of mental health consumer councils as a key component of advancing recovery as a model goal for the 

entire VA system. NAMI hopes you will use your oversight to examine how VA attorneys could reach a conclusion that a VA mental health consumer council is a Federal advisory committee within the meaning of the FACA, particularly in the face 

of the hundreds of councils that have been established by VA over the years. Hopefully you can change their minds. 

NAMI’s Veterans Council membership includes veterans who live with serious 

mental illness, family members of these veterans, and other NAMI supporters with 

an involvement and interest in the issues that affect veterans living with mental 

illness. Also our Veterans Council and other NAMI resources are committed to a 

Memorandum of Understanding NAMI secured in 2008 with the Department of Veterans Affairs, to bring NAMI’s signature education program, called ‘‘Family to Family,’’ directly into the VA mental health treatment environment. Family to Family 

is a formal twelve-week NAMI educational program that enables families living 

with mental illness to learn how to cope with and better understand it. 

NAMI’s Family to Family program provides current information about schizophrenia, major depression, bipolar disorder (manic depression), Post Traumatic 

Stress Disorder (PTSD), panic disorder, obsessive-compulsive disorder, borderline 

personality disorder, co-occurring brain disorders and addictive disorders, to family 

members of veterans suffering from these challenges. It supplies up-to-date information about medications, side effects, and strategies for medication adherence. During 

these sessions participants learn about current research related to the biology of 

brain disorders and the evidence-based, most effective, treatments to promote recovery from them. Family members gain empathy by understanding the subjective, 

lived experience of a person with mental illness. Our Family to Family volunteer 

teachers provide learning in special workshops for problem solving, listening, and 

communication techniques. They provide proven methods of acquiring strategies for 

handling crises and relapse. Also, Family to Family focuses on care for the caregiver, and how caregivers can cope with worry, stress, and the emotional overload 

that attends mental illness in families. We at NAMI are very proud of Family to 

Family, and we were especially pleased last year that Under Secretary Michael 

Kussman and VA’s Office of Mental Health saw the wisdom of finally bringing 

NAMI resources like Family to Family into VA mental health programs at the local 

level. 

Mr. Chairman, section 7321 of title 38, United States Code, requires VA to appoint a ‘‘Committee on Care of Veterans with Serious Mental Illness,’’ with clearly 

defined duties: to identify system-wide problems and specific VA facilities at which 

program enrichment is needed to improve treatment and rehabilitation, and to promote model programs that should be implemented more widely within VA’s mental 

health practice. These are the expectations of Congress for that committee. Since 

2006, however, this Committee—an activity that at one time displayed inspired 

leadership and effectiveness in meeting this Congressional mandate—has seemingly 

become a functional arm of VA Central Office (VACO) leadership, and is no longer 

an independent voice for better services for the most vulnerable enrolled patient 

population: the chronically mentally ill. As an endorsing organization that holds 

designated seats on this Committee, NAMI is in full agreement with the Independent Budget for FY2010 that the current committee structure and function 

should be replaced by another activity that has more independence and an ability 

to communicate its findings directly to the Secretary of Veterans Affairs and to Congress without interference. NAMI joins the Independent Budget in urging the Committee to take appropriate steps to reform this function. 

I joined the fight for better care for our returning servicemembers’ post traumatic 

stress injuries after losing my step-brother, Chris Dana, to a Post Traumatic Stress 

Disorder (PTSD)-induced suicide approximately fifteen months after he returned 

from Iraq where he served as a Humvee machine gunner with the 163rd Infantry 

Regiment of the Montana National Guard. 

Chris’s death was an ugly, painful, and needless tragedy. However, it did spark 

a major campaign in Montana for better treatment for our servicemembers and vetVerDate Nov 24 2008 15:27 Dec 01, 2009 Jkt 000000 PO 00000 Frm 00054 Fmt 6633 Sfmt 6621 H:\ACTIVE\022609.TXT SVETS PsN: PAULIN
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erans who are struggling with mental illnesses. The Governor put together a task 

force to analyze the problem and make recommendations. In October 2007, the Montana National Guard implemented all of the task force’s recommendations. By the 

summer of 2008, the National Guard Bureau recognized that Montana had implemented the best system in the country for caring for post traumatic combat stress 

injuries, depression and other readjustment challenges. 

Personally, I ended up giving up my practice as a corporate attorney to serve as 

Executive Director of NAMI Montana. In that role, I would like to explain to you 

some of the challenges that we have in treating Montana’s veterans that are struggling with mental illness. 

All of the challenges are tied to the fact that Montana is the fourth largest state 

with a relatively small population, less than a million people. The state of Montana 

contains an area of approximately 147,046 square miles. That area is large enough 

to fit more than thirty-six of the Big Island of Hawaii. Montana is over three and 

a half times the size of the state of Virginia. We are also double the size of the State 

of Washington. 

The population of Montana has a significant need for treatment for combat-related mental illnesses. We are also among the leading States in both the percent 

of wartime casualties per capita and the percent of wartime injuries per capita. I 

think that it is therefore a reasonable assumption that Montana is also among the 

highest States in PTSD related to the conflicts in Iraq and Afghanistan per capita. 

The logistical challenges of treating veterans with severe mental illnesses scattered across a state the size of Montana are obvious. But they are compounded by 

Montana’s lack of a strong mental illness treatment infrastructure for the VA to rely 

upon as a safety net. In NAMI’s 2006 Grade the States Report, Montana’s system 

for treating seriously mental illness graded out at an ‘‘F.’’ Based upon that grade, 

the VA cannot expect that the State of Montana will be able to provide treatment 

for veterans with mental illness who fall through the cracks of the VA system. 

While the Montana VA has admirably been able to utilize telemedicine to overcome some of the logistical challenges, some treatment challenges cannot be resolved with high technology fixes. For example, our state desperately needs geographically dispersed crisis beds to serve veterans in rural areas that have a mental 

health emergency. Put simply, if a veteran threatens to commit suicide in Scobey, 

Montana, we do not have a humane way to handle that threat. The distance from 

Scobey to our state mental hospital is 534 miles, an eight hour drive. That is a long 

time to have one of our combat heroes shackled in the back of a police car. It is 

also a long time for a small community that may have only three or four law enforcement personnel to give up a deputy and a patrol car. 

We need to ensure that the VA has access to, or can arrange, geographically-dispersed crisis beds to ensure that no veteran must be made to travel more than two 

or three hours to get to a safe place of care. 

The crisis beds issue is becoming even more critical due to the waiting periods 

at the Department of Veterans Affairs’ inpatient mental health treatment facilities. 

Last month, I worked with Senator Tester’s staff on the case of a Marine combat 

veteran with PTSD who had a co-occurring substance-use dependency problem. This 

veteran had been court-ordered into inpatient treatment because in the opinion of 

the court he needed immediate and critical help. The veteran was placed on a VA 

waiting list in November 2008 for an opening in March 2009. The court contacted 

me at the end of January when they were worried that the veteran was going to 

kill himself. Thankfully, Senator Tester’s staff ensured that the veteran got the help 

that he needed, but this veteran’s plight highlights the fact that our failure to treat 

a veteran’s mental illness at a preliminary stage will eventually lead to a higher 

and more expensive level of care. 

In the case of a crisis, it’s a level of care that the State of Montana really needs 

the Federal Government’s help on, because we cannot do it alone—especially given 

the current financial situation. 

That brings me to another important point. One of the major lessons from Chris’s 

death is that we can’t afford to wait for symptoms of the illness to become so overwhelming that servicemembers either reach out for help or have their lives collapse. 

In response to our bitter lesson, Montana implemented a face-to-face screening program for all of its returning servicemembers, upon redeployment and then every six 

months afterwards for two years. 

These screenings help open the way to provide effective treatment when the disease is in its initial stages. Just like any other illness, early treatment is more effective from both a medical and cost standpoint. In human terms, it can make the difference between whether a veteran moves on to be a productive member of society, 

ends up on the street—or worse. In VA financing terms, early intervention and 

treatment can lead to lower health care costs and reduced disability ratings. 

52 

These screenings will allow the Department of Defense to treat military personnel’s mental illnesses when they first arise, not drop them off on our rural VA 

health care system one step away from a full blown psychiatric or substance abuse 

crisis. 

I have been working with Senator Baucus and Senator Tester on developing draft 

legislation to implement the Montana Model on a national scale for the active duty, 

reserve and National Guard units and members who are coming home from combat 

deployments. I would really appreciate your support for that legislation. 

To summarize Mr. Chairman, in the year following my step-brother’s death, I was 

overwhelmed by the calls and letters that I received from veterans and family members who needed help. So I joined NAMI and gave up my practice as a corporate 

attorney to focus on advocating for people affected by severe mental illness. In that 

role, I have noticed three glaring issues that need to be addressed. 

The first issue is that we need to reduce the waiting times to gain access to inpatient mental health treatment facilities. Thankfully, as I mentioned earlier, Senator 

Tester’s staff ensured that a veteran in crisis was admitted earlier than VA had 

planned. But let me ask you: should we need to rely on a U.S. Senator’s intervention 

to get a combat veteran into a critical VA treatment program that might save his 

life? 

The second problem, especially important in Montana and other rural and frontier 

States, is that we need access to appropriate beds for our veterans who are in mental health crisis. The bottom line for me is that we need to ensure that the VA has 

access to, or can arrange, geographically dispersed crisis beds to ensure that no veteran must be made to travel more than two or three hours to get to a safe place 

of care. 

The third concern is that diversionary courts can be excellent tools to get veterans 

who are struggling with mental health issues the help that they need. In the instance of the Marine I described earlier, the drug court likely either saved his life 

or kept him out of prison. We have a mental health court in Missoula that is similarly effective at helping sick veterans receive the help they need. I have even read 

about a ‘‘Veterans Court’’ that was established in Buffalo, New York, designed to 

help combat veterans who have fallen through the cracks. I would urge this Committee and the VA to support the development of these diversionary courts for veterans, and especially combat veterans, and to make sure that VA reaches out and 

coordinates with the existing courts system to ensure the most timely and effective 

care possible, rather than allowing sick and disabled veterans to be convicted and 

go to jail or prison. 

Mr. Chairman, my colleagues at NAMI’s national office also asked me to highlight 

for the Committee a current collaboration between the Department of the Army and 

the National Institute of Mental Health (NIMH), on the development of effective 

suicide prevention strategies. According to my NAMI colleagues, the Army Secretary 

and NIMH Director have made this initiative a top priority for their respective 

agencies. I certainly agree it is critical that both the Army and the VA more effectively engage with the NIMH to ensure that suicide prevention efforts are grounded 

in sound scientific evidence, but I would also add from my experience that the 

Army’s efforts should extend to involvement of the National Guard Bureau and all 

the State National Guard adjutants, to bring these efforts to the ground in rural 

America, where our Guard members reside and must live after serving their deployments in combat. 

Mr. Chairman, the National Alliance on Mental Illness is committed to supporting 

VA efforts to improve and expand mental health care programs and services for veterans living with serious mental illness. Our members directly see the effects of 

what the national Veterans Service Organizations have reported through the Independent Budget for years: chronic under-funding and late funding of veterans’ health 

care has eroded the VA’s ability to quickly and effectively respond to present-day 

and projected requirements, even with the infusion of new funds it now is receiving. 

Until very recently forward motion has been stalled for years on VA’s ‘‘National 

Mental Health Strategic Plan,’’ to reform its mental health programs—a plan that 

NAMI helped develop and fully endorses. NAMI wants to see VA back on track for 

improved access to mental health services for veterans returning from Iraq and Afghanistan, as well as others diagnosed with serious mental illness—all important 

initiatives within the VA strategic plan. NAMI hopes the Committee will agree that 

oversight of VA’s implementation of the National Mental Health Strategic Plan and 

its recent announcement of a ‘‘Uniform Mental Health Service’’ benefits package, 

would be beneficial to ensuring its progress toward full implementation, to provide 

help to the newest war veterans and all veterans who live with mental illness. 

Mr. Chairman, this concludes my formal testimony. My colleagues at NAMI’s national office and I hope you will take all of our views into consideration as you conVerDate Nov 24 2008 15:27 Dec 01, 2009 Jkt 000000 PO 00000 Frm 00056 Fmt 6633 Sfmt 6621 H:\ACTIVE\022609.TXT SVETS PsN: PAULIN
53 

duct the important work of this Committee. Thank you again for inviting me to testify. I would be honored to answer any questions that you might have. 

Chairman AKAKA. Thank you very much, Mr. Kuntz. We are certainly glad to have you here. I will now defer to Senator Tester for 

his questions. 

Senator TESTER. Yes, thank you, Mr. Chairman. We will just 

kind of go down the line. 

Reverend Flippin, I have a couple questions on the CARE-NET 

program. First of all, is it Statewide? 

Rev. FLIPPIN. Yes, it is. It covers all 55 counties. 

Senator TESTER. That is good. Do you know—how is a person referred to your program? 

Rev. FLIPPIN. Through ten mini-grantees that we have dispersed 

throughout the State of West Virginia. Initially we were funded 

with enough money to go out and subcontract within our rural 

communities so we would be able to find out exactly what is going 

on. So we have our feelers throughout the State. 

Senator TESTER. OK. And I assume those same feelers that make 

the referring, they also know who to match people up with? 

Rev. FLIPPIN. No, they do not. 

Senator TESTER. How do you do that? 

Rev. FLIPPIN. That then becomes my job. [Laughter.] 

Let me give an example of what may happen. We receive a phone 

call from a young lady who is 20 years old, has a 2-year-old son; 

she is 4 months pregnant, and her husband in the Guard is currently in Afghanistan. She is having trouble trying to find a provider, and so she calls CARE-NET. I then call a local area in West 

Virginia and ask them to find us a provider who will at least talk 

with her and get her on the right track. That is basically it. 

Senator TESTER. Very good. How do you deal with issues that 

revolve around mental health? Or do you? 

Rev. FLIPPIN. Could you repeat that question? 

Senator TESTER. Excuse me. I will try to do it without the cough. 

How do you deal with issues that revolve around mental health? 

Or do you? Is that in your purview? 

Rev. FLIPPIN. Basically, we will do a referral. We will call someone in the mental health area, and then we will ask them for direction. 

Senator TESTER. All right. Well, I absolutely appreciate your 

work. Thank you very much for being here. 

Mr. Watson, you talked about your hospital facility in Tennessee, 

and I am just curious. Do you have mental health capabilities in 

your hospital? Do you have mental health professionals on staff? 

Mr. WATSON. We only have mental health capabilities for senior 

adults—that basically is 55 and over. The younger adults that require mental health capabilities, we must seek care in larger communities where there are mental health facilities. 

Senator TESTER. I got you. So that would be—you talked about 

the hospitals being 11⁄2 and 21⁄2 hours away. That is where they 

would be typically? 

Mr. WATSON. For veterans, yes, sir. 

Senator TESTER. How about for regular folks? How far would 

they—— 

54 

Mr. WATSON. For regular folks it would be 1 hour to Knoxville 

or 45 minutes to Oak Ridge, Tennessee. 

Senator TESTER. OK. Just your perspective, and I am going to 

ask you the same question, Mr. Loftus, because you deal with community health centers. You are dealing with a hospital. Do you 

think there are negative impacts that could happen on the VA with 

contracting services to hospitals? And you will get the same question about the community health center. Do you think there is any 

negative impacts to that? And if there are, what are they? Or if 

there are none, that is fine. 

Mr. WATSON. I do not believe there would be negative impacts. 

I think it would actually enhance the services that the VA is currently offering by contracting with local providers to take care of 

those veterans before it becomes an emergency. 

Senator TESTER. Good. How about you, Mr. Loftus? 

Mr. LOFTUS. Yes, I agree with that. As a matter of fact, there is 

a pilot test in VISN 6. The principal investigator is Dr. Harold 

Kudler, who is the head of VISN 6 psychiatry. I serve on a committee with him called ‘‘Virginia for Heroes.’’ We are doing a pilot 

test in Hampton, Virginia, where the VA works with the local Community Services Board, which are mental health services and field 

welfare offices. We were trying to get the PTSD/TBI assessments 

done at the lowest level in the community so these undiagnosed 

veterans can be screened and processed. This is a consortia between the State of Virginia, the Virginia Commission on Veterans, 

the Medical School of Virginia in Richmond, and VISN 6-Durham, 

North Carolina. 

The answer to your question is no, there is no stigma to it, as 

far as I am concerned. 

Senator TESTER. Actually, I am not talking from a stigma standpoint, just the numbers, I mean for providers. Your hospital has to 

have a certain number of patients to maintain a level of profitability. The same thing with the clinics. If you are going to stay 

open, you have to have a certain number of people. 

I guess the question I had is if we—and I agree there is need for 

contracting services, but I do not want to take away from the VA’s 

effectiveness by pulling down their numbers. But you do not see 

that as a problem? 

Mr. LOFTUS. No, no. The biggest problem is reimbursement. That 

is your biggest problem. Community health clinics only have four 

payers: the medically indigent, the Medicaid, the Medicare, on a 

sliding-fee schedule, and commercial pay. 

Senator TESTER. Right. 

Mr. LOFTUS. So, actually, the fusion of VA patients who are insured would actually be a boon to them. 

Senator TESTER. In Virginia, are there any cases where CBOCs 

are combined with community health care centers? 

Mr. LOFTUS. No. There is a CBOC in Danville, which is about an 

hour from where we are. But because of some idiosyncracies with 

the VA, there are medical records issues. If you signed up in Richmond and you go to Danville, you have got to take all your records 

from Richmond and take it to the Salem Hospital. So, there are territorial problems with the VA. 

55 

Senator TESTER. OK. I have got more questions, Mr. Chairman, 

but my time has run out. I will do another round if we can. 

Chairman AKAKA. Thank you very much. 

Senator Burris? 

Senator BURRIS. Thank you, Mr. Chairman. I would just like to 

commend the panel for your work in this area. It is going to take 

dedicated persons like you coming before us to make the case and 

let it be known what is going on out there. 

I would like to ask Reverend Flippin, Do you find your resources 

are strained by the need of veterans in West Virginia for professionals helping vets? Do they provide these services pro bono or at 

a discount? And what happens if the vet cannot afford the treatment? 

Rev. FLIPPIN. That is a complicated question for the State of 

West Virginia, and I would like to do that for the record. 

Senator BURRIS. OK. Thank you, sir. 

[The information requested was not received by press time.] 

Senator BURRIS. Mr. Watson, the issue in your area with access 

and continuity of care for veterans, why has this not been addressed previously? Or is it something that is just coming up? And 

what is the biggest weak link that has led to this failure to serve? 

Mr. WATSON. I think it has always been a problem for rural communities, for veterans to just get to the local VA facilities—21⁄2

hours to one facility, 31⁄2 to another. So I do not think it is a new 

issue. It has been ongoing for years. 

Typically what has happened is the veterans just seek care 

among the routine medical systems and avoid using VA systems, 

if at all possible, just because of the distances. There do become 

times when veterans have to access the system, and I think that 

is when they begin moving to drive those distances. But I do not 

think it is a new problem that has just occurred. 

Senator BURRIS. Now, would some of these be some of the Vietnam veterans who for so long did not come forward and now maybe 

some of them are coming forward, which is perhaps impacting the 

system more than it would normally? Not counting Desert Storm 

or the current Iraq/Afghanistan situation. 

Mr. WATSON. I think many of them have had private insurance 

through their employers, and so they have sought care among the 

local community providers. As they become unemployed or they retire and no longer have full coverage from their employers, then 

they will seek care among the VA system. 

Senator BURRIS. Do you see an increase in that, a pick-up from 

actually the Vietnam vets? Because they had all that confusion 

about those individuals who served, and they were really treated 

not so grandly when they returned home. And some of them were 

ashamed to even let it be known that they were Vietnam vets, 

which is just unconscionable. 

Mr. WATSON. I cannot say that we have seen an increase in numbers per se. It is just the traditional progress. If they no longer 

have commercial insurance or need supplements to Medicare and 

those type things, then they begin seeking care. 

Senator BURRIS. And one last question. Mr. Kuntz, how could the 

VA set up geographically diverse crisis beds for these mentally ill 

56 

patients? And where would they be located in your State? Or how 

would they be staffed? Do you have any thoughts on that? 

Mr. KUNTZ. Senator Burris, I think realistically it will have to 

be contracted out. In our State, if I was in charge, I would probably 

put one in Glasgow, Montana, in our northeast; one toward 

Glendive or I might actually just put money into Billings to make 

sure that their clinic stays open, because they have got a clinic but 

it is closing; potentially Kalispell in our northwestern section; and 

I would probably be happy with the State hospital in the southwest, potentially Lewistown in the central—but I think it is going 

to have to be a partnership with our hospitals, and it is going to 

be private staffing. 

We are working with the counties in the State to try to get them 

in, but I think that we are going to need some additional help, Senator. 

Senator BURRIS. Mr. Chairman, thank you very much. 

Chairman AKAKA. Thank you very much, Senator Burris. 

You have just talked about working with VA. That is what we 

hope can be improved. Let me ask each of you that question. 

From your vantage point, how could VA best work with you and 

your organization to help that? Reverend Flippin. 

Rev. FLIPPIN. First of all, I would say that the Veterans Administration and the Veterans Affairs Office, I think they have developed such a tight, bureaucratic organization that they do not welcome or they do not court outside assistance. I firmly believe that 

if we are going to be a bridge to our veterans, the community at 

large must be involved. The community at large cannot be closed 

out because we are not military. 

As an example, the community does not feel they are a part of 

the military force because they are not called upon to be directly 

involved in most of the activities that occur. And I find that to be 

the situation where I am daily dealing with the National Guard 

and the local community—the National Guard, they are doing a 

great job as far as referring their personnel. However, it is like a 

closed society, and the community wants to be involved in supporting our military veterans. The civilian community needs to be 

educated as well as the VA needs to realize that the good job they 

are doing is not getting to the community at large. 

And so, again, to summarize, I do not really believe we are going 

to help the invisible wounds, the mental illness and so forth, unless 

the civilian community is actively involved. And I am not talking 

about reaching out to churches; I am talking about reaching out to 

local community agencies who are nongovernmental or non-military aligned. And I thank you very much. 

Chairman AKAKA. Thank you, Reverend. 

Mr. Watson? 

Mr. WATSON. I believe that the best way for VAs to work with 

local community providers is just through partnerships. Use the 

physicians that we have in the communities to take care of the patients early in their disease processes. When we do have to admit 

them to a local hospital, make it easier for us to provide that care 

for them locally, if possible. If not, make it easier for us to transfer 

them to an appropriate level of facility as close to home as possible. 

57 

And, finally, reimburse us when we do take care of these patients 

in a timely manner. As I said, 1⁄4 of our population is below the 

poverty level. We are already caring for a lot of folks that cannot 

afford to pay. And when we take care of a veteran, we need to be 

reimbursed timely and reimbursed for the cost of that care. 

Chairman AKAKA. Thank you. 

Mr. Loftus? 

Mr. LOFTUS. Mr. Chairman, yes, I would like to propose that the 

VA actively look at doing a pilot test in the South Side of Virginia. 

We have got seven community health centers there. They are all 

brand-new, very modern. And there is a CBOC scheduled to be 

built in 2012 in Emporia. I do not know what the status of that 

is, but I certainly think we can implement many, if not all, of the 

recommendations that this Committee heard this morning as a 

pilot test. Thank you. 

Chairman AKAKA. Thank you. 

Mr. Kuntz? 

Mr. KUNTZ. Mr. Chairman, one of the critical things is educating 

family members. People with mental illness who have educated 

family members do better, and they are cheaper to treat. And the 

VA is partnering with NAMI to offer the family course. It is a free 

12-week course, and we just started up one in Helena last week; 

and we are pretty excited about it. I would have given anything to 

have taken that course when our family needed it. 

But one of the things that we need to do is work with the VA 

on offering that course via teleconference, because it is going to be 

hard to get family-to-family in Molokai or in Heart Butte. But we 

can do it via teleconference when they get the teleconference equipment in Molokai. 

Thank you, Mr. Chairman. 

Chairman AKAKA. Thank you so much. Thank you for your responses. 

I am going to ask Senator Tester for his questions and also to 

preside as Chair of the Committee. 

Senator TESTER [presiding]. Thank you, Mr. Chairman. Thank 

you very much. I have just a couple more questions. 

Thank you all for being here. I mean that as sincerely as possible. I appreciate your opinions and perspectives. I have got a few 

questions for Matt real quick. 

You know full well about Montana’s National Guard program 

that is requiring a face-to-face, in-person mental health evaluation 

for soldiers returning from combat. It is something that you addressed in your comments. How do you see that program working? 

Is it successful? Is it worthwhile? Is it money well spent? Is it time 

well spent? 

Mr. KUNTZ. Senator Tester, I think it is a brilliant program that 

helps get the National Guard members who need help in before 

their life spirals out of control and they reach for help. We would 

throw them the line before they ask for it. And with mental illness, 

it is utterly critical to get early treatment, and it is far more expensive if we wait. And I think that the best proof for how well this 

is working is from the Montana National Guard’s own actions. 

They have already been recognized as the best National Guard in 

the country at dealing with this. But this was originally funded, 

58 

this face-to-face screening using LCPCs—our counseling session 

once every 6 months for 2 years upon redeployment—was originally 

funded by a grant from TriWest, and that grant ran out. And the 

National Guard immediately picked it up. There was no doubt that 

this was helping their soldiers. 

Senator TESTER. If you think back to your brother’s situation, 

was there an evaluation with him when he came out? I am talking 

about a mental health evaluation. 

Mr. KUNTZ. There was a brochure that he was asked to fill out, 

Senator. 

Senator TESTER. Was his hidden injury—could it have been 

caught if there was an evaluation, in your opinion? 

Mr. KUNTZ. I believe so, Senator. I think that it may not have 

been caught immediately after redeployment, because I talked to 

him then, and he knew that he had some things that he was struggling with, but he thought it was just part of what he participated 

in. But the genius of the Montana screening model is it happens 

every 6 months. So, I do not think that they would have caught it 

upon redeployment. But, really, in my heart I believe that if they 

would have sat down with Chris 6 months later—when he could no 

longer go to drill, when he was having the flashbacks, when he was 

having trouble dealing with his own family—that is when that 

counselor could have got him to come out of his shell. But I will 

tell you, we tried later, a year later, and it was too late. 

So, we need staged things, because these things get worse. It is 

just like cancer or anything else. 

Senator TESTER. OK. Well, I certainly appreciate the perspective 

on a very difficult situation, and I once again want to echo what 

the Chairman said about the appreciation for you guys being here. 

We appreciate your time and appreciate your wisdom. 

We are adjourned. 

[Whereupon, at 12:04 p.m., the Committee was adjourned.] 

(59) 

A P P E N D I X 

PREPARED STATEMENT OF HON. BERNARD SANDERS, U.S. SENATOR FROM VERMONT

Thank you Mr. Chairman for calling this hearing today which focuses on such an 

important issue for every Member of this Committee because we all have rural 

areas in our states and suffer similar but also unique challenges in providing care 

to veterans in those areas. I want to welcome our witnesses who are with us today. 

Mr. Chairman, 12 out of Vermont’s 14 counties are either defined as entirely or 

mostly rural by VA. We have approximately 55,000 veterans in a state of roughly 

621,000. In other words, veterans make up nearly 9% of the population. We have 

beautiful towns and communities in Vermont but many of them are isolated and 

have trouble attracting quality health care providers and are far away from VA facilities. 

The FY2010 Independent Budget, which was just recently released, contains some 

interesting statistics on rural America and health which they compiled from a number of sources. Let me just list a few: 

• ‘‘Only 10 percent of physicians practice in rural areas despite the fact that onefourth of the U.S. population lives in these areas. State offices of rural health identify access to mental health care and concerns for stress, depression, suicide, and 

anxiety disorders as major rural health concerns. 

• Inadequate access to care, limited availability of skilled care providers, and stigma in seeking mental health care are particularly pronounced among residents of 

rural areas. 

• The smaller, poorer, and more isolated a rural community is, the more difficult 

it is to ensure the availability of high-quality health services. 

• Nearly 22 percent of our elderly live in rural areas; rural elderly represent a 

larger proportion of the rural population than the urban population. As the elderly 

population grows, so do the demands on the acute care and long-term-care systems. 

In rural areas some 7.3 million people need long-term-care services, accounting for 

one in five of those who need long-term care.’’ 

More specific to veterans, the IB states: 

• ‘‘There are disparities and differences in health status between rural and urban 

veterans. According to the VA’s Health Services Research and Development office, 

comparisons between rural and urban veterans show that rural veterans ‘have 

worse physical and mental health related to quality of life scores. Rural/Urban differences within some VISNs [Veterans Integrated Service Networks] and U.S. Census regions are substantial.’ ’’ 

And let’s take a moment to discuss where the members of our Armed Forces come 

from and return to when they are finished with their service. The Independent 

Budget notes that: 

• ‘‘More than 44 percent of military recruits, and those serving in Iraq and Afghanistan, come from rural areas. 

• Thirty-six percent of all rural veterans who turn to VA for their health care 

have a service-connected disability for which they receive VA compensation. 

• Among all VA health-care users, 40.1 percent (nearly 2million) reside in rural 

areas, including 79,500 from ‘highly rural’ areas as defined by VA.’’ 

In Vermont, like elsewhere in the country, many of our newer veterans are members of the National Guard and Reserve. As we all know, since September 11th, the 

Guard and Reserve have been called up to active duty in unprecedented numbers. 

Since that time more than 450,000 of these part-time soldiers have deployed to Iraq 

or Afghanistan; more than 800 of them have died. 

We need to make sure that the VA properly cares for these citizen-soldiers that 

have given so much. Frequently they are not as familiar with the benefits they are 

60 

entitled to and often do not have easy access to DOD military health facilities. This 

is the case in Vermont where we have no active-duty military installations. 

Given these challenges, we must redouble our efforts to provide both excellent VA 

care and access to that care in rural areas. Here are some of my priorities and interests in VA’s work in this area: 

1. Continue the Expansion of CBOCs and Vet Centers: I believe everyone on this 

Committee hears about the benefits of CBOCs and Vet Centers back in their states. 

We need more of them to provide health care, counseling, and other services closer 

to where veterans live, especially in rural areas. 

2. New Transportation Models: We need to explore new ways to develop programs 

partnering local, county, and state transportation agencies with those programs already operated by the Disabled American Veterans and the VA so that we can increase the help provided to bring veterans to the VA care that they need. I know 

that currently there are certain limitations on the type of VA patients that the DAV 

or VA employees can transport to VA for care and we need to examine changes to 

those rules. We need to use existing programs as much as possible and make sure 

we are leveraging resources that are already in place. 

3. Caring for Families: When we talk about care for veterans in rural areas we 

also need to make sure that we are talking about care for rural families of veterans. 

It is not just the veterans that may be isolated from care. We need to make sure 

that we are using the new authority which Chairman Akaka pushed for last Congress to allow the VA to provide more counseling services to the family members 

of veterans. What can we do to get more rural families of veterans to the VA? 

4. Increase the Use of Telehealth Services for Mental Health Counseling: In the 

White River Junction VA Medical Center in Vermont we are currently working on 

a pilot program proposal where the medical center would partner with a federally 

Qualified Health Center (FQHC) and a Community Mental Health Center (CMHC) 

to serve as locations to facilitate tele-mental health services. This would allow a veteran to come into a FQHC or CMHC and link up over a secure network with a VA 

mental health clinician down at the medical center. We are still in the development 

stages of this proposal but I hope it can become a model to be replicated in other 

parts of Vermont. 

5. More Peer-to-Peer Outreach: In recent years the VA has taken steps to improve 

its outreach to veterans using advertisements, letters, and phone calls. These are 

good steps but more needs to be done. Especially in rural areas, we need to do more 

peer-to-peer outreach where we use VA-trained veterans, preferably combat veterans, to help reach out to returning servicemembers, older veterans, and their families to make sure they know about and can access the services available to them 

at the VA, DOD, state and local agencies, and the profit and non-profit sectors. This 

could be for health care services but it could also be child care needs, employment, 

legal advice, etc. We have a program in Vermont that does this known as the 

Vermont Veterans and Family Outreach Program and it is quite effective. To date, 

over the last two years, the program has contacted 2,024 servicemembers and veterans and worked with them to fill out VA-developed mental health and TBI questionnaires and where appropriate, connect them to relevant services. 

6. Better Pay for VA Employees: In order to provide good quality care for our veterans we have to make sure that we have enough well qualified staff and that we 

do everything we can to retain those we have and attract others. In Vermont, the 

challenge we are experiencing is that the locality pay that determines how most of 

our workers are paid is not updated frequently enough and we are losing VA employees to other VA facilities in nearby states where pay is better. We need to make 

sure VA employees are paid competitive salaries so that they can afford to stay in 

rural areas. 

7. Do More to Expand Collaboration Between the Health Service Corps and VA: 

In preparation for this hearing, Committee staff research found that ‘‘the VA does 

not currently use certain Federal resources, such as the National Health Service 

Corps, to support its efforts.’’ I am a strong supporter of the National Health Service 

Corps and have worked to increase funding for them by $75 million in the American 

Recovery and Reinvestment Act that President Obama recently signed into law. I 

strongly urge the VA to develop a partnership with the excellent medical professionals that are part of this program. I am aware that the VA has other outstanding 

programs for recruitment and retention of nurses, physicians, and other health care 

professionals in rural areas. I believe partnering with the Health Service Corps 

would greatly compliment your efforts. We obviously don’t want to drain the Health 

Service Corps staff from other areas in need but surely more can be done to work 

together. 

These are just some of the steps I think we need to take in order to improve the 

care for our rural veterans and their families. I believe the VA has made significant 

61 

progress in this area but we have a long way to go. I look forward to learning about 

VA’s efforts and hearing from the members of our second panel who can tell us how 

they experience rural VA care in the real world. 

Thank you Mr. Chairman. 

PREPARED STATEMENT OF HARDY SPOEHR, EXECUTIVE DIRECTOR, PAPA OLA LOKAHI

Aloha Senator Akaka and Members of the Committee, Hawai′i Veterans, particularly those in rural areas, have multitudes of health care needs which presently are 

not being met by the Department of Veterans Affairs. It is commonplace at community meetings in Hawai′i’s rural areas to hear veterans identify their major issues 

and concerns: (1) lack of local access to primary care and specialty services; (2) lack 

of culturally sensitive health care providers; (3) inordinate amounts of time in communication, i.e. slow processing or no processing; and (4) lack of folks who can communicate effectively with them and inform them of their rights and services available to them. Often times these issues and concerns could be resolved very simply 

by having local health service providers already in these rural areas provide these 

veterans with their health care needs. Unfortunately, to date, the Department of 

Veterans Affairs has not seen fit to contract with community health centers or our 

Native Hawaiian Health Care Systems and/or other providers which could address 

our veteran’s health care needs right in their own respective communities. We 

would ask the Department begin to look at how best it could use existing service 

providers in rural areas to provide health care services to veterans. Unlike many 

VA clinics, most often the service providers themselves come from the same communities as do the veterans so there is instant rapport. 

Papa Ola Lokahi (POL), the Native Hawaiian Health Board, also would like to 

put forth the concept of utilizing the network of Native Hawaiian Health Care Systems (NHHCS), which operate throughout the State of Hawai′i—on every island— 

providing services to Native Hawaiians and others who avail themselves for health 

services. This network could be a valuable asset to the VA and its network of clinics. 

With the NHHCS, POL has recently undertaken a major veterans’ health initiative under the director of veteran Clay Park to better identify what the local issues 

are around health care for veterans and how better to address their identified 

needs. We would certainly look forward to assisting the Department of Veterans Affairs in any way that we could to improve the abilities of veterans to access and 

receive quality health care in rural areas in Hawai′i. 

Thank you for this opportunity to provide testimony on this critical matter for our 

country which has asked so much of our veterans. 

Æ