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[Senate Hearing 111-133]
[From the U.S. Government Publishing Office]

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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

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                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Lindsey O. Graham, South Carolina
Bernard Sanders, (I) Vermont         Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Roger F. Wicker, Mississippi
Jim Webb, Virginia                   Mike Johanns, Nebraska
Jon Tester, Montana
Mark Begich, Alaska
Roland W. Burris, Illinois
Arlen Specter, Pennsylvania \1\
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director

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

                            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

                   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 re-acclimating 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 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 
combat-related 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 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 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 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?

               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.
    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 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 long-term 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.
    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.
    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 
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 Sec. 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 non-profit 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 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 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.
                         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 established for the 2007-2008 school year. Six 
additional partnerships were selected in 2008.
    Both a recruitment and retention tool, the Employee Incentive 
Scholarship Program (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 appropriate 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 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 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 non-institutional 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 
tele-mental 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 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 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.
    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 highly-rural 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 
providers, 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 
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.
    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 
system 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.
    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:]
  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 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 non-VA care are getting the top quality for all 
services. So when we 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. However, 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 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.
    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? 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 
non-VA 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.
    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?
    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.
---------------------------------------------------------------------------
    \1\ Bodenheimer, T. ``Coordinating Care: A Perilous Journey through 
the Health Care System.'' New England Journal of Medicine. 2008; 10; 
358: 1064-1071.
    \2\ Gans, D et al. ``Medical Groups' Adoption of Electronic Health 
Records and Information Systems.'' Health Affairs. 2006; 24;5: 1323-
1333.
---------------------------------------------------------------------------
    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 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, 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 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.
    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 peer-to-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 military 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.
    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, CARE-
NET: 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.
    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.
    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 2\1/2\-hour drive. The next closest 
VA Medical Center is located in Murfreesboro, Tennessee, 3\1/2\ 
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 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 2\1/2\ 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.
    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 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.
    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 VA-Richmond 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.

    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, 3\1/2\ 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 effort 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 
kokua.
    [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.
    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 veterans 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.
    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 conduct 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 1\1/2\ and 2\1/2\ 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----
    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.
    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--2\1/2\ hours to one facility, 3\1/2\ 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 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.
    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, 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.]
                            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 one-fourth 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 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 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.
      

                                  
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