Evolving population trends--the aging of rural veterans, the growing number of female veterans and rates of homelessness among veterans--place significant demands on VA and rural delivery systems. Coordination among health care providers is essential to increasing the availability of services and expanding veteran outreach programs

Gale, John A., MS

Heady, Hilda R.

English

University of Southern Maine: Digital Commons@USM

University of Southern Maine USM Digital Commons Access / Insurance Maine Rural Health Research Center (MRHRC) 5-2013 Rural vets: Their barriers, problems, needs John A. Gale MS University of Southern Maine, Muskie School of Public Service, Maine Rural Health Research Center Hilda R. Heady Atlas Research Follow this and additional works at: https://digitalcommons.usm.maine.edu/insurance  Part of the Community Health and Preventive Medicine Commons Recommended Citation Gale, J. A., & Heady, H. R. (2013). Rural vets: Their barriers, problems, needs. Health Progress, 94(3), 49-52. This Article is brought to you for free and open access by the Maine Rural Health Research Center (MRHRC) at USM Digital Commons. It has been accepted for inclusion in Access / Insurance by an authorized administrator of USM Digital Commons. For more information, please contact jessica.c.hovey@maine.edu. BY JOHN A. GALE, M.S., AND HILDA R. HEADY, MSW, ACSWmericans from rural areas, in which 20 percent of our population resides, have historically answered the call to military service at higher rates than residents of urban communities. Over 44 percent of recruits come from rural areas compared to 14 percent from major cit-ies.1 Due to their higher rates of military service, rural Americans repre-sent a significant proportion of the veteran population, with 30 percent of U.S. veterans living in rural areas.2 This figure is expected to increase in the years to come. ARural veterans face numerous bar-riers to their access of health care, including: long travel distances to com-munity and U. S. Department of Veter-ans Affairs (VA) services; limited pro-vider choice; lack of specialty services; and inadequate provider supply. In addition, many providers lack “cultural sensitivity” to veterans’ issues, which creates a system that is less effective in meeting rural veterans’ needs. The geographic distribution of vet-erans across rural areas is one of many challenges faced by the VA in fulfill-ing its obligations to these individuals. Rural veterans suffer higher rates of depression, chronic disease and physi-cal health problems than other rural residents. In response to these issues, the VA has identified rural veterans as a population of interest for focused attention.3 DEMOGRAPHY OF RURAL VETERANSUsing the 2010 American Community Survey, the National Center for Veter-ans Analysis and Statistics provided a demographic overview of America’s 6.3 million rural veterans.4 It shows that, in general, rural veterans are older, less racially diverse, less edu-cated, more disabled and have greater health disparities than urban veterans. Rural male veterans are older than female veterans, with 70.5 percent of rural male veterans aged 55 and older compared to only 30.4 percent of rural female veterans. The age difference is explained by the influence of World War II, Korea and Vietnam veterans on the age profile of rural male veter-ans and the growth of the number of women in the military. Rural veterans are less racially diverse than rural non-veterans, with 91 percent white, 5.7 per-cent black, 2.7 percent Hispanic, 1 per-cent American Indian/Alaskan Native, and 1.1 percent Asian, native Hawaiian/other Pacific islander or other race. Almost 10 percent have not com-pleted high school, 33.9 percent have a high school diploma, 35 percent have an associate’s degree or some college, and 21.6 percent have a bachelor’s degree or higher. Almost 67 percent are employed, 6.4 percent are unem-ployed and 27.1 percent are not in the workforce. Approximately 6 percent live below the poverty level. Nearly 27 percent report one or more disabilities. In terms of periods of service, 26.4 percent served in peacetime, 6.5 per-cent in World War II, 10.4 percent in Korea, 36.4 percent in Vietnam, 11.8 percent in Gulf War I, and 9.2 percent in Gulf War II (Iraq and Afghanistan).Three evolving population trends place significant demands on VA and rural delivery systems. The first involves the aging of rural veterans, with 68 percent aged 55 and older.5 This trend will continue as the cohort of rural veterans between 55 years old and 65 years old (26.9 percent) ages up. The second trend involves the grow-ing number of female veterans. Women account for 8 percent (1.8 million) of veterans and are the fastest growing veteran cohort.6 The third trend involves homeless veterans, an estimated 131,000-200,000 on any given night and 262,000-400,000 annually.7 Homeless veterans represent all periods of service, with 47 percent having served during the Viet-nam era and 5 percent residing in rural areas. Although the majority are single males, women, often with children, are the fastest growing segment of home-less veterans.8Their Barriers, Problems, NeedsHEALTH PROGRESS             www.chausa.org            MAY - JUNE 2013 49Rural Vets: B R I N G I N G  V E T S  H O M E“I have become foul, and I cannot become clean again.”HEALTH CARE ISSUESA longitudinal study of veterans’ phys-ical and mental health-related quality of life indicates that rural veterans had lower physical scores than urban vet-erans, and those differences persisted over time.9 Rural veterans had better mental scores, but these differences declined over time. Although the Mil-lennium Cohort Study, composed of current and recent military personnel, found little evidence for rural/urban differences in health-related qual-ity of life measurements, the authors acknowledged previous studies that found rural/urban difference in older veterans.10 They suggested that the differential effect of residency pro-gresses slowly and only begins to show up over time. Health-related quality of life scores are based on a self-reported assessment of an individual’s multi-dimensional physical and mental sta-tus, including health risks and condi-tions. The data was collected through the VA’s “Survey of Healthcare Expe-riences of Patients” between 2002 and 2006. Lower scores indicated lower perceptions of health and are associ-ated with increased demand for health care services.Among rural veterans treated in VA outpatient settings, the most common diagnoses are hypertension, type II dia-betes, hyperlipidemia, post-traumatic stress disorder (PTSD) and depres-sion.11 Rural veterans also experience combat-related medical conditions including mild traumatic brain injury, PTSD and amputations. Rural areas have the highest percentage of veter-ans with service-related disabilities at 1.73 percent (compared to 1.47 percent for the U.S.).12The needs of aging, women and homeless veterans have significant implications for rural and VA deliv-ery systems. Growing numbers of aging veterans further burden already stressed rural long-term care ser-vices. More female veterans stimulate demand for gender-specific and men-tal health services. They also challenge the VA to evolve beyond its traditional service base of older men.13 The complex issues of homeless veterans, including substance abuse and mental health dis-orders, require rural and VA delivery systems to provide a comprehensive array of pri-mary care, behavioral health, case management, housing, prevention and supportive ser-vices. The growth in the num-ber of homeless female veterans fur-ther adds to this burden.The health care needs of veterans from different periods of service often are more directly related to their stages of life or socio-economic characteris-tics than their period of service. As dis-cussed earlier, aging veterans increase the demand for long-term care and other support services, while home-less veterans require a range of health care and supportive services. The link between period of service and ongoing health needs is most obvious for veter-ans of the Gulf War and of the Iraq War who experience a range of physical and behavioral health issues that include injuries associated with blast expo-sure (e.g., mild traumatic brain injury), PTSD, chronic joint pain (associated with carrying heavy packs), depres-sion, substance abuse, sleep issues and long-term effects of environmental and chemical exposure to pesticides, chem-ical and biological warfare agents, pro-phylactic drugs and vaccines, radia-tion, smoke from oil fires and open air burn pits, and occupational hazards (from working with chemicals, paints, and machinery during service).14 ACCESS BARRIERSBarriers to health care access include travel issues (involving time, distance MAY - JUNE 2013             www.chausa.org             HEALTH PROGRESS 50and cost), lack of transportation, lim-ited availability of VA services, lack of behavioral health and other specialty services, inadequate provider supply, coordination of care issues, imperfect understanding of VA benefits and lim-ited cultural sensitivity among com-munity providers regarding veterans’ needs.15 Travel and transportation issues are significant barriers, with reported one-way travel distances to VA primary care services averaging 45 to 54 miles.16 Veterans living more than 30 miles from VA services rely more heavily on local emergency depart-ment and primary care services for acute care issues.Twenty-five percent of veterans report that transportation consider-ations affect their ability to access care. Approximately 54 percent have only one car, 5.6 percent have no car and 11.1 percent lack a valid driver’s license. Thirteen percent rely on friends or family for transportation, and 11 per-cent use Disabled American Veterans van services when available. Limited availability of specialty and diagnostic services and concerns about the capac-ity of VA facilities were also identified barriers to care.17 Another significant barrier is the limited provider understanding of military culture, service-connected health care issues and the post-deploy-ment health and behavioral health care needs of rural veterans.18 This is a sig-nificant issue in light of the needs of veterans who served in the Gulf War and in Iraq. In testimony before the House Committee on Veterans’ Affairs, Jacob Gadd, the American Legion’s deputy director for health care, called for the development of military cul-ture and awareness training for non-VA providers to raise their awareness of military injuries/illnesses, reduce barriers to care, improve veterans’ sat-isfaction with services and the increase the effectiveness of service systems.19 EVOLVING NEEDSIt is no long possible to view rural vet-erans as a homogenous group. Changes Growing numbers of aging veterans further burden already stressed rural long-term care services. HEALTH PROGRESS             www.chausa.org            MAY - JUNE 2013 51in enlistment patterns are creating a more diverse population of rural vet-erans that includes a growing number of women, an aging cohort of veter-ans and a younger cohort of Gulf War and Iraq War veterans with potentially longer term consequences from their combat service. These changes are challenging traditional veteran ser-vices systems to revise their programs and community providers to broaden their capacity to address the evolving needs of rural veterans. To best meet our obligations to those who have served our country, it is critical to focus on opportunities to expand access to accessible, cultur-ally sensitive primary care, behavioral health, specialty care and other support services; improve coordination and co-management of veterans between com-munity and VA-based service systems; increase the availability of community-based services; explore the use of tech-nology and transportation programs to expand access to care; expand veteran outreach programs; improve the cul-tural competence of community pro-viders; and enhance our understand-ing of the needs of the most vulnerable rural veterans. JOHN A. GALE is research associate, Maine Rural Health Research Center, University of Southern Maine Muskie School of Public Service, Portland, Maine.HILDA R. HEADY is senior vice presi-dent and chair of the Rural Health Research and Policy Group, Atlas Research, Washington, D.C.NOTES1. Hilda R. Heady, “Rural Veterans: Invisible Heroes, Special People, Special Issues,” Journal of Rural Social Services 26, no. 3 (2011): 1-13; National Priorities Proj-ect, “Military Recruitment 2010,” http://nationalpriorities.org/en/analysis/2011/military-recruitment-2010/.2. Sidra Montgomery, Characteristics of Rural Veterans: 2010 — Data from the American Community Survey, (Washington, D.C.: National Center for Veterans Analysis and Statistics, July 2012) www.va.gov/ vetdata/docs/SpecialReports/Rural_ Veterans_ACS2010_FINAL.pdf.3. Montgomery, Characteristics of Rural Veterans4. Montgomery, Characteristics of Rural Veterans 5. Montgomery, Characteristics of Rural Veterans6. Women Veterans Task Force, 2012 Report: Strategies for Serving our Women Veterans (Washington D.C.: U.S. Department of Vet-erans Affairs, May 1, 2012) draft for public comment, www.va.gov/opa/publications/draft_2012_women-veterans_strategic-plan.pdf.7. Support Homeless Veterans, Inc., “Statis-tics — National Coalition for the Homeless Report” www.supporthomelessveterans.org/statistics.html (accessed March 18, 2013).8. Hilda R. Heady, “The Rural Homeless Prevention Services Project” (presentation, annual conference of the National Rural Health Association, Denver, Colo., April 18, 2012).9. Amy E. Wallace et al., “A Longitudinal Analysis of Rural and Urban Veterans’ Health-Related Quality of Life,” The Journal of Rural Health 26, no. 2 (2010): 153-163.10. Susan P. Proctor et al., “Examination of Post-Service Health-Related Quality of Life among Rural and Urban Military Members of the Millennium Cohort Study,” Journal of Rural Social Sciences 26, no. 3 (2011): 32-56. 11. Mary Beth Skupien, “Caring for Rural Vet-erans” (National Rural Health Day presenta-tion, Nov. 17, 2011) www.ruralhealth.va.gov/docs/NRHD_Webinar_Presentation_ wNarrative_Nov172011.pdf (accessed March 18, 2013).12. Marybeth J. Mattingly and Michelle J. Stransky, “Rural America and the South Have the Highest Percent of Veterans with Service-Related Disabilities,” Carsey Insti-tute Fact Sheet no. 16 (Fall 2009), www.carseyinstitute.unh.edu/publication/rural-america-and-south-have-highest-percent- veterans-service-related-disabilities (accessed March 18, 2013).13. The American Legion, “Women Vets Panel Examines Rural Health Care,” March 2, 2012, www.legion.org/careers/162060/women-vets-panel-examines-rural-health-care (accessed March 18, 2013).14. Juliette F. Spelman et al., “Post Deploy-ment Care for Returning Combat Veterans,” Journal of General Internal Medicine 27, no. 9 (September 2012): 1200-09.15. Colin Buzza et al., “Distance is Rela-tive: Unpacking a Principal Barrier in Rural Healthcare” Journal of General Internal Medicine 26, suppl. 2 (November 2011): 648-54; Mary Beth Skupien, “Caring for Rural Veterans.”16. Colin Buzza et al., “Distance is Relative”; Benjamin L. Schooley et al., “Rural Veteran Access to Healthcare Services: Investigating the Role of Information and Communica-tion Technologies in Overcoming Spatial Barriers,” Perspectives in Health Information Management (Spring 2010): 1-20.17. Colin Buzza et al., “Distance is Relative.”18. Jean-Paul Chretien and Katherine C. Chretien, “Coming Home from War,” Journal of General Internal Medicine online, Feb. 23, 2013, http://link.springer.com/ article/10.1007/s11606-013-2359-7 (accessed March 27, 2013); Juliette F.  Spelman et al., “Post Deployment Care.” 19. House Committee on Veterans Affairs Subcommittee on Health, VA Fee Basis Care: Examining Solutions to a Flawed System, Sept. 14, 2012, witness testimony of Jacob B. Gadd, Deputy Director for Healthcare, National Veterans Affairs and Rehabilitation Division, The American Legion, http:// veterans.house.gov/witness-testimony/ mr-jacob-b-gadd-0 (accessed March 24, 2014).Twenty-five percent of veterans report that transportation considerations affect their ability to access care. B R I N G I N G  V E T S  H O M EJOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES                        www.chausa.orgHEALTH PROGRESSReprinted from Health Progress, May-June 2013Copyright © 2013 by The Catholic Health Association of the United States®

Rural vets: Their barriers, problems, needs

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Rural vets: Their barriers, problems, needs

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