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Witness Testimony of Gerald M. Cross, M.D., FAAFP, Veterans Health Administration, Acting Principal Deputy Under Secretary for Health,, U.S. Department of Veterans Affairs

Good Morning, Members of Congress. Thank you for the opportunity to discuss VHA's ongoing efforts to provide safe, effective, efficient and compassionate health care to veterans residing in rural areas.

My remarks will briefly review the national challenge presented by rural health care, VHA's strategic direction and initiatives underway.

Among the entire enrolled VA population, 39% were classified as rural at the end of FY 2006. And among the entire enrolled VA population, 2% were classified as "highly rural." Highly rural refers to counties with less than 7 citizens per square mile.

Researchers have studied the rural health care experience, including a number of articles that looked at VA rural healthcare. Three studies have found that veterans living in rural areas tend to be slightly older, and more likely to qualify in priority group 5- that is, non service connected, zero % service connected, and low income. These same veterans were also less likely to be employed. The studies agree that rural veterans had slightly more physical health problems but fewer mental health conditions - as compared to suburban and urban veterans.

VHA's strategic direction is to enhance non-institutional care with less dependence on large institutions. Instead, we are providing more care at home and in the community.

VHA now has 717 Community Based Outpatient Clinics or CBOCs. Of this total, 320 or 45 percent of these are located in rural or highly rural areas. We've created Consolidated Mail-Out-Patient Pharmacies or CMOPs so that medications are delivered to the patient's home - instead of having the patient travel to the hospital. We provide home based primary care - devoting more than 175 million dollars to this program in FY08, and more than 95 million dollars for other home based programs. We are using tele-medicine and tele-mental health to reach into the veterans' homes and into community clinics. This allows us to evaluate and follow patients without them having to travel to large medical centers. We are far along with our mental health enhancement initiative that will add resources and greater mental health expertise in primary care clinics. We are also using a special internet site, providing information to veterans in their own home, including up to date research information, access to portions of their medical records, and the ability to refill medications on-line.

To accomplish this, VHA is emphasizing primary care and spreading out geographically. At the end of FY 06, 92.5% of our 5.4 million patients were located within 60 minutes of a VA healthcare facility. And 98.5% were within 90 minutes. Among those who live outside the sixty minute range, some are those veterans in highly rural areas and some are veterans living in Tribal areas.

In 2006 evaluations of veteran patient satisfaction, comparing rural versus urban veterans, we found that rural patients were more satisfied with their health clinics than their urban counterparts.

We also looked at the quality of care, comparing rural versus urban clinics. Looking at 40 standard measures, quality was virtually identical overall between rural and urban clinics.

To continue this strategic support for access and rural health care we have over 20 CBOCs for 2007. 43% of these CBOCs are in rural or highly rural areas. In addition to these clinics, VA is currently working on telecommunications strategies to provide Care Coordination/Home Telehealth services in rural areas. Since January 2004, VHA has trained over 3,500 staff nationally to provide care via CCHT.

In Ohio, there are 5 VA Medical Centers and 32 Community Based Outpatient Clinics (CBOCs). In close proximity to Appalachia, (the region in the United States that includes the southern Appalachian Mountains, extending roughly from southwestern Pennsylvania through West Virginia and parts of Kentucky and Tennessee to northwestern Georgia) we have 9 CBOCs in Southeastern Ohio and 2 in Kentucky. Specifically, East Liverpool (Columbiana County), New Philadelphia (Tuscarawas County), Athens (Athens County), Lancaster (Fairfield County), Cambridge (Guernsey County), Marietta (Washington County), Portsmouth (Scioto County), Batavia (Clermont County), and Zanesville (Muskingum County). The 2 (two) Kentucky CBOCs are in Bellevue (Covington, KY) and in Florence, KY. These CBOCs are located in rural areas of Ohio bordering southern Pennsylvania, West Virginia, and parts of Kentucky.

In addition, the Vet Center program provides quality readjustment counseling and removes unnecessary barriers to care for veterans and family members. Vet Centers engage in extensive community outreach activities to directly contact and inform area veterans and to maintain active community partnerships with local leaders and service providers to facilitate referrals for veterans in need.

Some Vet Centers are maintained in rural areas to ensure that rural veterans and families have access to readjustment counseling services. Additionally, we have established Vet Center outstations in rural areas. Outstations are administratively connected to a full sized Vet Center, use permanently leased space and are usually staffed by one or two counselors who provide full time services to area veterans on a weekly basis. The Vet Centers also maintain nontraditional hours to accommodate veterans traveling in from greater distances.

Vet Centers in Wheeling, Parkersburg and Huntington, West Virginia all located on the Ohio River provide outreach and readjustment counseling to veterans in rural Ohio.

In addition to our internal efforts outlined earlier, VA continues to look for ways to collaborate with complementary Federal efforts to address the needs of health care for rural veterans. We also have partnerships with HHS, including the Indian Health Service and Office of Rural Health providing health care in rural communities. We are also working to establish relationships with other entities, such as with the National Rural Health Association.

VHA recognizes the importance and the challenge of service in rural areas, and we believe our current and planned efforts are addressing these concerns for our current and emerging veterans.

This concludes my statement. At this time I would be pleased to answer any questions that you may have.