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David Hartley, Ph.D., MHA

David Hartley, Ph.D., MHA, and Professor, Muskie School of Public Service, Director, Maine Rural Health Research Center, University of Southern Maine, Portland, ME

Thank you for the opportunity to testify before this committee.  My testimony is based on 12 years as a manager of substance abuse treatment programs followed by 15 years as a rural health researcher, much of which has been focused on access to mental health services in rural America.  I brought that expertise to bear when I served on the Institute of Medicine’s Committee on the Future of Rural Health which met throughout 2004 and released its report early in 2005: Quality through Collaboration: The Future of Rural Health (IoM 2005).  Two years ago, I testified before this subcommittee in Washington DC, and reported that several of the recommendations of the IoM committee were directly relevant to the challenge of delivering high quality health care services to rural veterans.

Since 44% of new recruits come from rural places (Tyson 2005), we are seeing an increase in the numbers of veterans from Iraq and Afghanistan who are returning to rural America recovering from complex combat-related injuries, both physical and emotional.  The Veteran’s Healthcare System has unique expertise and resources to devote to the healing of these injuries.  In recent years, the VA has opened more community based outpatient clinics or CBOCs to make this expertise and these resources available to veterans who live at significant distances from VA medical centers.  We now have six CBOCs in Maine.

The Department of Veterans’ Affairs has arguably the best integrated health information network in the nation.  It also has extensive, evidence-based, patient-centered performance measures and a monitoring system to assure that all patients receive high quality, guideline concordant care.  That system gets good outcomes for those veterans who receive care from VA clinics, and from Community-Based Outpatient Clinics and contract providers who can meet the VA’s high standards of care.  There are several reasons why a veteran in need of help might not seek care at one of these facilities.  While CBOCs have improved access in many rural areas, there remain vast remote areas in our most rural states, including Maine, where VA facilities are still out of reach.  Also, some veterans prefer to seek care from the non-VA system, for a variety of reasons.  The significant numbers of veterans whose combat experience was with the National Guard are often in this category.  Citizen soldiers may be more familiar with citizen health care, and often do not register for VA benefits.  While many veterans prefer to receive care from VA providers, others feel just the opposite.  Our VA healthcare system needs to reach out to our civilian health care system to assure that these combat veterans get care consistent with their needs, and concordant with the special expertise of the VA healthcare system.

Clearly, one way the VA system can do this is by contracting with non-VA providers in rural areas where it is not efficient to open a CBOC.  The federal government has created several programs to attract providers to underserved areas, and to support them.  These include federally qualified health centers (FQHCs), critical access hospitals, and rural health clinics.  Some rural areas are also served by community mental health centers.  These programs were created as a federal response to the difficulty of recruiting providers to serve remote populations.  They exist in areas that have been designated as underserved.  In many rural areas, hospitals, clinics and health centers collaborate in recruiting efforts, often with the help of their state office of rural health, or state hospital association.  For the VA to open a new CBOC in a community that is already served by one or more of these entities is inefficient.  Rather, I would suggest that we have the technology and the expertise to help these rural sites provide care to rural veterans that is of the same high quality that urban vets receive.    This can be done through tele-health, through the VistA information system which is now available as open-access software to all providers, through direct clinical consultation and supervision between expert clinicians in VA medical centers and rural providers, and through the placement of VA providers in these non-VA rural sites, creating veterans’ access points.  With these resources at our disposal, care provided in a rural site for some of these combat injuries can be of the same high quality as that provided in a VA medical center.

My research has been in the area of rural behavioral health.  The IoM rural report found that behavioral health needs in rural America are not being met, due to a fragmented, under-funded, non-system.   Much of my research has sought to document the lack of specialty mental health services in rural areas, and to discover alternative models for delivering such services in the absence of psychiatrists, psychologists and psychiatric facilities.  The need for mental health services in rural America has been repeatedly identified as one of the topmost issues facing state-level officials and policymakers.  It now faces the VA healthcare system as well.

Evidence of the need for mental health services among veterans can be found in the high rates of combat zone suicide (Army News Service 2004), post-traumatic stress disorder, often not manifesting until a year or more after returning home, and in the VA’s recently published studies of rural-urban disparities in health-related quality of life, both for veterans with psychiatric disorders (Wallace et al. 2006) and for veterans in general (Weeks 2004).  Lacking specialty mental health services, rural people with psychiatric problems have typically sought help from their primary care practitioner.  Research tells us that such care has not always been of the highest quality, and often does not follow evidence-based guidelines for conditions such as depression, anxiety disorders and children’s mental health issues (Rost et al. 2002).  Two specific conditions of veterans now returning from Afghanistan and Iraq may not be accurately diagnosed by primary care practitioners who are not familiar with these conditions: post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI).  Once such disorders are suspected, it may be possible to refer vets to a VA specialist, and travel from a rural to an urban area for specialty care may simply be the only way to get quality care.  In many of our most rural states, however, there is no VA TBI program.  Moreover, the symptoms of PTSD typically affect the whole family, and may lead to domestic violence, child abuse, divorce, substance abuse and suicide.  Here too, the lack of services in rural areas poses a significant barrier to effectively addressing these problems. 

My research suggests that creative solutions are needed to meet the need for mental health and substance abuse treatment in rural areas.  Behavioral health research often entails precisely designed trials of various clinical interventions, many of which are unlikely to be implemented in rural areas.  Creative solutions to meet the behavioral health needs of rural veterans can be found by establishing a rural behavioral health research center charged to explore and evaluate new models for delivering care to veterans in remote areas.  This can best be accomplished through collaboration between a VA medical center and a federally funded rural health research center.  Such a collaboration might be facilitated by the VA Office of Rural Health and the federal Office of Rural Health Policy, in the Health Resources and Services Administration, working together.

As I stated to this subcommittee two years ago, the Veterans Administration has an opportunity to take advantage of decades of research, policy, and programs serving rural Americans, and combine those resources with its own, so as to improved access to quality care for rural veterans, and to bring its unique resources for quality improvement and information management to rural providers.  We can do this for our veterans.


Army News Service (2004).  Army suicide rate in combat zones elevated.  March 26, 2004.

Institute of Medicine, Committee on the Future of Rural Health Care (2005) Quality through Collaboration: the Future of Rural Health.  Washington DC: The National Academies Press.

Rost K, Fortney J Fischer E and Smith J (2002) Use, quality and outcomes of care for mental health: The rural perspective.  Medical Care Research and Review 59(3): 231-265.

Wallace AE, Weeks WB, Wang, S, et al.  (2006) Rural and urban disparities in health-related quality of life among veterans with psychiatric disorders.  Psychiatric Services.  57(6):1-6.

Tyson, AS (2005) “Youths in rural US are drawn to military.”  Washington Post.  November 4, 2005.

Weeks WB, Kazis LE, Shen Y etal. (2004)  Differences in health-related quality of life in rural and urban veterans. American Journal of Public Health 94:1762-67.