In this issue: Rural Health
From the HSR Director's Desk
Two of the top priorities of the VHA are to “connect Veterans to the soonest and best care” and to “hire faster and more competitively.” Nowhere are these priorities more salient than in rural settings, where Veterans face barriers to healthcare access that are exacerbated by provider shortages. The growth of digital technologies can address these barriers, but many rural communities lack access to high-speed internet. To this end, a research agenda that optimizes programs and policies that mitigate the complex health, economic, environmental, and infrastructure factors influencing access, quality, experience, equity, and outcomes of care for Veterans living in rural areas is vital toward achieving a learning health system that benefits all Veterans.
A core VHA Office of Research and Development (ORD) priority is enhancing Veteran access to high-quality treatments and clinical trials. ORD’s Health Systems Research (HSR) program focuses on cutting-edge methods to ensure Veterans across all populations and settings get effective treatments faster, notably through advances in implementation science, data science, engagement science, systems science, and policy analysis. Some examples of emerging HSR addressing rural Veteran access include implementation of telehealth for PTSD, home-based cardiac monitoring, population-based suicide prevention initiatives, and national evaluations of provider network and community care adequacy, staffing, and quality. Finally, our new Access and Community Care Engagement Network Team (ACCENT) Consortium of Research is poised to take HSR to the next level by providing knowledge management and translation of research into impacts for Veterans from rural areas.
—Amy Kilbourne, PhD, MPH, Acting Director, Health Systems Research
Nearly a quarter (4.4 million) of U.S. Veterans live in rural communities, where poverty, isolation, and access to healthcare often present bigger challenges than they do in urban settings. 
Compared to their urban counterparts, rural Veterans enrolled in VA healthcare tend to be older (55% are over the age of 65), medically complex, and more likely to have diabetes, obesity, high blood pressure, and heart conditions that require frequent, ongoing care. In addition, more than 300,000 Veterans living in rural settings served in Iraq and Afghanistan and have unique health considerations, such as exposure to burn pits.
VA’s Health Services Research & Development (HSR&D) and Office of Rural Health (ORH) collaborate with program offices to address rural healthcare challenges while supporting the strengths and resiliency that are common among rural Veterans. As rural health straddles several HSR portfolios and areas of focus, investigators study a range of concerns related to rural health, from access and equity to virtual care, complex chronic care, and mental and behavioral health.
Rural health research priorities include:
- Explore how virtual care can improve care access for rural Veterans and prevent or mitigate care disruptions during public health emergencies.
- Coordinate care between VA and community providers.
- Alleviate recruitment and retention challenges related to the rural healthcare workforce.
“Of the five dimensions of access—that is, geographical, virtual, temporal, financial, and cultural—rural Veterans are most impacted by geographical and virtual barriers. Long distances and lack of public transportation make travel to in-person care challenging. Less access to broadband internet in rural areas is a virtual barrier. Through research and innovations, we can overcome these and other barriers to make healthcare more accessible and equitable for rural Veterans.”
—Peter J. Kaboli, MD, MS, Acting Executive Director, VA Office of Rural Health
Themes that cut across the priority topics were noted during the 2022 HSR&D rural health State-of-the-Art Conference and include:
- Develop innovations in telehealth and other areas that address the unique access challenges of rural Veterans.
- Determine how to meet rural Veterans’ mental health needs and support their overall well-being.
- Recognize the culture of rural populations and determine how best to put forward culturally relevant recommendations.
- Study and support equity and inclusion in rural populations, and better understand sociodemographic variability in rural communities.
To accelerate research that will lead to measurable improvements in care—including the care of rural Veterans—HSR supports an Access and Community Care Engagement Network Team, whose partners include VA leadership, VISNs, and the Office of Rural Health.
Register for a cyberseminar to learn more about the ACCENT CORE.
What We’ve Done Lately
Recent impactful rural health research by HSR investigators includes:
Dozens of HSR-funded research projects that target rural health are currently underway. Examples include:
- Addressing social determinants of health among rural Veterans. Urban-focused research has shown a link between social and economic conditions and health. This study will examine social determinants of health in rural settings and align evidence-based screening and referral with Veterans’ unmet needs and available resources in rural VA settings. Researchers will develop and pilot a screening and referral intervention that can be replicated across VA sites. Operational partners will include the New England Veterans Integrated Service Network, the Office of Rural Health, and the Office of Social Work.
- Expanding access to opioid use disorder treatment in rural settings. Rural Veterans are 37% less likely to receive medication for opioid use disorder than their urban-dwelling counterparts. This study will address the substantial disparity in healthcare access for rural Veterans by leveraging the knowledge and experience of rural facilities that have successfully integrated buprenorphine into primary care, to inform the design of an implementation strategy that supports rural, primary care buprenorphine treatment.
- Understanding the effect of rurality and social risk factors on barriers to care and surgical outcomes. Although the Mission Act improves Veteran access to care, it raises the risk of care fragmentation, which is associated with increased length of hospital stay, readmission, and mortality. In addition, postoperative complications and readmissions are higher in minority and low socioeconomic status patients (SES). Low SES is also associated with frailty, one of the best predictors of 30-day postoperative complications and hospital readmissions. This study seeks to identify social risk factors—including ethnicity, race, SES, and place of residence—and care fragmentation that affect surgical outcomes to inform VA policy and resource allocation.
- Veteran engagement implementation strategies to prevent rural Veteran suicide. Engaging consumers in research helps vulnerable populations improve health behaviors and outcomes. This ongoing study aims to create a manual of methods to engage vulnerable Veteran consumers (including families, caregivers, and community members) in selecting and tailoring strategies for implementing or redesigning healthcare services. The manual will be piloted in the context of suicide prevention, focusing on rural Veterans, a population particularly vulnerable to suicide.
- Virtual Care QUERI Program. This program works to maximize implementation of technology-facilitated practices to improve access to high quality care for rural Veterans who receive care at home and in community-based outpatient clinics. The program’s partners include the Offices of Rural Health, Connected Care, Mental Health and Suicide Prevention, and Electronic Health Record Modernization.
“Virtual care technologies can improve rural Veterans’ access to and engagement in care. Our policy relevant and methodologically rigorous implementation research will maximize virtual care’s impact on rural Veterans and enable VA to reach a greater proportion of patients in need.”—John Fortney, PhD, Multiple Principal Investigator of the Virtual Care QUERI program, and Senior Research Career Scientist with HSR&D’s Center of Innovation for Veteran-Centered and Value-Driven Care
 RURAL VETERANS - Office of Rural Health (va.gov)