Veterans In Rural Areas Research Articles

Connecting unstably housed veterans living in rural areas to health care: Perspectives from Health Care Navigators.

To understand existing care practices and policies, and potential enhancements, to improve the effectiveness of the US Department of Veterans Affairs (VA) Supportive Services for Veteran Families (SSVF) Health Care Navigators (HCN) in linking Veterans experiencing housing instability in rural areas with health care services. We used primary data collected during semistructured interviews with HCNs (n = 21) serving rural areas across the United States during Spring 2022. We applied the Consolidated Framework for Implementation Research (CFIR) 2009 and the Social Ecological Model (SEM) to the collection and analysis of qualitative data to understand how HCNs administer services within SSVF and the larger community. We used rapid qualitative methods to summarize and analyze data. Templated matrix summaries identified facilitators and barriers to linking Veterans with health care services and policy and practice implications. Using CFIR 2009, we identified contextual factors affecting successful implementation of HCN services within SSVF; we offer a crosswalk between CFIR 2009 and the version updated in 2022. Framing facilitators and barriers within the SEM provided insight into whether implementation strategies should be addressed at a community, interpersonal, or intrapersonal level within the SEM. Facilitators included sufficient knowledge, training, and mentorship opportunities for HCNs and their capacity to collaborate within their organization and with other community-based organizations. Barriers included lack of local technology and housing resources, inadequate understanding of Veterans' service eligibilities and pathways to access those services, and deficient collaboration with the VA. Understanding facilitators and barriers experienced by HCN when linking unstably housed Veterans in rural areas with health care services can inform future strategies, including policy changes such as increased training to support HCNs' understanding of eligibility, benefits, and entitlements as well as improving communication and collaboration between VA and community partners.

Barriers and Facilitators to Teledermatology and Tele-Eye Care in Department of Veterans Affairs Provider Settings: Qualitative Content Analysis.

Veterans Affairs health care systems have been early adopters of asynchronous telemedicine to provide access to timely and high-quality specialty care services in primary care settings for veterans living in rural areas. Scant research has examined how to expand primary care team members' engagement in telespecialty care. This qualitative study aimed to explore implementation process barriers and facilitators to using asynchronous telespecialty care (teledermatology and tele-eye care services). In total, 30 participants including primary care providers, nurses, telehealth clinical technicians, medical and program support assistants, and administrators from 2 community-based outpatient clinics were interviewed. Semistructured interviews were conducted using an interview guide, digitally recorded, and transcribed. Interview transcripts were analyzed using a qualitative content analysis summative approach. Two coders reviewed transcripts independently. Discrepancies were resolved by consensus discussion. In total, 3 themes were identified from participants' experiences: positive perception of telespecialty care, concerns and challenges of implementation, and suggestions for service refinement. Participants voiced that the telemedicine visits saved commute and waiting times and provided veterans in rural areas more access to timely medical care. The mentioned concerns were technical challenges and equipment failure, staffing shortages to cover both in-person and telehealth visit needs, overbooked schedules leading to delayed referrals, the need for a more standardized operation protocol, and more hands-on training with formative feedback among supporting staff. Participants also faced challenges with appointment cancellations and struggled to find ways to efficiently manage both telehealth and in-person visits to streamline patient flow. Nonetheless, most participants feel motivated and confident in implementing telespecialty care going forward. This study provided important insights into the positive perceptions and ongoing challenges in telespecialty care implementation. Feedback from primary care teams is needed to improve telespecialty care service delivery for rural veterans.

Pre-implementation adaptation of suicide safety planning intervention using peer support in rural areas.

Currently, seventeen veterans die by suicide daily in the United States (U.S.). There are disparities in suicide behavior and access to preventative treatment. One disparity is the suicide rate in rural areas, including the state of Arkansas-suicide deaths among rural veterans increased 48% in the last 2 decades, double that of urban veterans. One major challenge for veterans in rural areas is the lack of healthcare providers to provide Safety Planning Intervention, which is an effective intervention to reduce suicide attempts in the general adult population and among veterans. One solution is more broadly implementing Safety Planning Intervention, by using peers to deliver the intervention in rural communities. Before implementation, the intervention needs to be adapted for peer-to-peer delivery, and barriers and facilitators identified. Since January 2021, using community-based participatory research, we collaboratively developed and executed a 1 year study to adapt Safety Planning Intervention for peer-to-peer delivery in rural communities and identified implementation barriers and facilitators prior to spread. From July 2022 to February 2023, we conducted group interviews with 12 participants: rural veterans with prior suicidal thoughts or attempts in one U.S. state, their support persons, and healthcare professionals with expertise in veteran suicide prevention, Safety Planning Intervention, and/or peer delivery. We collected qualitative data through interviews during nine, 2 h meetings, and quantitative data from one anonymous survey and real-time anonymous voting-all on the topic of core and adaptable components of Safety Planning Intervention and implementation barriers and facilitators for peer delivery in rural communities. Questions about adaptation were designed according to processes in the ENGAGED for CHANGE community-engaged intervention framework and questions about facilitators and barriers were designed according to the Health Equity Implementation Framework. Participants categorized which Safety Planning Intervention components were core or adaptable, and how freely they could be adapted, using the metaphor of a traffic light in red (do not change), yellow (change with caution), and green (change freely) categories. Participants made few actual adaptations (categorized according to the FRAME modification system), but strongly recommended robust training for peers. Participants identified 27 implementation facilitators and 47 barriers, organized using the Health Equity Implementation Framework. Two example facilitators were (1) peer-to-peer safety planning intervention was highly acceptable to rural veterans; and (2) some state counties already had veteran crisis programs that could embed this intervention for spread. Two example barriers were (1) some community organizations that might spread the intervention have been motivated initially, wanting to help right away, yet not able to sustain interventions; and (2) uncertainty about how to reach veterans at moderate suicide risk, as many crisis programs identified them when suicide risk was higher. Our results provide one of the more comprehensive pre-implementation assessments to date for Safety Planning Intervention in any setting, especially for peer delivery (also referred to as task shifting) outside healthcare or clinical settings. One important next step will be mapping these barriers and facilitators to implementation strategies for peer-to-peer delivery. One finding surprised our research team-despite worse societal context in rural communities leading to disproportionate suicide deaths-participants identified several positive facilitators specifically about rural communities that can be leveraged during implementation.

Rural-Urban Disparities in Video Telehealth Use During Rapid Mental Health Care Virtualization Among American Indian/Alaska Native Veterans

American Indian/Alaska Native veterans experience a high risk for health inequities, including mental health (MH) care access. Rapid virtualization of MH care in response to the COVID-19 pandemic facilitated care continuity across the Veterans Health Administration (VHA), but the association between virtualization of care and health inequities among American Indian/Alaska Native veterans is unknown. To examine differences in video telehealth (VTH) use for MH care between American Indian/Alaska Native and non-American Indian/Alaska Native veterans by rurality and urbanicity. In this cohort study, VHA administrative data on VTH use among a veteran cohort that received MH care from October 1, 2019, to February 29, 2020 (prepandemic), and April 1 to December 31, 2020 (early pandemic), were examined. At least 1 outpatient MH encounter during the study period. The main outcome was use of VTH among all study groups (ie, American Indian/Alaska Native, non-American Indian/Alaska Native, rural, or urban) before and during the early pandemic. American Indian/Alaska Native veteran status and rurality were examined as factors associated with VTH utilization through mixed models. Of 1 754 311 veterans (mean [SD] age, 54.89 [16.23] years; 85.21% male), 0.48% were rural American Indian/Alaska Native; 29.04%, rural non-American Indian/Alaska Native; 0.77%, urban American Indian/Alaska Native; and 69.71%, urban non-American Indian/Alaska Native. Before the pandemic, a lower percentage of urban (b = -0.91; SE, 0.02; 95% CI, -0.95 to -0.87; P < .001) and non-American Indian/Alaska Native (b = -0.29; SE, 0.09; 95% CI, -0.47 to -0.11; P < .001) veterans used VTH. During the early pandemic period, a greater percentage of urban (b = 1.37; SE, 0.05; 95% CI, 1.27-1.47; P < .001) and non-American Indian/Alaska Native (b = 0.55; SE, 0.19; 95% CI, 0.18-0.92; P = .003) veterans used VTH. There was a significant interaction between rurality and American Indian/Alaska Native status during the early pandemic (b = -1.49; SE, 0.39; 95% CI, -2.25 to -0.73; P < .001). Urban veterans used VTH more than rural veterans, especially American Indian/Alaska Native veterans (non-American Indian/Alaska Native: rurality b = 1.35 [SE, 0.05; 95% CI, 1.25-1.45; P < .001]; American Indian/Alaska Native: rurality b = 2.91 [SE, 0.38; 95% CI, 2.17-3.65; P < .001]). The mean (SE) increase in VTH was 20.34 (0.38) and 15.35 (0.49) percentage points for American Indian/Alaska Native urban and rural veterans, respectively (difference in differences [DID], 4.99 percentage points; SE, 0.62; 95% CI, 3.77-6.21; t = -7.999; df, 11 000; P < .001), and 12.97 (0.24) and 11.31 (0.44) percentage points for non-American Indian/Alaska Native urban and rural veterans, respectively (DID, 1.66; SE, 0.50; 95% CI, 0.68-2.64; t = -3.32; df, 15 000; P < .001). In this cohort study, although rapid virtualization of MH care was associated with greater VTH use in all veteran groups studied, a significant difference in VTH use was seen between rural and urban populations, especially among American Indian/Alaska Native veterans. The findings suggest that American Indian/Alaska Native veterans in rural areas may be at risk for VTH access disparities.

VA's implementation of universal screening and evaluation for the suicide risk identification program in November 2020 -Implications for Veterans with prior mental health needs.

United States Veterans are at higher risk for suicide than non-Veterans. Veterans in rural areas are at higher risk than their urban counterparts. The coronavirus pandemic intensified risk factors for suicide, especially in rural areas. To examine associations between Veterans Health Administration's (VA's) universal suicide risk screening, implemented November 2020, and likelihood of Veterans being screened, and receiving follow-up evaluations, as well as post-screening suicidal behavior among patients who used VA mental health services in 2019. VA's Suicide Risk Identification Strategy (Risk ID), implemented October 2018, is a national, standardized process for suicide risk screening and evaluation. In November 2020, VA expanded Risk ID, requiring annual universal suicide screening. As such, we are evaluating outcomes of interest before and after the start of the policy among Veterans who had ≥1 VA mental health care visit in 2019 (n = 1,654,180; rural n = 485,592, urban n = 1,168,588). Regression-adjusted outcomes were compared 6 months pre-universal screening and 6, 12 and 13 months post-universal screening implementation. Item-9 on the Patient Health Questionnaire (I-9, VA's historic suicide screener), Columbia- Suicide Severity Risk Scale (C-SSRS) Screener, VA's Comprehensive Suicide Risk Evaluation (CSRE), and Suicide Behavior and Overdose Report (SBOR). 12 months post-universal screening implementation, 1.3 million Veterans (80% of the study cohort) were screened or evaluated for suicide risk, with 91% the sub-cohort who had at least one mental health visit in the 12 months post-universal screening implementation period were screened or evaluated. At least 20% of the study cohort was screened outside of mental health care settings. Among Veterans with positive screens, 80% received follow-up CSREs. Covariate-adjusted models indicated that an additional 89,160 Veterans were screened per month via the C-SSRS and an additional 30,106 Veterans/month screened via either C-SSRS or I-9 post-universal screening implementation. Compared to their urban counterparts, 7,720 additional rural Veterans/month were screened via the C-SSRS and 9,226 additional rural Veterans/month were screened via either the C-SSRS or I-9. VA's universal screening requirement via VA's Risk ID program increased screening for suicide risk among Veterans with mental health care needs. A universal approach to screening may be particularly advantageous for rural Veterans, who are typically at higher risk for suicide but have fewer interactions with the health care system, particularly within specialty care settings, due to higher barriers to accessing care. Insights from this program offer valuable insights for health systems nationwide.

Delivery of Exposure and Response Prevention Among Veterans with Obsessive-Compulsive Disorder.

Veterans with obsessive-compulsive disorder (OCD) often face barriers to receiving evidence-based treatments such as exposure and response prevention (ERP). Through retrospective review of electronic medical records, this study examined the rates of ERP delivery in a national sample of 554 veterans newly diagnosed with OCD in the Veterans Health Administration between 2016 and 2017. Results indicated that only 4% of veterans (n = 22) received any ERP treatment; and, of those, 16 veterans received "true ERP." Veterans who received any ERP were younger than those who did not. ERP was primarily delivered by psychologists in urban facilities along the East and West coasts of the USA. The findings from this study emphasize the need to train more providers to effectively deliver ERP in addition to providing telehealth services to increase access to care for veterans in rural areas.

Providers' reflections on infrastructure and improvements to promote access to care for Veterans experiencing housing instability in rural areas of the United States: A qualitative study.

Veterans in rural areas of the United States face barriers to accessing healthcare and other services, which are intensified for those experiencing housing instability. Recent legislative acts have the potential to address obstacles faced by rural patients in the U.S. This study explores how infrastructure-including features related to the physical and digital environment-impacts the ability of rural Veterans experiencing housing instability to access healthcare and related services from the perspective of homeless service providers within the Veterans Health Administration (VHA). We conducted semi-structured telephone interviews (n=22) with providers in high/low performing and/or resourced communities across the U.S. in May and June 2021 and analysed transcripts using template analysis. Themes described by providers highlight how infrastructure limitations in rural areas can exacerbate health disparities for Veterans experiencing housing instability, the impact of COVID-19 on service access, and recommendations to enhance service delivery. Providers suggested that VHA reconfigure where and how staff work, identify additional resources for transportation and/or alternative transportation models, and increase Veterans' access to technology and broadband Internet. Federal infrastructure investments should address challenges faced by Veterans experiencing housing instability in rural areas and the concerns of providers connecting them with care.

E-Cigarette Use among Rural Military Veterans

E-cigarette use is more prevalent among veterans with mental distress; however, no studies have examined the impact of rurality on the relationship between mental distress and e-cigarette use among veterans. We obtained nationally-representative data on veterans from 2016 to 2018 Behavioral Risk Factor Surveillance System (BRFSS) surveys in order to explore the aforementioned relationship (n = 62,884). Results of generalized linear mixed models, stratified by rural-urban status, indicated that the relationship between mental distress and e-cigarette use was moderated by current traditional cigarette use, especially in highly rural areas. Our 33-state study showed that the rate of e-cigarette use among veterans with 14+ days of mental distress and current cigarette use living in highly urban areas was 8.93% (compared to 0.89% for those with no mental distress and no cigarette use, p < 0.001), while in rural areas, the prevalence of e-cigarette use among veterans with 14+ days of mental distress and current cigarette use was 12.75% (compared to 0.77% for those with no mental distress and no cigarette use, p < 0.001). Behavioral health programs for veterans in rural areas should target those with mental distress and e-cigarette use.

GRECC Connect Increases Access to Geriatric Specialty Care for Rural, Older Veterans With Complex Care Needs

A higher percentage of Veterans in rural areas are older, have multiple chronic conditions and select the VA for healthcare. To address the needs of rural older Veterans with complex needs, GRECC Connect hubs use case finding approaches combined with regular outreach and education to VA community-based outpatient clinic (CBOC) providers serving rural Veterans and caregivers. Alignment of GRECC Connect services with needs of providers and patients promotes establishment of therapeutic alliances in caring for medically complex older Veterans. After identifying high risk, high need patients, hubs use the following strategies to increase access to geriatric specialty care through telehealth modalities: 1) Co-management of patients through e-consultation and telehuddles (GRECC Connect interprofessional geriatric specialty care teams extend support to CBOC providers); 2) Clinical video telehealth to CBOCs and Video on Demand to Veteran homes (to reduce travel burden); and, 3) Tele-group visits (especially for behavioral health and caregiver support).

“You Don’t See Them on the Streets of Your Town”: Challenges and Strategies for Serving Unstably Housed Veterans in Rural Areas

ABSTRACTResearch on policy and programmatic responses to homelessness has focused largely on urban areas, with comparatively little attention paid to the rural context. We conducted qualitative interviews with a nationwide sample of rural-serving agencies receiving grants through the U.S. Department of Veterans Affairs’ Supportive Services for Veteran Families program to better understand the housing needs, available services, needed resources, and challenges in serving homeless and unstably housed veterans in rural areas. Respondents discussed key challenges—identifying unstably housed veterans, providing services within the rural resource context, and leveraging effective collaboration—and strategies to address these challenges. Unmet needs identified included emergency and subsidized long-term housing options, transportation resources, flexible financial resources, and additional funding to support the intensive work required in rural areas. Our findings identify promising programmatic innovations and highlight the need for policy remedies that are responsive to the unique challenges of addressing homelessness and housing instability in rural areas.

GAPS AND OPPORTUNITIES TO IMPROVE ACCESS TO HEALTHCARE FOR OLDER RURAL VETERANS

Almost 25% of US military veterans live in rural areas and over 70% of these are age 55 years or older. The physical, cognitive, and functional declines common to aging coupled with accumulated physical and psychological traumas often incurred through military service make caring for older Veterans an especially difficult challenge. Furthermore, the geographic distances associated with rural living pose a significant barrier to timely access to care for aging Veterans and caregivers living in remote communities. Significant gaps remain in VA’s understanding of the needs of this population, which is essential for developing adequate models of care. This symposium highlights various aspects of the rural older Veteran experience and will suggest opportunities for improving access to care for this population. The first presentation estimates the differential impact of rural status on mortality rates among older Veterans using mortality data from the General Social Survey (Wilmoth et al). A second study is an analysis of urban/rural differences in PTSD symptoms as function of multiple co-factors and accounting for geographic location (Kurth et al). Seaman et al present qualitative data regarding the experience of Veterans with head and neck cancer to understand how rurality impacts cancer survival (Seaman et al). The final presentation will highlight a model to address mental health problems in older Veterans in primary care (Geri-PACT [Kube et al]) and will specifically highlight how this VA program may be adapted to address such needs the needs of older Veterans in rural areas.

Supporting older military veterans in the rural US

Purpose The purpose of this paper is to provide an overview of rural older veterans in the US and discuss how the US Department of Veterans Affairs (VA) is increasing access to health care for older veterans in rural areas. Design/methodology/approach This is a descriptive paper summarizing population and program data about rural veterans. Findings VA provides a variety of health care services and benefits for older veterans to support health, independence, and quality of life. With the creation of the Veterans Health Administration Office of Rural Health (ORH) in 2006, the needs of rural veterans, who are on average older than urban veterans, are receiving greater attention and support. ORH and VA have implemented several programs to specifically improve access to health care for rural veterans and to improve quality of care for older veterans in rural areas. Originality/value This paper is one of the first to describe how VA is addressing the health care needs of older, rural veterans.

Impact of the clinical pharmacy specialist in telehealth primary care.

A telehealth-based chronic disease management program including clinical pharmacy specialists (CPSs) and the program's impact on primary care outcomes in a population of veterans are described. A telehealth program including CPS services was developed to improve healthcare access and quality for veterans in rural areas of the Pacific Northwest. Outcomes of medication management services provided by a CPS team during both clinical video telehealth and telephone encounters with 554 patients from October 2014 to March 2017 were assessed. Patients were targeted for diabetes (DM), hyperlipidemia (HLD), and hypertension (HTN) control and tobacco cessation; the respective primary outcomes were the mean changes from baseline in glycosylated hemoglobin (HbA1c) and blood pressure values and rates of guideline-indicated statin therapy and tobacco cessation. Patients in the DM and HTN groups had a mean absolute HbA1c reduction of 1.61% (95% confidence interval [CI], 1.39-1.83%; p < 0.0001) and a mean systolic blood pressure reduction of 26.00 mm Hg (95% CI, 22.99-28.50 mm Hg; p < 0.001), respectively. In the HLD group, 93% of patients were discharged on a lipid-lowering medication. Tobacco cessation was achieved in 42% of targeted patients. CPSs providing primary care comprehensive medication management services solely via telehealth improved disease management and access to healthcare in a population of rural veterans. Statistically significant improvements in DM and HTN outcomes were demonstrated along with clinically significant improvements in the areas of lipid management and tobacco cessation.

Justice Involvement and Treatment Use Among Rural Veterans.

Veterans in rural areas and veterans involved in the criminal justice system have experienced less access to, and use of, health care. However, there is limited information on the treatment needs and health care access of justice-involved veterans who live in rural areas. This study used national Veterans Health Administration data from fiscal year 2014 to examine the interactive effect of rural/urban residence and justice involvement on mental health and substance use disorder treatment entry among veterans diagnosed with mental health or substance use disorders. Of veterans residing in rural areas, 15,328 (2.5%) were justice-involved and 607,819 (97.5%) veterans had no known justice involvement. Among veterans in urban areas, 54,525 (4.3%) were justice-involved and 1,213,766 (95.7%) had no known justice involvement. Rural residence was associated with lower access to mental health or substance use disorder treatment in the non-justice-involved sample but not the justice-involved sample. Justice-involvement was associated with higher odds of entering mental health or substance use disorder treatment for veterans in rural and in urban areas. Substance use disorder treatment entry could be improved for all veterans, particularly rural veterans who are not justice-involved. Telehealth, outreach services, and integrated treatment may help address challenges to treatment entry experienced by rural veterans and justice-involved veterans.

Utilization of Mental Health Services by Veterans Living in Rural Areas.

There is concern that veterans living in rural areas may not be receiving the mental health (MH) treatment they need. This study uses recent national survey data to examine the utilization of MH treatment among military veterans with a MH condition living in rural areas, providing comparisons with estimates of veterans living in urban areas. Multivariable logistic regression is utilized to examine differences in MH service use by urban/rural residence, controlling for other factors. Rates of utilization of inpatient and outpatient treatment, psychotropic medication, any MH treatment, and perceived unmet need for MH care are examined. There were significant differences in MH treatment utilization among veterans by rural/urban residence. Multivariate estimates indicate that compared to veterans with a MH condition living in urban areas, veterans in rural areas had 70% lower odds of receiving any MH treatment. Veterans with a MH condition in rural areas have approximately 52% and 64% lower odds of receiving outpatient treatment and prescription medications, respectively, compared to those living in urban areas. Differences in perceived unmet need for mental health treatment were not statistically significant. While research indicates that recent efforts to improve MH service delivery have resulted in improved access to services, this study found that veterans' rates of MH treatment are lower in rural areas, compared to urban areas. Continued efforts to support the provision of behavioral health services to rural veterans are needed. Telemedicine, using rural providers to their maximum potential, and engagement with community stakeholder groups are promising approaches.

Trauma in Veterans With Substance Use Disorder: Similar Treatment Need Among Urban and Rural Residents.

The objective of this study is to determine whether rural residence is associated with trauma exposure or posttraumatic stress disorder symptoms among military veterans seeking treatment for substance use disorder (SUD) through the Department of Veterans Affairs (VA), Delivering mental health services to veterans in rural areas is a challenge, so identifying differences in the causes and outcomes of trauma exposure would assist in effectively targeting service delivery. Veterans (N = 196) entering SUD treatment at 3 Midwestern VA treatment centers were designated as either urban or rural, based on rural-urban commuting area (RUCA) codes. The veterans completed the Life Events Checklist, the Posttraumatic Stress Disorder Checklist, and the Addiction Severity Index's psychiatric status subscale. Hypothesized relationships between rural-urban residence and both trauma exposure and symptomology were tested using independent samples t tests, chi-square tests, and ordinary least squares regression. The range of traumatic experiences was similar between rural and urban veterans, and rural-urban residence was not significantly associated with the overall array of traumas experienced or the symptom measures' overall scores or subscores. Of 17 possible traumatic lifetime experiences, rural veterans differed from urban veterans on only 2, reporting significantly lower rates of transportation accidents and unwanted sexual experiences. In both the causes of trauma and the need for treatment, veterans residing in rural areas differ little from their urban counterparts.

Rural Women Veterans' Use and Perception of Mental Health Services

While the total number of veterans in the U.S. is decreasing overall, the number of women veterans is significantly increasing. There are numerous barriers which keep women veterans from accessing mental health care. One barrier which can impact receiving care is living in a rural area. Veterans in rural areas have access to fewer mental health services than do urban residing veterans, and women veterans in general have less access to mental health care than do their male colleagues. Little is known about rural women veterans and their mental health service needs. Women, who have served in the military, have unique problems related to their service compared to their male colleagues including higher rates of post-traumatic stress disorder (PTSD) and military sexual trauma (MST). This qualitative study investigated use of and barriers to receiving mental health care for rural women veterans. In-depth interviews were conducted with ten women veterans who have reported experiencing problems with either MST, PTSD, or combat trauma. All ten women had utilized mental health services during active-duty military service, and post service, in Veterans Administration (VA) community based-outpatient clinics. Several recurring themes in the women's experience were identified. For all of the women interviewed, a sentinel precipitating event led to seeking mental health services. These precipitating events included episodes of chronic sexual harassment and ridicule, traumatic sexual assaults, and difficult combat experiences. Efforts to report mistreatment were unsuccessful or met with punishment. All the women interviewed reported that they would not have sought services without the help of a supportive peer who encouraged seeking care. Barriers to seeking care included feeling like they were not really a combat veteran (in spite of serving in a combat unit in Iraq); feeling stigmatized by providers and other military personnel, being treated as crazy; and a lack of interest from those providing care in hearing their stories. This study may generate positive social change by helping providers approach women veterans in a way that is sympathetic to their experiences.

Improving Veterans’ Mobility in Small Urban and Rural Areas

The need for veterans’ transportation is growing rapidly because of the increasing number of older veterans as well as the many injured servicemen and -women returning from Iraq and Afghanistan. Thirty percent of veterans live in rural areas that often present transportation challenges. Many veterans in rural areas must travel extremely long distances to receive medical care, and veterans living in rural areas are reported to be in poorer health than veterans living in urban areas. The objective of this study was to identify veterans with mobility needs living in rural Minnesota, Montana, and North Dakota and to quantify the cost of feasible transportation options for meeting veterans’ mobility needs. This study included a survey of veterans and a simulation of their health care transportation costs. Online and paper surveys were distributed to veterans throughout Minnesota, Montana, and North Dakota. More than 80% of respondents classified themselves as disabled with nearly three-fourths of these indicating that their veteran disability rating was greater than 30%. The most common disability reported by survey respondents was having a mobility impairment, followed by hearing impairment and mental health issues. When a coordination effort between U.S. Department of Veterans Affairs (VA) health care centers and rural public transit agencies was simulated with @Risk risk analysis software, results varied by state and region because of varying operating costs and fare recovery rates. Overall, most simulations indicated that a coordination effort between VA health care centers and rural public transit agencies would be feasible if estimated ridership levels could be attained.

Peer support program for veterans in rural areas.

Peer support program for veterans in rural areas.

Providing Mental Health Care to Veterans in Rural Areas: Using Telehealth in Mobile Clinics

The purpose of this article is to provide information to improve the quality of care of veterans living in geographically isolated areas who require treatment for mental health issues. Because interactive care solutions are currently hot topics in the health care community, they should be viewed as possible strategies to meet the needs of this specialty group of veterans. An intervention using a mobile clinic and clinical video telehealth reduces distance barriers by making it possible for mental health specialists to come to rural veterans instead of the veteran attempting to find a way to get to the practitioner, who may be located in a clinic or hospital many miles away. This article focuses on an alternate strategy-telehealth in mobile clinics-as a possible solution to the mental health crisis of veterans in rural areas.