Office of Research & Development

VA research on

Rural Health


Introduction

Many Veterans who rely on VA for their health care live in remote areas. Our nation's rural and highly rural Veteran population is large and dispersed. It is also racially, ethnically, and culturally diverse. Providing comprehensive, high-quality health care to these Veterans is a challenge.

VA's Office of Rural Health (ORH), created in 2007, strives to eliminate the barriers between rural Veterans and the services they have earned and deserve, thus improving Veterans'Veterans' health and well-being by increasing access to care.

According to ORH, 5.2 million Veterans live in rural communities across the United States, and more than 32.9 million rural Veterans rely on VA for their health care. Veterans are more likely to live in rural areas than Americans who did not serve in the military. While 18 percent of Americans live in rural areas, 23 percenta quarter of Veterans do.

More than half (57 percent) of rural Veterans enrolled in VA health care are 65 years old or older. In addition, 6 percent are women; 9 percent report being members of racial and ethnic minorities; and nearly 435,000 are Veterans of our recent conflicts in Iraq and Afghanistan. About 44 percent of rural Veterans have one or more service-related disabilities.

Rural Veterans have lower average household incomes than other Veterans; they often face long driving distances to access quality health care; and there are fewer health care providers and nurses per capita in rural areas.

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Selected Major Accomplishments

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New, Ongoing, and Published Research

In the past 10 to 15 years, VA has launched a number of initiatives to expand and ensure access to high-quality health care for Veterans enrolled in the VA health care system who live in rural areas. VA researchers have been instrumental in these efforts by developing and evaluating new technologies, interventions, and models of care.

Veterans who live in remote areas of the country have faced challenges in accessing VA care.

VA researchers have focused on understanding these Veterans' health care needs, and on developing and evaluating new initiatives to fill the gaps. Some VA studies focus specifically on Veterans in rural areas, while others have a broader focus but explore issues or possible solutions that are relevant to rural health care.

With support from the Office of Research and Development, a Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) group, Improving Rural Veterans' Access/Engagement in Evidence-Based Healthcare, is working with VA's Office of Rural Health to ensure rural Veterans receive adequate levels of mental health care.

VA's Charleston Health Equity and Rural Outreach Innovation Center(HEROIC), one of the Office of Research and Development's 19 Centers of Innovation, aims to improve health outcomes among rural Veterans by examining the increasing role of technology on access.

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➤ Understanding patterns and quality of care

Review of studies on outpatient care—A 2011 Evidence-Based Synthesis Program review by researchers at VA's Minneapolis Health Care System looked at the overall issue of outpatient care in rural versus urban areas. The researchers reviewed more than 1,300 studies on the issue that have been published in the United States since 1990.

The research team found only weak evidence that rural health care disparities exist in some areas of care, such as mental health. However, they also found large gaps in the evidence base. In particular, virtually no research had been done in many areas important to VA and Veterans, such as traumatic brain injury.

Among their specific findings was that there was no difference between urban and rural Americans in the rates of influenza and pneumonia vaccination. There was also no conclusive evidence that women received better prenatal care in either rural areas or cities.

The researchers also learned that Americans living in rural areas were screened for colorectal cancer at lower rates than those in urban areas. They also found evidence that suicide rates among Americans might be higher in rural areas, and that people living in rural areas were hospitalized less frequently for schizophrenia and depression than their urban counterparts.

VA is using this evidence review to create more robust indicators of rural health disparities. In addition, Investigators are using the report to help focus their efforts on the areas of concern for rural Veterans it identified.

Use of VHA and non-VHA hospitals—Researchers from the White River Junction, Vermont, and Iowa City VA medical centers looked at how often Veterans enrolled with VA for care used VHA and non-VHA inpatient care, and whether this use varied substantially between rural and urban residents.

They found that in states with higher proportions of urban residents, use of non-VHA hospitals was lower for small or isolated rural town residents than urban residents; in more rural states it was greater. Rural enrollees also used VHA hospitals more than urban enrollees did if they lived in the south. The team concluded that vouchers for non-VHA inpatient care might have greater impact in rural states.

Differences in mortality from stroke—In 2015, researchers from several VA medical centers foundfound that the longer it took for Veterans to travel to a VA emergency room, the more likely they were to die in a hospital following a stroke.

The study team looked at more than 10,000 stroke cases that occurred during fiscal years 2007 and 2008 and were treated at VA hospitals. About 4 percent of those treated died during their hospital stay. The researchers found that if a patient had to travel 90 minutes or more to get to an emergency room, he or she was nearly 50 percent more likely to die in the hospital, compared with cases involving less than 30 minutes of travel time.

In an interview, the lead investigator for the project reminded Veterans and their families that,The researchers pointed out in certain emergency situations, VA can pay for non-VA emergency care. The researcherThey noted, also explained, that VA is considering partnering with non-VA stroke centers in areas where VA capacity is low.

Outreach for health care services—A study published in 2013 by researchers at the Tuscaloosa, Ala.,Alabama, VA Medical Center showed that a bit of extra assistance can go a long way in getting rural Veterans to take advantage of VA care and benefits. The researchers designed an outreach initiative that relies on motivational interviewing techniques and a 20-minute educational video. They visited local communities to let rural Alabama Veterans know about the health care services VA offers.

Of the 205 Veterans researchers to whom the research team reached out, half received motivational interviews with a social worker, watched the video, and received another half-hour of enrollment support. The other half received a typical VA enrollment package and some personal outreach. Six months after the outreach, 87 percent of the group receiving the extra "encouragement" had attended an appointment at the Tuskegee VA, compared with only 58 percent of the other group.

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➤ Rural Mental Health

Rural health CREATE—In 2013, VA established a CREATE initiative that focuses on improving rural Veterans' access to and engagement in evidence-based mental health care.

Individual projects in this initiative seek to:

  • develop a patient-centered survey instrument to measure Veterans' perceived access to mental health services;
  • test interventions to increase engagement in mental health care at VA community-based outpatient clinics (CBOCs);
  • test clinical and technology intervention to improve the quality and outcomes of mental health care provided at CBOCs; and
  • test new Web-based interventions and evidence-based training to enhance access to PTSD care for women Veterans and Veterans who use CBOCs for their mental health care.

Reasons rural Veterans don't seek mental health care—In 2016, a team of researchers from the Central Arkansas Veterans Healthcare System in Little Rock and the VA Puget Sound Health Care System in Seattle interviewed 25 rural Veterans and 11 rural mental health care providers on the attitudes they thought most influenced rural Veterans' decision to seek and continue to use mental health care. Both Veterans and providers agreed that the most important barrier was the importance rural Veterans place on independence and self-reliance. Stoicism, stigma associated with mental illness and health care, and a lack of trust in VA as a caring organization were also mentioned.

According to the survey participants, reluctance to seek care can be overcome by a perceived need for care and the support of other Veterans. Veterans are best encouraged to continue with care when they receive "warm handoffs" from medical to mental health care providers, when they perceive they are respected by providers and that the providers are perceived as caring about them, and when these providers are accessible to them and do not change over the course of treatment.

Use of psychotherapy among rural Veterans increasing—A 2015 study by researchers at three VA medical centers evaluated changes in rural and urban Veterans' use of psychotherapy between 2007-10, a period in which VA was making significant efforts to engage rural Veterans in mental health care. They found that in those years, the percentage of rural Veterans receiving psychotherapy increased from 17 to 22 percent, which the percentage of urban Veterans receiving such care increased from 24 to 28 percent.

The team concluded that gaps between rural and urban Veterans' use of psychotherapy were decreasing, and that efforts by VA to engage rural Veterans in care have been successful in reducing differences between the two groups.

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➤ Prevention

Preventing colorectal cancer—In 2011, VA published a review of previous studies of urban versus rural ambulatory care. The review included the observation that three previous studies of colorectal care screening rates found rates of screening were lower among rural Veterans compared to Veterans living in urban areas.

VA researchers in Iowa reported in 2014 that mailing stool tests to Veterans' homes, instead of waiting for the Veterans to be screened during office visits, was an effective measure for preventing colorectal cancer.

Approximately 1,500 Veterans between 51 and 64 years old who were overdue for colorectal screening were divided into three groups. One group received educational material in the mail; another was mailed the educational material and a fecal immunochemical test (FIT), which detects human blood in stool. The third group received neither the kits nor the educational material.

Overall, 21 percent of the total FIT group underwent screens within six months of the mailing, while only 6 percent in each of the other two groups received colorectal cancer screens during the study. The findings suggest that mailing screening kits, as opposed to waiting to screen patients during routine primary care visits, may be a more effective method to prevent colorectal cancer, especially for rural Veterans.

MRSA danger—In 2014, a studystudy by researchers at the Iowa City VA Health Care System and the University of Iowa showed that Veterans who live within 1 mile of a large hog farm were more than three times as likely as others to test positive for a type of bacteria known as MRSA, or methicillin-resistant Staphylococcus aureus.

MRSA infections can quickly become deadly because of the bacteria'sbacteria's resistance to common antibiotics.

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➤ Using new technologies

VA researchers have led the way in exploring the use of telehealth. Telehealth, or "connected health," as it is now referred to in VA, includes care provided through means such as the telephone, the Internet, videoconferencing, email, and text messaging.

These technologies are particularly important for Veterans living in rural areas, but also play a role in the delivery of care for other Veterans, such as those who are homebound because of illness or disability.

According to a 2016 VA news releasenews release, the department currently serves more than 677,000 Veterans through telehealth, approximately 12 percent of the total number of Veterans who receive health care from VA.

HIV and hepatitis C care—A study by VA researchers from the Greater Los Angeles Health Care System, published in 2012, found that Veterans living in rural areas preferred an HIV and hepatitis C telemedicine clinic to an in-person clinic. Veterans attended scheduled telemedicine appointments more often than in-person ones.

Teledermatology—Another 2012 study, by researchers from VA's Puget Sound Health Care System, found that 3 in 4 Veterans living in the Pacific Northwest described themselves as either "satisfied" or "highly satisfied" with teledermatology for their skin problems. Teledermatology relies on digital images taken by visiting nurses or other providers, and checked remotely by dermatologists.

SCAN-ECHO program supports rural providers—VA's Specialty Care Access Network-Extension for Community Healthcare Outcomes(SCAN-ECHO) program uses video teleconferencing technology to link primary care providers, many of whom work in rural communities, to specialists at VA medical centers.

This exchange of information enables rural primary care clinicians to get access to the latest advances in health care research from VA experts throughout the nation. It also provides rural clinicians with additional knowledge to provide levels of care that were not previously available in rural communities, and means that Veterans with chronic conditions who require complex care do not have to travel long distances to get the medical care they need.

Receiving PTSD services remotely—A 2015 study of rural Veterans with posttraumatic stress disorder (PTSD) at three VA medical centers found that receiving psychotherapy and related services remotely can have positive effects.

Half of the participants in the study, which included 266 middle-aged Veterans with PTSD symptoms, received care at either their local CBOC or their nearest VA medical center.

The other half received cognitive processing therapy (CPT), an evidence-based psychotherapy for PTSD, through an interactive video hookup with psychologists based at the medical center. The patients also received calls from nurse managers and pharmacists and had psychiatric consultations via video chat.

Participants in the telemedicine group were much more likely to engage in care for their PTSD and showed larger decreases in their symptoms. The team believes that the long drives associated with care at CBOCs and medical centers for rural Veterans prevented that group from taking full advantage of available treatment, leading to lower improvement rates.

A similar study, completed in 2014, looked at 125 Veterans with combat-related PTSD who lived on four remote Hawaiian Islands. Between 2009 and 2013, about half of those Veterans received CPT through video teleconferences. The others traveled to outpatient clinics in Hawaii to receive CPT in person.

The severity of the Veterans' PTSD was assessed at the beginning of treatment, at the halfway point of the sessions, at the end of treatment, and three and six months after treatment was completed. The investigators found that the outcomes of treatment using video teleconferencing were as good as those of in-person treatment.

The team concluded that video teleconferencing is a safe and effective way to increase access to specialty mental health care such as CPT for residents of rural or remote areas.

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➤ Telemental health

HEROIC study—The Charleston VA Health Equity and Rural Outreach Innovation Center (HEROIC) is one of 19 nationally funded VA HSR&D Centers of Innovation (COINs) aimed at increasing the impact of health-services research on the health and health care of Veterans. HEROIC's mission is to improve access and equity in health care for all Veterans by eliminating geographic, racial, ethnic, and gender-based disparities.

In 2015, a studyIn 2015, a study led by HEROIC researchers found that talk therapy delivered by two-way video calls is at least as effective as in-person treatment delivery for older Veterans with depression.

In the study, the research team recruited 241 Veterans aged 58 or older with major depression. The Veterans were randomly assigned to receive either telemedicine or same-room psychotherapy. bothBoth groups received the same kind of treatment: behavioral activation, a talk therapy that emphasizes reinforcing positive behaviors.

The team found that telemedicine-delivered psychotherapy produced similar outcomes to in-person treatment. After a year of treatment, 39 percent of telemedicine patients and 46 percent of in-person therapy patients were no longer depressed, according to structured clinical interviews.

The team concluded that telemedicine is a good option for depressed older adults who live in geographically isolated areas, have barriers to mobility, or have some kind of stigma.

Receiving PTSD services remotely—A 2015 study of rural Veterans with posttraumatic stress disorder (PTSD) at three VA medical centers found that receiving psychotherapy and related services remotely can have positive effects.

Half of the participants in the study, which included 266 middle-aged Veterans with PTSD symptoms, received care at either their local CBOC or their nearest VA medical center.

The other half received cognitive processing therapy (CPT), an evidence-based psychotherapy for PTSD, through an interactive video hookup with psychologists based at the medical center. The patients also received calls from nurse managers and pharmacists and had psychiatric consultations via video chat.

Participants in the telemedicine group were much more likely to engage in care for their PTSD and showed larger decreases in their symptoms. The team believes that the long drives associated with care at CBOCs and medical centers for rural Veterans prevented that group from taking full advantage of available treatment, leading to lower improvement rates.

A similar study, completed in 2014, looked at 125 Veterans with combat-related PTSD who lived on four remote Hawaiian Islands. Between 2009 and 2013, about half of those Veterans received CPT through video teleconferences. The others traveled to outpatient clinics in Hawaii to receive CPT in person.

The severity of the Veterans' PTSD was assessed at the beginning of treatment, at the halfway point of the sessions, at the end of treatment, and three and six months after treatment was completed. The investigators found that the outcomes of treatment using video teleconferencing were as good as those of in-person treatment.

The team concluded that video teleconferencing is a safe and effective way to increase access to specialty mental health care such as CPT for residents of rural or remote areas.

Telemedicine may help rural Veterans with PTSD— Telemedicine-based care delivered at community based outpatient clinics can successfully engage rural Veterans in evidence-based psychotherapy, and such care improves PTSD outcomes, according to a team led by researchers from the VA Puget Sound Health Care System in Seattle.

The investigators looked at 265 middle-aged Veterans with severe PTSD symptoms being treated at CBOCs in Shreveport, Louisiana; Little Rock, Arkansas; and Loma Linda California. Half of the patients received ordinary care at the CBOCs, and the other half were connected to care at VA medical centers via telehealth techniques including videoconferencing.

More than half of the patients (73 of 133) who received care via telemedicine received cognitive processing therapy, compared to 12 percent of those who did not, and patients in the telemedicine group also had significantly larger decreases in posttraumatic diagnostic scale scores.

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➤ Other telemedicine studies

Telehealth and HIV infection—VA's Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), located in Iowa City, develops, implements, and tests innovative strategies that expand access to high-quality primary and specialty care, especially for rural Veterans, while ensuring that the care delivered is safe and free of preventable infections.

In 2013,CADRE researchers looked at the feasibility of telehealth collaborative care for 24 Veterans with HIV infection in Iowa and Illinois. They found that, over the course of a year, the average travel time for health care over the course of a year for these patients decreased from 320 minutes to 170 minutes. VA's performance measures for HIV care were met for more than 90 percent of the patients in the study, and the team determined that this type of care is a feasible way to provide accessible and comprehensive care for rural Veterans with HIV.

Weight loss aided by videoconferencing—Veterans using a videoconferencing weight-loss program tended to lose more weight than their non-participating peers, according to a 2014 studystudy by researchers from the Sioux Falls, Iowa, VA Medical Center. The researchers broadcast a series of VA's MOVE! weight-management classes live to 60 Veterans at CBOCs in South Dakota and Iowa, and their weight loss was compared to that of a group of Veterans who had declined treatment.

Participants who attended at least 5 of the 12 classes lost, on average, 12 pounds more than those who did not. Moreover, they kept the weight off after a year.

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➤ Rural vs. urban care

HIV and hepatitis C care—A study by researchers from the Greater Los Angeles VA Health Care System, published in 2012, found that Veterans living in rural areas preferred an HIV and hepatitis C telemedicine clinic to an in-person clinic. Veterans attended scheduled telemedicine appointments more often than in-person ones.

Teledermatology—Another 2012 study, by researchers from VA's Puget Sound Health Care System, found that 3 in 4 Veterans living in the Pacific Northwest described themselves as either "satisfied" or "highly satisfied" with teledermatology for their skin problems. Teledermatology relies on digital images taken by visiting nurses or other providers, and checked remotely by dermatologists.

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➤ Support to providers

SCAN-ECHO program supports rural providers—VA's Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) program uses video teleconferencing technology to link primary care providers, many of whom work in rural communities, to specialists at VA medical centers.

This exchange of information enables rural primary care clinicians to get access to the latest advances in health care research from VA experts throughout the nation. It also provides rural clinicians with additional knowledge to provide levels of care that were not previously available in rural communities, and means that Veterans with chronic conditions who require complex care do not have to travel long distances to get the medical care they need.

Controlled trial of tele-support and education for women's health care—An ongoing study by VA's Women's Health CREATE aims to improve women's health care in Community-based outpatient clinics (CBOCs) through a technology-based educational and interactive communication intervention designed to support women's health providers.

This support includes both advanced patient-based education that will provide women's health care providers with a wide exposure to cases and issues related to women's health, especially related to gynecology and reproductive care, and facilitating interactive communication between women's health providers at CBOC and medical center based specialists.

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➤ Specific characteristics of care in rural areas

Limitations of PET scans—Positron emission tomography (PET) is a medical imaging technique that produces 3-D images showing differences between healthy and diseased tissue. PET commonly uses a radioactive tracer called FDG (fluorodeoxyglucose), so the test is sometimes called an FDG-PET scan.

FDG-PET scans are often used in combination with computed tomography (CT) scans to diagnose lung cancer. In 2014, a team from VA's Tennessee Valley Health Care System and Vanderbilt University Medical Center in Nashville foundfound that FDG-PET scans combined with CT are not as good at detecting lung cancer in regions where there is endemic infectious lung disease, compared with regions where such disease is not widespread. Many of these regions, including the Mississippi, Ohio, and Missouri River valleys, are largely rural.

The researchers reviewed 70 previous studies on FDG-PET. In patients who had pulmonary nodules but not lung cancer, FDG-PET was 16 percent more likely to give a false-positive result when the patients lived in regions where infectious lung disease is prevalent. This suggests that the lung diseases common in those regions may sometimes be mistaken for cancer on imaging tests.

Examples of regional lung diseases include histoplasmosis and blastomycosis, which are caused by inhaling airborne fungal spores. TB is also much more common in some regions of the United States than in others.

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➤ Care for rural women Veterans

Disparities in health and health care access between rural and urban women Veterans—A team of researchers from the VA Greater Los Angeles Healthcare System and the VA Center for Comprehensive Access and Delivery Research and Evaluation (CADRE) in Iowa City used data from the 2008-2009 National Survey to determine that rural women Veterans have significantly worse physical health functioning compared with urban women Veterans.

Rural women Veterans were also more likely to have a VA regular source of care, and to use VA health care. They also had fewer non-VA health care visits, although the overall number of health care visits for both groups were similar. Barriers to access to care for rural women Veterans included affordability and the availability of transportation.

Demographics of rural women Veterans—In 2014, VA'sVA's Office of Rural Health and the University of Colorado published a first-of-its-kind studystudy of the population demographics and health care needs of female rural Veterans enrolled in VA care.

The study found that women Veterans living in rural and highly rural areas were older and more likely to be married than their urban counterparts. Diagnostic rates were about equal across the groups for several mental health conditions, high blood pressure, and diabetes. However, anxiety not related to posttraumatic stress was significantly lower for highly rural Veterans.

Rural and highly rural Veterans were also less likely to visit VA for woman-specific care than were urban women Veterans. Those in highly rural areas were less likely to visit for mental health care, compared with urban women.

The authors recommended VA expand its use of telehealth, peer support, and other methods to better reach rural women Veterans, especially for woman-specific care and mental health care.

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➤ Partnering with non-VA providers

Through contracts and partnerships with community-based providers and agencies such as the Indian Health Service, and through the Veterans' Choice ProgramVeterans' Choice Program, which allows Veterans eligible to participate in the program the opportunity to receive care from private providers closer to their homes, VA is able to expand its network of services to Veterans living in remote areas. These collaborative efforts address needs in areas such as primary care, mental health care, long-term care, and hospice care.

Arkansas partnership—In North Little Rock, Ark.,Arkansas, VA has developed a partnership with clergy, representatives of nonprofit organizations, Veterans, and mental health providers to discuss ways to help Veterans in their area of Arkansas by creating a team of spiritual leaders and mental health workers.

According to researchers from VA's Office of Rural Health who published information about the project in a 2014 article, the partnership has helped rural Veterans who are uncomfortable contacting mental health care providers, and prefer instead to share problems with VA clergy or their church's pastor.

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More on Our Website

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Selected Scientific Articles by Our Researchers

Rural-urban differences in inpatient quality of care in US Veterans with ischemic stroke. Phipps MS, Jia H, Chumbler NR, Li X, Castro JG, Myers J, Williams LS, Bravata DM. After adjustment for key demographic, clinical, and facility-level characteristics, there does not appear to be a systematic difference in inpatient stroke quality of care between rural and urban VA medical centers. J Rural Health. 2014 Winter;30(1):1-6.

The effectiveness of telemedicine for weight management in the MOVE! program. Ahrendt AD, Kattelmann KK, Rector TS, Maddox DA. Videoconferencing is an effective method to provide the MOVE! Weight Management Program to Veterans. J Rural Health. 2014 Winter;30(1):113-9.

Residential proximity to large numbers of swine in feeding operations is associated with increased risk of methicillin-resistant Staphylococcus aureus colonization at time of hospital admission in rural Iowa veterans. Carrell M, Schweizer ML, Sarrazin MV, Smith TC, Perencevich EN. Among 1,036 patients, residential proximity within 1 mile of large swine facilities was associated with nearly double the risk of methicillin-resistant Staphylococcus aureus (MRSA) colonization at admission. Infect Control Hosp Epidemiol. 2014 Feb;35(2);190-3.

Alabama Veterans rural health initiative: a pilot study of enhanced community outreach in rural areas Alabama Veterans rural health initiative: a pilot study of enhanced community outreach in rural areas. Hilgemann MM, Mahaney-Rice AF, Stanton MP, McNeal SF, Pettey KM, Tabb KD, Litaker MS, Parmelee P, Hamner K, Martin MY, Hawn MT, Kertesz SG, Davis LL: Alabama Veterans Rural Health Initiative steering committee. There is need for a specific outreach intervention that speeds enrollment and engagement for rural individuals in VA services. J Rural Health. 2014 Spring;30(2):153-63.

Building partnerships with rural Arkansas faith communities to promote veterans' mental health: lessons learned. Sullivan G, Hunt J, Haynes TF, Bryant K, Cheney AM, Pyne JM, Reaves C, Sullivan S, Lewis C, Barnes B, Barnes M, Hudson C, Jegley S, Larkin B, Russell S, White P, Gilmore L, Claypoole S, Smith J, Richison R. Academics can partner with local faith communities to create unique programs that benefit the mental health of returning Veterans. Prog Community Health Partnersh. 2014 Spring;8(1):11-9.

Rural women Veterans demographic report: Defining VA users' health and health care access in rural areas. Brooks E, Dailey N, Bair B, Shore J. This report is the first of its kind to describe the population demographics and health care utilization of rural female Veteran patients enrolled in VA. J Rural Health, 2014 Spring;30(2):146-52.

Cognitive processing therapy for posttraumatic stress disorder delivered to rural Veterans via telemental health: a randomized noninferiority clinical trial. Cognitive processing therapy for posttraumatic stress disorder delivered to rural Veterans via telemental health: a randomized noninferiority clinical trial. Morland LA, Mackintosh MA, Greene CJ, Rosen CS, Chard KM, Resick P, Frueh BC. Providing cognitive processing therapy to rural residents with PTSD via video teleconferencing produced outcomes that were as good as in-person treatment. J Clin Psychiatry, 2014 May;75(5):470-6.

Evaluation of a home-based colorectal cancer screening intervention in a rural state. Charlton ME, Mangling MA, Halfdanarson TR, Makki NM, Malhotra A, Klutts JS, Levy BT, Kaboli PJ. Mailing FITs to average risk patients overdue for screening resulted in a significantly higher screening rate than educational materials alone or usual care, and may be of particular interest in rural areas. J Rural Health. 2014 Jun;30(3):322-32.

Accuracy of FDG-PET to diagnose lung cancer in areas with infectious lung disease: a meta-analysis Accuracy of FDG-PET to diagnose lung cancer in areas with infectious lung disease: a meta-analysis. Deppen SA, Blume JD, Kensinger CD, Morgan AM, Aldrich MC, Masssion PP, Walker RC, McPheeters ML, Putnam JB Jr, Grogan EL. FDG-PET scans combined with CT are not as good at detecting lung cancer in regions where there is endemic infectious lung disease, compared with regions where such disease is not widespread. JAMA. 2014 Sep 24:312(12):1227-36.

Telemedicine-based collaborative care for posttraumatic stress disorder: a randomized clinical trial.Improving access to noninstitutional long-term care for American Indian Veterans. Fortney JC, Pyne JM, Kimbrell TA, Hudson TJ, Robinson DE, Schneider R, Moore WM, Custer PJ, Grubbs KM, Schnurr PP. Telemedicine-based collaborative care can successfully engage rural Veterans in evidence-based psychotherapy to improve PTSD outcomes.JAMA Psychiatry. 2015 Jan;72(1):58-67.

Improving access to noninstitutional long-term care for American Indian Veterans. Kramer BJ, Creekmur B, Cote S, Saliba D. VA'sVA's home-based primary care program is flexible, and offers opportunities for expansion of health care access for American Indians and non-Indians, particularly in rural areas. J Am Geriatr Soc. 2015 Apr;63(4):789-96.

How does geographic access affect in-hospital mortality for Veterans with acute ischemic stroke? How does geographic access affect in-hospital mortality for Veterans with acute ischemic stroke? Ripley DC, Kwong PL, Vogel WB, Kurichi JE, Bates BE, Davenport C. Even after adjusting for the confounding effects of patient, treatment, and facility characteristics, travel time from home to admitting VA medical center was significantly associated with in-hospital mortality. Med Care. 2015 Jun;53(6):501-9.

Psychotherapy for depression in older veterans via telemedicine: a randomized, open-label, non-inferiority trial Psychotherapy for depression in older veterans via telemedicine: a randomized, open-label, non-inferiority trial. Egede KE, Acierno R, Knapp RG, Jejuez C, Hernandez-Tejada M, Payne EH, Frueh BC. Telemedicine-delivered psychotherapy for older adults with major depression is not inferior to same-room treatment. Lancet Psychiatry. 2015 Aug; 2(8):693-701.

Differences among states in rural veterans use of VHA and non-VHA hospitals. Differences among states in rural Veterans' use of VHA and non-VHA hospitals. West AN, Weeks WB, Charlton ME. Vouchers for non-VHA inpatient care might have greater impact in rural states. by making it easier for Veterans to use non-VHA hospitals. J Rural Health. 2015 Oct. 9. (Epub ahead of print)

Overcoming barriers to sustained engagement in mental health care: Perspectives of rural veterans and providers. Fischer EP, McSweeney JC, Wright P, Cheney A, Curran GM, Henderson K, Fortney JC. System support for peer and provider behaviors that generate trust and demonstrate caring may help overcome attitudinal barriers to treatment-seeking and sustained engagement in mental health care among rural veterans. J Rural Health. 2016 Sep;32(4):429-38.

Psychotherapy utilization among rural and urban veterans from 2007 to 2010. Mott JM, Grubbs KM, Sansgiry S, Fortney JC, Cully JA. Rural and urban veterans are increasingly making use of psychotherapy, and rural-urban gaps in psychotherapy use are shrinking. J Rural Health. 2015 Summer;31(3):235-43.

Telemedicine-based collaborative care for posttraumatic stress disorder: A randomized clinical trial. Fortney JC, Pyne JM, Kimbrell TA, Hudson TJ, Robinson DE, Schneider R, Moore WM, Custer PJ, Grubbs KM, Schnurr PP. Telemedicine-based collaborative care can successfully engage rural veterans in evidence-based psychotherapy to improve PTSD outcomes. JAMA Psychiatry. 2015 Jan;72(1):58-67.

Mixed-methods evaluation of a telehealth collaborative care program for persons with HIV infection in a rural setting. Ohl M, Dillon D, Moeckli J, Ono S, Waterbury N, Sissel J, Yin J, Neil B, Wakefield B, Kaboli P. Telehealth Collaborative Care is a feasible approach to providing accessible and comprehensive care for persons with HIV in rural settings. J Gen Intern Med. 2013 Sep;28(9):1165-73.

Evaluation of human immunodeficiency virus and hepatitis C telemedicine clinics. Saifu HN, Asch SM, Goetz MB, Smith JP, Graber CJ, Schaberg D, Sun BC. HIV and hepatitis C telemedicine clinics are associated with improved access, high patient satisfaction, and reduced health visit-related time. Am J Manag Care. 2012 Apr;18(4):207-12/

Teledermatology patient satisfaction in the Pacific Northwest. Hsueh MT, Eastman K, McFarland LV, Raugi GJ, Reiber GE. Patients were just as satisfied with teledermatology care as they were with face-to-face care at rural clinics for skin complaints. Telemed J E Health. 2012 Jun;18(5):377-81.

Health and health care access of rural women veterans: Findings from the National Survey of Women Veterans. Cordasco KM, Mengeling MA, Yano EM, Washington DL. Rural women veterans have significantly worse physical health function and were more likely to exclusively use VA care compared with urban women veterans. Affordability and transportation are major barriers to care for rural women veterans. J Rural Health. 2016 Sep;32(4):397-406.

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