Forging New Paths to Integrate Rural Veterans' Care Nationwide.

One quarter of all veterans in the United States, 5.2 million people, call rural communities home (see Figure 1). Three million of these veterans are enrolled in the US Department of Veterans Affairs (VA) for health care. Most rural veterans (82%) have other health insurance and many of them use it to see community providers in addition to their VA health care professionals. In addition, the Veterans Choice Act of 2014 created new avenues for VA and community health care providers to work together in providing veterans primary and specialty care closer to home. Indeed, community clinical workload for veteran care increased 27% last year. Now more than ever, as VA transforms from its traditional role as direct health care provider to an integrated provider and payer of care, the quality of rural veterans’ health care is dependent upon close relationships between community providers and VA. Fortunately, VA builds on a strong foundation and decades of partnerships in the delivery of care to veterans. Collectively, this includes 1,600 VA-run hospitals, clinics, and centers partnered with more than 1,200 Federally Qualified Health Centers, 1,300 Critical Access Hospitals, 4,000 Medicare-Certified Rural Health Clinics, and 160 Indian Health Service Facilities. From May 2015 through April 2016 these partnerships yielded more than 3.1 million authorizations for veterans to receive care in community hospitals and clinics, an 8% increase over the same period 1 year earlier. A critical component of VA’s transformation going forward is creating integrated VA and community health care systems. The establishment of VA’s Community Care Network will begin to identify high-performing providers based on quality, value, and commitment to veterans’ health. VA will incentivize providers based on the delivery of high-quality outcomes using common metrics that align with industry standards. These may include performance criteria for clinical outcomes, appropriateness criteria, access standards, and service levels. As more veterans access care in their local communities, integration and care coordination of VA and community health care services will become even more important. Yet, integration of VA and community care is complicated by the specialized treatment required to address the serviceand combat-related physical andmental trauma specific to our returning rural veterans. Add these factors to the innate challenges of rural care delivery, including provider shortages, geographic barriers, lack of transportation options, and rural community hospital closures, and we are left with a very complex health care environment that calls for creative solutions. We must find new paths to get the patient to care, or care to the patient, in a manner that is satisfying and empowering for patients and their caregivers. This challenge calls for VA and community health care organizations to work together in constructing a highperforming network to support the entire rural health care community through innovations in workforce enhancement and the use of technology across health care organizations to meet the demands of a modern, rural health care system.