Charting a Path to Comprehensive Healthcare for Rural Veterans, with Matt Coleman and James VanCleave

Organizations and resources mentioned in this episode:

• Kentucky Office of Rural Health, University of Kentucky College of Medicine
  • Kentucky Homeplace
• U.S. Department of Veterans Affairs (VA)
  • VA Community Care
  • U.S. Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) Program
  • The PACT Act and Your VA Benefits
• Federal Office of Rural Health Policy (FORHP)
  • Medicare Rural Hospital Flexibility Program (Flex Program)
• Mercy Health — Marcum and Wallace Hospital
• Gary Sinise Foundation
• Kentucky Association of Community Health Workers
• Camp Graves

Transcript

Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved. Today, joining me from the Kentucky Office of Rural Health is Matt Coleman, the office's director, as well as James VanCleave, Rural Project Manager, Veterans Services. Thank you both for joining us today.

Matt Coleman: Yeah. Thank you for having us.

James VanCleave: Thank you for having us. Yeah.

Andrew Nelson: In 2022, the Kentucky Office of Rural Health received a three-year grant from the Federal Office of Rural Health Policy. The resulting Expanding Healthcare Access for Rural Veterans Project seeks to fund Critical Access Hospitals, nonprofits, and projects trying to expand and improve healthcare for Kentucky's rural veterans. Can you tell us a little bit more about how and why that project came to be?

Matt Coleman: My predecessor, Ernie Scott, was the director at the time for the Kentucky Office of Rural Health. And this project is funded by HRSA [the Health Resources and Services Administration] through the Federal Office of Rural Health Policy eligible for those programs that do the Medicare Flexibility Program. So within that we saw that there's a need for Kentucky, especially knowing that we have around 300,000 veterans within our state and over, a little over 40% of those veterans are living within rural Kentucky. And just knowing the need for healthcare access in Kentucky in general, for the general population, know that that's amplified even more so for veterans. So with that, we applied for the funding with a focus around how can we get to the community level where these veterans are at. Like, how can we do some of those outreaches? How can we do activities? How can we work with the hospitals and clinics in those areas and make sure that we're actually bringing something to the veterans at the ground level?

Andrew Nelson: Can you tell us about some of the different types of activities that qualified for funding?

Matt Coleman: Yeah. So when we first started this project, the general funding is around, one, you can help providers in getting access, becoming official Community Care with the VA, or you can work in substance use, telehealth. There's a lot of different activities that qualify. But the main goal of this whole project is to make sure that you're getting veterans access to healthcare, whether that's with the VA or that's with the local clinic. And while we're supportive of all options, we're just trying to find what's going to work best for the veteran, right? So, with that, what we had planned to do is find a way to connect at the community level, connect to the local community providers that are going to be there for those veterans. And then find a way to connect them from there to the VA.

Of course, that was the beginning of our project. So, from there, what we decided to do, we had some seed funding, what we call mini-grants. We decided that with this community approach, we're going to do some outreach, like community health days. We had done some previously around vaccinations with COVID, but we wanted to focus some more around, what are some veteran resources out there, but also, we wanted to provide some funding around getting these providers, these hospitals, mental health centers, whatever stakeholders are out there trying to assist veterans, trying to help them with some funding on needs to connecting veterans to services.

So, I'm going to jump into some of the collaborations of what we've had with those. In the very beginning, our goal was to just let those community organizations really drive the work. Because our resources at our state office were kind of minimal in the realm of veterans and their healthcare, right? Our focus has not in the past been around helping those veterans access those services. So what we did, like I said, we provide those mini-grants for those community partners. So we had some really great results from that.

So we have a Critical Access Hospital in Irving, Kentucky — Mercy Health Marcum and Wallace — they started the first year of this program with some support groups. They addressed all kinds of things within multiple counties of their service area. So they did support around eating and diet, but also around substance use, mental health. They brought together many different veterans that felt like they had been overlooked because they're living in a rural area. So that was one of the big successes of one of these mini-grants was the fact that they were just able to get some of these extra parts and pieces that allowed them to do some of this outreach and, and some of this work that they've been wanting to do with their veterans. So, a fantastic job. And so what they're actually doing now is, turn this around two years, after that first year of funding, they're now working with the VA to provide [a] VA site for telehealth. They're going to originate telehealth within their local communities, connect the veterans to the VA, and then they're also assisting with when there's an in-person visit needed, connecting, getting those patients to the VA and making that care coordination for the veteran.

Andrew Nelson: What are some of the specific goals or prior priorities you wanted supported projects to have?

Matt Coleman: Yeah, so kind of our first goal, like we said, was hit that community level. So, within the first year of our project, we had a major challenge within our office. We had the unexpected passing of our director Ernie Scott. And so, from that we kind of had to pivot, right?

From there, we had to figure out, what does this look like with the personnel that we have and the strengths that we have within transitions of the office, right? Just like every other healthcare organization over the last three, four years since COVID hit, there's been a lot of transition within positions. And we've experienced kind of the same thing within our office. So we had to kind of pivot around, what do we have and what do we need? And so, our specific goal was, we could just support these organizations, and we could do the community-level work and that's it. We can mostly let the outside organizations assist us, right? But within that pivot, we found this great resource within what we were going to be bringing to the table.

And, and that resource is James, right? So, I pivoted, and I moved into this director position at the Kentucky Office of Rural Health, which allowed us to hire James, who has experience within the VA. Not only that, but he's a veteran himself. So, the amount of communication that is able to be achieved just from the get-go of him talking to a veteran or him talking to anybody. It's amazing just seeing how quickly that connection is made. And then from there, the amount of work that we can do. So, we had to adjust how we wanted to do some of our projects, right?

What we found to be a real benefit for this program was, James has some history and some knowledge of some of the red tape navigation and the navigation around the VA disability and benefits part of the process. And we understand there's a lot of veterans out there as they were talking to us, that felt like because they were denied for benefits or because they didn't have one paper right in the process that they felt like they were left behind, there was no hope, and that they might as well just not worry about the VA, the VA doesn't care, and that's not the case. It's just part of the system and how the process works. So in general, we brought James in and he's just absolutely all of a sudden started getting some contacts and started working with some veterans and started working with some of our other stakeholders.

Andrew Nelson: In the last couple of years, are there any commonalities you've seen between the geographical areas or perhaps certain demographics, that have the greatest need?

Matt Coleman: I feel like when, when we talk about Kentucky, a lot of people think of the Appalachian Mountains, and for sure, that's a definite barrier to care, right? You talk about somebody coming from the hollers and the hills of Kentucky just to navigate and go to their county seat, the local clinics, that might be 20, 30, 40 minutes, just within the same county. And then moving from there into, where is a local VA hospital, or where is a local VA Community-Based Outpatient Clinic? And that could be even further, you go 30 more miles than that, or however far, and that's talking within the Appalachian region. That's not mentioning, you have the same issue within western Kentucky, northern Kentucky. You have lakes that take up a massive expanse of access to where you have to go around, through, over, however, it's got to be different, those different geographical barriers. If you're in rural, transportation has always been named as a significant barrier.

So, one of those things that we've been working on is, as you mentioned, trying to work with whatever care coordination that we can, which has been great, through James. He understands some of these processes, some of the tools that the VA has, they have transportation, but also, we have some tools within our organization here where we're situated within the UK, University of Kentucky Center of Excellence in Rural Health. So with that, there's another program called Kentucky Homeplace, and that program is about 30 counties within Appalachia, Kentucky of community health workers [CHWs] that help provide an array of different resources and connections to, to the communities and the people within those communities that need assistance, right? So with that, we've been able to, to help provide some of that care coordination through those CHWs.

Andrew Nelson: James, I was wondering if you could just talk a little bit about how your experiences as a veteran helped to inform or guide the work you're doing now?

James VanCleave: Sure. As a veteran, I'm a disabled vet as well, I'm a kitchen table guy and one vet at a time. My main slogan is "connect, not compete." So many times, you have different agencies everywhere that, with good intentions, try to help a vet, but they leave out certain information. Or once they initiate something with a vet and they don't get any feedback, they can't get ahold of anyone, and so they give up. I'm different. And so, what I've been able to do I speak to each and every veteran, and as a result, our phones is, is ringing off the ringer. But one of the things I've been able to do is first educate the veteran that you are entitled to benefits.

A lot of veterans think that if they haven't been to war, then they're not entitled. A lot of veterans think that if they got other than honorable discharge, then they're not entitled. But the moment that you swore at the MEPS station [Military Entrance Processing Station], you uphold the Constitution, you are entitled to some benefits, to some type of health benefits as a veteran. And so, one by one I've been able to successfully help veterans through what they call means testing, to first get them the ability and eligibility to get health benefits right off the bat. And that entails getting a VA card, getting a primary care physician, specialty care physician, when they didn't have that at all at one time.

So I've been able to train the community health workers how to speak to a veteran, how to deal with the veterans, the proper paperwork that they need to apply for health benefits, any type of conversations out there. You have certain veterans with cancer — for instance, there's a veteran that needed a ramp. He tried everything that every different local agencies outside, inside, he wasn't able to get anything done. So what I was able to do is I reached out to [an] outside organization, the Gary Sinise Foundation, to help that veteran to get a built ramp specifically for the veteran. But there's a lot of stories out there, and there's a lot of veterans that's being diagnosed from toxins, from being in those different fields whether it's the burn pits or wherever they were located at.

And so I've just successfully been able to get them health benefits and get them compensation. You've got a lot of veterans that are homeless where there's a program called HUD-VASH [U.S. Department of Housing and Urban Development-VA Supportive Housing Program]. HUD-VASH is sort of like Section 8 for veterans. And so, I've been able to reach out to different agencies to make sure I can get homeless veterans off the street as well; at the same time, get them that help the health benefits that they need and possibly compensation. So, once you help one vet, you're going to get a whole lot of feedback in that community where, "Such and such helped me," and I hear it all the time where, "I initially contacted this agency, nothing happened." And so that, that was spread. And as a result, I constantly every day get veterans that would call me for help.

And I've been successful in helping those veterans. And I also, like I said earlier, it's all about connecting, not competing. And like I said, I'm a veteran as well. So, I speak that language, and I'm able to navigate in the system that can be kind of frustrating. And there's so much information that's bombarded on a lot of veterans. They just give up. And so, I just basically hold their hand and step by step get it done for them on their behalf.

Matt Coleman: It's not just about getting them healthcare, but it's about going from living in your car to having a home, right? Through HUD-VASH. It's about being able to get in and out of your home because of a ramp. It's because of not having to worry day to day about your expenses, right? Then think about mental health and how much mental health is affected by what your bank account may look like, and whether you can afford food. And so some of that, through some of this assistance with the benefits, the disability benefits, that's helped with all of these things. So I give all this credit to James and what he's been able to bring, just knowing the resources that are out there and connecting them with these veterans.

James VanCleave: The PACT Act, if you've heard of that, promises to address comprehensive toxins that was passed August of 2022. What that does is, it kind of eliminates the red tape with the VA for all veterans who previously had tried to apply for claims disability but was denied.

And there's specific forms even though that you can file a claim online but there are specific forms, step by step, that you will have to ascend to address certain claims that you are filing for, to include your medical records, whether civilian or military.

You have to request your DD214 [Certificate of Release or Discharge from Active Duty], your official personnel records, your medical records, and then you have to kind of investigate and go through those records to relate that as service connected with whatever diagnosis that you currently have. A lot of veterans think that, "Okay, I wasn't in a war, I don't have any benefits but something's going on with me." Well, here's the thing. A lot of veterans, and I educate them on this, you can still file for these claims as a secondary that led to your situation right now.

And so, once I educate their current doctors, whether it's a VA specialty, or whether it's a civilian doctor, I pretty much let them know that, okay, if you talk to your doctor, it's something that they call a Nexus letter, that's the VA N-E-X-U-S. And what that is, is basically your doctor basically saying, "Okay, this is your diagnosis and this is what you're here for. But in my medical opinion, I believe that this had happened from back when you were in the military at that time." Well, that one-page letter is a green light for a lot of veterans that otherwise, for years kept getting denied benefits and compensation. You don't have to have been at war to get any type of benefits, whatever is going on with you. That is where I'm good at, is navigating and connecting with their position to get this Nexus letter and get their records, and then sending the appropriate forms to where they get that acknowledgement, and it's been successful. So I'm glad to say that.

If you weren't a veteran, and if you got low income and you need housing, then you have a specific rate as far as income wise to qualify a regular family member for Section 8. Well, HUD-VASH is the same, but the only difference is it's for veterans. So, whether you got a veteran that's off the streets, that's homeless, or you got a veterans that with a minimum income, HUD-VASH is designed to get those veterans off the street to be able to get them in an apartment, to be able to pay for their utilities, their rent. Also, a lot of veterans with HUD-VASH, you have to have a certain disability certain percentage, lots of time. They got agencies that work with each other. If, let's say a veteran only got 10%, and they're like, well, you need, you need to be 30 or 40% disability. Well, HUD-VASH's got different agencies out there that kind of bridge the gap to make sure that that veteran is off the street regardless.

Matt Coleman: And, and if you want to go for the actual name of it, that's the U.S. Department of Housing and Urban Development-Veterans Affairs Supportive Housing Program. That's the, the full official name of it. And I think that, so James kind of hits on, on all of this, that Andrew, you, you nailed the, the kind of, the thing that we noticed in all of this is that there's a lot of names and, and terms and letters, right? So, so that's kind of the, the difficulty in navigating the system is, is if you don't have somebody that knows it, what does that mean? Or what does this resource, or how do I know to go from one paperwork to the other?

There's an issue with, how do we get… if this program only lasts for three years, right — it's a grant-funded program — what can we do to continue this work and keep these resources that James has provided, how can we keep that sustainability around it? Right? So with our connection within Kentucky Homeplace, which is that organization of community health workers, but also the Kentucky Association of Community Health Workers they allowed us to do a training for their community health workers with a continuing education credit for the certification to where we were able to train around 80 different community health workers in all of this paperwork, all of this red tape, and all of this process kind of have a cheat sheet for them, right?

So we're working to keep this program going and finding some other routes of funding and doing some different things. What we're really focused on is, how can we spread this, right? How can we make it bigger, scale it up? So that was part of the process of this, is connecting with the CHWs and providing this training to where James goes over each and every document form, what it means, some of the language that might get a little confusing or, or where the contact number, as he said, there's a number like who to contact, what some of the key language around what you need to say or ask about, who you need to contact, all of those different resources because there is a lot of information that's just specific to the VA and the VA programs.

Andrew Nelson: What are some notable challenges you've seen some of these projects overcome?

Matt Coleman: We have an organization that is in western Kentucky. They're called Camp Graves. They're actually housing, right? So they are temporary housing organizations for people in western Kentucky. So, I guess it was three or four years ago, western Kentucky was hit with a series of tornadoes that really devastated that area. A series of counties in that area, and thus Camp Graves and that organization was built. So, what their challenge was not only housing, but they were like, "Hey, these veterans are coming in —because they're specifically focused on veterans — these veterans are coming in without connections to anything." And then that's when we made a connection, and they're still continuing their work even three, four years later after [the] tornadoes. But it's not only "Are the veterans needing housing?" — they're needing employment, they're needing healthcare, they're needing all of these different things. So they're connecting them to their local VA, they're connecting them with the local employers around the area, they're doing job fairs. So just kind of hitting all the different scope around what healthcare is for everybody, right? If you don't have a house to live in or a shelter to live in, what takes priority, your health or trying to find somewhere to live or what to eat next? So that group has been doing some excellent work in, in that area in a space where you don't necessarily think this is healthcare but using those resources and they have a great connection with their local VA to be able to connect all of these different services and use that for their veterans.

So, they've just within a few months' time, we're assisting not only veterans, but their families. So you've also got to think we have an aging veteran population, and a lot of times that includes caregivers of those veterans and families and all of that. So, so that's kind of just one of the quick challenges I guess, that, that we've helped veterans come out of.

So, for me internally, having the resources and coordinating them and, and being able to do something in this realm is, is a success. Anytime we can assist our veterans, one veteran, a hundred veterans, a thousand, a hundred thousand, however many — just one veteran is enough for me to consider a project a success. Some, sometimes when we talk about rural, sometimes we forget that we're so obsessed with numbers, we have to get huge numbers to show that this is a success, but in rural, you're not always hitting huge numbers, right? Sometimes there's only a few veterans in a community, right? Seven or eight. But if we're able to make a difference for those seven or eight veterans and a difference for that community to show that they're not forgotten. Men and women, both, that reach back out to James after they've had their first appointment at the VA or after they've got successfully gotten their disability VA benefits, whatever it may be, that is what brings it as a success.

James VanCleave: If you can help out one veteran, what I've learned is that veteran is going to spread a word whether it's that veteran or his family members in that local community, they are going to spread the word in a good way where, "This is who helped me out." And then the community is going to see that, and as a result, they're going to constantly flood the phones. They're going to constantly try to get ahold of that person who's helping them. In that case, I'm honored. It's gratitude, that's all I get. I love it because I know that I'm able to provide that.

So, one of the things with these veterans there's specific things that you have to send in, and even when you send it in, you might get a denial. So, they give up, but I let them know right up front, "This is how we're going to do this," and I lay the roadmap out. Case in point, if you have a disability, you might get a denial the first time. Okay. But then there's a supplemental form that you have to send in and basically on that form, it's basically telling you, "Okay, when did you get denied?" So, the letter that the VA sent you that basically is telling you, "We denied this claim." You specifically put that date down there and you re-send it in through a supplemental form. It goes from supplemental to the decision review board all the way up to the appeals.

Matt Coleman: It's just sometimes it just takes time, and it takes extra paperwork. And, while that's stressful and has its own issues, that's why we are highlighting some of this work that James is doing and some of the works with the community health workers is because that can take off a big burden, if you have somebody that knows how to navigate the system and help you, because they're still people, right? They're still human. They're just trying to do their job the best that they see fit, and sometimes it just takes a little extra attention to some of this.

Andrew Nelson: Do you have any insights or suggestions for groups in other parts of the country that are trying to increase the availability of health services for veterans?

Matt Coleman: I think part of that is, start collecting some of the resources that are there. I think that there are a lot of resources out there. The VA is a great resource and a great place to start, but understand they also have limited resources. We're always talking about in rural how we're trying to do more with less, right? Or everybody wears multiple hats. You're always doing more than one job. It's the same in a lot of places, especially the same in the VA. So, understanding that they have a lot of resources at the VA. So, start by reaching out there, forming a relationship and seeing, "Okay, here's where some of these gaps are that we're seeing in our community level. What does that look like at the VA and how can we assist in building it from there?" And then going and looking at some of these other places that are VA Community Care programs already. Try to see what's there and then just kind of guide around those resources. So, depending on what you're wanting to do around healthcare for veterans' mental health or primary care, whatever it may be, I'd recommend start looking at some of these local resources first where you're looking to start this, because most likely it's something already there. It's just as we've found a lot of times the communication around it, it just hasn't been shared enough.

We've worked with a lot of different organizations, mental health organizations, hospitals, everybody has different capacity to pull a different amount of weight around this, but everybody's interested in finding some way to assist veterans. How do you identify veterans within your organization and what do you do with that information?

So, focusing around your question when you do intake or sign-ups or whatever, is it, are you asking, "Are you a veteran?" or have you changed that question to "Have you ever served?" right? "Have you ever served in the military? Any branch at any time?" That changes your response rate. You get a lot of people that will not self-report or self-identify, but by changing that question completely changes what you're getting, but then have a plan for what you're doing with it, right? Yes, you're taking in the numbers. What do you do when they self-identify as a veteran, do you start asking follow-up questions? If you're in healthcare, when you get them into the room is, are you asking them questions related to what happened with their service? Are you connecting them to other organizations that serve veterans specifically?

James VanCleave: I think we are at the tip of the iceberg. Just the feedback, the contacts from helping a veteran successfully and the word spreads in each and every community. The fact that that I'm a disabled vet and the fact that I just know how to navigate through the system on their behalf to be able to successfully get them that health benefits and possibly compensation is phenomenal because once it gets out, if you hear about it, "Well then, I'm definitely going to call this guy. I'm going to call this guy."

The VA is a wonderful source. There's a lot of resources out there. You've just got to know how to navigate and to contact who you need to know to successfully help that veteran out. So yeah, it's at the tip of the iceberg, but there's so many veterans that just need help. And once they're educated and know, "Oh, I didn't know this. I didn't know that I didn't have to go to war, but here's my diagnosis. I just didn't know that I have benefits." Once you educate them and just guide them successfully, then that gets out and it's very contagious and that's what's happening.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. In this episode, we spoke with Matt Coleman, Director of the Kentucky State Office of Rural Health, as well as James VanCleave, Rural Project Manager, Veteran Services. Look in our show notes for more information about their work and visit ruralhealthinfo.org for all things pertaining to rural health.