Enhancing Veteran Healthcare Access in Ohio: An Analysis

2. Overview • Background • Goals and Objectives • Methodology • Project Results • Conclusion • References • Questions

3. Background Total Ohio Population: 11,586,941 Veteran Population 779,187 6.72% • Large number of Ohio military veterans (2016). • Wait-time for health services increasing. • Disproportionate rate of healthcare issues compared to civilian counterparts (Olenick, Maria, et al, 2015). • Mental health • Substance abuse • Traumatic brain disorders • Post-traumatic stress disorders • Chronic pain • Suicide Veteran Population w/VA Healthcare: 261,967 2.26%

4. Background • Ohio Veteran Population Percentage per Census Tract

5. Background – Terminology • VHA: Veterans Health Administration • VAMC: Veteran Affairs Medical Center • CBOC: Community-Based Outpatient Clinic • VCP: Veteran Choice Program VA Choice Act of 2014 • Initially a 3 year, $10B program MISSION Act of 2018, $5.2B • Eligible veterans: • Enrolled as of August 1, 2014 • Recently discharged combat veteran with Choice Card • Veterans unable to schedule appointment within 30-days • Reside outside of 40-mile travel distance from VA Medical Center

6. Veteran Choice Program Eligibility • Choice Program Eligibility (va.gov, 2017): • VA can’t provide the required service. • Appointment not available at the nearest VA medical facility within 30 days. • Travel distance greater than 40 miles from the nearest VA medical facility. • Travel by air, boat, or ferry. • Veteran faces an excessive burden: • Geographic challenges; • Environmental factor: • Health problem that makes it hard to travel. • Eligible non-VA providers: • Current Patient-Centered Community Care facilities, also know as PC3s, are automatically eligible to provide healthcare services to veterans. • Additional facilities contracted to provide veteran health services. • Veterans must have pre-authorization before seeking services at non-VA facilities. Only exception is under emergency conditions.

7. Background – Previous Studies Hynes, Denise et al. (2007). Veterans' Access to and Use of Medicare and Veterans Affairs Health Care. • Factors related to access to VA Services. • Measure patient’s travel to VA Services. • Limited analysis to within a 20-30 mile distance. • As distance to service increased, use of VA healthcare services decreased. Schooley, Benjamin., et al., (2010). Rural Veteran Access to Healthcare Services: Investigating the Role of Information and Communication Technologies in Overcoming Spatial Barriers • Average travel distance was 54 miles. • Veterans were less likely to seek treatment if VA healthcare access was considered inconvenient. Buzza, Colin. (2011). Distance is Relative: Unpacking a Principal Barrier in Rural Healthcare • Distance was the most important barrier for rural veterans. • Other factors include health status, ability to travel, costs and work and family obligations.

8. Goals & Objectives • Overall Goal: Identify where veterans are located within Ohio and the type of facility within reasonable distance, per Federal regulations. • Objectives • Identify areas of high concentration of veterans and veterans with VA healthcare. • Evaluate the current veteran healthcare services for Ohio veterans. • Determine if additional VAMC areas would provide increased access to healthcare. • Compare coverage statistics of Ohio to Utah and New York.

9. Methodology: Required Datasets • U.S. Dept. of Commerce | Bureau of the Census • Veteran population data, 2016 • Census tract boundaries • Road networks • U.S. Department of Veterans Affairs | Veterans Health Administration • Veteran Affairs Medical Center (VAMC) • Community Based Outpatient Clinic (CBOC) • Federal Register • Driving distance eligibility guidelines for veteran choice program U.S. Census Bureau TIGER/Line Data

10. Methodology: Overview of the Analysis Python Script: • Filter Census Tables • Add/Format Fields • Calculate Fields Buffering: Select by Attribute: Select by Location: Apportioning: • State Boundaries • Roads • Medical Facilities • Roads • Tracts • Medical Facilities • Tracts • Service Areas Generate Service Areas: • VAMCs • CBOCs

11. Methodology: Analysis 40-Mile Buffer using Roads VAMCs and CBOCs within the 40-Mile Buffer

12. Methodology: Analysis VAMC Service Areas CBOC Service Areas

13. Methodology: Analysis VAMC Service Areas CBOC Service Areas

14. Methodology: Analysis

15. Methodology: Analysis 2010 Ohio Census Tracts VAMC Service Area CBOC Service Area

16. Methodology: Mapping Results 2010 Ohio Census Tracts VAMC Service Area

17. Methodology: Mapping Results 2010 Ohio Census Tracts CBOC Service Area

18. Methodology: Mapping Results How do Ohio statistics compare to New York and Utah?

19. Methodology: Mapping Results How do Ohio statistics compare to New York and Utah?

20. Methodology: Mapping Results Where are the concentrations of non-covered VAMC veterans in Ohio? Census Tract areas not covered by VAMC Service Area Census Tract density of Areas outside VAMC Coverage

21. Methodology: Mapping Results Possible locations for a new VAMC in densely populated areas? Possible new VAMC locations Service Area Results

22. Methodology: Mapping Results Possible locations for a new VAMC in densely populated areas? Toledo Results With Toledo Service Area

23. Methodology: Mapping Results Possible locations for a new VAMC in densely populated areas? Canton Results With Canton Service Area

24. Methodology: Mapping Results Possible locations for a new VAMC in densely populated areas? Youngstown Results With Youngstown Service Area

25. Methodology: Mapping Results What would coverage look like for an alternate site? What if we split the difference between Canton and Youngstown…Alliance? Results With Alliance Service Area

26. Conclusions • Identify areas of high concentration of veterans and veterans with VA healthcare. • High concentrations of veterans near WPAFB. • Percentage of veterans per census tract lower around other metro-areas. • Evaluate the current veteran healthcare services for Ohio veterans. • VAMC service area coverage is 60% (Specialized services) • CBOC service area coverage is 96% (Primary Care services) • Determine if additional VAMC areas would provide increased access to healthcare. • Alliance VAMC increases coverage by 10.23% • New VAMC location does not have to be in the most densely urban area to maximize coverage. • Compare coverage statistics of Ohio to Utah and New York. • VAMC coverage comparable to Utah, 12% less than New York. • CBOC coverage comparable to New York and exceeds Utah by 16%

27. References • ArcGIS Desktop Help (2017). Service area analysis. Retrieved April 19, 2018 from https://desktop.arcgis.com/en/arcmap/latest/extensions/network-analyst/service-area.htm • Buzza, Colin & Ono, Sarah & Turvey, Carolyn & Wittrock, Stacy & Noble, Matt & Reddy, Gautam & J Kaboli, Peter & Reisinger, Heather. (2011). Distance is Relative: Unpacking a Principal Barrier in Rural Healthcare. Journal of general internal medicine. 26 Suppl 2. 648-54. 10.1007/s11606-011-1762-1. • Census.gov (2017). TIGER/Line Shapefiles and TIGER/Line Files. Retrieved November 19, 2017 from https://www.census.gov/geo/maps-data/data/tiger-line.html • Census.gov (2018). TIGER/Line with Selected Demographic and Economic Data - 2016 ACS 5YR Tract. Retrieved March 2, 2018 from https://www.census.gov/geo/maps-data/data/tiger-data.html • DHS.gov (2018). Homeland Infrastructure Foundation-Level Data (HIFLD), Veterans Health Administration Medical Facilities, 2007. Retrieved October 15, 2018 from https://hifld-geoplatform.opendata.arcgis.com/datasets/veterans-health-administration-medical-facilities • ESRI (2012). Apportion Geoprocessing Tool. Retrieved May 24, 2018 from http://www.arcgis.com/home/item.html?id=73623e571150447f9058c462980054ee#! • Federalregister.gov (2015). Driving Distance Eligibility for the Veterans Choice Program. Retrieved October 21, 2017 from https://www.federalregister.gov/documents/2015/04/24/2015-09370/driving-distance-eligibility-for-the-veterans-choice-program#print • Federalregister.gov (2015). Expanded Access to Non-VA Care Through the Veterans Choice Program. Retrieved April 29, 2018 from https://www.federalregister.gov/documents/2015/10/29/2015-27481/expanded-access-to-non-va-care-through-the-veterans-choice-program • Hynes, Denise & Koelling, Kristin & Stroupe, Kevin & Arnold, Noreen & Mallin, Katherine & Sohn, Min-Woong & Weaver, Frances & Manheim, Larry & Kok, Linda. (2007). Veterans' Access to and Use of Medicare and Veterans Affairs Health Care. Medical care. 45. 214-23. 10.1097/01.mlr.0000244657.90074.b7. • Olenick, M., Flowers, M., & Diaz, V. J. (2015). US veterans and their unique issues: enhancing health care professional awareness. Advances in Medical Education and Practice, 6, 635–639. http://doi.org/10.2147/AMEP.S89479 • O’Sullivan, D. (2017). Project 8: Local Indicators of Spatial Association. Retrieved November 21, 2017 from https://www.e-education.psu.edu/geog586/l9_p11.html • Schooley, Benjamin L,M.B.A., PhD., Horan, T. A., PhD., Lee, P. W., PhD., & West, P. A., M.P.H. (2010). Rural veteran access to healthcare services: Investigating the role of information and communication technologies in overcoming spatial barriers. Perspectives in Health Information Management, , 1-1f. Retrieved from http://ezaccess.libraries.psu.edu/login?url=https://search-proquest-com.ezaccess.libraries.psu.edu/docview/213143936?accountid=13158 • Shively, James. (2017). GEOG 586, Geographic Information Analysis. Final Project: Using GIS to Define Level of Veteran Healthcare in Ohio. • VA.gov (2017). Veterans Choice Program (VCP). Retrieved April 29, 2018 from https://www.va.gov/COMMUNITYCARE/programs/veterans/VCP/index.asp • Va.gov (2014). Non-VA Medical Care Program Fact Sheet for Interested Providers. Retrieved April 29, 2018 from https://www.va.gov/opa/choiceact/documents/FactSheets/Fact-Sheet-For-VACAA-Providers.pdf

28. Questions? James Shively, GISP Advisor: Dr. Fritz Kessler

29. VA Resources Ohio Department of Veteran Services: http://dvs.ohio.gov • Main Number: 614-644-0898 • Benefits Info: 877-644-6838 • Vets Crisis Line: 800-273-8255 Veteran Choice Program: https://www.va.gov/COMMUNITYCARE/programs/veterans/VCP/index.asp • Choice Program Support Line: 866-606-8198 Frequently Asked Questions https://www.va.gov/COMMUNITYCARE/programs/veterans/VCP/VCP-FAQs.asp Find answers to frequently asked questions concerning the Veterans Choice Program. Fact Sheet: Veterans Choice Program – Unusual or Excessive Burden Eligibility Criteria https://www.va.gov/COMMUNITYCARE/docs/pubfiles/factsheets/VHA-FS_VCP-Eligibility.pdf Describes specific requirements related to the unusual or excessive burden VCP eligibility criteria. VA Form: 10-10EZ – Application for Health Benefits https://www.va.gov/vaforms/form_detail.asp?FormNo=10EZ For Veterans to apply for enrollment in the VA health care system, which is required for a Veteran to use VCP to get care. The information provided on this form is used by VA to determine your eligibility for medical benefits. Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113-146, August 7, 2014) https://www.gpo.gov/fdsys/pkg/PLAW-113publ146/pdf/PLAW-113publ146.pdf