Goals and Objectives

The main goal of the TWV program is to reduce suicide risk among rural Veterans by improving access to and use of both VA and community-based care, resources, and support services. TWV works to strengthen how communities respond to the needs of local Veterans so that Veterans can receive timely, coordinated, and culturally informed support.

The TWV VHA research team also studies how the program is implemented and how it affects suicide risk among rural Veterans. This helps VA and communities better understand which community-based strategies are most effective.

Key objectives of TWV include:

• Evaluating how the TWV program is implemented in different rural communities.
• Exploring outcomes associated with TWV, such as changes in suicide risk factors and protective factors.
• Describing the context of suicide risk for rural Service members and Veterans, including local challenges, strengths, and cultural factors.
• Assessing changes in community readiness, connectedness, stigma, and help-seeking over time.

Methodology

Communities are recruited into TWV through outreach led by the Western Interstate Commission for Higher Education, in partnership with VHA leadership and staff. Recruitment targets communities where many Veterans live in rural or highly rural areas and where suicide risk is higher.

To be eligible, communities must meet criteria such as:

• More than 50% of VHA-enrolled Veterans in that county live in rural or highly rural areas.
• A county-level suicide rate (per 100,000 residents) higher than the median suicide rate of all counties in that state.
• A Veteran resident population greater than the median Veteran residency rate of all counties in that state.

TWV communities receive the TWV toolkit plus technical support and coaching over a 36‑month period. The work follows five phases:

• Phase 1 – Build your team: Identify the core TWV team, including Veterans and community members, and select the Steering Committee, Facilitator, and Coordinator.
• Phase 2 – Learn about your community: Conduct a community readiness assessment, complete a strengths, weaknesses, opportunities, and threats (SWOT) analysis, and carry out a visible network survey (for example, using the PARTNER Tool) to understand local partnerships.
• Phase 3 – Teach your team: Provide individual suicide prevention trainings and teach the TWV team about suicide prevention focus areas and strategies.
• Phase 4 – Plan for action: Develop a written action plan that includes strategies across six focus areas, such as training, connectedness, communication, and lethal means safety.
• Phase 5 – Follow your plan and measure results: Implement the action plan, review and revise it at least twice a year, and collect data about TWV activities and progress on action plan goals.

After 36 months of engagement with TWV coaching, communities graduate and continue their suicide prevention efforts with local leadership and independent facilitation, often in collaboration with other VA and community programs.

Impact on Rural Veteran Health

TWV has reached many rural communities across the United States. Dozens of TWV communities have graduated from the program, and additional communities are currently enrolled and expected to graduate in the coming years.

TWV communities report a wide range of activities and outcomes. For example, many communities distribute gun locks and provide education on safe firearm storage as part of their lethal means safety work. In a recent fiscal year, most reporting TWV communities distributed thousands of gun locks to support safer storage and reduce suicide risk. Since TWV began community-facing work in 2017, participating communities have reported serving hundreds of thousands of Veterans, including tens of thousands in a single recent year.

TWV communities and partners also conduct community surveys to better understand local needs and changes over time. Between December 2023 and May 2024, nearly 4,000 individuals (including Veterans, Service members, and non-Veterans) in three TWV communities completed pre‑ and post‑implementation surveys. These surveys focused on:

• Community readiness to address suicide prevention.
• Connectedness and support among community members.
• Experiences with health care providers.
• Help-seeking behaviors and stigma.
• Lethal means safety, including attitudes and practices around firearm and medication storage.
• Awareness of suicide prevention resources.

Survey results showed that many respondents were at least somewhat willing to talk about access to firearms in the home, including with mental health and primary care providers. However, only a small percentage said that any health care provider had ever talked with them about firearm access in the home. A relatively low share also reported discussing safe storage of medications with providers. Some respondents did not agree that gun locks and safes reduce suicide risk, which shows a need for more education about lethal means safety.

Qualitative information collected from TWV communities has highlighted several important themes:

• Veterans can easily isolate in rural areas. Physical distance, limited transportation, and fewer social opportunities can make it easy to withdraw and hard to stay connected.
• Rural areas may lack common resources. Some communities lack services such as 9‑1‑1 coverage, clear rural addressing, or nearby health care facilities. These gaps can create stress and delay care.
• Veterans can reach other Veterans. Veterans often feel more comfortable speaking openly with fellow Veterans who share similar experiences, which can make peer support especially powerful.
• Veterans need purpose and community. Having meaningful roles and being part of a supportive community can protect against suicide risk and improve well‑being. Activities that give Veterans a sense of mission and connection—such as volunteering or helping others—can benefit both the Veterans providing help and those receiving it.

These findings show that TWV is helping rural communities better understand suicide risk, increase awareness of lethal means safety, and build stronger support networks for Veterans.

Key Takeaways

Rural Suicide Prevention: Together With Veterans (TWV) supports rural communities in putting public health suicide prevention best practices into action in ways that fit local needs and cultures. The program is consistent with the goals of the VHA National Strategy for Preventing Veteran Suicide.

Through TWV, rural communities:

• Engage Veterans as leaders in suicide prevention efforts.
• Form strong partnerships among VA, community organizations, and local leaders.
• Implement evidence-informed strategies that promote help-seeking, connection, and lethal means safety.
• Develop and carry out community-centered action plans that can continue after the initial 36‑month TWV period.
• Use data and community feedback to understand needs, measure progress, and refine strategies.

With many communities already graduated and others currently enrolled, evaluation of TWV is ongoing. Findings are expected to help identify best practices for implementing community-based suicide prevention programs that support Veterans in rural areas across the country.

Download the Printable PDF for Healthcare Providers and Researchers.

References

• United States Department of Health and Human Services & National Action Alliance for Suicide Prevention. National Strategy for Suicide Prevention: Goals and Objectives for Action.
• McCarthy JF, Blow FC, Ignacio RV, Ilgen MA, Austin KL, Valenstein M. Suicide among patients in the Veterans Affairs health system: Rural–urban differences in rates, risks, and methods.
• Buzza C, Ono SS, Turvey C, Wittrock S, Noble M, Reddy G, Reisinger HS. Distance is relative: Unpacking a principal barrier in rural healthcare.
• Hirsch JK. A review of the literature on rural suicide: Risk and protective factors, incidence, and prevention.
• U.S. Department of Veterans Affairs. National Strategy for Preventing Veteran Suicide 2018–2028. Office of Mental Health and Suicide Prevention.
• Additional national and state data sources on suicide, mortality, and population characteristics.

Contact

• Lisa Brenner, PhD, and Nazanin Bahraini, PhD, Program Managers, Rocky Mountain Regional VA Medical Center, Aurora, CO. Lisa.Brenner@va.gov / Nazanin.Bahraini@va.gov
• Funding Acknowledgement: Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, NOMAD #PRFY-00560.
• Suggested Citation: Brenner, L. A., & Bahraini, N. H. (2025). Rural Suicide Prevention: Together With Veterans (TWV). Department of Veterans Affairs, Veterans Health Administration. Washington, DC: Office of Rural Health.

Rural Health - Navigation

• Office of Rural Health Home page:
  https://www.ruralhealth.va.gov/index.asp
• Enterprise-Wide Initiatives (EWI) page:
  https://www.ruralhealth.va.gov/Enterprise-Wide-Initiatives-EWI.asp
• Veterans Rural Health Resource Centers (VRHRC) page:
  https://www.ruralhealth.va.gov/Veterans-Rural-Health-Resource-Center-VRHRC.asp