Women Veterans: Services, Challenges and Improvements Credit Dr. Hayes for content material Brief Bio – AD, RESERVE, Dep Presented by: Shenekia Williams Johnson, RN, BSN, MAOM, VISN 6 Lead WVPM Content credit to Patricia M. Hayes, PhD, Chief Consultant, Office of Patient Care Services, VA Veterans Administration

History of Women in the U.S. Military Source: America’s Women Veterans: Military Service History and VA Benefits Utilization Statistics, Department of Veterans Affairs, National Center for Veterans Analysis and Statistics, Nov. 23, 2011; http://www.va.gov/VETDATA/docs/SpecialReports/Final_Womens_Report_3_2_12_v_7.pdf 2/2013

As Women Veteran Population Increases, Total Vet Population Declines Women comprised 6% of Veteran patients in FY10. The number of women Veterans has been growing faster than the number of men Veterans. Compared to men, women were, on average, substantially younger: 42% of women and 12% of men were less than 45 years old. Women were more likely than men to carry a service-connected disability status and to have a service-connected disability rating of at least 50 percent,7 and were more likely than men to live in a large urban area. Sources: VetPOP 2007 and VetPOP 2011 ADUSH for Policy and Planning 2/2013

VISN 6 Female Enrollees

VISN 6 Female Users

VISN 6 Market Penetration

Age distribution of women Veteran patients, FY01 and FY10 Aging Population 58% of women VA users are 45+ √ Menopausal Needs √ Geriatric Care √ Inpatient/Extended Stays Age distribution of women Veteran patients, FY01 and FY10 Next 20 years … more intensive health care services and support as caregivers Shifting Age Distribution in VHA Women Veterans. In FY01, the age distribution of women showed two main peaks: The tallest peak had a maximum at age 44, and the second peak had a maximum at age 77. By FY10, this pattern had shifted. The peak that had been tallest in FY01 was even taller in FY10 and had its maximum at age 48. The second peak had its maximum at age 86. Meanwhile, a substantial new third peak had appeared, with its maximum at age 27. In FY10, 42% of women Veteran patients were 18–44 years old, 45% were 45–64 years old, and 13% were 65+ years old. Source: Women’s Health Evaluation Initiative and VHA Women’s Health Services. Sourcebook: Women Veterans in the Veterans Health Administration. Volume 2. Sociodemographics and Use of VHA and Non-VA Care Fee. 2012 (in press). 2/2013

Service Connections in Women Veterans Service-connected disability status among Veteran patients, by gender, FY10 High Levels of Service-Connected Disability Status in VHA Women Veterans. As of FY10, more than half of women Veteran patients in VHA had received a service-connected disability rating. The proportion of women Veterans receiving service-connected disability ratings increased over the decade. Further, in FY10, a higher proportion of women Veterans who were 18–44 years old had a service-connected disability rating than women who were 45–64 or 65+ years old. Source: Women’s Health Evaluation Initiative and VHA Women’s Health Services. Sourcebook: Women Veterans in the Veterans Health Administration. Volume 2. Sociodemographics and Use of VHA and Non-VA Care Fee. 2012 (in press). 2/2013

Accomplishments….. Since 2008, Women’s Health Services dramatically changed the delivery of healthcare services for women Veterans: Trained over 2,000 providers! Focused on reducing Gender Disparities in clinical care. Implemented Designated Women’s Health Providers (DWHP) and now have evidence of efficacy. Updated 1330.02 Women Veteran Program Manager (WVMP) policy. Released 1330.03 Maternity Care policy. Increased scope of medical and surgical specialty care, and focus on specific conditions.

Accomplishments…. Women Veteran Call Center (WVCC) center reaching thousands of women. Development of new Mobile Apps (on verge of release). Women’s Health Evaluation Initiative (WHEI) Sourcebook Volume-1-3 provides in-depth information about the women Veterans we serve. Emergency services, telehealth, and strategic planning toolkits. Intensive collaborations with research to understand the effects of military service on women’s lives. WH education and culture change campaigns.

Privacy, Environment of Care (EOC): Progress, Gaps Privacy and EOC monitored monthly Monies distributed to field to correct deficiencies (FY 13: $41M; FY11: $20M; FY12: $400K) 97% of bathroom/privacy curtain deficiencies corrected (old definition) Broader issues of privacy remain a source of dissatisfaction for women Veterans and a barrier to their use of VA services Discuss VISN 6 accomplishments 2/2013

Research: Driving the Agenda Worked with VA Office of Research to define needs in women’s health research in VA, enhance research on women Veterans Established Practice Based Research Network (PBRN) – Durham one of 4 initial sites Women’s Health Evaluation Initiative (WHEI) More VA research on women Veterans published over 5-year period (2004- 2008) than the preceding 25 years 2/2013

Voice of the Veteran To know her, we must find ways to listen

What do the Women Veterans Say? Voice of the Veteran Survey, March 22 –April 8, 2011 –30 separate locations, over 2200 Veterans, only about 5 percent women Always treat Veterans with respect and dignity –Ask and listen –Personalize the encounter –Partner with Veterans to plan their healthcare –Be aware of first impressions by front line staff

What do the Women Veterans Say? Design and redesign processes to be Veteran-centric and not VA-centric –Redesign scheduling processes at Veteran convenience –Eliminate waits and delays –Enhance mental health services –Expand access to women’s health services

Designated Women’s Health Providers Satisfaction with Care In a secondary analysis of data from the VA Survey of Health Care Experiences of Patients (SHEP) satisfaction of 8,151 women Veterans was examined. Satisfaction of women who were assigned to DWHPs was compared to that of women who were not assigned to DWHPs. Women Veterans overall experiences with outpatient care were slightly better for those receiving care from DWHPs compared to those receiving care from non-DWHPs.

Designated Women’s Health Providers Satisfaction with Care Con’t Compared to women Veterans seeing DWHPs versus non-DWHPs experiences for 6 outpatient composites were: • Access (42.1 vs 37.7), Communication(74.1 vs 71.0) , Shared Decision- Making (61.6 vs 58.8), Self-management support (56.0 vs 50.3), Comprehensiveness (67.4 vs 62.0, and Office Staff (66.0 vs 64.4) Bastian L, Trentalange M, Murphy T, et al. Association between Women Veterans’ Experiences with VA Outpatient Healthcare and Designation as a Women’s Health Provider in Primary Care Clinics. Women’s Health Issues. Unknown 2014; 20

Interpreted Results from National Surveys of Women Veterans (Donna Washington, et. Al.) Recognition and Respect: Change the Culture Access: Distance, Time and Space -Flexible, real-time choices Design services around needs and expectations about healthcare Information: Many still don’t know what services VA has for women - Women Veterans don’t know us

Barriers to Care 2/2013

Women Don’t Identify Themselves as Veterans “We don’t know if it’s because they had different roles, because they felt like they didn’t do the same thing as some of our male Veterans … whatever it is, they are still not self-identifying.” General Allison Hickey VA Under Secretary for Benefits 9/27/12 2/2013

Lack of Knowledge of VA Services 39% have zero or almost no knowledge of needed information about VA Misperceptions in all cohorts about who is eligible for VA care OEF/OIF/OND more knowledgeable than other cohorts about available women’s health and readjustment services Source: 2010 National Survey of Women Veterans, (D. Washington) 2/2013

Barriers to using VA health care among Women Veterans who considered, but did not use, VA* 31% didn’t think they were eligible 21% didn’t know how to apply for benefits 20% said closest VA is too far from home Other challenges: Difficulty getting time off for appointments Child/eldercare responsibilities Discuss Focus Group Findings within VISN 6on Rural Women Veterans *Not mutually exclusive Source: 2010 National Survey of Women Veterans, (D. Washington) 2/2013

Barriers to Care National Survey 2014 The next voice of our women Veterans Survey interviews completed for nearly 8,000 women –Users and Non-Users of VA –Random but at least 400 women Veterans per VISN Data analysis now underway Complete report to WHS expected early 2015

Women Veterans Health Care 2/2013

Delivery of Comprehensive Primary Care Complete primary care from one designated women’s health provider at one site including CBOCs and HCCs Care for acute and chronic illness Gender-specific primary care Preventive services Mental Health services Coordination of care Reproductive Health Care Emergency Services for women 2/2013

Creating Truly Integrated, Veteran Driven Care Care Coordination across specialty care especially for those conditions which present differently in women, or are more common in women •Cardiology •Endocrine •Pain conditions including musculoskeletal Non VA Care (Fee and PC-3) •Maternity Care, Infertility Care •Mammography •GYN and GYN Cancer Care

Breast Care Mammography and Breast Cancer Treatment Mammography can be provided in house or through Non-VA Purchased Care. 52 VHA Health Care sites are now offering on site digital mammography VA exceeds the private sector in mammography screening rates. 85% of Women Veterans age eligible women Veterans received mammography screening in 2013. Women’s Health Services collaborated with Diagnostic Services and Non-VA Purchased Care to streamline and standardize processes for ordering and tracking and outside mammograms.

Women’s Health Cardiovascular Initiatives VA has teamed with the American Heart Association’s Go Red For Women® movement to help inform women Veterans of their risk for cardiovascular disease—the #1 killer of women including women Veterans. The Memorandum of Understanding (MOU) between VA and AHA allows the organizations to work together to advance mutual goals relating to cardiovascular disease and stroke, particularly those related to the AHA’s Go Red for Women® (GRFW) movement.

Role of the WVPM Required full-time in every health care system Linchpin for improved Women's Health Services Leader of facility Women's Health Program Resource for women Veterans in the community notes 2/2013

Public Health/Women’s Health Prevention Grants FY13:18 grants

Public Health/Women’s Health Prevention Grants FY 14: 10 grants Project focuses on the dissemination and use of materials already developed by the Public Health/Women’s Health quality improvement grants in FY 13 Two grants awarded for up to $10,000 each under five topics: – Domestic Violence/Interpersonal Violence – Eating disorders – Dining with Diabetes – Stress Reduction – Lactation Two awardees for each topic paired with mentor from FY 13 grants

Specialty Care Grants FY14-FY15: Five Grants Awarded – Genitourinary Rehabilitation – Diabetes Self-Management – Headache Management – Acupuncture & Mindfulness, Chronic Pain – Fibromyalgia Multidisciplinary Approach to Care

What is Reproductive Health? Reproductive health is a critical part of health. Reproductive health encompasses gynecologic health throughout life, preconception care, maternity care, cancer care, and the interaction of these with other health conditions (e.g., reproductive psychiatry). Reproductive health care is a set of health care services that address the well-being and function of reproductive processes, reproductive functions, and the reproductive system at all ages and stages of life.

Reproductive Health-Health System Perspective Understand the population and unique needs Evidence based research and best practices Engage and be responsive key stakeholders Veterans, Providers, Program Offices Develop and implement policies and programs Enhance system capacity and structure and provide resources Change the culture and language “Everyone’s job to take care of women Veterans”

Reproductive Health and Related Needs of Women Veterans Across the Life Course

Reproductive Health Program Initiatives High Quality Maternity Care Reproductive Mental Health Emergency Services for Women Safe Prescribing Preconception Care Healthy Aging and Reproductive Health Reproductive Health Workforce

Report on the State of Reproductive Health in Women Veterans First such report •Identifies top 5 reproductive health diagnoses among women Veterans using VA by age group (18-44, 45-64, ≥65) •Articulates vision for RH care in VA •To access the full report, please visit: http://www.womenshealth.va.gov/ docs/SRH_FINAL.pdf

Maternity Care

Demand for VA Maternity Care Increasing •The number of deliveries paid for by VA increased by 44% between 2008 and 2012 (Mattocks 2014)

Overarching Goal: Changing the Culture 2/2013

National Women Veterans Communications Workgroup: VA-wide campaign to enhance the language, practice and culture of VA to be more inclusive of women Veterans National Women Veterans Communications Workgroup: Tasked with developing strategies to reach women Veterans (inside and outside VA) and VA employees Outcome: Needs of women Veterans are always considered across program offices and in policy and key decisions 2/2013

Culture Change Present at New Employee Orientation Content in New Patient Handbooks Messaging as posted here National Women’s Call Center WH Clinics Attend varied outreach events

Questions? Shenekia.WilliamsJohnson@va.gov; www.womenshealth.va.gov 2/2013 43