1. What Does Women’s Health Care Look Like in the VA? Elizabeth M. Yano, PhD, MSPH; Bevanne Bean-Mayberry, MD, MHS; Ismelda Canelo, MPA; Andrew B. Lanto, MA; Donna L. Washington, MD, MPH VA Greater Los Angeles HSR&D Center of Excellence UCLA Schools of Public Health and Medicine Academy Health  Washington DC  June 10, 2008 Center for the Study of Healthcare Provider Behavior

2. Background Changing demographics of military –15% of active military, 17% of National Guard/Reserves and 20% new recruits are women Women veterans among fastest growing segments of new users of VA health care –Overall about 11% market penetration –As high as 40% of OEF/OIF electing to use VA Women veterans who use the VA have unique health care needs –Lower functional status vs. male vets, non-vet women –Special mental health care needs (PTSD, MST)

3. Background Gaps in care historically documented –Congressional eligibility reforms changed array of services to be made available to women veterans Including mandated provision of gender-specific services Considerable debate about how best to organize care for women veterans –Numerical minority creates challenges –VA providers with limited exposure to women VHA faces considerable challenges in meeting women veterans’ health care needs –Complicated casemix, growing caseload, service mix

4. Objective To evaluate how VA women’s health care is organized and how well VA is adapting to women veterans’ health care needs –VHA Handbook 1330.1 recommends specific primary care delivery models for women Separate women’s health clinics Designated women’s health providers in general primary care –Legislation requires attention to privacy and appropriate service availability

5. Design and Sample Time-series organizational surveys –Key informants at network, facility, clinic levels –2001 and 2007 National census of all VA health care facilities serving 200+ women veterans –Respondents included all VA regional network directors, chiefs of staff, senior WH clinicians –Focus on clinic-level results (82% and 86% RRs) –Facilities represent 80% of women veterans seen in VA settings Focus on clinic-level results

6. Survey Development Domain development anchored in diffusion theory and Donabedian structure-process- outcome framework Expert panel review and priority-setting of domains using modified Delphi techniques –Representatives from VA and non-VA –Experience`e with different care model variations Iterative survey item/scale development, cognitive interviews and pilot testing

7. Measures Clinic structure/operations –General PC, women’s, gyn and mental health –Half-day sessions open, service availability Privacy/sensitivity –Physical space arrangements (exclusive, reserved vs. shared exam rooms and waiting rooms) –% same-gender providers available Service availability (VA vs. not, on vs. offsite) –Basic women’s health services (e.g., paps, mamms) –Specialized women’s health services (e.g., breast cancer surgery, prenatal care)

8. GYN clinic 21% no GYN clinic 3% Source: Yano, et al. Women’s Health Issues (2003) Most VAs had Designated WH Providers in PC or a Women’s Clinic (2001)

9. What Does VA Women’s Primary Care Look Like Now? (2007) Source: Yano, Washington, Bean-Mayberry (HSR&D #IIR 04-036) (2007). BUT 44% deliver gender-specific exams only GYN clinic 9% no GYN clinic 11%

10. Shifts Towards Integrated Primary Care Delivery (2001-2007) % of VA Facilities Proportion of Women Veterans Using General Primary Care for All/Most of their Primary Care Needs

11. Integrated Primary Care (2007) 42% of VAs have designated WH providers in general PC to whom women veterans are preferentially assigned –56% have one for whole PC practice –9% have one in each PC team –18% have a WH primary care team –Others: randomly assigned, count NPs, no specifics Lack adequate clinical expertise in WH (p<.05) Lack same-gender providers (p<.01) (32% vs. 74%) Designated WH providers only available 6 half- day sessions/week

12. VA Gynecology Clinics 20012007 Separate VA gynecology clinic 58%44% % exclusive/reserved exam rooms 87%87% % exclusive/reserved waiting rms 41%51% Mean half-days/week open 2.33.1 Service availability: % offering surgical specialty % offering surgical specialty % offering obstetrical care % offering obstetrical care35%10%53%7%

13. VA Mental Health Care for Women 20012007 % designated WH providers in general outpatient mental health mean half-days/week open mean half-days/week open % same-gender provider avail* % same-gender provider avail*43%5.741%34%6.969% % separate women’s MH clinic % exclusive/reserved rooms % exclusive/reserved rooms % exclusive/reserved waiting rms % exclusive/reserved waiting rms % same-gender providers* % same-gender providers* mean half-days/week open mean half-days/week open11%14%33%67%4.412%58%38%63%5.8 *All/most of the time

14. Women’s Health Service Availability Non-VA referrals Available onsite Other VA

15. Women’s Health Service Availability Available onsite Other VA Non-VA referrals Non-VA refs Avail onsite Non-VA

16. Conclusions Designating a WH provider in general PC a common approach –Meaning of designation unclear (training, clinical experience, organizational supports) Growth of women’s clinics balanced by focus on gender-specific exams –Increased fragmentation rather than one-stop shopping model –Gender-sensitive mental health provision lags VA facilities split in decision to improve onsite capability to deliver WH care (build vs. buy)

17. Implications VA will continue to face challenges in ensuring high-quality care for women veterans –Recent influx increases demand for evidence-based management solutions Early evidence demonstrates better outcomes for separate women’s clinics for: –Gender-specific processes of care (e.g., paps) –Patient ratings of care (e.g., accessibility, continuity) –But less clear advantages for gender-neutral quality (e.g., diabetes quality, colorectal cancer screening) Future work needed to develop evidence-based implementation plans that map to local structure