STATEMENT OF
PATRICIA HAYES, PH. D.
CHIEF CONSULTANT
WOMEN VETERANS HEALTH STRATEGIC HEALTH CARE GROUP
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
SENATE COMMITTEE ON VETERANS AFFAIRS
JULY 14, 2009
* * *

Good morning, Mr. Chairman and Ranking Member. Thank you for the opportunity to
discuss how the Department of Veterans Affairs’ (VA) has provided, and will continue to improve, health care availability for women Veterans. I would like to thank the Chair, this Committee and Senator Murray specifically for your interest in working with VA to ensure women Veterans receive the care they have earned through service to their country.

The Secretary has recently testified before this Committee that enhancing primary care for women Veterans is one of VA’s top priorities. VA recognizes that the number of women Veterans is growing with women becoming increasingly dependent on VA for their health care. Of the 1.8 million women Veterans in the United States more than 450,000 have enrolled for care. This number is expected to grow by 30 percent in the next 5 years. Women currently comprise approximately 14 percent of the active duty military, 17.6 percent of Guard and Reserves and 5.9 percent of VA health care users.

Women who were deployed and served in the recent conflicts in Afghanistan and Iraq are enrolling in VA at historical rates. Of all women who were deployed and served in Afghanistan or Iraq, 44 percent have enrolled and 43 percent have used VA between 2 and 11 times. This suggests that many of our newer women Veterans rely more heavily on VA to meet their health care needs and tomorrow’s Veterans receive the care they need. Women Veterans served; they deserve the best care anywhere.

Current Challenges
Women Veterans entering VA’s system are younger and have health care needs distinct from their male counterparts. The average age of women Veterans is 48 years old, compared to 61 years old among men. Nearly all newly enrolled women Veterans accessing VA care are under 40 and of childbearing age. This trend creates a need to shift how we provide health care.

General primary care and gender-specific care needs of women Veterans are currently provided through a multi-visit, multi-provider model that may not achieve the continuity of care desired. Additionally, some VA facilities rely on outside providers for gender- specific primary care and specialty gynecological care through the use of fee-basis care. This approach to women’s health delivery can provide challenges in providing continuity of care.

Moving to a more comprehensive primary care delivery model could challenge VA clinicians, who may have dealt predominately with male Veterans and sometimes have little or no exposure to female patients. VA facilities may also need to increase both focus and resources on women’s health (e.g., space, staffing, appropriately equipped exam rooms) to ensure adequate privacy for women during examinations. Initiatives are underway and under development to address these and other changes brought on by the increasing number of women Veterans seeking care from VA.

The quality of health care VA provides to women Veteran’s exceeds the care many would receive in other settings (including commercially managed care systems, Medicare and Medicaid). For example, VA’s system of quality management and preventive patient care, supported by technology like our electronic health record and clinical reminders, ensures women are screened for unique health concerns like cervical cancer or breast cancer at higher rates than non-VA health care programs. On the other hand, VA is aware of existing disparities between male and female Veterans in our system. The Department is particularly concerned with performance measures related to cardiovascular disease, the leading cause of death in women. Performance scores for several quality measures, including high blood pressure, high cholesterol and diabetes, all of which contribute to cardiovascular disease risk, show a consistent difference between men and women Veterans. Gender-neutral prevention measures such as colon cancer screening, depression screening and immunizations show a disparity between men and women Veterans as well. For example, although VA significantly outperforms Medicare on colorectal cancer screening, only 75 percent of women Veterans are screened compared with 83 percent of male Veterans. These issues and other quality issues are being addressed.

Some women report that lack of newborn care and child care forces them to seek care elsewhere. VA recently supported section 309 of S. 252, which would authorize VA to furnish health care services up to 7 days after birth to a newborn child of a female Veteran who is receiving maternity care furnished by VA if the Veteran delivered the child in a VA health care facility or in another facility pursuant to a contract for service related to such delivery. We similarly supported a companion measure in the House. We believe benefits such as these will help improve women Veterans‘ perception that VA welcomes them and will provide complete, effective and compassionate care.

Current Initiatives
VA recognizes the need to continually improve our services to women Veterans, and has initiated new programs including the implementation of comprehensive primary care throughout the nation, enhancing mental health for women Veterans, staffing every VA medical center with a women Veterans program manager, creating a mini-residency education program on women’s health for primary care physicians, supporting a multi¬faceted research program on women’s health, improving communication and outreach to women Veterans, and continuing the operation of organizations like the Center for Women Veterans and the Women Veterans Health Strategic Healthcare Group.

Comprehensive Primary Care for Women Veterans
VA is implementing an innovative approach to women’s health care that seeks to reduce the possibilities of fragmented care, quality disparities, and lack of provider proficiency in women’s health by fundamentally changing the experience of women Veterans in VA.

In March 2008, the former Under Secretary for Health charged a workgroup to define necessary actions for ensuring every woman Veteran has access to a VA primary care provider capable of meeting all her primary care needs, including gender-specific and mental health care, in the context of a continuous patient-clinician relationship. This new definition places a strong emphasis on improved coordination of care for women Veterans, continuity, and patient-centeredness. In November 2008, the workgroup released its final report identifying recommendations for delivering comprehensive primary care. These recommendations included: (1) delivering coordinated, comprehensive primary women’s health care at every VA health care facility by recognizing best practices and developing systems and structure for care delivery appropriate to women Veterans; (2) integrating women’s mental health care as part of primary care, including co-locating mental health providers; (3) promoting and incentivizing innovation in care delivery by supporting local best practices; (4) cultivating and enhancing capabilities of all VA staff to meet the comprehensive health care needs of women Veterans; and (5) achieving gender equity in the provision of clinical care.

To implement these goals and recommendations, the Women Veterans Health Strategic Health Care Group developed a women’s comprehensive health implementation planning (WCHIP) tool to assist facilities in analyzing its own current health care delivery for women Veterans and plans for primary care delivery enhancement. Every VA health care facility was requested to convene a multidisciplinary planning and implementation team to address comprehensive primary care for women Veterans. The WCHIP tool outlines an analysis of current services and projected use, a market analysis and a needs assessment, which facilitated the development of a business plan. This plan includes resource needs, goals, timelines, budgets, training needs and program evaluation metrics to deliver comprehensive health care to women Veterans. No later than August 1, 2009, facilities will finalize their analyses and action plans based on the WCHIP tool. These plans will be instrumental in decisions for directing resources for fiscal 2010 and 2011.

To achieve the goal of providing comprehensive primary care for women Veterans, VA has designed three models to promote the delivery of optimal primary care. Under the first model, women Veterans are seen within a gender neutral primary care clinic. Under the second model, women Veterans are seen in a separate but shared space that may be located within or adjacent to a primary care clinic. Under the third model, women Veterans are seen in an exclusive separate space with a separate entrance into the clinical area and a distinct waiting room. In this scenario, gynecological, mental health and social work services are co-located in this space. Each of these models can be tailored to local needs and conditions to systemize the coordination, continuity, and integration of women Veterans’ care. One-third of VA facilities have already adopted
the third model of comprehensive primary care delivery and found it to be very effective. Access and wait times are better at sites where gender-specific services are available in an integrated women’s primary care setting, regardless of whether the care was delivered in a separate space (such as a women’s clinic) or incorporated within general primary care clinics. VA facilities that have established a “one-stop” approach to primary care delivery have already reported higher patient satisfaction on care coordination for contraception, sexually transmitted disease screening, and menopausal management.

In addition to improving the primary care infrastructure for women Veterans, VA is committed to advancing the entire range of emergency, acute, and chronic health care services needed by women Veterans to develop an optimal continuum of health care. Such a continuum of health care includes: enhancing and integrating mental health care, medical and surgical specialty care, health promotion and disease prevention, diagnostic services and rehabilitation for catastrophic injuries.

Enhancing Mental Health
VA has identified that 37 percent of women Veterans who use VA health care have a mental health diagnosis; these rates are higher than those of male Veterans. Women Veterans also present with complex mental health needs, including depression, post- traumatic stress disorder (PTSD), military sexual trauma (MST), and parenting and family issues.

In response, VA has instituted policy requirements, such as that outlined in its Handbook on Uniform Mental Health Services in VA Medical Centers and Clinics, to emphasize the importance of being aware of gender-specific issues when providing mental health care. In particular, the Handbook identifies services every health care facility must have available for women Veterans to ensure integrated mental health services as a part of comprehensive primary care for women Veterans. For example, the services provided optimally involve a designated, co-located, collaborative provider (psychologist, social worker, or psychiatrist) and care management with an emphasis on the need for safety, privacy, dignity, and respect to characterize all gender-specific services provided. Facilities are strongly encouraged to give patients treated for other mental health conditions the option of a consultation from a same-sex provider regarding gender-specific issues. All inpatient and residential care facilities must provide separate and secured sleeping accommodations for women. Every VA facility has a designated MST coordinator who serves as a contact person for related issues. VA is ensuring a concerted effort to provide quality mental health care appropriate to the needs of women Veterans.

Women Veterans Program Managers
In order to ensure improved advocacy for women Veterans at the facility level, VA has mandated all VA medical centers appoint a full-time Women Veterans Program Manager. These Women Veterans Program Managers support increased outreach to women Veterans, improve quality of care provision, and develop best practices in organizational delivery of women’s health care. They serve as advisors to facility directors in identifying and expanding the availability and access of inpatient and outpatient services for women Veterans and provide counseling on a range of gender- specific care issues. Women Veterans Program Managers also coordinate and provide appropriate local outreach initiatives to women Veterans. As of June 2009, each of VA’s 144 health care systems has appointed a full-time Women Veterans Program Manager.

Mini-Residency Training in Women’s Health
As the number of women Veterans continues to grow, particularly women of childbearing age, VA recognizes many primary care providers need to update their women-specific clinical experience. VA is offering waves of mini-residencies in women’s health across the country in strategic geographic locations. Each mini- residency lasts two and a half days and is taught by national women’s health experts. Clinical staff receive presentations on contraception, cervical cancer screening and sexually transmitted infections, abnormal uterine bleeding, chronic abdominal and pelvic pain, post-deployment readjustment issues for women Veterans, and other womens’ health topics. Early results from this program indicate its success in increasing competencies in 12 areas of women’s health care. As of June 2009, 216 participants (119 physicians, 77 nurse practitioners, 10 physician assistants, 9 registered nurses and 1 therapist) from 90 VA medical centers and 28 community-based outpatient clinics have either scheduled or completed this program.
Research on Women Veteran’s Health Issues

VA has clearly established women’s health as a research priority and intensified its efforts in the last decade. Currently, VA’s Office of Research and Development supports a broad research portfolio focused on women’s health issues, including studies on diseases prevalent solely or predominantly in women, hormonal effects on diseases in post-menopausal women, and health needs and health care of women Veterans. VA’s Office of Health Services Research and Development is funding 27 research projects in this area. VA is also conducting a study that will survey 3,500 women Veterans (both those who use VA health care and those who do not) to identify the changing health care needs of women Veterans and to understand the barriers they
face in using VA health care. We anticipate receiving the results of this study within the next several months, and we will share these findings with the Committee. VA is also conducting risk assessments to track the effects of deployments on women Veterans and improve our epidemiological data on Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) women Veterans through the National Health Study for a New Generation of U.S. Veterans (an OEF/OIF cohort study). We are enrolling 60,000 Veterans for this study – of these 12,000 are women.

Outreach Initiatives
Effective internal and external communication and outreach to women Veterans is critical to the success of implementing comprehensive care. Surveys and research show that women Veterans are often not aware of the services and benefits available to them. VA is engaging in multiple efforts to correct this. For example, VA’s Center for Women Veterans and the Women Veterans Health Strategic Health Care Group will continue to expand its ongoing outreach and communications plan to ensure increased public awareness of women Veterans and their service to our country and increased awareness by women Veterans of VA health care.
Center for Women Veterans

The Center’s mission is to ensure that women Veterans have access to VA benefits and services on par with male Veterans; that VA programs are responsive to the gender- specific needs of women Veterans; that joint outreach is performed to improve women Veterans’ awareness of VA services, benefits, and eligibility criteria; and that women Veterans are treated with dignity and respect. The Center coordinates and collaborates with Federal, State and local agencies, Veterans service organizations and community- based organizations.

Women Veterans Health Strategic Healthcare Group
VA has developed a women Veterans health care “brand” within VA and among women Veterans. VA has made available upgraded communication resources, processes, and tools to Veterans Integrated Service Networks (VISN) and facilities. VA is building on the OEF/OIF call center to reach out to women Veterans. New scripts, new outreach materials and training are being developed to ensure women Veterans are aware of VA’s services and benefits. While these efforts have created an important foundation upon which to build, it will take sustained and coordinated planning to successfully reach out to women Veterans.

Future Plans
While significant efforts are underway, we recognize that more must be done. VA must provide recurring funds to build adequate infrastructure for primary care and expand services to provide a full continuum of care for women Veterans at its secondary and tertiary care facilities. This investment of resources will contribute to the continuing goal of delivering quality health care focused on privacy, safety, sensitivity, dignity and continuity.

Expanding Access to Gynecology
Gynecologists are indispensable in providing care for women with abnormal findings on pelvic exams, such as abnormal pap smears, complicated cases of pelvic pain and abnormal vaginal bleeding in addition to specialized services in urology-gynecology, gynecology-oncology and obstetrics care. As VA primary care physicians increase their proficiency in women’s health care to meet the needs of the growing numbers of women Veterans, primary care physicians will need to have on-site gynecologists available to act as experts, consultants and teachers. VA plans to have a gynecologist available at each of VA’s 144 health care systems by 2012.

Expanding Innovative Technology
In the area of innovative technologies, VA is expanding its efforts to dramatically transform and improve care for women Veterans by enhancing its electronic health records system to provide more functionality related to women’s health, including clinical reminders, pharmacy alerts for teratogenic drugs, improved decision support, gender-specific health history and screening questionnaires, e-videos and other tools for shared decision-making, particularly with regard to preference-sensitive health care choices (e.g., breast cancer surgery and treatments).

Conclusion
Mr. Chairman, VA’s commitment to women Veterans is unwavering. We stand now at a unique moment in time where our actions and plans today will build the system that will provide care equal to the health care needs of all of America’s Veterans, regardless of gender. Thank you once again for the opportunity to testify. My colleagues and I are prepared to address any additional questions you might have.