ABSTRACT
The Veterans Health Administration (VA) has undertaken a major initiative to transform primary care delivery through implementation of Patient Aligned Care Teams (PACTs). Based on the ...patient-centered medical home concept, PACTs aim to improve access, continuity, coordination, and comprehensiveness using team-based care that is patient driven and patient centered. However, how PACT principles should be applied to meet the needs of special populations, including women veterans, is not entirely clear. While historical differences in military participation meant women veterans were rarely seen in VA healthcare settings, they now represent the fastest growing segment of new VA users. They also have complex healthcare needs, adding gender-specific services and other needs to the spectrum of services that the VA must deliver. These trends are changing the VA landscape, introducing challenges to how VA care is organized, how VA providers need to be trained, and how VA considers implementation of new initiatives, such as PACT. We briefly describe the evolution of VA primary care delivery for women veterans, review VA policy for delivering gender-sensitive comprehensive primary care for women, and discuss the challenges that women veterans’ needs pose in the context of PACT implementation. We conclude with recommendations for addressing some of these challenges moving forward.
Despite substantial efforts to counter sexual assault and harassment in the military, both remain persistent in the Armed Services. In February 2021, President Biden directed the U.S. Department of ...Defense to establish a 90-day Independent Review Commission on Sexual Assault in the Military (IRC) to assess the department’s efforts and make actionable recommendations. As servicemembers discharge from the military, effects of military sexual trauma (MST) are often seen in the Veterans Health Administration (VA). In response to an IRC inquiry about VA MST research, we organized an overview on prevalence, adverse consequences, and evidence-based treatments targeting the sequelae of MST. Women are significantly more likely to experience MST than their male counterparts. Other groups with low societal and institutional power (e.g., lower rank) are also at increased risk. Although not all MST survivors experience long-term adverse consequences, for many, they can be significant, chronic, and enduring and span mental and physical health outcomes, as well as cumulative impairments in functioning. Adverse consequences of MST come with commonalities shared with sexual trauma in other settings (e.g., interpersonal betrayal, victim-blaming) as well as unique aspects of the military context, where experiences of interpersonal betrayal may be compounded by perceptions of institutional betrayal (e.g., fear of reprisal or ostracism, having to work/live alongside a perpetrator). MST’s most common mental health impact is posttraumatic stress disorder, which rarely occurs in isolation, and may coincide with major depression, anxiety, eating disorders, substance use disorders, and increased suicidality. Physical health impacts include greater chronic disease burden (e.g., hypertension), and impaired reproductive health and sexual functioning. Advances in treatment include evidence-based psychotherapies and novel approaches relying on mind-body interventions and peer support. Nonetheless, much work is needed to enhance detection, access, care, and support or even the best interventions will not be effective.
•Time trend data are important to quantify the health burden of alcohol use disorder (AUD) and to predict healthcare needs.•AUD prevalence for US Veteran men decreased annually from 2010 to 2019, ...mainly among younger Veterans.•AUD diagnoses among male Veterans Health Administration (VA) patients increased overall and among younger patients.•Trends in clinically-detected alcohol misuse mirrored trends in population prevalence but not clinical AUD diagnoses.
Data on time trends are important to track the health burden of alcohol use disorder (AUD) and plan for alcohol-related healthcare needs. Our aim was to estimate time trends in AUD for male VA patients and to assess whether trends in documented diagnosis rates were similar to trends in unhealthy alcohol use measured through clinical screening or trends in AUD prevalence among US veterans in the general population.
We used VA electronic health record data (10/1/2009–9/30/2019) to measure AUD diagnosis rates and clinical alcohol screening data to measure unhealthy alcohol use. We used data from the National Survey on Drug Use and Health to measure AUD prevalence for 2010–2019. We estimated time trends using regression models with year entered as a linear term.
For male VA patients, AUD diagnosis rates increased overall and for most age groups, Alcohol screening rates increased, but the proportion with unhealthy alcohol use decreased, except among older patients. AUD prevalence for male US veterans decreased by −0.17 percentage points (pp) annually (p = 0.010), reflecting a strong decreasing trend for ages 18–34 years (−1.20 pp per year, p < 0.001).
Increasing trends in AUD diagnoses among VA patients are a contrast to the decreasing trends in unhealthy alcohol use and AUD population prevalence among male US veterans. However, differences in trends by age group highlights a need to better understand the process of clinical AUD identification, particularly for younger men.
ABSTRACT
Background
Primary care telephone access has been associated with patient satisfaction and emergency department utilization even after accounting for objective appointment wait times. ...However, relatively little is known about how to best structure and manage telephone access in primary care.
Objective
Assess how primary care telephone access is structured and managed and explore how variation in telephone management may affect primary care teams and patients.
Design
We used 2016 administrative and patient survey data to select six Veterans Administration medical centers (VAMCs) with above-average primary care access (time to third next available appointment) but variable patient-reported access, geographic region, and urbanicity. Semi-structured interviews were conducted August –October 2017.
Participants
Forty-three key stakeholders knowledgeable about primary care, telephone management, and operational priorities nationally and/or within each VAMC.
Key Results
Telephone access was organized and managed differently across sites. Regional call centers were perceived as more efficient but less flexible in tailoring processes to meet local needs. Patient preferences for speaking with their own care teams were cited as a reason to manage telephone access locally rather than regionally, particularly in rural sites. Sites with high patient-rated access described call center functions as well-integrated with primary care team workflow, while those with low patient-rated access perceived telephone management practices as negatively affecting primary care team workload. Call center understaffing was a major barrier to optimal telephone access in all six sites, though rural sites reported greater challenges with provider recruitment and retention.
Conclusions
In VA, efforts to improve telephone access have focused on centralizing call center operations but current call center performance metrics do not account for the extent to which call center functions are integrated with primary care workflows or may impact patient experience. Efforts to improve primary care access should carefully consider impact of telephone management practices on providers and patients.
Background
Capturing military sexual trauma (MST) exposure is critical for Veterans’ health equity. For many, it improves access to VA services and allows for appropriate care.
Objective
Identify ...factors associated with nondisclosure of MST in VA screening among women.
Design
Cross-sectional telephone survey linked with VA electronic health record (EHR) data.
Participants
Women Veterans using primary care or women's health services at 12 VA facilities in nine states.
Main Measures
Survey self-reported MST (sexual assault and/or harassment during military service), socio-demographics and experiences with VA care, as well as EHR MST results. Responses were categorized as “no MST” (no survey or EHR MST), “MST captured by EHR and survey,” and “MST not captured by EHR” (survey MST but no EHR MST). We used stepped multivariable logistic regression to examine “MST not captured by EHR” as a function of socio-demographics, patient experiences, and screening method (survey vs. EHR).
Key Results
Among 1287 women (mean age 50, SD 15), 35% were positive for MST by EHR and 61% were positive by survey. Approximately 38% had “no MST,” 34% “MST captured by EHR and survey,” and 26% “MST not captured by EHR”. In fully adjusted models, odds of “MST not captured by EHR” were higher among Black and Latina women compared to white women (Black: OR = 1.6, 1.2–2.2; Latina: OR = 1.9, 1.0–3.6). Women who endorsed only sexual harassment in the survey (vs. sexual harassment and sexual assault) had fivefold higher odds of “MST not captured by EHR” (OR = 4.9, 3.2–7.3). Women who were screened for MST in the EHR more than once had lower odds of not being captured (OR = 0.3, 0.2–0.4).
Conclusions
VA screening for MST may disproportionately under capture patients from historically minoritized ethnic/racial groups, creating inequitable access to resources. Efforts to mitigate screening disparities could include re-screening and reinforcing that MST includes sexual harassment.
ABSTRACT
BACKGROUND
Timely access to healthcare is essential to ensuring optimal health outcomes, and not surprisingly, is at the heart of healthcare reform efforts. While the Veterans Health ...Administration (VA) has made improved access a priority, women veterans still underutilize VA healthcare relative to men. Eliminating access disparities requires a better understanding of the barriers to care that women veterans’ experience.
OBJECTIVE
We examined the association of general and veteran-specific barriers on access to healthcare among women veterans.
DESIGN AND PARTICIPANTS
Cross-sectional, population-based national telephone survey of 3,611 women veterans.
MAIN MEASURE
Delayed healthcare or unmet healthcare need in the prior 12 months.
KEY RESULTS
Of women veterans, 19% had delayed healthcare or unmet need, with higher rates in younger age groups (36%, 29%, 16%, 7%, respectively, in 18–34, 35–49, 50–64, and 65-plus age groups; p < 0.001). Among those delaying or going without care, barriers that varied by age group were: unaffordable healthcare (63% of 18–34 versus 12% of 65-plus age groups); inability to take off from work (39% of those <50); and transportation difficulties (36% of 65-plus). Controlling for age, race/ethnicity, regular source of care, and health status, being uninsured (OR = 6.5; confidence interval CI 3.0–14.0), knowledge gaps about VA care (OR = 2.1; 95% CI 1.1–4.0), perception that VA providers are not gender-sensitive (OR = 2.4; CI 1.2–4.7), and military sexual assault history (OR = 2.1; CI 1.1–4.0) predicted delaying or foregoing care, whereas VA use and enrollment priority did not.
CONCLUSIONS
Both general and veteran-specific factors impact women veterans’ access to needed services. Many of the identified access barriers are potentially modifiable through expanded VA healthcare and social services. Health reform efforts should address these barriers for VA nonusers. Efforts are also warranted to improve women veterans’ knowledge of availability and affordability of VA healthcare, and to enhance the gender-sensitivity of this care.
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