Critical Topics in Military Women’s Health:
Women Veteran’s Health
AMSUS Annual Meeting,
November, 2018
Sally Haskell, MD, MS
Deputy Chief Consultant, Women’s Health Services (WHS)
Veterans Health Administration
November 29, 2018
Source: America’s Women Veterans, National Center for Veterans Analysis and Statistics, Nov. 23, 2011. Veterans: Military Service History and VA Benefits Utilization Statistics, Department of 3, 2011; http://www.va.gov/VETDATA/docs/SpecialReports/Final_Womens_Report_3_2_12_v_7.pdf
Women in the Military: A Growing Trend
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Number Of Women Veteran VHA PatientsIn Each Year, Fiscal Year(FY) 2000-FY 2017
159,810
231,907
317,122
439,791
484,317
0
100,000
200,000
300,000
400,000
500,000
600,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
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The number of women Veterans using VHA services has tripled since 2000, growing from 159,810 in FY00 to 484,317 in FY17, representing a 203% increase over 17 years.
Age Distribution of Women Veteran Patients
FY00 and FY17
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0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
15 25 35 45 55 65 75 85 95 105
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FY00
FY17
Cohort: Women Veteran VHA patients with non-missing ages 18-110 years (inclusive) in FY00 and FY17. Women in FY00: N=159,553; FY17: N=484,156.Source: WHEI Master Database, FY00-FY17
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Race/Ethnicity Distribution of Women and Men Veteran
Patients by Age, FY17
Cohort: Women and men Veteran VHA patients with non-missing ages 18-110 years (inclusive) in FY17. Women: N=484,156; Men: N=5,523,491.Source: WHEI Master Database, FY17 (using OMOP and Vital Status File data to identify race/ethnicity)
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Cohort: Women Veteran VHA patients. Women in FY00: N=159,810; FY15: N=439,791.Source: WHEI Master Database, FY00-FY15
Domain Frequencies Among Women Veteran Patients
Domain
FY15N=439,791
%
Infectious Disease 27.5
Endocrine/Metabolic/Nutritional 51.2
Cardiovascular 36.1
Respiratory 32.3
Gastrointestinal 31.6
Urinary 15.0
Reproductive Health 31.2
Breast 6.8
Cancer 5.1
Hematologic/Immunologic 9.6
Musculoskeletal 58.7
Neurologic 31.8
Mental Health/Substance Use Disorder 48.4
Sense Organ 33.3
Dental 10.5
Dermatologic 22.6
Other 52.1
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* Indicates an increase of 5 or more in rank order from FY00.Cohort: Women Veteran VHA patients. Women in FY00: N=159,810; FY15: N=439,791.Source: WHEI Master Database, FY00-FY15
Top 20 Conditions in Women Veteran VHA Patients, FY00 and FY15
FY15N=439,791
Rank Condition %1 Hypertension 27.22 Depression, Possible - Other 26.7
3 Lipid Disorders 25.24 Joint Disorders - Lower Extremity 23.85 Spine Disorders - Lumbosacral 22.86 Dermatologic Disorders - Other 20.37 Anxiety Disorders - Other 19.78 Overweight/Obesity 19.69 Refraction Disorders 18.5
10 Posttraumatic stress disorder (PTSD) 18.411 Musculoskeletal Conditions - Other 18.112 Headache 17.313 Eye Disorders - Other 16.314 Esophageal Disorders 16.015 Major Depressive Disorder 14.2
16Joint Disorders - Unspecified or Multiple Joints 13.8
17 Tobacco Use Disorder 13.118 Thyroid Disorders 13.0
19Allergic and Other Chronic Sinusitis/Rhinitis 12.7
20 Spine Disorders - Other/Unspecified 12.6
Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND)
Medical Diagnoses of 149,452 Women Veterans seen in VA (2002-2015,Quarter 3)
• Musculoskeletal (MSK) 62%
• Mental Disorders 57%
• Nervous System/Sense Organs 51%
• Genitourinary System 46%
• Digestive System (Dental) 41%
• Endocrine System 40%
• Respiratory 38%
• Skin Diseases 32%
• Injury/Poisoning 31%
• Infectious/Parasitic Diseases 23%
• Circulatory 21%
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Total VHA Primary Care Encounters Among Women and
Men Veteran VHA Patients, FY17
Cohort: Women and men Veteran VHA patients in FY17. Women: N=484,317; Men: N=5,523,756. Source: WHEI Master Database, FY17
VA Provides Full Continuum Of Health Care For Enrolled Women Veterans
• Comprehensive Primary Care (acute care, chronic illness and gender-specific care from a single provider)
• Routine Gynecological care• Mental Health • Disease Management, Prevention and Screening• Emergency Care• Infertility Care • Maternity Care (Newborn care up to 7 days)• Specialty Care• Hospice/Palliative Care• Long-Term Care Services and Supports
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VHA Services for Women Veterans
• VHA expanding services and sites of care:
– Increasing primary care providers trained to care for women: Over 3,400 across country
– Gynecologists on site: 196 across country
– Mammography on site: 60 sites across country and more coming
– Telehealth services: tele-gynecology, tele-mental health, tele-wellness
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VETERANS HEALTH ADMINISTRATION
Delivery of Comprehensive Primary Care
• Complete primary care from one designated women’s health provider (DWHP) at one site, including community based outpatient clinics (CBOCs)
– Care for acute and chronic illness
– Gender-specific primary care
– Preventive services
– Mental Health services
– Coordination of care
– Measured with women’s health
primary care evaluation tools
and evaluated by site visits
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• Contraception
• Preconception Care
• Maternity Care Coordination
• Newborn care for up to 7 days
• Infertility treatment
• Menopause management
• Gynecological surgery
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Reproductive Health
MATERNITY CARE
• Part of benefits package for women Veterans since 1996.
NEWBORN CARE
• Section 206 of the Caregivers and Veteran Omnibus Health Service Act enacted May 2010.
VA Maternity and Newborn Care
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VA Maternity and Newborn Care
Use of VA maternity care has increased by 44 percent in the past 5 years.
VA maternity care is outsourced and provided through community care.
Effective maternity care coordination is a critical component of maternity care for women Veterans.
•VA Care
•Preconception Care
•Safe Prescribing
Co-Morbid Conditions
•VA Care
•Obstetrics Care in the Community
•VA Care Coordination
Pregnancy •Care in the Community Completion
•Obstetrics Record Transfer
•VA Care / Follow-up
Postpartum
VHA is Promoting Complementary and Integrative Health Services
• Helping Veterans focus on self-management and health
– mind-body techniques, meditation
– Mindfulness Apps
– yoga, Tai-chi
– massage
– art and music experiences
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Prosthetic Equipment for Women
• Women-specific prosthetic items include, but are not limited to:
– Breast Pumps
– Nursing Bras
– Wigs for hair loss
– Long-Acting Reversible Contraception (e.g., Intrauterine Devices)
– Maternity Support Belts Items
– Vaginal Dilators
– Women’s eyeglasses, shoes, etc
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Continuum Of Mental Health Care
• Women are increasingly using VA health and mental health services
• In Fiscal Year (FY) 2017, 44 percent of women Veterans who used VA accessed mental health services
• VA offers a full continuum of mental health services for women Veterans
– General outpatient
– Specialty services
– Evidence-based therapies
– Inpatient and residential treatment options (mixed-gender and women-only)
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Mental Health Issues Among Women Veterans
• Women Veterans are more likely than male Veterans to be diagnosed with a mental health condition by VA provider
• In fiscal year 2017:
– 40 percent of female VHA users had confirmed mental health diagnosis
– 25 percent of male VHA users had confirmed mental health diagnosis in FY17
• As compared to male Veterans, women Veterans have:
– Higher rates of depression and anxiety
– Lower rates of substance use
– Higher rates of mental health and medical comorbidities
• Clinical complexity among women Veterans with mental health concerns is an area of special focus
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Innovative Clinical Training Initiatives
Multidisciplinary Eating Disorders Treatment Team Training
– 8-week, 24-hour training delivered via video conferencing
– 21 teams currently in place
• Skills Training in Affective and Interpersonal Regulation (STAIR)
– Cognitive-behavioral trauma treatment that teaches skills for managing strong emotions and building healthy relationships
– Live web-based trainings in Advanced STAIR and Parenting STAIR
• Women’s Mental Health Mini-Residency
– 3-day, face-to-face training in gender-tailored treatment approaches, including psychotherapies and psychiatric medications
– Participants create Action Plans to advance women’s mental health care locally and represent their facilities as Women’s Mental Health Champions
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Military Sexual Trauma (MST)
• MST is the term used by VA to refer to experiences of sexual assault or repeated, threatening sexual harassment that occurred during a Veteran’s military service
• Unfortunately, military sexual trauma (MST) is a part of some women’s military experience and can have a significant impact on their mental and physical health
• VA has implemented a universal screening program in which all Veterans seen for health care are asked about experiences of MST
• Data from this program reveal that when screened by a VA health care provider, about 1 in 4 women and 1 in 100 men report experiencing MST
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VA Has Specialized Services To Help
• All VA health care facilities provide free treatment for any mental and physical health conditions related to a Veteran’s experiences of MST
– Outpatient, inpatient, residential, and pharamaceutical treatment
• Eligibility for this free care is expansive and some Veterans may be able to receive MST-related care even if they are not able to receive other VA care
– No length of service requirements
– No service connection required
– No documentation of the MST required
• To access care, Veterans can contact the facility MST Coordinator to learn about services available or ask their existing VA healthcare provider for a referral
– More information is also available at www.mentalhealth.va.gov/msthome.asp
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Telehealth and Connected Health
• Telehealth services
– Tele-gynecology
– Tele-mental health
– Tele-wellness
– Tele-pharmacy
• My HealtheVet: https://www.myhealth.va.gov
• Pharmacy refills, lab results
• Secure messaging to VA provider
• New app for appointments rolling out now
• Many health apps on VA App store: PTSD Coach, MOVE, and Weight loss
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• As of August 31, 2018, the WVCC received 79,692 calls and made 1,213,639 calls with 632,000 of these calls being successful (spoke with Veteran or left a voice message).
• Implemented chat feature in May 2016 to increase access for women Veterans, responded to 1,689 chats.
Women Veterans Call Center
Culture Change in VA
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Air Force (AF) and Veterans Affairs Women’s Initiative Transition Assistance for Service Members
Department of Defense(DoD)/VA Health Executive Committee identified transition between DoD and VA as the #1 barrier to care for female Veterans• Myriad of challenges in relation to suicide
• Difficult to navigate VA during crisis
• Get those who need it into mental health support quickly
AF/VA partnered to pilot a program and address health care gaps for female Veterans• Pilot 1 day health care presentation w/tour of VA facility
• Registration w/ VHA and VBA
• “Hot hand off” between DoD and VA before separation
• Track females 2 years post service to determine effects of health care presentation, does it address original problem set
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QUESTIONS??
• Contact:
• Sally Haskell
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