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

2

3

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

# W

om

en

Vet

era

n P

atie

nts

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

4

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

# W

om

en

Vet

era

n P

atie

nts

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

5

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)

6

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

7

* 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%

8

9

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

10

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

11

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

12

• Contraception

• Preconception Care

• Maternity Care Coordination

• Newborn care for up to 7 days

• Infertility treatment

• Menopause management

• Gynecological surgery

13

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

14

15

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

16

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

17

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)

18

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

19

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

20

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

21

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

22

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

23

24

• 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

25

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

26

QUESTIONS??

• Contact:

• Sally Haskell

• Sally.Haskell@VA.gov

27