B. Josea Kramer, PhDVA Greater LA Healthcare System Geriatric Research Education Clinical Center

Bruce Finke, MDIndian Health ServiceActing CMO, Nashville AreaElder Health Consultant

VA Health Services Research and Development Service, ACC 03-304

VA Greater Los Angeles Healthcare System InvestigatorsElizabeth Yano, PhD Debra Saliba, MD, MPH Stella Sarkisyan, MPH, MSW Donna Washington, MDLaurence Z. Rubenstein, MD, MPH

Overview: “VHA and IHS: Access for American Indian and Alaska Native Veterans”

Objectives:• Describe AIAN veterans’ health needs • Describe use of VHA and IHS• Inform interagency planning efforts

Photo: Maxine Judkins

Methods:• Administrative data• Organizational survey• Focus groups• Expert panel

VHA IHS

Service states 50 35

States with hospitals 50 13

Entitlement

Background: VHA-IHS Memorandum of Understanding, 2003VHA and IHS resources

Overview: “VHA and IHS: Access for American Indian and Alaska Native Veterans”

High rates of military participation

BackgroundAmerican Indian Alaska Native Female Veterans

Many AIAN women are eligible for care from IHS and VHA

• Little is known about AIAN women• health needs• use of VHA and IHS

Overview“Federal healthcare for AIAN women veterans”

• Demographic and health characteristics

• Use of VHA and/or IHS care• Strategies for closer alignment

of federal resources

Minnie Spotted Wolf WWII – Marine Reserve Corps

Study Population

All AIAN who used IHS and/or VHA

N=64,746

Women N=5,856 (9%)

Linked and merged FY 02 and FY 03 data:

VHA - National Patient Care Database

IHS – National Patient Information Reporting System

Study population: 3 user groups

VHA-only IHS-onlyDual Users

Study population: Limitations

VHA-only IHS-onlyDual Users

Does not include the following American Indians and Alaska Natives veterans

Tribally enrolled veterans who are not in IHS-NPIRS

IHS users of urban clinics

Tribal facilities that do not submit data to IHS-NPIRS

IHS-only users may under-report veterans

Healthcare by VHA and/or IHS

non-veterans

veterans

IHS-only users 36%

VHA-only users 24%

N = 5,856

Dual users40%

Non-veteran dual users of VHA

Sharing agreemnens, 65%

Other agreements, 5%

Employees, 20%

Humanitarian & Collateral, 10%

IHS-only VHA-only Dual users

Age (mean) in years 41.4 47.3 44.0

% Wartime 57% 58%

Service connected injury or illness, %* (all AIAN)

< 50% service connected

(AIAN men)

> 50% service connected

(all AIAN)

  46%

(41%)

25.6%(21.9%)

20.5%(18.7%)

40%(39%)

25.1%(20.7%)

14.6%(17.5%)

Characteristics: AIAN Women

* Veterans only

Medical diagnoses: AIAN female veterans

*Outpatient

Top dx in rank order* VHA FY03

IHS only

VHA only

Dual users

Diabetes (3) 1 4 1

Hypertension (1) 2 3 2

Depression 3 2 3

PTSD (2) 1 4

Hyperthyroidism 4 10

Esophageal Reflex 6 8

Veterans’ use of VHA and/or IHS% outpatient encounters by user groups

0

5

10

15

20

25

30

35

40

45

IHS Hospital No IHS Hospital

IHS-only

VHA-only

Dual users

n=2,774 n=1,348

AK, AZ, MT, NE, NV, NM. NC, ND, MN,

MS, OK, SD, WY

AL, CA, CO, CT, FL, ID, IN, IA, KS,

LA, MI, ME, MA, NY, OR, RI, SC, TX, UT, WI, WA

%

*Dual users include only veterans

35 IHS Service States

Veterans’ use of VHA and/or IHS by state

0%10%20%30%40%50%60%70%80%90%

100%

DualIHS-onlyVHA-only

* No IHS hospitals

Top 10 states in study population

Dual users: VHA and/or IHS clinics

0% 20% 40% 60% 80% 100%

Primary care

Specialty

Mental health

Diagnostic

VHA IHS Both

*Dual users include only veterans

• High rate of service connected injuries and illness.

• PTSD, hypertension, diabetes & depression are prevalent conditions.

• Utilization patterns of VHA and/or IHS vary by location and by clinical resources.

• There is potential for overlaps in care for veterans who use both VHA and IHS.

Summary

Policy Implications:

• Expanding VHA care to all eligible female AIAN veterans would not require new types of services.

• Strategies for closer alignment of VHA and IHS may vary in recognition of utilization patterns.

• Coordination mechanisms should be established to reduce the potential for fragmentation of care for all dual users of VHA and IHS.

Policy Implications

Misty Warren, ChoctawNaval Test Parachutist

Mary Cornfield, Seneca Desert Shield/Storm

Cora Sinard, OneidaWWI – Army Nurse

Eva Mirabel, TaosWWII Air Corps

Janet Malcolm, OneidaViet Nam Era, Army Corps

Honoring American Indian women veterans