Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696589046170.pdf (United States)
STATEMENT OF DR. PATRICIA HAYES CHIEF CONSULTANT FOR WOMEN’S HEALTH SERVICES VETERANS HEALTH ADMINISTRATION (VHA) DEPARTMENT OF VETERANS AFFAIRS (VA) BEFORE THE HOUSE APPROPRIATIONS COMMITTEE SUBCOMMITTEE ON MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES February 28, 2019 Good Morning Madam Chairwoman, Ranking Member Carter, and distinguished Members of the Subcommittee.

I appreciate the opportunity to discuss the high-quality care and support VA is providing to our women Veterans.
I am accompanied today by Dr. Susan McCutcheon, VHA’s National Mental Health Director for Family Services, Women’s Mental Health and Military Sexual Trauma.

Overview The number of women Veterans enrolling in VA health care is increasing, placing new demands on a VA’s health care system.

Women make up 16.2 percent of today’s active duty military forces and 19 percent of National Guard and Reserves.
Based on the upward trend of women in all service branches, the expected number of women Veterans using VA health care will rise rapidly and the complexity of injuries of returning troops is also likely to increase.

More women are choosing VA for their health care than ever before.

The number of women Veterans using VHA services has tripled since 2001, growing from 159,810 to 500,000 today.
To address the growing number of women Veterans who are eligible for health care, VA is strategically enhancing services and access for women Veterans.

Access to Care Every VHA health care system across the United States now has a fulltime Women Veteran’s Program Manager tasked with advocating for the health care needs of women Veterans using that facility.
Mini-residencies in women’s health with didactic and practicum components have been disseminated system wide to enhance clinician proficiency; since 2008, over 5,800 health care providers have been trained in this national program.

Under a new collaboration with the Office of Rural Health, a pathway for accelerating access to women’s health training for rural primary care providers has been established.

Meanwhile, VHA is actively recruiting additional providers with experience in women’s health care.
Numerous initiatives have been launched to improve access to state-of-the-art reproductive health services, mental health services and emergency services for women Veterans, and others have focused on enhancing care coordination through technological innovations such as registries and mobile applications.

1 VA has enhanced provision of care to women Veterans by focusing on the goal of developing Women’s Health Primary Care Providers (WH-PCP) at every site of VA care.
VA has at least two WH-PCP at all of VA’s health care systems.

In addition, 90 percent of community based outpatient clinics (CBOCs) have a WH-PCP in place.

We are in the process of training additional providers to ensure that every woman Veteran has an opportunity to receive her primary care from a WH-PCP.
VA has implemented women’s health care delivery models of care that ensure women receive equitable, timely, high-quality primary health care from a single primary care provider and team, thereby decreasing fragmentation and improving quality of care for women Veterans.

VA is proud of high quality health care for women Veterans.

We are on the forefront of information technology (IT) for women’s health.
Because quality measures show that women Veterans are more likely to receive breast cancer and cervical cancer screening than women in private sector health care, VA is redesigning the electronic medical record to track breast and reproductive health care.

Unlike other health care systems, VA analyses quality performance measures by gender.

This has been key in the reduction and elimination of gender disparities in important aspects of health screening, prevention, and chronic disease management.
Scope of Services VA provides full services to women Veterans, including comprehensive primary care, gynecology care, maternity care, specialty care, and mental health services.

Comprehensive Primary Care To provide the highest quality of care to women Veterans, VA offers women Veterans assignments to trained and experienced designated WH-PCPs.

The providers can provide general primary care and ender specific primary care in the context of a longitudinal patient/provider relationship.
National VA satisfaction and quality data indicate that women who are assigned to WH-PCPs have higher satisfaction and higher quality of gender specific care than those assigned to other providers.

Importantly, we also find that women assigned to WH-PCP’s are twice as likely to choose to stay in VA care over time.

Gynecology Care VA offers many gynecologic services, including complex gynecology care such as gynecologic surgery and treatment of gynecologic cancers.
Women Veterans have access to gynecology care as a basic component of high-quality care.

For those facilities where VA does not have a gynecologist on site (24 out of 160), Veterans receive services through care in the community.

In 2017, VA held its first-ever national VA gynecology conference: VA Gynecology Health System - Optimizing Access and Facilitating Best Practices Training.

The mission of this conference was to optimize access to gynecologic services for women Veterans.
A second Gynecology conference is planned for June 2019, focusing on specific gynecologic surgery skills.

2 Maternity Care Maternity benefits for enrolled women have been included in the VA medical benefits package since 1996.

In general, these benefits begin with the confirmation of pregnancy.

VA medical facilities do not provide on-site obstetric care to pregnant Veterans.
However, female Veterans receiving their care through VA have their pregnancies diagnosed at a VA medical facility and receive further maternity care through community (non-VA) health care providers.

Some Veterans will continue to receive other health care services, such as mental health services during their pregnancies, through the VA health care system.
Once a pregnancy is diagnosed, the VA Maternity Care Coordinator (MCC) educates the Veteran on maternity benefits and process for maternity care throughout the pregnancy.

MCC helps the Veteran navigate and coordinate care between VA and maternity care providers in the community and is available to answer questions and remain in communication throughout the pregnancy.
Because of high rates of mental health conditions in women Veterans using VA health care, it is essential that they are supported by MCC during pregnancy and encouraged to return to VA primary care women’s health after their delivery.

VA offers newborn care for up to 7 days after the birth of a child.
Newborn care includes, but is not limited to, inpatient care, outpatient care, medications, immunizations, circumcision, well-baby office visits, neonatal intensive care, and other appropriate post-delivery services.

Infertility and Adoption Reimbursement Services VA provides infertility services, other than in vitro fertilization (IVF), to all enrolled Veterans.
Veterans receiving care through VA are offered infertility evaluation and treatment, regardless of service connection, sexual orientation, gender identity, gender expression, or relationship or marital status.

This includes diagnostic testing and many infertility treatments, with the exception of IVF.

Recent legislation authorizes IVF, and other infertility testing and treatment, for married Veterans with a service-connected disability that results in infertility.
VA provides infertility testing and treatment, including IVF, to eligible Veterans and their spouses.

The Veteran must be legally married, and meet the eligibility requirements of a service-connected condition that results in infertility.

Eligible Veteran couples can receive a total of three IVF cycles; and cryopreservation storage of their own gametes and embryos without time limits.

Donor eggs, sperm, embryos and surrogacy are not covered benefits.
Treatment with IVF is provided by specialists in the community, with care coordinated among relevant VA providers and the VA facility’s Women Veteran Program Manager.

VA implemented regulations to provide reimbursement of qualifying adoption expenses incurred by Veterans with a service-connected disability that results in the 3 inability to procreate without the use of fertility treatment.
Covered Veterans may request this $2000 reimbursement for qualifying adoption expenses incurred for adoption finalized after September 29, 2016.

Mental Health Services VA has witnessed a 154 percent increase over the past decade in the number of women Veterans accessing VA mental health care.

Over 40 percent of women Veterans who use VA have been diagnosed with at least one mental illness and many struggles with multiple, clinically complex conditions, such as trauma, mood, and eating disorders.
VA’s mental health programming for women Veterans is guided by the principles of gender-sensitive care.

Gender-sensitive care is informed by known differences in how men and women experience emotional problems and treatment and recognizes the importance of offering choice, flexibility, and options for care.
To ensure that VA mental health providers have the skills and expertise to meet women Veterans’ unique and diverse treatment needs and preferences, Office of Mental Health and Suicide Prevention (OMHSP) has developed innovative clinical trainings and initiatives to strengthen mental health services for the growing population of women Veterans.
These initiatives expand the portfolio of treatment options available to women Veterans and complement the strong cadre of evidence-based practices available to all Veterans.

Here are some examples: • In 2016, OMHSP conducted the first VA Women’s Mental Health Mini-Residency.

During this intensive 3-day training, national experts led sessions on gender- tailored psychotherapies and psychiatric medication management, with a focus on the influence of hormonal changes and the reproductive cycle.
Participants serve as local Women’s Mental Health Champions and, as part of the training, developed Action Plans to disseminate women’s mental health practices at their facilities.

In 2018, VA partnered with Department of Defense (DoD) to conduct a joint Women’s Mental Health Mini-Residency.

• OMHSP developed clinical training programs in STAIR (Skills Training in Affective and Interpersonal Regulation) and Parenting STAIR.
STAIR and Parenting STAIR are cognitive-behavioral trauma treatments that teach skills for managing strong emotions and building healthy relationships, including parenting relationships.

These are important areas of functioning that can be highly disrupted in women with histories of serious interpersonal traumas, such as sexual assault.
• To address an identified need for eating disorder treatment options, OMHSP partnered with Women’s Health Services (WHS) to develop a cutting edge multidisciplinary eating disorder treatment team training, aligned with the Joint Commission’s rigorous standards for outpatient eating disorder care.

Coordinated, specialized clinical care is needed to effectively treat serious eating disorders, which are associated with increased risk for suicide attempts and death by suicide.
4 • OMHSP developed a monthly training series to enhance knowledge of gender- tailored prescribing practices.

Physiological changes across a woman’s lifecycle can affect her mental health and suicide risk.

For example, pharmacologic treatment of bipolar disorder in women poses unique challenges due to interactions between estrogen, progesterone and several mood stabilizing medications.

In addition, several mood stabilizing medications pose risks during pregnancy and breastfeeding.
Military Sexual Trauma Unfortunately, some women experience sexual assault or harassment during their military service, and may struggle even years later with its aftereffects.

VA’s services for military sexual trauma (MST) can be critical resources to help them in their recovery journey.
Services for any mental and physical health conditions related to MST are available for free at every VA medical center and eligibility is expansive: Veterans do not need to have reported their experiences at the time or have any documentation that they occurred, and may be able to receive free MST-related care even if they are not eligible for other VA care.

VHA has a number of initiatives to help ensure that targeted, specialized services are available and that Veterans are aware of these services.
Since FY 2007, these efforts have resulted in a 297 percent increase in the number of women Veterans receiving MST-related outpatient care, indicating the positive impact of these efforts.

Some key initiatives include maintaining a full continuum of outpatient, inpatient, and residential mental health services.
As part of the universal screening program, every Veteran seen for VA health care is asked whether he or she experienced MST, so that they can be connected with MST-related services as appropriate, and every VA health care system has a designated MST Coordinator who can help Veterans access MST-related services and programs.

VHA also has a range of initiatives to promote continued expansion of its MST- related programming and promote provider expertise.
These include bimonthly training calls for staff, an annual conference on treatment program development, online courses, a community of practice intranet website, and a national MST Consultation Program available to any VA staff member with a question relating to assisting Veterans who experienced MST.

These are important efforts, but outreach and engagement efforts must remain an ongoing area of emphasis to ensure Veterans have access to the care they need.
Child Care VA is aware of the challenges faced by Veterans with children in regard to access to medical appointments and other medical care, counseling, and care giving services.

Women Veterans currently are and will continue to be an important part of the 5 Veteran community and an important part of VA.

The total number of women Veteran patients age 18-44 increased from 81,832 in Fiscal Year (FY) 2000 to 187,137 in FY 2015, a 2.3-fold increase.
From the 2015 Study of Barriers to Care for Women Veterans, when queried about the possibility of on-site child care, three out of five women (62 percent overall) indicated that they would find on-site child care very helpful, but in general this was not a significant factor in whether they choose to utilize VA care.
Public Law 111-163, Caregivers and Veterans Omnibus Health Services Act of 2010, Section 205, initially authorized VA to provide child care services through a pilot and every year since, the Department of Veterans Affairs Expiring Authorities Act has allowed VA to continue the services.

Most recently, the Military Construction, Veterans Affairs and Related Agencies Act of 2018 permitted funding to be used in fiscal years 2019 and 2020 to carry out and expand the child care pilot program.
Since 2011, VA has been providing child care services through the pilot program offered at Buffalo, New York, Veterans Integrated Service Network (VISN) 2; Northport, New York, VISN 3; American Lake-Puget Sound (American Lake), Washington, VISN 20; and Dallas, Texas, VISN 17.

While mothers were the largest users of drop-in child care services at 47 percent; fathers utilized the service nearly as much at 44 percent; and grandparents utilized the service at 9 percent.
Utilization and costs vary at each of the sites, however what is consistent is Veteran satisfaction with the service.

VA is on record in previous Congresses seeking permanent, discretionary authority to the Secretary to provide child care assistance for the children of eligible Veterans while those Veterans are accessing health care services at facilities.

Women Veteran Call Center In 2014, VA established a hotline specific for women Veterans.
The Women Veteran Call Center (WVCC) makes outgoing calls to women Veterans to provide information about VA services and resources and responds to incoming calls from women Veterans their families and caregivers.

The call center implemented a chat feature in May 2016 to increase access for women Veterans and has responded to 1,689 chats.
As of August 31, 2018, the WVCC has received 79,692 calls and has made 1,213,639 outgoing calls, with 632,000 of these calls being successful (spoke with Veteran or left a voice message).

The WVCC is adding texting services this spring.

Expanding Mammograms Mammograms for women Veterans are available on-site at 64 VHA health care sites where digital mammography is available.
When VA cannot provide these services in-house, VA utilizes community care authority to provide mammograms near to where the Veteran lives.

VHA has also convened a task force of subject matters experts from women’s health, oncology, radiology, surgery, and radiation oncology to develop guidance to standardize and enhance breast cancer care in VA facilities nationally.
Despite these accomplishments, VHA agrees with a recent VA Office of Inspector 6 General report that tracking the results of mammograms performed outside VA has been a challenge.

In response, VA has established national guidelines for mammography and cervical cancer tracking.
VA has partnered with the office of Rural Health to fund positions for cervical cancer and breast cancer screening coordinators at 27 rural sites and has established education, toolkits and a national community of practice for Mammogram Coordinators.

VA has been working to ensure that test results from studies done outside of VA are documented in the Computerized Patient Record System and that patients are notified of normal and abnormal mammography results within an appropriate timeframe.
VA completed two IT projects that will revolutionize tracking and results reporting for breast cancer screening and follow-up care: the Breast Care Registry and the System for Mammography Results Reporting.
These systems are designed to work together to identify, document, and track all breast cancer screening and diagnostic imaging (normal or abnormal), order results, notify patients, and follow-up to ensure that all women Veterans receive high-quality, timely breast care, whether treatment is provided within or outside of VA. Quality Care VA is proud of its high-quality health care for women Veterans.
Beginning as far back fiscal year 2008, VHA launched a concerted Women’s Health improvement effort, focusing providers’ attention on gender disparity data.

From 2008 to 2011, VA saw a significant reduction in gender disparity for many measures, including hypertension, diabetes, pneumococcal vaccine, and influenza prevention.

Improvements were also made in screening measures for colorectal cancer, depression, posttraumatic stress disorder, and alcohol misuse.
In FY 2011, VA included Gender Disparity Improvement as a performance measure in the VISN Director Performance Plans, which concentrated management attention on systems to continuously reduce gender disparity.

WHS has continued to publish reports on these efforts; the FY 2017 report illustrates that VA has made continued progress in closing the gap in gender disparities.
At the close of FY 2017, small gender gaps existed in only a few measures including cholesterol management in high-risk patients, diabetes care, and rates of influenza.

Since 2014 VA has tracked access by gender and identified small but persistent disparities in access for women Veterans, who overall are waiting longer for appointments than male Veterans.
To mitigate this disparity VA has identified sites with longest wait times for women Veterans and is working with those sites directly on initiatives to improve access, including designating more women’s health providers through hiring or training, and improved provider and team efficiency.

VA has conducted site visits at all health care systems to assess the quality of the women’s health program.
After completing a national review in 2017, VA developed an Evidence Based Quality Improvement Process to assist sites with women’s health quality improvement projects.

VA has completed EBQI initiatives at 14 sites and will complete 7 additional site projects in 2019.

7 Barriers to Care Even though VA continues to successfully expand its female-centric health care coverage, the Department has encountered several challenges in meeting the demand of the increasing women Veteran population.
Although VA has made it a priority to provide top-notch training to providers and other clinical staff, VA is unable to keep up the demand to have trained providers to care for women Veterans.

Provider turnover continues to be an issue, and a national shortage of primary care providers results in recruitment challenges.

In 2018, VHA Leadership directed that Privacy and Dignity Standards for Women Veterans be extended to all Veterans.
A Workgroup on Privacy and Environment of Care worked to define all terms and standards for privacy and environment of care.

The definitions were incorporated in the Appendix C of VHA Directive 1330.01, Health Care Services for Women Veterans and was published on July 24, 2018.
In addition, VA’s Construction and Facility Management (CFM) identified appropriate updates for Design Standards and released a Design Alert to the field in October 2018, which effectively updated the 2010 CFM design standards to extend to all Veterans.
New Initiatives/Outreach Office of Rural Health Training Initiative Women’s Health Services (WHS) has partnered with VHA Office of Rural Health (ORH) to develop and implement a training to specifically meet the needs of rural primary care providers and nurses at rural CBOCs and VA medical centers.
This mini- residency for rural providers and nurses launched in June 2018 and is on track to visit up to 35 rural clinical sites during its first program year and up to 40 sites per year thereafter, supporting the highest level of care for women Veterans in rural areas.
Telehealth Services for Women WHS understands it may be difficult to always make an appointment in person and is collaborating with Office of Connected Care and ORH to ensure that primary and specialty care is delivered via telehealth to women Veterans both in rural areas of the country and in other geographical areas where there is a shortage of providers.
The nationwide initiative, Virtual Integrated Multisite Patient Aligned Care Team (V- IMPACT), implements virtual women’s health PACT teams in their primary care hub sites for the provision of gap coverage in VA facilities with a shortage of women’s health providers.

In addition, WHS has worked with ORH to ensure the inclusion of Women’s Health Clinical Pharmacy Specialists (CPS) in their recent initiative to expand the availability of CPS via telehealth to rural VA facilities.
Lastly, WHS is actively working to promote the use of Video Connect among women’s health providers to improve access to primary care.
8 Transition Assistance Pilot Program The Women’s Health Transition Assistance Training Pilot Program (WH TAP Pilot) is a collaboration between the Air Force Women’s Health Initiative Team (AFWHIT) and the Veterans Health Administration’s (VHA) Office of Women’s Health Services conducted under the auspices of the VA/DoD Health Executive Committee, Clinical Care and Operations Business Line, Women’s Health Workgroup (HEC CCO BL WHWG).
The aim of this initiative is to increase transitioning Servicewomen’s knowledge about the VHA health care system, the VHA enrollment process and eligibility and specific services and resources available for separating Servicewomen.
The ultimate goal of the WH TAP Pilot is to increase timely enrollment and utilization of VA health care services among eligible women after they separate from the military, and to “provide a female perspective” and connect Servicewomen to relevant care services available through the VHA.
Musculoskeletal Training VA tracks prevalence of medical conditions among women Veterans and has noted that Musculoskeletal conditions such as back pain and joint pain are the most common conditions in women Veterans, often resulting in poor quality of life and chronic pain.

To address this problem, VA has developed a Musculoskeletal Training program to train providers in the physical exam and diagnosis of Musculoskeletal conditions common in women Veterans.
This training has been conducted at seven VA sites and will be conducted at the national simulation center in 2019.

An additional collaborative provider Musculoskeletal training with DoD was piloted in 2018 and will be repeated in Dayton, Ohio in 2019.

Conclusion VA continues to make significant strides in enhancing the language, practice, and culture of the Department to be more inclusive of women Veterans.
These gains would not have been possible without consistent Congressional commitment in the form of both attention and financial resources.

It is critical that we continue to move forward with the current momentum and preserve the gains made thus far.

Your continued support is essential to providing high-quality care for our Veterans and their families.

Madam Chairwoman, this concludes my testimony.

My colleague and I are prepared to answer any questions.

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