**VA Advisory Committee on Women Veterans Members Present:**

Marsha Four, USA, Chair COL Kathleen Morrissey, NJARNG, Retired, Vice
Chair

SFC Gwen Diehl, USA, Retired Cynthia Falzone, USA

COL Jacqueline Morgan, USAF, Retired Carlene Narcho, USA

CDR Joan O'Connor, USNR, Retired Lorna Papke-Dupouy, USMC

COL Shirley Ann Quarles, USAR CAPT Emily Sanford, USN, Retired

CMSgt Sara A. Sellers, USAF, Retired CMSgt Luc M. Shoals, ANG, Retired

**Advisory Committee Members Excused:**

Edward Hartman, USA Winsome E. Sears, USMC

**Ex-Officio Members Present:**

COL Denise Dailey, Military Director, Defense Advisory Committee on
Women in the Services (DACOWITS)

Lily Fetzer, Director, VA Regional Office, San Diego, CA

**Advisory Committee on Women Veterans Advisors Present:**

Carole Turner, Director, VA Women Veterans Health Program

CDR Lucienne D. Nelson, Senior Policy Advisor, Office of Public Health
and Science, USPHS

Lindee Lenox, Acting Director, Memorial Programs Service, National
Cemetery Administration

**Center for Women Veterans Staff Present:**

Dr. Irene Trowell-Harris, Director Betty Moseley Brown, Associate
Director

Desiree Long, Senior Program Analyst Rebecca Schiller, Program Analyst

**Also Present:**

Claudia Dewane, Deputy Field Director, VHA

The entire site visit package, with attachments, is located in a binder
in the Center for Women Veterans.

\*Questions and answers relative to each presentation can be found in
Addendum 1

**Monday, June 20, 2005**

**Kenneth H. Mizrach, Director, VANJHCS** *(Attachment #1)*

-   Two VHA facilities

    -   East Orange

    -   Lyons

-   Comprehensive health care provided through:

+-------------------------+--------------------+----------------------+
| -   Primary Care        | -   Tertiary Care  | -   Long-Term Care   |
+-------------------------+--------------------+----------------------+
| -   Surgery             | -   Psychiatry     | -   Neurology        |
+-------------------------+--------------------+----------------------+
| -   Oncology            | -   Dentistry      | -   Geriatrics       |
+-------------------------+--------------------+----------------------+
| -   Physical Medicine   |                    |                      |
|     and Rehabilitation  |                    |                      |
+-------------------------+--------------------+----------------------+

-   Affiliations

    -   University of Medicine and Dentistry of New Jersey

    -   New Jersey Dental School

    -   Robert Wood Johnson Medical School

    -   Trenton State Psychiatric Hospital

-   Unique women enrolled in VANJ -- 1,392 (FY04)

-   Enrolled in East Orange Gynecology Care -- 343 (FY04)

-   Enrolled in Lyons Gynecology Care -- 100 (FY04)

-   Enrolled in Primary Care -- 1,135 (FY04)

-   Breakdown of clinical/support staff:

    -   5 Medical Doctors (2 Obstetrics/Gynecology Care)

    -   2 Family Practitioners

    -   1 Women's Urologist

    -   1 Nurse Practitioner

    -   1 RN per clinic at East Orange, Lyons and Community Based
        Outpatient Clinics (CBOCs)

    -   1 Practice Manager per Gynecology Care Clinic

    -   1 Mammogram Coordinator

**James J. Farsetta, FACHE, Director, VISN 3** *(Attachment #2)*

-   Would like to find a way to streamline families into VA similar to
    Tri-Care

-   Homeless women veterans with children pose a problem

    -   Assistance with access to community services is provided

-   Some deficiencies in mammography Performance Measures have been
    recognized and corrective actions put into place

-   Looking at how to improve services to women veterans

-   Women veteran numbers are increasing

-   Need to identify weaknesses and strengths

**Irene Trowell-Harris, R.N., Ed.D, Director, Center for Women
Veterans**

-   Overview of the Center *(Attachment #3)*

**Marsha Four, RN, Chair, Advisory Committee on Women Veterans**

-   Overview of the Advisory Committee on Women Veterans *(Attachment
    #4)*

**Briefings from VISN 3 Leadership**

-   **Judith Feldman, M.D., M.P.H., Chief Medical Officer**

    -   Increasing number of women veterans

    -   Mammography measure was a problem because of lack of sensitivity

    -   Reconfigured Women's Health Care Council

        -   Added additional member, staff and patients, to the council

        -   Multi-disciplinary

        -   Established Women's Care Council

    -   Difficulty in accessing Mental Health care

        -   Problems with women veterans coming in because they wanted a

> safer, more secure environment

-   Very active with Advanced Clinic Access

    -   Virtually eliminated wait times

-   Using Military Sexual Trauma (MST) screen to get women into Primary
    Care system

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-   **James Smith, Ph.D., VISN 3 Quality Management Officer**
    *(Attachment #5)*

    -   VISN 03 Data

        -   Breast cancer screening measure at 68%

        -   Cervical cancer screening measure at 75%

        -   Overall satisfaction measure at 81%

        -   Outpatient satisfaction measure at 96%

        -   Appointment time satisfaction measure at 100%

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-   **Sarah Garrison, M.D., M.P.H., Chair, VISN 3 Women Veterans Health
    Council** *(Attachment #6)*

    -   Looking at how to effectively and efficiently provide services

    -   Ensure high quality healthcare

    -   Ensure accessibility and timeliness of care

    -   Safe environment for care

    -   Need to prepare for increase in women veterans

    -   Panel Management concept

        -   Identify women veterans under care

        -   Ensure women veterans are receiving appropriate
            comprehensive care

    -   Identification of vulnerable populations

    -   30% of total women veterans in system are seen in Mental Health

-   **Mara Kushner, VISN 3 Mental Health Care Line Business
    Manager***(Attachment #7)*

    -   Mental Health Executive Board

        -   Mental Health clinicians from all sites in the VISN

        -   Establish guidelines for more consolidated and uniform
            services

    -   Programs for Women Veterans:

        -   Military Sexual Trauma Initiative

            -   Need for similar tracking codes for Military Sexual
                Trauma throughout the country

            -   MST clinical reminder is set for once in a lifetime if a
                response has been satisfied when asked. This is just not
                enough.

            -   Development of software to track MST

            -   Total screened positive -- 2,448; 989 women veterans

            -   Provide education to Primary Care Providers

            -   Awareness Posters

            -   Ongoing communications between VISN MST Coordinators

        -   Homeless Veterans Initiative

            -   Project TORCH (The Outreach and Rehabilitation Center
                for Homeless Veterans) -- New York Harbor Health Care
                System (NYHHCS)

                -   Pilot site for homeless women veterans

                -   Expedited crisis intervention

            -   Beacon House -- Northport VAMC

                -   Homeless Grant and Per Diem Provider

                -   Transitional residence for homeless women veterans

            -   Bridget House -- New Jersey Health Care System (NJHCS)

                -   Homeless Grant and Per Diem Provider

                -   Transitional residence

        -   Incarcerated Veterans Initiative

            -   Multi-agency partnership to create fresh start

            -   Optimize chances for successful community reintegration

            -   Improve access to range of VA services and benefits

            -   Decrease criminal behavior and recidivism

            -   Women are not routinely asked by prison system if they
                are veterans

        -   Women's Health/Mental Health Peer Support Initiative

            -   Improve health care outcomes for women veterans with
                mental illness

            -   Reduce isolation

            -   Improve satisfaction

            -   Increase adherence to health care regimen

            -   Expand NJHCS Mental Health Per Specialist Program

            -   Target outreach to educate and train Peer Specialists

            -   Develop collaboration between mental health and women's
                health

            -   Partner with mental Illness Research, Education and
                Clinical Center (MIRECC) to develop outcome measurement

            -   4,931 total users

            -   29% had history of mental health services; 37% had no
                contact with Primary Care; 19% had not contact with
                Women's Health Clinic

            -   Increase gender specific Post Traumatic Stress Disorder
                (PTSD) services

**VISN 3 Women Veterans Program Managers**

-   **East Orange/Lyons (VANJHCS)(Michelle Stefanelli)** *(Attachment
    #8)*

    -   1,400 total unique women patients (FY04)

    -   3,500 total out-patient visits (FY04)

    -   450 total enrolled in WHC

    -   129 inpatient visits (FY04)

    -   5% of total women veterans in NJ enrolled

    -   22 Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF)
        women veterans

    -   Women's Clinic

        -   Meets once a week

        -   5 part-time clinicians

            -   2 Obstetrics/Gynecology Care

            -   2 Family practitioners

            -   1 Nurse practitioner

        -   All mammograms are fee-basis as of July 1, 2001

        -   Gender-specific services

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```
-   **Castle Point/Montrose (VA Hudson Valley)(Renate Moson)**
    *Attachment #9)*

    -   Serves 7 New York State counties and parts of Pennsylvania

    -   150,000 veterans; Serving 830 women

    -   Women Veterans Advisory Committee:

        -   Two (2) employee women veterans; One (1) consumer woman
            veteran

    -   Women's Health Clinic

        -   Full day at Castle Rock; Half day at Montrose

        -   Services provided by female internist and female nurse

        -   Gender-specific Care

            -   Osteoporosis, Cervical and Breast Cancer screening

                -   Breast and Osteoporosis done by contract or fee
                    basis

            -   Patient education

            -   Gynecology specialty referral to Bronx/Albany VA

            -   Infertility Evaluation and treatment at Bronx/Albany VA
                and fee-basis

            -   Obstetric/maternity care is fee-basis

    -   Military Sexual Trauma/Sexual Trauma (MST/ST)

        -   Treatment offered at both campuses

        -   Weekly MST/ST group with female psychologist

        -   Individual MST/ST therapy

        -   Referrals to Bay Pines

    -   PTSD Treatment

        -   Residential and outpatient service at Montrose

        -   Bi-monthly Women's Mental Health Clinic at Montrose

    -   Substance Abuse Treatment Program (SATP)

        -   Residential and outpatients

    -   Dom care for Homeless Veterans Program

        -   Dom with 60 beds total

        -   Vocational Rehabilitation

        -   Health Care for Homeless Veterans

    -   Behavioral Health

        -   Acute and long-term inpatient

        -   Community Residential Care Program

        -   Mental Health Intensive Case Management Program (MHICM)

        -   Community Supportive Housing Program

        -   Community Senior Support Services Program

    -   Private or semi-private rooms with attached bathroom

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```
-   **Manhattan (VA New York Harbor HCS)(Karen Faber)** *(Attachment
    #10)*

    -   1,041 visits in FY04; 35% increase

    -   Health care Services

        -   Primary Care in mixed gender environment

        -   Gynecology

            -   Separate waiting area and dedicated exam rooms

        -   Mental Health

        -   Mammography fee-basis to Brooklyn campus. Shuttle provided

        -   Bone Density

        -   Specialty Services

    -   Gynecology Oncology fee-basis to NYU

    -   Obstetrics fee-basis and community care

    -   On-site breast surgery

    -   On-site MST treatment with referral if necessary

    -   Environment of care

        -   Private rooms and bathroom facilities

        -   Privacy curtains in all inpatient rooms and outpatient exam
            rooms

    -   Women Veterans Advisory Committee

        -   Combined with New York, Brooklyn and St. Albans

        -   Three (3) veteran consumers who are not employees

        -   Co-chaired by Women Veterans Program Managers

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```
-   **Brooklyn (VA New York Harbor HCS)(Kathleen Mertz)** *(Attachment
    #10)*

    -   2,010 visits in FY04

    -   Health care services

        -   Primary Care

        -   Gynecology Care

        -   Bone Density

        -   Mammography

        -   Mental health services including MST screening and treatment

        -   Specialty services

    -   Obstetrics and gynecology surgery and oncology fee-basis

    -   Infertility treatment fee-basis

    -   Weight management on-site

    -   Environment of care

        -   Dedicated suite with separate waiting area

        -   Mammography 2 days per week

        -   Primary Care 5 days per week

        -   Gynecology 4 days per week

        -   Psychology 3 days per week

    -   Women Veterans Advisory Council

        -   Combined with New York, Brooklyn and St. Albans

        -   Breast Cancer Awareness activities

        -   Cancer Survivor's Day

        -   Yearly events sponsored by Vietnam Veterans of America

-   **Bronx (Blanca Faber)** *(Attachment #11)*

    -   Tertiary care facility

    -   311 hospital beds; 112 extended care beds

    -   4 Community Based Outpatient Clinics (CBOC's)

    -   802 unique women veterans seen in FY04

    -   56% were post Vietnam to Persian Gulf

    -   Health care services

        -   Primary Care

        -   Gynecology Care

        -   Preventive screenings

            -   Breast Cancer

            -   Cervical Cancer

            -   Osteoporosis

            -   Colorectal cancer

            -   Cholesterol

            -   High blood pressure

        -   Patient health education

            -   Annual physical

            -   Breast self-exams

            -   Smoking cessation

            -   Nutrition

            -   Family planning

            -   Menopause

            -   Osteoporosis

            -   Sexual transmitted diseases

    -   Mammography is fee-basis

    -   Mental health services in mixed gender setting

    -   Women's Health Practice

    -   Gynecology Clinic and surgeries

    -   Women Veterans Health Committee does have non-employee female
        veteran

    -   Environment of care

        -   Shared suite with family practice

        -   Women's Health exam rooms are exclusive to women

        -   Outpatient exam rooms and inpatient rooms have privacy
            curtains

        -   Access to private bathroom

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```
-   **Northport (Cheryl Hansen)** *(Attachment #12)*

    -   Total unique women veterans -- FY04 -- 890

    -   Gynecology

    -   Women's Primary Care

        -   Open daily

        -   Community Center

        -   Private exam rooms with bathrooms

        -   On site counseling and crisis management

        -   Stress management for patients and staff

    -   Women's Wellness Center

    -   Mammography Task Force

    -   Military Sexual Trauma

        -   MST Screening Software is up and running

        -   Over 35,000 veterans screened

        -   Over 300 women screened positive

    -   Homeless Women Veterans

        -   Beacon Houses

        -   Amazing Houses

        -   Interfaith nutrition

        -   Suffolk County Department of Social Services

        -   Salvation Army Northport Residence

        -   Long Island Consortium for the Homeless

    -   Planning

        -   Improve Performance Measures for cervical and breast cancer
            screening

        -   Decrease the no-shows for mammograms

        -   Better utilize community resources

        -   Research on exploring the outcome of sexual trauma on the
            lives of affected veterans

**Tuesday, June 21**

**Tour East Orange Campus**

-   Ambulatory Care Area

-   Women's Health Clinic

-   Inpatient Areas (including Mental Health)

-   War-Related Illness and Injury Study Center

**Urology (Patricia Gilhooly, M.D., Women's Health Services)**
*(Attachment #13)*

-   Urologic Problems

    -   Overactive Bladder

        -   Urinary frequency and urgency

        -   Urgency incontinence

        -   Prevalence unknown

        -   Dietary factors

    -   Neurogenic Bladder

    -   Urinary Incontinence

        -   Stress (leakage with increase in abdominal pressure)

        -   Urge (need to rush to the bathroom)

        -   Mixed (combination of stress and urge)

        -   Overflow (failure to empty bladder)

        -   Insensate (decreased awareness of leakage)

        -   Jeopardizes dignity

    -   Hematuria

    -   Recurrent Urinary Tract Infections

    -   Prolapse

-   Research

    -   Chronic fatigue and sexual dysfunction in female Gulf War
        veterans

    -   Psychotropic medication and urinary incontinence

    -   Open-label study of the efficacy and safety of certain
        medications in patients with overactive bladder symptoms

    -   Need to widen the medications available on the formulary

**Contraception Management (Carol Stickel, N.P., Women's Health
Services)** *(Attachment #14)*

-   Gynecology Care Clinic Provides

+----------------------------------------+-----------------------------+
| -   Counseling on natural family       | -   Male condoms            |
|     planning                           |                             |
+----------------------------------------+-----------------------------+
| -   Vaginal diaphragm                  | -   Spermicidal             |
|                                        |     preparations            |
+----------------------------------------+-----------------------------+
| -   Oral hormonal                      | -   Hormonal injection      |
+----------------------------------------+-----------------------------+
| -   Transdermal                        | -   Hysterectomy            |
+----------------------------------------+-----------------------------+
| -   Intrauterine contraceptive device  | -   Tubal ligation and      |
|                                        |     vasectomy               |
+----------------------------------------+-----------------------------+

-   Maternity care is fee-basis

**War-Related Illness and Injury Study Center (WRIISC) Gudrun Lange,
Ph.D., Acting Director, WRIISC** *(Attachment #15)*

-   Two (2) congressionally mandated WRIISCs

    -   New Jersey and Washington, DC

    -   Created in response to the needs of deployed Gulf War veterans
        with difficult to diagnose illnesses

-   Mission

    -   Provide clinical services to veterans with deployment-related
        health concerns and illnesses to improve their health-related
        quality of life

    -   Advance knowledge of ways to care for veterans with medically-
        unexplained symptoms to improve their health-related quality of
        life

    -   Advance knowledge of and improving communication among veterans,
        the

> health care community and researches regarding deployment-related
> health
>
> concerns and illnesses

-   Advance knowledge of medically-unexplained symptoms in veteran and
    other populations

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```
-   Medically-unexplained symptoms

    -   Chronic fatigue syndrome

    -   Fibromyalgia

    -   Irritable bowel syndrome

    -   Multiple chemical sensitivities

-   10 female Gulf War veterans (16%) evaluated to date (74 total
    veterans)

-   Add focus on new population of veterans

-   8 female OEF/OIF veterans (28%) evaluated to date (37 total
    veterans)

-   Research related to Women's Health

    -   Early environmental determinants of vulnerability to
        pyridostigmine bromide (Shelley Weaver, PhD)

        -   Determine how stress in mothers can be a source of
            individual differences in vulnerability to chemical
            exposures during deployment

    -   Chronic physical and mental illness care in women veterans (Usha
        Sambamoorthi, PhD; Patricia Findley, DrPh, MSW, LCSW)

        -   Document care patterns of veteran women with co morbid
            cardiovascular conditions and major depression using
            longitudinal data for the years between 1999 and 2005.

    -   Reintegration: a group intervention for deployed mothers (Gudrun
        Lange, PhD and Karen Quigley, PhD)

        -   Improved readjustment of OEF/OIF women veterans, who are
            mothers of dependent children, into civilian life through
            focused reintegration training.

**Newark VA Regional Office, John McCourt, Director** *(Attachment #16)*

-   13^th^ in the Nation in veteran population (592,307)

-   20^th^ in the Nation in women veteran population (30,486)

-   **Sharon E. Brown, Women Veterans Coordinator** *(Attachment #17)*

    -   Assists with claims

    -   Follow up on claims

    -   Notification of decision (positive or negative)

    -   Explain Appeals Process

    -   Outreach letter

    -   Personal interaction

    -   Networking

    -   More shelters needed for women veterans

    -   Assigned to VAMC Women Veterans Advisory Council at East Orange

**Newark Vet Center, Ann Talmage, Team Leader** *(Attachment #18)*

-   PTSD (three groups, including two during evening hours)

-   Women veterans

-   Substance abuse

-   Medical Hold/Charlie Company

-   Prior time limited groups

+-----------------------------------+-----------------------------------+
| -   Women Vietnam veterans        | -   Stress management             |
+-----------------------------------+-----------------------------------+
| -   Art therapy                   | -   Gold Star Mothers             |
+-----------------------------------+-----------------------------------+
| -   Anger management              | -   Field trips to The Wall       |
+-----------------------------------+-----------------------------------+
| -   WW II Group                   | -   Field trips to WW II memorial |
+-----------------------------------+-----------------------------------+
| -   Music therapy                 | -   "Lifers" prison group         |
+-----------------------------------+-----------------------------------+
| -   Substance abuse recovery      | -   September 11 discussion group |
+-----------------------------------+-----------------------------------+

-   Presentations to returning troops on a daily basis

-   Referrals of thousands to local Vet Centers and other VA facilities

-   Family Readiness Group

-   On-site counseling services

-   Liaison with VA health care/benefits, community agencies

-   **Jane Harris, Ph.D., Sexual Trauma Counselor** *(Attachment #19)*

    -   Military Sexual Trauma Program

        -   Outreach

        -   Counselor training and continuing education

        -   Evolution of treatment approaches

            -   Mind-body connection

                -   Eye Movement Desensitization and Reprocessing (EMDR)

                -   Sensory Experiencing

            -   Groups

                -   Evolving membership

                -   Evolving context and content

**Wednesday, June 22**

**Prosthetics, Richard Clark, VANJHCS Chief, Prosthetics** *(Attachment
#20)*

-   Fully Integrated Service

    -   8 purchasing agents

    -   16 Orthotist/Prosthetists

    -   Computer Aided Design and Computer Aided Manufacturing (CADCAM)
        system

    -   Consolidated Home Oxygen Program

        -   1,000 patients

    -   \$33,687,728 annual budget

-   Major Programs

    -   Artificial limbs/terminal devices

    -   Manual wheelchairs

    -   Power wheelchairs

    -   Home Oxygen

    -   Denver Distribution Center (DDC) items

    -   Surgical implants

    -   Dental implants

    -   Eyeglasses

**Quality Management, Linda Mowad, R.N., Ph.D., Quality Manager**
*(Attachment #21)*

-   Scope of activities

    -   Performance/Quality Improvement

    -   Accreditation Readiness

    -   Utilization Management

    -   Patient safety

        -   Root Cause Analysis (RCA)

        -   18 last year

        -   Failure Mode and Effect Analysis (FMEA)

        -   Patient Safety Reporting System (PSRS)

    -   Risk Management

        -   1100 incidents annually

        -   Increasing number of Tort Claims

        -   6 Boards of Investigation last year

    -   Credentialing and privileging

    -   Policy management

    -   Research compliance

    -   Works closely with Compliance

**Women's Advisory Committee, Dr. Beryl E. West, MD, Chief Ambulatory
Care/Clinical Advisor Women's Health Program** *(Attachment #22)*

*\*no other presentation was given by the VAMC East Orange Women's
Advisory Committee*

-   Mammograms fee based out to three (3) local accredited Mammogram
    Centers

    -   Changing technology

    -   Budgetary constraints

    -   Antiquated equipment

-   Process developed and followed with a number of problems

    -   Timeliness of care

    -   Poor tracking

    -   Performance scores fell to all time low

-   Action taken

    -   Mammogram Coordinator assigned primary duties

    -   Mandated all patients would have authorization and orders prior
        to leaving

-   Results

    -   100% retrieval rate

    -   Closing the loop on process

    -   Track and follow up abnormal results more efficiently

    -   Track no-shows

**New Jersey Department of Military and Veterans Affairs and New Jersey
Veterans Memorial Homes, Colonel Stephen G. Abel, USA, Retired, Deputy
Commissioner of Veterans Affairs** *(Attachment #23)*

-   23,000 women veterans

-   869 total NJ Army National Guard

-   400 total NJ Air National Guard

-   Three state veterans nursing homes

    -   Vineland

        -   218 total -- 9 women

    -   Menlo Park

        -   312 total -- 14 women

    -   Paramus

        -   290 total -- 5 women

**Questions to Dr. Feldman and Mr. Farsetta regarding Panel Management
can be found in Addendum 1**

**National Cemetery Administration (NCA), Kimberly Wright, Director,
Memorial Service Network 1** *(Attachment #24)*

-   Honors veterans with a final resting place and lasting memorials
    that commemorate their service to our Nation

-   Mission driven, results oriented, customer focused

-   120 cemeteries

-   1,492 Full time employees

-   \$313 Million for total programs

-   Five Memorial Service Networks

    -   Philadelphia, PA

    -   Atlanta, GA

    -   Denver, CO

    -   Indianapolis, IN

    -   Oakland, CA

-   Provide burial space for veterans and maintain cemeteries as
    National shrines

-   Administer the Federal grants program for construction of state
    veterans cemeteries

-   Administer the Presidential Memorial Certificate Program

-   Encourage states to build veterans cemeteries

**New York National Cemetery Complex, Nadine Bruh-Schiffer, Deputy
Director** *(Attachment #25)*

-   Comprised of Calverton, Long Island and Cypress Hills National
    Cemeteries

-   Largest and most complex cemetery system within NCA

-   Two new initiatives

    -   Referral to Vet Centers for Bereavement Counseling

    -   Customer Service Standard Operating Procedures (SOP)

**Research, Richard Wedeen, M.D., ACOS for Research**

-   \$4.3M from VA/same from outside funding sources

-   63 investigators

-   Diabetes research

-   **Shelly Weaver, Ph.D., Researcher** *(Attachment #26)*

    -   Our environments have everlasting effect on children

    -   Effects of stress may be passed on through epigenetic events
        causing chemical change in Deoxyribonucleic Acid (DNA), turning
        off the stress responders in the brain

        -   Results in long-lasting anxiety in children

    -   Recent studies

        -   Internet Disclosure Treatment for Multi-symptom Illness,
            Helena Chandler, PhD

        -   Functional Imaging of Pain in Veterans with Unexplained
            Muscle Pain, Dane Cook, PhD

        -   Pain Sensitivity in Gulf Veterans with Medically Unexplained
            Musculoskeletal Pain, Dane Cook, PhD

        -   Provider Effect on Outpatient Utilization in Veterans with
            Symptoms, Drew Helmer, MD, MS

        -   Ambulatory Care Pilot Project, Drew Helmer, MD, MS

        -   Pituitary-Adrenal Function in People with Fatiguing Illness,
            Benjamin Natelson, MD

        -   Prospective Study of Functional Status in Veterans at Risk
            for Unexplained Illness, Karen Quigley, PhD

        -   Risk Perception and the Psychobiological Sequelae of
            Vaccination, Karen Quigley, PhD

**Thursday, June 23**

**Tour Lyons Campus:**

-   Ambulatory Care

-   Women's Health Clinic

-   Nursing Home Care Unit

-   Mental Health and Behavioral Sciences Area

**Radiology, Jyoti Shah, M.D., Chief, Radiology Service** *(Attachment
#27)*

-   Heart disease -- largest killer and disabler of American women

    -   More abdominal symptoms

    -   Less survival that male counterparts

    -   Females reaction during heart attack totally different than that
        of males

    -   Double stress -- work and home

    -   Risk behaviors

        -   Smoking

        -   Drinking

        -   Diabetes

        -   Hypertension

    -   Estrogen and Tomoxiphen therapy

**Geriatrics, Samer Nasr, M.D., ACOS for Extended Care** *(Attachment
#28)*

-   Geriatric and Extended Care Programs

    -   Nursing Home

        -   270 beds

        -   Long term care

            -   Priority for those with service connected disability

            -   Female veterans on 1B for security reasons

        -   Rehabilitation

            -   Evaluation, management and rehabilitation

            -   Comprehensive integrated inpatient rehab program

        -   Healthy aging and recovery care program

            -   Veterans with psychiatric diagnosis and/or cognitive
                compromise, i.e., dementia and Alzheimer's

        -   Secure unit

            -   Those who need a secure and protected environment

        -   Palliative care program

            -   Comfort care and symptom management for life-ending
                diseases

        -   Respite

    -   Home Based Primary Care

        -   Medical professionals visit homes of veterans who cannot
            easily come to VANJ facilities

    -   Care Coordination/Home Telehealth

        -   Monitors vital signs at home and sends information to nurse

        -   Video phones

        -   Decrease patient visits to Emergency Room and acute hospital
            admissions

        -   151 patients on Home Telehealth by end of FY05

    -   Palliative Care

        -   Enhance quality of life

        -   Decrease deaths in ICU

        -   Increase comfort and symptom management

    -   Community Care

        -   Contracts for services in community to supplement continuum
            of care

            -   Nursing Home Services

            -   Adult Day Healthcare

            -   Homemaker/Home Health Aides

            -   Home Hospice

    -   State Veterans Home

        -   Monitor quality of care through annual inspections

        -   Monitor patient safety events

        -   Provision of patient safety tools and training

**OEF/OIF Returning Veterans, Michelle Stefanelli, MBA, MSW, LCSW, Iraqi
Freedom Coordinator** *(Attachment #29)*

-   520 enrolled in VA New Jersey Health Care System

-   Coordinate in identifying those returning from combat

-   Provide those needing VA benefits with VA services

-   Assure the needs are met

-   Reduce "red tape"

-   Streamline health care services and VA benefits

-   Coordinate services

-   Staff education

**Mental Health and Behavioral Sciences, Miklos Losonczy, M.D., ACOS for
Mental Health and Behavioral Sciences** *(Attachment #30)*

-   Over 9,000 veterans treated annually for mental health care needs

-   400 women veterans use mental health (MH) services

-   39% of mental health users are service connected for mental health
    problems

-   Over 90% are Priority 1-6

-   Of women service connect for psychosis, 50% use VA services in VISN3

-   Of women service connected for PTSD, 68% use VA services

-   Patient Based Program for the Veteran with Serious Mental Illness

    -   Serious and persistent mental disorder of at least 12 month' s
        duration

-   Geriatric Psychiatry Patient Based Program

    -   Aging veterans with major recurrent depression, significant
        dementia, concurrent psychiatric disorder

-   Support for the Medically Ill Veteran Patient Based Program

    -   Mental health care to veterans with primary medical care needs

-   General Psychiatry Patient Based Program

    -   Interdisciplinary treatment team providing medical support and
        sub-specialties

-   Veteran Advisory Council for Mental Health

-   Veteran Advisory Council for VISN 3

-   Research and Grants

    -   New Jersey Co-Occurring Disorder Study

-   **John Kuhn, M.S.W., Coordinator for Homeless Services**

    -   Help veterans discover purpose, a sense of community and a
        connection to higher power

    -   Provide housing and skills training with job placement

-   **Ronald Fudge, Ph.D., Chief, Substance Abuse Treatment Program**

    -   Incorporate recent advances in the areas of assessment,
        motivational

enhancement, treatment planning, and relapse prevention

-   **Risa Goldstein, Ph.D., Coordinator, Post-Traumatic Stress Disorder
    Program**

    -   Provides assessment and treatment to improve symptom management

**Friday, June 24**

**Open Forum with Women Veterans Community (Town Hall Meeting)**

**(VA Staff and Advisory Committee responses are indicated in
*italics*)**

-   Women being charged a \$50 co-pay and told it is a "facility fee"

-   Billing issues relative to fee-basis care

-   Training needed in Fiscal Department on billing and documentation

    -   *All facilities providing care have been instructed to bill the
        VA direct, not the veteran*

    -   *All individuals with billing questions or problems were
        directed to bring their bills to the Fiscal Department and they
        will be addressed one on one*

-   Insensitivity of some of the doctors

    -   *Sensitivity training is on-going*

    -   *Provider education at all levels is taking place*

    -   *Identifying those who are more sensitive*

-   Transportation continues to be an issue

-   Lack of "halfway" housing for women

    -   *VA has 11 Pilot Programs*

    -   *Recent VA Homeless Grant and Per Diem grants have addressed the
        need for special programs for women veterans*

-   Great care, open access to doctor, wonderful networking

-   Doctors at East Orange will not prescribe the same medications as
    Hackensack

-   Had to do without medications because the pharmacy "was out" and she
    would have to "do without"

    -   *Pharmacy problems should be brought to the attention of the
        Primary Care Provider*

-   Need better Agent Orange related training

-   Breaches in privacy, i.e., employees disclosing medical conditions

-   Mammography reports not being sent to the VA by the fee-basis
    provider

-   No camera or security in the tunnel system at Lyons

-   Insensitivity of police investigating reported incident

-   Need for MST center in the VISN for women

-   Every level must be held accountable

-   Women veterans being interviewed for C and P exams should be
    interviewed by women

-   Decisions made relative to pain level without history or profile of
    pain

-   Initially denied claim for sexual trauma; needs help in getting
    retro Service Connected dollars

-   Could not see pulmonary without a consult. Asked for that
    requirement in writing; hasn't gotten it yet

-   Appears that C and P examiners are not looking at active duty
    military records when claims are filed

    -   *Women Veterans Coordinator at Regional Office is always
        available to assist with claims related problems*

-   Only one (1) Service Officer at East Orange; he's never around

    -   *If individuals are not satisfied with the assistance they are
        receiving from their Service Officer, they are able to revoke
        that Power of Attorney and seek assistance from a different
        Veteran Service Officer*

-   Hospitalized in the Manhattan VA in the 1960's. Records have
    disappeared

    -   *Records were not computerized and many have been lost*

**Exit Briefing with Key Leadership**

-   **Review of Committee process for site selection**

-   **Review of the Committee process of formulating its Exit Briefing**

    -   Daily committee discussions of the briefings and tours of the
        day

    -   Remarks serve as recognition of VISN4 and NJHCS strengths and as
        a resource for consideration

-   **Outreach**

    -   **Strengths**

        -   Recognition of need from VHA, VBA, Vet Center

        -   Investment in this arena

    -   **Considerations**

        -   Greater investment in One VA Team Approach

        -   Inclusion of New Jersey Department of Veterans Affairs

        -   Enhance relationships and outreach coordination to
            constituents via NJ State House elected officials

-   **Women Veterans Program Managers**

    -   **Strengths**

        -   Recognize some of past issues

        -   Established women veterans council

        -   Realize that no-show rates are unacceptable

        -   WVPMs are dedicated to their mission

        -   Effective outreach materials, i.e. MST poster

        -   Visibility of WVPM by posting of picture throughout the
            healthcare system

        -   Management is making effort to develop role of WVPM based on
            published guidance

    -   **Considerations**

        -   Apply advanced clinic access to women's clinic to improve
            the waiting time

        -   Access to strategic planning and leadership

        -   Include WVPMs in leadership planning and decision making
            processes

        -   Assess time allocation and workload management of WVPM

        -   Consider separate WVPMs for each of the integrated
            facilities

        -   Concept of "panel management" should be thoroughly analyzed
            prior to implementation: seems to be an existing component
            of 1330.2

            -   Consider pilot program prior to full implementation

            -   Consider entire scope (1330.2) of WVPM role during
                implementing of concept

            -   WVPM need to be fully supported by the Director

            -   Written communication to all staff of role and authority
                of WVPM in panel management

            -   If panel management is other than a 1330.2 component:
                this is additional collateral duty

            -   Welcome up-date briefing in November 2005

        -   Ensure the use of DSS to capture entire workload that
            supports WVPMs functions

        -   Leadership to collaborate with VISN Health Council and Women
            Veterans Health Program Office to develop quantifiable
            performance measures for WVPM

        -   Refer to 1330.2 Attachment C for guidelines to the role and
            responsibility of VISN3 Lead WVPM

        -   Inclusion of VBA Women Veterans Coordinator on VHA Women
            Veterans Advisory Council

-   **Women Veterans Health Service**

    -   **Strengths**

        -   Customer service surveys indicate positive results as
            compared with male veterans

        -   Advance clinical access in primary care

        -   Recruiting campaign through OIF/OEF outreach efforts

        -   Acknowledge improvement in mammography tracking and new
            coordinator position

        -   Commend Urology Program for their identification of women's
            urological issues

        -   Commend Radiology Program for their identification of
            women's issues in heart disease

    -   **Considerations**

        -   Pap Smear co-payment disparities: evaluate system over-ride
            of co-pay

        -   Fragmented care and follow-up especially gender specific
            care

        -   Pap smears and mammography performance indicators are below
            threshold

        -   Add additional medications to Formulary for overactive
            bladder

        -   Transportation for mammography -- mobile mammography

        -   Link payments for maternity care to provider feedback

        -   Develop liaison with New Jersey Department of Military and
            Veterans Affairs for women veterans

        -   Concerns for remaining mammography machines at Brooklyn and
            Bronx

        -   Revise posters to include uniformed services and Reserve and
            Guards

        -   Make concerted effort in WRIISC to maximize women veterans
            recruitment

-   **Prosthetics**

    -   **Strengths**

        -   Prosthetic Department ensures adequate samples of women's
            eyeglasses and shoes

        -   Prosthetic uses CADCAM technology to improve prosthetic
            appliances

        -   Progressive in prosthetics approach

    -   **Consideration**

        -   Upgrade of equipment: CADCAM

-   **Regional Office**

    -   **Strengths**

        -   Reaching out by case managing personal trauma claims

        -   Women Veterans Coordinator

        -   Immediately added WVC to Committee

        -   Nice letter of outreach

        -   Created a culture to refer women to WVC

        -   Homeless Coordinator collaborates with community homeless
            providers

        -   OEF/OIF outreach at Ft. Dix

    -   **Considerations**

        -   Coordinated quarterly dial-up conference calls for all WVCs

        -   Improve outreach efforts and targeted outreach for women
            veterans

        -   Improve timeliness for claims

        -   Increase outreach to veterans utilizing a One VA Team
            approach

        -   Collaborate with VHA and Vet Center in women veterans
            outreach

-   **Vet Center**

    -   **Strengths**

        -   Bereavement Counseling

        -   Created pamphlets and handouts as mail outs for their
            facilities

        -   Success with men and women in groups -- very powerful

        -   Created nice environment although inner city

        -   Good job of veterans pictures throughout

        -   Evening meetings

        -   OEF/OIF - Outreach at Ft. Dix (going beyond)

    -   **Considerations**

        -   Opportunity to increase collaboration with medical centers
            and regional office

        -   Signage outside

        -   Revise posters to include uniformed services and Reserve and
            Guard

-   **Quality Management**

    -   **Strengths**

        -   Impressed with comprehensive monitoring program

        -   Recognized problem with MST program

    -   **Considerations**

        -   Work with Office of Quality and Performance for ability to
            aggregate data by gender by VISN and medical center level

        -   Ongoing provider training for MST instead of relying on
            clinical reminder

        -   Utilize aggressive partnership between Primary Care and
            Mental Health

-   **Environment of Care**

    -   **Strengths**

        -   WVPM was readily identified

        -   East Orange -- committed staff, clean setting

        -   Credit to Mental Health leadership evolution and deep
            commitment to the cause of Mental Health

        -   Glass doors creating private space for the women's health
            clinic

        -   Lyons -- excellent, committed staff

        -   Credit to mental health leadership evolution and deep-seated
            commitment to the cause of mental health

        -   Patients up and moving, engaged in activities

        -   "Edenizing" -- utilizing natural products on the grounds

        -   Staff sensitivity added to positive environment

        -   Caring, nurturing staff

        -   Private space for women

        -   Lyons -- PTSD unit -- progressive thinking and planning
            ahead for an MST unit

    -   **Considerations**

        -   Continue oversight of exam table placement in all areas
            where gynecological exams are given

        -   Lyons -- consider more veteran memorabilia and pictures with
            inclusion of women veterans especially in areas where women
            are treated

        -   Lyons - excellent programs such as MAVERIC, horticulture

        -   Women's personal care items in canteen

        -   East Orange -- no identified private space for women in
            primary care

        -   East Orange -- 6 examining rooms and 1 bathroom: consider
            the addition of a bathroom in procedure room

-   **Homeless**

    -   **Strengths**

        -   Women's transitional housing in Middlesex County

        -   Videos are powerful tools

        -   Concept of peer support programs

        -   Proactive in approach to secure HUD grants

        -   Development of formerly homeless veterans businesses

    -   **Consideration**

        -   Empower WVPM to partner with community agencies

-   **National Cemetery Administration**

    -   **Strengths**

        -   Referral to vet centers for bereavement counseling

        -   Provision of claims forms in packets to families of those
            being buried in national cemeteries

        -   Innovative programs such as gravesite locator

    -   **Consideration**

        -   One VA Team approach to outreach

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