**Transcript of Cyberseminar**

**Spotlight on Women’s Health**

**Women’s Assessment Tool for Comprehensive Health: The WATCH Self- Assessment National Roll-Up**

**Presenter: Sally Haskell, MD**

**May 16, 2013**

**Women’s Assessment Tool for Comprehensive Health: The WATCH Self- Assessment National Roll-Up**

**May 16, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact: sally.haskell@va.gov*

Dr. Haskell:So hello everybody. It is a pleasure to be here to tell you a little bit about our WATCH assessment tool for comprehensive health. So what I am going to do today is talk to you a little bit about why we do the WATCH, what is the challenge, a little bit about the state of women’s Veteran’s healthcare and then our WATCH initiative methods and results and basically what are some of the limitations and the conclusions. So wanted to start off with a poll question just so that I can get a little bit of an idea who is in the audience. So I would like to know what is your primary role in the VA? 

Moderator:Thank you. Attendees, please just click the square next to the answer that best is your – that best describes your primary role in the VA. Great we have had eighty percent of our audience vote. So I will close it and share those results. Sally, you should be able to see them if you want to talk through it real quick. 

Dr. Haskell:[crosstalk] It looks like we have got six percent students, twenty-two percent clinicians, thirty percent researchers, twenty percent women Veteran program managers and twenty-six percent other. So great. I will move on. So let me tell you a little bit about the overview of the challenge. We know that the number of women Veterans using Veteran VHA services has doubled in the past decade. We are actually expecting doubling again in another five years. So this has meant a real change in the needs of services that are provided throughout VA. So in 2008 the under secretary of health released a report that actually surveyed the current state of healthcare delivery to women Veterans. 

And what they found were gaps in the current healthcare delivery services to women, some of those gaps were specifically a lot of fragmentation of care particularly in primary care services. And one of their recommendations was actually to conduct site assessments to better understand the delivery of care to women Veterans. So since 2008 there has been a huge change in the care of women Veterans within VA. We have placed full time women Veteran program managers at every facility. We have implemented comprehensive primary care for women’s health by launching VHA handbook 1330.01 back in May of 2010. 

When we have had a campaign to really change the language, practice, and culture of VA so that we are more inclusive of women Veterans. But despite these changes we still find that gaps exist in some women’s health programs and that there is a continued need for assessment. So to try to better understand the state of women Veteran’s healthcare several years ago women’s health services actually worked with subject matter experts to create a tool to assess the development of women’s health programs. And this tool was actually created to be used during site visits. We have been working with a contractor for the last I guess three or four years now visiting sites. And I know a lot of you are familiar with these site visits. We visited, I think, nearly sixty VA sites and used this assessment tool that was created. And I will tell you a little bit more about that data towards the end of the talk. 

The women’s assessment tool for comprehensive health or the WATCH initiative self-assessment actually grew out of this assessment tool that was initially created for site visits. So what we did was we really expanded that tool so that it would provide quite a lot more data than what was originally designed for the site visits and then additionally a component of it is actually the tool that is still being used for the site visits. So the self-assessment is conducted by all women’s health programs and it provides all the facilities an opportunity to really focus on their women’s health programs and on the requirement for achieving comprehensive health. 

So the last initiative self-assessment has been administered as an online survey in fiscal years 2010, 2011, and 2012. And the survey has actually sort of changed and grown over the last three years. It is completed by the women’s Veteran program manager at the facility. And then it is reviewed by facility and VISN leadership before it is submitted. So I am going to tell you a little bit about the design of the survey. So it is a two part survey this year in FY12. Part A is at the healthcare system level so that the women Veteran program manager provides information about the entire healthcare system in part A including the demographics, the enrollment, and utilization data for women Veterans as well as the women Veteran program management staff and strategic planning efforts about the women Veteran program. 

And also in that part is the section that was originally designed as the site assessment tool and that is called the capability section. And then the second part is part B. And that is the site specific survey. And in that part we wanted the women Veteran program managers to answer questions about every single site of care so that those were for both the medical centers and the CBOC in their healthcare system. And they answered questions about the models of care delivery and about designated women’s health primary care providers. 

In terms of methods the women Veteran program managers completed self-assessments for a hundred and forty healthcare systems in both FY11 and 12. And we specifically defined a healthcare system as containing one parent site which was defined by what is call VAST, the Veterans affairs site tracking, and then all the sites that are affiliated with that parent. And there were in FY11 and FY12 the assessments included dropdown menus for the sites in each healthcare system. And in FY11 we included additional primary care sites that were not listed in VAST. In FY12 the analysis only included primary care sites that were found in the VAST list. 

The reason I am telling you this is because you will notice as we move forward that there are some differences in the numbers of sites between FY11 and FY12. That can affect the denominator on some of our measures so that becomes important later on. So again you will see fiscal year 2011 there were a hundred and fifty medical centers. Fiscal year 2012, a hundred and forty-eight. In terms of CBOC again, seven ninety-five to seven forty-three. And this year a total of eight hundred and ninety-one sites. This slide really is beginning to show you a little bit about what the WATCH survey looks like. This is the screen that the women Veteran program managers would see when they clicked on the link for the survey. I am just going to run quickly through some of these slides. 

This is just to give you an idea of what the survey entails. In this first part A, this was a healthcare system level so that they had to choose their healthcare system and then in – this is – and it is a sample of part B, again, where they would select their healthcare system. And this is asking them – saying that we would like to know about the models of care available at each site in your healthcare system. So they had to answer this for their main facility and for each of their CBOCs separately. And again, this is just showing how you would select your specific site and then you would select – within your healthcare system you would select your CBOC or your parent facility. 

And then you would indicate the models of care that were available to women Veterans within this particular site, model one, model two, model three. And you were asked to indicate all of the models of care in case you have more than one model. And this is just an example of some of the questions that we wanted to ask at the site specific level. So examples of asking about extended hours, asking about women’s health PACT teamlets. And whether this model – this particular clinic that you are talking about, this model one clinic, was in the Baltimore CBOC here, whether it provided comprehensive primary care. So we have this data then for every division, every site of care. 

But now I am going to go on and talk about some of our results. So this is enrollment. So in FY12 we had five hundred and eighty-three thousand five hundred and eighty unique women Veterans enrolled in VHA. And one thing that is interesting if you take a look at this, a lot of folks tend to often think that the bulk of our – the growth of our women Veteran patients has been in young Veterans. But you actually see that the oldest group of – or the largest group of enrollees is actually age forty-five to sixty-four year old women. And this is the same slide but this is actually showing those women Veterans who are receiving care in FY12. And so three hundred and sixty-two thousand, nine hundred and thirty-nine. Sixty-four thousand of those were OEF/OIF vets. And again you will see that the largest group is representing that forty-five to sixty-four year old age group. 

The next thing we did is we looked at stop codes. So as everybody, hopefully everybody knows, 323 is the stop code for primary care, 322 is the stop code for being seen in a comprehensive women’s primary care clinic. And we have stop codes for gynecology. And 704 is the stop code for a gender specific preventive care visit and that would be someone attending something like a PAP smear clinic which of course we are trying to phase out. So you will see we had most of our women being seen in primary care 323 or comprehensive women’s primary care clinics, 322. 

And so this is an interesting slide. So the stop code 323 as I was saying before is actually intended for comprehensive primary care that is being done in an integrated model one primary care clinic. So you can see that the reality is that if stop code 323 is actually being used in model one, two, and three clinics when if all was right in the world the stop code would only be used for model one clinics. Stop code 322 is actually indicated for comprehensive women’s clinics in model two and model three. So again you see that there is this variation. The stop codes are not always being used correctly. And 704 is gender specific preventive care should actually never be used for comprehensive primary care. So just some interesting data to show us that we have some work to do in straightening out the stop code issues. 

Next we looked at diagnoses. And I wanted to make sure that everyone is aware that this data is actually – this bases on individual ICD9 codes so that these are not groupings. These are just single codes. So hypertension most common ICD9 code followed by depression, PTSD, lumbago, diabetes. So and this follows the pattern you see in many other – follows the pattern of many other analyses where the most common diagnoses tend to be mental health, musculoskeletal, cardiovascular risk factors, hypertension, hyperlipidemia. So interesting data. And remember this is a national roll up here. 

Another thing that we focused on in women’s health is strategic planning. And the importance of this is that we are seeing this huge growth in the population of women Veterans doubling in the last ten years expecting it to double again in the next five years. And folks really need to have a strategic plan in place to understand how they are going to be able to provide the capacity to take care of these women Veterans that are coming in. so we wanted to know number one do sites have women Veteran health committees that can assist with strategic planning and do they actually have a strategic plan. And we are finding in FY12 that ninety-seven percent of a hundred and forty healthcare systems had a women Veteran health committee. But unfortunately only forty-six of all that, forty-six percent of all the healthcare systems had a written strategic plan. 

This graph at the bottom actually compares FY11 to FY12 and it is interesting on some – and this is the percent of the healthcare systems in a VISN. It is sort of interesting that – it makes sense that a certain percent would have had a strategic plan one year and then more had it the next year. What does not make sense is some of these sites where they had strategic plans and then they had less strategic plans the following year. That may be because people define the idea of having a strategic plan a little more stringently in FY12 as we started kind of focusing and talking a little more about strategic planning. So they may have thought they had one and then realized they really did not have one. So I will move on to the next slide. 

We wanted to know about key personnel of the women healthcare program. It is required that every healthcare system have a women Veteran program manager. So – and it is a full time position. It is required by policy to be a full time position. So a hundred and thirty-one healthcare systems had at least one full time women Veteran program manager. Four had one part time. four healthcare systems had their WVPM position filled in an acting capacity and one healthcare system did not have their WVPM position. Moving on to women’s health medical directors or champions this is the recommendation in policy 1330.01 that there should be a women’s health medical director or a women’s health clinical champion. So a hundred and twenty-six out of a hundred and forty healthcare systems did have a women’s health medical director or a women’s health champion. But fourteen still did not have either identified. 

The other thing that is required is a CBOC women’s health liaison. And we found that a hundred and twenty-two out of a hundred and thirty-nine healthcare systems had a women’s health liaison at each CBOC. This slide looks at the professional designation of the women Veteran program managers. You will see that the bulk of them are RNs and then MPs and social workers, a small percentage of PAs and I think there was one MD women Veteran program manager. And then the professional designations of the women’s health medical directors, they are mostly MDs. And then if we look at their clinical specialty majority are internal medicine, some family practice. And we do have a number of gynecologists who are actually serving as women’s health medical directors. 

So next I am going to talk about comprehensive primary care. So comprehensive primary care is really what we began to roll out in May of 2010 with policy 1330.01. And this means that you have provision of complete primary care, one primary care provider at one site. And that that primary care provider should fulfill all primary care needs including care for acute and chronic illness, gender specific primary care, preventive health services, and basic mental health services. What this was really all about was trying to decrease fragmentation of care so that women would not be having to go to one primary care provider for their general medical care and another provider for their gender specific care. So we are trying to get all of that care to be done by one provider in one visit. So one stop shopping for women’s health. 

So this slide looks at the percent of healthcare systems and VA sites that delivered comprehensive primary care in FY11 and FY12. So we are really excited about this slide. This is really showing us that at this point a hundred percent of all the healthcare systems are delivering comprehensive primary care. Now that does not mean that every single woman is getting comprehensive primary care. It just means that somewhere within their healthcare system they are delivering comprehensive primary care. If you look at all sites of care we are up around something like eighty-three, eighty-four percent of all sites of care delivering comprehensive primary care. So it has really been really great progress just within one year that we have seen this growth. 

And this is looking at the same data but just looking at it by VISN and the percent of sites in each VISN and you look across you see that most VISNs are really making substantial improvements between FY11 and FY12. This next slide looks at designated women’s health providers. So what is the definition of a designated women’s health provider? Designated women’s health provider is a primary care provider who is interested and proficient in women’s health, who is preferentially assigned women Veterans within their panel. And for those of you who are familiar with policy 1330.01 it says that a women’s health primary care provider’s panel should be comprised of at least ten percent female patients. But what we have learned, what we know, is that this is actually not possible in a lot of sites particularly in CBOCs because of the small numbers of female patients. And so if it is impossible at a site for a designated women’s health provider to have a panel of ten percent women then we expect an alternative plan to ensure proficiency. And those alternative plans can be things like attending a mini-residency, attending an equivalent training, that type of continuing medical education. 

So again this is another slide that is really exciting for us that a hundred percent of the healthcare systems now have at least one designated women’s health provider. Now we know that that is obviously not enough. But it is getting there. And again we have seen this really substantial growth in the number of sites overall that have a designated women’s health provider on-site. And this is the slide showing the percent of women who were assigned to a primary care panel in PCMM and are assigned to a designated women’s health primary care provider. So what you can see is that even though a hundred percent of healthcare systems have at least one designated women’s health provider and over eighty percent of all sites of care have at least one designated women’s health provider, only sixty-six percent of women overall are actually assigned to a designated women’s health provider. So that means that there are a lot of women out there who are not, who are still not assigned to designated women’s health providers. 

Next I am going to talk about models of care. So I was referring to models of care earlier and sort of realizing that maybe not everyone on the call understands what our – what the models of care are. So model one is what we consider a general primary care clinic or an integrated primary care clinic. So comprehensive women’s health primary care can be delivered by a designated women’s health primary care provider but that designated women’s health primary care provider can actually work in any of three different models of care. So as I said model one is an integrated general primary clinic where you have a designated women’s health provider who is one of the providers in that clinic. Model two is what we call a separate but shared space. That is the most confusing model. That is one that can either be a section of a primary care clinic that is sort of sectioned off as the women’s health part of the primary care clinic. Or it can be a space that is used by women’s health on some days and used by another type of specialty on other days. 

Model three is what we call a comprehensive women’s health center that is a separate women’s health center that has primary care but also has other services for women such as gynecology, mental health, and other additional services. So each VA medical center or CBOC might have one or more models of care. So an example is many facilities now actually have separate comprehensive women’s clinics. But usually not all of the women in that facility are assigned to the separate women’s clinic. And so you may have something like fifty percent of the women in a facility are assigned to the women’s clinic but the other women are disbursed in the general primary care clinic. So that would be an example of a facility that has a model one and a model three. 

So this is just showing you that in terms of sites that have model care one only, so there are forty-nine medical centers. And most of the CBOCs have model one only which means that they have integrated care for men and women. And there are eighteen sites that have model two only, twenty-six sites that have model three only. And you will see that some sites have model one and two and some sites have model one and model three. 

So this figure we thought sort of helps make a little more sense of what I was just showing in the previous slide. This is actually 2011 data. So remember I was telling you between 2011, 2012 we have different numbers of medical centers and CBOCs. But you will see in this so I think to me one of the things that I want to take away from this is well, how many model three clinics are there? So that means how many comprehensive women’s clinics are there? So in 2011 there were sixty-six in VA medical centers and there were nine are actually in CBOCs. And these are in some of the very large CBOCs. So then I will go to the same slide for 2012 and just the bottom line here, there are now sixty-five model three clinics in medical centers and fourteen. So we get asked this a lot, how many comprehensive women’s clinics are there? Last year there were – in FY11 there were seventy-five. Now there are seventy-nine. And it is not our focus that there should necessarily be a comprehensive women’s health but it is just something that there is always a lot of interest in. but we really believe that comprehensive women’s health can be provided in any of those three different models of care. 

So I am going to go now to talk about PACT. So women’s health PACT teamlet should include a designated women’s health primary care provider. So there has been a lot of confusion really about what is a women’s health PACT teamlet. And whenever there is a designated women’s health primary care provider her PACT teamlet should be a women’s health PACT teamlet. And it is recommended that that teamlet have a three to one staffing ratio. So what we found was that only sixty-six percent of the eight hundred and ninety-one sites delivering primary care had at least one women’s health PACT teamlet. So let us – what that is telling us is that there actually are a lot of sites of care that have what they consider to be a designated women’s health provider but for whatever reason her teamlet has not been designated as a women’s health teamlet. So that is an area where we see that we have a gap. 

And this is the percent of sites with at least one women’s health PACT teamlet by VISN. And you can see that in most cases – so this is showing FY11 and FY12, and we deidentified these VISNs, they are not in any particular order. But you can see that in most cases it is improving in terms of the percent of sites that have at least one women’s health PACT teamlet. And then this is the percent of designated women’s health providers who are assigned to a women’s health PACT teamlet in PCMM. So only seventy percent of those who are designated as women’s health primary care providers are actually assigned to a women’s health PACT teamlet in PCMM. 

Next we wanted to move on to look at PACT staffing. So the concern was – is are women’s health PACTs staffed at appropriate levels? Are they staffed at levels similar to primary care PACTS? And we also wanted to know whether that varied depending on the model of care. So there was some concern that possibly the comprehensive women’s clinics would not be adequately staffed. But interestingly what we are seeing here in this data is that the comprehensive women’s clinics are actually – seem to be more likely to have the PACT staffing of the three to one ratio than the model one and model two clinics. And so this first grouping here is just the overall three to one ratio. And then here we look at the number of PACTs that have an RN, the number of women’s health PACTs that have a clerk, and the number of women’s health PACTs that have an LPN or an LVN. 

We looked at extended hours. And remember this is FY12. When we do the WATCH survey next year I expect that we will see a huge change in this extended hours because now of course the extended hours memo has gone out and it is going to be required that sites provide extended hours that include primary care and women’s health. But you can see in FY12 a fairly low percentage of sites provided extending evening hours, morning hours, and Saturday hours. Looks like at least one had extended Sunday hours. 

Another thing we wanted to look at was women’s health specialty services. And we included mental health, specialty gynecology, social work, and pharmacy. And when we talk about specialty gynecology we want to make it clear that we are talking about referral to a gynecologist for something that is beyond a routine PAP smear that should be being done by a primary care provider, of course. So this talks about – the slide talks about co-location. So it is very important that mental health services are co-located for women Veterans. So we have found that over eighty percent of the time mental health services are co-located for women Veterans if they are in an integrated primary care clinic but for model two and model three women’s health clinics there is less integration of mental health services. We also consider this a gap in care. We would like to see a hundred percent of the comprehensive women’s clinics having mental health services co-located. 

Now for specialty gynecology eighty percent of the time the model three clinics have specialty gynecology co-located. Actually according to the definition of a model three clinics specialty gynecology should be co-located a hundred percent of the time. Social work services you can see here again more likely to be provided in an integrated clinic, less likely to be provided in a comprehensive women’s clinic. Similarly with pharmacy services. And this is showing the same data but looking at CBOCs. Sort of similar patterns, not entirely consistent with the previous slides. 

And then some comprehensive women’s centers model threes have additional co-located services. And these can included breast surgery clinics, having a health behavior coordinator on-site, having a nutritionist or having a special OEF/OIF/OND [laughter] clinic within the women’s clinic or having a women’s MOVE! Program. So you can see that a certain percentage of them do have these services particularly the health behavior coordinators, nutritionists, OEF/OIF and MOVE!

So I am going to talk a little more specifically about specialty gynecology services now. So we wanted to know depending on what model of care a woman was seen in where she is going or where she is being sent to receive her specialty gynecology services. And so in this slide we look at it separately by model one, model two, and model three. So it may be easier to start over here with model three where we see that in the light blue here are the majority of women are receiving their specialty gynecology services within the model three clinics. Sometimes they are going to another site within that VA. Very rarely they are going to another site within the healthcare system. 

The purple is bad and that is where they are going to another site that is more than fifty miles away. And you can see the same thing. If you look at model one clinics you will find that it is kind of rare in a model one clinic that gynecology is co-located there. And that most of those women are either being referred to another site within the VA or another site within the healthcare system. And a fairly large percent are going to another site which is more than fifty miles away. So that is obviously what we are trying to avoid. 

And this – what we did next was kind of break this down. The same data and we broke it down by medical centers – does not include the CBOCs on those slides. And then this slide is only CBOCs. And so one thing you see about the CBOCs is that there is a fair amount of this that the women are being sent to either another site within the healthcare system or another site more than fifty miles away. Now I am going to move on into the components of the report that is actually the part that was based on the capabilities that were designed for the site assessment tool. So the site assessment tool was basically designed to assess four major components of the women’s health program. And that included the women’s health program, the healthcare services, the outreach communication and collaboration, and patient centered care or PACT.

And these four components were divided up into thirty-five capabilities in FY11, thirty-six in FY12. And each of these – so basically it is sort of thirty-six questions. Does your healthcare system have this? Does it have that? does it have that? And each of these questions was scored on a Likert scale of needs development, being developed, developed, or highly developed. Those of you who are on the call who have actually had a site visit are very familiar with this because this is how the sites are reviewed and scored. But the – when the Veteran program managers also had to fill out those same questions as a section of the WATCH survey I am going to show the data for FY11 because the FY12, this portion of the data for FY12, is actually still being rolled up as we speak. But this is the national roll up actually of the self-assessment for these particular questions. And this is the program part, the program capabilities. 

It asks question about oh well, the things you see below: organizational structure, leadership, women’s health committee, strategic planning. And the green part, dark green means it is highly developed. Light green means it is developed. And yellow means being developed. And red is the worst which means it needs development. And so this is from the self-assessment. And so you will see that this was in FY11. The things sort of nationally needing development were the women’s Veteran health committees, strategic planning, finance, human resources, cross coverage, contracting. 

And then we looked also at healthcare services and the healthcare services are comprehensive primary care, women’s health program staffing, were women able to get their care in a single visit? And I will not reop all of these but you can take a look at them yourself. And based on the self-assessment there were gaps in availability of urgent care and emergency care for women Veterans. And obviously the yellow – various also that are still being developed. And the dark green is areas where we were – where sites considered themselves to be developed or highly developed. 

And then this is the section of outreach, communication, and collaboration. This tends to be an area where women’s health programs do very wel particularly in outreach, external partnerships; academic affiliates are weaker in some sites, obviously, stronger in others. And then patient centered care. This is an area where we are improving a lot. In 2011 we were still seeing some sites that were still being developed in areas of patient centered care. And so this is actually showing the same data and it shows you how we collected this data from the site visits. So we – as of 4/2/2013 there has been fifty-eight facilities that have been visited. This is the same data. 

It is sort of – for the most part the site visit data comes out to be fairly similar to the self-assessment data. So this is the program capabilities. These are the healthcare services capabilities. You will see in the site visits we are finding a deficit in the women being able to get their women’s healthcare in a single visit. That means getting gender specific care and their routine care in a single visit. This is outreach, communication, and collaboration, looks pretty similar. And remember that – so it is a little bit confusing because the site visits, and probably not really a valid comparison and it will be better when we have the data from FY12. But these are site visits that have occurred in FY10, 11, and 12 and 13 all rolled up together. [laughter] And we are look – I mean, what we looked at for the self-assessments would just be FY11 data. And this is the patient centered care and PACT from the site visits as well. 

This is an interesting slide that compares the self-assessment data for the sites that have been visited. And if the site visit results were less favorable it is red if the site visits were less favorable than self-assessment. And it is green if the site visits were more favorable. So you can see that there is a mixture. Some of the things where the site visits were less favorable would be organizational structure, leadership involvement, women’s health committees, I will just move over here, VISN support, getting healthcare in a single visit. So you can see that in some cases in self-assessment folks thought they were doing better than they were really doing. But in some cases they were actually doing better than they thought they were doing. 

So what are our data limitations? Obviously the WATCH tool is – the self-assessment is – the accuracy is limited to the respondent’s assessment. The site assessments are potentially more accurate although we cannot guarantee with the site assessments that we see every aspect of the program. We did do a very thorough job of data validation in terms of really checking all the outliers. We tried to, anyway, check all the outliers and confirm them with the women Veteran program managers to make sure somebody had not filled something out in error. But it is impossible to really validate every single data point even though we did a very exhaustive job. But I think that is also a limitation. 

So the findings and conclusions: so one important thing that I think I highlighted during the talk is that less than half of the healthcare systems actually have a written strategic plan for provision of services to women Veterans. And we think that that is an area that we are working on very hard this year. So hopefully next year it will look better. Most healthcare systems had the required women’s health program personnel positions filled including a women Veteran program manager and a CBOC liaison. Most healthcare systems had the recommended women’s health program personnel positions filled including women’s health medical director or women’s health champion. All a hundred and forty healthcare systems had a designated women’s health primary care provider and provided comprehensive primary care at at least one of their sites. 

And one of our most exciting things was that over fifty sites had implemented comprehensive primary care between FY11 and 12 so that we are now only fourteen percent of eight hundred and ninety-one primary care sites do not have this capability. So it is not perfect but it is – fifty new sites in a year was pretty exciting. And but despite having comprehensive primary care in all the sites only thirty-four percent of – I mean, only sixty-six percent of our women are assigned to a designated women’s health PCP. So thirty-four percent of the women are still not assigned. 

So that is the end of my talk. I wanted to acknowledge the folks in VSSC who have worked really hard both in creating the survey for us this year as well as really getting the VSSC site on tool created so that this data will be available for everyone to see on VSSC. We are expecting it to be available any day now. And then Anu Torgal in our women’s health program office has really just worked unbelievable hard in making all of this happen. And I want to thank her very much for all of her efforts. So I would be more than happy to answer any questions, thank you. 

Moderator:Thank you very much, Sally. We do have some good questions that have come in and for anybody that joined us after the top of the hour, to submit your question simply type it in to the GoToWebinar dashboard write-in section where it says ask the staff a question. So the first one PACT continually interferes with using 322 for any provider other than women’s health primary care providers so that we cannot use it for mental health, RD, PharmD, et cetera visits in the model three clinics. Does this create any problems for quote counts for services housed in model three clinics? 

Dr. Haskell:Well, 322 is really meant to be used for comprehensive primary care. So I think – and I probably need some help answering this question. But I believe that mental health services provided within a comprehensive primary care clinic should actually correctly be using a mental health stop code. There are – I think it is possible that there can be a primary stop code and a secondary stop code which might help to alleviate some of this confusion. But 322 really is about primary care, comprehensive primary care. 

Moderator:Thank you. In reference to page thirty-eight, how does the A-U list for VISN related to the actual VISN number? 

Dr. Haskell:Let me see. Now I have to remember that thing of how do I get back to my thirty-eight. 

Moderator:Yes, you were in the right spot, yes, hover over that, the one that looks like a piece of paper, then hover over go to slide. And then you can go straight to it. 

Dr. Haskell:There we go, thank you. So what is the question again? 

Moderator:How does the A-U for VISN relate to the actual VISN number? 

Dr. Haskell:Oh it is just randomly mixed up. 

Moderator:[laughter] Can we [laughter] can we have a repeat definition of model one? What does fit actually look like? Women in same waiting area with men going into same clinic area but seeing women’s health primary care provider? 

Dr. Haskell:Yes. So a model one clinic is a gender integrated clinic so it is a general primary care clinic. So women would be in the same waiting area. But their provider would be a designated women’s health provider. So that is someone who is interested and proficient in the care of women Veterans and preferentially assigned women Veterans. So within that model one clinic the hope would be that most of the women would be assigned to designated health providers so and ideally there would be more than one. There would ideally be several designated health providers and all of the women would be assigned to those providers because they would be the experts in women’s healthcare. 

Moderator:`Thank you very much. That is the final question we have pending. While we wait for any more would you like to give some concluding comments. 

Dr. Haskell:Well, I would just like to thank everyone for attending. And hope that the presentation was useful and I would certainly be happy to – if anyone would like to contact me with any further questions I would certainly be happy to. I am just available at the VA email sally.hospital@va.gov. 

Moderator:We would like to thank – go ahead. 

Dr. Haskell:That is it. 

Moderator:I was just going to say we would like to thank you very much for sharing your expertise with the field, especially this topic. It is very, very timely. So with that I would like to thank our attendees also for joining us. And as you exit today’s webinar please wait for the survey to pop up on your screen and be sure to provide your feedback for this presentation. It is your feedback that gears the direction our program heads in. so thanks again Sally and everybody enjoy the rest of your day. 

Dr. Haskell:Thank you. 

[End of audio]

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