Funded by the VA HSR&D (Project# SDR 10-012)

Spotlight on Women Cyberseminar Series
Health Care Services For Wom

Veterans

Melissa McNeil, MD, MPH

Director, VA Pittsburgh Women’s Health Program

Chief, Section of Women’s Health

University of Pittsburgh
An average patient. . . 

 A 27 yo female with migraine headaches 

presents for evaluation

 Her headaches occur 1 Her headaches occur

1

-2X per month al

2X per month al

in the week just before the onset of her menses

 Sh ib f 800 tid t She uses ibupro

fen 800 mg tid

to manag

these headaches but recently has had to sick 1-2 da

y p s 

per month due to her head
More about the patient. . . 

 The review of systems reveals that her menses 

regular every 28 days and are normal in flow

 She is not currently sexually active She is not currently sexually activeHow should she be managed?
Option #1: Traditional Care

 Her PCP prescribes sumatriptan for acute 

management of her headaches

 Neurology is consulted for help in managing the Neurology is consulted for help in managing the

headaches (6 wk wait)

 She is given an appt to gynecology for her ann

smear (8 wk wait)
Option #1: Traditional Care

 Neurology recommends topiramate for her hea

management

 Gynecology performs her pap smear Gynecology performs her pap smear She returns to you in 3 months still with headac

and now having concentration problems from htopiramate

 Her menstrual cycle is now 2 weeks late
Option #2: Comprehensive Prim

Care for Women Care for Women

 Seen in the Women’s Center by a provider with 

expertise in gender specific primary care expertise in gender specific primary care

 As part of her initial hx and px, a pelvic exam a

smear are performed

 Continuous OCPs are initiated for managemen

migraines
Option #2: Comprehensive Prim

Care for Women Care for Women

 She returns in three months with rare migraine 

headaches no subsequent sick days and no sheadaches, no subsequent sick days, and no s

effects from her topiramate

 As an added bonus, her menstrual cycles rema

regular every three months
You do the math . . .

 Traditional care:

• 2 extra clinic visits taking two months to com• Poor control of headaches Poor control of headaches• Possibly pregnant

 Comprehensive Women Comprehensive Women s’ Care:

• One stop shopping• Appropriate management of perimenstrual m

headaches
But Do Women’s Health Clinics R

Make a Difference? Make

a Difference?

 The answer is yes. . . .  B th d k ? B

u

t

how 

do we 

know

?

 Study published in Journal of General In

Medicine in March 2003 Medicine in March 2003

 Patients from 8 VA Medical Centers in V

were surveyed

 Overall satisfaction and gender specific 

satisfaction was measured

Bean –Mayberry et al, JGIM, volume 18, March 2003
Patient Satisfaction

 Patients were randomly chosen for survey Stratified by medical center Al t tifi d b h th t th i Also s

tratifi

e

d

by w

h

ether or no

t th

eir care was 

delivered in a women’s clinic (WC) or in a tradprimary care clinic (TC)
Patient Satisfaction

 For overall satisfaction, patients were asked a s

item question from the VA National Survey of Ambulatory Care Ambulatory Care

 In addition, gender specific satisfaction was ass

using the Primary Care Satisfaction Survey for developed by the HHS funded Centers of Excein Women’s Health
Results

 971 women returned surveys

• 61.7% from Women’s Clinics• 38 3% from Traditional Clinics 38.3% from Traditional Clinics

 Patients in WC settings were:

• Significantly younger (55 5 vs 63 years) Significantly younger (55.5 vs 63 years)• More likely to be nonwhite (15.5% vs 9.4%)• No difference in marital status, educational s

income or overall health income, or overall health
Results: Health Care Use

 Equally likely to have seen their regular provide

most recent visit most recent visit

 Women in WC less likely to have providers out

the VA (30.9% vs 52.4%)

 More likely to see other VA providers (65 3% vs 

More likely to see other VA providers (65.3% vs 
PCSSW Satisfaction Results

 5 Domains of Care Identified

• Getting Care• Privacy and Comfort Privacy and Comfort• Communication• Complete Care• Follow up CareOn 19 out of 28 

q ,p uestions, WC 

patients mo

frequently than TC patients gave ratings excellent
Principles That Should Guide Ca

Women Veterans Women Veterans

High Quality Care for Women Should Involve: Comprehensive primary care Provided b

y proficient and interested clinicians

 Focused on safety, dignity, and sensitivity to ge

specific needs

 The right care in the right place at the right time The right care in the right place at the right time Using state of the art health care equipment an

technology
The Vision (and Now the Mandat

 The VHA handbook for Health Care Services t

Women Veterans delineates the following new standard requirement for the delivery of heastandard requirement for the delivery of hea

care to women veterans:

 Women patients seen at VA Medical Centers o

associated CBOCs will receive complete primaand coordination bypy p one 

primary care 

provider 

site. This provider should be able to:

• Care for acute and chronic illness• Provider Gender specific primary care Provider Gender specific primary care
What is Gender Specific Primary 

 Contraception counseling Medications in pregnancy and lactation M tf anagemen

t o

f menopause

 Evaluation of pelvic and abdominal pain

Abnormal va

g g inal bleedin

g

 Vaginal Infections/STI treatment Urinary Incontinence Osteoporosis detection and management Osteoporosis detection and management MST, sexual trauma, domestic violence Breast and cervical cancer screening
What is NOT Gender 

Specific Primary Care Specific Primary Care

 It is important to recognize that those women’s 

offering only gender offering only gender

-specific care (Pap clinics o

specific care (Pap clinics o

gynecology clinics alone) do not meet the defincomprehensive primary care.

 Primary care may be delivered utilizing a team 

but it is expected that gender specific primary cbut it is expected that gender specific primary cprovided by the same clinician that renders othroutine care without multiple encounters or visitscheduled over different days scheduled over different days
VA Standard vs Community Stan

 How many of you in the audience receive your 

a one stop a one stop

-shopping model? shopping model?

 Certainly not the community standard Reflects that the VA is striving to be a national 

in the provision of health care for women therein the provision of health care for women, thereraising the standard of care for all women!!!
Key Components of the Model

Include all of the following: D i t d W ’ H lth P i C P 

Designa

t

e

d

Women’s 

Health

P

rimary 

Care 

Pro

 Delineation of WH PCP 

proficiencies

 Models of delivery for comprehensive care Access to specialty care
Designated Women’s Health

Primary Care Providers Primary Care Providers

 All enrolled women veterans must receive 

comprehensive primary care from a designated comprehensive primary care from

a designated 

PCP who is interested and proficient in the delicomprehensive care to women

 An interested provider is one who is knowledge

concerned, engaged, and willing to participate concerned, engaged, and willing to participate primary care of women
Designated Women’s Health 

Primary Care Providers Primary Care Providers

 Women veterans assigned to a PCP who is no

designated WH PCP must be offered the oppodesignated WH PCP must be offered the oppofor reassignment

 HOWEVER, all patient requests will be honored

if the request is for a non designated WH PCP

• In 

a cases, a a ge e ts ust be ade to p o de 

ll cases,

arr

a

nge

m

e

nts must be made to

p

r

ovide 

specific care within the primary care setting

 Designated WH PCPs must be preferentially as

Designated WH PCPs must be preferentially aswomen veterans within their primary care pane
Designated Women’s Health 

Primary Care Providers Primary Care Providers

 Each facility must ensure that an appropriate n

of designated WH PCPs is available to ensure of designated WH PCPs is available to ensure 

access goals are met for women veterans

 The receipt of basic mental health services is a

required component of comprehensive primary 

 Women veterans must be able to designate a 

preference for a female or a male provider; if necessary fee basis can be used necessary, fee basis can be used
WH PCP Proficiency

 To maintain proficiency in women’s health, eac

must ensure that the patient panel of every desWH PCP is comprised of al least 10% female pWH PCP is comprised of al least 10% female p

 Each designated WH PCP will spend at least o

day every week practicing or precepting in a wohealth practice

 For facilities where women’s health is integrate

primary care, designated WH PCPs must have equivalent number of women patients (currently equivalent number of women patients (currently 

panel size is 120 female patients)
WH PCP Proficiency

 If insufficient numbers of female patients are av

to support the recommended numbers, an alterplan must be developed Suggestions include: plan must be developed. Suggestions include:

• A provider being precepted at a VA Women’s Clinic o

regul l h d l db i larly sc

h

e

d

ule

d

basis

• Working with a contract to hone practice skills

 Each facility must participate in and support an 

ongoing staff and provider education plan to primprove and maintain skills
Models of Comprehensive Prim

Care Delivery for Women Care Delivery for Women

 Model 1: General Primary Care Clinics

• Designated WH PCPs see women in a gender Designated WH PCPs see women in

a gender

-neutra

neutra

care clinic

• Mental health must be co-located

• Efficient referral to gynecology must be available Efficient referral to gynecology must be available

 Model 2: Separate but Shared Space

• Separate but shared space located within or adjacen

P i C li i d t l h lth P

rimary 

Care cli

nic areas; gyne an

d men

t

al health m

located as well

 Model 3: Women’s Health Center

• Geographically separate space• Specialty services available on site
Recommendations for Structu

Change in Delivery of Care Change in Delivery of Care

 Appointment times recommended

• New women: 60 minutes New women: 60 minutes• Routine follow up: 30 minutes• Urgent Appointment: 30 minutes

 Panel Sizes

• Strong consideration should be given to adjusting pa

d d t d t d th i d f downwar

d

to accommo

d

a

t

e

d the unique nee

ds o

f wo

veterans in the primary care setting

• Recommend that the panel size will be reduced by th

of i ti t l t 20% f th t t l b 

f unique patien

ts equal to 20% o

f the 

t

o

t

al num

ber o

veterans in the mixed provider panel
Special Considerations

 How do we measure proficiency? How do we develop and maintain competent w

health primary providers that can meet these health primary providers that can meet theseproficiency standards?

 How do we incentivize providers to seek and m

this designation? 

• New skills• More responsibilit

y 

 for added areas of care AND for o

training

• More to do in an office visit

 Given that there are increased 

p y roficienc

y

requirements, should there be increased pay?
Patient-Aligned Care Teams (P

& Women & Women s Health ’s Health

Sarah Hudson Scholle, MPH, DrPH

Assistant Vice President, Research

July 15, 2010
Agenda

• Patient-Aligned Care Teams (PA

/Patient-Centered Medical Hom(PCMH) 

• NCQA’s Medical Home program • Medical Home & Women Medical Home & Women s Heal

’s Heal
NCQA: A Brief Introductio

• Private, inde

pendent nonprofit 

health care quality oversight organization founded in 1990

• Committed to measurement,

transparency and accountabilit

• Unites diverse groups around co

g p g q

oal: im

provin

g health care 

qua
PCMH (aka PACT)

• Model of care that provides patient-ce

comprehensive, accessible, and coorcare and a systems

-based approach 

and safety

• First articulated in pediatrics in 1960s• Joint Principles adopted by primary ca

physician groups in 2008

• Growing adoption of model in public a

private sector, including VA, where it ias PACT (Patient-Aligned Care Teams)as PACT (Patient
Promise of the PCMH

• Different stakeholders emphasize diffe

benefits

• Physician groups: Improve work life of 

and staff, particularly primary care 

• Policymakers & payers: Reduce costs 

Reduce costs 

Improve quality of care

• C d t Consumer

a

dvoca

tes: I ti 

Improve patien

experiences
Evidence for the PCMH

• Well-designed trials support many com

of the medical home (e g RCTs demoof the medical home (e.g., RCTs demobenefits of Chronic Care Model)

• Preliminary studies suggest benefits (G

Health, North Carolina, Geisinger)

– Improved quality– Reduced clinician burn-out– Improved patient experiences (sometime– Reduced costs of care
Definitions of PCMH

Joint Principles 

(AAFP, AAP, ACP, AOA 2007)

Consume

(NPW

Care Team

• Ongoing relationship with a personal 

p

h

ysician. 

• interdisciplinary 

p y

• Qualified 

provid

• Team at practice level is led by 

physician 

p 

choice leads tea

Whole-Person Orientation 

• Whole-person orientation. provide all 

the 

patient’s health care needs and 

• “Knows” its pat

p

person oriented 

for arranging care with other qualified professionals.

patients’ unique preferences.

Care 

Coordination

• Care is coordinated and/or integrated 

across all elements of the complex

• Coordinates its 

Coordination across all elements of the complex across care sett

health care system and the patient’s community 

across care sett

over time, in concollaboration wifamily.

Self-Mgmt

• Practices advocate for their patients

• Patients and the

Support

• Practices advocate for their patients, 

a care-planning process driven by a compassionate, robust partnership of physicians, patients, and patients’ 

families

• Patients and the

supported in mahealth.

families.

Shared Decisionmaking

• Patients actively participate in 

decisionmaking, and feedback is sought to ensure that their 

expectations are being met

• Patients and clin

in making treatm

expectations are being met. 
Definitions of PCMH

Joint Principles (AAFP, AAP, ACP, AOA 2007) Consumer Principle

Access

• Enhanced access to care is 

available throu

gh s

ystems such as 

• The patient has 

g y care.

open scheduling, expanded hours, and new options for communication among patients, their 

personal 

p

h

ysicians, and 

• Open communic

patients and the encouraged and 

p py

practice staff. 

Quality Improvement

• Evidence-based medicine and 

clinical decision-support tools 

• Qualit

y im

provement efforts

• Collaborates wit

advisors in qual

y p and 

practice red

• Patient & family participation• Health IT support optimal care 

p 

• Regularly evalu

care 

• Routinely under

identif

y 

 and elim

disparities in the received by its p

Payment

• Payment recognizes the added 

value provided to patients who 

have a PCMH.

Communication and Trust

• The PCMH foste

of trust and resp
NCQA’s Program for the

Patient-Centered Medical Hom

• Originally developed to address purchaser d

tool to evaluate outpatient care efforts to imsystematic care

• In January 2008, aligned standards with Join• Endorsed for use in demonstrations by nume

physician organizations (ACP, AAFP, AAP, AOas we as Patient Centered Primary Care Coll(PCPCC)

• Endorsed by National Quality Forum as Endorsed by National Quality Forum as prac

“prac

systems assessment survey”

• Leading tool in demonstrations using payme

(Bitton 2010) 
Theoretical Frameworks Informin

Development of PPC

-PCMH

Based on best avaialble empiric evidence in each area and on testin

validity of elements in field tests using on site audit as “gold” 

Chronic Care

Model

Patient Centered

Care

Cultural 

Competence 

Clinical information Respect Patient Values Culturally P

Systems

Decision SupportPatient SelfManagement

Accessible Family-Centered Continuous Coordinated

competent interactions

Language 

services

PW

Management 

Delivery System 

Redesign

Community Linkages

Coordinated

Community LinkagesCompassionate Culturally Appropriate 

services

Reducing 

disparities

CQ

Health Systems Emotional Support 

Information and 

Education 

Physical Comfort

E

Physical ComfortQuality Improvement 

PRIMARY CARE

First contact-comprehensive-continuous-coordina
Linkage of PCMH to Reimburse

One Model

Pay for Performance

Quality Resource Use and Patient Experience

Fee Schedule for Visits/Procedures

Quality, Resource Use and Patient Experience

P t P ti t f R i d M di l H Payment per Patient for Recognized Medical Hom

(services not normally reimbursed)
PCMH 2011 Overview (6 standards/25 

1. Access and Continuity Access and Continuity 

4 Self Care & Com

A. Access During Office HoursB. Access After HoursC. Electronic Access

4. Self-Care & Com

A. Self-Care Process

5. Track & Coordina

A Test Tracking and 

C. Electronic AccessD. Continuity E. Medical Home ResponsibilitiesF. Culturally/Linguistically Appropriate 

A. Test Tracking and B. Referral Tracking aC. Coordination with 

Transitions

Services

G. Practice Team

2. Identify/Manage Patient Populations

i f i

6. Performance Mea

/Quality Improvem

A. Measures of Perfo

A. Patient In

formation

B. Clinical DataC. Comprehensive Health Assessment

D Using Data for Population Management

B. Patient/Family ExpC. Report PerformancD. Quality Improvem

i i

D. Using Data for Population Management

3. Plan/Manage Care

A. Implement Evidence-Based GuidelinesB Identify High Risk Patients

E. Electronic Reportin

Optional Patient Expe

B. Identify High Risk PatientsC. Manage CareD. Manage Medications E. Electronic Prescribing

Optional Performanc
Issues in Defining PCMH

• How to further assess patient-centered

including patient survey results?

• What are the responsibilities of PCMH p

versus larger entity? 

– Integrate behavioral health/risk factor assessment 

– Comprehensiveness at a single site

• When should performance results be p

scoring?

• What about meaningful use of health IT• How to adapt to promote quality and c

across settings?

• How to streamline requirements, docum
How does the PCMH 

add W ’ H lth

ddress Women

’

s Health

• NCQA’ t l i il t i lt NCQA’

s tool i

s

silent on specialty

• ACOG: “women’s health homes”

• Ob/gyns are seeking PCMH desig
PCMH & Women’s Healt

• Access: how to provide timely ac

all f ’ d ? ll 

of women’s nee

d

s? 

• Comprehensive vs. coordinated: 

ensure integration of women’s gereproductive and behavioral heaneeds? 

• Patient-centered: how to encour

shared decision-makin

g p and 

pat

engagement in care/practice? 
Gaps in Current Measure

f W ’ H lth for Women

’

s Health

• Measures focus on access to visits 

– Do not consider the content of care received

• Measures address women’s cancers and Chlam

th f ll f ti d th

e full range

of preventive nee

d

s

– Depression, weight assessment, and illicit and 

substance use

• Measures do not address the interrelatedness of 

g p eneral and re

productive health

– Preemptive family planning discussions

• Where many important measures do exist, they a

captured in routine ways

– Can not be used in quality improvement and 

accountability
Issues 

• Leadership • Consumer demand• E id b Evidence base

• Feasibility
For more information:

Sarah Hudson Scholle MPH DSarah Hudson Scholle, MPH, D

scholle@ncqa.org

202 955 1726

www.ncqa.org