Women’s Health CREATE 

Overview 

Elizabeth M. Yano, PhD, MSPH

Women’s Health CREATE Director

Spotlight on Women’s Health Cyber Seminar

VA HSR&D Service  January 27, 2014

1 
Women Veterans in VA

• Women Veterans (WVs) fastest growing segment of 

new VA healthcare users

– Legislative changes opened military careers to women (e.g., 

20% of new recruits now women) and mandated VA to 

deliver gender-specific care

– ↑ efforts to enroll returning Veterans from Iraq and 

Afghanistan (OEF/OIF) into VA care (>50% enrolled vs. 11%)

– Women veteran VA users doubled in past 10 years

• Projected to be 10% (or higher) of total user population by 2018

• Rapid increase in #s in childbearing years (42% of WVs vs. 

12% of MVs <45 years old)

• Complexity of care demands changing (rapidly)

2 
Women Veterans in VA

• Significant comorbid physical and mental health 

conditions among VA users

– Higher disease burden than female non-Veterans

– Comparable disease burden to male Veterans

– Greater mental health burden compared to male Veterans

– High rates of sexual harassment, abuse, assault histories

• Numerical minority creates challenges for VA

– Historical predominance of men in VA settings

• Gaps in safety and privacy for women (GAO)

• Limited gender-specific service availability (GAO)

• VA providers with little/no exposure to women

3 
4 

Determinants of Women Veterans’ 

Quality of Care in VA

VA Women’s 

Clinics

↑ Pap smears

↑ Mammograms

↑ Access

Continuity

Coordination

↑

↑ 

No change in 

other measures*

4 

*Gender-neutral (aka general PC clinics) better or worse depending on measure

Source: Yano EM, Washington DL, Bean-Mayberry B. Impact 

 of Practice Structure on the Quality of Care for Women 

 Veterans. VA HSR&D Project #04-036 (2005-07).
5

In a nutshell, what worked?

5

VA Women’s 

Clinics

Comprehensiveness

Quality

On-site 

services 

WH 

Experts

Skillmix 

5
6 

Research-Clinical-Policy Partnerships

6 6 

• Under Secretary for Health  tasked a work group

• Established acceptable women’s clinic models 

• Women’s Health Services (WHS) developed new 

VHA Handbook and field-based assessment tools

• Health Care Services for Women Veterans 

(1330.01) (May 2010)

• Women’s Assessment Tool for Comprehensive 

Health (WATCH)

6 
Key Focal Point Statements in

VHA Handbook 1330.01

• “...each VA facility must ensure that eligible women Veterans 

have access to comprehensive medical care, including care for 

gender-specific and mental health conditions...comparable to 

care provided for male Veterans.” 

• “...all enrolled women Veterans need to receive comprehensive 

PC from a designated WH PC provider who is interested and 

proficient in the delivery of comprehensive PC to women, 

irrespective of where they are seen” and “regardless of the 

number of women Veterans utilizing a particular facility.”

• Environments sensitive to women Veterans’ needs, safety, and 

dignity

7 
VA Women’s Health CREATE

• What is a CREATE? = Collaborative Research to 

Enhance & Advance Transformation & Excellence*

– Group of coordinated research projects conducted in a 

focused high-priority area in partnership with VA leaders

• Women’s Health CREATE goal: Use research to accelerate 

implementation of comprehensive care for women Veterans

– Principal partner: Women’s Health Services (Hayes)

• Focus on fundamental issues in how VA delivers care 

to women Veterans in context of national VHA policy

– Ensure access to comprehensive healthcare services

– Within environments that preserve privacy, dignity, safety

8 

*All CREATES described at 

www.hsrd.research.va.gov/create 
Women’s Health CREATE Aims

1. To examine patient, provider, and organizational 

barriers and facilitators to implementation of 

comprehensive care delivery for women Veterans;

2. To assess determinants of these factors underlying 

delivery of comprehensive care for women Veterans 

and implications for their quality and experiences of 

VA care; and,

3. To evaluate the effectiveness and impact of 

alternate models of delivering comprehensive care 

to women Veterans

9 
Five Component Projects (P1-P5)

10

P1

Determinants of Attrition 

(Frayne, Hamilton)

P2

Impact of 

Comprehensive Care on 

WH (Yano, Rose)

P3

Adapting Medical Homes 

for Women 

(Yano, Rubenstein)

P4

Supporting WH Providers 

in Distant Clinics 

(Washington, Cordasco)

P5

Coordination and Quality 

of Outsourced Care 

(Bastian, Mattocks)
Overarching CREATE Partners

• Veterans Health Administration (VHA)

– Funded by VA's Office of Research & Development (ORD) 

Health Services Research & Development (HSR&D) Service

– Women’s Health Services (WHS)

• Patricia Hayes, PhD (Chief Consultant) 

• Sally Haskell, MD (Deputy Chief Consultant for Clinical Operations and 

Director of Comprehensive Women's Health)

– Mental Health Services (MHS) 

• Susan McCutcheon, EdD, RN (Director, Family Services, Women’s Mental 

Health, and Military Sexual Trauma) 

11

For more information, contact Elizabeth Yano, PhD, MSPH (PI)

at elizabeth.yano@va.gov and/or Angela Cohen, MPH

(CREATE Program Manager) at angela.cohen2@va.gov. 
Overarching CREATE Partners 

Continued

• Also benefits from additional project-specific 

partners 

– Examples: National Primary Care/PACT Program Office, 

Office of Specialty Care Services, National Radiology 

Program, VISN Leaders

• WH CREATE Executive Steering Committee 

• National Women Veterans Council

12

For more information, contact Elizabeth Yano, PhD, MSPH (PI)

at elizabeth.yano@va.gov and/or Angela Cohen, MPH

(CREATE Program Manager) at angela.cohen2@va.gov. 
Lost to Care: 

Attrition of Women Veterans New to VHA

13

Women’s Health CREATE “P1”

Susan Frayne, MD, MPH

Center for Innovation to Implementation (Ci2i)

VA Palo Alto Health Care System

Alison Hamilton, PhD, MPH

Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP)

VA Greater Los Angeles Healthcare System
Background/Study Rationale

Many women are new to VHA

•Among WV using VHA outpatient care in FY09:

– 14% new (no use in prior 3 years)

– 56% had joined VHA since FY03

•Geographic variability in distribution of new WV

Friedman S (2011) Women’s Health Issues 21(4S) 

14

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Background/Study Rationale

Attrition: Common in New WV

•Definition: 

– No use of VHA outpatient care in subsequent 2 years

•Attrition among WV using VHA outpatient care in FY06:

– 30% of new WV patients

– 8% of ongoing WV patients

Friedman S (2011) Women’s Health Issues 21(4S) 

16

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Project #1 Goals & Study Design

• Project goals: 

– To assess whether and how patient experiences of VHA 

care contribute to attrition

– To recognize patient subgroups at risk for attrition

– To identify promising, patient-centered remedies

• Study design:

– Mixed methods convergent parallel design

• concurrent timing of quantitative and qualitative strands 

• methods prioritized equally

• results mixed during the overall interpretation

– Conceptual model incorporating

• Andersen Behavioral Model of Health Service Use

• Consumer Choice Theory

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17

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Project #1 Specific Aims: Quantitative

• Aim 1: To identify predictors of attrition 

– using existing data to model predictors of VA attrition 

among a FY11 national cohort of new WV VHA patients 

(N~50,000)

• Aim 2: To characterize patterns of attrition over 

time

– using existing data to examine longitudinal trends in 

attrition rates (FY03-FY11)

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18

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Project #1 Specific Aims: Qualitative

• Aim 3: To understand perspectives of attriters and 

non-attriters. 

– telephone interviews with a national stratified sample of 

women primary care patients new to VHA in FY10 (N~125)

• attriters and non-attriters from high/low attrition 

facilities

• Aim 4: To explore plans for future VHA use among 

current VHA users. 

– focus groups with recent (FY15 Q1-2) new WV VHA users 

(N~36) at two facilities 

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19

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Conceptual Model

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Aims 1 & 2 Key Variables

• Cohort

– Women Veterans new to VHA (WHEI-M; OEF/OIF/OND Roster for 

subcohort)

• Dependent variable

– “Attriter” if no VHA outpatient use and no fee basis outpatient use in 

the “2nd year” and “3rd year” after her index visit (WHEI-M)

• Predictor variables 

– Receipt of DWHP Care (Designated Women’s Health Provider Assessment of 

Workforce Capacity (DAWC))

– Patient Experiences of Care (WHEI-M)

– Contextual Factors & Community Resources (PCMM, WATCH, Area 

Resource File, American Hospital Association Annual Survey of Hospitals)

– Patient Characteristics (WHEI-M, Medicare/Medicaid)

21
Aim 3 Phone Interview Domains

Stratified national sample, WV new to VHA in FY10 (n=125)

• RQ3.1: How do patient experiences influence women’s decision to 

attrit from VHA? 

– Patient experiences (e.g., with DWHP, in women’s clinic, with travel time, 

with patient-provider relationship) 

• RQ3.2: How do contextual factors (VHA organizational 

characteristics/community health care resources) and patient factors 

influence women’s decision to attrit? 

– VHA organizational characteristics (e.g., women’s health clinic, 

satisfaction), community health care resources and patient characteristics 

(e.g., PTSD, pregnancy, rurality, dual eligibility, social and peer support)

• RQ3.3: What are patient-centered perspectives on organizational or 

policy improvements that would reduce attrition? 

– Contextual factors, especially VHA organizational characteristics that 

could be modified 22
Aim 4 Focus Group Domains

Current new users in LA/Iowa City (n ~ 36)

• Current experiences of health care in VHA and in the community

• Plans to return to VHA for future healthcare, with probes about 

factors that would encourage them to return

• How services and policies could be changed or developed to 

prevent attrition and outreach to women who have not returned 

or who have never used VHA

• Priorities re factors that would prevent attrition, i.e., what do 

they want the VHA to do for them that would encourage them to 

return 

– Marketing theory: focusing consumers on “desired outcomes” 
Women’s Health CREATE “P2”

Impact of Delivery of Comprehensive 

Women’s Health Care in the VA

Elizabeth Yano, PhD (PI)

Danielle Rose, PhD & Ann Chou, PhD (Co-PIs)

Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP)

VA Greater Los Angeles Healthcare System

24
Background/Study Rationale

• Delivering comprehensive care to women Veterans 

can be a challenge in VA

– Rapid growth in VA use, yet no changes in on-site availability 

of services 

– Wide variations in how local VA facilities achieve 

comprehensiveness 

• General primary care/PACT clinics and women’s health clinics

• Integrated mental health care vs. referral to outpatient MH specialty

• Different levels of in-house reproductive health/gynecology services

• VA ↑ policy guidance on comprehensive care, ↑ WH 

provider training, ↑ quality x gender reporting

– Implementation varies, local barriers/facilitators vary

25
Project #2 Specific Aims

• Aim 1: To assess determinants of variations in the 

delivery of comprehensive care to women Veterans

• Aim 2: To study the impact of comprehensive care 

delivery on women Veterans’ quality and 

experiences with VA care

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Comprehensive Care

27

• Comprehensive care 

– First contact care (i.e., the usual and preferred route for 

entry into the healthcare system, including assessing and 

sorting out needs and making appropriate referrals) 

– Subsequent care of “any health problem at any given stage 

of a patient’s life cycle” (adapted from IoM)

• Range of services available/provided considering 

population needs – problem-related 

– Primary care, subspecialty care, mental health care, genderspecific care organized from VA entry through care journey

• Requires personal relationship with provider and 

coordination to achieve timely care per standards
Study Design and Sampling Plan

28

National VA 

Organizational 

Survey

Quality of 

VA Care

VA Care 

Experiences

All VA facilities serving 200+

women Veterans (n~300)

Key informant approach

Receipt of Guideline-Concordant

Chronic Disease Care and

Preventive Screenings

Access, continuity, coordination
Determinants

• Organizational determinants

– Practice characteristics (e.g., primary care and 

women’s health program features, coordination, quality 

improvement, environmental management)

– Facility characteristics (e.g., size, academic affiliation, 

complexity, context within which care is delivered)

• Area determinants

– Location (e.g., urban/rural, Census region)

– Area demographics (e.g., poverty level)

– Health care area resources (e.g., primary care 

shortage area)

29
Quality & Experience Measures

• Quality of VA Care measures

– Corporate Data Warehouse (CDW) derived quality 

indicators

• Chronic disease (e.g., diabetes, ischemic heart disease)

• Prevention (e.g., receipt of cancer screenings, 

immunizations and vaccinations)

• Care Experience measures

– Access measures (PACT Compass/CDW)

– Survey of Healthcare Experiences for Patients 

(SHEP)

30
Women’s Health CREATE “P3”

Implementation of VA Women’s Health 

Patient Aligned Care Teams (WH-PACTs)

Becky Yano, PhD, MSPH (PI) & Lisa Rubenstein, MD, MSPH (Co-PI)

Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP)

VA Greater Los Angeles Healthcare System

31
Background/Study Rationale

• VA undertaking patient-centered medical homes

– Non-VA PCMH associated with ↑ quality, ↑ patient and 

provider/staff satisfaction, while ↓ costs and ↓ disparities 

• VA’s PCMH model—Patient Aligned Care Teams 

(PACTs)—holds promise for ↓ WVs’ gaps in care

– Teamlets include PC providers, nurses, admin support

– Larger PC team of pharmacists, social workers, dietitians, 

health coaches, integrated mental health

– Links to medical home “neighborhoods” (specialists, hosps)

– Goal ↑ access, continuity, coordination, comprehensiveness 

using team-based care that’s patient-driven, pt-centered

32
Background/Study Rationale

• How VA should adapt PACT to meet the needs of 

WVs not part of original initiative

– No specific accommodations for gender-specific care or 

gender-sensitivity 

– No specific guidance on WH clinic-based programs

– WH clinic models vary in delivery of comprehensive PC

• VHA Handbook on comprehensive care delivery for 

WVs (1330.01) fills key policy gaps

– Aligns with PACT, requires comprehensive PC in one-stop 

visit, attention to gender-specific care and sensitivity

– Specifies range of acceptable care models/attributes

33
So what to do?

• We have national strategic priorities in hand

• We have evidence of PCMH effectiveness and 

early evidence of PACT promise and value

• We have evidence of PC features in general PC 

and WH clinics that contribute to quality

• We have national expert panel consensus on 

gender-sensitive comprehensive care features

• We needed an approach to tailoring PACT to 

evidence and women Veterans’ needs

34
Project #3 WH PACT Specific Aims

• To assess the effectiveness of evidence-based 

quality improvement (EBQI) methods for 

developing a WH-PACT model using a cluster RCT

– PACT features (accessible, continuous, team-based, 

patient-driven and patient-centered); 

– Comprehensive care (PC, gender-specific care, integ MH); 

– Gender-sensitive care delivery

• To examine impacts of receipt of WH-PACT 

concordant care on women Veterans’ outcomes 

– Chronic disease care, prevention, health status, use, costs

35
WH PACT Specific Aims (cont’d)

• To evaluate the processes of EBQI-supported WHPACT implementation

– Better understand influences of practice context

– Document EBQI methods and WH-PACT implementation

– Examine barriers/facilitators to EBQI-supported WH-PACT 

implementation using mixed methods (e.g., interviews)

• To develop implementation/evaluation tools for use 

in EBQI-supported WH-PACT model adaptation, 

implementation, sustainability, spread to other VAs

36
So what is the intervention?

• Intervention = evidence-based quality 

 improvement (EBQI) 

– An implementation strategy for adapting/tailoring 

research evidence into routine practice and policy

– We are NOT evaluating whether PACT works

• Although under Aim #2, we will explore whether WH 

PACT concordant care improves WVs’ outcomes

– We are NOT evaluating whether it’s better to 

deliver PC to women in general PC or WHCs

• Participating VAMCs span all care model types

37
What is EBQI?

• Multi-level research-clinical partnership QI approach

• Uses top-down/bottom-up features to engage local 

organizational senior leaders and QI teams

– National strategic directives serve as guides

– Regional expert panels set innovation design priorities

– Local interdisciplinary QI team design and implement local 

activities in context of prior evidence and change methods

• Researchers serve as technical experts and guides

– Train in QI, help teams structure QI (aims and measures), 

provide formative feedback

– Provide practice facilitation to support implementation and 

across-site collaboration (data sharing, lessons learned)

38
Study Design: Cluster Randomized Trial

• 2:1 allocation (8 intervention + 4 control VAMCs)

• Supports appraisal of variations in implementation processes in 

intervention VAMCs

• Capitalizes on VA WH Practice Based Research Network

39

VISN A VISN B VISN C VISN D

R 

2 E

VAMCs

1 C

VAMC

2 E

VAMCs

1 C

VAMC

2 E

VAMCs

1 C

VAMC

2 E

VAMCs

1 C

VAMC

R R R 

R = random assignment
Formative & Summative Evaluation

EBQI for 

WH PACT

Women 

Veteran 

Surveys (CATI)

PC and WH 

Provider/ 

Staff Surveys 

(Web)

Practice 

Surveys

Stakeholder 

Interviews

Teamlet 

Effectiveness 

Interviews

Administrative 

Data (quality, 

costs, use)

40

Baseline, 12- and 

24-months follow-up

RAND UCLA

Baseline data

collection starting up
Controlled Trial of Tele-Support and 

Education for 

Women’s Health Care in CBOCs

41

Women’s Health CREATE “P4”

Donna Washington, MD, MPH (PI) & Kristina Cordasco, MD, MPH, MSHS (Co-PI)

Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP)

VA Greater Los Angeles Healthcare System 
Background 

• VA primary care workforce’s exposure to and 

expertise in managing women’s gender-related care 

is variable

• To ensure quality care, VA mandated designated 

women’s health providers (DWHPs) in every VA 

facility and instituted intensive training opportunities 

– WH mini-residencies

• Continuous education, with re-enforcement of 

learning points, is needed to produce and maintain 

long-term gains in knowledge

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Background (cont’d)

• In a VISN 22 operations initiative, we launched

– The 1st VA WH SCAN-ECHO: series of primary care provider 

(PCP)-specialist clinical tele-videoconferencing sessions for 

didactic education & discussion of patient cases

– WH electronic (e-) consults: secure electronic 

communications between PCPs & specialists, w/ specialists 

reviewing charts to provide care recommendations

• Together we call WH SCAN-ECHO & e-consults 

“DWHP Support”

• This research project will evaluate the effectiveness 

of DWHP Support

43

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Project #4 Specific Aims

• Aim 1: To evaluate the effect of DWHP 

Support on WH care quality and efficiency

– Quality assessed by guideline adherence

– Efficiency assessed by specialist referral patterns

• Aim 2: To explore the impact of DWHP 

Support in changing DWHP behavior and selfrated WH knowledge, skills, and self-efficacy

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Project #4 Specific Aims (cont’d)

• Aim 3: To assess attitudes about DWHP 

Support and its use, specialist time for its 

implementation, and other features that could 

influence DWHP Support’s effectiveness, 

sustainability and spread

• Aim 4: To develop tools to measure quality of 

WH care in VA

45

45

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Study Design

• 4-year mixed methods study with DWHP 

Support being rolled out one healthcare system 

at a time (“stepped wedge design”)

• Quantitative Methods

– Chart review: quality & efficiency of care

– Surveys of DWHPs: perceptions of program 

elements / events; self-efficacy delivering WH care

• Qualitative Methods

– Semi-structured interviews with DWHPs and 

specialists, assessing needs, attitudes, perceptions

46
Sampling Plan

47

Healthcare 

system

Providers 

(DWHPs)

Women Veteran 

patients with 

selected 

conditions / 

presentations
Data Sources and Measures

• Quality assessment tool development

– Literature review; Expert panel methods

• Quality assessment

– Administrative data (CDW); Chart reviews (CAPRI)

• DWHP self-assessment, attitudes, perceptions

– Self-assessment tool; Survey instrument; 

Interview guide

48
Evaluation of Quality and Coordination of 

Non-VA Care for Women Veterans

Lori Bastian, MD

VA Connecticut Healthcare System

Kristin Mattocks, PhD

VA Central Western Massachusetts Healthcare System

Women’s Health CREATE “P5”
Background 

• The VA relies on outsourced (non-VA) care to provide specialized health 

services not provided within the VA (i.e., mammography and prenatal 

care) to women Veterans (WVs)

• 34% of WVs in VA care also utilize some fee basis care and the number 

continues to increase on an annual basis. Despite increasing numbers of 

WVs relying on non-VA care, little is known about the quality of non-VA 

care. 

• A majority (75%) of VA facilities contract with hospitals and other facilities 

for diagnostic mammograms

• Facilities are not monitored for quality according to standards set forth in the 

Mammography Quality Standards Act of 1992 (PL 102-539)

• Given that mammography is the highest-volume gender-specific care for 

women (51,396 mammograms in FY09), understanding the quality of this 

type of care is of utmost importance to the VA

50

50
Project #5 Specific Aims

• Aim 1

– To understand providers’ and fee basis managers’ strategies for 

provision, coordination, and quality oversight of non-VA care

• Aim 2

– To understand perceptions and experiences with non-VA care among 

women Veterans

• Aim 3

– To evaluate the quality of gender-specific services for women Veterans 

using a case example mapped to VHA Handbook priorities (e.g., Do VA 

facilities utilizing non-VA care for mammography meet key quality 

standards compared to VA facilities providing in-house 

mammograms?)

51

51

51
Study Design

52
Select twenty sites nationally with low, medium, and high use of non-VA care 

among women Veterans 

Aim 1

•Conduct telephone interviews with 2-3 providers and 1-2 fee basis managers at each site 

focusing on the challenges of referrals to and coordination with non-VA care, with a particular 

focus on challenges of incorporating mammography results back into VA care

Aim 2

•Conduct telephone-based interviews with 6-8 women Veterans at each site focusing on their use 

of non-VA care. As an inclusion criterion, 50% of women that we will interview will have received 

a mammography from a non-VA care provider in the past two years. The remaining 50% of the 

women will have received some type of non-VA care in the previous two years. 

Aim 3

• Conduct medical record reviews of women Veterans at the same 20 sites (ages 40-74) with 

either non-VA or in-house mammograms in FY12

53

Sampling Plan
Data Sources and Measures

54

Aim 1 Research Questions Conceptual domains {“Q”=Question number in Appendix 5}

 

RQ#1A: What are the processes (clinical decisionmaking, practice supports) underlying how providers 

utilize non-VA care for their female patients? What are 

providers’ experiences with non-VA care? How is nonVA care coordinated with ongoing VA care? How are the 

barriers/facilitators to using non-VA care? How could 

the process to refer patients to non-VA care be 

improved?

Perceived availability & sufficiency of VA services (Grand Tour Question--

Provider)

Clinical processes (Question 1—Provider)

Coordination of care (Question 2—Provider)

Perceived quality of non-VA services (Question 3—Provider)

 

RQ#1B: What are fee basis managers’ experiences with 

non-VA care? How are contracting decisions made? 

How is the quality of non-VA care monitored and 

evaluated?

Perceived availability & sufficiency of VA services (Grand Tour 

Question—Fee Manager)

Organizational decisions regarding fee/contract (Question 1—Fee 

Manager)

Payment of care (Question 2—Fee Manager)

Perceived quality of non-VA services (Question 3—Fee Manager)

Aim 2 Research Questions Conceptual domains {“Q”=Question number in Appendix 5}

RQ#2A: What are women Veterans’ experiences 

(coordination, perceived quality, satisfaction,) with nonVA care (both fee basis and contract services)?

Experiences with Care (Question 1—Patient)

Satisfaction (Questions 2 & 4--Patient)

Coordination of care (Question 3—Patient)

RQ#2B: How can access to, and coordination of, non-VA 

care be improved for women Veterans?

Access (Question 3—Patient)

Coordination of care (Question 3—Patient)

Satisfaction (Questions 2&4—Patient)
55

Data Sources & Measures (cont’d)

AIM 3: 

• Administrative Data (CDW, DSS, TIU text notes, Vital Status)

• Chart Reviews (CPRS/CAPRI)

– Phase 1 is to determine whether or not mammogram results are 

appropriately acknowledged in the medical record

– Phase 2 is to measure the number of days after an abnormal 

mammogram (defined as BIRADS 0, 4, or 5) that results are evaluated 

and followed up

• We will also collect patient’s age, race category (Asian, African American, 

Caucasian, other); service connectivity (non-service connected, 0, 1-49% service 

connected, 50-100% service connected); body mass index (BMI) and breast density
WH CREATE Contact Information

• For more information contact: 

– Elizabeth Yano, PhD, MSPH (Overall WH CREATE 

Principal Investigator) at elizabeth.yano@va.gov

and/or 

– Angela Cohen, MPH, CHES (WH CREATE Program 

Manager) at angela.cohen2@va.gov 

Thank you for your time and interest

QUESTIONS???

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