VA Health Care: Preliminary Findings on VA's Provision of Health Care Services to Women Veterans
Published: 2009-07-16T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Historically, the vast majority of VA patients have been men, but that is changing. VA provided health care to over 281,000 women veterans in 2008--an increase of about 12 percent since 2006--and the number of women veterans in the United States is projected to increase by 17 percent between 2008 and 2033. Women veterans seeking care at VA medical facilities need access to a full range of health care services, including basic gender-specific services--such as cervical cancer screening--and specialized gender-specific services--such as treatment of reproductive cancers. This testimony, based on ongoing work, discusses GAO's preliminary findings on (1) the on-site availability of health care services for women veterans at VA facilities, (2) the extent to which VA facilities are following VA policies that apply to the delivery of health care services for women veterans, and (3) some key challenges that VA facilities are experiencing in providing health care services for women veterans. GAO reviewed applicable VA policies, interviewed officials, and visited 19 medical facilities--9 VA medical centers (VAMC) and 10 community-based outpatient clinics (CBOC)--and 10 Vet Centers. These facilities were chosen based in part on the number of women using services and whether facilities offered specific programs for women. The results from these site visits cannot be generalized to all VA facilities. GAO shared this statement with VA officials, and they generally agreed with the information presented.
section_title: What GAO Found
paragraphs: The VA facilities GAO visited provided basic gender-specific and outpatient mental health services to women veterans on-site, and some facilities also provided specialized gender-specific or mental health services specifically designed for women on-site. Basic gender-specific services, including pelvic examinations, were available on-site at all nine VAMCs and 8 of the 10 CBOCs GAO visited. Almost all of the medical facilities GAO visited offered women veterans access to one or more female providers for their gender-specific care. The availability of specialized gender-specific services for women, including treatments after abnormal cervical cancer screenings and breast cancer, varied by service and facility. All VA medical facilities refer female patients to non-VA providers for obstetric care. Some of the VAMCs GAO visited offered a broad array of other specialized gender-specific services on site, but all contracted or fee-based at least some services. Among CBOCs, the two largest facilities GAO visited offered an array of specialized gender-specific care on-site; the other eight referred women to other VA or non-VA facilities for most of these services. Outpatient mental health services for women were widely available at the VAMCs and most Vet Centers GAO visited, but were more limited at some CBOCs. While the two larger CBOCs offered group counseling for women and services specifically for women who have experienced sexual trauma in the military, the smaller CBOCs tended to rely on VAMC staff,often through videoconferencing, to provide mental health services. The extent to which the VA medical facilities GAO visited were following VA policies that apply to the delivery of health care services for women veterans varied, but none of the facilities had fully implemented these policies. None of the VAMCs and CBOCs GAO visited were fully compliant with VA policy requirements related to privacy for women veterans in all clinical settings where those requirements applied. For example, many of the medical facilities GAO visited did not have adequate visual and auditory privacy in their check-in areas. Further, the facilities GAO visited were in various stages of implementing VA's new initiative to provide comprehensive primary care for women veterans, but officials at some VAMCs and CBOCs reported that they were unclear about the specific steps they would need to take to meet the goals of the new policy. Officials at facilities that GAO visited identified a number of challenges they face in providing health care services to the increasing numbers of women veterans seeking VA health care. One challenge was that space constraints have raised issues affecting the provision of health care services. For example, the number, size, or configuration of exam rooms or bathrooms sometimes made it difficult for facilities to comply with VA requirements related to privacy for women veterans. Officials also reported challenges hiring providers with specific training and experience in women's health care and in mental health care, such as treatment for women veterans with post-traumatic stress disorder or who had experienced military sexual trauma.

section_title: Letter
paragraphs: I am pleased to be here today as the subcommittees consider issues  related to the Department of Veterans Affairs’ (VA) delivery of health care  services to women veterans. Historically, the vast majority of VA patients  have been men, but that is changing. As of October 2008, there were more  than 1.8 million women veterans in the United States (representing  approximately 7.7 percent of the total veteran population), and more than  102,000 of these women were veterans of the military operations in  Afghanistan and Iraq, known as Operation Enduring Freedom (OEF) and  Operation Iraqi Freedom (OIF). According to VA data, in fiscal year 2008,  over 281,000 women veterans received health care services from VA—an  increase of about 12 percent since 2006. Looking ahead, VA estimates that  while the total number of veterans will decline by 37 percent between 2008  and 2033, the number of women veterans will increase by more than   17 percent over the same period.
The health care services needed by women veterans are significantly  different from those required by their male counterparts. Women veterans  are younger, in the aggregate, than their male counterparts. Based on an  analysis conducted by the VA in 2007, the estimated median age of women  veterans was 47, whereas the estimated median age of male veterans was  61. Women veterans seeking care at VA medical facilities need access to a  full range of physical health care services, including basic gender-specific  services—such as breast examinations, cervical cancer screening, and  menopause management—and specialized gender-specific services such  as obstetric care (which includes prenatal, labor and delivery, and  postpartum care) and treatment of reproductive cancers. Women veterans  also need access to a range of mental health care services, such as care for  depression.
In addition, women veterans of OEF/OIF present new challenges for VA’s  health care system. Almost all of these women are under the age of 40—  58 percent are between the ages of 20 and 29. VA data show that almost   20 percent of women veterans of OEF/OIF have been diagnosed with post- traumatic stress disorder (PTSD). Additionally, an alarming number of  them have experienced sexual trauma while in the military. As a result,  many women veterans of OEF/OIF have complex physical and mental  health care needs.
Congress and others have raised concerns about how well VA is prepared  to meet the physical and mental health care needs of the growing number  of women veterans, particularly veterans of OEF/OIF. Traditionally,  women veterans have utilized VA’s health care services less frequently  than their male counterparts. In fiscal year 2007, 15 percent of women  veterans used VA’s health care services, compared to 22 percent of male  veterans. VA believes that part of this difference may be attributable to  barriers that the current care models at many VA medical facilities present  to women veterans. For example, women veterans have often been  required to make multiple visits to a VA facility in order to receive the full  spectrum of primary care services, which includes such basic gender- specific care as cervical cancer screenings and breast examinations.  Because many of these women work or have child care responsibilities,  multiple visits can be problematic, especially when services are not  available in the evenings or on weekends.
VA has taken some steps to improve the availability of services for women  veterans, including requiring that all VA medical facilities make the  Women Veterans Program Manager (WVPM)—an advocate for the needs  of women veterans—a full-time position and providing funding for  equipment to help VA medical facilities improve health care services for  women veterans. Additionally, in November 2008, VA began a systemwide  initiative to make comprehensive primary care for women veterans  available at every VA medical facility—VA medical centers (VAMC) and  community-based outpatient clinics (CBOC). In announcing this initiative,  VA established a policy defining comprehensive primary care for women  veterans as the availability of complete primary care—including routine  detection and management of acute and chronic illness, preventive care,  gender-specific care, and mental health care—from one primary care  provider at one site.
You asked us to examine VA’s health care services for women veterans. In  my testimony today, I will discuss our preliminary findings, based on visits  to selected VA facilities, regarding (1) the on-site availability of health care  services at VA facilities for women veterans, (2) the extent to which VA  facilities are following VA policies that apply to the delivery of health care  services for women veterans, and (3) some key challenges that VA  facilities are experiencing in providing health care services for women  veterans.
To examine the availability of health care services at VA facilities for  women veterans and to determine the extent to which VA facilities are  following VA policies that apply to the delivery of health care services for  women veterans, we reviewed applicable VA policies and available VA  data, and interviewed officials from VA headquarters, Veterans Integrated  Service Networks (VISN), and VA facilities. In addition, we conducted site  visits to a judgmental sample of nine VAMCs located in Atlanta and Dublin,  Georgia; San Diego and Long Beach, California; Minneapolis and St. Cloud,  Minnesota; Sioux Falls, South Dakota; and Temple and Waco, Texas. We  also visited 10 VA CBOCs affiliated with these nine VAMCs, and eight Vet  Centers, which are counseling centers that help combat veterans readjust  from wartime military service to civilian life. We used VA data to select  these sites based on several factors, including the number of women  veterans using health care services at each VAMC and whether facilities  offered specific programs for women veterans, such as outpatient or  residential treatment programs for women who have PTSD or have  experienced military sexual trauma (MST). See appendix I for additional  details on the selection criteria we used and information on the number of  women veterans using health care services at each VAMC and CBOC we  visited. To further examine the availability of services for women veterans,  we obtained information from each VAMC and CBOC regarding the  organization and availability of primary care services, basic gender- specific services, specialized gender-specific services, and mental health  services in outpatient, residential, and inpatient settings; and the  availability of specific clinical services such as prenatal care, osteoporosis  treatment, mammography, and counseling for MST. When services were  not available on site, we determined whether they were available through  fee-for-service arrangements (fee basis), contracts, or sharing agreements  with non-VA facilities. During our site visits we also toured each facility  and documented observations of the physical space in each care setting.  We examined how facilities were implementing VA policies pertaining to  ensuring the privacy of women veterans in outpatient, residential, and  inpatient care settings; and VA’s model of comprehensive primary care for  women veterans. Finally, to identify key challenges that VA facilities are  experiencing in providing health care services for women veterans, we  reviewed relevant literature; interviewed VA officials in headquarters,  medical facilities, and Vet Centers; interviewed VA experts in the area of  women veterans’ health; and documented challenges observed during our  site visits. The findings of our site visits to VA facilities cannot be  generalized to other VA facilities. We shared the information contained in  this statement with VA officials, and they generally agreed with the  information we presented.
We conducted our performance audit from July 2008 through July 2009 in  accordance with generally accepted government auditing standards. Those  standards require that we plan and perform the audit to obtain sufficient,  appropriate evidence to provide a reasonable basis for our findings and  conclusions based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives.
subsections: section_title: Background
subsections: section_title: VA Health Care System
paragraphs: VA’s integrated health care delivery system is one of the largest in the  United States and provides enrolled veterans, including women veterans,  with a range of services including primary and preventive health care  services, mental health services, inpatient hospital services, long-term  care, and prescription drugs. VA’s health care system is organized into   21 VISNs that include VAMCs and CBOCs. VAMCs offer outpatient,  residential, and inpatient services. These services range from primary care  to complex specialty care, such as cardiac and spinal cord injury care.  VAMCs also offer a range of mental health services, including outpatient  counseling services, residential programs—which provide intensive  treatment and rehabilitation services, with supported housing, for  treatment, for example, of PTSD, MST, or substance use disorders—and  inpatient psychiatric treatment. CBOCs are an extension of VAMCs and  provide outpatient primary care and general mental health services on site.  VA also operates 232 Vet Centers, which offer readjustment and family  counseling, employment services, bereavement counseling, and a range of  social services to assist combat veterans in readjusting from wartime  military service to civilian life.
When VA facilities are unable to efficiently provide certain health care  services on site, they are authorized to enter into agreements with non-VA  providers to ensure veterans have access to medically necessary services.  Specifically, VA facilities can make services available through  referral of patients to other VA facilities or use of telehealth services,    sharing agreements with university affiliates or Department of Defense    contracts with providers in the local community, or   allowing veterans to receive care from providers in the community who  will accept VA payment (commonly referred to as fee-basis care).
section_title: VA Policies Pertaining to Women’s Health
paragraphs: Federal law authorizes VA to provide medically necessary health care  services to eligible veterans, including women veterans. Federal law also  specifically requires VA to provide mental health screening, counseling,  and treatment for eligible veterans who have experienced MST. Although  the MST law applies to all veterans, it is of particular relevance to women  veterans because among women veterans screened by VA for MST,   21 percent screened positive for experiencing MST. VA provides health  care services to veterans through its medical benefits package—health  care services required to be provided are broadly stated in a regulation  and further specified in VA policies. Through policies, VA requires its  health care facilities to make certain services, including gender-specific  services and primary care services, available to eligible women veterans.  Gender-specific services that are included in the VA medical benefits  package include, for example, cervical cancer screening, breast  examination, management of menopause, mammography, obstetric care,  and infertility evaluation. See table 1 for a list of selected basic and  specialized gender-specific services that VA is required to make available  and others that VA may make available to women veterans.
In November 2008, VA established a policy that requires all VAMCs and  CBOCs to move toward making comprehensive primary care available for  women veterans. VA defines comprehensive primary care for women  veterans as the availability of complete primary care—including routine  detection and management of acute and chronic illness, preventive care,  basic gender-specific care, and basic mental health care—from one  primary care provider at one site. VA did not establish a deadline by which  VAMCs and CBOCs must meet this requirement.
VA policies also outline a number of requirements specific to ensuring the  privacy of women veterans in all settings of care at VAMCs and CBOCs.   These include requirements related to ensuring auditory and visual privacy  at check-in and in interview areas; the location of exam rooms, presence  of privacy curtains, and the orientation of exam tables; access to private  restrooms in outpatient, inpatient, and residential settings of care; and the  availability of sanitary products in public restrooms at VA facilities.  1n 1991, VA established the position of Women Veteran Coordinator—now  the WVPM—to ensure that each VAMC had an individual responsible for  assessing the needs of women veterans and assisting in the planning and  delivery of services and programs to meet those needs. Begun as a part- time collateral position, the WVPM is now a full-time position at all  VAMCs. In July 2008, VA required VAMCs to establish the WVPM as a full- time position (no longer a collateral duty) no later than December 1, 2008.  Clinicians in the role of WVPM would be allowed to perform clinical duties  to maintain their professional certification, licensure, or privileges, but  must limit the time to the minimum required, typically no more than   5 hours per week.
section_title: VA Mental Health Services
paragraphs: In September 2008, VA issued the Uniform Mental Health Services in VA  Medical Centers and Clinics, a policy that specifies the mental health  services that must be provided at each VAMC and CBOC. The purpose of  this policy is to ensure that all veterans, wherever they obtain care in VA’s  health care system, have access to needed mental health services. The  policy lists the mental health care services that must be delivered on site  or made available by each facility. To help ensure that mental health staff  can provide these services, VA has developed and rolled out evidence- based psychotherapy training programs for VA staff that treat patients  with PTSD, depression, and serious mental illness. VA’s training programs  cover five evidence-based psychotherapies: Cognitive Processing Therapy  (CPT) and Prolonged Exposure (PE), which are recommended for PTSD;  Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment  Therapy (ACT), which are recommended for depression; and Social Skills  Training (SST), which is recommended for serious mental illness. The  training programs involve two components: (1) attendance at an in-person,  experientially-based, workshop (usually 3-4 days long), and (2) ongoing  telephone-based small-group consultation on actual therapy cases with a  consultant who is an expert in the psychotherapy.
section_title: VA Facilities Provided Basic and Specialized Gender-Specific Services and Mental Health Services to Women Veterans, though Not All Services Were Provided On Site at Each VA Facility
paragraphs: The VA facilities we visited provided basic gender-specific and outpatient  mental health services to women veterans on site, and some facilities also  provided specialized gender-specific or mental health services specifically  designed for women on site. All of the VAMCs we visited offered at least  some specialized gender-specific services on site, and six offered a broad  array of these services. Among CBOCs, other than the two largest facilities  we visited, most offered limited specialized gender-specific care on site.  Women needing obstetric care were always referred to non-VA providers.  Regarding mental health care, we found that outpatient services for  women were widely available at the VAMCs and most Vet Centers we  visited, but were more limited at some CBOCs. Eight of the VAMCs we  visited offered mixed-gender inpatient or residential mental health  services, and two VAMCs offered residential treatment programs  specifically designed for women veterans.
subsections: section_title: Basic Gender-Specific Care Services Were Generally Available On site at VA Medical Facilities
paragraphs: Basic gender-specific care services were available on site at all nine of the  VAMCs and 8 of the 10 CBOCs that we visited. (See table 2.) These  facilities offered a full array of basic gender-specific services for women— such as pelvic examinations, and osteoporosis treatment—on site. One of  the CBOCs we visited did not offer any basic gender-specific services on  site and another offered a limited selection of these services. These  CBOCs that provided limited basic gender-specific services referred  patients to other VA facilities for this care, but had plans underway to offer  these services on site once providers received needed training. In general,  women veterans had access to female providers for their gender-specific  care: of the 19 medical facilities we visited, all but 4 had one or more  female providers available to deliver basic gender-specific care.
The facilities we visited delivered basic gender-specific services in a  variety of ways. Seven of the nine VAMCs and the two large CBOCs we  visited had women’s clinics. The physical setup of these clinics ranged  from a physically separate dedicated clinical space (at five facilities) to  one or more designated women’s health providers with designated exam  rooms within a mixed-gender primary care clinic. Generally, when  women’s clinics were available, most female patients received their basic  gender-specific care in those clinics. When women’s clinics were not  available, female patients either received their gender-specific care  through their primary care provider or were referred to another VA or non- VA facility for these services.
Basic gender-specific services were typically available between 8:00 a.m.  and 4:30 p.m. on weekdays. At one CBOC and one VAMC, however, basic  gender-specific care was only available during limited time frames. At the  CBOC, a provider from the affiliated VAMC traveled to the CBOC 2 days  each month to perform cervical cancer screenings and pelvic  examinations for the clinic’s female patients. In general, medical facilities  did not offer evening or weekend hours for basic gender-specific services.
section_title: While All VAMCs Offered at Least Some Specialized Gender-Specific Services On site, CBOCs Typically Referred Patients Needing These Services to Other VA or Non-VA Medical Facilities
paragraphs: The provision of specialized gender-specific services for women, including  treatment after abnormal cervical cancer screenings and breast cancer  treatment, varied by service and by facility. (See table 3.) All VA medical  facilities referred female patients to outside providers for obstetric care.  Some of the VAMCs we visited offered a broad array of other specialized  gender-specific services on site, but all contracted or fee-based at least  some services. In particular, most VAMCs provided screening and  diagnostic mammography through contracts with local providers or fee- based these services. In addition, less than half of the VAMCs provided  reconstructive surgery after mastectomy on site, although six of the nine  VAMCs we visited provided medical treatment for breast cancers and  reproductive cancers on site. In general, the CBOCs we visited offered  more limited specialized gender-specific services on site. For example,  while most CBOCs offered pregnancy testing and sexually transmitted  disease (STD) screening, counseling, and treatment, only the largest  CBOCs offered IUD placement on site. Most CBOCs referred patients to  VA medical facilities—sometimes as far as 130 miles away—for some  specialized gender-specific services. Because the travel distance can be a  barrier to treatment for some veterans, officials at some CBOCs said that  they will fee-base services to local providers on a case-by-case basis. At  both VAMCs and CBOCs, specialized gender-specific services were usually  offered on site only during certain hours: for example, four medical  facilities only offered these services 2 days per week or less.
section_title: Outpatient Mental Health Services Were Widely Available at Most VAMCs and Vet Centers, but More Limited at Smaller CBOCs
paragraphs: A range of outpatient mental health services was readily available at the  VAMCs we visited. The types of outpatient mental health services available  at most VAMCs included, for example, diagnosis and treatment of  depression, substance use disorders, PTSD, and serious mental illness. All  of the VAMCs we visited had one or more providers with training in  evidence-based therapies for the treatment of PTSD and depression. All  but one of the VAMCs we visited offered at least one women-only  counseling group. Two VAMCs offered outpatient treatment programs  specifically for women who have experienced MST or other traumas. In  addition, several VAMCs offered services during evening hours at least   1 day a week. While most outpatient mental health services were available  on site, facilities typically fee-based treatment for a veteran with an active  eating disorder to non-VA providers.
Similarly, the eight Vet Centers we visited offered a variety of outpatient  mental health services, including counseling services for PTSD and  depression, as well as individual or group counseling for victims of sexual  trauma. Five of the eight Vet Centers we visited offered women-only  groups, and six had counselors with training or experience in treating  patients who have suffered sexual trauma. Vet Centers generally offered  some counseling services in the evenings.
The outpatient mental health services available in CBOCs were, in some  cases, more limited. The two larger CBOCs offered women-only group  counseling as well as intensive treatment programs specifically for women  who had experienced MST or other traumas, and two other CBOCs offered  women-only group counseling. The smaller CBOCs, however, tended to  rely on staff from the affiliated VAMC, often through telehealth, to provide  mental health services. Five CBOCs provided some mental health services  through telehealth or using mental health providers from the VAMC that  traveled to the CBOCs on specific days.
section_title: While Most VAMCs Offer Mixed-Gender Residential or Inpatient Mental Health Services, Few Have Specialized Programs for Women Veterans
paragraphs: While most VAMCs offer mixed-gender residential mental health treatment  programs or inpatient psychiatric services, few have specialized programs  for women veterans. Eight of the nine VAMCs we visited served women  veterans in mixed-gender inpatient psychiatric units, mixed-gender  residential treatment programs, or both. Two VAMCs had residential  treatment programs specifically for women who have experienced MST  and other traumas. (VA has ten of these programs nationally.) None of the  VAMCs had dedicated inpatient psychiatric units for women. VA providers  at some facilities expressed concerns about the privacy and safety of  women veterans in mixed-gender inpatient and residential environments.  For example, in the residential treatment programs, beds for women  veterans were separated from other areas of the building by keyless entry  systems. However, female residents in some of these programs shared  common areas, such as the dinning room, with male residents, and  providers expressed concerns that women who were victims of sexual  trauma might not feel comfortable in such an environment.
section_title: Medical Facilities Had Not Fully Implemented VA Policies Pertaining to the Delivery of Health Care Services for Women Veterans
paragraphs: The extent to which VA medical facilities we visited were following VA  policies that apply to the delivery of health care services for women  veterans varied, but none of the facilities had fully implemented VA  policies pertaining to women veterans’ health care. In particular, none of  the VAMCs or CBOCs we visited were fully compliant with VA policy  requirements related to privacy for women veterans. In addition, the  facilities we visited were in various stages of implementing VA’s new  initiative on comprehensive primary care: most medical facilities had at  least one provider that could deliver comprehensive primary care services  to women veterans, although not all of these facilities were routinely  assigning women veterans to these providers. Officials at some VA  facilities reported that they were unclear about the specific steps they  would need to take to meet VA’s definition of comprehensive primary care  for women veterans.
subsections: section_title: None of the Facilities Were Fully Compliant with VA Policies Related to Ensuring the Privacy of Women Veterans
paragraphs: All facilities were fully compliant with at least some of VA’s privacy  requirements; however, we documented observations in many clinical  settings where facilities were not following one or more requirements.  Some common areas of noncompliance included the following:    Visual and auditory privacy at check-in. None of the VAMCs or CBOCs  we visited ensured adequate visual and auditory privacy at check-in in all  clinical settings that are accessed by women veterans. In most clinical  settings, check-in desks or windows were located in a mixed-gender  waiting room or on a high-traffic public corridor. In some locations, the  check-in area was located far enough away from the waiting room chairs  that patients checking in for appointments could not easily be overheard.  In a total of 12 outpatient clinical settings at six VAMCs and five CBOCs,  however, check-in desks were located in close proximity to chairs where  other patients waited for their appointments. At one CBOC, we observed a  line forming at the check-in window, with several people waiting directly  behind the patient checking in, demonstrating how privacy can be easily  violated at check-in.
Orientation of exam tables. In exam rooms where gynecological exams  are conducted, only one of the nine VAMCs and two of the eight CBOCs  we visited were fully compliant with VA’s policy requiring exam tables to  face away from the door. In many clinical settings that were not fully  compliant at the remaining facilities, we observed that exam tables were  oriented with the foot of the table facing the door, and in two CBOCs  where exam tables were not properly oriented, there was no privacy  curtain to help assure visual privacy during women veterans’ exams. At  one of these CBOCs, a noncompliant exam room was also located within  view of a mixed-gender waiting room. Figure 1 shows the correct and  incorrect orientation of exam tables in two gynecological exam rooms at  two VA medical facilities.
Restrooms adjacent to exam rooms. Only two of the nine VAMCs and  one of the eight CBOCs we visited were fully compliant with VA’s  requirement that exam rooms where gynecological exams are conducted  have immediately adjacent restrooms. In most of the outpatient clinics  we toured, a woman veteran would have to walk down the hall to access a  restroom, in some cases passing through a high-traffic public corridor or a  mixed-gender waiting room.
Access to private restrooms in inpatient and residential units. At  four of the nine VAMCs we visited, proximity of private restrooms to  women’s rooms on inpatient or residential units was a concern. In one  mixed-gender inpatient medical/surgical unit, two mixed-gender  residential units, and one all-female residential unit, women veterans were  not guaranteed access to a private bathing facility and may have had to use  a shared or congregate facility. In two of these four settings, access to the  shared restroom was not restricted by a lock or a keycard system, raising  concerns about the possibility of intrusion by male patients or staff while a  woman veteran is showering or using the restroom.
Availability of sanitary products in public restrooms. At seven of the  nine VAMCs and all 10 of the CBOCs we visited, we did not find sanitary  napkins or tampons available in dispensers in any of the public restrooms.
section_title: Medical Facilities Were in Various Stages of Implementing VA’s Initiative on Comprehensive Primary Care for Women Veterans, but Officials at Some Facilities Were Unclear about the Steps Needed to Implement VA’s New Initiative
paragraphs: VA has not set a deadline by which all VAMCs and CBOCs are required to  implement VA’s new comprehensive primary care initiative for women  veterans, which would allow women veterans to obtain both primary care  and basic gender-specific services from one provider at one site. Officials  at the VA medical facilities we visited since the comprehensive primary  care for women veterans initiative was introduced reported that they were  at various stages of implementing the new initiative. Officials at 6 of the 7  VAMCs and 6 of the 8 CBOCs we visited since November 2008—when VA  adopted this initiative—reported that they had at least one provider who  could deliver comprehensive primary care services to women veterans.  However, some of the medical facilities we visited reported that they were  not routinely assigning women veterans to comprehensive primary care  providers.
Officials at some medical facilities we visited were unclear about the steps  needed to implement VA’s new policy on comprehensive primary care for  women veterans. For example, at one VAMC, primary care was offered in  a mixed-gender primary care clinic and basic gender-specific services  were offered by a separate appointment in the gynecology clinic,  sometimes on the same day. The new comprehensive primary care  initiative would require both primary care and basic gender specific  services to be available on the same day, during the same appointment.  Officials at this facility said that they were in the process of determining  whether they can adapt their current model to meet VA’s comprehensive  primary care standard by placing additional primary care providers in the  gynecology clinic so that both primary care services and basic gender- specific services could be offered during the same appointment, in one  location. Facility officials were uncertain about whether it would meet  VA’s comprehensive primary care standard if primary care and basic  gender-specific services were still delivered by two different providers.
However, VA’s comprehensive primary care policy is clear that the care is  to be delivered by the same provider. Another area of uncertainty is the  breadth of experience a provider would need to meet VA’s comprehensive  primary care standard. Officials from VA headquarters have made it clear  that it is their expectation that comprehensive primary care providers have  a broad understanding of basic women’s health issues—including initial  evaluation and treatment of pelvic and abdominal pain, menopause  management, and the risks associated with prescribing certain drugs to  pregnant or lactating women. However, in one location, we found that the  only provider who was available to deliver comprehensive primary care  may not have had the proficiency to deliver the broad array of services  that are included in VA’s definition, because the facility serves a very low  volume of women veterans and opportunities to practice delivering some  basic gender-specific services are limited.
section_title: VA Officials Identified Key Challenges Related to Space, Hiring Staff with Specific Experience and Training, and Establishing the WVPM as a Full-time Position
paragraphs: VA officials at medical facilities we visited identified a number of key  challenges in providing health care services to women veterans. These  challenges include physical space constraints that affect the provision of  care, including problems complying with patient privacy requirements,  and difficulties hiring providers that have specific experience and training  in women’s health, as well as hiring mental health providers with expertise  in treating veterans with PTSD and who have experienced MST. Officials  at some VA medical facilities also reported implementation issues in  establishing the WVPM as a full-time position.
subsections: section_title: VA Facility Officials Identified Space Constraints as a Challenge Affecting the Provision of Health Care Services to Women Veterans
paragraphs: Officials at VA medical facilities we visited reported that space constraints  have raised issues affecting the provision of health care services to women  veterans. In particular, officials at 7 of 9 VAMCs and 5 of 10 CBOCs we  visited said that space issues, such as the number, size, or configuration of  exam rooms or bathrooms at their facilities sometimes made it difficult for  them to comply with some VA requirements related to privacy for women  veterans. At some of the medical facilities we visited, officials raised  concerns about busy waiting rooms and the limited space available to  provide separate waiting rooms for patients who may not feel comfortable  in a mixed-gender waiting room, particularly women veterans who have  experienced MST. Officials at one CBOC said they received complaints  from women veterans who preferred a separate waiting room. At this  facility, space challenges that affected privacy were among the factors that  led to the relocation of mental health services to a separate off-site clinic.  VA facility officials told us that some of the patient bedrooms at two  VAMC mixed-gender inpatient psychiatric units that were usually  designated for female patients were located in space that could not be  adequately monitored from the nursing station. VA policy requires that all  inpatient care facilities provide separate and secured sleeping  accommodations for women and that mixed-gender units must ensure safe  and secure sleeping arrangements, including, but not limited to, the ability  to monitor the patient bedrooms from the nursing station.
VA facility officials also told us they have struggled with space constraints  as they work to comply with VA’s new policy on comprehensive primary  care for women and the requirements in the September 2008 Uniform  Mental Health Services in VA Medical Centers and Clinics, as well as the  increasing numbers of women veterans requesting these services. For  example, officials at a VAMC said that limitations in the number of primary  care exam rooms at their facilities made it difficult for providers to deliver  comprehensive primary care services in an efficient and timely manner.  Providers explained that having only one exam room per primary care  provider prevents them from “multitasking,” or moving back and forth  between exam rooms while patients are changing or completing intake  interviews with nursing staff. Similarly, mental health providers at a  medical facility said that they often shared offices, which limits the  number of counseling appointments they could schedule, and primary care  providers sometimes have two patients in a room at the same time  separated by a curtain during the intake or screening process. In addition,  at one VAMC, officials reported that the facility needed to be two to three  times its current size to accommodate increasing patient demand.
VA officials are aware of these challenges and VA is taking steps to  address them, such as funding construction projects, moving to larger  buildings, and opening additional CBOCs. However, some of these  projects will not be finished for a few years. In the interim, officials said,  some facilities are leasing additional space or contracting some services to  community providers.
section_title: VA Facility Officials Identified Difficulties Hiring Primary Care Providers with the Specific Training and Experience Needed to Provide Services to Women Veterans
paragraphs: VA facility officials reported difficulties hiring primary care providers with  specific training and experience in women’s health. VA’s comprehensive  primary care initiative requires that women veterans have access to a  designated women’s health primary care provider that is “proficient,  interested, and engaged” in delivering services to women veterans. The  new policy requires that this primary care provider fulfill a broad array of  health care services including, but not limited to    detection and management of acute and chronic illness, such as  osteoporosis, thyroid disease, and cancer of the breast, cervix, and lung;    gender-specific primary care such as sexuality, pharmacologic issues  related to pregnancy and lactation, and vaginal infections;    preventive care, such as cancer screening and weight management;   mental health services such as screening and referrals for MST, as well as  evaluation and treatment of uncomplicated mental health disorders and  substance use disorders; and    coordination of specialty care.
Officials at some facilities we visited told us that they would like to hire  more providers with the required knowledge and experience in women’s  health, but struggle to do so. For example, at one VAMC, officials reported  that they had difficulty filling three vacancies for primary care providers,  which they needed to meet the increasing demand for services and to  replace staff who had retired. They said it took them a long time to find  providers with the skills required to serve the needs of women veterans.  Similarly, at one CBOC, officials reported that it takes them about 8 to 9  months to hire interested primary care physicians. Further, officials at  some facilities we visited said that they rely on just one or two providers  to deliver comprehensive primary care to women veterans. This is a  concern to the officials because, should the provider retire or leave VA,  the facility might not be able to replace them relatively quickly in order to  continue to provide comprehensive primary care services to women  veterans on site.
VA officials have acknowledged some of the challenges involved in  training additional primary care providers to meet their vision of  delivering comprehensive primary care to women veterans. A November  2008 report on the provision of primary care to women veterans cites  insufficient numbers of clinicians with specific training and experience in  women’s health issues among the challenges VA faces in implementing  comprehensive primary care. To help address the knowledge gap, VA is  using “mini-residency” training sessions on women’s health. These training  sessions—which VA designed to enhance the knowledge and skills of  primary care providers—consist of two and one-half days of case-based  learning and hands-on training in gender-specific health care for women.  During the mini-residency, providers receive specific training in  performing pelvic examinations, cervical cancer screenings, clinical breast  examinations, and other relevant skills.
section_title: VA Medical Facility and Vet Center Officials Identified Challenges Hiring Mental Health Providers with Training and Experience in Treating PTSD and MST
paragraphs: VA medical facility and Vet Center officials reported challenges hiring  psychiatrists, psychologists, and other mental health staff with specialized  training or experience in treating PTSD and MST. Medical facility officials  often noted that there is a limited pool of qualified psychiatrists and  psychologists, and a high demand for these professionals both in the  private sector and within VA. In addition, two officials reported that  because it is difficult to attract and hire mental health professionals with  experience in treating the veteran population, some medical facilities have  hired younger, less experienced providers. These officials noted that while  younger providers may have the appropriate education and training in  some evidence-based psychotherapy treatment methods that are  recommended for treating PTSD and MST, they often lack practical  experience treating a challenging patient population.
Some officials reported that staffing and training challenges limit the types  of group or individual mental health treatment services that VA medical  facilities and Vet Centers can offer. For example, officials at one VAMC  said that they had problems attracting qualified mental health providers to  work at its affiliated CBOCs. The facility posted announcements for  psychiatrist and psychologist positions, but sometimes received no  applications. Because the facility has not been able to recruit mental  health providers, it relies on contract providers and fee-basing to deliver  mental health services to veterans in its service area. At one Vet Center,  officials told us that because none of their counselors have been trained to  counsel veterans who have experienced MST, patients seeking counseling  for MST are usually referred to the nearby CBOC or VAMC. At one CBOC,  a licensed social worker reported that he provides individual counseling  for about seven women who have experienced MST, even though he has  limited training in this area. He said that this situation was not ideal, but  said that he consults with mental health providers at the associated VAMC  on some of these cases, and that without his services some of these  women might not receive any counseling.
VA officials told us that they are aware of the challenges involved in  finding clinical staff with specialized training and experience in working  with veterans who have PTSD or have experienced MST. A VA official told  us that as part of a national effort to enhance mental health providers’  knowledge of clinically effective treatment methods and make these  methods available to veterans, VA has developed evidenced-based  psychotherapy training for VA mental health staff. In particular, CPT, PE,  and ACT are evidence-based treatment therapies for PTSD and also  commonly used by providers who work with patients who have  experienced MST. A VA headquarters official who is responsible for  these training programs told us that as of May 4, 2009, 1,670 VA clinicians  had completed VA-provided training in evidence-based therapies. Although  VA is providing training in these evidence-based therapies, VA officials  stated that this training is not mandatory for VA mental health providers  who work with patients who have PTSD or have experienced M ST.
section_title: Some VAMC Officials Reported That Establishing the WVPM as a Full-time Position Has Raised Implementation Issues
paragraphs: Some VA officials expressed concerns that certain aspects of the new  policy making the WVPM a full-time position may have the unintended  consequence of discouraging clinicians from applying for or staying in the  position, potentially leading to the loss of experienced WVPMs. One  concern that some WVPMs raised during our interviews was that they  were interested in performing clinical duties beyond the minimum  required to maintain their professional certification, but would not be able  to do so under the new policy. The new policy limits a WVPM’s clinical  duties to the minimum required to maintain professional certification,  licensure, or privileges, typically no more than 5 hours per week. Another  concern was that the change to full-time status could result in a reduction  in salary for some clinicians because the position could be classified as an  administrative position, depending on how the policy is implemented at  the VAMC. At two VAMCs we visited, such concerns had discouraged the  incumbent WVPM from accepting the full-time position.
VA headquarters officials told us that they are aware of and have  expressed their concerns to VA senior headquarters officials about  unintended consequences of the new policy. VA headquarters officials  provided VISN and VAMC leadership with some options that they could  use to help avoid or minimize the potential loss of experienced WVPMs.  For example, one option that could be approved on a case-by-case basis is  to use a job-sharing arrangement that would allow the incumbent WVPM  and another person to each dedicate 50 percent of their time to the WVPM  position, performing clinical duties the other 50 percent, in order to  transition staff into the full-time position or as a succession planning  effort. VA headquarters officials said that action on this issue was  important because VA does not have the time or resources to train new  staff to replace experienced WVPMs who may leave their positions.
Mr. Chairmen, this completes my prepared remarks. I would be happy to  respond to any questions either of you or other Members of the  Subcommittees have at this time.
For further information about this testimony, please contact Randall  Williamson at (202) 512-7114 or williamsonr@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs may be found on  the last page of this statement. GAO staff who made major contributions  to this testimony are listed in appendix II.
section_title: Appendix I: Information on the Selection of VA Facilities Examined in This Report
paragraphs: We selected locations for our site visits using VA data on each VA medical  center (VAMC) in the United States. Our goal was to identify a  geographically diverse mix of facilities, including some facilities that  provide services to a high volume of women veterans, particularly women  veterans of Operation Enduring Freedom (OEF) and Operation Iraqi  Freedom (OIF); some facilities that serve a high proportion of National  Guard or Reserve veterans; and some facilities that serve rural veterans.  We also considered whether VAMCs had programs specifically for women  veterans, particularly treatment programs for post-traumatic stress  disorder (PTSD) and for women who have experienced military sexual  trauma (MST). For each of the factors listed below, we examined available  facility- or market-level data to identify facilities of interest:  total number of unique women veteran patients using the VAMC;   total number of unique OEF/OIF women veteran patients using the VAMC;    proportion of unique women veterans using the VAMC who are OEF/OIF    proportion of unique OEF/OIF women veterans using the VAMC who were  discharged from the National Guard or Reserves;    within the VA-defined market area for the VAMC, the proportion of women  veterans who use VA health care and live in rural or highly rural areas; and    availability of on-site programs specific to women veterans, such as  inpatient or residential treatment programs that offer specialized  treatment for women veterans with PTSD or who have experienced MST,  including programs that are for women only or have an admission cycle  that includes only women; and outpatient treatment teams with a  specialized focus on MST.
We selected a judgmental sample of the VAMCs that fell into the top 25  facilities for at least two of these factors. Once we had selected these  VAMCs, we also selected at least one community-based outpatient clinic  (CBOC) affiliated with each of the VAMCs and one nearby Vet Center,  which we also visited during our site visits. In selecting these CBOCs and  Vet Centers, we focused on selecting facilities that represented a range of  sizes, in terms of the number of women veterans they served.
Tables 5 and 6 provide information on the unique number of women  veterans served by each of the VAMCs and CBOCs we selected for site  visits.
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Marcia A. Mann, Assistant  Director; Susannah Bloch; Chad Davenport; Alexis MacDonald; and  Carmen Rivera-Lowitt made key contributions to this testimony.
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