VA Health Care: Facilities Have Taken Action to Provide Language Access Services and Culturally Appropriate Care to a Diverse Veteran Population
Published: 2008-05-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Department of Veterans Affairs (VA) faces challenges in bridging language and cultural barriers as it seeks to provide quality health care services to an increasingly diverse veteran population in terms of race, ethnicity, sex, and age. To meet the needs of veterans with limited English proficiency (LEP), VA issued an LEP Directive that provides guidance for medical centers in assessing language needs and, if needed, developing language access services designed to ensure effective communication between English-speaking providers and those with LEP. In addition, VA is also challenged to deliver health care services in ways that are culturally appropriate--that is, respectful of and responsive to the cultural values of a diverse veteran population. In light of these challenges, GAO was asked to discuss the (1) actions VA has taken to implement its LEP Directive and the status of veterans' utilization of language access services, and (2) efforts VA has made to provide culturally appropriate health care services. GAO reviewed VA's policies and the LEP Directive, interviewed VA officials and reviewed efforts by 6 VA medical centers and 10 other VA facilities to implement VA's LEP Directive and to provide culturally appropriate health care services. GAO also reviewed documents from 17 other VA medical centers related to implementation of the LEP Directive.
section_title: What GAO Found
paragraphs: VA reported that as of June 2007, all of its medical centers had taken action to implement the guidance in VA's LEP Directive. Specifically, medical center officials told VA that they had assessed the language needs of their veteran service populations, and, if necessary, developed language assistance policies and offered language access services, including providing translated materials and interpretation services. The VA medical centers GAO reviewed provided translated materials to meet the various language needs of their veteran service populations and offered interpretation services as well. For example, VA medical centers maintained a list of bilingual medical center staff who can provide interpretation services during a clinical encounter between a provider and a veteran with LEP. In addition, five of the six VA medical centers GAO reviewed can access telephone interpretation services that are provided through a contract to help ensure that medical staff can communicate with veterans and their families with LEP. According to officials at medical centers GAO reviewed, utilization of language access services is low. However, VA officials told GAO that they expect the demand for language access services to grow as the increasingly diverse military servicemember population transitions to veteran status. VA medical centers are addressing the need for culturally appropriate health care services through staff training and tailoring health care services. Medical centers provide training for medical center staff to facilitate the delivery of culturally appropriate health care services including an annual mandatory training on the health care needs of veterans in various age groups. VA medical centers and other VA facilities GAO reviewed have implemented a variety of measures to meet the needs of their culturally diverse veteran populations. For example, three VA facilities GAO reviewed offer spiritual services, such as the use of medicine men and traditional healing rituals, in order to meet the needs of Native American veterans. Also, VA has minority veterans program coordinators at each medical center to identify barriers to health care for minorities and advise medical center officials in developing services to make health care more accessible and culturally appropriate for minority veteran populations. VA medical centers GAO reviewed have also initiated outreach efforts to promote the availability of culturally appropriate care. In commenting on a draft of this report, VA stated that it agreed with the information presented as it pertained to VA.

section_title: Letter
paragraphs: The veteran population served by the Department of Veterans Affairs (VA)  will become more diverse in terms of race, ethnicity, sex, and age. VA data  show that racial and ethnic minorities account for about 20 percent of the  veteran population and that about 7 percent of veterans are women. We  reported in 2005 that racial and ethnic minorities accounted for about   33 percent of servicemembers in the military; about 16 percent of  servicemembers were women. Based on the higher diversity among  servicemembers in the military compared to veterans, VA officials  anticipate that the veteran population eligible to receive health care  services from VA will become more diverse as current members of the  military are discharged or released from active duty and transition to  veteran status. In addition to racial and ethnic diversity, VA has seen an  increase in the number of younger Operation Enduring Freedom and  Operation Iraqi Freedom veterans using VA health care services and  officials expect this number to continue to grow.
As its veteran population becomes more diverse, VA faces challenges in  bridging language and cultural barriers as it seeks to provide quality health  care services to its veteran population. For example, a study  commissioned by the California Endowment and the Robert Wood  Johnson Foundation found that to help meet the needs of a diverse patient  population, health care institutions, such as VA medical facilities, should  provide language access services. Language access services are designed  to ensure effective communication between English speakers and those  with limited English proficiency (LEP). This may include providing  translated versions of informational brochures or consent forms and  making staff available who can interpret providers’ instructions for  patients or their family members with LEP. Several studies have found that  the implementation of language access services in health care settings can  increase access to care, quality of care, and health outcomes.
Research suggests that providing culturally appropriate health care  services is an integral part of quality health care, and that cultural factors  can have a significant influence on the delivery of health care services and  can compromise access for culturally diverse populations. At the federal  level, HHS has published a set of standards for medical facilities that state  that health care services should be delivered in ways that are culturally  appropriate—that is, respectful of and responsive to the cultural values of  a diverse population. This can mean, for example, recognizing the role of  the extended family in medical decisions for a particular ethnic group and  including these individuals in discussions of a patient’s medical care and  treatment. According to HHS’s standards, providing culturally appropriate  services to culturally diverse patients has the potential to improve access  to care, quality of care, and ultimately, health outcomes. Prior to the  enactment of the National Defense Authorization Act (NDAA) for Fiscal  Year 2008, there was no specific statutory requirement for VA to provide  culturally appropriate care. However, several provisions in the 2008 NDAA  require the consideration of the gender-, ethnic group-, or age-specific  needs of veterans, including a direction to provide age-appropriate nursing  home care.
To meet the needs of persons with LEP, the President issued an executive  order in August 2000 that required all federal agencies to develop and  implement a system by which persons with LEP can have meaningful  access to the services provided by the agency. The order also instructs  federal agencies to work to ensure that recipients of federal financial  assistance provide meaningful access to their LEP applicants and  beneficiaries. According to the order, each agency must develop a plan  that outlines the steps the agency will take to ensure that persons with  LEP have meaningful access to the programs and services it provides. In  response to this order, in January 2002, VA issued a directive of its own— referred to in this report as the LEP Directive —to assist VA programs,  including its medical centers, in providing appropriate language access  services for veterans with LEP. The LEP directive provides guidance to  medical centers and other facilities within VA to help them comply with  EO 13166; medical centers and other facilities that do not adopt all of the  specific practices outlined in the directive are not necessarily out of  compliance with the executive order as long as medical center officials  take reasonable steps to assess and meet the language needs of the  veteran service population. Additionally, because the diversity of the  veteran service population varies across VA medical centers, some  medical centers may not have a need to take all the actions identified in  VA’s LEP Directive.
In light of the increasing diversity of the veteran population in terms of  race, ethnicity, sex, and age, you asked for information about the steps VA  has taken to provide language access services for veterans and its efforts  to deliver health care services in ways that are culturally appropriate for  veterans’ diverse cultural values. This report discusses the (1) actions VA  has taken to implement its LEP Directive and the status of veterans’  utilization of available language access services, and (2) efforts VA has  made to provide culturally appropriate health care services. We did not  assess VA’s compliance with EO 13166 and instead describe actions taken  under VA’s LEP Directive in response to EO 13166.
To describe the actions VA has taken to implement its LEP Directive as  well as veterans’ utilization of available language access services and the  efforts VA has made to provide culturally appropriate health care services,  we reviewed an executive order, federal guidance, and VA policy and  procedures. We also selected five Veterans Integrated Service Networks  (VISN) to review. We selected these five VISNs based on the number of  racial and ethnic minority veterans living in each VISN and geographic  variation. Within these five VISNs we selected a judgmental sample of 16  VA facilities, including six VA medical centers, five community-based  outpatient clinics (CBOC), and five Vet Centers, to include in our review.  From our sample of VA facilities, we conducted site visits to medical  centers and associated CBOCs, and Vet Centers, located in Chicago,  Illinois; Durham, North Carolina; and Los Angeles, California. For the  remainder of VA facilities in our sample, we conducted in-depth telephone  interviews with medical center, CBOC, and Vet Center officials in Bath,  New York; Prescott, Arizona; and Richmond, Virginia. We conducted in- depth interviews with VA officials and staff from each of the 16 VA  facilities to learn about actions taken at their facility to provide language  access services for veterans with LEP, the utilization of these services, and  the efforts the facility has made to provide culturally appropriate health  care services. At the six VA medical centers we reviewed in depth, we  examined documents related to efforts by the centers to assess the  language needs of their service population and, if necessary, provide  language access services. In addition, we interviewed officials in each of  the five VISNs we selected for review. The information we collected from  the six medical centers and five VISNs we reviewed is not generalizable to  all VISNs and VA medical centers.
Additionally, in order to obtain information on the steps VA has taken  through its medical centers to provide language access services under its  LEP Directive, we selected a random sample of 20 VA medical centers and  requested copies of language needs assessments conducted by medical  center officials and language assistance policies. We received  documentation from 17 of the 20 medical centers. We conducted follow-up  with the three medical centers that did not provide documentation but did  not receive the requested materials from them. We did not evaluate the  quality of the language needs assessments or language access policies  provided by the 17 medical centers or from the 6 medical centers we  visited or reviewed in depth. The information we collected from our  sample of 17 medical centers is not generalizable to all VA medical  centers. In addition to interviews we conducted with VA officials, we also  interviewed officials from the Department of Justice (DOJ), as well as  experts in the field of language access services and the provision of  culturally competent health care services. We conducted this  performance audit from February 2007 through March 2008, 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 based on our audit objectives.
subsections: section_title: Background
paragraphs: EO 13166, Improving Access to Services for Persons with Limited  English Proficiency, requires that all federal agencies take reasonable  steps to ensure meaningful access to their programs and services for  people with LEP. DOJ has issued guidance that spells out four factors  agencies need to consider in determining whether they are taking  reasonable steps in this regard: (1) the number or proportion of LEP  persons in the eligible service population; (2) the frequency with which  LEP individuals come in contact with the program; (3) the importance of  the services provided by the program; and (4) the resources available.  Reasonable steps to ensure meaningful access could include developing  language access services and guidance for implementing these services.  The EO required that each federal agency create a plan outlining steps it  will take consistent with DOJ guidance to ensure meaningful access to its  services by LEP individuals. The EO did not require DOJ to evaluate the  plans or to monitor the implementation of these plans.
In 2002, in response to EO 13166, VA created and implemented VHA  Directive 2002-006. It provided a framework for VA medical centers to  assess and determine if there was a need to develop language assistance  policies and language access services. The medical centers retain  flexibility to determine exactly how they will comply with the EO, but they  must do so in accordance with the four factors as outlined by DOJ and  reiterated in the LEP Directive. In February 2007, VA issued VHA Directive  2007-009, which renewed VA’s guidance on language assistance policies.  In its LEP Directive, VA outlined the steps that constitute an effective  language assistance program at its medical centers, including an  assessment of the language needs of the veteran population served and  identification of the non-English languages encountered by medical center  staff. If a VA medical center identifies a specific language need among its  veteran service population, VA’s LEP Directive also indicated that the  medical center should develop and implement a language assistance policy  to ensure meaningful communication. According to the directive, the  policy should describe how the medical center plans to provide language  access services and ensure that all veterans receive meaningful access to  VA health care services, regardless of the veterans’ level of English  proficiency. VA’s LEP Directive also provided medical centers with  examples of ways to provide language access services—including,  translating written materials, hiring bilingual staff, and contracting with  interpreter services.
VA’s Equal Employment Opportunity (EEO) office is responsible for  overseeing the implementation of VA’s LEP Directive. As such, this office  conducted surveys of VA medical centers to assess whether medical  center officials were following the steps outlined in the LEP Directive,  such as conducting an assessment of language needs, or otherwise taking  reasonable steps to provide language access services for veterans being  served. VA’s Center for Minority Veterans (CMV) is also involved in  helping medical centers meet the language and cultural needs of the  veteran population. CMV is responsible for ensuring that eligible minority  veterans receive VA benefits and services.
Culturally appropriate health care is care that is respectful of and  responsive to the cultural needs of patients. According to HHS, providing  culturally appropriate services to culturally diverse patients has the  potential to improve access to care, quality of care, and ultimately, health  outcomes. HHS has published a set of standards for all medical facilities  regarding the delivery of culturally appropriate care. Other national  organizations also recognize the importance of culturally appropriate care  and have established standards or recommendations for its provision. For  example, the Joint Commission has standards related to culturally  appropriate health care that must be met by hospitals, including VA  medical centers, to receive accreditation.
section_title: VA Medical Centers Are Implementing VA’s LEP Directive; However, Utilization of Language Access Services Is Low
paragraphs: VA medical centers are implementing VA’s LEP Directive in terms of  assessing the language needs of its veteran service population, and, if  necessary, developing language assistance policies. VA medical centers  and facilities have offered language access services that include providing  translated materials and interpretation services to meet the needs of  veterans with LEP. VA medical center officials reported a low utilization of  these language access services. However, VA and medical center officials  told us that they expect the demand for language access services to grow  as the increasingly diverse servicemember population transitions to  veteran status.
subsections: section_title: VA Medical Centers Have Implemented the LEP Directive
paragraphs: VA stated that by June 2007 all of its medical centers had taken actions to  implement the guidance in VA’s LEP Directive. According to VA, all of its  medical centers have assessed the language needs of its veteran service  population, and, as necessary, developed language assistance policies. Our  visits to three VA medical centers and in-depth telephone interviews with  staff at three VA medical centers provided a more detailed account of the  variety of language access services being offered at VA medical centers.
VA first surveyed each of VA’s medical center directors in December 2005  to assess if medical centers were following the guidance in VA’s LEP  Directive. The survey contained 10 “yes” or “no” questions to gauge the  extent of medical centers’ efforts to implement the LEP Directive. The  questions ranged from issues such as overall language assistance policies  to efforts to provide language access services. If a “no” response was  provided for any question, the medical center directors completing the  survey were instructed to indicate a tentative date by which they would  take action to address the item. VA required medical center directors and  VISN directors to ensure that the responses for individual medical centers  were completed. However, VA did not require that VISN or medical center  directors provide documentation to support their “yes” responses to the  survey.
The results of the 2005 survey showed that 65 percent of VA medical  centers had assessed the language needs of their veteran service  population and that 60 percent of the centers had developed a language  assistance policy. While completing the survey, VA medical center  directors reported information about other medical center efforts to meet  the needs of LEP veterans, including efforts to translate documents and  hire bilingual interpreters. For example, 87 percent of VA medical center  directors reported establishing a list of staff available for interpretation  services and that 24 percent of VA medical centers had translated written  documents into languages other than English.
After conducting its initial survey, VA took several steps to help medical  centers improve their efforts to implement the LEP Directive, according to  a VA official. VA staff made follow-up calls to VA officials from the medical  centers that did not respond to the survey or that were identified by the  survey as not conducting efforts consistent with the LEP Directive.  During these follow-up efforts, VA staff offered guidance to medical center  officials on conducting language needs assessments and developing  language assistance policies in ways that were consistent with the LEP  Directive. According to officials we interviewed at two VA medical  centers, the guidance was helpful in their facilities’ assessment of language  needs among their service population and development of language  assistance policies.
According to VA, the follow-up efforts proved successful, as all medical  centers reported that they had assessed the language needs of their  veteran service population, and, as necessary, developed language  assistance policies. In July 2007, VA reported that as a result of its follow- up efforts, all of VA’s medical centers, in accordance with the LEP  Directive, had assessed the language needs of their veteran service  population and developed language assistance policies as needed. VA  concluded that because of the progress and efforts made by its medical  centers to implement the LEP Directive, VA would not conduct any  additional evaluations of medical center implementation of the LEP  Directive. Instead, VA said it would rely on the medical centers to monitor  their own LEP language access needs and programs.
section_title: VA Medical Centers and Facilities Offer a Variety of Language Access Services for Veterans with LEP
paragraphs: VA medical centers and other VA facilities have access to a variety of  translation services. At the national level, VA has translated its widely  distributed benefits publication into Spanish and makes information from  this publication available in Spanish on its Web site. All VA medical  centers have computer software that offers medical treatment consent  forms in Spanish and additional software that allows VA staff to access  patient education materials in several languages other than English, such  as Spanish and Korean.
The VA medical centers and facilities included in our in-depth review also  provide translated materials to meet the various language needs of their  veteran service populations. We found that all six medical centers in our  in-depth review translate written materials on their own. For example,  staff at one medical center we interviewed told us that they translated  educational materials on traumatic brain injuries into Spanish. However,  staff at the medical centers reported that they primarily rely on publicly  available translated documents rather than translating written materials on  their own because of the cost of independently translating documents. The  sources of these publicly available materials range from other federal  agencies to results of an Internet search. For example, according to VA  officials, patient educators at some medical centers use patient education  materials on a range of topics including heart disease and diabetes that  have been translated into Spanish by HHS’s Food and Drug  Administration. VA medical center staff can also use materials translated  by staff at other medical centers. For example, staff at one medical facility  we reviewed reported that the VA medical center located in San Juan,  Puerto Rico, has shared patient education materials they have translated  into Spanish with other VA medical centers. Medical center staff we  interviewed also reported using professional groups within VA, such as  EEO managers or patient educators, to identify and share existing  translated materials. However, these groups are limited in their  membership and, as such, might not be aware of all translated materials  available at VA medical centers. Additionally, VA medical facilities  included in our review generally offer translated materials specific to the  services they provide, when needed. For example, one Vet Center we  reviewed translated a pamphlet on post-traumatic stress disorder into  Spanish for its largely Hispanic veteran service population.
As part of language access services, VA medical centers we reviewed in  depth provide language interpretation services to help address the  language needs of veterans with LEP. Staff we interviewed at all six  medical centers we reviewed had the ability to provide interpretation  services to veterans with LEP and were doing so in several different ways.  For example, staff members at all six of these medical centers maintained  a list of bilingual medical center staff who volunteered to provide  interpretation services during a clinical encounter between a provider and  a veteran with LEP. Medical center staff primarily used people from this  list to provide needed interpretation services. In addition, staff at five of  the six VA medical centers had contract telephone interpretation services  available as a means to help effectively communicate with veterans and  their families with LEP. Moreover, two of the three medical centers we  visited advertised within the medical center, in languages other than  English, the availability of language interpretation services to veterans and  their families with LEP. In these medical centers, we observed signs  posted near entrances and elevators that advertised, in multiple languages,  free language interpretation services for veterans and their family  members.
In addition to efforts made by VA’s medical centers to provide language  access services, some of VA’s Vet Centers have also made efforts to  provide language access services to ensure that veterans with LEP have  meaningful access to counseling and other services. Vet Centers provide  language access services to veterans’ family members with LEP to ensure  that they are able to participate in counseling sessions, such as marital and  family counseling. For example, at one Vet Center we visited, the entire  staff was bilingual to help accommodate the needs of its mostly Hispanic  veteran service population. In cases where bilingual staff were not  available, four of the five Vet Centers where we conducted interviews had  agreements with the local VA medical center to access its list of bilingual  staff available for interpretation services.
section_title: VA Medical Center Officials Report Low Utilization of Language Access Services; However, Officials Expect the Demand for These Services to Grow
paragraphs: Officials at the VA medical centers and facilities included in our in-depth  review reported that veterans seldom use VA’s language access services.  For example, officials and staff we interviewed from five of the six  medical centers in our review stated that their facility had a contract in  place for telephone interpretation services but only one medical center  reported ever utilizing these services. Staff at the medical center that  reported utilizing the interpretation service stated that the use was  infrequent. Moreover, staff we interviewed at the six VA medical centers  we reviewed reported that most veterans speak English and staff at one  medical center reported that veterans prefer to receive written materials in  English. Staff at one medical center told us that they stopped routinely  offering translated materials after veterans—for whom English was not  their primary language—stated their preference for materials in English.  However, translated documents were made available upon request.  Despite the low utilization of interpretation services, such as the use of a  contracted telephone interpretation service, officials at all six medical  centers in our in-depth review reported using bilingual staff to serve as  volunteer interpreters when needed. In addition, in our review of 17 other  medical centers’ language needs assessments, officials from one medical  center volunteered utilizing telephone interpretation services four times in  the 2 years prior to our request in July 2007, while another medical center  volunteered in its assessment that veterans at the facility never used the  facility’s contracted telephone interpretation service.
VA medical center officials told us that they expect the demand for  language access services to grow as the increasingly diverse  servicemember population transitions to veteran status. The  servicemember population is more diverse—in terms of race, and  ethnicity—than the current veteran population. VA officials we  interviewed projected that the increased diversity of the military  servicemember population will directly translate to an increased level of  diversity in the veteran population as these servicemembers end their  military careers and become veterans who may be eligible for VA health  care services. Staff from several VA facilities told us that they have  recently witnessed demographic changes in their service population. For  example, two Vet Centers we visited told us that they have experienced an  increase in the number of veterans and family members needing language  access services in Spanish to facilitate marital and family counseling  sessions.
section_title: VA Medical Centers Are Addressing the Need for Culturally Appropriate Health Care Services through Staff Training and Tailoring Health Care Services
paragraphs: In an effort to address the cultural differences represented in its veteran  service population, VA medical centers have conducted training programs  to increase staff awareness about cultural diversity and the need for  culturally appropriate health care services. Additionally, VA medical  centers and facilities tailored a variety of health care services to different  segments of the veteran population and promoted the availability of  culturally appropriate health care services by targeting outreach efforts to  different segments of the veteran population.
subsections: section_title: VA Medical Centers Provided Training to Staff to Increase Awareness about the Need for Culturally Appropriate Health Care Services
paragraphs: VA medical centers have provided a variety of training programs for staff  to both raise cultural awareness and to assist medical center staff in  providing culturally appropriate health care services. According to VA  medical center officials we interviewed, medical center staff are required  to annually complete one mandatory VA-developed training course on the  health care needs of veterans of various age groups. The six VA medical  centers we reviewed have offered training to help staff understand cultural  diversity as well as appreciate the need for culturally appropriate health  care. These training efforts included locally-developed training on  diversity given to new staff during orientation and on-line diversity  training that is available to all staff. One of the six medical centers we  reviewed in depth also developed training to help staff better understand  what it was like for a veteran in general to serve in the military, as well as  what it was like for a veteran who served during a particular military  service era, such as the Vietnam War. The training materials also provided  information on the types of medical diagnoses that may be related to a  veteran’s service, such as exposure to environmental hazards.  Additionally, individual medical centers developed programs designed to  increase awareness of veteran diversity and different cultural practices.  For example, four VA medical centers we reviewed reported using  celebrations and events in conjunction with heritage months (e.g., African  American Heritage Month and Women’s History Month) as educational  opportunities to increase medical center staff awareness of veteran  cultures and diversity. Programs included speakers, cultural fairs, and  presentations open to staff and veterans at the individual VA medical  centers.
section_title: VA Medical Centers and Facilities Have Provided Health Care Services Tailored to Meet the Needs of a Culturally Diverse Veteran Population
paragraphs: VA medical centers and facilities have provided numerous health care  services designed to meet the needs of the culturally diverse veteran  population that differs in terms of race, ethnicity, sex, as well as age.  According to VA officials, these services have varied across VA medical  centers, CBOCs, and Vet Centers, depending on the needs of the veteran  populations served. During our in-depth review of 16 VA medical centers  and facilities, officials identified a number of health care services that are  provided in a culturally appropriate manner:    Two medical centers and one Vet Center offer spiritual services, which  include the use of medicine men and traditional healing rituals, in order to  meet the needs of Native American veterans.
Three medical centers and one CBOC have increased the use of modern  technology, such as text-messaging appointment reminders, to  communicate more effectively with younger veterans, who are typically  accustomed to such means of communication.
One Vet Center offered a counseling group exclusively for African  American veterans and one Vet Center offered counseling groups for  women veterans.
According to staff we interviewed, services tailored to different segments  of the population are often designed using information gained from  specific veteran requests, veteran focus groups, or through  recommendations of special-emphasis population groups.
To facilitate the delivery of culturally appropriate health care services, all  VA medical centers have a minority veterans program coordinator. The  role of the minority veterans program coordinator is to identify barriers to  health care and advise medical center officials in developing services to  make health care more accessible and culturally appropriate for minority  veteran populations. Minority veterans program coordinators also work  directly with minority veterans in an effort to facilitate access to and use  of VA health care services.
To promote the availability of culturally appropriate care, the six VA  medical centers included in our in-depth review have implemented a  variety of targeted outreach efforts to different veteran populations. For  example, officials at two of the six medical centers we reviewed reported  working closely with military and National Guard bases located near the  medical center to increase awareness of VA health benefits among  younger veterans and their families. According to VA staff, these outreach  efforts helped younger veterans understand that VA was not just “their  grandfather’s VA” and that VA medical centers serve veterans from all  military conflicts. At one medical center, officials we interviewed reported  outreach efforts to help Hispanic, younger, and female veterans recognize  when they might need medical services, for example treatment for post- traumatic stress disorder or depression. These outreach efforts included  participating in community health fairs and ceremonies held to welcome  home servicemembers from the combat theaters. VA staff said they  tailored these efforts to different communities, and staff at one medical  center reported including materials in Spanish.
section_title: Agency Comments and Our Evaluation
paragraphs: VA reviewed a draft of this report and sent us comments by email. VA  agreed with the information presented as it pertained to VA. In  commenting on the development of resources and education to help  facilitate the delivery of culturally competent care, VA noted that there are  different solutions based on local needs and supports a multimodality  strategy as opposed to a “one module fits all” approach. We agree and as  we discussed in our report, VA medical facilities do conduct training for  staff and tailor health care services in an effort to address the differing  needs for culturally appropriate health care services in particular  locations. These efforts and services are often locally developed in  response to the characteristics and needs of the veteran population  served.
As arranged with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days after its  issuance date. At that time, we will send copies of this report to the  Secretary of Veterans Affairs. We will also provide copies to others upon  request. In addition, the report is available at no charge on the GAO Web  site at http://www.gao.gov. If you or your staff have any questions about  this report, please contact me 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 report. GAO staff that made  major contributions to this report are listed in appendix I.
section_title: Appendix I: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the contact above, Marcia Mann, Assistant Director;   Melanie Anne Egorin; Krister Friday; Adrienne Griffin; Samantha Poppe;  and James Walker made contributions to this report.