1. Understanding Women Veterans

2. History of Women in the U.S. Military
As this slide depicts, more women are in the pipeline today.
Not many women were in the military during WWII and Korea. There was a law capping enrollment to 2%. The law was lifted in 1967.
By Gulf War 1, women comprised 11% of the military. Today numbers are approaching 20%.
Source: America’s Women Veterans: Military Service History and VA Benefits Utilization Statistics, Dept of Veterans Affairs, Nat Center for Veterans Analysis & Statistics, Nov. 23, (
By Gulf War 1, women comprised 11% of the military. Today the numbers are approaching 20%.

3. Women VHA users doubled since 2000
Since 2000, the number of female Veterans using VA health care has more than doubled, from 159,000 in 2000 to more than 360,000 in This growth rate has outpaced that of the male Veteran population.
Growth rate has outpaced that of the male Veteran population

4. Growth is expected to continue
12% of OEF/OIF/OND Veterans
18% of National Guard/Reserves
This rapid growth is expected to continue. Currently, women comprise:
12% of OEF/OIF/OND Veterans
18% of National Guard/Reserves
6% of VA health care users
System-Wide Implication: VA is working tirelessly to enhance care and access to serve more women Veterans coming through the door
6 % of VA health care users

5. As Women Veteran Population Increases, Total Vet Population Declines
All Veterans
(millions)
Women Veterans
(millions) 25
2.5
VetPOP 2011 Projections 20
2.0
VetPOP 2007 Projections 15
1.5 10
1.0
The light blue block shows the number of all Veterans. The number each year is going down as WWII Veterans pass away.
We’ve been examining this data for more than 10 years. The yellow line is the projected number of women Veterans as of 2007.
Just this year, we obtained new numbers from the Census Bureau which shows that 2011 projections are much higher than anticipated. 5
0.5
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020

6. Nurses play a critical role in provision of health care to women Veterans
Nurses are first line of care for patients and their families
Nurses provide direct treatment to patients; help execute the team’s care plan
Nurses create an atmosphere of safety, privacy and security for our women patients
Nurses provide patient education and resources for continued care
Why are you here?
Nurses are critical for the services we provide to our women Veterans for so many reasons.
You help promote RESPECT for the Veteran. You are the first line of service and therefore lay the foundation of respect for our women Veterans and their service to our country.
We want to bring training to nurses because:
Nurses play a critical role in the provision of health care to women veterans
Nurses are the first line of care for patients and their families
Nurses provide direct treatment to patients, and help to execute the medical team’s care plan
You create the atmosphere of safety, privacy and security for our patients: you are critical to providing a safe and secure atmosphere and environment for women Veterans who are seen in our facilities
Nurses provide patient education and resources for continued care

7. Nursing scope of practice continues to evolve
Nurses are the linchpin for the woman Veteran’s interaction with the care team.
They are the initial contact, coordinating and closing out all activities related to women Veterans.
Comprehensive Primary Care for Women has always been patient-centered. This model is now known as Patient Aligned Care Teams or PACT.
PACT
Depends on a core team of health care personnel who work with the Veteran to plan for her overall health.
Engages the Veteran as a partner in her health care
Emphasizes a personal relationship, team delivery of holistic care, care coordination across specialties/care setting, open access, affordable care
You have an evolving role in Women’s Health/PACT teams. This model of care must addresses many challenges including coordination of fragmented care (fee basis, ER care, gyn care, maternity care, etc.).
The scope of nursing practice continues to expand at the VA. Continuing education is important because of the varied roles of nursing, and the importance of working to the highest level of training.
Nurses serve as Care Managers for PACT teams – In this role, they coordinate resources for comprehensive care including linking Veterans with resources/coordinating resources for the woman Veteran (this is particularly important for women Veterans with lots of non-VA care.
LPNs and health care techs assist with pelvic exams
There are RNs on PACT teams who take calls from the patient panel -- they are critical to the Veteran’s engagement with their health care and with the health care facility
When we surveyed providers, we found that many had been trained in women’s health early in their careers, but now felt rusty. As your practice shifts to caring for more women, your skills need to evolve too.
For women’s health, nurses are the linchpin for the Veteran’s interaction with the care team. They are the initial contact, and they coordinate and closeout all activities relating to the woman Veteran. Comprehensive Primary Care for Women has always been patient-centered. This model is now known as Patient Aligned Care Teams or PACT:
A team-based model of care led by a personal provider who enables continuous and coordinated care throughout a patient's lifetime to maximize health outcomes.
Depends on a core team of healthcare personnel who work with the Veteran to plan for her overall health.
Engage the Veteran as a partner in her health care
Emphasis on the personal relationships, team delivery of holistic care, care coordination across specialties/ settings of care, open access and affordable care

8. Care is provided in different settings
Comprehensive Women’s Health Centers (CWHCs)
Integrated Primary Care Clinics
Community-Based Outpatient Clinics (CBOCs)
Lots of other settings (e.g.,specialty clinics)
Care is provided in a variety of settings:
Comprehensive Women’s Health Centers (CWHCs)
Integrated Primary Care Clinics
Community-Based Outpatient Clinics (CBOCs)
Lots of other settings (e.g. specialty clinics)
The majority of women Veterans will be seen in all manners of settings, particularly CBOCs and Integrated Primary Care Clinics.
No matter where women Veterans are present, it is important for nurses to know how to care for this unique and growing population. Our overall goal is to have the right care for women Veterans, no matter where they are seen.
We talked a bit about comprehensive primary care. Let’s consider what that includes…
No matter where women Veterans are present, it is important for nurses to know how to care for this unique and growing population. Our overall goal is to have the right care for women Veterans, no matter where they are seen.

9. Poll Question Comprehensive Primary Care for women Veterans includes:
Only gender-specific exams like mammograms and pap smears
The care provided at main facilities not CBOCs
Gynecology consultation
Complete primary care & care coordination by one primary care provider at one site to include care for acute and chronic illness as well as gender-specific primary care
What are your thoughts on comprehensive primary care for women Veterans? What do you think it includes?
We’ll come back to this issue in a moment. First, though, let’s take a look at some of unique aspects of our patients – women Veterans.

10. Different generations . . .
27.7
Gulf War (Post 9/11)
Most female Veterans alive today served during Gulf War II and peacetime. Largest peace-time period since advent of All-Volunteer Force was May 1975 to July Large proportions of female Veterans also served during Gulf War era.
23.7
Gulf War (Pre 9/11)
Vietnam Era
12.7
Korean War
3.3
Gulf War (Post 9/11)
5.0
This slide shows the percent of all living women Veterans by Period of Military Service. The highest number of living women Veterans are those who served during the Gulf War and during peacetime. Significant numbers also served during Vietnam (12.7%).
As practitioners, it’s important to consider what Veterans experienced during the different eras of service.
Source: U.S Census Bureau, American Community Survey PUMS,2011. Prepared by the National Center for Veterans Analysis and Statistics.
Note: Periods of military service shown here are coded with women who have multiple periods of service being placed into their most recent period of service
Peacetime only
27.6
As practitioners, it’s important to consider what Veterans experienced during the different eras of service.

11. Different conflicts . . . Different experiences . . .
WWII/
Korea
Vietnam
Gulf Wars
OEF/OIF/OND
WWII/Korea
Chemical warfare agent experiments
Agent Orange exposure
Exposure to nuclear weapons (including testing or clean-up)
Cold injury
Vietnam
Hepatitis C
Cold War
Nuclear weapons testing (Atomic Veterans)
Gulf Wars
Chemical or biological agents
Dermatologic issues
Infectious diseases (e.g., Leishmaniasis)
Reproductive health issues
Depleted uranium exposure
Smoke exposures
Immunizations
Most Recent Deployments
Mental health issues
Dermatologic issues
Hearing issues (and vision loss)
Infectious diseases (e.g., Leishmaniasis, Rabies)
Traumatic brain or spinal cord injury
Blast injuries (penetrating/blunt trauma, burns)
Traumatic amputation
Embedded fragments (shrapnel)

12. Different Health Needs . . . The Changing Face of VA
Women Veterans ages comprise nearly 45% of female VA health care users; women ages 65 and older make up nearly 14%.
Aging women
Largest sub-population
Menopausal needs
Geriatric care
Inpatient/extended stays
Pain management
Aging women
Largest sub-population
Menopausal needs
Geriatric care
Inpatient/extended stays
Pain management
The face of the VA is changing. We’re seeing more older women. This is the largest subpopulation of women Veteran VA users.
Women Veterans aged 45 to 64 comprise nearly 45% of female VA health care users; women aged 65 and older make up nearly 14%. Like their younger female Veteran counterparts, this population uses VA for their mental health care. Some have experienced trauma in the military including Military Sexual Trauma (MST) and combat trauma.*
Pain management is also important for both older and younger women Veterans.
This older population has menopausal needs. And as this generation ages, we may see more older women Veterans on inpatient units or at VA facilities for extended stays.
*U.S. Code (United States Code (U.S.C.) Title 38 § 1720D) permanently authorizes VA to provide health care and outreach to both women and men Veterans who experienced incidents of sexual assault and sexual harassment while serving on active duty or active duty for training in the military.

13. Different Health Needs . . . The Changing Face of VA
Frequent visits
Service-connected disabilities
Maternity care (Veterans and staff may not know that we cover maternity and newborn care)
Working women
Often juggling jobs and child/elder care; need flexibility.
Mental health needs - 32% have MH diagnoses
Readjustment
MST
Prosthetic supplies geared towards women (shoes, lactation, post-mastectomy, wigs)
Young women
Frequent visits
Service-connected disabilities
Maternity care (lot of Veterans and even staff may not know that we cover maternity and newborn care)
Working women
They are often juggling jobs and child/elder care responsibilities and they need flexibility.
Mental health needs—32% have MH diagnoses
Readjustment
MST
Prosthetic supplies geared towards women (shoes, lactation, post-mastectomy, wigs)
Young Women

14. Poll Answer
Comprehensive Primary Care for women Veterans includes:
Only gender-specific exams like mammograms and pap smears
The care provided at main facilities not CBOCs
Gynecology consultation
Complete primary care & care coordination by one primary care provider at one site to include care for acute and chronic illness as well as gender-specific primary care
Earlier, we asked for your idea of what constitutes comprehensive care for women Veterans.
The choices were:
Only gender specific exams like mammograms and pap smears
The care provided at main facilities not CBOCs
Gynecology consultation
Complete primary care & care coordination by one primary care provider at one site to include care for acute and chronic illness as well as gender-specific primary care
The correct response is D. We’ll talk more about comprehensive primary care in the next few slides.
To find out more about what comprehensive primary care for women Veterans includes, please refer to VHA Handbook for more information.

15. Comprehensive Primary Care
VHA Handbook defines the scope of health care services for women Veterans:
Every site of care must have a designated WH provider & team
99% of VAMCs and 60-70% of CBOCs now have at least one
Focus isn’t on building stand-alone clinics, but on providing right care wherever the woman Veteran goes
Our WH providers are interested and proficient in the delivery of comprehensive primary care
We can’t hire them all – we need to train existing providers
Comprehensive Primary Care
What do we mean by comprehensive primary care?
VHA Handbook defines the scope of health care services for women Veterans:
Every site of care must have a designated women’s health provider and team
99% of our medical centers and approximately 60-70% of our CBOCs now have at least one designated women’s health provider
Note: our focus isn’t on building stand alone clinics, but the right care wherever the woman Veteran goes
Our WH providers are interested and proficient in the delivery of comprehensive primary care to women, irrespective of where women are seen (freestanding medical centers, primary facilities, CBOCs and independent clinics).
We know we can’t hire them all – we need to train existing providers
We are rolling out a lot of training for nurses and providers to better care for women Veterans. This program is part of that initiative.
So, how are we delivering comprehensive primary care? Mental health. Co-located gynecology services.

16. Unique needs of women Veterans
Gender-specific primary care
(Pap smears, HPV testing & vaccine
Breast cancer screening
Birth control
Preconception counseling & care
Maternity & newborn care
Menopausal support
Emergency services for women Veterans
General Care
Health evaluation & counseling
Prevention & screening
Health coaching
Substance use counseling & treatment
Disorders & conditions that are more common in women or have unique aspects for women
General Care
Gender Specific Care
Comprehensive Primary Care
General Care – management of acute and chronic conditions
Health evaluation and counseling: One of the most frequent issues involves musculoskeletal issues and chronic pain resulting from stressors during combat missions (heavy equipment, jumping, running, driving long distances)
Prevention and screening (gender-neutral): cardiac, colon cancer
Health coaching: nutrition counseling, weight control, smoking cessation
Substance use counseling and treatment
Pay attention to disorders and conditions that are more common in women or have unique aspects for women such as thyroid disease, migraines, osteoporosis, etc. v
**Provide services while ensuring that privacy and dignity are provided to women Veterans. Nurses and all members of the team play a big role in that.

17. Where do we go from here?
Start by changing the culture of the VA to be more inclusive of women!
Now that we understand the uniqueness of our patients – women Veterans – where do we go from here?
Start by changing the culture of VA to be more inclusive of women!

18. How WHS is changing the VA culture
Our Vision & Mission
To meet the unique needs of women Veterans by delivering the highest quality of health care to each woman, while offering her the privacy, dignity, and sensitivity to gender-specific needs that she deserves.
How my office, Women’s Health Services, is trying to change the culture:
Our VISION
To meet the unique needs of women Veterans by delivering the highest quality of health care to each woman, while offering her the privacy, dignity, and sensitivity to gender-specific needs that she deserves.
Ideal: Women Veterans Experience of VA
High-quality, equitable care on par with that of men
Care delivered in a safe and healing environment
Seamless coordination of services
Recognition as Veterans
Our MISSION:
Within VA: Serve as a trusted resource for the field and work to ensure that women Veterans experience timely, high quality comprehensive care in a sensitive and safe environment at all points of care.  
Beyond VA: In line with VA’s overarching mission, seek to continually improve personalized, proactive, patient-driven health care for women Veterans and to lead the nation in women’s health care. NEXT SLIDE 

19. Change the VA Culture for Women Veterans
We’ve developed messaging and posters…….

20. How WHS is Changing the VA Culture Our Goals
Patient-centered model of care
VA health policies for women
Workforce education & training
Integrated reproductive health
Research on effects of service on women Veterans’ lives
Goal 1: Transform health care delivery for women Veterans, using a personalized, proactive, patient-centered model of care
Goal 2: Develop, implement, and influence VA health policy as it relates to women Veterans
Goal 3: Ensure a proficient and agile workforce through training, education, effective measures, and assessment
Goal 4: Develop, seamlessly integrate, and enhance VA reproductive health care
Goal 5: Drive the focus and set the agenda to increase understanding of the effects of military service on women Veteran’s lives
SLIDE 

21. Specialized Support Women Veterans Call Center
Women Veterans Program Manager (WVPM)
At each VA Medical Center nationwide, a Women Veterans Program Manager is designated to advise and advocate for women Veterans, and coordinate all the services they need
Women Veterans Call Center (WVCC)
This outgoing call center is aimed at increasing women Veterans' knowledge, enrollment, and utilization of VHA health care services; the outgoing call center provides women Veterans with information on VA health care services, benefits and eligibility
An incoming arm of the WVCC was launched April 23; representatives at VA-WOMEN ( ) receive and respond to questions from Veterans, their families and caregivers about the many VA services
Women Veterans Program Manager

22. VA Caregiver Support Line
Specialized Support
VA Caregiver Support Line
VA Caregiver Support Line ( ). The following types of calls can be referred to the Caregiver Support Line:
Caller is a family member who provides care for a physically or emotionally disabled Veteran
Caller is a family member experiencing stress, or one who has questions about, or problems with, services provided.
Caller is a Veteran serving in the role of Caregiver and has questions about services available to assist in the care-giving journey.
Veterans Crisis Line
Connects Veterans in crisis and their families/friends with qualified, caring VA responders who can provide support
and press 1; or send a text message to
Veterans’ Crisis Line

23. Maximize Available Resources
All of our resources are available to you on our SharePoint site (shown here)
Also a lot of information is available on our website

24. Resources are Easily Accessible on the Women’s Health Services SharePoint
Videos
(internal/external)
FAQs
Health Campaigns
Videos: Available on SharePoint
VHA Facebook & Twitter messages highlight women Veterans’ information
Fact Sheets are available on Sharepoint
Women’s Health Campaigns:
Outreach campaigns aimed at reaching women Veterans, media, Public Affairs Officers, and community organizations
Key Messages:
VA aims to meet the unique needs of women Veterans, offering them the privacy, dignity, and sensitivity to gender-specific needs that they deserve
VA offers a full continuum of care for women Veterans provided by an interested, proficient and designated women’s health clinician across facilities
VA understands women’s experiences in the military…and can meet their unique health care needs across all adult life stages better than anyone NEXT SLIDE
Messages
Facts and Statistics

25. Targeted Campaigns – Focused on Critical Health Care Issues for Women Veterans and VA Staff
As part of our outreach activities, our monthly campaigns target critical health issues for women Veterans.

26. Research Materials Sourcebook Vol II
Research is a key component in the VA's initiative to improve services for women Veterans. VA has just released a report which examines the demographic profiles of female VA patients—who they are, how old they are, where they live, and how they use the VA.
Gender Differences in Performance Measures
This report shows that between 2008 and 2011, VA improved gender disparities in almost all measures and exceeded both private and public sector care on most measures.