VA Health Care
Preliminary Findings on VA's Provision of Health Care Services to Women Veterans
Gao ID: GAO-09-884T July 14, 2009
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) 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 8 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.
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.
GAO-09-884T, VA Health Care: Preliminary Findings on VA's Provision of Health Care Services to Women Veterans
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Testimony:
Before the Committee on Veterans' Affairs, U.S. Senate:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 9:30 a.m. EDT:
Tuesday, July 14, 2009:
VA Health Care:
Preliminary Findings on VA's Provision of Health Care Services to Women
Veterans:
Statement of Randall B. Williamson:
Director, Health Care:
GAO-09-884T:
GAO Highlights:
Highlights of GAO-09-884T, a testimony before the Committee on
Veterans‘ Affairs, U.S. Senate.
Why GAO Did This Study:
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) 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 8 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.
What GAO Found:
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.
View [hyperlink, http://www.gao.gov/products/GAO-09-884T] or key
components. For more information, contact Randall B. Williamson at
(202) 512-7114 or williamsonr@gao.gov.
[End of section]
Mr. Chairman and Members of the Committee:
I am pleased to be here today as the Committee considers 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).[Footnote 1] Additionally, an alarming
number of them have experienced sexual trauma while in the military.
[Footnote 2] 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
[Footnote 3] and available VA data, and interviewed officials from VA
headquarters, Veterans Integrated Service Networks (VISN),[Footnote 4]
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.
Background:
VA Health Care System:
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.[Footnote 5] 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.[Footnote 6]
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.[Footnote 7] Specifically, VA facilities can make
services available through:
* referral of patients to other VA facilities or use of telehealth
services,[Footnote 8]
* sharing agreements with university affiliates or Department of
Defense medical facilities,
* 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).
VA Policies Pertaining to Women's Health:
Federal law authorizes VA to provide medically necessary health care
services to eligible veterans, including women veterans.[Footnote 9]
Federal law also specifically requires VA to provide mental health
screening, counseling, and treatment for eligible veterans who have
experienced MST.[Footnote 10] 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.[Footnote 11]
Gender-specific services that are included in the VA medical benefits
package[Footnote 12] 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.
Table 1: Selected Clinical Services That VA Is Required to Make
Available and Others That VA May Make Available to Women Veterans, by
Category:
Services that VA medical facilities may make available to women
veterans:
Primary care/basic gender-specific services[A]:
* Intake and initial assessment, including screening for military
sexual trauma (MST)[B];
* Routine physical exams;
* Intimate partner violence screening;
* Smoking cessation counseling;
* Smoking cessation treatment;
* Nutrition counseling;
* Weight management and fitness;
* Urgent/emergent gender-related care--normal hours;
* Urgent/emergent gender-related care--evenings, weekends, and
holidays;
* Pelvic examination[B];
* Clinical breast examination[B];
* Education on performing breast self-examination[B];
* Cervical cancer screening[B];
* Menopause management[B];
* Uncomplicated vulvovaginitis treatment[B];
* Osteoporosis screening[B];
* Osteoporosis treatment[B];
* Hormone replacement therapy[B];
* Prescription of oral contraceptives[B].
Specialized gender-specific services[A]:
* Treatment after abnormal cervical cancer screening[B];
* Surgical sterilization--evaluation[B];
* Surgical sterilization;
* Sexually transmitted disease (STD) screening;
* STD counseling;
* STD treatment;
* Intrauterine device (IUD) placement;
* Pregnancy test--urine;
* Pregnancy test--serum;
* Prenatal care;
* Labor and delivery;
* Postpartum care;
* Infertility evaluation[B];
* Endometriosis treatment;
* Evaluation of polycystic ovarian syndrome[B];
* Treatment of polycystic ovarian syndrome[B].
* Screening mammography[B];
* Diagnostic mammography;
* Surgical treatment of breast cancer[B];
* Surgical treatment of reproductive cancer[B];
* Medical treatment of breast cancer[B];
* Medical treatment of reproductive cancer[B].
Source: GAO review of VA data.
Notes: The data are from a review of VHA Handbook 1330.1 and VA's
annual Plan of Care and Clinical Inventory Survey.
[A] The distinction between "basic" and "specialized" gender-specific
services is based on the definitions included in VHA Handbook 1330.1
and the 2003 article by Yano and Washington. Elizabeth Yano and Donna
Washington, "Availability of Comprehensive Women's Health Care Through
Department of Veterans Affairs Medical Center." Published by Donna
Washington, et al., in Women's Health Issues, v. 13 (2003).
[B] Denotes a service that VA medical facilities are required to make
available to women veterans, based on VHA Handbook 1330.1.
[End of table]
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.[Footnote 13] 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.
VA Mental Health Services:
In September 2008, VA issued the Uniform Mental Health Services in VA
Medical Centers and Clinics,[Footnote 14] a policy that specifies the
mental health services that must be provided at each VAMC and CBOC.
[Footnote 15] 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[Footnote
16] 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.
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:
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.
Basic Gender-Specific Care Services Were Generally Available On site at
VA Medical Facilities:
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.
Table 2: On-site Availability of Selected Basic Gender-Specific
Services for Women Veterans at Selected VA Facilities:
Service: Pelvic exam and cervical cancer screening;
VAMC, by number: 1: Service available on site;
VAMC, by number: 2: Service available on site;
VAMC, by number: 3: Service available on site;
VAMC, by number: 4: Service available on site;
VAMC, by number: 5: Service available on site;
VAMC, by number: 6: Service available on site;
VAMC, by number: 7: Service available on site;
VAMC, by number: 8: Service available on site;
VAMC, by number: 9: Service available on site;
CBOC, by number: 1: Service available on site;
CBOC, by number: 2: Service available on site;
CBOC, by number: 3: Service available on site;
CBOC, by number: 4: Service available on site;
CBOC, by number: 5: Service available on site;
CBOC, by number: 6: Refer to another VA facility;
CBOC, by number: 7: Refer to another VA facility[A];
CBOC, by number: 8: Service available on site;
CBOC, by number: 9: Service available on site;
CBOC, by number: 10: Service available on site.
Service: Prescription of oral contraceptives;
VAMC, by number: 1: Service available on site;
VAMC, by number: 2: Service available on site;
VAMC, by number: 3: Service available on site;
VAMC, by number: 4: Service available on site;
VAMC, by number: 5: Service available on site;
VAMC, by number: 6: Service available on site;
VAMC, by number: 7: Service available on site;
VAMC, by number: 8: Service available on site;
VAMC, by number: 9: Service available on site;
CBOC, by number: 1: Service available on site;
CBOC, by number: 2: Service available on site;
CBOC, by number: 3: Service available on site;
CBOC, by number: 4: Service available on site;
CBOC, by number: 5: Service available on site;
CBOC, by number: 6: Service available on site;
CBOC, by number: 7: Refer to another VA facility[A];
CBOC, by number: 8: Service available on site;
CBOC, by number: 9: Service available on site;
CBOC, by number: 10: Service available on site.
Service: Osteoporosis treatment;
VAMC, by number: 1: Service available on site;
VAMC, by number: 2: Service available on site;
VAMC, by number: 3: Service available on site;
VAMC, by number: 4: Service available on site;
VAMC, by number: 5: Service available on site;
VAMC, by number: 6: Service available on site;
VAMC, by number: 7: Service available on site;
VAMC, by number: 8: Service available on site;
VAMC, by number: 9: Service available on site;
CBOC, by number: 1: Service available on site;
CBOC, by number: 2: Service available on site;
CBOC, by number: 3: Service available on site;
CBOC, by number: 4: Service available on site;
CBOC, by number: 5: Service available on site;
CBOC, by number: 6: Service available on site;
CBOC, by number: 7: Refer to another VA facility[A];
CBOC, by number: 8: Service available on site;
CBOC, by number: 9: Service available on site;
CBOC, by number: 10: Service available on site.
Service: Menopause management;
VAMC, by number: 1: Service available on site;
VAMC, by number: 2: Service available on site;
VAMC, by number: 3: Service available on site;
VAMC, by number: 4: Service available on site;
VAMC, by number: 5: Service available on site;
VAMC, by number: 6: Service available on site;
VAMC, by number: 7: Service available on site;
VAMC, by number: 8: Service available on site;
VAMC, by number: 9: Service available on site;
CBOC, by number: 1: Service available on site;
CBOC, by number: 2: Service available on site;
CBOC, by number: 3: Service available on site;
CBOC, by number: 4: Service available on site;
CBOC, by number: 5: Service available on site;
CBOC, by number: 6: Service available on site;
CBOC, by number: 7: Refer to another VA facility[A];
CBOC, by number: 8: Service available on site;
CBOC, by number: 9: Service available on site;
CBOC, by number: 10: Service available on site.
Source: GAO.
Note: We collected this information using a data collection instrument
during site visits to VA medical facilities from October 2008 through
April 2009. Some VA facilities reported that serious or complicated
cases may be referred to other VA medical facilities.
[A] This facility may also fee-base this service to an outside provider
on a case-by-case basis.
[End of table]
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.
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:
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.
Table 3: On-site Availability of Selected Specialized Gender-Specific
Services for Women Veterans at Selected VA Facilities:
Service: Treatment of sexually transmitted diseases (STD);
VAMC, by number: 1: Service available on site;
VAMC, by number: 2: Service available on site;
VAMC, by number: 3: Service available on site;
VAMC, by number: 4: Service available on site;
VAMC, by number: 5: Service available on site;
VAMC, by number: 6: Service available on site;
VAMC, by number: 7: Service available on site;
VAMC, by number: 8: Service available on site;
VAMC, by number: 9: Service available on site;
CBOC, by number: 1: Service available on site;
CBOC, by number: 2: Service available on site;
CBOC, by number: 3: Service available on site;
CBOC, by number: 4: Service available on site;
CBOC, by number: 5: Service available on site;
CBOC, by number: 6: Service available on site[A];
CBOC, by number: 7: Refer to another VA facility;
CBOC, by number: 8: Service available on site;
CBOC, by number: 9: Service available on site;
CBOC, by number: 10: Service available on site.
Service: Treatment after abnormal cervical cancer screening;
VAMC, by number: 1: Service available on site;
VAMC, by number: 2: Service available on site;
VAMC, by number: 3: Refer to another VA facility[B];
VAMC, by number: 4: Service available on site;
VAMC, by number: 5: Service available on site;
VAMC, by number: 6: Service available on site[C];
VAMC, by number: 7: Service available on site[A];
VAMC, by number: 8: Service available on site[A,C];
VAMC, by number: 9: Service available on site[A];
CBOC, by number: 1: Service available on site;
CBOC, by number: 2: Service available on site;
CBOC, by number: 3: Refer to another VA facility;
CBOC, by number: 4: Refer to another VA facility;
CBOC, by number: 5: Refer to another VA facility[C];
CBOC, by number: 6: Refer to another VA facility;
CBOC, by number: 7: Refer to another VA facility[C];
CBOC, by number: 8: Refer to another VA facility;
CBOC, by number: 9: Refer to another VA facility;
CBOC, by number: 10: Refer to another VA facility.
Service: Intrauterine device (IUD) placement;
VAMC, by number: 1: Service available on site;
VAMC, by number: 2: Service available on site;
VAMC, by number: 3: Refer to another VA facility[B];
VAMC, by number: 4: Service available on site;
VAMC, by number: 5: Service available on site;
VAMC, by number: 6: Service available on site;
VAMC, by number: 7: Service available on site[A];
VAMC, by number: 8: Service available on site;
VAMC, by number: 9: Service available on site;
CBOC, by number: 1: Service available on site;
CBOC, by number: 2: Service available on site;
CBOC, by number: 3: Refer to another VA facility;
CBOC, by number: 4: Refer to another VA facility;
CBOC, by number: 5: Refer to another VA facility[C];
CBOC, by number: 6: Refer to another VA facility;
CBOC, by number: 7: Refer to another VA facility[C];
CBOC, by number: 8: Refer to another VA facility;
CBOC, by number: 9: Refer to another VA facility;
CBOC, by number: 10: Refer to another VA facility.
Service: Screening mammography;
VAMC, by number: 1: Service available on site;
VAMC, by number: 2: Refer to a contract provider[D];
VAMC, by number: 3: Service available on site;
VAMC, by number: 4: Refer to a contract provider;
VAMC, by number: 5: Service available on site;
VAMC, by number: 6: Refer to a fee-basis provider;
VAMC, by number: 7: Refer to another VA facility;
VAMC, by number: 8: Refer to a contract provider;
VAMC, by number: 9: Refer to a contract provider[D];
CBOC, by number: 1: Refer to another VA facility;
CBOC, by number: 2: Refer to a fee-basis provider;
CBOC, by number: 3: Refer to a contract provider;
CBOC, by number: 4: Refer to another VA facility;
CBOC, by number: 5: Refer to a contract provider;
CBOC, by number: 6: Refer to another VA facility;
CBOC, by number: 7: Refer to another VA facility[C];
CBOC, by number: 8: Refer to a contract provider;
CBOC, by number: 9: Refer to a contract provider;
CBOC, by number: 10: Refer to a contract provider.
Service: Obstetric care;
VAMC, by number: 1: Refer to a fee-basis provider;
VAMC, by number: 2: Refer to a fee-basis provider;
VAMC, by number: 3: Refer to a fee-basis provider;
VAMC, by number: 4: Refer to a fee-basis provider;
VAMC, by number: 5: Refer to a fee-basis provider;
VAMC, by number: 6: Refer to a fee-basis provider;
VAMC, by number: 7: Refer to a fee-basis provider;
VAMC, by number: 8: Refer to a fee-basis provider;
VAMC, by number: 9: Refer to a fee-basis provider;
CBOC, by number: 1: Refer to a fee-basis provider;
CBOC, by number: 2: Refer to a fee-basis provider;
CBOC, by number: 3: Refer to a fee-basis provider;
CBOC, by number: 4: Refer to a fee-basis provider;
CBOC, by number: 5: Refer to a fee-basis provider;
CBOC, by number: 6: Refer to a fee-basis provider;
CBOC, by number: 7: Refer to a fee-basis provider;
CBOC, by number: 8: Refer to a fee-basis provider;
CBOC, by number: 9: Refer to a fee-basis provider;
CBOC, by number: 10: Refer to a fee-basis provider.
Service: Medical treatment of breast and reproductive cancers;
VAMC, by number: 1: Service available on site[C];
VAMC, by number: 2: Service available on site[C,E];
VAMC, by number: 3: Service available on site[C];
VAMC, by number: 4: Service available on site[C];
VAMC, by number: 5: Service available on site;
VAMC, by number: 6: Refer to another VA facility[C];
VAMC, by number: 7: Refer to another VA facility;
VAMC, by number: 8: Service available on site[E];
VAMC, by number: 9: Refer to another VA facility;
CBOC, by number: [Data about the availability of this service were not
collected at CBOCs].
Service: Reconstructive surgery after mastectomy;
VAMC, by number: 1: Refer to a fee-basis provider;
VAMC, by number: 2: Service available on site;
VAMC, by number: 3: Service available on site[C];
VAMC, by number: 4: Service available on site;
VAMC, by number: 5: Service available on site;
VAMC, by number: 6: Refer to a fee-basis provider;
VAMC, by number: 7: Refer to a fee-basis provider;
VAMC, by number: 8: Refer to a contract provider;
VAMC, by number: 9: Refer to another VA facility;
CBOC, by number: [Data about the availability of this service were not
collected at CBOCs].
Source: GAO.
Notes: We collected this information using data collection instruments
during site visits to VA medical facilities from October 2008 through
April 2009.
[A] This facility may refer this service to another VAMC.
[B] This facility refers this service to a large CBOC located
approximately 13 miles from this facility.
[C] This facility may also fee-base this service to a non-VA provider
on a case-by-case basis.
[D] This facility provided screening mammography services through a
contract provider. That contract provider has a mobile unit that offers
screening mammography services on site at the VAMC a few days a month.
[E] This facility contracts for associated stereotactic biopsies.
[End of table]
Outpatient Mental Health Services Were Widely Available at Most VAMCs
and Vet Centers, but More Limited at Smaller CBOCs:
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.
While Most VAMCs Offer Mixed-Gender Residential or Inpatient Mental
Health Services, Few Have Specialized Programs for Women Veterans:
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.
Medical Facilities Had Not Fully Implemented VA Policies Pertaining to
the Delivery of Health Care Services for Women Veterans:
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.
None of the Facilities Were Fully Compliant with VA Policies Related to
Ensuring the Privacy of Women Veterans:
None of the VAMCs and CBOCs we visited were fully compliant with VA
policy requirements related to privacy for women veterans in all
clinical settings where those requirements applied. Table 4 summarizes
the extent to which the facilities we visited complied with VA policy
requirements related to privacy for women veterans.
Table 4: VA Facilities' Compliance with VA Privacy Requirements:
Privacy requirement: Adequate visual and auditory privacy at check-in;
Compliance with requirement: VAMC, by number: 1: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 2: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 3: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 4: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 5: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 6: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 7: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 8: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 9: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: CBOC, by number: 1: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: CBOC, by number: 2: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: CBOC, by number: 3: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: CBOC, by number: 4: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: CBOC, by number: 5: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: CBOC, by number: 6: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 7: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: CBOC, by number: 8: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 9: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: CBOC, by number: 10: Facility was not
compliant with requirement in any clinical settings.
Privacy requirement: Adequate visual and auditory privacy in the
interview area;
Compliance with requirement: VAMC, by number: 1: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 2: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 3: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 4: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 5: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 6: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 7: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 8: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 9: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 1: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: CBOC, by number: 2: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 3: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 4: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: CBOC, by number: 5: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 6: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 7: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 8: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 9: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 10: Facility was
compliant with requirement in all clinical settings.
Privacy requirement: Exam rooms located so they do not open into a
public waiting room or a high-traffic public corridor;
Compliance with requirement: VAMC, by number: 1: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 2: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 3: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 4: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 5: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 6: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 7: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 8: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 9: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: CBOC, by number: 1: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 2: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 3: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 4: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 5: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 6: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 7: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 8: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 9: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 10: Facility was
compliant with requirement in all clinical settings.
Privacy requirement: Privacy curtains present in exam rooms;
Compliance with requirement: VAMC, by number: 1: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 2: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 3: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 4: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 5: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 6: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 7: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 8: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 9: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 1: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 2: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 3: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 4: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 5: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 6: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 7: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 8: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 9: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 10: Facility was
compliant with requirement in all clinical settings.
Privacy requirement: Exam tables placed with the foot facing away from
the door (if not possible, placed so they are fully shielded by privacy
curtains)[A];
Compliance with requirement: VAMC, by number: 1: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 2: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 3: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: VAMC, by number: 4: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: VAMC, by number: 5: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 6: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: VAMC, by number: 7: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 8: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: VAMC, by number: 9: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: CBOC, by number: 1: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 2: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 3: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 4: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 5: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 6: N/A;
Compliance with requirement: CBOC, by number: 7: N/A;
Compliance with requirement: CBOC, by number: 8: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 9: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 10: Facility was not
compliant with requirement in any clinical settings.
Privacy requirement: Changing area provided behind privacy curtain;
Compliance with requirement: VAMC, by number: 1: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 2: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 3: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 4: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 5: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 6: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 7: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 8: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 9: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 1: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 2: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 3: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 4: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 5: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 6: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 7: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 8: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 9: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 10: Facility was
compliant with requirement in all clinical settings.
Privacy requirement: Toilet facilities immediately adjacent to
examination rooms where gynecological exams and procedures are
performed;
Compliance with requirement: VAMC, by number: 1: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 2: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 3: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: VAMC, by number: 4: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 5: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 6: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 7: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: VAMC, by number: 8: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: VAMC, by number: 9: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: CBOC, by number: 1: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 2: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 3: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 4: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 5: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC, by number: 6: N/A;
Compliance with requirement: CBOC, by number: 7: N/A;
Compliance with requirement: CBOC, by number: 8: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 9: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 10: Facility was not
compliant with requirement in any clinical settings.
Privacy requirement: Sanitary napkin and/or tampon dispensers and
disposal bins in at least one women's public restroom;
Compliance with requirement: VAMC, by number: 1: Facility was compliant
with requirement in all clinical settings[B];
Compliance with requirement: VAMC, by number: 2: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: VAMC, by number: 3: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: VAMC, by number: 4: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: VAMC, by number: 5: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: VAMC, by number: 6: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: VAMC, by number: 7: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: VAMC, by number: 8: v
Compliance with requirement: VAMC, by number: 9: Facility was compliant
with requirement in all clinical settings[B];
Compliance with requirement: CBOC, by number: 1: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 2: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 3: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 4: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 5: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 6: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 7: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 8: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 9: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC, by number: 10: Facility was not
compliant with requirement in any clinical settings.
Privacy requirement: Privacy curtains in inpatient rooms (exception:
psychiatry and mental health units);
Compliance with requirement: VAMC, by number: 1:
Compliance with requirement: VAMC, by number: 2: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 3: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 4: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 5: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 6: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 7: N/A;
Compliance with requirement: VAMC, by number: 8: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 9: Facility was not
compliant with requirement in any clinical settings;
Compliance with requirement: CBOC: [This requirement does not apply to
CBOCs].
Privacy requirement: Access to a private bathroom facility (with toilet
and shower) in close proximity to the patient's room (inpatient and
residential units);
Compliance with requirement: VAMC, by number: 1: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 2: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 3: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 4: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 5: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: VAMC, by number: 6: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 7: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 8: Facility was compliant
with requirement in at least one--but not all--clinical settings;
Compliance with requirement: VAMC, by number: 9: Facility was compliant
with requirement in all clinical settings;
Compliance with requirement: CBOC: [This requirement does not apply to
CBOCs].
Source: GAO.
N/A: We did not tour any clinical settings at this facility where this
requirement must be applied;
Notes: We collected this information using data collection instruments
during site visits to VA medical facilities from October 2008 through
April 2009.
[A] We did not observe any clinical settings where it was not possible
to orient exam tables with the foot facing away from the doorway.
[B] At this facility, sanitary napkins, tampons, or both were available
free of charge in baskets that had been placed in public restrooms.
[End of table]
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[Footnote 17] we visited were fully compliant with VA's policy
requiring exam tables to face away from the door.[Footnote 18] 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.
Figure 1: Correct and Incorrect Placement of Exam Tables in
Gynecological Exam Rooms at VA Medical Facilities:
[Refer to PDF for image: two photographs]
Correct placement of the exam table;
Incorrect placement of the exam table.
Source: GAO.
[End of figure]
* 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.[Footnote 19] 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.
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:
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.
VA Officials Identified Key Challenges Related to Space, Hiring Staff
with Specific Experience and Training, and Establishing the WVPM as a
Full-time Position:
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.
VA Facility Officials Identified Space Constraints as a Challenge
Affecting the Provision of Health Care Services to Women Veterans:
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.
VA Facility Officials Identified Difficulties Hiring Primary Care
Providers with the Specific Training and Experience Needed to Provide
Services to Women Veterans:
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.[Footnote 20] 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.
VA Medical Facility and Vet Center Officials Identified Challenges
Hiring Mental Health Providers with Training and Experience in Treating
PTSD and MST:
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.[Footnote 21] 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 MST.
Some VAMC Officials Reported That Establishing the WVPM as a Full-time
Position Has Raised Implementation Issues:
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. Chairman, this completes my prepared remarks. I would be happy to
respond to any questions you or other Members of the committee 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.
[End of section]
Appendix I: Information on the Selection of VA Facilities Examined in
This Report:
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
veterans;
* 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.
Table 5: Women Veterans' Health Care Utilization at Selected VA Medical
Centers (VAMC):
VAMC, by number: VAMC 1;
Number of unique women veterans served in fiscal year 2008: 6,464;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of women veterans served: 19.5;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the total number of veterans served (both men and women): 8.5.
VAMC, by number: VAMC 2;
Number of unique women veterans served in fiscal year 2008: 6,360;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of women veterans served: 22.4;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the total number of veterans served (both men and women): 12.8.
VAMC, by number: VAMC 3;
Number of unique women veterans served in fiscal year 2008: 4,497;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of women veterans served: 8.2;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the total number of veterans served (both men and women): 7.3.
VAMC, by number: VAMC 4;
Number of unique women veterans served in fiscal year 2008: 3,588;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of women veterans served: 19.4;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the total number of veterans served (both men and women): 10.2.
VAMC, by number: VAMC 5;
Number of unique women veterans served in fiscal year 2008: 2,324;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of women veterans served: 11.7;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the total number of veterans served (both men and women): 4.8.
VAMC, by number: VAMC 6;
Number of unique women veterans served in fiscal year 2008: 1,846;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of women veterans served: 20.2;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the total number of veterans served (both men and women): 3.9.
VAMC, by number: VAMC 7;
Number of unique women veterans served in fiscal year 2008: 1,841[A];
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of women veterans served: 19.8;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the total number of veterans served (both men and women): 5.1[A].
VAMC, by number: VAMC 8;
Number of unique women veterans served in fiscal year 2008: 999;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of women veterans served: 12.5;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the total number of veterans served (both men and women): 1.0.
VAMC, by number: VAMC 9;
Number of unique women veterans served in fiscal year 2008: 995;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of women veterans served: 22.5;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the total number of veterans served (both men and women): 6.9.
Source: VA data and GAO analysis.
[A] This VAMC is part of the same health care system as VAMC 1. Some of
these veterans may also have received services at VAMC 1.
[End of table]
Table 6: Women Veterans' Health Care Utilization at Selected Community-
Based Outpatient Clinics (CBOC):
CBOC, by number: CBOC 1;
Number of unique women veterans served in fiscal year 2008: 2,926;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of unique women veterans served: 12.5.
CBOC, by number: CBOC 2;
Number of unique women veterans served in fiscal year 2008: 1,750;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of unique women veterans served: 27.0.
CBOC, by number: CBOC 3;
Number of unique women veterans served in fiscal year 2008: 599;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of unique women veterans served: 90.2.
CBOC, by number: CBOC 4;
Number of unique women veterans served in fiscal year 2008: 554;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of unique women veterans served: 51.0.
CBOC, by number: CBOC 5;
Number of unique women veterans served in fiscal year 2008: 224;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of unique women veterans served: 13.1.
CBOC, by number: CBOC 6;
Number of unique women veterans served in fiscal year 2008: 115;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of unique women veterans served: 8.5.
CBOC, by number: CBOC 7;
Number of unique women veterans served in fiscal year 2008: 103;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of unique women veterans served: 21.2.
CBOC, by number: CBOC 8;
Number of unique women veterans served in fiscal year 2008: 88;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of unique women veterans served: 54.4.
CBOC, by number: CBOC 9;
Number of unique women veterans served in fiscal year 2008: 48;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of unique women veterans served: 9.1.
CBOC, by number: CBOC 10[A];
Number of unique women veterans served in fiscal year 2008: 42;
Percentage increase between fiscal year 2006 and fiscal year 2008 in
the number of unique women veterans served: not applicable[A].
Source: VA data and GAO analysis.
[A] This facility opened in 2007, so percentage increase since fiscal
year 2006 does not apply.
[End of table]
[End of section]
Appendix II: GAO Contact and Staff Acknowledgments:
GAO Contact:
Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov:
Staff Acknowledgments:
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.
[End of section]
Footnotes:
[1] PTSD may develop following exposure to combat, natural disasters,
terrorist incidents, serious accidents, or violent personal assaults
like rape. People who experience stressful events often relive the
experience through nightmares and flashbacks, have difficulty sleeping,
and feel detached or estranged. These symptoms can occur within the
first few days after exposure to the stressful event but may also be
delayed for months or years. If symptoms continue for more than 30 days
and significantly disrupt an individual's daily activities, a diagnosis
of PTSD is made.
[2] VA defines military sexual trauma (MST) as "psychological trauma,
which in the judgment of a VA mental health professional resulted from
a physical assault of a sexual nature, battery of a sexual nature, or
sexual harassment which occurred while the veteran was serving on
active duty or active duty for training." VA reported that in fiscal
year 2008, 21 percent of women screened for MST, screened positive for
having experienced MST.
[3] The scope of services VA requires to be provided to women veterans,
including requirements for ensuring the privacy of women veterans, are
outlined in Veterans Health Administration (VHA) Handbook 1330.1, and
the requirements for WVPM are outlined in VHA Handbook 1330.02 and in a
July 2008 VA directive titled "Women Veteran Program Managers Full-Time
FTEE Positions."
[4] The management of VAMCs and CBOCs is decentralized to 21 regional
networks referred to as VISNs.
[5] See 38 U.S.C. § 1710(a), 38 C.F.R. § 17.38 (2008). Any veteran who
has served in a combat theater after November 11, 1998, including OEF/
OIF veterans, and who was discharged or released from active service on
or after January 28, 2003, has up to 5 years from the date of the
veteran's most recent discharge or release from active duty service to
enroll in VA's health care system and receive VA health care services.
See 38 U.S.C. § 1710(e)(1)(D), (e)(3)(C). Veterans who were discharged
or released before January 28, 2003, and who did not enroll in VA's
health care system are eligible for these VA health care services for 3
years after January 28, 2008.
[6] All veterans who have served in a combat theater, including OEF/OIF
veterans, are eligible for Vet Center services. See 38 U.S.C. §
1712A(a).
[7] See 38 U.S.C. § 1703.
[8] Telehealth is the provision of health services from a distance
using telecommunications technologies, such as videoconferencing.
[9] 38 U.S.C. § 1710.
[10] 38 U.S.C. § 1720D.
[11] These services are defined in VHA Handbook 1330.1, VHA Services
for Women Veterans (revised July 16, 2004) and VHA Handbook 1160.01,
Uniform Mental Health Services in VA Medical Centers and Clinics (Sept.
11, 2008).
[12] See 38 C.F.R. § 17.38 (2008).
[13] VHA Handbook 1160.01 and VHA Handbook 1330.1.
[14] VHA Handbook 1160.01.
[15] The mental health services that must be provided in CBOCs differ
according to the size of the clinics.
[16] Psychotherapies that have consistently been shown in controlled
research to be effective for a particular condition or conditions are
referred to as "evidence-based."
[17] We visited 10 CBOCs, but 2 of the CBOCs we visited did not offer
gynecological exams.
[18] According to VA policy, if it is not possible for exam tables to
be placed with the foot facing away from the door, they may be placed
so that they are fully shielded by privacy curtains. However, we did
not observe any clinical settings where it was not possible to orient
exam tables with the foot facing away from the door.
[19] We visited 10 CBOCs, but 2 of the CBOCs we visited did not offer
gynecological exams, so this requirement was not applicable at those 2
CBOCs.
[20] Department of Veterans Affairs, Report of the Under Secretary for
Health Workgroup, Provision of Primary Care to Women Veterans, Office
of Public Health and Environmental Hazards, Women Veterans Health
Strategic Health Care Group (Washington, D.C.: November 2008).
[21] According to VA officials, these therapies address the PTSD
diagnosis commonly associated with sexual trauma. Other diagnoses
commonly associated with MST are depression and generalized anxiety.
[End of section]
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