REVIEW URRENT C OPINION
Strategies for transforming reproductive healthcare delivery in an integrated healthcare system: a national model with system-wide implications Laurie C. Zephyrin a,b, Jodie G. Katon a,c,d, and Elizabeth M. Yano e,f
Purpose of review As the number of women serving in the US military has grown, so too has the number of women using the US Department of Veterans Affairs Healthcare System (VA). This poses tremendous opportunity to integrate reproductive health services across a national healthcare system. This review summarizes the approaches used to assess, rapidly design, and integrate VA’s first National Reproductive Health Program. Recent findings Compared with the civilian population, women Veterans have poorer health status including increased likelihood of medical comorbidities and mental health conditions. Given these complex health needs, a health systems approach that integrates reproductive health with other needs is essential in this vulnerable population. Summary Delivery of high-quality reproductive healthcare must incorporate a systems perspective. Promoting major organizational and cultural change in a national system has required use of an evidence-based strategic framework, which has relied on several key tenets including the following: understanding the population of women Veterans served, developing research–clinical partnerships, building interdisciplinary initiatives for system-wide integration of reproductive healthcare, and developing innovative tools for enhancing care delivery. This approach can serve as a model for other healthcare systems committed to developing an integrated system of reproductive healthcare and addressing reproductive health conditions in women with complex needs. Keywords health policy, health system, programmatic development, reproductive health, women Veterans
INTRODUCTION
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The number of women serving in the US military has grown substantially over the past decade. Concomitant with this increase in servicewomen, the number of women Veterans continues to grow – with over 2.2 million in the United States. These women Veterans are enrolling in the US Department of Veterans Affairs Healthcare System (VA) in record numbers [1]. Women make up approximately 7% of the 8 million VA enrollees receiving care within a network of almost 1000 clinics and 150 hospitals nationwide [2]. In fiscal year 2013, approximately 390 000 women Veterans used VA – more than double the number over a decade ago [3 ]. Demographic changes among VA users have resulted in a diverse age distribution of women Veterans, reflecting periods of service in the Gulf Wars, the Vietnam War, and a smaller cohort from &
World War II [3 ,4]. Although growth has been especially rapid among younger women Veterans
a
Reproductive Health, Women’s Health Services, Office of Patient Care Services, US Department of Veterans Affairs, Washington, District of Columbia, bDepartment of Obstetrics and Gynecology, New York University Langone School of Medicine, New York, New York, cVA Puget Sound Healthcare System, dUniversity of Washington School of Public Health, Seattle, Washington, eVA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System and fHealth Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA Correspondence to Laurie C. Zephyrin, MD, MPH, MBA, Director, Reproductive Health, Women’s Health Services, Office of Patient Care Services, US Department of Veterans Affairs, 810 Vermont Avenue, Washington, DC 20420, USA. Tel: +1 202 461 0373; e-mail: Laurie. [email protected], [email protected] Curr Opin Obstet Gynecol 2014, 26:503–510 DOI:10.1097/GCO.0000000000000124
1040-872X ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-obgyn.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Healthcare management strategies
KEY POINTS The number of women Veterans in the United States has grown quickly and substantially, resulting in a need to understand the reproductive health of this population. Promoting major organizational change in a health system in which women are a numerical minority has required use of an evidence-based strategic framework relying on several key tenets that can serve as a model to integrating reproductive health across a healthcare system. Key tenets include understanding the population of women Veterans served to ensure design of a responsive system of reproductive healthcare; developing research–clinical partnerships to assess reproductive health services and test new care models; building interdisciplinary initiatives to integrate reproductive health across the healthcare system; and developing innovative tools for enhancing reproductive healthcare delivery. The experience in establishing a reproductive health program in the VA can inform other healthcare systems seeking to expand services or when developing new systems of care in specific settings (e.g., developing countries).
in their childbearing years (18–45 years old) [5], numerous women Veteran VA users are already out of their childbearing years and thus have differing reproductive healthcare needs than their younger counterparts [6 ]. The infusion of women Veterans in varying stages of life has brought reproductive health across the life course to the forefront as an increasingly prominent national issue for VA policy and practice. The mission of VA’s Office of Women’s Health Services is to ensure that women Veterans experience timely, high-quality comprehensive care in a sensitive and safe environment [7]. Reproductive healthcare is a core component of this mission, and the ultimate goal is to integrate and optimize reproductive healthcare delivery across the diverse array of VA healthcare settings. The goal of this article is to outline the approaches used to assess, rapidly design, and integrate reproductive healthcare in the VA national healthcare system. Promoting major organizational change in a system in which women are a numerical minority has required use of an evidence-based strategic framework, which has relied on several key tenets: &&
(1) understanding the population of women Veterans served, including their reproductive health needs, to ensure design of a responsive system of reproductive healthcare; 504
www.co-obgyn.com
(2) developing research/clinical partnerships to assess reproductive health services and develop and test new care models; (3) building interdisciplinary initiatives to integrate reproductive healthcare across the healthcare system; and (4) developing innovative tools for enhancing reproductive healthcare delivery. We anticipate that these strategies, in addition to system-wide culture change and gender awareness, may serve as a model for integration of reproductive healthcare into other healthcare systems in the United States and beyond.
UNDERSTANDING WOMEN VETERANS AND THEIR REPRODUCTIVE HEALTH NEEDS Reproductive healthcare is an integral component of comprehensive healthcare for women Veterans [8]. Optimal reproductive health is not simply the absence of reproductive disease but a state of complete physical, mental, and social well-being [9]. This is especially important for women Veterans who may have unique exposures as a result of their military service. A growing body of work emphasizes understanding the role of early life and behavioral factors on reproductive health, the central role of reproductive health in the health of women and their families, and the importance of integrating reproductive healthcare within a primary care medical home [10–12]. Within this context, it is important to realize that the reproductive health needs of women Veterans are shaped by their military experiences in addition to early life experiences and coexisting medical or mental health conditions (Fig. 1) [6 ]. Compared with the civilian population, women Veterans, particularly those who use the VA, have poorer health status, increased likelihood of having experienced childhood physical or sexual abuse, and a greater likelihood of depression and posttraumatic stress disorder [13–15]. Approximately 23% of women Veterans who use VA healthcare screen positive for military sexual trauma (sexual assault or repeated threatening sexual harassment incurred during military service) [16,17]. Given the nature of the current conflicts and removal of bans on women serving in combat positions, women Veterans are increasingly likely to have had combat exposure [18]. Finally, more than half of women Veterans using VA have a service-connected disability – an injury or illness that was incurred or aggravated during service. Some of these women will require life-long care [3 ,4,19]. Given these complex &&
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Volume 26 Number 6 December 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Life stage
Transforming reproductive healthcare delivery Zephyrin et al.
Military service
Strategies for transforming reproductive healthcare delivery in an integrated healthcare system: a national model with system-wide implications Laurie C. Zephyrin a,b, Jodie G. Katon a,c,d, and Elizabeth M. Yano e,f
Purpose of review As the number of women serving in the US military has grown, so too has the number of women using the US Department of Veterans Affairs Healthcare System (VA). This poses tremendous opportunity to integrate reproductive health services across a national healthcare system. This review summarizes the approaches used to assess, rapidly design, and integrate VA’s first National Reproductive Health Program. Recent findings Compared with the civilian population, women Veterans have poorer health status including increased likelihood of medical comorbidities and mental health conditions. Given these complex health needs, a health systems approach that integrates reproductive health with other needs is essential in this vulnerable population. Summary Delivery of high-quality reproductive healthcare must incorporate a systems perspective. Promoting major organizational and cultural change in a national system has required use of an evidence-based strategic framework, which has relied on several key tenets including the following: understanding the population of women Veterans served, developing research–clinical partnerships, building interdisciplinary initiatives for system-wide integration of reproductive healthcare, and developing innovative tools for enhancing care delivery. This approach can serve as a model for other healthcare systems committed to developing an integrated system of reproductive healthcare and addressing reproductive health conditions in women with complex needs. Keywords health policy, health system, programmatic development, reproductive health, women Veterans
INTRODUCTION
&
The number of women serving in the US military has grown substantially over the past decade. Concomitant with this increase in servicewomen, the number of women Veterans continues to grow – with over 2.2 million in the United States. These women Veterans are enrolling in the US Department of Veterans Affairs Healthcare System (VA) in record numbers [1]. Women make up approximately 7% of the 8 million VA enrollees receiving care within a network of almost 1000 clinics and 150 hospitals nationwide [2]. In fiscal year 2013, approximately 390 000 women Veterans used VA – more than double the number over a decade ago [3 ]. Demographic changes among VA users have resulted in a diverse age distribution of women Veterans, reflecting periods of service in the Gulf Wars, the Vietnam War, and a smaller cohort from &
World War II [3 ,4]. Although growth has been especially rapid among younger women Veterans
a
Reproductive Health, Women’s Health Services, Office of Patient Care Services, US Department of Veterans Affairs, Washington, District of Columbia, bDepartment of Obstetrics and Gynecology, New York University Langone School of Medicine, New York, New York, cVA Puget Sound Healthcare System, dUniversity of Washington School of Public Health, Seattle, Washington, eVA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System and fHealth Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA Correspondence to Laurie C. Zephyrin, MD, MPH, MBA, Director, Reproductive Health, Women’s Health Services, Office of Patient Care Services, US Department of Veterans Affairs, 810 Vermont Avenue, Washington, DC 20420, USA. Tel: +1 202 461 0373; e-mail: Laurie. [email protected], [email protected] Curr Opin Obstet Gynecol 2014, 26:503–510 DOI:10.1097/GCO.0000000000000124
1040-872X ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-obgyn.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Healthcare management strategies
KEY POINTS The number of women Veterans in the United States has grown quickly and substantially, resulting in a need to understand the reproductive health of this population. Promoting major organizational change in a health system in which women are a numerical minority has required use of an evidence-based strategic framework relying on several key tenets that can serve as a model to integrating reproductive health across a healthcare system. Key tenets include understanding the population of women Veterans served to ensure design of a responsive system of reproductive healthcare; developing research–clinical partnerships to assess reproductive health services and test new care models; building interdisciplinary initiatives to integrate reproductive health across the healthcare system; and developing innovative tools for enhancing reproductive healthcare delivery. The experience in establishing a reproductive health program in the VA can inform other healthcare systems seeking to expand services or when developing new systems of care in specific settings (e.g., developing countries).
in their childbearing years (18–45 years old) [5], numerous women Veteran VA users are already out of their childbearing years and thus have differing reproductive healthcare needs than their younger counterparts [6 ]. The infusion of women Veterans in varying stages of life has brought reproductive health across the life course to the forefront as an increasingly prominent national issue for VA policy and practice. The mission of VA’s Office of Women’s Health Services is to ensure that women Veterans experience timely, high-quality comprehensive care in a sensitive and safe environment [7]. Reproductive healthcare is a core component of this mission, and the ultimate goal is to integrate and optimize reproductive healthcare delivery across the diverse array of VA healthcare settings. The goal of this article is to outline the approaches used to assess, rapidly design, and integrate reproductive healthcare in the VA national healthcare system. Promoting major organizational change in a system in which women are a numerical minority has required use of an evidence-based strategic framework, which has relied on several key tenets: &&
(1) understanding the population of women Veterans served, including their reproductive health needs, to ensure design of a responsive system of reproductive healthcare; 504
www.co-obgyn.com
(2) developing research/clinical partnerships to assess reproductive health services and develop and test new care models; (3) building interdisciplinary initiatives to integrate reproductive healthcare across the healthcare system; and (4) developing innovative tools for enhancing reproductive healthcare delivery. We anticipate that these strategies, in addition to system-wide culture change and gender awareness, may serve as a model for integration of reproductive healthcare into other healthcare systems in the United States and beyond.
UNDERSTANDING WOMEN VETERANS AND THEIR REPRODUCTIVE HEALTH NEEDS Reproductive healthcare is an integral component of comprehensive healthcare for women Veterans [8]. Optimal reproductive health is not simply the absence of reproductive disease but a state of complete physical, mental, and social well-being [9]. This is especially important for women Veterans who may have unique exposures as a result of their military service. A growing body of work emphasizes understanding the role of early life and behavioral factors on reproductive health, the central role of reproductive health in the health of women and their families, and the importance of integrating reproductive healthcare within a primary care medical home [10–12]. Within this context, it is important to realize that the reproductive health needs of women Veterans are shaped by their military experiences in addition to early life experiences and coexisting medical or mental health conditions (Fig. 1) [6 ]. Compared with the civilian population, women Veterans, particularly those who use the VA, have poorer health status, increased likelihood of having experienced childhood physical or sexual abuse, and a greater likelihood of depression and posttraumatic stress disorder [13–15]. Approximately 23% of women Veterans who use VA healthcare screen positive for military sexual trauma (sexual assault or repeated threatening sexual harassment incurred during military service) [16,17]. Given the nature of the current conflicts and removal of bans on women serving in combat positions, women Veterans are increasingly likely to have had combat exposure [18]. Finally, more than half of women Veterans using VA have a service-connected disability – an injury or illness that was incurred or aggravated during service. Some of these women will require life-long care [3 ,4,19]. Given these complex &&
&
Volume 26 Number 6 December 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Life stage
Transforming reproductive healthcare delivery Zephyrin et al.
Military service
