INTRODUCTION

Patient-centered medical homes have been shown to improve quality of care and patient, provider, and staff satisfaction, while reducing costs.1 , 2 The VA has mandated national implementation of its medical home model—Patient Aligned Care Teams (PACTs), which focus on continuity through team-based care, patient access, care management/coordination, and patient-centered communication.3

VA leaders have increasingly begun to explore how and when PACT should be adapted for special populations based, for example, on age, gender, or condition. The purpose of this article is to describe the evolution of primary care (PC) for one of those special populations, women veterans, review VA policy on delivery of gender-sensitive comprehensive PC for women, and discuss implications of women’s complex care needs for PACT implementation.

Why Women Veterans?

Unlike the typically balanced gender mix of practices outside the VA, women veterans represent a numerical minority, at about 7 % of VA users. Their numbers have created proficiency challenges among VA providers and logistical and fiscal challenges to delivering comprehensive PC in gender-sensitive environments that take account of women’s military roles/experiences and complex healthcare needs.3 – 5 Women VA users have higher mental health burdens than their male counterparts, including high rates of exposure to military sexual trauma, which require trauma-sensitive approaches to care and special attention to the safety and security of clinic environments.6 – 8 Their quality of care has also lagged behind that of men,9 and they typically have to seek multiple visits within and outside the VA to achieve the level of care men achieve through a single on-site visit.10 – 11

Evolution of VA Primary Care for Women

The VA healthcare system has been investing in improved PC delivery for women since the early US Government Accounting Office reports that were critical of the VA’s lack of gender-specific services, gaps in care, and privacy/safety concerns.12 , 13 Landmark legislation followed (PL102-585) (1992), which led to the establishment of eight Comprehensive Women’s Health (WH) Centers by 1994. Designed to provide “one-stop shopping” through interdisciplinary teams in same-gender environments, these centers were quickly overwhelmed with demand.14 , 15 The VA concurrently mandated creation of WH Clinics or Women’s PC teams (e.g., designated WH provider/team in general PC) for the rest of the VA, consistent with model programs in the community.16 – 18 These changes occurred in parallel with PC delivery improvements integral to the VA’s quality transformation of the mid to late 1990s.19 , 20

Women’s clinic prevalence subsequently expanded eight-fold, improving access to gender-specific services, while the volume of women seen in the VA doubled over the decade.10 , 21 Recruitment of WH clinicians and reliance on academic trainees/fellows were deciding factors in building these programs.22 , 23 However, the range of WH services available on site actually declined through 2007, as four in ten of the new women’s clinics focused chiefly on gender-specific exams.24 The new clinics were also less consistently able to offer same-gender providers or adequate privacy compared to the original comprehensive centers.24 Women’s clinics offering more comprehensive services enjoyed better women’s ratings of care and higher quality, as did integrated general PC clinics that included experienced WH providers and made gender-specific care available.11 , 25 – 28

VA Policy on Gender-Sensitive Comprehensive Primary Care for Women

Recognition of women’s special needs led to VA policy action requiring system-wide achievement of patient-centered comprehensive PC for women.29 Launched alongside PACT in 2010, the policy established standards for what constitutes “complete PC” in either separate comprehensive women’s clinics or gender-integrated PC clinics, with one or more designated WH providers and explicit attention to gender sensitivity (Table 1). Compliance also requires co-location of mental health care, co-location or efficient referral to specialty gynecology services, use of state-of-the-art equipment and technology, and ready access to female chaperones for gender-specific exams.

Table 1 Tenets of Gender-Sensitive Comprehensive Primary Care for Women Veterans: Implications for VA Patient Aligned Care Teams (PACTs)
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PACT and Women Veterans’ Health

The PACT model itself does not include specific accommodations for gender-specific care or improved gender sensitivity. Medical home evaluations outside the VA typically fail to report outcomes by gender, providing a limited evidence base to support potentially useful adaptations other than those that may improve provision of gender-specific services.30 , 31 VA policy nonetheless establishes expectations that VA PC and women’s clinics will develop comparable team-based staffing, meet the same standards for access and continuity, and be equally accountable for all prevention and chronic disease performance measures and expansion of telephone care and secure messaging.

Despite policy alignment, challenges remain (Table 1). For example, access to PACT resources in individual women’s clinics varies, as does availability of designated WH providers, female chaperones and privacy arrangements in integrated models. Greater reliance on community providers for women’s services increases care coordination demands on PACT teams. Women veterans also tend to bypass community-based practices to get to women’s clinics at larger VA medical centers,32 which may meet their preferences but adversely affect PACT continuity measures.

CONCLUSION

There is growing awareness of the complexity and constraints of effectively and efficiently delivering PC to women veterans in a healthcare system where they represent a characteristically low volume of patients. An underlying tension remains unresolved on how best to achieve PACT goals for women in a system that has been described as a “patchwork quilt with gaps.”33 , 34 Some evidence suggests that the VA may have one visit to “make or break” women’s decisions to use VA care, especially under the promise of broader healthcare options under the Affordable Care Act.35

Careful attention must be paid to the differences in how women access and use PC, the mix of their healthcare needs, and the proficiencies that PC teams must acquire and sustain. PACT outcomes should be reported by gender to identify intervention opportunities for reducing gender disparities in care.36 Gender-sensitive measures of women veterans’ experiences with PACT care should also be used to tailor PC to meet their needs.37 , 38 Research-clinical partnerships may also help accelerate testing of innovative approaches to delivering the fundamental tenets of PACT to special populations, bringing evidence-based approaches to bear on these issues.39 – 41 Key lessons may yield insights for ensuring that all veterans equitably benefit from the promise of PACT.