VA Testimony of Betty Brown before Congress on July 12, 2007

United States Department of Veterans Affairs

STATEMENT BY BETTY MOSELEY BROWN, ED.D.
ASSOCIATE DIRECTOR, CENTER FOR WOMEN VETERANS
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS AND THE SUBCOMMITTEE ON HEALTH OF THE U.S. HOUSE OF REPRESENTATIVES COMMITTEE ON VETERANS' AFFAIRS

July 12, 2007

Chairman Hall, Chairman Michaud, and Members of the Subcommittees, I am pleased to testify today on behalf of the Department of Veterans Affairs (VA) about services in VA for women veterans. Particularly, I will address how VA serves women veterans through its current programs, how present and future strategies will address the needs of this growing population, and what outreach efforts are being conducted by VA to women veterans. The Center for Women Veterans was established by Public Law No. 103-446 in November 1994 to oversee VA programs for women veterans. The Center's mission is to ensure that women veterans receive benefits and services on par with male veterans; that VA programs are responsive to gender-specific needs of women veterans; that outreach is performed to improve women veterans' awareness of services, benefits and eligibility criteria; and that women veterans are treated with dignity and respect. The Director, Center for Women Veterans, acts as the primary advisor to the Secretary and Deputy Secretary on all matters related to policies, legislation, programs, issues, and initiatives affecting women veterans.

How is the Department of Veterans Affairs (VA) serving women through its current programs?

The Center for Women Veterans monitors changes in services through briefings by the three VA administrations and assesses the impact these changes may have on the delivery of services for the Nation's 1.75 million women veterans --from programs for homeless women veterans with children, elderly women veterans, women veterans living in rural areas, and for those women still unaware they, too, are veterans, since many do not identify themselves as such. The Center regularly monitors VA briefings during Transition Assistance Programs to ensure that active duty women are provided access to information on the benefits and services aVAilable to them as veterans prior to their release from active duty.

The Advisory Committee on Women Veterans was established by Public Law 98-160 in 1983. The Advisory Committee is charged with advising the Secretary of Veterans Affairs on VA benefits and services for women veterans, assessing the needs of women veterans, reviewing VA programs and activities designed to meet those needs, and developing recommendations addressing unmet needs. The Advisory Committee submits a biennial report to the Secretary incorporating the Committee's findings and recommendations.

As a means of obtaining information regarding the delivery of health care and services to women veterans, the Advisory Committee conducts site visits to VA facilities throughout the country. In addition, the Advisory Committee tours the facilities and meets with senior officials to discuss services and programs aVAilable to women veterans. During site visits, the Advisory Committee also hosts open forums with the women veterans' community, encouraging women veterans to discuss issues and ask questions related to VA benefits and services. The Advisory Committee meets twice a year at VA Central Office (VACO) and receives briefings from the Veterans Health Administration (VHA), Veterans Benefits Administration (VBA), National Cemetery Administration (NCA) and other staff offices. These briefings update the Committee on the status of VA programs and respond to concerns raised during the site visits. The Advisory Committee uses information from these site visits and briefings in its biennial reports to the Secretary.

In the 2006 Report of the Advisory Committee on Women Veterans, the Advisory Committee made 23 recommendations. Some of the key report issues included outreach, behavioral and mental health care, military sexual trauma, health care, research and studies, strategic planning, training, and women veterans who are homeless. The 2006 Report has been provided to Congress.

Regarding women veterans health program, the Advisory Committee, in its 2006 Report, recommended VA ensure the Center is provided an annual update on the effectiveness of the VHA Women Veterans Program Managers Program. VHA officials, including the Women Veterans Health Strategic Healthcare Group (formerly known as Women Veterans Health Program), briefed the Center and Advisory Committee members on this issue at the February - March 2007 meeting of the Advisory Committee. In addition, the Women Veterans Health Strategic Healthcare Group works closely with the Center on issues that are frequently referred to Women Veterans Program Managers in field facilities.

In FY 2006, the VHA served 235,901 women veterans in our health system. By comparison, in FY 2001 VHA served 171,161 women veterans. This is a five year relative increase of 37.8 percent.
In FY 2006, 14 percent of the census-projected number of all women veterans utilized VHA services. This compares to 22 percent of all male veterans utilization.
Of the total number of women who have been discharged from active duty after deployment in Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF), 37.5 percent, or 25,960 women veterans, have been to a VHA healthcare facility at least once. This compares to a male utilization rate of 32 percent for OIF/OEF veterans.
There are 22 VA health care facilities that have dedicated, comprehensive women's center space.

VHA's Women Veterans Health Strategic Healthcare Group (WVHSHG) studies the continuum of care aVAilable to women veterans through an annual Plan of Care-Clinical Inventory Report. This Report surveys aVAilability of all related types of physical and mental health services for women at each medical facility. Every facility has a designated Women Veterans Program Manager to serve as program administrator, veteran advocate and referral source to appropriate care; this report also tracks their time allotment.

In addition, in 2006 WVHSHG co-sponsored Elizabeth Yano, PhD, MSPH, Deputy Director VA Greater Los Angeles HSR&D Center of Excellence and Associate Professor at UCLA, to survey VISN Leadership, facility and program directors regarding provision of care models in women's health in VHA. We expect delivery of this report in late 2007, informing VHA of the provision of primary care to women veterans through models of specialized women's health clinics and in models of mixed-gender primary care sites, including community based outpatient sites. This study will clarify which models of care for women provide the best performance outcomes and higher patient ratings of care.

Realizing the current influx of returning women veterans will increase the number of women seen by VHA in the next several years, VHA has initiated programs to identify interested primary care providers and provide them with intensive training in women's health. The needs assessment for this program will be implemented in September 2007 through VA's Employee Education Service efforts. This program will be especially important in addressing the health care needs of rural women. We also recognize that the majority of women veterans new to VHA are of child bearing age and could be at risk for birth defects from some prescription medications. This presents new challenges which we are addressing through initiatives in pharmacy management and provider education.

VHA is committed to expanding the focus of women veterans' health care beyond the issues of gender specific screening for breast and cervical cancer. In the United States, heart disease is the number one cause of death in women, and WVHSHG has proposed initiatives in improved management and prevention for heart disease risk including cholesterol, weight management and smoking cessation. On June 22, 2007, VHA's Office of Public Health and Environmental Hazards awarded two clinical demonstration grants specific to smoking cessation programs for women veterans.

Another focus area for women veterans' health is prevention and detection of cancers, particularly colorectal cancers, through improved screening of women veterans. We are eVAluating factors related to the fact that fewer women than men receive colorectal cancer screening, both within VA and in community samples.

Mental Health

There are specialized women's mental health services in VHA:

Specialized inpatient and residential programs for women veterans - these programs are for women who need more intensive treatment and support. While in these programs, women live either in the hospital or in a residence with other women. Length of stay for these programs ranges from 28 days to 18 months.
Inpatient and residential programs with cohort treatment for women or separate women's wings- these are programs for women who need more intensive treatment and support, like the specialized inpatient and residential programs discussed above. However, these programs accept both men and women and accept women in groups at specific start dates or have separate space for women.
Women's Stress Disorder Treatment Teams - these are specialized outpatient mental health programs that focus on the treatment of Post Traumatic Stress Disorder and other problems related to trauma.
Women's Homelessness Programs - although many VA homelessness programs serve women, there are also programs specific for women veterans that provide services for those who are homeless or at risk of becoming homeless.
Military Sexual Trauma (MST) Coordinators - every VA facility has a designated MST Coordinator who serves as a point of contact for MST-related issues. Vet Centers also have specially trained sexual trauma counselors.
Sexual Trauma Treatment Provided in Residential or Inpatient Settings - there are programs that offer sexual trauma-specific treatment in a residential or inpatient setting. Programs range from those solely dedicated to the treatment of sexual trauma; to those with a special track emphasizing the treatment of sexual trauma; to those with two or more staff members with expertise in sexual trauma who, in the context of a larger program not focused on sexual trauma, provide treatment targeting this issue.
MST Support Team - In FY07, VA's Office of Mental Health Services established a Military Sexual Trauma (MST) Support Team that is designed to help ensure that VA is in compliance with legally mandated monitoring of MST screening and treatment. The team also helps to coordinate and expand legally mandated education and training efforts related to MST, and to promote best practices in the field.
National Training Initiatives in Evidence-Based Practices for PTSD - there are currently two national initiatives to train therapists in evidence-based practice for PTSD being funded by VA's Office of Mental Health. The first one is to train and support therapists to conduct cognitive processing therapy, a highly effective treatment for PTSD and related symptoms. The second therapy is an exposure therapy for PTSD called prolonged exposure. There have been a number of studies supporting the use of exposure treatment for PTSD.
In addition, there is a wide range of services for women aVAilable through VA's Readjustment Counseling Services and Vet Center Programs. Female veterans who served in combat theaters are eligible for the full range of readjustment services as provided by VA's Vet Center Program. Since the onset of the Vet Center program, women veterans have been provided outreach services to promote early intervention and access to VA care, preventive educational services, counseling for substantive readjustment problems (including war-related PTSD services), family counseling and employment related services. Since 1993, female veterans of any era have also been able to access military related sexual trauma counseling at Vet Centers. Vet Centers promote the hiring of female veteran service providers at equal to or higher than the representation of women in the military. Access to care for women veterans is also promoted through the Vet Center program's working group. The working group is composed of female staff members who assist management by educating their fellow Vet Center staff on the contributions made by women in the military and exploring gender-related issues to promote gender-sensitive services to women veterans.

Research

Currently, the VHA Office of Research and Development (ORD) is supporting a broad portfolio focused on women's health issues, including studies on diseases preVAlent solely or predominantly in women [e.g., certain types of cancer (breast, cervical, oVArian), lupus, human papillomavirus (HPV) and hormonal effects on diseases in post-menopausal women], research focusing on women subjects (e.g., PTSD in women, osteoporosis in women, multiple sclerosis in women) and research on the health care of women veterans.

ORD's efforts to support research that will improve the health care of the growing number of women veterans can be categorized in three areas:

Research assessing VA's organization of care for women veterans and the implications for improved quality of care.
Research on the unique experiences of women veterans regarding risks, treatment and health care outcomes related to sexual and other military traumas.
Research examining the general health care needs and service utilization of women veterans.
In 2001, VA's Office of Research and Development created a Center of Excellence for Research aimed at identifying factors which cause disparities in health outcomes across racial, ethnic, and gender lines, as well as ways for promoting equity in health and health care. This center, co-located at two sites (Pittsburgh and Philadelphia), has 29 core investigators who have contributed over 128 peer-reviewed scientific articles over the past two years.

Veterans Benefits Administration

In fiscal year 2006, Vocational Rehabilitation and Employment Program (VR&E) received 57,856 applications of which 9,895 were female veterans. During the entire fiscal year, VR&E had 52,982 active participants of which 12,627 were female veterans.
In fiscal year 2006, 193,112 female veterans received compensation for a service-connected disability.
In fiscal year 2006, the percent of guaranteed loans was increased for women veterans with 12.2 percent in FY06 with 17,355 loans to women veterans at an average loan amount of $173,923.
In fiscal year 2006, 8,442 women separating from service used their education benefits under the Montgomery GI Bill (MGIB). Since the inception of the MGIB, 214,369 female veterans have used their benefits under Chapter 30 of the program. This represents a 72.7 percent rate of usage.
There are 58,086 female veterans covered under the Veterans Group Life Insurance (VGLI) program. The total amount of coverage in force for female veterans is $17.6 billion for an average coverage of $123,300.
Presented and participated in 8,541 VA benefits briefings attended by 393,345 active duty military service members including guard and reserve members.
To promote accuracy and consistency in the claims review process, VBA has taken a number of actions. For example, in the past four years, VBA has published guidance and conducted training for employees on the full range of issues related to PTSD claims adjudication - from development of the claim to proper application of the rating schedule.
VBA and VHA have worked collaboratively to modifying the examination request worksheets and the examination templates related to PTSD. This ensures that the information gathered during the exam is uniform and sufficient to make the determinations concerning entitlement and degree of impairment.

What are the present and future needs of these growing populations and what strategies does VA have for meeting them?

The last national survey of female veterans was conducted in 1985, leaving VHA policy makers and managers with limited information with which to adequately plan for future health care services for women veterans. To address this knowledge gap, the WVHSHG commissioned Donna Washington, MD, MPH, VA Greater Los Angeles HSR&D Center of Excellence, to conduct a National Survey of Women Veterans. The objectives of the National Survey of Women Veterans are: (1) identify the current demographics, health care needs, and VA experiences of women veterans; (2) determine how health care needs and barriers to VA health care use differ among women veterans of different periods of military service, e.g., OEF/OIF versus earlier periods; and (3) assess women veterans preference for and perceived VAlue of different types of VA interventions to improve access and quality. VA will survey between 2,500 and 3,200 women veterans across the nation, including equal numbers of VA users and nonusers. The survey began in April of 2007 and the final report will be submitted by December 31, 2008.

The recent eleVAtion of the Women Veterans Health Program to the Women Veterans Health Strategic Healthcare Group has positioned the office to gain expertise in the population of women veterans, strategically plan for health care delivery and provide leadership in clinical knowledge of this unique group of women and to catalyze optimal integration of women veterans health issues across all VHA programs and offices. We aim to be a world leader in innoVAtive and high quality care to women veterans.

What outreach efforts are being conducted by VA to women veterans?

We continue to outreach to the women veterans' community with increased emphasis on our partnerships with federal, state, and county agencies, national Veterans Service Organizations and community organizations. To enhance collaboration and better serve our women veterans, representatives from the Department of Health and Human Services, the Department of Labor, the Department of Defense, and VA Administrations (VHA, VBA and NCA) serve on the Advisory Committee on Women Veterans as appointed ex officio members. The Center's Director serves as an ex officio member on the Defense Advisory Committee on Women in the Services. In this role, she ensures that DoD and VA collaboratively address military and women veterans' health and benefits issues.

The Center published the 25 most Frequently Asked Questions from women veterans in English and Spanish based on thousands of inquiries from women veterans. These questions are posted on the Center's website and the VA website.

The next National Summit on Women Veterans Issues will be June 20-22, 2008. We are planning to outreach to the military services, particularly the Reserves and National Guard. We are planning VArious workshops, including "Readjustment Counseling Service: Outreach and Transition Services for Veterans Families," "Gender Differences: What the Data Shows," and "Mental Health Issues." Our previous summit was attended by over 300 women veterans, federal, state and veteran advocates and developed recommendations for how to better serve women veterans.

Since October 2001, the Center staff has completed nearly 100 media interviews and hundreds of keynote speeches, participated in veterans forums, and monitored Transition Assistance sessions and veterans briefings. To ensure veterans' issues are addressed quickly during forums, VA has assigned local women veterans program managers from VA Medical Centers and women veteran coordinators from Regional Offices to accompany Center staff to answer general questions and see that health care and benefit issues raised regarding individual cases receive immediate attention. In addition, Center staff works closely with numerous other VA advisory committees and councils, Department of Defense, Department of Labor, Department of Health and Human Services, Women's Policy, Inc., state and local agencies, and VSO's to address and resolve women veterans issues.

VA is grateful for the work of the Advisory Committee because its activities and reports play a vital role in helping VA assess and address the needs of women veterans.

This concludes my formal testimony. I will be pleased to answer any questions.