Systems Transformation: Integration of Reproductive Health in Health Systems
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1 Systems Transformation: Integration of Reproductive Health in Health Systems Laurie Zephyrin MD, MPH, MBA Director, Reproductive Health Women s Health Services (WHS) Veterans Health Administration (VHA) Department of Veterans Affairs (VA) Health System
2 Reproductive Health state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity Population Health Perspective WHO s Sustainable Development Goals 2030 Universal access to sexual and reproductive-health services Integrate reproductive health into national strategies and programs Eliminate all forms of violence against all women and girls in the public and private spheres Strong focus on equity and the importance of addressing the needs of the poor or disadvantaged Emphasize strengthening health systems and.. integrating technology, communities
3 Innovation and Adaptation of a VA Health System As a health system, the VA strives to: Understand the population and its unique needs, with an emphasis on emerging and priority populations Engage and is responsive to key stakeholders, including women Veterans, community providers, and academic partners Develop and implement evidence based policies and program to provide necessary resources to enhance system capacity and structure Innovates to ensure care delivery incorporates evidence based research, IT tools, EHR enhancements, and new care delivery models VA Healthcare System The VA Healthcare System is the largest integrated health care delivery system in the United States Over 9 Million Enrollees 18 Veteran s Integrated Networks Over 1200 Community Based Outpatient Clinics Over 140 VA Medical Centers
4 # Women Veteran Patients Number Of Women Veteran VHA Patients In Each Year, Fiscal Year(FY) 2000-FY 2017 The number of women Veterans using VHA services has tripled since 2000, growing from 159,810 in FY00 to 484,317 in FY17, representing a 203% increase over 17 years. 600, , , , , , , , , , , Care for Women Veterans Gender-specific services provided at VA facilities: o Gynecologic care (Basic and Specialty) o Contraceptive care and counseling o Mammography o Breast and cervical cancer screening and treatment o Menopause-related care o Emergency Medicine Services not provided at VA facilities: o Obstetrical/maternity care o Specialty Infertility services Note: Individual VA facilities are unique in their availability to provide particular services to Veterans. Factors such as local Veteran demographics, proximate academic affiliates, availability of specialists affect where women Veterans can go, within and outside of VA, to receive genderspecific care. PCP plays critical role with GYN and mental health providers
5 # Women Veteran Patients Age Distribution of Women Veteran Patients FY00 and FY17 14,000 12,000 10,000 FY00 FY17 8,000 6,000 4,000 2, Age Cohort: Women Veteran VHA patients with non-missing ages years (inclusive) in FY00 and FY17. Women in FY00: N=159,553; FY17: N=484,156. Source: WHEI Master Database, FY00-FY17 Women Veterans Who Use VA Health Care Compared to non Veterans, women Veterans who use Reproductive Health Risks VA health care have Increased chronic medical & psychiatric conditions Increased risk of pregnancy complications elevated risk of poor pregnancy outcomes Veterans need high-quality preconception services 10
6 Service Connected Disability* Mental Health Pregnancy and Maternity Care Use of VA maternity care has increased by 44% in the past 5 years Current PTSD Symptoms* Current Depression Symptoms* Hx PTSD Hx Depression* *P = 0.02 *P = 0.01 None 0-40% % *P = 0.02 *P = 0.02 Did not Use VA Prenatal Benefits (n=237) Percentage, % Effective maternity care coordination is a critical component of maternity care for women Veterans Maternity Care Transitions for a High Risk Population Pre-Pregnancy Physical Problems % VA Care Preconception CarePrescribing Safe VA Care Ob Care in the Community VA Care Coordination Care Completion in the Community Ob Record Transfer VA Care/Follow- Up Musculoskeletal Endocrine Neurologic Pre-Pregnancy Mental Health Problems 17% 10% 10% % Depression Anxiety 28% 21% Use of VA maternity care has increased by 44% in the past 5 years Nearly all VA maternity care is outsourced
7 Pre-pregnancy Primary Care Preconception care can improve overall wellness and pregnancy outcomes Reproductive life planning Women Veterans value reproductive life planning discussions within primary care Reproductive life planning tools and electronic record enhancements to facilitate risk-benefit discussions when prescribing high risk medications can enhance preconception care Caring for Women Veterans Employ a health systems approach to gender-specific care Integrate with primary care, mental health, and specialty care Strengthen care coordination Develop innovative models of care delivery and accountability Strengthen clinical partnerships between public and private health care settings, academic departments, and VHA
8 Women s Health Primary Care Providers Designated Women s Health PCP- is trained and experienced in women s health and is preferentially assigned women Veterans In 2010, VA established policy requiring the provision of comprehensive women s healthcare by DWHPs The Importance of PCPs: Women assigned to WH-PCPs were more likely to: 1 Have higher rates of satisfaction 2 Receive improved care quality 3 Have lower attrition 4 Have high quality contraception counseling Maternity Care Transformation First National Policy for Maternity Care Maternity Care Coordinators (MCC) At each VA Medical Center Facilitate communication between non-va maternity care providers and VA-based health care providers. Provide support and education. Assist with lactation needs Screen for post-partum needs MCC Community of Support VA maternity care coordinators and reproductive health subject matter experts to share best practices MCC Telephone Care Program, Maternity Dashboard, Telehealth Support
9 IT Innovations to Support PCP and Enhance Reproductive Healthcare Delivery VA s National Electronic Health Record (VistA) provides a robust platform upon which tools to address reproductive health issues can be developed Currently there enhancements underway to develop solutions for: Safe Prescribing Preconception Care Maternity Care Safe Prescribing: Teratogenic Medications Safe prescribing and teratogenic and electronic medical record enhancements Enhanced Medication order checks were vitals display (LMP and launched in VA's electronic reproductive status) medical record to notify providers when prescribing a Clinical reminders high-risk medication TDrugs (pregnancy & project lactation Future enhancements will status) include: Point of care decision making assistance Computerized notifications, alerts and tools Alerts to ordering provider Order Checks (Medicines & imaging studies)
10 VA Preconception Mobile App Clinical Measures for Preconception Wellness* Intended/planned to become pregnant Entered prenatal care within first trimester Daily folic acid/multivitamin consumption Tobacco free Absence of uncontrolled depression Healthy BMI Optimal blood sugar control Medications (if any) are not teratogenic No single measure alone is sufficient to describe preconception wellness Taken in aggregate can be a marker of wellness and receipt of quality preconception care * Obstet Gynecol May;127(5):863-72
11 Innovation and Adaptation of a VA Health System As a health system, the VA strives to: Understand the population and its unique needs, with an emphasis on emerging and priority populations Engage and is responsive to key stakeholders, including women Veterans, community providers, and academic partners Develop and implement evidence based policies and program to provide necessary resources to enhance system capacity and structure Innovates to ensure care delivery incorporates evidence based research, IT tools, EHR enhancements, and new care delivery models Contact information For more information, contact: Dr. Laurie Zephyrin Director, Reproductive Health Women s Health Services Department of Veterans Affairs Laurie.Zephyrin@va.gov
12 Women Veterans Call Center
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