Project Background/Rationale: Women Veterans are a rapidly growing proportion of VA patients. While entitled to receive care equivalent to their male counterparts, women Veterans may receive lower quality care, in part due to a VA primary care (PC) workforce that has limited experience caring for women, particularly their gender-specific conditions. This workforce may be especially challenged in community-based outpatient clinics (CBOCs), where access to women's health (WH) expertise may not be readily available. CBOC PC providers (PCPs) typically have small caseloads of women Veterans, making it difficult for these providers to maintain their WH knowledge and skills. To ensure quality care for women Veterans, VA mandated designated WH providers (DWHPs) in every VA facility, and instituted intensive training opportunities-""""""""WH mini- residencies""""""""-for these providers. Although highly valuable in delivering a standard level of specialized WH training, these one-time trainings are not sufficient, as knowledge attenuates over time. Serial education re- enforcement over time is needed to produce and maintain long-term gains in knowledge or skills. Furthermore, additional supports, such as enhanced communication between PCPs and specialists, are necessary to achieve and sustain quality gains. Objectives: We propose to test """"""""DWHP Support,"""""""" an intervention designed to improve CBOC-based DWHP delivery of comprehensive WH care. DWHP Support combines: 1) advanced WH serial patient-based education that exposes DWHPs, over time, to a depth and breadth of WH cases and issues;and 2) interactive communication between CBOC DWHPs and VA Medical Center-based specialists for """"""""just in time"""""""" support of DWHP WH care. The intervention is technology-supported and delivered virtually. We hypothesize that DWHP Support will improve the quality and efficiency of WH care in CBOCs.
Our specific aims are:
Aim #1 : To evaluate the effect of DWHP Support on WH care quality and efficiency, in a quasi-experimental controlled trial, comparing CBOCs in an intervention VA region (VISN) to a usual care VISN;
Aim #2 : To explore the impact of DWHP Support in changing DWHP behavior and self-rated WH knowledge, skills, and self-efficacy;
Aim #3 : To assess attitudes about DWHP Support and its use, specialist time for its implementation, and other features that could influence DWHP Support's effectiveness, sustainability and spread;
Aim #4 : To develop tools to measure quality of WH care in VA. Methods: We will conduct a prospective, quasi-experimental controlled trial of DWHP Support versus usual care for CBOC DWHPs. This will be a two-VISN study where the level of assignment to intervention versus control will be the VISN. We will use a mixed methods analytic approach to measure the intervention's effect after 1 year, while also evaluating the implementation process and use of the intervention. We will operationalize existing evidence-based WH performance guidelines for quality measurement of VA WH care. Anticipated Impact: This proposal aims to improve WH care in CBOCs with a technology-based educational and interactive communication intervention designed for WH providers. To measure the intervention's effectiveness, this project will develop WH quality measures that will be valuable tools for other VA efforts to improve WH care. Our findings on effectiveness and implementation could influence VA's approach and use of technology-supported interventions for other clinical conditions and in other special populations.

Public Health Relevance

VA community-based outpatient clinics (CBOCs) typically serve only a small number of women Veterans, and generally do not have the women's health care resources that are available in larger settings. Women Veterans using these sites for primary care must sometimes travel to other sites to receive women's health care. That can create travel burdens, reduce continuity of care, and negatively affect patient outcomes. This research is designed to improve women's healthcare delivery in CBOCs by supporting women's primary care providers with a technology- based intervention that combines ongoing education and interactive communication with women's health specialists. Findings from this research will impact VA women's health clinical practice and education, and will advance science in delivering technology-supported non-face- to-face care that is applicable to other clinical conditions and patient populations.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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Special Emphasis Panel (HCR4)
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VA Greater Los Angels Healthcare System
Los Angeles
United States
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Zuchowski, Jessica L; Hamilton, Alison B; Washington, Donna L et al. (2017) Drivers of Continuing Education Learning Preferences for Veterans Affairs Women's Health Primary Care Providers. J Contin Educ Health Prof 37:168-172
Washington, Donna L; Steers, W Neil; Huynh, Alexis K et al. (2017) Racial And Ethnic Disparities Persist At Veterans Health Administration Patient-Centered Medical Homes. Health Aff (Millwood) 36:1086-1094
Cordasco, Kristina M; Zuchowski, Jessica L; Hamilton, Alison B et al. (2015) Early lessons learned in implementing a women's health educational and virtual consultation program in VA. Med Care 53:S88-92