Implementation of Women's Health Patient Aligned Care Teams

Women Veterans' numerical minority in VA healthcare settings has created logistical
challenges to delivering gender-sensitive comprehensive services. These challenges have only
grown as more women Veterans have enrolled in VA care. Access and quality have lagged behind
that of male Veterans, while gender sensitivity, including adequate attention to
privacy/safety and awareness of women's military roles and experiences, is often lacking.
On-site availability of gender-specific services has also not kept pace, with women Veterans
more likely to be outsourced for gender-specific care now than they were ten years ago.
Further, while the proportion of VA facilities having women's health (WH) clinics has
increased, prior research has demonstrated that as many as 40% of them were not delivering
comprehensive primary care services, instead focusing only on gender-specific exams. Lack of
gender-sensitive, comprehensive care for women has also been associated with measurable
decrements in women's ratings of VA access, continuity and coordination, as well as measures
of technical quality.

The investigators aim to assess the effectiveness of evidence-based quality improvement
(EBQI) methods for developing a WH PACT model using a cluster randomized trial design (Aim
#1); examine impacts of receipt of WH-PACT concordant care on women Veterans' outcomes (Aim
#2); evaluate processes of EBQI-supported WH-PACT implementation (Aim #3); and develop
implementation and evaluation tools for use in EBQI-supported WH-PACT model adaptation,
implementation, sustainability and spread to additional VA facilities (Aim #4).

EBQI is a systematic approach to developing a multi-level research-clinical partnership
approach to engaging local organizational senior leaders and quality improvement teams in
adapting and implementing new care models in the context of prior evidence, local practice
context, and provider behavior change methods, with researchers providing technical support
and practice facilitation. In a cluster randomized trials, the investigators will evaluate
WH-PACT model achievement using patient, provider and practice surveys. The investigators
will examine intermediate changes in provider, staff and team knowledge and attitudes. Using
analyses of secondary administrative and performance data, the investigators will also
explore impacts of receipt of WH-PACT care on quality of chronic disease care and prevention,
health status, utilization and costs. Using mixed methods, the investigators will assess
pre-post EBQI practice context; document WH-PACT implementation; and examine
barriers/facilitators to EBQI-supported WH-PACT implementation through a combination of
semi-structured interviews and monthly formative progress narratives and administrative data
review.

Inclusion Criteria:

Facility inclusion criteria:

- VA medical center (VAMC)

- Located in a VISN that has 3 or more VAMCs

- Membership in the Women's Health Practice Based Research Network (PBRN)

Key Stakeholder (interviews) inclusion criteria:

- VISN and VAMC leaders (SES), VAMC primary care/PACT directors, VAMC women's health
medical directors, Women Veteran Program Managers (VISN and VAMC), VISN
representatives in mental health, health information technology/informatics, quality
improvement/system redesign, at least one Nurse Executive (VISN or VAMC)

- Intervention and control VAMCs

Provider (surveys and interviews) inclusion criteria:

- Primary care providers (MD, DO, NP, PA) who have seen 1+ women Veterans in the past
year

- Teamlet primary care provider interviews (MD, DO, NP, PA) at intervention VAMCs

- Surveys of primary care providers (MD, DO, NP, PA) at intervention and control VAMCs

- Surveys of larger primary care/PACT team members (e.g., clinical pharmacists, health
coaches)

Staff (surveys and interviews) inclusion criteria:

- Primary care/PACT clinical staff (non-providers) in primary care/PACT teams/teamlets
that have seen 1+ women Veterans in the past year

- Teamlet member interviews at Intervention VAMCs

Patient inclusion criteria:

- Women Veterans seen in participating VAMCs with 3+ primary care visits in general primary
care and/or women's health clinics in the past year

Exclusion Criteria:

Facility exclusion criteria:

- VA facilities that are not VAMCs (e.g., community-based outpatient clinics or CBOCs)

- VAMCs in VISNs with fewer than 3 VAMCs

- VAMCs that are not members of the WH PBRN

Key Stakeholder (interviews) exclusion criteria:

- Stakeholders outside of the participating VISNs (1, 4, 12, 23) and VAMCs (see study
sites)

Provider (surveys and interviews) exclusion criteria:

- VA providers who do not deliver primary care in participating VAMCs

- VA primary care providers who have not seen or do not see women Veteran patients for
primary care delivery at a participating VAMC

- Teamlet providers at control VAMCs will not be interviewed

Staff (surveys and interviews) exclusion criteria:

- Primary care clinical staff not participating in PACT (e.g., assigned to primary care
rolls but not actually associated with primary care/PACT direct patient care delivery)

- Primary care/PACT clinical staff at control VAMCs will not be interviewed

Patient exclusion criteria:

- Women Veterans who do not use the VA for their health care or for their primary care
needs

- Women Veterans with fewer than 3 VA primary care visits in the prior year and
therefore not exposed to PACT or WH PACT

- Women Veterans with terminal illness and/or poor prognosis or other health concerns
for whom enrollment and survey participation would prove an inappropriate burden