Veterans Health Administration Screening for Military Sexual Trauma May Not Capture Over Half of Cases Among Midlife Women Veterans

BackgroundApproximately 1 in 3 women veterans endorse military sexual trauma (MST) during Veterans Health Administration (VHA) screening. Higher rates have been reported in anonymous surveys.ObjectiveWe compared MST identified by VHA screening to survey-reported MST within the same sample and identified participant characteristics associated with discordant responses.MethodsCross-sectional data were drawn from an observational study of women veterans aged 45–64 enrolled in VHA care in Northern California, with data from mail- and web-based surveys linked to VHA electronic health records (EHRs). Between March 2019 and May 2020, participants reported sociodemographic characteristics, current depressive (Patient Health Questionnaire-9) and posttraumatic stress (PTSD checklist for DSM-5) symptoms, and MST (using standard VHA screening questions) in a survey; depression and posttraumatic stress disorder diagnoses (ICD-10 codes) and documented MST were identified from EHRs. Associations between sociodemographic characteristics, mental health symptoms and diagnoses, and discordant MST reports (EHR-documented MST vs. MST reported on survey, not in EHR) were examined with multivariable logistic regression.ResultsIn this sample of midlife women veterans (n = 202; mean age 56, SD = 5), 40% had EHR-documented MST, and 74% reported MST on the survey. Sociodemographic characteristics, mental health symptoms, and diagnosed depression were not associated with discordant MST responses. Women with an EHR-documented PTSD diagnosis had fivefold higher odds of having EHR-documented MST (vs. survey only; odds ratio 5.2; 95% confidence interval 2.3–11.9).ConclusionsVHA screening may not capture more than half of women who reported MST on the survey. VHA screening may underestimate true rates of MST, which could lead to a gap in recognition and care for women veterans.     

Predictors of Veterans Affairs Health Service Utilization by Women Veterans during Pregnancy

BackgroundResearchers have examined predictors of Veterans Affairs (VA) service use by women veterans in general, but less is known about predictors of VA service use by pregnant veterans. This study examined characteristics associated with planned and actual VA service use by pregnant veterans.MethodsThis study includes data from 510 pregnant veterans enrolled in the Center for Maternal and Infant Outcomes Research in Translation Study. Women veterans completed phone interviews during their first trimester and at 3 months postpartum. The Center for Maternal and Infant Outcomes Research in Translation surveys assessed medical and mental health conditions, VA health care use, trauma history, and pregnancy complications. We conducted bivariate and multivariable logistic regression models assessing planned and actual use of VA services during pregnancy.ResultsLifetime post-traumatic stress disorder (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.11–2.69) and history of military sexual trauma (OR, 1.85; 95% CI, 1.19–2.87) were significantly associated with planned VA service use in multivariable models. Lifetime diagnoses of anxiety (OR, 1.78; C.I., 1.15–2.75) were associated with an increased likelihood of actual VA use during pregnancy, whereas Hispanic ethnicity (OR, 0.59; 95% CI, 0.36–0.96), younger age (OR, 0.95; 95% CI, 0.91–0.99), and access to private health insurance (OR, 0.55; 95% CI, 0.37–0.84) were associated with a decreased likelihood of actual VA service use during pregnancy.ConclusionsResults emphasize the association between high-risk mental health characteristics and specific demographic characteristics with VA service use among pregnant veterans. Study findings highlight a continued need for women's health care at the VA, as well as the availability of VA providers knowledgeable about perinatal health issues, and informed community providers regarding women veterans' health.     

Women Veterans’ Experiences with Perceived Gender Bias in U.S. Department of Veterans Affairs Specialty Care

BackgroundIn the past decade, the U.S. Department of Veterans Affairs (VA) has responded to a dramatic increase in women veterans seeking care by expanding Women's Health training to more than 5,000 women's health primary care providers and changing the culture of the VA to be more inclusive of women veterans. These initiatives have resulted in increased patient satisfaction and quality of care, but have focused mostly on primary care settings. Less is known about women's experiences in specialty care within VA. This qualitative study sought to examine women veterans' experiences with VA specialty care providers, with a focus on cardiovascular, musculoskeletal, and mental health care settings.MethodsSemistructured interviews were conducted with 80 women veterans who served during the Iraq and Afghanistan conflicts at four VA facilities nationwide. Interviews focused on understanding women veterans’ experiences with VA specialty care providers, including their perceptions of gender bias.ResultsFour major themes emerged from interviews, including that 1) women did not feel that VA specialty care providers listened to them or took their symptoms seriously, 2) women were told their health conditions or symptoms were attributable to hormonal fluctuations, 3) women noted differences in care based on whether the VA specialty provider was male or female, and 4) women provided recommendations for how gender-sensitive specialty care might be improved.ConclusionsThis study is the first to highlight the perceived gender bias experienced by women veterans in VA specialty care. Women felt that their symptoms were disregarded or diminished by their specialty care providers. Although women veterans report positive experiences within women's health clinics and the primary care setting, their negative experiences in VA specialty care suggest that some providers may harbor unintentional or unconscious gender biases.     

Military Sexual Trauma and Adverse Mental and Physical Health and Clinical Comorbidity in Women Veterans

IntroductionMilitary sexual trauma (MST)—exposure to sexual harassment or assault during military service—is a major health priority for the Veterans Health Administration (VHA). We examined the health correlates of MST in the largest sample of U.S. women veterans studied to date.MethodsUsing national VHA electronic medical record data, we identified 502,199 women veterans who enrolled in the VHA between January 1, 2000, and December 31, 2017, had at least one VHA visit, and were screened for MST (exclusive of those who declined to answer the screening). We conducted logistic regression analyses to examine associations of a positive MST screen with various mental and physical health conditions—defined by administrative diagnostic codes—and comorbidity of mental and/or physical health conditions. Models were adjusted for demographic and military service characteristics, along with duration in the VHA.ResultsApproximately 26% (n = 130,738) of women veterans screened positive for MST. In fully adjusted models, a positive MST screen was associated with greater risk of having all mental and physical health conditions examined, except cancer-related conditions, ranging from 9% greater odds of rheumatic disease to 5.4 times greater odds of post-traumatic stress disorder. MST was also associated with greater comorbidity, including greater odds of having ≥2 mental health conditions (odds ratio [OR], 3.28; 99% confidence interval [CI], 3.20–3.37), having ≥2 physical health conditions (OR, 1.26; 99% CI, 1.22–1.29), and having ≥1 mental health condition and ≥1 physical health condition (OR, 2.05; 99% CI, 2.00–2.11).ConclusionsFindings suggest that MST is common in women veterans and may play a role in the clinical complexity arising from comorbid conditions.     

Five-year Trends in Women Veterans' Use of VA Maternity Benefits, 2008–2012

BackgroundAn increasing number of young women veterans are returning from war and military service and are seeking reproductive health care from the Veterans Health Administration (VHA). Many of these women seek maternity benefits from the VHA, and yet little is known regarding the number of women veterans utilizing VHA maternity benefits nor the characteristics of pregnant veterans using these benefits. In May 2010, VHA maternity benefits were expanded to include 7 days of infant care, which may serve to entice more women to use VHA maternity benefits. Understanding the changing trends in women veterans seeking maternity benefits will help the VHA to improve the quality of reproductive care over time.ObjectiveThe goal of this study was to examine the trends in delivery claims among women veterans receiving VHA maternity benefits over a 5-year period and the characteristics of pregnant veterans utilizing VHA benefits.DesignWe undertook a retrospective, national cohort study of pregnant veterans enrolled in VHA care with inpatient deliveries between fiscal years (FY) 2008 and 2012.ParticipantsWe included pregnant veterans using VHA maternity benefits for delivery.Main MeasuresMeasures included annualized numbers and rates of inpatient deliveries and delivery-related costs, as well as cesarean section rates as a quality indicator.Key ResultsDuring the 5-year study period, there was a significant increase in the number of deliveries to women veterans using VHA maternity benefits. The overall delivery rate increased by 44% over the study period from 12.4 to 17.8 deliveries per 1,000 women veterans. A majority of women using VHA maternity benefits were age 30 or older and had a service-connected disability. From FY 2008 to 2012, the VHA paid more than $46 million in delivery claims to community providers for deliveries to women veterans ($4,993/veteran).ConclusionsOver a 5-year period, the volume of women veterans using VHA maternity benefits increased by 44%. Given this sizeable increase, the VHA must increase its capacity to care for pregnant veterans and ensure care coordination systems are in place to address the needs of pregnant veterans with service-connected disabilities.     

Implementing and Evaluating a Telephone-Based Centralized Maternity Care Coordination Program for Pregnant Veterans in the Department of Veterans Affairs

PurposeThe purpose of this study was to develop and evaluate a comprehensive, telephonic maternity care coordination (MCC) program for all pregnant veterans enrolled for care at New England Department of Veterans Affairs (VA) facilities that comprise the Veterans Integrated Service Network 1.Research DesignTelephone interviews were conducted with postpartum women veterans who had participated in the MCC program during their pregnancies. The program evaluation instrument assessed satisfaction and use of MCC services, prenatal education classes, and infant and maternal outcomes (e.g., newborn birthweight, insurance status, maternal depression) using both closed-ended and open-ended questions.ResultsA substantial majority (95%) of women enrolled in the MCC program expressed satisfaction with the services they received in the program. Women were most satisfied with help understanding VA maternity benefits and acquiring VA services and equipment, such as breast pumps and pregnancy-related medications. More than one-third of women noted their infants had experienced health problems since delivery, including neonatal intensive care unit hospitalizations. A majority of women planned to return to VA care in the future.ConclusionsOur findings suggest that MCC services play an important role for women veterans as they navigate both VA and non-VA care systems. MCC staff members coordinated maternity, medical, and mental health care services for women veterans. Additionally, by maintaining contact with the veteran during the postpartum period, MCC staff were able to assess the health of the mother and the infant, and refer women and their infants to medical and psychosocial services in the community as needed.     

Veterans Health Administration and Medicare Outpatient Health Care Utilization by Older Rural and Urban New England Veterans

CONTEXT: Older veterans often use both the Veterans Health Administration (VHA) and Medicare to obtain health care services. PURPOSE: The authors sought to compare outpatient medical service utilization of Medicare-enrolled rural veterans with their urban counterparts in New England. METHODS: The authors combined VHA and Medicare databases and identified veterans who were age 65 and older and enrolled in Medicare fee-for-service plans, and they obtained records of all their VHA services in New England between 1997 and 1999. The authors used ZIP codes to designate rural or urban residence and categorized outpatient utilization into primary care, individual mental health care, non-mental health specialty care, or emergency room care. FINDINGS: Compared with their urban counterparts, veterans living in rural settings used significantly fewer VHA and Medicare-funded primary care, specialist care, and mental health care visits in all 3 years examined (P<.001 for all). Compared with urban veterans, veterans living in rural settings used fewer VHA emergency department services in 1998 and 1999 but more Medicare-funded emergency department visits in 1997. The authors found some evidence of substitution of Medicare for VHA emergency visits in rural veterans, but no other evidence of like-service substitution. Rural veterans were more reliant on Medicare for primary care and on VHA services for specialty and mental health care. CONCLUSIONS: These findings suggest that rural access to federally funded health care is restricted relative to urban access. Older veterans may choose different systems of care for different health care services. With poor access to primary care, rural veterans may substitute emergency room visits for routine care.     

Factors Impacting Perceived Access to Early Prenatal Care among Pregnant Veterans Enrolled in the Department of Veterans Affairs

Background

Despite the relatively recent Department of Veterans Affairs (VA) policy advances in providing care for veterans and their infants during the perinatal period, little information exists regarding access to prenatal care for women veterans. Currently, VA medical centers do not provide onsite pregnancy care for veterans, but pay for care from community obstetricians through the Veterans Choice Program (VCP) and related non-VA care programs. The VCP is subcontracted to two large contractors, Health Net and TriWest, to assist the VA in administering the VCP. To date, no studies have evaluated women’s perceived access to prenatal care under the VCP.

The Veterans Health Administration and military sexual trauma

Objectives. We examined the utility of the Veterans Health Administration (VHA) universal screening program for military sexual violence.Methods. We analyzed VHA administrative data for 185 880 women and 4139888 men who were veteran outpatients and were treated in VHA health care settings nationwide during 2003.Results. Screening was completed for 70% of patients. Positive screens were associated with greater odds of virtually all categories of mental health comorbidities, including posttraumatic stress disorder (adjusted odds ratio [AOR]=8.83; 99% confidence interval [CI] = 8.34, 9.35 for women; AOR = 3.00; 99% CI = 2.89, 3.12 for men). Associations with medical comorbidities (e.g., chronic pulmonary disease, liver disease, and for women, weight conditions) were also observed. Significant gender differences emerged.Conclusions. The VHA policies regarding military sexual trauma represent a uniquely comprehensive health care response to sexual trauma. Results attest to the feasibility of universal screening, which yields clinically significant information with particular relevance to mental health and behavioral health treatment. Women’s health literature regarding sexual trauma will be particularly important to inform health care services for both male and female veterans.The persistence of sexual violence within the US armed forces is a fact long recognized by military officials, policymakers, health care professionals, and the media. The risk of exposure to sexual violence within the military is high. The annual incidence of experiencing sexual assault is 3% among active duty women and 1% among active duty men. Sexual coercion (e.g., quid pro quo promises of job benefits or threats of job loss) and unwanted sexual attention (e.g., touching, fondling, or threatening attempts to initiate a sexual relationship) occur at an annual rate of 8% and 27%, respectively, among women and 1% and 5% among men.1 Research on deployment stress finds that such experiences constitute important duty-related hazards.2The Veterans Health Administration (VHA) has adopted the term military sexual trauma (MST) to refer to severe or threatening forms of sexual harassment and sexual assault sustained in military service. In response to such widespread exposure in the military and the lasting deleterious consequences of sexual violence, the VHA has implemented a universal screening program for MST. For patients that screen positive, treatment for any MST-related injury, illness, or psychological condition is provided free of charge regardless of eligibility or co-pay status. These policies may represent the most comprehensive health policy response to sexual violence of any major US health care system. To our knowledge, we are the first to study the VHA’s MST program, which provides an unparalleled opportunity to investigate the feasibility and clinical utility of screening for sexual violence and provides unique data to characterize the burden of illness associated with MST.US epidemiological data indicate significant deleterious health and mental health correlates for sexual trauma. Among traumatic events, rape holds the highest conditional risk for posttraumatic stress disorder (PTSD); these data and data specific to military samples confirm that sexual trauma poses a risk for developing PTSD as high as or higher than combat exposure.3^–5 In addition to PTSD, civilian and veteran women exposed to sexual assault or sexual harassment exhibit a range of other mental health and medical conditions.6^–15 These data have led to a greater awareness of sexual trauma issues among physicians and to the development of interventions and guidelines for the treatment and referral of sexual trauma in health care settings.16^–18These health sequelae may be magnified among veterans, because a number of issues uniquely associated with military settings may intensify the effect of this experience.19 Perpetrators are typically other military personnel, and victims often must continue to live and work with their assailants daily, which increases the risk for distress and for subsequent victimization. Unit cohesion may create environments where victims are strongly encouraged to keep silent about their experiences, have their reports ignored, or are blamed by others for the sexual assault, all of which have been linked to poorer outcomes among civilian assault survivors.20 Preliminary studies of MST among women veterans support this hypothesis and have found increased self-reports of depression, substance abuse, and gynecological, urological, neurological, gastrointestinal, pulmonary, and cardiovascular conditions.6^,10The VHA was first authorized to provide outreach and counseling for sexual assault to women veterans after a series of hearings on veteran women’s issues in 1992. Increased attention to these issues led Congress to extend services to male veterans shortly thereafter. In 1999, the VA’s responsibility was extended from counseling to “all appropriate [MST-related] care and services” and universal screening was initiated. Most recently, Public Law 108-422, signed in 2004, made the VA’s provision of sexual trauma services a permanent benefit. Screening programs and treatment benefits apply only to sexual trauma that occurred during military service. Each VA hospital now has a designated coordinator to oversee MST screening and treatment, and standardized training materials for MST screening are available to all VHA providers.21Universal screening is accomplished through the use of a clinical reminder in the electronic medical record. An alert remains visible to all clinicians until screen results are entered. Documentation of a positive screen enables the provider to code the visit as MST related so that care is delivered free of charge. The extent to which these resources have encouraged providers to screen for MST has not been evaluated. Most research from civilian sectors suggest that only a minority of patients are screened for violence by their health care providers.22 However, VHA screening is integrated with standard clinical procedures, and training on the sensitive nature of MST screening is required at each VA hospital. Both of these factors are reliably associated with better screening compliance.22^,23The utility of screening policies to address this widespread veterans’ health issue is complicated because MST is not a syndrome, diagnosis, or construct associated with clear treatment indications. This stands in contrast to most other health care screening targets, such as cervical cancer or depression. Contrary to the American Medical Association’s recommendation for universal screening for violence against women,24^,25 the US Preventive Services Task Force concluded that the evidence does not currently support this approach, citing a lack of intervention research and insufficient evidence that screening ultimately improves health status.26Rebuttals to the Task Force conclusions emphasize the necessity of a broader view: violence against women is a risk or maintaining factor for a variety of health conditions and therefore a key treatment consideration for these patients.27 This perspective is especially relevant for addressing MST in the VHA health care system. Quantifying the types of health impairment associated with positive screens for MST is a first step toward evaluating the utility of universal screening. If screening detects clinically significant information, a positive screen would be an important factor in selecting appropriate treatment. Further evaluation of screening and treatment programs can then assess access to care according to the specific health outcomes found to be relevant to veteran men and women who have experienced sexual trauma.MST has been primarily considered a women’s issue. Men comprise the majority of the armed forces, however, and the incidence of sexual harassment and assault reported by men during military service is significant. The approach to MST should therefore attend to both women and men and examine gender associated with MST as an initial step in the development of gender-specific interventions. Ours is the first examination of nationwide screening data for MST in the VHA and directly informs continued efforts to develop a gender-specific response to the health-related costs of military service and war. Specifically, we examined 3 issues: (1) whether universal screening detects a substantial population of VHA patients who report MST, (2) whether a greater burden of medical and mental illness is found among patients who screen positive for MST compared with patients who screen negative, and (3) whether the burden of illness associated with MST varies by patient gender.     

The Focus They Deserve: Improving Women Veterans’ Health Care Access

PurposeVeterans Health Administration (VHA) initiatives aim to provide veterans timely access to quality health care. The focus of this analysis was provider and staff perspectives on women veterans' access in the context of national efforts to improve veterans’ access to care.MethodsWe completed 21 site visits at Veterans Health Administration medical facilities to evaluate the implementation of a national access initiative. Qualitative data collection included semistructured interviews (n = 127), focus groups (n = 81), and observations with local leadership, administrators, providers, and support staff across primary and specialty care services at each facility. Deductive and inductive content analysis was used to identify barriers, facilitators, and contextual factors affecting implementation of initiatives and women veterans’ access.ResultsParticipants identified barriers to women veterans' access and strategies used to improve access. Barriers included a limited availability of providers trained in women's health and gender-specific care services (e.g., women's specialty care), inefficient referral and coordination with community providers, and psychosocial factors (e.g., childcare). Participants also identified issues related to childcare and perceived harassment in medical facility settings as distinct access issues for women veterans. Strategies focused on increasing internal capacity to provide on-site women's comprehensive care and specialty services by streamlining provider training and credentialing, contracting providers, using telehealth, and improving access to community providers to fill gaps in women's services. Participants also highlighted efforts to improve gender-sensitive care delivery.ConclusionsAlthough some issues affect all veterans, problems with community care referrals may disproportionately affect women veterans’ access owing to a necessary reliance on community care for a range of gender-specific services.     

Substance Use Disorder Treatment Services for Women in the Veterans Health Administration

PurposeThe present study used national Veterans Health Administration (VHA) facility-level data to examine the extent of women's specialty substance use disorder (SUD) treatment programming in the VHA. In addition, the study compared facilities with women's specialty SUD programming with facilities without to determine whether having this programming was associated with serving other special patient populations, treatment staffing, and breadth of service provision.MethodsThe study used data from the VHA Program Evaluation and Resource Center's Drug and Alcohol Program Survey, conducted in 2015 (100% response rate among VHA specialty SUD treatment programs). Program responses were calculated at the facility level (n = 140 VHA facilities).Main FindingsThe majority of VHA facilities (85%) provided women veterans with SUD-specific individual psychotherapy. However, only 30% of facilities provided SUD-specific groups for women only, and only 14% provided SUD–posttraumatic stress disorder groups for women only in specialty SUD treatment. VHA facilities with greater numbers of specialty SUD treatment staff members, a greater breadth of staff roles, and a broader scope of treatment services, activities, and practices were more likely to provide women-only groups.ConclusionsBecause the number of women veterans in specialty SUD treatment is likely to continue to grow, these data serve as a benchmark against which future administrations of the Drug and Alcohol Program Survey will document the extent to which VHA services are responsive to their needs.     

Local Leaders' Perspectives on Women Veterans’ Health Care: What Would Ideal Look Like?

Background

The Veterans Health Administration (VHA) faces challenges in providing comprehensive, gender-sensitive care for women. National policies have led to important advancements, but local leadership also plays a vital role in implementing changes and operationalizing national priorities. In this article, we explore the notions of ideal women veterans' health care articulated by women's health leaders at local VHA facilities and regional networks, with the goal of identifying elements that could inform practice and policy.

Mind the Gap: Assessing the Disconnect Between Postpartum Health Information Desired and Health Information Received

IntroductionSeeking and receiving health information are critical aspects of prenatal and postpartum care; however, many informational sources lack postpartum content. This study explores the gaps between information desired and information received postpartum and identifies the sources women use for health information seeking, with an emphasis on emergent online and mobile phone-based resources.MethodsParticipants were recruited from our community partners’ client base for a cross-sectional study. Mothers (n = 77) of a child 48 months or younger completed a survey on health information seeking, health information needs, and technology use. Postpartum health information gaps were defined as topics about which a participant indicated that she wanted information, but did not receive information. Bivariate analyses assessed the association between demographic characteristics, sources of health information used during pregnancy, and postpartum information gaps.ResultsHealth care providers, Internet-based resources, and mobile applications were common sources of health information during pregnancy. Mental and sexual health were the most common types of postpartum health information gaps. In bivariate analyses, higher income and education were associated with postpartum information gaps in mental health and sexual health, respectively (p < .05).ConclusionsPostpartum health information gaps were common in this sample, particularly for topics in mental and sexual health. Unexpected associations between higher levels of education and income and postpartum health information gaps were observed in bivariate analyses. Health educators have the opportunity to capitalize on high rates of Internet information seeking by providing health information online. Health care providers must incorporate mental and sexual health into routine postpartum care.     

Transitions in Dual Care for Veterans: Non-Federal Physician Perspectives

Many veterans receive care from both the Veterans Health Administration (VHA) and the non-VHA health system, or dual care. Non-federal physicians practicing in Nebraska were surveyed to examine their perspectives on the organization and delivery of dual care provided to veterans. A paper-based survey was mailed to all 1,287 non-federal primary care physicians (PCPs) and a purposive sample of 765 specialist physicians practising in Nebraska. Rural physicians are more likely to incorporate care coordination practices in their clinical practice, compared to urban physicians. More rural physicians report difficulties in patient transfers, and referrals to the VHA, in prescribing for veteran patients, and in contacting a VHA provider in an emergent situation regarding their veteran patient. More PCPs also report difficulties in referrals to the VHA. However, more rural and primary care physicians follow up with their veteran patients post referral to the VHA. There was agreement among the physicians that the current dual care system needed improvements to provide timely, efficient, coordinated and high quality care to veterans. The specific areas identified for improvement were coordination of care, information sharing, medication management, streamlining of patient transfers, reimbursement for care provided outside the VA, and better delineation and clarity of the boundaries of each system and roles and responsibilities of VA and non-VA providers in the care of veterans.     

Implications of Comprehensive Mental Health Services Embedded in an Adolescent Obstetric Medical Home

Purpose Mental health issues in perinatal adolescents are well documented and studies have shown high rates of depressive disorders among this population. Treatment is challenging because pregnant adolescents are poorly adherent with mental health services. We describe a novel integrated mental health care program for pregnant and parenting adolescent mothers and their children. Methods The Colorado Adolescent Maternity Program (CAMP) is a comprehensive, multidisciplinary teen pregnancy and parenting medical home program serving an ethnically diverse and low socioeconomic status population in the Denver metro area. We describe the Healthy Expectations Adolescent Response Team (HEART), an embedded mental health care program focused on improving identification of mental health symptoms and increasing rates mental health treatment in adolescent mothers. Results From January 1, 2011–January 16 2014, 894 pregnant adolescents were enrolled in CAMP and 885 patients were screened for mental health issues. Prior to HEART’s inception, 20 % of patients were identified as having mood symptoms in the postpartum period. Successful referrals to community mental health facilities occurred in only 5 % of identified patients. Following the creation of HEART, 41 % of patients were identified as needing mental health services. Nearly half of the identified patients (47 %) engaged in mental health treatment with the psychologist. Demographic factors including age, parity, ethnicity, and parent and partner involvement did not have a significant impact on treatment engagement. Trauma history was associated with lower treatment engagement. Conclusion Our findings suggest that an embedded mental health program in an adolescent obstetric and pediatric medical home is successful in improving identification and engagement in mental health treatment. Key components of the program include universal screening, intensive social work and case management involvement, and ready access to onsite mental health care providers. Limitations of the program are discussed as well directions for future research.     

Psychotherapy Utilization,Preferences, and Retention among Women Veterans with Post-traumatic Stress Disorder

BackgroundPsychotherapy is the gold standard treatment for post-traumatic stress disorder (PTSD), yet psychotherapy use and retention among veterans is low. Little is known about the barriers to care and factors associated with women veterans' PTSD psychotherapy use and retention. Using a nationally representative sample of 986 women Veterans Health Administration primary care users with PTSD and a perceived need for mental health care, we examined 1) the proportion of women who used psychotherapy, 2) retention in psychotherapy among women who used any psychotherapy, and 3) individual factors related to psychotherapy use and retention.MethodsWomen completed a survey on their mental health care experiences. Outpatient mental health care use in the year before the survey was obtained from Veterans Health Administration administrative data.ResultsMost women (79.1%) used psychotherapy, and 41.7% of those women had a minimal therapeutic dose of psychotherapy (≥8 visits). Mental health diagnostic comorbidity and being African American/Black or identifying as neither African American/Black nor White were significantly associated with higher psychotherapy use. Mental health diagnostic comorbidity, exposure to military sexual trauma, and receiving treatment aligned with gender-related and group-related preferences were associated with higher psychotherapy retention. Being a parent was associated with lower retention.ConclusionsAlthough a significant proportion of women veterans with PTSD are using psychotherapy, retention is enhanced when women are able to obtain treatment aligned with their preferences. Thus, efforts to promote patient-centered, shared decisions regarding mental health treatment options could increase the efficacy and efficiency of treatment for PTSD among women.     

Characterization of U.S. State Laws Requiring Health Care Provider Reporting of Perinatal Substance Use

BackgroundState policies pertaining to health care provider reporting of perinatal substance use have implications for provider screening and referral behavior, patients’ care seeking and access to prenatal substance use disorder treatment, and pregnancy and birth outcomes.ObjectivesThis study sought to characterize specific provisions enacted in state statutes pertaining to mandates that health care providers report perinatal substance use, and to determine the proportion of births occurring in states with such laws.MethodsWe conducted a systematic content analysis of statutes in all U.S. states that mentioned reporting by health care providers of substance use by pregnant women or infants exposed to substances in utero; inter-rater reliability was high. We calculated the number of states, and proportion of U.S. births occurring in states, with processes for mandatory reporting of perinatal substance use to authorities, and substance use disorder treatment provision for individuals who are reported.ResultsTwenty states (corresponding with 31% of births) had laws requiring health care providers to report perinatal substance use to child protective authorities, and four states (18% of births) had laws requiring reporting only when a health care provider believed the substance use was associated with child maltreatment. About one-half of states (13) with any reporting law had a provision promoting substance use disorder treatment in the perinatal period.ConclusionsFindings inform the ongoing debate about how health policies may be used to reduce the population burden of perinatal substance use.     

Do Maternity Care Coordination Services Encourage Use of Behavioral Health Treatment among Pregnant Women on Medicaid?

ObjectiveMaternity care coordination (MCC) may provide an opportunity to enhance access to behavioral health treatment services. However, this relationship has not been examined extensively in the empirical literature. This study examines the effect of MCC on use of behavioral health services among perinatal women.MethodsMedicaid claims data from October 2008 to September 2010 were analyzed using linear fixed effects models to investigate the effects of receipt of MCC services on mental health and substance use–related service use among Medicaid-eligible pregnant and postpartum women in North Carolina (n = 7,406).ResultsReceipt of MCC is associated with a 20% relative increase in the contemporaneous use of any mental health treatment (within-person change in probability of any mental health visit 0.5% [95% CI, 0.1%–1.0%], or an increase from 8.3% to 8.8%); MCC in the prior month is associated with a 34% relative increase in the number of mental health visits among women who receive MCC (within-person change in the number of visits received 1.7% [95 CI, 0.2%–3.3%], or from 0.44 to 0.46 mental health visits). No relationship was observed between MCC and Medicaid-funded substance use–related treatment services.ConclusionsMCC may be an effective way to quickly address perinatal mental health needs and engage low-income women in mental health care. However, currently there may be a lost opportunity within MCC to increase access to substance use–related treatment. Future studies should examine how MCC improves access to mental health care such that the program's ability can be strengthened to identify women with substance use–related disorders and transition them into available care.