This case study was developed with funding and support from the Implementation Research Institute at Washington University in St. Louis.
Women Veterans are the fastest-growing segment of users in the Veterans Health Administration (VA).1 The VA has invested heavily in delivering care for women Veterans that is effective, comprehensive, and gender-tailored;2,3 yet gender differences continue in cardiovascular and diabetes risk factor control.4,5 Depression is also more common among women Veterans than civilian women before and after giving birth,6 which is especially concerning given the link between depression and suicide.7 Distance from the VA, living in a rural area, and other challenges, such as negative opinions of VA care, mental health issues, discrimination based on sexual and/or gender minority identities, and harassment on VA grounds, can also keep women from regularly using VA care.
Begun in 2015, the Enhancing Mental and Physical Health of Women through Engagement and Retention Quality Enhancement Research Initiative (EMPOWER QUERI) has focused on gender-tailored care for women Veterans at the VA.8 Based out of the VA Greater Los Angeles Healthcare System, early EMPOWER studies found that women prefer gender-specific (women only) care and telehealth care delivered by phone, video call, or online.9 The new EMPOWER 2.0 program builds on that work by expanding access to telehealth, evidence-based, preventive lifestyle and mental health services for women Veterans in rural and urban-isolation areas.
EMPOWER 2.0 will work with up to 800 women Veterans across 20 VA facilities throughout the U.S. to implement three evidence-based practices:
- Virtual Diabetes Prevention Program (DPP), a lifestyle intervention shown to prevent and/or delay progression to type 2 diabetes;10
- Telephone Lifestyle Coaching Program (TLC), which provides telehealth, individual-level, personalized health coaching focused on wellness and cardiovascular disease prevention;11 and
- Reach Out, stay Strong, Essentials (ROSE),an intervention to prevent perinatal depression that can be delivered via telehealth.12
EMPOWER 2.0 will improve women Veterans’ access to telehealth preventive lifestyle and mental health services. Increasing access to preventive care could reduce disparities in cardiovascular disease, diabetes, and depression experienced by women Veterans.4–6 The project will also benefit the VA and other large healthcare systems, and the field of implementation science more broadly, by comparing different ways of helping sites offer the evidence-based practices. For example, the project will explore using different strategies for training providers and organizing women’s healthcare. This effort will provide valuable information on what kind of strategies work better for helping sites to achieve results quickly and at lower cost. Study findings will be used to generate “implementation playbooks,” or brief guidebooks for how to implement new evidence-based practices, to help program partners in encouraging spread of these practices across VA. Rural communities often lack access to preventive care,13 and by focusing on rural women Veterans, this project could also offer lessons for improving rural healthcare delivery.
The ultimate goal of EMPOWER 2.0 is improved VA telehealth care delivery and clinical health outcomes for women Veterans.
Erin P. Finley, PhD, MPH;i,ii,iv Alison Hamilton (primary contact), PhD, MPH;i-iii Tannaz Moin, MD, MBA MSHS;i-iii Bevanne Bean-Mayberry, MD, MHS;i-iii Melissa M. Farmer, PhD;i,ii Ariel Lang, PhD, MPH;v,vi Sally G. Haskell, MD, MSvii,viii
i Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
iiVeterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, CA
iiiDavid Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
ivUniversity of Texas Health Science Center, San Antonio, TX
vVA San Diego Healthcare System, San Diego, CA
viUniversity of California San Diego, San Diego, CA
viiVA Connecticut Healthcare System, West Haven, CT
viiiYale School of Medicine, Yale University, New Haven, CT
Veterans Health Administration offices: VA Women’s Health Services, National Center for Health Promotion and Disease Prevention, Office of Mental Health and Suicide Prevention, Office of Primary Care, Office of Patient-Centered Care and Cultural Transformation, Office of Rural Health
EMPOWER 2.0 was funded by the VA Quality Enhancement Research Initiative
Check out the Impact Profile, a one-page summary of project impact.
Learn more about the project
Demonstrated benefits are those that have been observed and are verifiable. Potential benefits are those logically expected with moderate to high confidence.
EMPOWER 2.0 will increase access to preventive telehealth services for women Veterans, including those in rural and urban-isolation areas.
The EMPOWER 2.0 team is testing different training and support strategies to ensure VA women’s telehealth rollouts are successful. Potential.
The EMPOWER 2.0 will work with VA sites to increase preventive telehealth care options for cardiovascular disease, diabetes, and depression among women Veterans at risk for health disparities. Potential.
The EMPOWER 2.0 team will develop research reports and implementation playbooks on comparative effectiveness and cost of different strategies for implementation of telehealth care services in the VA. Potential.
EMPOWER 2.0 reports will support VA program offices in developing evidence-based policies for future rollouts. Potential.
This research has community and policy implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.
Community: Historically, women Veterans have faced challenges in accessing VA care, often related to living far from VA care facilities or having negative experiences with and/or perceptions of VA care. Many women Veterans are also at risk for health disparities related to rurality, race/ethnicity, mental health concerns, and sexual and/or gender minority identities. EMPOWER 2.0 will work with VA sites to increase preventive telehealth options for women – including services like health coaching across life stages and education during pregnancy — increasing women’s ability to access care services in a way that is safe, convenient, and appropriate for them. Improving access to these tailored preventive services has the potential to improve health outcomes for women Veterans, including cardiovascular disease, diabetes, and depression.
Policy: VA provides a national, integrated healthcare system for Veterans. To ensure care services are both high quality and accessible, the VA faces the challenge of continuous quality monitoring and improvement that often requires rolling out new programs across hundreds of sites nationally to better meet Veterans’ needs. Because these rollouts can take time and resources, the EMPOWER 2.0 team is testing different training and support strategies for making sure the rollouts are successful. The information on what strategies work best, and the comparative cost and return-on-investment of different strategies, will be used to develop research reports and guidance for VA national program offices. These reports, in turn, will support program offices in making evidence-based policy decisions as they engage in planning for future rollouts.
- Frayne S, Phibbs C, Saechao F, et al. Sourcebook: Women Veterans in the Veterans Health Administration. Volume 3. Sociodemographics, Utilization, Costs of Care, and Health Profile. Women’s Health Evaluation Initiative, Women’s Health Services, Veterans Health Administration, Department of Veterans Affairs; 2014. Accessed November 4, 2021. https://www.womenshealth.va.gov/docs/sourcebook_Vol_3_FINAL.pdf
- deKleijn M, Lagro-Janssen ALM, Canelo I, Yano EM. Creating a roadmap for delivering gender-sensitive comprehensive care for women Veterans: results of a national expert panel. Med Care. 2015;53(4 Suppl 1):S156-164. doi:10.1097/MLR.0000000000000307
- Yano EM, Haskell S, Hayes P. Delivery of gender-sensitive comprehensive primary care to women veterans: implications for VA patient aligned care teams. J Gen Intern Med. 2014;29(Suppl 2):703-707. doi:10.1007/s11606-013-2699-3
- Goldstein KM, Melnyk SD, Zullig LL, et al. Heart matters: gender and racial differences cardiovascular disease risk factor control among veterans. Womens Health Issues. 2014;24(5):477-483. doi:10.1016/j.whi.2014.05.005
- Vimalananda VG, Biggs ML, Rosenzweig JL, et al. The influence of sex on cardiovascular outcomes associated with diabetes among older black and white adults. J Diabetes Complications. 2014;28(3):316-322. doi:10.1016/j.jdiacomp.2013.12.004
- Kroll-Desrosiers AR, Crawford SL, Moore Simas TA, Clark MA, Bastian LA, Mattocks KM. Rates and correlates of depression symptoms in a sample of pregnant veterans receiving Veterans Health Administration care. Womens Health Issues. 2019;29(4):333-340. doi:10.1016/j.whi.2019.04.008
- Gross GM, Kroll-Desrosiers A, Mattocks K. A longitudinal investigation of military sexual trauma and perinatal depression. J Womens Health (Larchmt). 2020;29(1):38-45. doi:10.1089/jwh.2018.7628
- Hamilton AB, Farmer MM, Moin T, et al. Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER): a protocol for a program of research. Implementation Science. 2017;12(1):127. doi:10.1186/s13012-017-0658-9
- Dyer KE, Moreau JL, Finley E, et al. Tailoring an evidence-based lifestyle intervention to meet the needs of women Veterans with prediabetes. Women Health. 2020;60(7):748-762. doi:10.1080/03630242.2019.1710892
- Moin T, Damschroder LJ, AuYoung M, et al. Results from a trial of an online Diabetes Prevention Program intervention. Am J Prev Med. 2018;55(5):583-591. doi:10.1016/j.amepre.2018.06.028
- Damschroder LJ, Reardon CM, Sperber N, Robinson CH, Fickel JJ, Oddone EZ. Implementation evaluation of the Telephone Lifestyle Coaching (TLC) program: organizational factors associated with successful implementation. Transl Behav Med. 2017;7(2):233-241. doi:10.1007/s13142-016-0424-6
- Zlotnick C, Tzilos G, Miller I, Seifer R, Stout R. Randomized controlled trial to prevent postpartum depression in mothers on public assistance. J Affect Disord. 2016;189:263-268. doi:10.1016/j.jad.2015.09.059
- Rural veterans. US Department of Veterans Affairs, Office of Rural Health website. Accessed November 10, 2021. https://www.ruralhealth.va.gov/aboutus/ruralvets.asp