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“We now have an evidence base that practitioners can use to transform care for women veterans, and the VA is adopting our research at an unprecedented clip.”
— Dr. Elizabeth Yano
WHEN ELIZABETH (BECKY) YANO, MSPH ’87, PhD ’96, BEGAN HER TRAINING in epidemiology, biostatistics and health policy, the idea that she might use her Fielding School education to spearhead a transformation in how the nation’s largest integrated health system provides care for its female patients was the furthest thing from her mind.
But after Yano arrived at the VA Greater Los Angeles Healthcare System (VAGLAHS) in 1989 for what was intended to be a short stint — to help evaluate the VA’s first primary care demonstration project — she discovered that the Veterans Health Administration, which serves more than 9 million veterans through care provided at more than 1,200 facilities across the country, was an institution with a great interest in using research to implement policy changes. “Once I saw the kind of impact I could have, I never left,” Yano says.
For much of the last two decades, Yano, an adjunct professor in FSPH’s Department of Health Policy and Management, has led a research enterprise that has sought to identify and address gaps in knowledge about women veterans’ health and health care needs in ways that improve the quality of care they receive, as well as their satisfaction with the patient experience in the VA system.
The Women’s Health Practice-Based Research Network, which involved four sites when it was funded in 2010, has grown to 60 sites across the country with plans to expand even further over the next two years. Yano explains that in addition to increasing the participation of women veterans in multisite studies and quality improvement projects, this infrastructure has been integral to the VA’s ability to test and implement evidence-based quality improvement (EBQI) initiatives, which expedite the incorporation of scientific findings into clinical settings through partnerships involving researchers and clinic administrators and staff.
This rapid adoption of findings is illustrated by the CREATE-funded research to tailor the VA’s patient-centered medical home model — in which patients work in partnership with members of a health care team, each of whom has a defined role, to ensure coordinated, patient-centered care — in ways that promote gender-sensitive care for women veterans. “Before we even finished the trial, the approach we were testing was adopted for use with the VA’s lowest-performing facilities, and we’re now evaluating how well improving and tailoring care to women veterans works in twice the number of VA facilities as we did for the previous trial,” Yano says.
Among the co-investigators on the original study is Dr. Emmeline Chuang, assistant professor in FSPH’s Department of Health Policy and Management. Chuang interviewed providers and staff who see women veterans across eight regions of the U.S. to learn more about their work experience and how that influenced the delivery of care. “Part of what’s exciting about this intervention is that it focuses on building local capacity,” Chuang says. “The idea is to empower providers and staff to pilot-test and refine changes designed to improve performance so that they can sustain these ongoing quality improvement efforts after the intervention ends.”
In addition to teaching in FSPH’s Executive Masters of Public Health program offered by the Department of Health Policy and Management, Yano has been invited by Chuang to deliver guest lectures to her students on topics that include implementation science and organizational research. Yano also serves on the dissertation committees of several Fielding School PhD candidates. Among them is Julian Brunner, who, while completing his FSPH dissertation on the use of electronic health records in primary care settings, has been working on Yano’s VA team, publishing several peer-reviewed articles on topics related to health care for women veterans. “Traditionally as a researcher you publish papers and hope to capture the attention of people who make decisions,” Brunner says. “What draws me to the work we’re doing at the VA is that the research is designed with input from the policymakers, guaranteeing that it will be relevant and have real-world impact.”
The Women’s Health Research Network headed by Yano remains as robust as ever, with 15 career development awardees around the country and another 15 young investigators soon to be awarded or readying their applications, allowing Yano to continue thinking in ambitious terms about an overarching research agenda for women veterans at the VA. High on her priority list is the ongoing effort to use the evidence-based quality improvement approach to spread promising practices across the more than 1,200 sites where the VA provides care. “We need to ensure that every woman veteran is treated with the same dignity by providers who are proficient and prepared to deliver comprehensive services,” she says. “Within that context, we need to work on improving trauma-sensitive environments and trauma-sensitive care delivery. There are still providers who see a woman veteran and assume she is the spouse of a male veteran. There are still those who see a woman who is missing a leg and can’t believe that it was from combat. The VA has done a lot of work to bring people along, but we have a lot more work to do.”
Thanks to the foundation laid by Yano and her colleagues, the VA is well positioned to continue moving forward. Yano notes that the volume of research and published papers on the health and health care of military women and women veterans has grown exponentially since the 2004 VA women’s health research agenda recommendations were made. “We now have an evidence base that practitioners can use to transform care for women veterans,” Yano says, “and the VA is adopting our research at an unprecedented clip.”