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. 2018 Apr 16;2017:750–759.

The “Safety Net” of Community Care: Leveraging GIS to Identify Geographic Access Barriers to Texas Family Planning Clinics for Homeless Women Veterans

Lori Gawron 1,2, Warren B P Pettey 1,3, Andrew Redd 1,3, Ying Suo 1,3, David K Turok 2, Adi V Gundlapalli 1,3,4,5
PMCID: PMC5977597  PMID: 29854141

Abstract

The Veterans Healthcare Administration (VHA) is developing a civilian referral system to address specialty access issues to VHA healthcare. Homeless women Veterans may not have the resources to navigate referral systems when travel to VHA Medical Centers (VAMCs) is limited, especially for family planning needs. Recent Texas legislation restricted funding to civilian, publically-funded family planning clinics, limiting comprehensive services. This study’s goal was to assess geographic availability of VAMCs and family planning clinics for homeless Texan women Veterans. We identified 3,246 Texan women Veterans, age 18-44y with administrative homelessness evidence anytime between 2002-2015. Significant clusters of homeless women Veterans were near VHA facilities, yet mean travel distance was 24.1 miles (range 0-239) to nearest family planning clinic compared to 82.6 miles (range 0.8316.4) to nearest VAMC. Community clinics need ongoing civilian funding support if the VHA is to rely on their geographic availability as a safety net for vulnerable Veterans.

Introduction

Women Veterans are the fastest growing population of Veterans Health Administration (VHA) eligible users, nearly doubling in the past decade and numbering more than 2 million in 2015.1,2 Women Veterans who access care in the VHA are a vulnerable population with a high prevalence of medical and mental health comorbidities 1,3, military sexual trauma experiences 4, and have a 4-fold increased risk of homelessness compared to the civilian population 5. In order to meet the unique needs of this growing population, the VHA prioritized expansion of comprehensive primary care that includes reproductive health care by a single, women’s health provider.6 This comprehensive care should include family planning services but may require travel to an urban, Veterans Healthcare Administration Medical Center (VAMC) for more advanced services, such as insertion of an intrauterine device (IUD), due to provider availability or training.7 To avoid this travel barrier, the VHA is increasingly developing policies to partner with healthcare providers closer to Veterans’ homes.8 This community referral process (Veterans Choice Program) can be challenging for Veterans to utilize. They must first make contact with a VHA provider through a VAMC or Community-Based Outpatient Clinic (CBOC), obtain a referral for non-VHA or “Choice” care, await an authorization process, and then wait until an appointment is scheduled with an eligible civilian provider. Unfortunately, this practice only works if trained civilian providers are geographically accessible to meet the Veterans’ needs.

Homeless women are at increased need for family planning services, due to elevated risks for sexual trauma and infections (STIs), unintended pregnancy, and adverse outcomes, such as preterm birth.9–13 Women Veterans are at greater risk for homelessness than civilian women due to the prevalence of military sexual trauma (MST), unemployment, disability, poor overall health, and anxiety disorders or post-traumatic stress disorder.14 Homeless women Veterans are highly reliant upon the VHA and, unlike Veterans with more resources, may not be able to overcome travel barriers or the logistics of the “Choice” referral process to access family planning services-especially for more time-sensitive needs, such as access to emergency contraception or STI treatment. Additionally, they are less likely to have public or private insurance to access non-VHA care through civilian healthcare providers, thus publically-funded family planning clinics are their safety net for services. Publically-funded clinics typically rely upon Title X federal funding, payments from Medicaid insurance plans, and state-funded family planning waivers, with federal policies requiring all qualified providers remain eligible to participate in care funded by these federal programs.15,16 Recent political challenges to this healthcare infrastructure have progressed in several states and at a national level and Texas became the first state to enforce a string of legislative initiatives beginning in 2011 that drastically impacted publically-funded family planning clinics.17 These initiatives excluded Planned Parenthood clinics from federally funded programs, diverted family planning funds to other government programs, and shifted funds from comprehensive family planning providers to those with limited service abilities.18 By 2015, 25% of publically-funded Texas family planning clinics had closed.18 Additionally, clinics offering comprehensive contraceptive services, including IUD placement, decreased from 71% to only 46% of those remaining, and Medicaid-funded childbirths had risen.18,19

In order for the VHA to ensure the family planning needs of women Veterans are met, an assessment of safety net services, especially in rural settings where VAMCs are not accessible and many high-risk women Veterans reside, needs to be completed. Texas is an extreme example with several years of data on the impact of restrictive funding changes for these clinics. Some of these same changes, such as exclusion of Planned Parenthood clinics from Medicaid funding and limiting Medicaid and Title X coverage, are being considered at a national level as part of the debate over U.S. healthcare coverage. These changes would further limit Veterans from seeking care outside the VHA, even when VHA clinics are geographically distant for impoverished Veterans. Therefore, the objectives of this study were to assess the geographic availability of VAMCs and publically-funded family planning clinics for homeless Texan women Veterans through information visualization tools. This work is a necessary first step to develop geographic interventions to improve gender-specific care within the VHA or guide policies for non-VHA care, as each region will likely have unique needs.

Methods

The University of Utah Investigational Review Board and the Research and Development Committee at the Veterans Administration Salt Lake City Health Care System approved this study.

We identified women Veterans in the state of Texas with administrative evidence of homelessness at any time (“ever-homeless”) who accessed the VHA between fiscal years (FY) 2002-2015 using a national VHA research database of administrative and clinical data managed by the Veteran’s Informatics and Computing Infrastructure (VINCI).20 We included only women Veterans age 18-44y in birth cohorts for each fiscal year. Homelessness was identified through International Classification of Diseases, Ninth Revision (ICD-9) codes, Homeless Care stop codes, or treatment specialty codes.21 In reality, the exact moment a Veteran becomes homeless is known only to the Veteran or those close to them. They come to the attention of the healthcare system when they have been identified as being homeless by a provider and coded in administrative data based on statements by the Veteran regarding housing instability or an interest in VHA homeless services that are available to those experiencing homelessness. This method of identifying homelessness among Veterans using administrative data has been validated and has been peer-reviewed and published by the Office of Inspector General of the US Department of Veterans Affairs and VHA researchers 22–25 . Thus, in this study, we use administrative data to identify those women Veterans who are experiencing homelessness and have been noted as such in VHA electronic data.

Demographic variables included age at entry into VHA services, marital status, race/ethnicity, and religious affiliation. Military characteristics included branch of service, combat exposure, and results (positive or negative) of screening for a history of military sexual trauma (MST) in VHA. While MST status was not routinely screened for, or reliably captured, in structured data until 2004, Veterans who accessed care prior to 2004 were screened at follow-up encounters.25

We defined the geographic “residence” of the homeless women Veteran’s last known zip code reported at the VHA site where the homelessness designation was made. For women with only post office box (PO Box) numbers, we assigned the associated zip code as their “residence”, as the PO boxes were assumed to be in close proximity to where the homeless women Veterans were staying. The population density of homeless women Veterans per zip code were plotted on a map with locations of VAMCs. The geographic distribution of all 18-44-year-old women Veterans using county-level counts from the National Center for Veterans Analysis and Statistics of women veterans were used as map background.

Travel distance was measured first as the number of drive miles between the Veteran’s “residence” zip code and the nearest Texas VAMC. Drive distance was calculated as miles using a 2010 network of roads and using the “Closest Facility” method in the Network Analyst extension of ESRI’s ArcGIS software suite. To visualize the change in availability of publically-funded family planning clinics before and after the exclusion of Planned Parenthood, we mapped all available Texas Planned Parenthood Clinics, as of 2010, using publically available county-level data from the Guttmacher Institute.17 To capture currently available (March 2017) publically-funded clinics that provide family planning services, we used publically-available data from the Texas Health and Human Services “Healthy Texas Woman” website and searched by zip code under “Find a Doctor”.26 We then geocoded these clinic addresses. Travel distance was calculated in the same manner as for distance to VAMCs, measured as the number of drive miles between the Veteran’s “residence” zip code and the nearest currently available clinic according to the Texas Health and Human Services website. Some clinics did not appear appropriate for homeless women Veterans, i.e. high school and teen health clinics, and were censored from analysis.

As the stage of Texas is geographically large with the bulk of the population clustered in several relatively urban areas, we used a local spatial statistic (Cluster and Outlier Analysis (Anselin Local Moran’s I), part of the spatial statistics extension for ESRI’s ArcGIS software suite) to identify zip codes that had non-random similarity and dissimilarity count values (both high and low values) of homeless women veteran as compared to neighboring zip codes. Results were expressed as Z scores, with high values indicating similarity with neighboring zip codes and low Z scores indicating dissimilar values, and as p-values. We also applied a false discovery rate correction to account for multiple testing dependency and spatial dependency (gives a more conservative answer). The method also classifies features that have statistically significant values according to how different their Z Score values. Cluster: High are features with neighbors that have similarly high values, and High Outlier are features that have high values near neighbors with low values.

As the real-world travel burden (or the experienced conceptualization of space) is based on road travel distance rather than linear distance, we compared each zip code count value of homeless women veterans to its closest 30 neighbors where the neighborhood was defined as road distance. The reason for this approach is that while two points (an origin and a destination) can be linearly very close, actual travel may be much farther (and sometimes much farther) if a bona fide barrier (such as a mountain, valley, or river) prevents an approximate straight drive between the origin and destination. We reasoned, therefore, that a street network conceptualization of space was a more appropriate for comparing places.

We then mapped these analysis values to compare the results to the proximity of VHA facilities and to the countywide count of all women veterans of childbearing years. While CBOC VHA facilities do not routinely provide specialty family planning services, such as IUD placement, veterans who visit these facilities can be identified as being homeless or be referred for non-VHA/Choice care, and therefore we wanted to see if these facilities were also near significant clusters of homeless women veterans.

Results

We identified 41,747 women Veterans nationally with administrative evidence of homelessness who had accessed the VHA between FY2002-2015.We then limited the cohort to state of Texas zip codes only, resulting in 3,246 homeless Texan women Veterans for analysis. The majority (35%) was in the age group 18-34 years at time of entry into the VHA during the study period. Those included were most likely to have served in the army (59%) and had low combat exposure (10%). Most (48%) identified as African American and non-Hispanic (85%). The homeless women Veterans also had a high prevalence of being positive for military sexual trauma screening (39%). (Table 1)

Table 1.

Sociodemographic and military characteristics of ever-homeless women Veterans in Texas who accessed the Veterans Healthcare Administration between fiscal years 2002-2015 (N=3,246)

Variable Value n (%)
Age group 18-34y 1127 (35)
35-44y 1054 (32)
>44y 1065 (33)
Race Black 1555 (48)
White 1315 (41)
Ethnicity Not Hispanic 2773 (85)
Hispanic 300 (9)
Marital status Married 636 (20)
Single/Other 2610 (80)
Religion Christian 2440 (75)
Non-Christian 168 (5)
Service branch Air Force 465 (14)
Army 1928 (59)
Marine Corps 111 (3)
Navy 578 (18)
Combat experience Yes 340 (10)
Military sexual trauma history Yes 1261 (39)
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Homeless women Veterans were frequently co-located in areas of high population density for all reproductive age women Veterans in Texas. High countywide counts of women veterans were located in counties with large cities, such as Dallas, Fort Worth, Houston, Austin, San Antonio, Corpus Christi, and El Paso. (Figure 1)

Figure 1.

Figure 1.

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Map: Geographic distribution of homeless women Veterans in relation to all reproductive age women Veterans and Veterans Healthcare Administration Medical Centers

The mean distance from Texas Zip Codes to VAMCs was 82.6 miles (range 0.8-316.4). Counties with the greatest travel distance were in the far west near El Paso and far south near Brownsville, both along the Rio Grande River and sharing a national border with Mexico. (Figure 2)

Figure 2.

Figure 2.

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Map: Drive distance from homeless women Veterans’ Zip Codes to Veterans Healthcare Administration Medical Centers

We completed a cluster and outlier analysis for statistically significant clusters of homeless women veterans by zip code in relation to all reproductive age women veterans (represented in Figure 1 as shaded counties) and VHA Facilities. “Cluster: High” represents a statistically significant count near other features with high values, and “High Outlier” represents a statistically significant count near other features with low values. Homeless women veterans tended to be clustered around VA facilities (both VAMC and CBOC) in counties that had general high counts of women veterans. Of Texas’ 2,629 Zip codes, 90 (almost all in relatively urban areas) were classified as “Cluster: High” and three were “High Outlier” (two in El Paso and one in Houston), representing 1,286 (40%) of the 3,246 homeless women veterans. While there was no overall clustering of homeless women veterans in El Paso, there were two zip codes with in the city of El Paso with counts high enough to be considered statistical outliers. Notably, the headquarters for the active Army base, Fort Bliss, is in El Paso. (Figure 3)

Figure 3.

Figure 3.

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Map: Hot Spot Analysis for statistically significant clusters of homeless women veterans by zip code (Getis-Ord Gi* statistic) in relation to Veterans Healthcare Administration Medical Centers

The number of publically-funded family planning clinics decreased starting in 2011, following the exclusion of Planned Parenthood Clinics from funding sources, and other clinics were added as funding recipients, even though they do not provide comprehensive family planning services.18 To represent these changes, we explored the drive distances from zip codes to current publically-funded family planning clinics (as of March 2017) and also show the count by county of formerly funded 2010 Planned Parenthood Clinics. As of March 2017, homeless women Veterans have a mean drive distance of 24.1 miles (range 0-239) to the nearest publically-funded family planning clinic. In particular, Planned Parenthood Clinics formerly had a heavy concentration in the far south, which now require some of the longest driving distances for women to access care at currently funded clinics. (Figure 4)

Figure 4.

Figure 4.

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Map: Drive distances from homeless women Veterans’ Zip Codes to current Family Planning Clinics, also showing the count by county of formerly funded 2010 Planned Parenthood Clinics.

Discussion

In order to overcome access barriers to specialty care, the VHA is increasing the focus on community civilian partners to meet the healthcare needs of the Veteran population.8 High-risk, homeless women Veterans may not be able to navigate the often complex process to access this option, yet they still need the same civilian healthcare safety net that non-Veterans use, especially for family planning services. Women with a history of military or lifetime sexual trauma and homeless women are vulnerable populations at increased risk for repeat sexual trauma. The high prevalence of MST in this study population highlights the needs for access to reproductive healthcare. In using Texas as an example of the impact of restrictive legislative family planning policies, we found publically-funded family planning clinics are more geographically accessible than VAMCs for homeless women Veterans. Unfortunately, these clinics do not routinely provide comprehensive family planning service, especially in more rural areas, as funding changes limit services, close clinics, and uproot affiliated healthcare providers.18 Ongoing assessments of comprehensive Texas family planning services found clinics were able to serve 54% fewer clients between 2011 and 2021-2013. In a similar comparison to our results, closure of Texas abortion clinics resulted in increased one-way travel distance for women from 22 miles to 85 miles with additional out of pocket expenses and reported difficulty in clinic access.27 Public or private insurance coverage and non-VHA/Choice benefits will not increase access, when trained providers are not geographically available to accept the coverage. Additionally, the most socio-economically disadvantaged women will not be able to access coverage options, as many of the same states with the most restrictive Medicaid eligibility requirements are also states without family planning waivers or national family planning Title X clinic funding to fill gaps for uninsured women.16,17

National VHA priorities include improved access to healthcare for women and homeless Veterans, and family planning services are an essential component of preventive healthcare.28 Despite these commitments, many women Veterans currently bypass VHA services due to lack of availability of gender-specific care29, confusion regarding VHA eligibility and travel distance to the nearest VHA facility30. Longer drive time is also associated with attrition from VHA health care in women Veterans, identifying a continued need for improvement in service provision.31 VHA policies and priorities attempt to standardize healthcare services and quality across the nation. Despite these goals, there are vast geographic differences for Veterans to access publically-funded, civilian services between “conservative” states like Texas and more “liberal” states such as California, where family planning services and providers are abundant due to MediCal coverage and Title X funded clinics. As the nation weighs conservative changes to federal family planning funding and restructuring of the entire VHA referral system, the adverse outcomes seen in vulnerable Texan women and the resultant impact on our women Veterans needs to be considered.

We acknowledge several limitations of this study. The use of structured data to identify homelessness among women Veterans may lead to misclassification of their true homelessness status. We also looked at any housing instability (ever homeless), instead of a limited timeframe around homeless designation. Even though homelessness is not typically a constant over many years, many socio-economic stressors pre-date and persist beyond the administrative capture of homelessness and would likely result in the need for healthcare safety net clinics. We made the assumption that homeless women Veterans who cannot access care at a VAMC would also have challenges in accessing a non-VHA/Choice referral allowing for clinical coverage outside of publically-funded clinics. The VHA will pay for transportation for many Veterans who are eligible for this benefit, dependent upon level of disability or service-connection, but the Veteran again needs to navigate the system to access this coverage option. The current clinic mapping does not include homeless clinics that may offer some free family planning services, but previous literature shows family planning options are highly variable and limited in these settings.32

Conclusions

In summary, homeless women Veterans represent the most vulnerable subset of women Veterans at greatest risk for adverse reproductive outcomes. Current restrictive funding changes have limited the safety net services of publically-funded family planning clinics in the state of Texas, despite the improved geographic availability of these clinics over VAMCs. As national efforts are underway to establish civilian care as the “cure” to access issues within the VHA, the impact of civilian funding changes in Texas on the availability of family planning services and providers for women Veterans need to be considered. The current push to exclude Planned Parenthood clinics from federal funding will increase the unmet need of comprehensive family planning services nationwide, including for our vulnerable homeless women Veterans.

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