Distance to Veterans Administration Medical Centers as a Barrier to specialty care for homeless women Veterans

Abstract

Homeless women Veterans have a high prevalence of chronic mental and physical conditions that necessitate healthcare, but travel burdens to specialty services may be overwhelming to navigate for this population, especially for those in rural settings. Access to specialty care is a key priority in the Veterans Health Administration (VHA) and understanding the geographic distribution and rural designation of this population in relation to medical centers (VAMC) can assist in care coordination. We identified 41,747 women Veterans age 18–44y with administrative evidence of homelessness in the VHA anytime between 2002–2015. We found 7% live in rural settings and 29% live >40miles from a VAMC. The mean travel distance for homeless women Veterans with a rural designation to a VAMC specialty center was 107 miles. Developing interventions to overcome this travel burden and engage vulnerable Veterans in necessary care can improve overall health outcomes for this high-risk population.

Introduction

Women Veterans are the fastest growing population of U.S. Veterans Health Administration (VHA) eligible users, nearly doubling in the past decade and numbering more than 2 million in 2015. [6] Women Veterans who access VHA services are a vulnerable population with high prevalence of medical and mental health comorbidities [3; 6] and experience a 4-fold increased risk of homelessness compared to the civilian population [2]. In order to meet the needs of this growing population, the VHA prioritized expansion of comprehensive primary care by a single, designated women’s health provider (DWHP). [9] While a DWHP may be located at Community Based Outpatient Centers (CBOCs), any specialty care services, including gynecology or other medical specialties, require a referral to a Veterans Affairs Medical Center (VAMC) or to a community civilian provider, if available. Rural women Veterans have significantly worse physical health than urban Veterans, are more likely to use VHA services, and report that transportation difficulties affect health care decision-making. [5] Longer drive time is also associated with VHA attrition in women Veterans, identifying a continued need for service provision improvements. [7]

Healthcare for homeless Veterans is characterized as resource intensive due to their complex mental, physical, and socioeconomic needs. [3] Homeless women Veterans have additional reproductive health needs to avoid adverse pregnancy outcomes and, unlike Veterans with more resources, may not be able to overcome travel barriers to access specialty care. Additionally, they are less likely to access care through non-VHA providers due to lack of insurance and homeless civilian clinics have variable services and are typically located in urban settings. Thus, we undertook this study to understand the impact of travel distance to VAMCs and rural designation on access to specialty care services in homeless women Veterans.

1. Methods

1.1. Participants

We identified all women Veterans with administrative evidence of homelessness at any time 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). [1] Homelessness was identified through previously validated International Classification of Diseases, Ninth Revision (ICD-9) codes, Homeless Care stop codes, or treatment specialty codes. [8] We included only women Veterans age 18–44y in birth cohorts for each FY. 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.

1.2. Measures

We extracted demographic and military characteristics on all homeless women Veterans, then defined their geographic “residence” as the last known zip code reported at the VHA site of homelessness designation. The population density of homeless women Veterans per zip code was plotted on a map with locations of VAMCs. The map background included the geographic distribution of all 18–44y women Veterans using the National Center for Veterans Analysis and Statistics county-level counts.

Travel distance was measured first as the number of drive miles between the Veteran’s “residence” zip code and the nearest VAMC within their Veterans Integrated Service Network (VISN). Finally, the census tract-based Rural-Urban Commuting Area Codes (RUCA) were used to assess the effect of rurality on travel distance. These codes were developed from the 2010 work commuting data from the U.S. Census Bureau and classify census tracts using measures of population density. We spatially joined these area classifications to ZIP Code data point files. There are two levels of classification and only the first level was used in this analysis: metropolitan (urban-focused, 81% of U.S. population), micropolitan (large rural city/town, 9.6% of U.S. population), small rural town (5.2% of U.S. population), and isolated small rural communities (4.2% of U.S. population). [4]

2. Results

We identified 41,747 women Veterans age 18–44y with administrative evidence of homelessness at any time between FY2002–2015. Of the participants, 19% were married, 43% identified as black, 87% non-Hispanic, 54% served in the US Army, and 40% reported a history of military sexual trauma.

We then excluded any participant with a zip code outside the continental US and those with missing or incomplete zip codes, leaving 33,873 Veterans geocoded to ZIP Codes. The U.S. Census rural designation identified 6.9% (2,321) of homeless women Veterans as living in isolated, small, or large rural settings. We found 9,665 (28.5%) of homeless women Veterans lived >=40miles from the nearest VAMC (the distance defined as “undue travel burden” by the VHA) and this group had a mean drive distance of 94.7 miles (range 40–427.9). Even those living <40 miles from a VAMC or a CBOC (32,962 (97.3%)) had a mean travel distance of 15.9 miles (range 0–39.9). The Rural-Urban Commuting Area designation for urban vs. rural found the mean drive distance to a VAMC ranged from 42.9 miles for those in a metropolitan core area to 107.4 miles for those in an isolated rural area. When drive distances also included a CBOC option, drive distances dropped to 14.5 miles and 46.8 miles, respectively (Table 1). Figure 1 illustrates a regional view of the national map for calculating travel distances.

Table 1.

Homeless women Veterans’ Rural-Urban Commuting Area Codes (RUCA) and travel distance to Veterans Affairs Medical Centers (VAMC) and VAMC or Community Based Outpatient Clinic (CBOC)

RUCA Core Code	Count of geocoded homeless women Veterans (%)	Mean Drive Miles for VAMC	Mean Drive Miles for VAMC or CBOC
Metropolitan	30,330 (89.6)	42.9	14.5
Micropolitan	2,080 (6.2)	82.6	28.4
Small Town	970 (2.8)	92.3	37.8
Isolated Rural	493 (1.5)	107.4	46.8
Total	33,873 (100)	63.6	23.9

Figure 1.

Veterans Affairs Medical Centers (VAMC: orange) and Community Based Outpatient Clinics (CBOC: green) in the Southwest United States are shown plotted against Zip Code-based populations of homeless women Veterans. For many of these areas, drive distances to VAMCs for specialty care are much greater than would be required if CBOCs were also an option.

3. Discussion

Homeless women Veterans need access to specialty care for high-risk medical, mental health, or behavioral issues, but rural homeless women Veterans may experience insurmountable barriers to this care due to travel distance. This study highlights the geographic distribution of reproductive age homeless women Veterans outside the expected urban areas where VAMCs with homeless and gender-specific services are primarily located. As these are reproductive age women, travel barriers can not only impact health outcomes, but also adversely affect a pregnancy, if it occurs in the settings of poorly managed chronic conditions. Geocoding and subsequent generation and consideration of travel distances to care facilities can assist policy-makers in developing targeted interventions to improve access to comprehensive preventive health and specialty care services in the VHA for high-risk, cost-intensive populations, in order to minimize adverse outcomes and improve quality of life for Veterans nationwide. Not surprisingly, extending specialty care access to CBOCs would allow more homeless women veterans to obtain the health services they need.