“This most recent work on veterans’ access to primary care expands further the litany of VA health care deficiencies and weaknesses that we have identified over the years,” Debra Draper, director of the Government Accountability Office’s (GAO) health-care team, said in testimony to the House Committee on Veterans’ Affairs. “As of April 1, 2016, there were about 90 GAO recommendations regarding veterans’ health care awaiting action by VHA … (including) more than a dozen recommendations to address weaknesses in the provision and oversight of veterans’ access to timely primary and specialty care, including mental health care.

“Until VHA can make meaningful progress in addressing these and other recommendations,” she added, “the quality and safety of health care for our nation’s veterans is at risk.”

On average, the wait time nationally for primary care appointments was seven days as of April 1.

The new GAO report looked at wait times for newly enrolled veterans seeking primary care appointments at six VA medical centers around the country. Among a random sample of 180 of those veterans, 60 who requested care had not been seen at all by primary care providers, in some cases because the VA never contacted them or because they were left off an eligibility list in error. For the other 120 who requested care and were seen, the average time between their initial requests that the VA contact them for appointments and the dates they were seen ranged from 22 to 71 days.

While slightly more than half were seen by providers in less than 30 days, the veterans’ experiences varied widely, even within the same medical center, with 12 veterans waiting more than 90 days, the report says.

The most recent national data from the VA shows that, on average, the wait time for primary care appointments as of April 1, 2016, was seven days – down from 7.94 days a year ago.

In Connecticut, the West Haven VA shows a wait time for primary care of just 1.72 days – relatively low nationally. Overall, more than 97 percent of veterans seeking health care in West Haven get appointments scheduled within 30 days, the data show.

Other VAs have much longer waits. The average wait for a primary care appointment in Fayetteville, NC, is 52.76 days; in White City, Oregon, 51.14 days; and in Dover, Tenn., 48 days.

Nationally, wait times for specialty care average 10 days, and for mental health care, four days. At the West Haven VA, wait times are 4.86 days for specialty care and 2.25 days for mental health care, the most recent data show.

The GAO report found that two factors generally impacted veterans’ wait times: Appointments were not always available when veterans wanted to be seen, and “weaknesses in VA medical scheduling practices” led to some veterans not being contacted on a timely basis.

“Officials at each of the six medical centers in our review told us that they have difficulty keeping up with the demand for primary care appointments for new patients because of shortages in the number of providers, or lack of space due to rapid growth in the demand for these services,” the GAO said.

Also, the report says, the VA does not properly record the time that veterans wait to be seen, starting from the veterans’ “preferred dates” for appointments, instead of the dates that veterans initially contact the VA to schedule appointments. These “scheduling errors, such as incorrectly revising preferred dates when rescheduling appointments, understated the amount of time veterans waited to see providers,” the GAO said.

For example, one veteran mentioned in the report applied for VA health care benefits in December 2014, which included a request to be contacted for an initial appointment. The VA medical center contacted the veteran to schedule a primary care appointment 43 days later. When making the appointment, the medical center recorded the veteran’s preferred date as March 1, 2015, and the veteran saw a provider on March 3, 2015. Although the medical center’s data showed the veteran waited two days to see a provider, the total amount of time that elapsed from the veteran’s request until the veteran was seen was actually 76 days.

The GAO recommended that the VA monitor the full amount of time that veterans wait to see a primary care provider and improve contact with veterans seeking appointments – recommendations that the VA accepted.

The “Female Veterans Suicide Prevention Act” would expand the Department of Veterans Affairs’ annual evaluation of mental health and suicide-prevention programs to include data specific to female veterans. The act also would require the VA to determine which programs are the most effective for female veterans.

The state Department of Veterans’ Affairs is working to improve outreach to female veterans.

“With suicide among women veterans happening at an alarming rate, (the proposed bill) will help save lives by ensuring VA is providing the care, counseling and outreach these veterans need,” Blumenthal said. Co-sponsors include Sens. Barbara Boxer (D-CA), Joni Ernst (R-IA), and Sherrod Brown (D-OH).

In the recent study, VA researchers tracked more than 173,000 veteran and non-veteran suicides in 23 states from 2000 to 2010, in order to compare suicide rates among different subgroups. They found that the overall rate of veteran suicides increased by about 25 percent over that 10-year period, while the non-veteran rate increased by 12 percent. Of note, while the suicide rate for female non-veterans rose 13 percent, it climbed 40 percent for female veterans.

In addition, the suicide rate for women veterans in 2010 was 34.6 per 100,000 – six times the rate (5.4) among women civilians. The difference in rates among men was smaller – 36 per 100,000 for veterans, compared to 21.4 for non-veterans.

The VA researchers said there were a number of possible factors for the higher suicide rates among veterans than civilians, including a higher incidence of adverse childhood experiences, injuries such as traumatic brain injury, and military sexual trauma among women.

The higher disparity in suicide rates between women veterans and non-veterans suggests “possible gender-based differences in the effectiveness of VA suicide prevention initiatives,” they said. “These results further support continued efforts to better understand health disparities, including suicide, among women veterans, (as well as) the most effective clinical and public health strategies to prevent suicide among this fastest-growing subgroup.”

The study also found that VA health programs seemed to help men more than women. Overall, veterans who utilized such programs were less likely to commit suicide than those who didn’t. But while the suicide risk among VA-enrolled men decreased over 10 years, there was “no meaningful change” among women veterans over time.

There are more than two million women veterans in the U.S., making them the fastest-growing population of veterans treated by the VA. While the VA has made strides to improve mental health and suicide prevention programs aimed at women, there is no gender-specific data available on the efficacy of these programs.

In Connecticut, the state legislature last year directed the state Department of Veterans’ Affairs to improve outreach and needs assessments of the more than 16,000 women veterans in the state – but no new money was allocated for the effort.

Emily Hein, a spokeswoman for the state department, said the agency has been strengthening partnerships with the VA and veterans’ service groups in an effort to improve outreach to women. Women veterans can be a “harder population to reach” than men because many of them are busy with family responsibilities or don’t reach out for help, she said.

“We’re working through partnerships to open communication” to women veterans, Hein said.

She said she was hopeful that more funding and programs would be made available at the federal level to deal with women veterans’ unique mental health and other needs.

They love taking their two dogs to parks, but avoid busy weekends. “It’s not the dogs, it’s the people,” Andrew said, who suffers from Post Traumatic Stress Disorder (PTSD).

Andrew, now 28, came home to Griswold in 2007 after a Humvee rollover accident left him with traumatic brain injury, PTSD, depression and back problems. Brianna became his caretaker and advocate while holding a fulltime job and mining her computer at night for help.

On Facebook, she found the VA Caregiver Support Program for Post 9-11 Veterans, designed to help disabled veterans stay in their homes and provide support for family members who care for them.  Its services range from monthly stipends to home modifications.  The VA started taking applications last May, and so far, just 18 Connecticut caregivers are participating, said Bonnie Cecarelli, caregiver support coordinator.  She said the response is consistent throughout New England and predicted it will grow as more veterans return home.  The U.S. Department of Veteran Affairs estimated that nationally, 3,596 veterans will qualify during the program’s first year, costing about $69.04 million.

Brianna’s dedication to Andrew is typical of the program’s participants, said Cecarelli who works at the West Haven VA Hospital. “These girls are amazing and they’re young,” she said, adding “the vets come back and they’re different.  They stay with them, the poor girls, and their lives are changed.” Brianna and Andrew were only married for eight weeks before he left for Afghanistan.

The program was established after a study showed that disabled veterans fare better at home than in institutions, Cecarelli said. To be eligible, a veteran must have served after Sept. 11, 2001, have physical or mental injuries from military service, and have an unpaid family or friend caregiver. A nurse visits the home to assess the veteran’s needs and the caregiver is required to complete a training program, either online or at classes.

Among benefits are: monthly stipends that range from $500 to $2,600; travel and per diem payments when veterans have medical appointments; health insurance for caregivers who don’t have it; respite care; medical equipment; airplane travel to visit friends and relatives or for them to visit; peer mentoring among caregivers; and a direct link to the VA through the caregiver coordinator, who is required to return their calls within a day.

Jennifer and Jonah Hughes, of Hartford, probably would have lost their house without their monthly stipend of $1,900 from the program, Jennifer said.  “It’s just been amazing for us that we have this program,” she said.

Jonah, an Army veteran, suffered brain damage, physical injuries and PTSD from a roadside bomb attack in Iraq. He was discharged last year and still hasn’t received any of the VA disability payments that he has applied for and that they were counting on. Jennifer cares for him and their three children, ages 7, 3 and 2. She home schools the oldest, who is autistic.  Her husband, 35, has about five doctors’ appointments a week, and the kids go along.

Tony Bacewicz Photos

Marco, Andrew and Brianna.

For Brianna, the program’s link to Cecarelli is crucial. “I don’t know what I’d do without her,” she said, recalling how once she spent 3 ½ hours on hold for a VA help line.  With Cecarelli, she said, she has “a family advocate, someone there who knows you.”  The guarantee of getting a call back within a day is unusual for the VA, she said.

One day, Brianna placed a frantic call to Cecarelli. VA staff members weren’t allowing Andrew to bring his service dog, a Golden Retriever, Marco, into his doctor’s office.  Cecarelli intervened and the trained dog, which calms Andrew, went with him.

“The pet thing works.  It puts me in a good mood,” said Andrew.  “I can go to more crowded places than I used to, and not be so anxious,” he said, explaining that he focuses on the dog, not the people. “Wherever he goes, Marco goes,” said Brianna, who describes herself as “persistent” when it comes to getting help for her husband.

Cecarelli is required to call the caregivers every 90 days. But, she encourages more contact, welcoming phone calls during office hours and visits when they’re at the VA for appointments.

Cecarelli is still tweaking the program.  For example, she suspended a weekly support group at 5:30 p.m. in West Haven after sparse attendance.  She is starting it again this spring as a monthly group to make it less burdensome for the caregivers who live around the state.  “A support group shouldn’t stress you out,” Cecarelli said. But, she added, “I think it would be so helpful for them to talk about common issues.”

The new schedule still won’t work for Jennifer Hughes and Brianna Pavlak.  Jennifer said she can’t leave her husband and children alone for much more than an hour.  “It’s so overwhelming when you have someone who is injured, to even make dinner,” said Jennifer, 30. She said she hasn’t even had time to find a pediatrician since she moved to Hartford in February, 2011.

Brianna, 29, works until 4:30 p.m. with toddlers at the Coast Guard day care center in New London and then heads home to be with Andrew.
None of the veterans now in the program have jobs and caregivers often can’t leave them to work. “Many are struggling” financially, Cecarelli said.  The stipends they receive are based on the hours a veteran needs supervision and partial pay rate of home health care aides.

Most of the caregivers have no help, and little or no family support, Cecarelli said. But, they have resisted respite care offered in the program, saying the veteran “wouldn’t like it” or “we don’t want a stranger in the house,” she said.

The Pavlaks have a friend, a Vietnam veteran, who takes Andrew to doctor’s appointments when Brianna has to work. On those days, she talks to the doctor by phone. She takes off from work to go to Andrew’s neurology appointments in West Haven.

Bonnie Cecarelli, VA caregiver support coordinator.” credit=” 

Cecarelli said some of the families moved to Connecticut to be far from relatives,  who may not understand effects of PTSD, such as: outbursts of rage; anxiety around people; nightmares; flashbacks; the jitters from constantly being on the lookout for danger; and just the fact that the veterans are not their old selves.

The Hughes family moved to Hartford from Germany after Jonah’s third Iraq   deployment. Jennifer hails from California and Jonah, Florida. They don’t know anyone in Connecticut, Jennifer said, explaining that was a motivating reason for the choice. “To go back to family where people remember how you used to be, it’s easier to be here,” she said.

The Pavlaks live near Andrew’s family. His brother is helping him fix up the two-family duplex the couple recently bought. But, Andrew’s relatives don’t always understand his postwar behavior, which can include depression, survivor guilt and hyper-focusing on news about war.

Brianna sees the caregiver program as an important tool. “A lot of veterans are not getting help,” she said, explaining that dealing with the VA bureaucracy is “so frustrating, such a runaround.  Veterans don’t know who to go to. They give up.  I hope with programs like this, it will empower families not to give up.”

For information on the caregiver program contact Cecarelli at 203-932-5711, ext. 2297 or go to the National Council For Aging Care.

Trina Parker of West Haven, said many women like her, who were in the military in peace time think that VA services are just for veterans of war, and they often don’t even see themselves as soldiers.

Another woman veteran, Juliet Taylor, who served in Iraq, said many female vets don’t take advantage of health services at the VA in West Haven because they connect it with “old men” who are Vietnam War veterans. They envision the women’s health center there as a “dungeon” since it’s in a basement.  As a result, many don’t get any health care.  “While the services are great at the VA, it’s not a place where we go.  There’s a stigma attached to the VA.  I didn’t care what they had there.  I didn’t want to go,” she said.

The two women spoke at the VA Connecticut Homeless Veteran Summit attended by service providers and veterans.  The conference, at the VA’s Errera Community Care Center in West Haven, focused on services for female veterans.

Out of more than 15,000 women veterans in the state, 2,752 go to the VA for health care, said Jane Sarja, women’s program manager for VA Connecticut.  In an interview, she admitted that it’s a challenge to attract more women vets partly because of misconceptions that “the VA doesn’t know how to take care of women.”  She said a separate women’s health center opened at the West Haven VA in 1996 in a basement to give women privacy.  The center will move to an upper floor next year, and will still be separated from men’s services, she said.  “It will provide the same privacy and good care,” she said.

“We’ve made great strides, but we have a long way to go,” she said.  VA health services are provided at the main health facilities in West Haven and Newington and in outpatient clinics in New London, Danbury, Stamford, Waterbury, Windham and Winsted.

Parker, the Marine Corps vet, served from 1982 to 1986.  Afterward, she suffered from anxiety, alcoholism and PTSD, which she attributed to “unwanted sexual advances” while in the service.  She couldn’t hold a job and was homeless at times, living with friends. In 2003, she applied for welfare and was sent to the state Dept. of Labor for employment assistance.

The staff member happened to be a female veteran who referred her to Errera, where she received mental health care.  “If I had the opportunity of mental health treatment 17 years before, it would have saved me 17 years of aging with alcohol,” she said. “I didn’t know about the VA.  Nobody was out there letting you know,” she added.

Parker has worked at Errera as a peer specialist for five years, the longest she’s held a job. She has been sober for eight years. In an interview, she said she is starting a new job in late November in Bedford, MA, helping women veterans.  She’s passionate about reaching out to women from her peacetime era who, she said, are “falling through the cracks.”

But, Taylor, the Iraq War veteran, said many women veterans, regardless of their era, aren’t getting health care because they refuse to go to the VA.  She said she finally went for dental care five and a half years after she left the Army.  She had been rejected by two clinics for insurance reasons, then referred to a facility that only treated male veterans.

She said she received such good care at the VA, she has since brought other women vets there for help.  One hadn’t had her prescription eyeglasses checked for 15 years.

She urged VA officials to “get out into the community” to reach out to women veterans.  She suggested community colleges because many women veterans, herself included, attend the schools because it’s paid for under the federal GI Bill, and there’s often money left to pay for housing.

Others at the conference said they had never thought of community colleges as resources for reaching veterans and now plan to tap them.  They also suggested contacting domestic violence centers which may serve female veterans, using personal contact instead of relying on events to spread the word, and changing language in publicity so it refers to people who served in the military, so there is no confusion about wartime vs peacetime service and the definition of the word “veteran.”

Sarja, the VA women’s program manager, said the VA is “committed to working very hard” to convince women to take advantage of its services.  She said that although West Haven is the only VA facility in the state with a separate space for treating women, there are doctors in each VA location that are “specially trained in women’s health.”

“We know that tens of thousands of women will be coming back from Iraq and Afghanistan. They are not going away.  The numbers of women vets are rising,” she said.

The report shows that over a five-year period from 2006 through 2010, more than 2 million veterans received mental health care from the U.S. Department of Veterans Affairs. Iraq and Afghanistan veterans accounted for an increasing proportion of those veterans—from 4 percent in the 2006 fiscal year, to 12 percent in 2010. That percentage continues to grow, veterans’ advocates say.

In 2010, more than 139,000 Iraq and Afghanistan veterans received mental health care from the VA—up from just 34,500 in 2006.

In Connecticut, VA figures show that more than 7,600 Iraq and Afghanistan veterans received some kind of VA care in the one-year period between Oct. 1, 2010 and Oct. 1, 2011, with about 280 receiving mental health care.  Data through March 2011 show that more than 2,190 Iraq and Afghanistan veterans had been treated for potential PTSD by the VA and vet centers in Connecticut. Nationally, more than 202,000 veterans of those wars have been seen by the VA for possible PTSD.

The GAO report identifies key barriers that hinder veterans from accessing mental health care from the VA, including stigma, lack of awareness of mental health care services, logistical challenges to accessing care, and special concerns about the VA care offered. For example, the report found, younger veterans may be reluctant to seek VA care because of concerns that the health care system primarily serves older, Vietnam-era veterans.

Similarly, female veterans may perceive that VA care is male-oriented, the GAO study suggested. Women are a growing demographic in the veteran population—from fiscal year 2010 to 2020, the percentage of women among total veterans is projected to increase from about 8 percent to about 10 percent, according to VA estimates.

VA officials said they have taken a number of steps to expand the agency’s mental health care services, including increasing the mental health staff from about 14,000 in fiscal year 2006 to more than 21,000 in fiscal year 201l; expanding the availability of telephone-based mental health services; and integrating mental health care into its primary care settings. Specifically, VA now requires its primary care clinics to conduct mental health screenings and has placed mental health care providers in some primary care settings.

While veterans’ advocates applaud those moves, they remain concerned that the VA is not able to keep up with the growing number of returning troops who need psychological help, especially those in rural or remote areas.

In a separate report, VA statistics show that VA’s Crisis Line, which was set up in 2007 as a suicide prevention hotline, has fielded more than 460,000 calls to date and claims more than 16,800 “rescues” of veterans and active-duty service members. Suicides of troops who serve in Iraq and Afghanistan has been a concern of both veterans’ advocates and military leaders, who have implemented a host of outreach and education programs to try to reduce suicide rates.