Abstract Coordinating care between Veterans Health Administration (VA) and community providers is essential for providing high-quality comprehensive maternity care to women veterans, particularly those with chronic medical or mental health issues. We iteratively developed and assessed feasibility, as well as facilitators and barriers, of implementing the VA Maternity Care Coordinator Telephone Care Program, and identified specific health needs of pregnant women Veterans served by the program. We used three Plan–Do–Study–Act cycles. The final program consisted of materials supporting seven structured phone calls spanning initiation of pregnancy care through six weeks postpartum. We used logs to measure veteran uptake and surveys and field notes to capture care-coordinator perceptions about potential program value and facilitators and barriers to implementing it. We conducted a medical record review assessing pregnant veterans’ need for coordination of services for physical and mental health problems and health behaviors. Veterans’ uptake was 60%. Implementation facilitators included conducting training sessions for program coordinators and tailoring materials to address differences across VA facilities. Implementation barriers included limited information and communication technology tools to support the program and lack of coordinator time for delivering the telephone care. Among 244 pregnant veterans, 41% had pre-pregnancy chronic physical problem(s); 34% mental health problem(s); 18% actively or recently smoked. Implementation of a telephone-based care coordination program for pregnant veterans was feasible. Effective program spread required tailoring for local variations in resources and processes, investing in information and communication technology tools and allocating coordinator time to deliver care. Pregnant women veterans have a substantial burden of physical health, mental health, and risky health behaviors needing care coordination. Implications Practice: Pregnant women veterans have a high need for coordination services in that they have a substantial burden of pre-pregnancy chronic physical and mental health problems, as well as a high incidence of pregnancy complications. Policy: Given the substantial and growing maternity care coordination needs among pregnant veterans, especially those with chronic medical and mental illness, further investments in programs such as the Maternity Care Coordinator Telephone Care Program need to be prioritized. Research: Future research should investigate strategies for, and the role of, information and communication technology tools for meeting the care coordination needs of pregnant veterans. INTRODUCTION Maternity care coordination programs are associated with increased utilization of beneficial health services, improved maternal and birth outcomes, and decreased costs, especially for women with chronic or pregnancy-related physical or mental health conditions or social vulnerabilities [1–7]. More specifically, relative to mothers not receiving care coordination services during pregnancy, mothers receiving such services are more likely to utilize supplemental nutritional services, give birth to infants with improved birth weights [1–3], and have a lower infant mortality rate . Additionally, infants born to these mothers incur lower medical costs in their first 60 days of life . Women veterans, the fastest growing subset of the Veterans Health Administration (VA) patient population [8, 9], have particularly high prevelances of chronic medical and mental health conditions, as well as adverse health behaviors [10–14]. More specifically, women veterans are more likely than nonveteran women to be overweight or obese, have painful musculoskeletal issues, be diagnosed with depression and/or posttraumatic stress disorder (PTSD), engage in smoking, have poorer self-reported physical and mental health, and have lower social support. Women veterans are more likely than their male counterparts to have high burdens of military sexual trauma, with associated mental health issues. Multiple studies suggest that veterans using VA maternity benefits have an even higher burden of chronic mental illness than the overall population of women VA users, potentially reflecting higher reliance on VA services among veterans with mental illness [15–17]. A growing body of research suggests that the high burden of chronic disease and mental illness among pregnant VA users may contribute to a higher risk of adverse pregnancy outcomes, such as gestational diabetes, preeclampsia, and spontaneous preterm birth [17–20]. VA maternity benefits, originally established in 1996, include coverage for prenatal care, labor and delivery, postpartum care, and, newly added in 2010, newborn coverage for the first seven days of life . VA purchases maternity care from non-VA providers or, in a minority of cases, uses Department of Defense providers . The number of veterans using VA maternity benefits is expanding rapidly with a five-year near doubling in the number of deliveries paid for through VA benefits from 1,442 deliveries in 2008 to 2,730 deliveries in 2012 . Given the increased need and vulnerability of women veterans using VA maternity benefits, providing high-quality, coordinated maternity care is viewed by VA leaders as integral to meeting VA’s goal of providing comprehensive care for women veterans . Coordinating care for veterans with coexisting physical or mental health issues is especially challenging because, although veterans receive their maternity care from community (non-VA) providers, they continue to use VA providers for on-going treatment of their mental and nonobstetric physical health conditions. For patients who develop medical complications during pregnancy (e.g., gestational diabetes, cardiac complications), the patient’s care may additionally need to be coordinated with a community or VA provider who specializes in these conditions. Simultaneously using VA and community services may result in care fragmentation, lack of role clarity among providers (uncertainty about which provider is responsible for key tasks), lack of VA and community provider communication (e.g., about medications and test results), deficiencies in patient records exchange, and delays in authorizations . Effective care coordination aims to optimize communication between providers for pregnant patients so that all providers are up-to-date on the veteran’s current medications, test results, and management plans. Rural pregnant veterans may face additional challenges due to shortages of local providers, increased distance between veterans’ residence and both VA and community providers, and poorer physical health compared with their urban counterparts [25–27]. To address these care coordination needs, in 2012, VA established a national maternity care coordination policy requiring that each pregnant veteran using VA maternity benefits has a maternity care coordinator (MCC) . MCC responsibilities include tracking and coordinating care for pregnant veterans using VA maternity care benefits as well as acting as a liaison between the patient and VA and community providers caring for her. In addition, the MCC acts as a specialized care manager for pregnant Veterans, assessing pregnant veterans’ needs, supporting self-management, and linking the veteran to needed resources [21,28]. To support MCCs in delivering effective care management, we used quality improvement methodology to iteratively develop the VA Maternity Care Coordinator Telephone Care Program (MCC-TCP) . Further, we aimed to conduct a developmental implementation-focused evaluation, assessing the program’s feasibility, as well facilitators and barriers encountered in its implementation. Finally, to support refinement of MCC-TCP materials, we aimed to assess the physical, mental, and smoking status of program participants. METHODS Program development Using Plan–Do–Study–Act (PDSA) cycles, with the Institute of Healthcare Improvement’s quality improvement framework guiding each PDSA, we iteratively developed MCC-TCP over three years . In the first year (PDSA cycle #1), we aimed to draft preliminary program materials and test them in patients served by one VA facility (with “VA facility” denoting the combination of a VA Medical Center, which commonly has primary care, including women’s health primary care, specialty care, emergency and hospital services and is based in an urban hub, as well as all of its affiliated community-based outpatient clinics, with primary care, including women’s health primary care, and limited additional services, which are typically placed into less urban or rural communities). To do this, we formed an interprofessional workgroup, consisting of VA women’s health experts including nurses, social workers, and physicians. This workgroup used their professional experiences and an environmental scan (internet searches using PubMed and Google Scholar to identify manuscripts and other evidence-based resources) to preliminarily identify care coordination, information, and screening needs of pregnant and postpartum veterans. From these needs, we developed topics to be covered over a series of phone calls with pregnant veterans and training scripts for each topic. We tested these initial materials by the workgroup’s nurse, in the role of an MCC, making phone calls, over a three-month period, to pregnant veterans in the catchment area of this initial VA facility in Southern California. The MCC took detailed notes on problems she encountered using the materials and on omissions in their content. The workgroup met weekly, and based on the MCC’s notes, iteratively revised materials to address problems, and added additional topics and phone calls to correct omissions. VA facilities vary in size and resources, which VA classifies by a five-tier system (1a, 1b, 1c, 2, 3) with 1a being the largest, most-resourced systems . The site for this initial implementation was a level 1a facility. In the second year (PDSA cycle #2), in order to test and refine materials to support spread, we expanded the program’s implementation, to include three additional facilities, two also serving large metropolitan areas in Southern California (another level 1a and one level 1b facility), and to test our program for use with rural women, a level 1a facility serving both metropolitan and nonmetropolitan areas in the Midwest. One or two MCCs in each facility were trained on using the materials we had developed in PDSA #1 and then implemented them in their facility. Again, MCCs noted problems with, and omissions in, the materials, which were relayed to the project team by both monthly team meetings and ad hoc electronic mail (e-mail). The predominant theme of feedback was that the approach outlined in the materials for meeting Veterans’ needs did not account for local variations in resources and processes. For example, VA sites varied substantially in their processes for women veterans obtaining medications and pregnancy-related supplies, as well as in their resources for supporting smoking cessation and approaches for responding to women veterans with urgent mental health or interpersonal violence issues. MCCs also encountered additional veteran needs not addressed in our materials. We again iteratively revised and developed additional materials so that MCCs could customize materials to fit their local processes (e.g., insert details on local mechanisms and points of contact) and addressed these omissions. MCCs also reported anecdotally that women veterans residing in rural locales appeared to have more care coordination needs, potentially more physical and mental health comorbidities, and more difficulty accessing services. Therefore, to ensure that the program materials were aligned with rural pregnant veteran needs, in the third year (PDSA cycle #3), we expanded the program to seven additional VA facilities (one level 1b; two level 1c; three level 2; and one level 3), serving a large proportion of rural women veterans across all four regions of the USA. We further conducted a developmental implementation-focused evaluation, detailed below, obtaining further MCC assessment of acceptability and usability of the materials and modified them as needed . Throughout all years, MCC time for participating in and providing assessments and feedback about the program, was funded by national VA policy offices responsible for women’s health and rural health. For all, the role of MCC was combined with other duties, such as performing care coordination for other women’s health issues or serving as the nurse care manager in a women’s clinic. The final program contents include a program manual, which contains outlines to guide calls and scripts for training MCCs; note templates for documenting these calls in VA’s electronic medical record (EMR); an electronic call log, which uses Microsoft Excel®, for MCCs to track calls; a resources and processes workbook, to assist MCCs in determining local variations in resources and processes related to maternity care; templates for documenting calls; web-based tutorials demonstrating how to use program materials; and an educational webinar series to educate MCCs in maternity care subjects. The developed program manual supports up to eight scheduled calls, starting with pregnancy verification (call #1), and then follow-up calls at 12 weeks (call #2), 20 weeks (call #3), 28 weeks (call #4), and 36 weeks (call #5) gestation. There is an additional call at 41 weeks (call #6) for women who are still pregnant at this stage of gestation. Then, there is a call at one-week postpartum (call #7) and the last call is at six weeks postpartum (call #8). Between scheduled phone calls, the MCC is available to the veteran as needed and makes additional (unscheduled) phone calls to follow-up on problems identified during the scheduled calls. There are 12 call topics, as summarized in Table 1. Within topics, some materials are to be covered with every veteran, and others only if appropriate for the Veteran’s needs (e.g. smoking or alcohol cessation education and support only if the veteran reports use). Each call has an outline, or checklist, to guide the call. An excerpt from the call outline for the first call is shown in Fig. 1, showing the health problems and medication reconciliation, smoking and alcohol use topics that are part of that call. Under each topic, there are specific prompts to help the MCC remember the content that needs to be covered for that topic. Outlines indicate the tab in the manual where the training script for that topic is located, so that the MCC can easily refer to that script if needed during a call. Table 1 Maternity Care Coordinator Telephone Care topics, by call First contact 12 weeks 20 weeks 28 weeks 36 weeks 41 weeks (if still pregnant) 1 week postpartum 6 weeks postpartum VA maternity care benefits X X X X X X X X Chronic health problems X X X X X X X X Smoking assessment/cessation X X X Alcohol assessment/cessation X Depression and suicide screening X X X X X X X Interpersonal violence screening X X X X Pregnancy-related classes X X Breastfeeding support X X X X X Information on women infants and children (WIC) program X Family planning X X X Postpartum obstetric care X X Transitioning back to VA primary care X First contact 12 weeks 20 weeks 28 weeks 36 weeks 41 weeks (if still pregnant) 1 week postpartum 6 weeks postpartum VA maternity care benefits X X X X X X X X Chronic health problems X X X X X X X X Smoking assessment/cessation X X X Alcohol assessment/cessation X Depression and suicide screening X X X X X X X Interpersonal violence screening X X X X Pregnancy-related classes X X Breastfeeding support X X X X X Information on women infants and children (WIC) program X Family planning X X X Postpartum obstetric care X X Transitioning back to VA primary care X View Large Table 1 Maternity Care Coordinator Telephone Care topics, by call First contact 12 weeks 20 weeks 28 weeks 36 weeks 41 weeks (if still pregnant) 1 week postpartum 6 weeks postpartum VA maternity care benefits X X X X X X X X Chronic health problems X X X X X X X X Smoking assessment/cessation X X X Alcohol assessment/cessation X Depression and suicide screening X X X X X X X Interpersonal violence screening X X X X Pregnancy-related classes X X Breastfeeding support X X X X X Information on women infants and children (WIC) program X Family planning X X X Postpartum obstetric care X X Transitioning back to VA primary care X First contact 12 weeks 20 weeks 28 weeks 36 weeks 41 weeks (if still pregnant) 1 week postpartum 6 weeks postpartum VA maternity care benefits X X X X X X X X Chronic health problems X X X X X X X X Smoking assessment/cessation X X X Alcohol assessment/cessation X Depression and suicide screening X X X X X X X Interpersonal violence screening X X X X Pregnancy-related classes X X Breastfeeding support X X X X X Information on women infants and children (WIC) program X Family planning X X X Postpartum obstetric care X X Transitioning back to VA primary care X View Large Fig 1 View largeDownload slide Excerpts from the call outline and training scripts for first call. Fig 1 View largeDownload slide Excerpts from the call outline and training scripts for first call. We developed and implemented training sessions to educate the MCCs in each of the MCC-TCP components. This training included an initial session containing an overview of the materials, as well as a second interactive session, with coaching of and feedback to the MCC, in which MCCs practiced using the program manual by interacting with a simulated patient. As part of our usability assessments, MCCs reported that building their foundational knowledge base would facilitate their use of program materials. Therefore, we also developed an educational webinar series contains 10 topics: smoking, nutrition, mental health, common complaints of pregnancy, overview of testing during pregnancy, postpartum contraception, genetic testing during pregnancy, intimate partner violence, breastfeeding, and pregnancy-related loss and grief. Each one-hour webinar presentation was developed and delivered by a content expert. The webinars occurred at approximately one-month intervals and were broadcast via Lync®, which allowed capturing of MCC participation and provided a forum for the submission of questions for the presenter. MCCs participated in these webinars following their training in the MCC-TCP components. Developmental evaluation We evaluated MCC-TCP using electronic databases tracking veteran participation (i.e., attempts and completion of telephone calls for each veteran receiving VA maternity care benefits) and time MCCs spent implementing the program. By conducting surveys and collecting field notes, we captured care-coordinator perceptions about potential program value and facilitators and barriers to implementation. MCCs filled in call logs documenting the date of each attempted and completed phone call for each veteran using maternity care benefits in their facilities. MCCs separately filled in time logs documenting the number of minutes they spent reviewing veterans’ EMR, speaking with the veteran, documenting in the EMR, and performing other related care coordination tasks. We utilized SurveyMonkey® to administer a survey to the MCCs to assess the feasibility of MCC-TCP. The survey asked respondents to rate the usefulness and ease of use of the different components of the program materials, as well as the training sessions. Questions assessing usefulness were phrased as: “Overall, how useful is the [designated program component] in helping you [designated task]?” (Potential responses: very useful, somewhat useful, not useful, no opinion.) Questions assessing ease of use were phrased as: “Overall, how easy or difficult is it for you to use the [designated program component]?” (Potential responses: very easy, somewhat easy, neither easy nor difficult, somewhat difficult, very difficult.) MCCs were also asked to specify the extent to which lack of time had been a barrier for making program phone calls and then comment in free text on other barriers, as well as facilitators, to implementation and overall impressions regarding the program. We additionally gathered feedback on specific components of the program, as well as information on facilitators and barriers to implementation, through collection of field notes during monthly conference calls with participating MCCs. Assessment of physical and mental health needs We conducted an EMR review assessing pregnant veterans’ need for resources and coordination of services for chronic and pregnancy-related physical and mental health problems and health behaviors. We reviewed MCC notes of a convenience sample of pregnant veterans receiving phone calls from MCCs participating in the program between October 1, 2013, and September 30, 2015, purposefully oversampling veterans residing in zip codes designated as rural to enable comparisons of the needs of rural versus urban patients given that the MCCs reported that they perceived the needs of rural women veterans to be greater . MCC call logs were used to determine which veterans, as of March 31, 2015, had received three or more completed MCC phone calls. In order to minimize the instances in which MCC notes provided an incomplete accounting of the veteran’s pre-pregnancy and pregnancy-related medical and mental health issues, we excluded veterans with less than three completed MCC phone calls (and therefore less than three MCC notes). We selected all veterans with three or more calls who had a zip code designated as rural. Among veterans with urban zip codes who had three or more calls, charts were selected at random, with the intention of sampling two urban veterans for each rural veteran (since the number of urban veterans available for sampling was much greater than the number of rural veterans). Each selected veteran’s EMR documentation was accessed using VA’s compensation and pension record interchange, which allows a read-only view of EMRs across the VA enterprise. An experienced medical record abstractor, a registered nurse (but not one of the MCCs), reviewed all MCC notes using a structured abstraction form ( Appendix A). If the MCC note referenced a note from another discipline (e.g., mental health), the medical record abstractor reviewed that note as well. For each veteran, we collected details on any physical or mental health problems that predated the current pregnancy as well as prior pregnancy-related problems. We also collected details on any obstetric complication(s) noted in the current pregnancy and any newly developed physical or mental health issue(s). Newly developed physical and mental health issues were defined as being mentioned in the MCC note as a new diagnosis or a symptom for which the veteran sought medical attention, without mention of this having been a symptom or diagnosis the patient had before the pregnancy. We also noted if the MCC indicated that the veteran was an active smoker, defined as currently smoking or having quit smoking within one year before pregnancy. Data were entered electronically using Research Electronic Data Capture (REDCap) hosted through VA . A second team member, a physician (KMC), then reviewed the data the nurse abstractor had entered into REDCap to further classify the documented obstetric, medical, and mental health problems or symptoms, using ICD9 code groupings as a guide, classifying documented illness by their major headings . Descriptive statistics were obtained, and rural and urban veterans compared, with use of STATA/SE 13.1 . All project activities were determined to be quality improvement and program development and therefore nonresearch, by the Institutional Review Board of VA Greater Los Angeles Healthcare System. RESULTS Developmental evaluation Call logs revealed that the program, in its third year, served 957 pregnant veterans, across the 11 VA healthcare systems in which our program was implemented. Of the 4576 attempted phone calls to these veterans, 2748 (60%) were completed (for the remaining, the veteran was not reachable or available). MCC time logs showed that, over the course of a pregnancy, MCCs spent on average 150 minutes per veteran implementing the program. On average, 23% of this time was spent reviewing charts in preparation for calls, 38% was spent making phone calls (including leaving messages for veterans when they did not answer phone calls), 27% was spent on documenting calls and activities, and 12% was spent performing other care coordination activities. All 12 MCCs (across 11 facilities) responded to the survey. Overall, 6/12 (50%) of the MCCs rated the program manual as being “very easy” to use, 4/12 (33%) rated it as “somewhat easy,” 1/12 (8%) rated it as “neither easy nor difficult” to use, and 1/12 (8%) rated it as “somewhat difficult.” The call log was rated as being “very useful” by six (50%) and “somewhat useful” by the remaining six (50%) MCCs in helping identify when scheduled patient calls were needed. Some MCCs viewed the call log as being less useful for identifying when unscheduled calls were needed (33% “very useful,” 42% “somewhat useful,” 25% “not useful”) and for identifying other tasks, outside of patient calls, that were needed (42% “very useful,” 33% “somewhat useful,” 25% “not useful”). The workbook for documenting local resources and processes was rated as being “very useful” by five (42%), “somewhat useful” by six (50%), and “not useful” by one (8%) MCCs. The training sessions were viewed as “very useful” by nine (75%) and “somewhat useful” by three (25%) of MCCs. In the free-text section of the survey, one MCC wrote: “I appreciate being a part of the customer service we provide. I think the patients also appreciate that they have someone to contact to help them through a situation.” Review of field notes of monthly project calls with MCCs revealed information regarding barriers to implementation. There was a consistent theme across MCCs reporting they lacked adequate time to make phone calls and carry out coordination activities. Several MCCs reported that this role was a collateral duty with other clinical duties, and they felt they were given inadequate time to perform the duties required for the MCC role. MCCs additionally reported frustration that a good amount of their time was being spent on attempting phone calls and leaving messages when veterans would not answer their phones. The theme of not having sufficient time for this role was also echoed in response to free-text questions assessing MCC perceptions about the program barriers. One MCC wrote: “I think that our facility underestimated the time commitment that putting a program like this in place requires.” Field notes from calls also documented that MCCs need enhanced information technology tools (beyond the Excel-based call log provided) to track phone calls and other needed tasks and to assist in documentation of calls and activities (beyond the basic note templates provided). Despite these challenges, a recurrent theme was MCCs satisfaction with being able to assist pregnant women veterans, and veterans’ favorable response to this program. One MCC wrote “I love connecting with these women and providing them the resources they need. They are truly appreciative of all we are able to do for them.” Physical and mental health needs We reviewed the medical records of 244 pregnant veterans residing in eight geographically dispersed states, served by 13 unique MCCs. The average age of sampled veterans was 30, ranging from 21 to 43 years. Table 2 shows our findings of pre-pregnancy chronic physical and mental problems. MCC notes documented that 41% of the women had one or more chronic physical problems. The most common type of problem was musculoskeletal (17%), with endocrine (10%), neurologic (10%), and gastrointestinal (10%) problems also being common. More than one-third of the sampled pregnant veterans had one or more chronic mental health issues. Depression was the most prevalent mental health condition with 28% of women having this noted; 20% had PTSD or another anxiety disorder; and 3% had some other mental health condition. Seven percent were active smokers during pregnancy; 10% had smoked in the year before pregnancy but were not smoking at the time of MCC first assessment. Table 2 Prevalences among program participants of pre-pregnancy physical and mental health problems and active or recent smoking Number (%) of pregnant veterans (n = 244) Pre-pregnancy physical problems 100 (41%) Musculoskeletal 42 (17%) Endocrine 25 (10%) Neurologic 24 (10%) Gastrointestinal 21 (9%) Cardiovascular 12 (5%) Pulmonary 9 (4%) Hematologic 8 (3%) Dermatologic 6 (2%) Breast 2 (1%) Renal/urologic 3 (1%) Infectious diseases 3 (1%) Rheumatologic 3 (1%) Otolaryngology 2 (1%) Problems involving one organ system 60 (24%) Problems involving two organ systems 22 (9%) Problems involving three or more organ systems 18 (7%) Pre-pregnancy mental health problems 83 (34%) Depression 69 (28%) PTSD/anxiety 51 (21%) Other 6 (3%) Active/recent smoking 43 (18%) Smoking currently 18 (7%) Smoking in year before pregnancy (not currently) 25 (10%) Number (%) of pregnant veterans (n = 244) Pre-pregnancy physical problems 100 (41%) Musculoskeletal 42 (17%) Endocrine 25 (10%) Neurologic 24 (10%) Gastrointestinal 21 (9%) Cardiovascular 12 (5%) Pulmonary 9 (4%) Hematologic 8 (3%) Dermatologic 6 (2%) Breast 2 (1%) Renal/urologic 3 (1%) Infectious diseases 3 (1%) Rheumatologic 3 (1%) Otolaryngology 2 (1%) Problems involving one organ system 60 (24%) Problems involving two organ systems 22 (9%) Problems involving three or more organ systems 18 (7%) Pre-pregnancy mental health problems 83 (34%) Depression 69 (28%) PTSD/anxiety 51 (21%) Other 6 (3%) Active/recent smoking 43 (18%) Smoking currently 18 (7%) Smoking in year before pregnancy (not currently) 25 (10%) View Large Table 2 Prevalences among program participants of pre-pregnancy physical and mental health problems and active or recent smoking Number (%) of pregnant veterans (n = 244) Pre-pregnancy physical problems 100 (41%) Musculoskeletal 42 (17%) Endocrine 25 (10%) Neurologic 24 (10%) Gastrointestinal 21 (9%) Cardiovascular 12 (5%) Pulmonary 9 (4%) Hematologic 8 (3%) Dermatologic 6 (2%) Breast 2 (1%) Renal/urologic 3 (1%) Infectious diseases 3 (1%) Rheumatologic 3 (1%) Otolaryngology 2 (1%) Problems involving one organ system 60 (24%) Problems involving two organ systems 22 (9%) Problems involving three or more organ systems 18 (7%) Pre-pregnancy mental health problems 83 (34%) Depression 69 (28%) PTSD/anxiety 51 (21%) Other 6 (3%) Active/recent smoking 43 (18%) Smoking currently 18 (7%) Smoking in year before pregnancy (not currently) 25 (10%) Number (%) of pregnant veterans (n = 244) Pre-pregnancy physical problems 100 (41%) Musculoskeletal 42 (17%) Endocrine 25 (10%) Neurologic 24 (10%) Gastrointestinal 21 (9%) Cardiovascular 12 (5%) Pulmonary 9 (4%) Hematologic 8 (3%) Dermatologic 6 (2%) Breast 2 (1%) Renal/urologic 3 (1%) Infectious diseases 3 (1%) Rheumatologic 3 (1%) Otolaryngology 2 (1%) Problems involving one organ system 60 (24%) Problems involving two organ systems 22 (9%) Problems involving three or more organ systems 18 (7%) Pre-pregnancy mental health problems 83 (34%) Depression 69 (28%) PTSD/anxiety 51 (21%) Other 6 (3%) Active/recent smoking 43 (18%) Smoking currently 18 (7%) Smoking in year before pregnancy (not currently) 25 (10%) View Large Table 3 shows the frequency of physical and mental health issues pregnant veterans in our sample newly developed during pregnancy, or within 6 weeks postpartum, including obstetric complications. Thirty-six percent of the sampled veterans reported having a new nonobstetric physical symptom or problem, with the most common being infectious diseases (9%) and musculoskeletal issues (9%), followed by gastrointestinal issues (5%) and cardiovascular issues, not including hypertension (4%). New mental health symptoms affected 11% of the women, with depression being the most commonly noted. Thirty-eight percent of the veterans reported having had one or more obstetric complications, with gestational diabetes being the most common complication (11%). No significant differences were detected between rural and urban veterans with respect to physical or mental health issues or health-related behaviors before or during pregnancy (data not shown). Table 3 Prevalences among program participants of new obstetric and physical and mental health problems Number (%) of pregnant veterans (n = 244) New nonobstetric physical issue 88 (36%) Infectious diseases 23 (9%) Musculoskeletal 22 (9%) Gastrointestinal 11 (5%) Cardiovascular (other than hypertension) 10 (4%) Endocrine (other than gestational diabetes) 5 (2%) Hematologic 5 (2%) Renal/urologic 4 (2%) Neurologic 3 (1%) Pulmonary 3 (1%) Dermatologic 3 (1%) Dental 3 (1%) Breast 2 (1%) Rheumatologic 1 (1%) New mental health issue 26 (11%) Depression 19 (8%) PTSD/anxiety 8 (3%) Other 2 (1%) Obstetric complications 93 (38%) Gestational diabetes 27 (11%) Pre-eclampsia/eclampsia 11 (5%) Vaginal bleeding 11 (5%) Preterm labor 8 (3%) Hypertension 7 (3%) Fetal abnormalities 7 (3%) Miscarriage/fetal demise 6 (3%) Other obstetric symptoms or problems 18 (7%) Number (%) of pregnant veterans (n = 244) New nonobstetric physical issue 88 (36%) Infectious diseases 23 (9%) Musculoskeletal 22 (9%) Gastrointestinal 11 (5%) Cardiovascular (other than hypertension) 10 (4%) Endocrine (other than gestational diabetes) 5 (2%) Hematologic 5 (2%) Renal/urologic 4 (2%) Neurologic 3 (1%) Pulmonary 3 (1%) Dermatologic 3 (1%) Dental 3 (1%) Breast 2 (1%) Rheumatologic 1 (1%) New mental health issue 26 (11%) Depression 19 (8%) PTSD/anxiety 8 (3%) Other 2 (1%) Obstetric complications 93 (38%) Gestational diabetes 27 (11%) Pre-eclampsia/eclampsia 11 (5%) Vaginal bleeding 11 (5%) Preterm labor 8 (3%) Hypertension 7 (3%) Fetal abnormalities 7 (3%) Miscarriage/fetal demise 6 (3%) Other obstetric symptoms or problems 18 (7%) View Large Table 3 Prevalences among program participants of new obstetric and physical and mental health problems Number (%) of pregnant veterans (n = 244) New nonobstetric physical issue 88 (36%) Infectious diseases 23 (9%) Musculoskeletal 22 (9%) Gastrointestinal 11 (5%) Cardiovascular (other than hypertension) 10 (4%) Endocrine (other than gestational diabetes) 5 (2%) Hematologic 5 (2%) Renal/urologic 4 (2%) Neurologic 3 (1%) Pulmonary 3 (1%) Dermatologic 3 (1%) Dental 3 (1%) Breast 2 (1%) Rheumatologic 1 (1%) New mental health issue 26 (11%) Depression 19 (8%) PTSD/anxiety 8 (3%) Other 2 (1%) Obstetric complications 93 (38%) Gestational diabetes 27 (11%) Pre-eclampsia/eclampsia 11 (5%) Vaginal bleeding 11 (5%) Preterm labor 8 (3%) Hypertension 7 (3%) Fetal abnormalities 7 (3%) Miscarriage/fetal demise 6 (3%) Other obstetric symptoms or problems 18 (7%) Number (%) of pregnant veterans (n = 244) New nonobstetric physical issue 88 (36%) Infectious diseases 23 (9%) Musculoskeletal 22 (9%) Gastrointestinal 11 (5%) Cardiovascular (other than hypertension) 10 (4%) Endocrine (other than gestational diabetes) 5 (2%) Hematologic 5 (2%) Renal/urologic 4 (2%) Neurologic 3 (1%) Pulmonary 3 (1%) Dermatologic 3 (1%) Dental 3 (1%) Breast 2 (1%) Rheumatologic 1 (1%) New mental health issue 26 (11%) Depression 19 (8%) PTSD/anxiety 8 (3%) Other 2 (1%) Obstetric complications 93 (38%) Gestational diabetes 27 (11%) Pre-eclampsia/eclampsia 11 (5%) Vaginal bleeding 11 (5%) Preterm labor 8 (3%) Hypertension 7 (3%) Fetal abnormalities 7 (3%) Miscarriage/fetal demise 6 (3%) Other obstetric symptoms or problems 18 (7%) View Large DISCUSSION In summary, our findings show that implementing the MCC-TCP program was feasible, as demonstrated by successful implementation across 11 VA facilities. The program was perceived by the MCCs implementing it as valuable in meeting the care coordination needs of pregnant veterans. Consistent with, and expanding upon, prior research, we observed that pregnant women veterans using VA maternity care had a high need for care coordination services because of their substantial burden of pre-pregnancy chronic physical and mental health problems, as well as a high incidence of pregnancy complications. Given the growing demand for maternity care among VA users, with high prevalences of mental health and medical comorbidities, and with previous studies demonstrating the clinical benefit of care coordination services during pregnancy, further investments in maternity care coordination programs, such as MCC-TCP, need to be prioritized. Barriers to implementing such programs at their full potential, such as those illustrated in our findings, must be addressed. This work shows that implementing such care coordination programs is time-intensive, and it is essential that facility leadership prioritize giving care coordinators the time necessary to meet pregnant veterans’ needs. Information technology tools to support task tracking and care documentation have the potential to make this effort more efficient; however, investment must be made to develop, deploy, evaluate, and sustain such tools. This work also suggests the importance of providing adequate training to those responsible for implementing such programs. Training with simulated patients, although potentially time and resource intensive, may be particularly valuable for improving knowledge and skills among medical providers . Finally, the extent to which we experienced local variations in resources and processes, and needed to adapt the program to account for these differences, supports the importance of staged implementation, with tailoring, to facilitate intervention spread. The model of MCCs attempting phone calls should be examined and compared with alternative methods of communicating with veterans, with respect to acceptability, effectiveness, and efficiency. Information and communication technologies (e.g., virtual care; mHealth) for chronic disease management have been successfully utilized in nonpregnant veterans with chronic physical and illnesses [37, 38]. Outside VA, early research and development of virtual and mHealth for maternity-related care and care coordination shows promise that this may be a feasible modality for communication, with the potential for positive effects on outcomes, particularly for patients with chronic illness comorbidities and gestational diabetes [39–41]. The VA maternity care coordination model, in which a nurse is coordinating and acting as a care manager for vulnerable veterans utilizing multiple providers, is one that draws on the experience of previously successful VA interventions. For example, VA successfully uses case management to coordinate and integrate mental health and primary care services within VA . Further, as veterans become increasingly likely to simultaneously receive care from both VA and community sources, this model should be looked to for its applicability to improving communication and coordination of care between VA and community providers for all Veterans . This work adds to previously published literature suggesting that veterans using VA maternity benefits have a significant need for care coordination and care management support. The observed rates of mental illness substantiate and add to the current literature in this area. Previous studies have shown that 40% of recently pregnant veterans had been diagnosed with depression, either before or during pregnancy [17, 18]. Our findings, with similar cumulative prevalences (36%), substantiate this literature and add to it by distinguishing between women with depression pre-pregnancy (28%) and those with pregnancy-related depression (8%). Furthermore, we found higher rates of depression in comparison to rates of depression documented for nonveteran recently pregnant women, which have been observed to be 13–15% [16, 43]. Rates of anxiety disorders (including PTSD) in our sample were also double those observed among nonveteran recently pregnant women (12%) . The higher burden of mental health issues among women veterans, compared with nonveteran women, has been attributed to multiple potential factors including combat and other military trauma (including military sexual trauma), nonmilitary adult trauma, and childhood abuse [16, 44]. This inventory of prevalences of pre-pregnancy physical problems among veterans is an additional new contribution to the literature. Previous studies of the general women veteran population have shown musculoskeletal problems to be a highly prevalent medical issue among women veterans and our findings reflect this . The etiology of this higher musculoskeletal pain prevalence among women Veterans is poorly understood, and likely multifactorial, including injuries during military service and training, sequelae from obesity, and mental health risk factors . Treatment of chronic pain during pregnancy is complicated by risks that pharmacologic agents confer onto the fetus . Therefore, pregnant veterans need to have access to nonpharmacologic alternatives for pain management, and clinicians with expertise in providing these alternative modalities during pregnancy. With respect to pregnancy complications, we replicated what has been previously shown in that our sample had a higher incidence of gestational diabetes (11%) than observed in other nonveteran patient populations (4–8%) [19, 22, 46, 47]. This is particularly concerning given the well-established increased risk gestational diabetes confers on later development of type 2 diabetes and cardiac disease [48, 49]. Although growing, the number of pregnant veterans using VA services has been historically low and therefore VA primary care providers, mental health providers, and other specialists may be less comfortable comanaging nonobstetric physical and mental health issues of pregnant veterans. VA has established many educational initiatives to build capacity of its provider workforce to meet the needs of women veterans . This work supports the need for these initiatives to include building VA providers’ knowledge and skills in comanagement of pregnant women with chronic physical and mental health conditions. Our findings should be interpreted in the context of its limitations. MCC-TCP’s developmental implementation-focused evaluation should not be considered definitive but rather as a prompt for further study. Understanding MCC-TCP’s effect on veterans' use of services, clinical and care efficiency outcomes, as well as patient experience, would be valuable. With respect to program planning, our workgroup did not include veteran or community provider representation. It is unknown how including these important perspectives would have enhanced program development. Separately, while it is common for implementation and evaluation activities to work hand-in-hand given the intrinsic value of internal PDSA cycles for program improvement, the interpretation of evaluation findings may be biased. Specific to our medical record review, our results may actually be an underestimate of the burden of physical and mental health comorbidities, as well as obstetric complications, as we relied on patient report to the MCC and we utilized free text, rather than coded EMR data, which has been shown to generally underestimate condition prevalence . Finally, the generalizability of our findings is limited to VA maternity care coordination, and the geographic distribution of our program implementation was not representative of the distribution of all pregnant veterans using VA services, in that we purposefully selected sites with higher proportions of rural veterans and then oversampled rural veterans for our chart review. This work, nonetheless, provides an important contribution to the literature documenting the care coordination needs and comorbid physical and mental health issues in pregnant veterans. The substantial physical and mental health burden of pregnant veterans suggests that care coordination is particularly important for this patient population. The MCC-TCP provides a potential foundation for meeting this need. Funding Support for this work was provided by the U.S. Department of Veterans Affairs (VA) Office of Rural Health and the Office of Women’s Health Services in Patient Care Services. Dr. Yano’s time was supported by a VA Health Services Research and Development (HSR&D) Senior Research Career Scientist Award (RCS#05-195), with additional support from the VA Women’s Health Research Network (SDR#10–012). Dr. Katon is supported by a VA Health Services Research and Development Career Development Award (VA HSRD CDA 13–266). Compliance with Ethical Standards Conflict of Interest: The views expressed within are solely those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or The United States Government. All authors have reported having no conflict of interests with this work. Primary Data: The reported findings have not been previously published and the manuscript is not being simultaneously submitted elsewhere. The MCC Telephone Care Program was previously described in presentations at the VA Health Services Research and Development Conference on Partnerships for Research & Care of Women Veterans, July 2014, and the annual research meeting of Academy Health, June 2017. The authors have full control of all primary data and agree to allow the journal to review these data, if requested. Ethical Approval: This work was performed as quality improvement and was therefore determined to be nonresearch by the Institutional Review Board of VA Greater Los Angeles Healthcare System. All procedures were performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki. Informed Consent: Formal consent is not required above what is standard for receipt of healthcare. There were no animals used in the conduct of this research. Acknowledgments We would like to thank Ms. Anna Dickey, RN, BSN, for conducting the medical record review. APPENDIX A Maternity Care Coordinator Telephone Care Program Chart Abstraction Tool Demographics 1 Patient age at time of presentation of pregnancy to VA: 2. Current zip code of patient residence Pre-pregnancy Health Problems 3 Did the mother present with pre-pregnancy medical problems? □Yes □No □Not indicated Specify: 4 Did the mother present with pre-pregnancy mental health problems? □Yes □No □Not indicated Specify: Pregnancy-related Health Problems/Complications 5 Did the mother present with any newmedical problems developed during pregnancy? □Yes □No □Not indicated Specify: 6 Did the mother present with any obstetric problems? □Yes □No □Not indicated Specify: 7 Did the mother present with any newmental health problems developed during pregnancy? □Yes □No □Not indicated Specify: 4 Tobacco Use/Exposure 8 Was the mother an active smoker during the pregnancy? □Yes □No □Not indicated 9 Was the mother an active smoker prior to the pregnancy? □Yes, but not in the year prior to pregnancy □Yes, during the year prior to pregnancy □Yes, no information about quit date □No, never smoked □Not indicated References 1. 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