36C24218R0013-005.pdf

Department of Veterans Affairs Veterans Health Administration Washington, DC 20420

VHA DIRECTIVE 1330.01(1)

Transmittal Sheet February 15, 2017

HEALTH CARE SERVICES FOR WOMEN VETERANS

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive defines the scope of health care services to women Veterans. It delineates essential components necessary to ensure that all enrolled women Veterans have access to appropriate services, regardless of the VHA site of care.

2. SUMMARY OF MAJOR CHANGES:

a. This VHA directive updates the description of the standard requirements for the delivery of health care to women Veterans and specifies services that must be provided at each Department of Veterans Affairs (VA) medical facility. The assignment of women Veterans to designated Women’s Health Primary Care Providers WH-PCP is clarified and the requirements for designation and maintenance as a WH-PCP are defined in this directive.

b. Clarify that a physician, Nurse practitioner, or Physician’s Assistant can serve as Women’s Health Medical Director or Women’s Health Champion.

c. Merged Appendix C and D, Veterans Health Environmental Privacy and Security, and removed repetitive elements that are covered elsewhere on the Environment of Care survey tool.

3. RELATED ISSUES: VHA Handbook 1330.02 and VHA Handbook 1330.03.

4. RESPONSIBLE OFFICE: The Chief Consultant, Women’s Health Services (10P4W) is responsible for the contents of this VHA directive. Questions may be referred to 202-461-1070.

5. RESCISSIONS: VHA Handbook 1330.01, Health Care Services for Women Veterans, dated May 21, 2010, is rescinded.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of February 2022. This VHA directive will continue to serve as national policy until it is recertified or rescinded.

David J. Shulkin, M.D.

Under Secretary for Health

DISTRIBUTION: Emailed to the VHA Publication Distribution List on February 16, 2017.

February 15, 2017 VHA DIRECTIVE 1330.01(1) i

CONTENTS

HEALTH CARE SERVICES FOR WOMEN VETERANS

1. PURPOSE 1

2. BACKGROUND 1

3. DEFINITIONS 3

4. POLICY 5

5. RESPONSIBILITIES 6

6. COMPREHENSIVE CARE FOR WOMEN VETERANS 12

7. ADDITIONAL SERVICES FOR WOMEN VETERANS 28

8. WOMEN’S HEALTH EDUCATION, TRAINING, AND CULTURAL

COMPETENCY 30

9. DATA COLLECTION AND QUALITY ASSURANCE 31

10.THE HEALTH CARE ENVIRONMENT 31

11.REFERENCES 34

APPENDIX A

GUIDANCE FOR THE DEVELOPMENT OF THE WOMEN’S HEALTH MEDICAL

DIRECTOR POSITION IN VHA HEALTH CARE SYSTEMS A-1

APPENDIX B

DESIGNATED WOMEN’S HEALTH PRIMARY CARE PROVIDER (WH-PCP) AND

WOMEN’S HEALTH PATIENT ALIGNED CARE TEAM (WH-PACT) SUGGESTED

COMPETENCY DOMAINS B-1

APPENDIX C

VETERANS HEALTH ENVIRONMENTAL PRIVACY AND SECURITY C-1

APPENDIX D

PANEL MANAGEMENT D-1

HEALTH CARE SERVICES FOR WOMEN VETERANS

1. PURPOSE

This Veterans Health Administration (VHA) directive establishes the minimum requirements to ensure that all eligible and enrolled women Veterans, irrespective of where they obtain care in VHA, have access to all medically necessary services.

AUTHORITY: 38 U.S.C. 501, 1710, 1720D, 7301(b).

2. BACKGROUND

The Department of Veterans Affairs (VA) is improving access, services, resources, facilities, and workforce capacity to make health care more accessible, more sensitive to gender-specific needs, and of the highest quality for the women Veterans of today and tomorrow. While women Veterans constitute a minority of Veterans, they deserve the same level of services provided to male Veterans. VHA Women’s Health Services (WHS, 10P4W) works to ensure that timely, equitable, high-quality, comprehensive health care services are provided in a sensitive and safe environment at VA medical facilities nationwide. VA strives to be a national leader in the provision of health care for women, thereby raising the standard of care for all women.

a. Public Law 102-585, Veterans Health Care Act of 1992, Title I, enacted November 4, 1992, authorizes VA to provide gender-specific services, such as Papanicolaou tests (Pap smears), breast examinations, menopause management, mammography, and reproductive health care services to eligible women Veterans. In addition, this law authorizes VA to provide women Veterans counseling services needed to treat conditions related to sexual trauma experienced while serving on active duty.

b. Public Law 102-585 also mandates that a VHA official in each region must serve as coordinator of women’s services with specific responsibility for assessing the needs of and enhancing services for women Veterans. As a result of the realignment of VHA the position of Regional Women Veterans Coordinator is re-titled Deputy Field Director (DFD), Women Veterans Health Program.

c. Public Law 103-452, the Veterans Health Programs Extension Act of 1994, signed November 2, 1994, authorizes VA to provide appropriate care and services for conditions related to sexual trauma. The law also made VA’s authority to treat sexual trauma gender-neutral.

d. Public Law 104-262, Veterans’ Health Care Eligibility Reform Act of 1996, required VA to establish and implement a national enrollment system. Maternity and infertility services, excluding in-vitro fertilization (IVF), are included in VA’s Uniform Medical Benefits package.

e. Public Law 106-117, Veterans Millennium Health Care and Benefits Act, signed November 30, 1999, extended VA’s authority to provide counseling and treatment for conditions related to sexual trauma.

f. VA’s Uniform Medical Benefits package includes pregnancy and delivery services as authorized by law and certain medically necessary infertility services.

NOTE: See Title 38 Code of Federal regulations (CFR) Sections 17.38(a)(1)(xiii) and 17.38(b) [care needed to promote, preserve, or restore health]. Abortions, abortion counseling, and in-vitro fertilization (IVF) are expressly excluded from the medical benefits package. NOTE: See Title38 CFR, Section17.38(c)(1) & (2).

g. P. L. 108-422, Veterans Health Programs Improvement Act of 2004, granted VA permanent authority to provide counseling and treatment for conditions related to military sexual trauma and extended eligibility to Veterans who experienced sexual trauma while on active duty for training status.

h. Public Law 110-387, Veterans Mental Health and Other Care Improvements Act of 2008, enhances domiciliary care for women Veterans, and requires that VA domiciliary programs are adequate, with regard to capacity and safety, to meet the needs of women Veterans.

i. Public Law 111-163, Caregivers and Veterans Omnibus Health Services Act of 2010, Pursuant to 38 U.S.C. § 1786, VA may provide newborn health care services, for up to but not more than, date of birth and 7 calendar days after the birth of the child, all post-delivery care services, including routine health care services that a newborn child requires, if the woman Veteran delivered the child in a VA medical facility or in another facility pursuant to a VA contract relating to such delivery. These services are part of VA’s medical benefits package. NOTE: See 38 CFR § 17.38 (a)(1) (xiv).

j. Public Law 113-146, Veterans Access, Choice, and Accountability Act of 2014, Title III, Section 301 requires biennial reporting regarding staffing of medical facilities including workload, staffing and wait times for Women’s Health.

k. Public Law 113-146, Veterans Access, Choice, and Accountability Act of 2014, Title IV, Health Care Related to Sexual Trauma expands eligibility for sexual trauma counseling and treatment to Veterans who experienced sexual trauma while on inactive duty training, permits (but does not require) VA to expand eligibility for sexual trauma counseling and treatment under Title 38 US Code 1720D to include Active Duty members of the Armed Forces, and updates VA reporting requirements.

l. VHA Handbook1330.02, Women Veterans Program Manager, establishes the minimum requirements for health care professionals appointed as Women Veterans Program Managers (WVPMs). It outlines the duties, responsibilities, performance standards, and functional statements for Veterans Integrated Service Network (VISN) Lead WVPMs and VA medical facility WVPMs who are responsible for planning, executing, monitoring, and evaluating the Women Veterans Health Program services at the local level.

m. VHA Handbook 1330.03, Maternity Health Care and Coordination, establishes new VHA procedures for furnishing and coordinating the maternity care of eligible, enrolled, women Veterans. This includes women receiving their maternity care within

VA or by a non-VA provider at VA expense through VA medical facilities. These procedures establish a VA-wide standard of practice for maternity care and its coordination.

n. Under Secretary for Health’s Information Letter 10-2014-10, Guidance on Emergency Medical Services for Women, provides guidance for Emergency Departments (ED) and Urgent Care Clinics (UCC) to ensure delivery of quality care to all women Veterans when accessing VA emergency services.

3. DEFINITIONS

a. Administrative Parent. An administrative parent is defined as a collection of all the points of service that a leadership group (VA Medical Facility Director, Deputy VA Medical Facility Director, Chief of Staff, Associate or Assistant Director, and Nurse Executive) manages. The points of service can include any institution where health care is delivered. All of the data that originate from these points of service roll up to a single station number representing the administrative parent for management and programmatic activities.

b. Co-Location. Co-location means having primary care and gender-specific specialty care (i.e. mental health services, gynecology care) in the same physical location (clinic) in order to optimize care delivery.

c. Comprehensive Primary Care for Women Veterans. Comprehensive primary care for women Veterans is the provision of complete primary care and care coordination at one site by a Designated Women’s Health Primary Care Provider (WH- PCP) and Women’s Health Patient Aligned Care Team (WH-PACT) team. The WH- PCP and WH-PACT should, in the context of a longitudinal relationship, fulfill all primary care needs, including:

(1) Care for Acute and Chronic Illness. Care for acute and chronic illness is the routine detection and management of acute and chronic conditions commonly seen in primary care including, but not limited to: acute upper respiratory infection, headache and back pain, dizziness, urinary tract infection, high blood pressure, cardiovascular disorders, diabetes, osteoporosis, thyroid disease, kidney disease, gastrointestinal disease, lung disease, etc.

(2) Gender-Specific Primary Care. Gender-specific primary care is screening for breast and cervical cancer and referral of abnormal findings to specialty services for appropriate follow-up, and basic gynecology care including contraception counseling and basic contraceptive care; sexually transmitted infection (STI) treatment;

management of menopause-related concerns; initial evaluation and treatment of conditions such as pelvic and abdominal pain, abnormal vaginal bleeding, vaginal infections, urinary incontinence, breast masses, mastitis, etc.

(3) Preventive Services. Preventive services include age-appropriate cancer screenings, nutrition counseling, STI and HIV screening and counseling, Intimate

Partner Violence (IPV) screening, smoking cessation counseling and treatment, immunizations, etc.

(4) Mental Health Services. Mental health services include initial assessment and treatment, as needed, for a variety of mental health disorders which include mild depression, anxiety, substance abuse, and the appropriate referral to mental health as indicated.

(5) Coordination of Care. Coordination of care includes working across care settings, accessing health care providers and community programs, and communicating with patients, primary and specialty providers regarding evaluation and treatment plans both within and outside of the VA to ensure continuity of care.

NOTE: It is important to recognize that women’s clinics offering only gender-specific care (Pap clinic or gynecology care alone) do not meet the definition of comprehensive primary care for women Veterans. Comprehensive primary care for women Veterans may be delivered utilizing a team model, and it is expected that gender-specific primary care is provided by the same clinician who renders other routine primary care, preferably without multiple encounters or visits scheduled over different days.

d. Chaperone. A Chaperone is a person who serves as a witness for both a patient and a medical practitioner as a safeguard for both parties during a medical examination or procedure.

e. Designated Women’s Health Primary Care Provider (WH-PCP). Designated women’s health primary care provider is a primary care provider who is trained, and experienced in women’s health. A WH-PCP does not have to be of female gender. A WH-PCP is preferentially assigned women Veterans to their primary care patient panels. For the required qualifications of a WH-PCP, see paragraph 6 (d).

f. Exclusive Space. Exclusive space is a separate physical location for the delivery of comprehensive primary care to women Veterans and it is not shared by other services providing care to male Veterans.

g. Military Sexual Trauma (as defined in Title 38 U.S.C. 1720D). Military sexual trauma (MST) is “physical assault of a sexual nature, battery of a sexual nature or sexual harassment which occurred while a Veteran was serving on active duty, active duty for training, or inactive duty training.” Sexual harassment is further defined as “repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character.”

h. Rights of Conscience. Rights of conscience (ROC) refers to a request by a provider to opt-out of an aspect of clinical care because it violates the provider’s conscience to provide that care, based on “the right to protect his or her moral integrity

– to uphold the soundness, reliability, wholeness and integration of one’s moral character.”

i. Separate Shared Space. Separate shared space is a separate physical location for the delivery of comprehensive primary care to women Veterans that may be used by other services on days when women Veterans are not being seen.

j. Specialty Gynecology Care. Specialty gynecological care includes the management of gynecological conditions that require more advanced evaluation or management (medical or surgical) than can be provided through the gender-specific services offered by the primary care provider. Specialty gynecologic care includes, but is not limited to, evaluation and medical and/or surgical management.

k. Women’s Health Patient Aligned Care Team. Women’s Health Patient Aligned Care Team (WH-PACT) is a team or teamlet in which the provider is a WH-PCP. All members of the team or teamlet must be able to competently perform their roles related to providing comprehensive primary care for women. WH-PACT members must have sufficient training and expertise to care for women Veterans.

4. POLICY

a. It is VHA policy that all eligible and enrolled women Veterans have access to all medically necessary services in accordance with the procedures and guidelines specified in this directive.

b. The requirements in this directive apply to all sites of care that provide care directly and indirectly to women Veterans. Each VA medical facility must ensure that eligible women Veterans have access to high-quality, equitable, comprehensive medical care which includes but is not limited to primary care, mental health, specialty care, spiritual and pastoral care, residential care, and urgent/emergent care in an environment that provides privacy, dignity and security. It is everyone’s responsibility in a VA medical facility to care for all Veterans including women Veterans.

(1) Comprehensive primary care to women should be delivered by a WH-PCP and WH-PACT who are interested, trained, and experienced in the delivery of such care, irrespective of where patients are seen.

(2) Comprehensive primary care must be delivered using one, or any combination of, the comprehensive women’s health models of care which best meet the needs of women Veterans in the health care system.

(3) All newly enrolled women Veterans must be assigned to a WH-PCP. Women who are currently receiving care at a VA medical facility must be offered the choice to receive their comprehensive medical care from a WH-PCP. The goal is that at least 85% of women Veterans should be assigned to a WH-PCP.

(4) Each Administrative Parent (Health Care System) must have a full-time Women Veterans Program Manager (WVPM) to execute comprehensive planning for women’s health care that ensures privacy, security, and dignity and improves the overall quality of care provided to women Veterans. WVPMs work collaboratively with administrative and clinical leaders, and the Women’s Heath Medical Director (WHMD) to ensure that the needs of women Veterans are met across the health care system. (See VHA Handbook 1330.02).

(5) Each Administrative Parent (Health Care System) must have a WHMD or Women’s Health Clinical Champion responsible for clinical oversight of the women’s health program.

(6) Each medical facility must engage in an on-going, continual process to assess and correct physical deficiencies and environmental barriers to care for women Veterans. The use of the VHA Environment of Care (EOC) assessment and compliance tool will allow for management planning for correction of deficiencies. A review to evaluate structural, environmental, and psychosocial patient safety and privacy must be conducted on an annual basis, at a minimum, and be recorded through the EOC committee, including the plan for correction of deficiencies with a timeline for correction of deficiencies and an outline of budget commitment for corrections.

5. RESPONSIBILITIES

a. WHS Chief Consultant. The WHS Chief Consultant is responsible for the management, administration, technical aspects, program planning, policies, evaluations, integration, and implementation of national women’s health program’s activities (e.g.

comprehensive health, education, reproductive health and others). These activities include clinical services evaluation and coordination of women Veterans health care;

women Veterans’ health policy, epidemiology, and research. It also includes other women Veterans’ health issues as defined by VA on an evolving and as-needed basis.

(1) The Chief Consultant, in collaboration with Patient Care Services, is responsible for developing and implementing national directives, program initiatives, and VHA guidance related to women’s health issues.

(2) Initiating, promoting, and leading effective collaborations with VISN and health care system Directors to integrate the delivery of comprehensive health care services to women Veterans across the national health care system and continuously evaluates and improves the delivery of health care to women Veterans.

b. VISN Director. Each VISN Director is responsible for:

(1) Ensuring that VA medical facilities have appropriate resources such as equipment, space, and staffing which includes gynecology and WH-PCP FTEE to ensure that comprehensive health care is delivered to women Veterans.

(2) Ensuring that all staff members assume the responsibility of caring for women Veterans.

(3) Ensuring that all Administrative Parents (Health Care Systems) provide gynecology care either on-site or through Care in the Community.

(4) Ensuring that all VA medical facilities have an appropriate number of WH-PCPs to provide care to their population of women Veterans.

(5) Ensuring that a Lead WVPM is designated to serve as the VISN representative on women Veterans’ issues and as a member of the WHS Field Advisory Group.

(6) Ensuring that the Lead WVPM position maintains a minimum of .5 FTEE for job responsibilities and reports directly to the VISN Director or Chief Medical Officer (e.g.

maintains a schedule of at least quarterly meetings and program updates with the Network Director or Chief Medical Officer). (VHA Handbook 1330.02).

(7) Ensuring that the VISN Lead WVPM has direct access to top management in the VISN and serves on appropriate administrative and clinical boards or committees.

(8) Ensuring that the VISN Lead WVPM has funding and staff support for data analysis and project implementation, as well as funding for travel to meetings with the WVPMs in the VISN.

NOTE: VHA Handbook 1330.02, Appendices A and B describe work performed at the VISN level.

c. VA Medical Facility Director: Each VA medical facility Director is responsible for:

(1) Ensuring that all staff members assume the responsibility of caring for women Veterans with dignity and sensitivity.

(2) Ensuring that Administrative Parents (Health Care Systems) have appropriate resources such as equipment, space, and staffing, including gynecology and an appropriate number of WH-PCP FTEE to ensure that comprehensive health care is delivered to all women Veterans at all sites of care in the health care systems including VA medical centers and CBOCs.

(3) Ensuring that all facilities provide all aspects of gynecology care including but not limited to office visits, surgical procedures, emergency department care, and consultations either on-site or through Care in the Community in accordance with Gynecology Policy. VA medical facilities with Surgical Programs are required to have on-site Gynecology.

(4) Ensuring that a Women’s Health Medical Director (WHMD) is appointed to serve as the clinical leader for women’s health in the Administrative Parent (Health Care System), and ensuring the WHMD has a minimum of 4 hours per week administrative time separate from clinical duties (see Appendix A). It is recommended but not required that the WHMD is a physician.

NOTE: APRNs or PAs who are currently serving as WHMDs can continue in their current roles.

(5) Ensuring that each Administrative Parent (Health Care system) must have a Women Veterans Health Committee (WVHC), comprised of appropriate facility leadership and program directors, which develops and implements a Women’s Health Program strategic plan to guide the program and assist with carrying out improvements for providing high-quality equitable care for women Veterans. The WVHC must maintain an active charter, meet at a minimum quarterly and report to leadership with signed minutes at the Executive Quadrad level.

(6) Appointing a clinical health care professional as full-time WVPM. The position is mandated to be a full-time leadership and management position and free of collateral duties with a maximum of clinical time (1/8 FTEE) allotted only for purpose of maintaining credentialing. The WVPM must be a health care professional such as a registered nurse (RN); social worker or psychologist; doctor of medicine (MD/DO);

nurse practitioner (NP); physician assistant (PA); pharmacist; or other allied health care professional.

(7) Ensuring that the WVPM reports directly to the Chief of Staff or health care system Director and has direct access to top management in the health care system, serves on appropriate administrative and clinical boards and/or committees. (See VHA Handbook 1330.02).

(8) Ensuring that the name, location, and business telephone number of the WVPM is posted and appropriately publicized in each VA medical facility (e.g. on the Administrative Parent (Health Care System) website and accessible through the VA medical facility locator web tool http://www.va.gov/directory/guide/home.asp).

(9) Ensuring that appropriate administrative support staff is designated and available to assist the WVPM and WHMD with data and reporting requirements.

(10) Ensuring that each CBOC has appointed a women’s health clinical liaison who collaborates with the WVPM at the parent health care system.

d. VA Medical Facility Chief of Staff. The VA medical facility Chief of Staff is responsible for:

(1) Ensuring that all staff members have sufficient training, experience, and access to clinical information resources to be able to provide high-quality comprehensive health care to women Veterans in all areas (e.g. primary care, specialty care, spiritual and pastoral care, ED, in-patient units, mental health, surgical care, nursing care, diagnostic services, and clinical pharmacy).

(2) Ensuring that clinical leadership in Primary Care, Mental Health, and Specialty/Acute Care plan and implement equitable, high-quality, comprehensive health care services for women Veterans, including gender-specific specialty services, in a secure and sensitive environment in all areas of the health care system.

(3) Holding primary care leadership accountable for identifying designated experienced, and proficient women’s health primary care providers at each of the facility’s sites of care. WH-PCPs must be trained or experienced in women’s health care.

(4) Ensuring all women Veterans are offered assignment to a WH-PCP. All newly enrolled women Veterans must be assigned to a WH-PCP. Women who are already receiving care at a VA medical facility must be offered the choice to receive their comprehensive medical care from a WH-PCP.

(5) Ensuring that mental health providers have sufficient training, experience, and clinical information resources to provide high quality care to meet the specific mental health care needs of women Veterans.

(6) Assessing, developing, and maintaining services needed to deliver high-quality gynecologic care by incorporating gynecology service needs into facility strategic planning efforts.

(7) Ensuring processes and procedures are in place for 24 hours per day and 7 days per week (24/7) for ED and facility call coverage for gynecologic care. These local processes and procedures should be developed in collaboration with the ED Director, Chief of Nursing, and Chief of Gynecology (if available) and/or Chief of Surgery.

Ensuring on-site care or off-site Non-VA Medical Care, when necessary, to accommodate these needs.

(8) Ensuring that adequate staffing is provided for all care coordination needs of women Veterans, including that the coordination of breast and cervical cancer screening is assigned to appropriate support staff and not assigned as a collateral duty to the WVPM.

(9) Ensuring appropriate and timely breast and cervical cancer screening follow-up, tracking and reporting.

e. Associate Director for Patient Care Service/Nurse Executive. The Associate Director for Patient Care Services/Nurse Executive is responsible for ensuring that the primary care, emergency care, mental health, specialty care, spiritual and pastoral care, and inpatient and operating room nursing staff have the training, experience, and clinical information resources needed to provide high quality care for women Veterans.

f. Primary Care Leadership (e.g. Chief of Ambulatory Care, Chief of Primary Care, etc.) Primary Care Leadership is responsible for:

(1) Designating primary care representation on the Women Veterans Health Committee (WVHC).

(2) Working closely with the WVPM and WHMD on all matters affecting comprehensive primary care to women Veterans.

(3) Ensuring that WH-PCPs are designated at each site of care within each VA medical facility and that the number of WH-PCPs available is appropriate to the number of women Veterans accessing care, following primary care panel size recommendations. (VHA Handbook 1101.10, Patient Aligned Care Team (PACT), and VHA Handbook 1101.02, Primary Care Management Module).

(4) Ensuring that WH-PCPs have appropriate panel size reduction. (AppendixB)

(5) Ensuring that all newly enrolled women Veterans are assigned to WH-PCPs that all women already receiving care are offered assignment to WH-PCPs, with a goal of 85% of women Veterans are assigned to WH-PCPs.

(6) Ensuring that all WH-PACT teamlets where the provider is a WH-PCP are designated in Primary Care Management Module (PCMM) as women’s health teamlets.

(7) Ensuring that WH-PACT teamlets have appropriate staffing ratios as outlined in VHA Handbook 1101.10.

(8) Maintaining records of training or experience of WH-PCPs.

g. Women Veterans Program Manager (WVPM). See VHA Handbook 1330.02 for a detailed position description. Each VA medical facility must designate a full-time WVPM to assess the need for, and implementation of, services for eligible women Veterans, and to provide leadership and oversight to ensure that identified needs are met at the facility.

h. Women’s Health Medical Director (WHMD) or Women’s Health Clinical Champion. The WHMD is responsible for (See Appendix A):

(1) Serving as a clinical leader for women’s health and functioning as the clinical subject matter expert for women’s health issues in the health care system.

(2) Working closely with the WVPM, forming the foundation of the women’s health program.

(3) Collaborating with primary care leadership and participating in all primary care leadership meetings at the health care system level.

(4) Working with other clinical services such as specialty care, surgery, radiology, mental health, laboratory, and emergency department to ensure appropriate clinical services are available to women Veterans.

(5) Collaborating with WVPM and facility leadership and primary care leadership to determine the appropriate model of care for Comprehensive Women’s Health Care at all sites of care at the health care system, including the VA medical facility and CBOC’s.

(6) Collaborating with the WVPM, VA medical facility leadership and primary care leadership to ensure that women Veterans are offered and assigned to WH-PCPs.

(7) Collaborating with Primary Care Leadership and the WVPM to ensure that WH- PCPs are given appropriate panel size reduction.

(8) Collaborating with WVPM and Primary Care/WH-PACT leadership and the WVPM to ensure that appropriate support staffing is provided to WH-PACT team.

(9) Collaborating with gynecology services to ensure appropriate services for women Veterans, including service line agreements, co-location in comprehensive women’s clinics, ED coverage, urgent consultation, etc.

(10) Working with quality management team to monitor and review all clinical performance measures by gender. Establishing priorities and direction for implementing quality improvement on clinical quality measures that apply to women’s health.

(11) Developing or supervising clinical education programs for women’s health providers and trainees.

(12) Collaborating with VA medical facility Learning Officer to assess clinical women’s health learning needs.

(13) Participating in groups created for Women’s Health Medical Directors.

Participates in monthly national Women’s Health calls.

(14) WHMD/WHCC must have at least 4 hours of administrative time per week to perform the above duties.

(15) It is recommended that the WHMD be a WH-PCP.

i. Women Veterans Health Committee (WVHC).

(1) Each Administrative Parent (Health Care System) must have a WVHC that develops and implements a WH strategic plan at the local facility level to guide the women’s health program and assists with carrying out improvements for providing high quality equitable care for women Veterans. The committee must maintain an active charter, meet quarterly at a minimum, and report to leadership with signed minutes at the Clinical Executive Board CEB level.

(2) The WVPM must either chair or co-chair the WVHC.

(3) Core members of the WVHC must consist of the following: WVPM, WHMD, representatives from primary care, mental health, medical and/ or surgical subspecialties, gynecology, pharmacy, social work and care management , nursing, ED, radiology, laboratory, quality management, business office/Non-VA Medical Care, and a member from executive leadership. Other members may include, but are not limited to, leadership support such as finance, strategic planning, engineering, EMS, and representatives from other services such as pathology services, extended care, prosthetic service, domiciliary care, chaplain, public and consumer affairs, VA Transition & Care Management, minority veteran coordinator, patient representative, Readjustment Counseling Service, nutrition services, MST coordinator, Community Living Centers, Veterans Benefits Administration, homeless programs.

NOTE: In compliance with the Federal Advisory Committee Act, 5 U.S.C. App., women Veteran consumers, representatives of VSOs, and other non-Federal employees may only serve as consultants to the WVHC. Consultants do not regularly attend WVHC meetings and do not participate in any collective fact finding, dispensing of advice, or decision making. Consultants provide only individual advice and factual information as requested by the WVHC.

6. COMPREHENSIVE CARE FOR WOMEN VETERANS

a. Comprehensive Primary Care. VHA policy requires that the full scope of primary care is provided to all eligible Veterans. Therefore, regardless of the number of women Veterans utilizing a particular health care system, all sites that offer primary care services must offer comprehensive primary care to women Veterans. The Women’s Health Program works in close collaboration with primary care, mental health, and specialty and acute care to ensure equal access to high-quality health care services in all sectors for women Veterans, and that such care is provided in a sensitive environment. All necessary gender-specific primary care services must be available at every site of care in the health care system. Comprehensive primary care for women Veterans is patient centered and fully consistent with the principles of WH-PACT. The WH-PACT standards of patient centeredness, access, continuity, and coordination of care in the setting of team-based care must be applied in delivering primary care for women Veterans. All women Veterans receiving primary care must be offered assignment to a WH-PACT teamlet consistent with VHA Handbook 1101.10.

NOTE: All primary care providers having completed training as internists, family physicians, NP or PA are credentialed to provide care to women Veterans. However because women Veterans are still a minority population within VHA, to provide the highest quality care, it is required that all women Veterans are offered assignment to WH-PCPs and WH-PACTs who have received training and/or experience in the care of women Veterans. Primary care provided by WH-PCPs enhances women Veterans’ satisfaction with care and enhances quality of gender-specific care.

b. Assignment to a WH-PCP. All newly enrolled women Veterans must be assigned to WH-PCPs. Each woman Veteran already enrolled for primary health care must be offered assignment to a WH-PCP and a WH-PACT Team, who assume responsibility for providing, coordinating and ensuring continuity of care irrespective of where she is seen (VA medical facilities, CBOCs, outpatient clinics, etc.).

(1) If women Veterans are already assigned to providers who are not WH-PCPs, they may continue assignment with these providers due to Veteran preference if appropriate arrangements are made for the women to receive gender-specific care (from another provider) at the same site of care. Women Veterans should not be required to travel to appointments on separate dates or locations to receive routine primary care and gender-specific primary care.

(2) Requests for primary care provider reassignment from women Veterans will be honored and processed according to the VA medical facility’s standard procedure, even if the request is for a non-WH-PCP.

(3) In all cases, arrangements must be made to provide gender-specific care within the primary care setting.

(4) Each VA medical facility must ensure that an appropriate number of WH-PCPs are available at each site of care to ensure that all VHA access goals are met for women Veterans. Cross-coverage for vacations and sick days must be provided by WH-PCPs. In addition each facility and CBOCs that treat more than 10,000 patients must ensure that comprehensive women’s primary care is able to be provided by WH- PCPs during extended hours, after hours, and on weekends to the extent required by VHA Directive 2013-001, Extended Hours Access for Veterans Requiring Primary Care Including Women’s Health and Mental Health Services at VA Medical Centers and Selected Community Based Outpatient Clinics, or subsequent policy issue.

(5) Transgender Veterans requesting primary care in a Women’s Health Clinic or a Designated Women’s Health Provider (DWHP) in a mixed gender primary care clinic should be assigned to WHC or DWHP as requested. (VHA Directive 2013-003 Providing Health Care for Transgender and Intersex Veterans, or subsequent policy issue)

c. WH-PACT. Assignment of women Veterans preferentially to WH-PACT panels allows for women to be clustered in teams, where the provider and staff members can provide consistent experience and expertise in the care of women and maintain processes and procedures specifically tailored to women Veterans. These may include trained nursing staff members to triage gender-specific complaints or assist with gender-specific procedures; processes for ordering and tracking mammography and cervical cancer screening; ensuring chaperones and gender-specific equipment and supplies are readily made available.

(1) All PACT teamlets with a WH-PCP as the provider will be designated a WH- PACT teamlet. This must be entered into PCMM as a WH-PACT teamlet.

(2) WH-PACTs may function in gender integrated primary care clinics, or in women’s clinics. WH-PACTs in integrated primary care clinics may be mixed gender. That is, a WH-PCP may care for both men and women Veterans on a WH-PACT teamlet panel.

(3) WH-PACT must be staffed according to WH-PACT guidelines (see VHA Handbook 1101.10) and requires enhanced staffing due to needs for chaperones and care coordination. All members of a WH-PACT should be experienced and knowledgeable in the care of women Veterans.

(4) The following staffing is recommended:

(a) Teamlet positions:

1. Primary care provider position: WH-PCP;

2. RN position: RN Care Manager;

3. License practical/vocational nurse (LPN/LVN) or health technician (HT) position: Clinical Associate;

4. Other Position: Chaperone (additional HT, LPN, etc.); and

5. Clerk position: Administrative Associate.

(b) Discipline-specific team members for WH-PACTs are assigned in PCMM as follows:

1. SW position: Social Worker;

2. Pharmacy: Clinical Pharmacy Specialist;

3. Dietitian Nutritionist: Registered Dietitian Nutritionist;

4. Other position: Gynecologist;

5. Other position: Military Sexual Trauma Coordinator;

6. Other position: Mental Health Provider; and

7. Other position: RN Mammogram/Pap/Maternity Care Coordinator.

Note: Facilities may determine the extent of MST Coordinator involvement, but at a minimum, WH-PACT teamlets should establish a working relationship with the facility MST Coordinator and seek consultation or include him/her in discussion of specific cases as appropriate.

d. Requirements for Women’s Health Primary Care Providers (PCP) and WH- PACT Teamlets.

(1) It is recommended that women Veterans be clustered in teams where the provider and all team members have experience, knowledge and established systems of care to provide equitable, high-quality care to women Veterans.

(2) It is recommended the WH-PACT teamlets are assigned a panel size of at least 100 women Veterans, thus allowing all teamlet members to care for a volume of patients to support maintenance of expertise in the care of women.

(3) In order to be initially designated as a WH-PCP, a provider must have at least one of the following:

(a) Documentation of attendance at a Women’s Health Mini-Residency within the previous 3 years;

(b) Documentation of at least 20 hours of women’s health continuing medical education (CME) or continuing education unit (CEU) within the previous 3 years;

(c) Documentation of at least 3 years in a practice with at least 50% women patients within the previous 5 years;

(d) Evidence of completion of an internal medicine or family practice residency;

women’s health fellowship; or women’s health, adult, or family practice NP or PA training within the previous 3 years;

(e) Documentation of a current preceptorship arrangement with an experienced WH- PCP such as weekly meetings (for at least 6 months); or

(f) Evidence of being recognized as a known women’s health leader and subject matter expert with experience practicing, teaching, and/or precepting women’s health;

and

(4) In order to maintain the designation as a WH-PCP, a provider must complete at least 10 hours of CME or CEU in women’s health every 2 years.

e. Mental Health Services in Primary Care. Forty-seven percent of women Veterans using VHA had a mental health or substance use disorder diagnosis in fiscal year 2014. A required component of comprehensive primary care involves receipt of integrated mental health services in the same physical location as primary care, thus integrating services and improving the quality of care delivered to women Veterans.

Patients requiring more intensive comprehensive and specialized mental health services will be referred to mental health clinics.

f. Choice of Provider. Facilities must give women Veterans the option to designate their preference for a female or male primary care provider. When a woman Veteran requests a female or male provider, accommodation must be made. VA Community Care Options and Non-VA Care can be used if necessary to ensure the request is satisfied.

g. Delivery of Comprehensive Primary Care for Women Veterans Clinic Models. All women Veterans must be assigned to receive comprehensive primary care conveniently located to their place of residence. A health care system may choose one or more of the following comprehensive primary care clinic models to best meet the needs of women Veterans and to achieve the standards for comprehensive primary care for women Veterans.

(1) Model 1: General Primary Care Clinics. Comprehensive primary care is delivered to women Veterans by WH-PCPs and WH-PACT teamlets within a gender-integrated primary care clinic. Mental health services for women should be co-located in the general primary care clinic in accordance with Primary Care-Mental Health Integration. Efficient referral to specialty gynecology care must be available within the health care system.

(2) Model 2: Separate but Shared Space. Comprehensive primary care is delivered to women Veterans by WH-PCPs and WH-PACT teamlets in a separate space that may be located within or adjacent to primary care clinic areas.

(a) This separate space is dedicated for women Veterans’ use.

(b) It may be open part-time or full-time and may be used by other services when women Veterans are not being seen.

(c) This option may be selected by sites that choose to have a designated area for women Veterans’ primary care but do not have facility space for a separate comprehensive women’s clinic or do not have the women Veteran population to support a full-time women’s clinic staff.

(d) Gynecological care and mental health services should be co-located in this space and readily available.

(3) Model 3: Comprehensive Women’s Health Center (WHC). VA medical facilities with a large women Veterans population are encouraged to create WHCs that provide the highest level of coordinated, high-quality, comprehensive care to women Veterans. Comprehensive primary care is delivered to women Veterans by WH-PCPs and WH-PACT teamlets in an exclusive separate space:

(a) Whenever possible, a WHC should have a separate entrance into the clinical area and a separate waiting room with attention to privacy, sensitivity, safety and physical comfort.

(b) Specialty gynecological care, mental health, and social work services and pharmacy must be co-located in this space.

(c) Other sub-specialty services such as breast care, endocrinology, rheumatology, neurology, cardiology, nutrition, etc., may also be provided in the same physical location.

NOTE: Women’s health centers require appropriate staffing above and beyond WH- PACT staffing ratios which are recommended for primary care teams. Appropriate Support Staffing must be provided for gynecology services and other specialty-care services within WHCs. Specialty gynecology clinics may not be utilized solely for routine breast and cervical cancer screening.

h. Special Considerations in the Delivery of Comprehensive Primary Care.

(1) Appointment Times. Adequate appointment lengths for both new and follow-up visits are necessary to provide comprehensive primary care to women Veterans. It is recommended that appointment lengths for primary care visits be sufficient to allow time for gender-specific care during the primary care encounter.

(2) Appointment Duration. Appointment duration recommendations for all practice settings:

(a) New women’s health appointment–60 min;

(b) Comprehensive visit that includes a routine Pap smear--60 min;

(c) Routine follow-up appointment–30 min; and

(d) Urgent appointment–30 min.

(3) Panel Sizes. Panel sizes must be adjusted downward to accommodate the unique needs of women Veterans and higher utilization by women in the primary care setting which includes longer appointment time, increased numbers of visits, phone calls, and care coordination requirements compared to male Veterans. Panel size for WH-PCPs should be adjusted according to attached panel size guidelines (VHA Handbook 1101.10 and VHA Handbook 1101.01) (see appendix D).

(4) Community-Based Outpatient Clinics.

(a) All female patients seen at CBOCs must receive the same high-quality comprehensive primary care that is received by female patients at the parent health care system.

(b) All CBOCSs must have at least two WH-PCPs. (Because of small populations of women at most CBOCs, CBOC WH-PCPs will usually have mixed gender panels) It is necessary to have two WH-PCPs to provide full coverage for women during sick leave and vacation. In CBOCs with only one provider appropriate arrangements must be made for coverage during leave. This may include care at another VA site or Care in the Community.

(c) CBOCs and independent clinics must designate a women’s health clinical liaison to coordinate women’s health services with the WVPM at the main facility. The liaison is usually a nurse or social worker, but may be a provider. The role of the liaison is to be the point of contact who communicates with the WVPM about issues related to women’s health care, environment of care and policy, and to communicate these messages to other staff at the CBOC.

(5) Mobile Clinics. Mobile clinics which offer primary care services must assure equitable access to comprehensive primary care services for both men and women.

This includes the provision of gender-specific primary care to women Veterans.

(6) Chaperones.

(a) For Physical Examinations:

1. A female chaperone must be in the examination room during breast and pelvic exams; and

2. In addition to breast examinations and pelvic examinations, and Pap smears, this includes procedures such as urodynamic testing or treatments such as pelvic floor physical therapy.

(b) For Radiologic Procedures:

1. Mammography does not require a chaperone (all mammography technologists in VA are female);

2. Breast Ultrasound, Breast MRI, Pelvic Ultrasound, Pelvic or Femoral Vascular Ultrasound or any procedure that exposes the groin or pubic area: For the protection of both the patient and the radiologist or technologist, it is highly recommended that male radiologists or technologists have a chaperone present. Female radiologists and technologists should ask female patients if they want a chaperone and provide chaperones on request; and

3. Trans-vaginal ultrasound requires a chaperone regardless of the gender of the radiologist or technologist.

NOTE: In addition to these requirements a radiologist or technologist may request a chaperone for an imaging procedure according to their clinical judgment.

(c) For Electrocardiograms and Echocardiograms:

1. It is highly recommended for protection of both the patient and the RN or technologist that male nurses or technologists have a chaperone present. Female nurses or technologists should ask female patients if they want a chaperone and provide chaperones on request.

2. The following staff may function as female chaperones: MDs, RNs, HTs, LPNs and other clinical personnel such as radiology technologists.

NOTE: Female volunteers who have had prior experience working in a clinical health care environment may be chaperones when a specific position description outlining the duty’s position and expectations has been written in collaboration with the Chief of Voluntary Services, the description has been approved, and staff members have been educated on the role limitations of the volunteer chaperone (see VHA Handbook 1620.01, Voluntary Service Procedures). Female volunteer chaperones will have had prior experience working in a clinical health care environment as an RN, LPN, or HT.

(7) Transgender Veterans: Patients will be addressed and referred to based on their self-identified gender. Room assignments and access to any facilities for which gender is normally a consideration will give preference to self-identified gender, or medical needs of the Veteran, irrespective of appearance and/or surgical history in a manner that respects the privacy needs of transgender and non-transgender patients.

i. Preventive Care for Women Veterans. Must follow VHA guidelines for Clinical Preventive Services http://vaww.prevention.va.gov/Guidance_on_Clinical_Preventive_Services.asp..

Preventive care for women Veterans must include but is not limited to age and risk appropriate screening for breast, and cervical cancer and osteoporosis screening.

Screening for intimate partner violence and military sexual trauma must be completed as part of preventive care, with connection to recommended services in the case of a positive screen.

(1) Breast Cancer Screening.

(a) Breast cancer screening may be done onsite at VA facilities with in-house mammography programs, or offsite, through Non-VA Medical Care or contract mechanisms, or mobile mammography units.

1. VHA Mammography Program Standards. NOTE: Refer to 38 U.S.C. 7319(b) and VHA Handbook 1105.03, Mammography Program…