36C26219R0026-030.doc

VA Loma Linda Healthcare System

Healthcare System (HCS) Policy 11-25

Loma Linda, CA DATE: January 16, 2019

HCS Policy 11-25

WOMAN VETERANS HEALTH PROGRAM

I.

POLICY: To provide high quality, comprehensive, inpatient and outpatient health care services to eligible women Veterans. Women Veterans will have equal access to care; will be afforded privacy; and will be provided gender-specific health care services on a par with the care that male Veterans receive for their gender-related needs.

II.

RESPONSIBILITIES:

A. VHA policy maintains that the full scope of primary care is provided to all eligible Veterans seeking on-going health care. Therefore, regardless of the number of women Veterans utilizing a particular facility, all sites that offer primary care services must offer comprehensive primary care to women Veterans. The Women Veterans Program Manager (WVPM) will work 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; care is provided in a sensitive environment; and, all necessary gender specific services are available at every facility and at the Community-Based Outpatient Clinics (CBOCs).

B. VA Loma Linda Healthcare System (VALLHCS) primary care clinics will offer all eligible women Veterans access to comprehensive medical care, including care for gender-specific conditions and mental health conditions, that is comparable to care provided for male Veterans.

C. All newly enrolled women Veterans must be assigned comprehensive primary care from a designated Women’s Health Primary Care Provider (WH-PCP) who is interested and proficient in the delivery of comprehensive primary care to women, irrespective of where they are seen in the freestanding medical center, outpatient clinics, and/or CBOCs. Women who are currently receiving care at a VA medical facility must be offered the choice to receive their comprehensive care from a WH-PCP. The goal is that at least 85% of women Veterans should be assigned to a WH-PCP D. There will be a designated full-time WVPM to execute comprehensive planning for women’s health issues that improves the overall quality of care provided to women Veterans.

E. The Medical Director of the Women’s Clinic will be responsible for the training of residents and students who provide gender-specific care in the Women’s Health Clinic.

F. Patient Eligibility Section, Health Administration Service, will be responsible for the administrative aspects of eligibility, admitting procedures, and other administrative functions pertaining to care for women Veterans.

G. The Chief of General Internal Medicine Section, Medical Service, will be responsible for insuring primary care providers are knowledgeable about gender-specific health care issues.

III.

PROCEDURES:

A. General Care:

1.

Women Veterans who apply for care will be evaluated as any other Veteran for eligibility and need for medical care. Such evaluations and examinations will be conducted to provide maximum privacy with sensitivity toward the special needs of the women Veterans. Women Veterans in need of hospitalization for either service-connected or nonservice-connected conditions may be authorized inpatient care at a non-VA Medical Care facility if the VA, or other government facility, is incapable of providing necessary care or if the necessary services are unavailable because of privacy considerations. They may also be referred to a non-VA Medical Care facility for care if this facility cannot provide appropriate outpatient services.

2.

Women Veterans who are not assigned to a women’s health designated provider and request care for gender-related conditions will be referred to the Women’s Health Clinic in the Ambulatory Care Center (ACC).

3.

Women Veterans in need of hospitalization or nursing home care will be assigned to an appropriate room/bed with condition of adequate privacy; this includes women who are in need of inpatient care for a mental health diagnosis.

4.

Inpatient or outpatient care for gender-related conditions will be provided through the use of staff attending physicians, or consulting gynecologists, referral to another VA Medical Center and or sharing agreements with affiliated hospitals, or other -VA Medical Carefacilities.

5.

Request for referrals to other VA medical centers will be initiated by the attending physician and coordinated by the facility transfer coordinator. All referrals will be in accordance with HCS Policy11-67 Continuum of Care.

6.

Requests for referral to non-VA Medical Care facilities will be initiated by the attending physician. The request will be referred to the Chief of Staff, through the appropriate chief of service. The approved request will be forwarded to the Care in the Community service for necessary authorization and obligation of funds.

7.

Women Veterans who have special needs such as a shelter for battered women, and child care will be referred to Social Work Service for an assessment and referral, as appropriate, to community resources, not at VA expense.

8.

Homeless women Veterans will be referred to Social Work Service or the Veterans Affairs Supportive Housing (VASH) Program.

IV. SUPPLEMENTAL INFORMATION:

A.

Definitions:

1. Women Veterans Program Manager: The WVPM is an advocate for women Veterans providing leadership by establishing, coordinating and integrating accessible high-quality health care services with multiple disciplines within VA medical facilities and across VHA organizational elements at the VISN level.

B.

References: VHA Handbook 1330.01 Health Care Services for Women Veterans; VHA Handbook 1330.03; VHA Directive 1332; IL 10-2014-10 Guidance on Emergency Medical Services for Women; Loma Linda VA-ED Nursing Service Emergency Department Nursing Standard Operating Procedure Management of Sexual Assault Victim, dated May 16, 2016 C. Attachments:

V.

COLLABORATED WITH: Women Veterans Health Clinic Medical Directors; Employee Health Physician; Women Veterans Trauma Recovery Program Coordinator; QM Manager; Chief of Medicine; Public Affairs Officer; Chief Imaging Service; Chief Path and Lab Service; Chief, Gynecology Section; Chief of Pharmacy Service; Chief of Behavioral Medicine; Chief, Health Administration Service; Chief GIM Section; Chief of Emergency Department; CBOC Coordinator.

VI. RESCISSION: HCS Policy 11-25, Woman Veterans Health Program, dated July 11, 2014 VII. REVIEW AND REISSUE DATE: January 16, 2022

VIII.

POLICY COORDINATOR: Office of the Chief of Staff

RANDY QUINTON, INTERIM MEDICAL CENTER DIRECTOR

Chair, Executive Leadership Team Attachment A

Comprehensive Primary Care for Women Veterans

A. All newly enrolledy women Veterans must be assigned to WH-PCPs. . All necessary gender specific services must be available at every facility and Community-Based Outpatient Clinic (CBOC).

B. 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.

C. The designated WH-PCP must be interested and proficient in the delivery of comprehensive primary care to women, irrespective of where they are seen.

D. Women Veterans who are already assigned to a Primary Care Provider (PCP) who is not a designated WH-PCP must be offered the opportunity for reassignment to a designated WH-PCP. 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.

E. To ensure that women Veterans receive equal opportunity to change PCPs, requests for PCP reassignment from women Veterans will be honored and processed according to facility standard procedure, even if the request is for a non-WH-PCP.

F. Designated WH-PCPs must be preferentially assigned women Veterans within their primary care patient panels.

G. Mental Health Services: Basic mental health services are offered 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.

H. Choice of Provider: Women Veterans will be given the option to designate their preference for a female or male provider. When a woman Veteran requests a female or male provider, accommodation must be made. Non-VA Medical Care can be used if necessary to ensure the request but time/access measures should be suspended.

I. 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

J. 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). 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.

K. 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. 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.

(1) 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

Attachment B

GUIDELINES FOR WOMEN VETERANS’ HISTORY & PHYSICAL EXAMINATION

A. The primary care provider must document a detailed history of the woman Veteran including: current and past medical and surgical history; a gynecologic and obstetric history; history of allergies; family history of disease; a psycho-social history including military service; and an occupational history.

B. Military service history must include: the branch and length of military service; location and period of deployment(s); type of work done for the military; possible exposures; and injuries or trauma experienced.

C. The initial intake history must include screening for military sexual trauma and must be done prior to the physical examination while the patient is fully dressed.

D. When clinically indicated, the primary care provider must also perform a complete physical examination that includes the head and neck, cardiovascular, respiratory, abdominal, musculoskeletal, and neurological systems. A complete primary care examination for women should be completed. Gender specific exams should be performed by designated women’s health providers.

E. If a patient is due for a cervical cancer screening examination and this is not included as a part of a complete physical examination, the reason(s) for deferring the examinations must be clearly documented in the medical record.

F. Patient dignity and privacy must be maintained at all times during the course of a physical examination. Privacy curtains must shield the actual examination area. Placement of the examination table needs to minimize inadvertent exposure of the patient during a physical examination (i.e., the foot of the table must be facing away from the door). Examination room doors must have locks. Gowns, sheets, and other appropriate apparel must be available to protect the patient’s dignity and avoid embarrassment. The patient must never be asked to disrobe in the provider’s immediate presence.

G. Appropriate draping techniques must be used during the breast and pelvic examination or during examinations or procedures when these areas are exposed (e.g., EKG, chest auscultation).

H. When medical students, nurse practitioner students, or physician assistant students participate in the provision of comprehensive primary care or gender-specific specialty care to women Veterans, they must be appropriately supervised as defined by relevant handbooks.

I. A female chaperone must be in the examination room during examinations or procedures involving the breast and genitalia, regardless of the gender of the provider.

Attachment C

WOMEN’S HEALTH PRIMARY CARE PROVIDER PROFICIENCY

A. The Women’s Health Primary Care Provider (WH-PCP) must be fully proficient in providing the complete range of primary care.

B. Where women’s health is integrated into primary care, a designated WH-PCP is recommended to have 100 women Veterans assigned to their panel, thus allowing for all teamlet members to care for a volume of patients to support maintenance of expertise in the care of women. In order to be initially designated as a WH-PCP, a provider must have at least one of the following:

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

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

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

(4) 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;

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

(6) 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

(7) 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. This documentation will be verified by credentialing department.

Attachment D

SPECIAL CONSIDERATIONS IN THE DELIVERY OF COMPREHENSIVE PRIMARY CARE

A. Appointments: 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 visit be sufficient to allow time for gender-specific care during the primary care encounter.

1. 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

B. 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)

1.Women’s Health PACT teamlets should be adjusted to allow for more frequent and longer visits made by Women Veterans.

2.Panel sizes should be reduced by twenty percent of the proportion of the panel that is female. Recommended WH-PACT patient panel size is calculated according to the following equation:

a. X = Y – 0.2(Z); and

b. X = modeled panel size adjusted for number of women Veterans; Y= panel size unadjusted for women Veterans; Z= number of women Veterans assigned to the WH-PACT.

C. CommunityBased Outpatient Clinic (CBOC): All female patients seen at CBOCs must receive the same high quality, comprehensive primary care that is offered to female patients at the parent facility. CBOCs and independent clinics must designate a Women’s Health clinical liaison to coordinate women's issues with the parent facility and works closely with the WVPM. 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.

D. Chaperones

(a) For Physical Examinations: A female chaperone must be in the examination room during breast and pelvic exams; and

(b). 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.

(c) For Radiologic Procedures: Mammography does not require a chaperone (all mammography technologists in VA are female);

(d) 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

(e) 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

(f) For Electrocardiograms and Echocardiograms: 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.

(g) 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.

Attachment E

PREVENTIVE CARE FOR WOMEN VETERANS

Preventive care for women Veterans must include age-appropriate screening for colon, breast and cervical cancer. Preventive services must also include: nutrition counseling; weight management and fitness counseling; sexually transmitted infection screening and counseling; smoking cessation counseling and treatment; counseling to reduce alcohol use; immunizations, etc when applicable. Special consideration needs to be given to breast and cervical cancer screening.

A. Breast Cancer Screening: Breast cancer screening includes mammography, with or without clinical breast examination.

B. Mammography Program Standards: Imaging Service will be responsible for establishing a routine quality control program for mammography. Quality control of all aspects of mammography shall be performed in accordance with the guidelines established by the American College of Radiology (ACR) and Mammography Quality Standards Act (MQSA). NOTE: Refer to 38 U.S.C. 7319(b) and VHA Mammography Handbook 1104.1 for full details regarding Mammography Program Standards.

1. All VHA and mammography programs are required to provide a report of the results of the mammographic examination to the patient within 30 calendar days, consistent with the requirements of 21 CFR Part 900.12(c). Furthermore, when the mammography report assessment is "Suspicious" or, "Highly Suggestive of Malignancy" (BI-RADS codes 4 or 5, respectively), the results and recommended course of action must be communicated as soon as possible. FDA guidance recommends no longer than 5-business days.

2. Imaging Service will appoint a Mammogram Coordinator.

3. Eligible patients may receive a walk in screening mammogram, without an appointment or pre-existing order.

C. Cervical Cancer Screening: Cervical cancer screening includes a speculum examination and cervical pathology evaluation performed by the primary care provider in accordance with VHA guidelines. The results of normal (NEM-No Evidence of Malignancy) must be communicated to the patient in terms easily understood by a layperson within 14-calendar days from the date of the pathology report and the Human Papilloma Virus (HPV) report becoming available to the ordering provider. Documentation of a letter and/or verbal communication with the patient must be entered into CPRS. If using the United States Postal Service, confirmation of the receipt of these results is not required. For any abnormal cervical pathology report, the results must be communicated within 7-calendar days of the report (including cytology and HPV) becoming available to the ordering provider.

1. Pap coordinator will be appointed by nursing service to track abnormal pap smears and ensure appropriate follow-up action is taken.

Attachment F

GENDER-SPECIFIC SPECIALTY CARE FOR WOMEN VETERANS

Gender-specific specialty services must include:

A. Gynecological Care: The requesting practitioner will enter the gynecology consult and track to ensure patient is scheduled for outpatient Gynecology Clinic appointment. Specialty and Subspecialty Gynecologic Care must be provided either on-site or through Care in the Community. Large sites with surgical programs will be required to provide Specialty Gynecology Care on-site. The facility must ensure staffing is sufficient to provide needed gynecologic care (e.g., assisting with office procedures, chaperone, etc.).A gynecologist will be available to both inpatients and outpatients.

NOTE: When a womean Veteran requests a female or male gynecology provider, accommodation must be made. In order to satisfy the patient request, referral to network sites or use of Choice or non- medical care may be utilized. In cases of emergent delivery of care, the accommodation may not be possible and this can be documented in CPRS as such

B. Maternity Care: VHA is authorized to provide comprehensive pre-natal, intra-partum and post-partum care to eligible women Veterans. Maternity benefits begin with the confirmation of pregnancy and continue through the final post-partum visit, usually at 6-8 weeks after the delivery or when the Veteran is medically released from obstetric care.

1. Maternity care needs to include appropriate (community standard) education and tools such as: genetic consultation with a physician when clinically indicated, childbirth preparation, parenting education, breastfeeding support and lactation classes, and breast pumps.

2. Newborn care is available for Veterans enrolled in VA care and receiving VA maternity benefits. All medically necessary and appropriate post-delivery services (including transfer) are included in this benefit (see 38 CFR § 17.38 (a)(1)(xiv)) for seven days post-delivery.

C. Infertility: Infertility services can be provided on-site, through network referrals, negotiated comprehensive contract packages with consultants, contractual or sharing agreements, or through non-VA care to the extent the Veteran is eligible. VA and non-VA provider care must be coordinated in order to ensure delivery of high-quality care consistent with evidence-based standards. (See VHA Directive 1332 Infertility Evaluation and Treatment) D. Mental Health: Co-located mental health services for women Veterans to the Women’s Health Clinic will be available. Mental health services must be provided to women Veterans according to VHA Handbook 1160.01.

E. Care for Conditions Related to Military Sexual Trauma (MST):

1.

The service provided by this facility under Public Law 102-585 for women Veterans to overcome psychological trauma which resulted from physical assault of a sexual nature, battery of a sexual nature, or sexual harassment while on active duty in the military. The Women Veteran Trauma Recovery Program will identify and analyze issues, needs and concerns of the women Veterans in regard to this issue. Full requirements for services for conditions related to MST are found in VHA Directive 1115, Military Sexual Trauma (MST) Program.

4. The program providers will specifically develop policies, coordinate training in assessing symptoms of sexual trauma for HCS Staff and attempt to increase hospital and community (visual) awareness of Public Law 102.585.

3.

Referrals for sexual trauma counseling can be made via CPRS to Behavioral Health Intake Program (BHIP).

Attachment G

URGENT/EMERGENT CARE

A. Urgent and emergent care needs of women Veterans are available during normal hours as well as during evenings, weekends and holidays.

B. Equipment is available to treat female patients (tables, lights, Sexually Transmitted

Infections (STI) kits, speculums, medications, etc).

C. All VA medical facilities where women’s health is offered, including emergency room and CBOCs, must have access to point of care testing for urine pregnancy and vaginitis to include BD Affirm Bacterial Vaginosis.

D. All Administrative Parents (Health Care Systems) must have “stat” qualitative (urine and/or serum) and quantitative human chorionic gonadotropin (hCG) testing available 24 hours per day and 7 days per week (24/7) with results available to the ordering clinician stat or within 1 hour of order.

E. All staff that provides urgent care treatment to Veterans will have access to ongoing training in women’s health to maintain proficiency in topics such as, but not limited to: documenting a menstrual and obstetric history; evaluation of acute abdominal pain; vaginal bleeding in early pregnancy; and gender-based differences in the presentation of myocardial infarction and other disease processes available on demand in TMS.

F. Emergency Department will be properly equipped to provide urgent and emergency care for women Veterans. Requirements include equipment and staff to treat female patients during normal business hours, as well as nights, weekends, and holidays.

G. Competencies. All staff members providing emergent/urgent care treatment to women Veterans should have sufficient training and expertise to care for women presenting with issues such as, but not limited to:, abdominal/pelvic pain, acute vaginal bleeding, vaginal bleeding and/or pelvic pain in early pregnancy, acute sexual assault, recognizing and assessing the presence and impact of interpersonal violence and appreciating gender differences in the presentation of acute coronary syndromes

H. Sexual assault evaluation: Acute sexual trauma will be processed through the

Emergency Department. The emergency room personnel will immediately notify the sheriff’s department which in turn will process the client through the appropriate local agency/medical center for patient investigation. ( See Loma Linda VA-ED Nursing Service Emergency Department Nursing Standard Operating Procedure Management of Sexual Assault Victim dated May 16, 2016) I. Pregnant patient with vaginal bleeding, acute abdominal, or in labor will be transferred using non-VA Medical Care to a facility that can manage these patients for immediate care if gynecologist is not readily available in house.

J. Any GYN emergency or consultative services needed after hours, page VA Loma Linda GYN service attending.

Attachment H

ADDITIONAL SERVICES FOR WOMEN VETERANS

A. Prosthetics Services: Prosthetics Service and Supply, Purchase and Distribution Department ensures that supplies specific to women’s health are properly stocked, easily requested, and provided in a timely manner (e.g., intra-uterine devices (IUDs), breast pumps, breast prosthesis, compression stockings, etc.).

B. Tele-Health Programs: Women Veterans have specific health care needs that must be considered as Tele-health programs expand; services must be tailored to meet their needs.

C. Physical Medicine and Rehabilitation: Services are tailored to the unique needs of women Veterans including ordering and stocking equipment and supplies that are the correct size and fit for women Veterans.

D. Pharmacy Services: Local Women’s Health Program officials assure that the unique medication needs of women Veterans are clearly communicated at the local, VISN and National levels.

1. Ensure availability of Levonorgestrel (Plan B) emergency contraception to patients the same day of their appointment, to include CBOC patients who have access to a designated contracted pharmacy to have this medication filled.

2. A mechanism to monitor the prescription of high risk teratogenic medications (FDA class D or X) which could be prescribed to women with the potential to become pregnant. Women need to be counseled on the risks and benefits of such prescriptions and documentation of patient counseling must be recorded in CPRS.

Attachment I

THE HEALTH CARE ENVIRONMENT

A. Measures must be taken to maintain and adjust care environments to support their dignity, privacy, and security. The privacy and security needs of women Veterans must be addressed when planning new construction, remodeling older facilities, or improving patient care programming. The WVPM and appropriate members of the facility must participate in these reviews on a routine basis.

B. Environment of Care: Ambulatory Care Dignity, Respect and Security: Veterans must be provided adequate visual and auditory privacy at check-in. Patient names are not posted or called out loudly in hallways or clinic areas. Veterans must be provided adequate visual and auditory privacy in the interview area.

1. The examination rooms must be located in a space where they do not open into a public waiting room or a high-traffic public corridor. Appropriate locks (either electronic or manual) for examination room doors are required (allowing staff to have key or code access in the case of emergency). When doors are closed, all healthcare personnel must knock, WAIT, and enter only after being invited in.

2. Privacy curtains must be present and functional in examination rooms. Privacy curtains must encompass adequate space for the healthcare provider to perform the examination unencumbered by the curtain. A changing area must be provided behind a privacy curtain.

3. Examination tables must be placed with the foot facing away from the door. If this is not possible, tables must be fully shielded by privacy curtains.

4. Patients who are undressed or wearing examination gowns must have proximity to women's restrooms that can be accessed without going through public hallways or waiting rooms.

5. If toilet facilities cannot be located in close proximity to the examination room, the woman must be discreetly offered the use of a toilet facility before she disrobes for the exam.

6. Availability of diaper changing stations in designated male and female restrooms.

7. Sanitary napkin and tampon dispensers and disposal bins must be available in women’s public restrooms. Tampons and sanitary pads should also be available in examination rooms where pelvic examinations are performed and in bathrooms within close proximity.

8.. Hospital gowns, pajamas, or robes in sizes or styles appropriate for women will be available for women Veterans admitted to the facility.

9.. A female Veteran must not share a single bathroom between rooms with a male patient in the adjoining room, even if the bathroom is locked. Female patients must have private and secure toilet in their room and access to the women’s bathroom facilities with shower in close proximity to their room. A private and secure bathroom must have an appropriate locking mechanism (allowing staff members to have key or code access in the case of emergency) while also allowing the patient to signal for hospital staff members if they are in distress.

NOTE: It is not sufficient to have a group shower room with a sign on the door when it is utilized by women.

10. If a pelvic or breast examination is indicated during an inpatient admission, adherence to all privacy and security standards is required. Patient dignity and privacy must be maintained at all times.

11. Nursing intake and assessment forms must include gender specific data such as last menstrual period and current pregnancy or breastfeeding status.

Attachment J

Inpatient Care Dignity, Respect and Security A. When clinically unrelated to an acute hospitalization, a screening pelvic and breast examination may be deferred. Upon discharge from the acute hospitalization, a follow-up appointment needs to be arranged to complete these examinations if clinically indicated.

B. If a pelvic or breast examination is necessary during an inpatient admission,; adherence to all privacy and security standards is required as delineated in the physical examination guidelines for women Veterans. Patient dignity and privacy must be maintained at all times.

C. Privacy curtains must be placed in all inpatient rooms, with the exception of Psychiatry and Mental Health units.

D. Female patients must have access to private and secure women’s bathroom facilities (toilet and shower) in close proximity to their room. A private and secure bathroom must have an appropriate locking mechanism (allowing staff to have a key or code access in the case of emergency) while also allowing the patient to signal for the hospital staff if they are in distress. NOTE: It is not sufficient to have a group shower room with a sign on the door when it is utilized by women.

E. Female pajamas and robes must be stocked and provided on all inpatient units.

F. Nursing intake and assessment forms need to be modified to capture gender-specific data such as last menstrual period and current pregnancy or breastfeeding status.

G. Diaper changing stations need to be available in designated male and female restrooms.

H. Any woman Veteran who is admitted as an inpatient for non-obstetrical reasons will be provided an OB/GYN consultation as soon as possible to ensure that health needs related to her maternity care are met. The GYN attending will determine if immediate inpatient consultation needs to be completed, or if additional lab tests or imaging is required to confirm the pregnancy, or if chart review with outpatient followup will be adequate. A note will be written in the patient’s chart. Communication with her obstetrician will be established at the time of her admission and a discharge summary will be provided to her obstetrician upon discharge. If the patient does not have an established obstetrical provider, the maternity care coordinator will need to be notified so that appropriate referrals are made for future obstetrical outpatient care.

Attachment K

Inpatient Mental Health A. Inpatient Mental Health units must ensure safe and secure sleeping arrangements for women Veterans including, but not limited to, door locks, access bar codes, or controlled access ID card scanners. All locking arrangements must be in compliance with National Fire Protection Association (NFPA) 101, Life Safety Code.

B. Mixed gender units must ensure safe, private, and secure sleeping and bathroom arrangements for women Veterans including, but not limited to, proximity to staff, door locks and gender-specific personal care and hygiene products.

C. Women veterans greater than 20 weeks gestation will be transferred to a facility that canprovide fetal monitoring.

Attachment L

ADMINISTRATION OF PLAN B OR PLAN B ONE-STEP

A. VA Loma Linda Health Care System will offer and provide the Plan B or Plan B One-Step when medically indicated.

B. Responsibilities: All primary care and emergency room providers (physician/nurse practitioner/physician assistant) are responsible for dispensing approved emergency contraception (EC), such as Levonorgestrel EC ( Plan B or Plan B One-step) same day of visit. The drug is most effective the sooner it is taken after an episode of unprotected intercourse, generally up to 72-hours. Plan B One-Step may be provided for use up to 120 hours after the episode, although effectiveness is lower.

1. If a provider declines to provide Levonogestrel EC for immediate use to the patient because of right of consciousness (ROC) the supervisor will ensure that the patient receives medication the same day.

2. In addition to requests for Levonorgestrel EC for immediate use, VA providers may request that Levonorgestrel EC be provided to certain women Veterans before it is needed, also known as “advanced provision.”

C. Procedures:

1. The provider will obtain pertinent history.

a. The provider should inquire the date and the time of unprotected intercourse. In addition, inquire whether the act of intercourse for which the EC is being requested was consensual. If not, the physical and psychological assessment for sexual assault victims should be initiated.

b. A pregnancy test is not necessary before administering emergency contraception, unless pregnancy is suspected because of history, symptoms, or a missed or abnormal last menstrual period. A physical examination is also not necessary before providing oral EC.

(1) Oral EC will not interrupt an established pregnancy and is not known for adverse affects on the pregnancy or fetus if administered inadvertently.

2. The provider will order medication in the CPRS to be picked up same day at the Medical Center’s pharmacy. Community Based Outpatient Clinic (CBOC) providers will write or call in script to contracted pharmacy for pick up same day.

a. Plan B One-Step – patient will be instructed to take Levonorgestrel 1.5mg orally one time immediately upon receiving medication.

b. Plan B – contains two tablets of Levonorgestrel 0.75mg and is to be taken 12 hours apart.

3. Patient Education:

a. Menstrual bleeding after oral EC typically occurs within one week of expected time. A pregnancy test should be performed if bleeding had not occurred within three to four weeks or if there is persistent vaginal bleeding or abdominal pain.

b. Women using oral EC should be advised that a risk of pregnancy still exists if they have unprotected sexual intercourse after EC have been taken. A repeat course of EC can be given, but it is preferable that they begin regular use of nonemergency contraception, which can be initiated that day after emergency contraception administration.

c. Oral EC is not intended for use as a routine form of birth control therefore, patient should be counseled about immediate initiation of a long-term effective contraceptive method.

D. References: VHA Handbook 1330.01, IL 10-2012-006, Guidance on the Right of Conscience (ROC) and Levonorgestrel Emergency Contraception (EC).

Attachment M

MEDICAL MANAGEMENT OF THE PREGNANT PATIENT

A.

VA Loma Linda Health Care System provides appropriate medical management of the pregnant patient.

B.

All primary care and emergency room providers (physician/nurse practitioner/physician assistant) need to be aware of the process to ensure all pregnant patient get timely and appropriate medical management of their pregnancy. Women of child bearing age should be counseled about pregnancy testing prior to anesthesia, sedation, radiological procedure, or surgery. Based on the patient’s indication for surgery or type of procedure, medical history, menstrual history, and method of contraception, a pregnancy test should be offered. However, a patient who refuses a pregnancy test will not be denied appropriate care and treatment. If a pregnancy test is positive, the patient, surgeon, and anesthesia provider will discuss whether to proceed with the surgery or radiological procedure.

C.

PROCEDURES:

1.

General Care

a. All women Veterans of child-bearing age (local policy age ≤55 years) triaged in outpatient clinics or emergency room should be asked about pregnancy status and last menstrual period.

b VA providers need to be aware of the process required for obtaining and entering referrals for maternity care for their patients to ensure that eligible women Veterans have access to timely prenatal care. VHA is authorized to provide comprehensive pre-natal, intra-partum and post-partum care to eligible women Veterans. Maternity benefits begin with the confirmation of pregnancy, preferably in the first trimester, and continue through the final post-partum visit, usually at 6-8 weeks after the delivery or when the Veteran is medically released from obstetric care.

(1) Obtain pregnancy test (urine or blood) on all women Veterans of child-bearing age (local policy ≤55 years who come to the outpatient clinics or emergency room) if evaluation of the presenting complaint and any potential treatment could be affected by pregnancy or could adversely affect the well-being or outcome of a pregnancy. Point of care pregnancy testing is available at VA off site locations where comprehensive women’s health is offered and in the emergency room.

(2) Send referral to Women’s Health Clinic for maternity care coordinator to manage Veterans prenatal care.-.(See VHA handbook 1330.03)

2.

Pregnancy complications a.

Pregnant patients when presenting with urgent/emergent pregnancy related complications (i.e., vaginal bleeding, acute abdominal pain in a pregnant patient, or a pregnant patient in labor) will be transferred using non-VA Medical Care to a facility that can manage these patients for immediate care if obstetrician/gynecologist (OB/GYN) is not readily available in house.

(1) Provider will consult with on-call OB/GYN.

(a) A complete history and physical as well as ultrasound and appropriate labs will be obtained for proper triaging of her care.

(2) The accepting OB/GYN will determine if patient will present to emergency room or labor and delivery of the receiving hospital.

(3) “Stat” quantitative human chorionic gonadotropin (hCG) testing is available to patients in the emergency room within 1 hour of order.

(4) First trimester ultrasound is available 24/7.

b.

In the case of imminent delivery, patient should be transferred safely to the emergency room.

(1) OB kits will be readily available.

(2) Mother and baby should be transferred to a non-VA Medical Care facility when stable.

3.

Threatened spontaneous abortion, inevitable spontaneous abortion, or incomplete spontaneous abortion; spontaneous abortion.

a.

Provider will consult with on-call OB/GYN.

(1) A complete history and physical as well as ultrasound and appropriate labs will be obtained for proper triaging of her care.

(2) If medically necessary, 1st trimester Rhogam is available.

4. Patients presenting with urgent/emergent pregnancy-related complications in a CBOC, patient will be transferred to nearest emergency room.

5. If a woman Veteran who is admitted as an inpatient has an incidental finding of a pregnancy unrelated to the acute medical condition under treatment, a GYN consultation as soon as possible should be obtained to ensure health needs related to her maternity care are met. The GYN attending will determine if immediate inpatient consultation needs to be completed, or if additional lab tests or imaging is required to confirm the pregnancy, or if chart review with outpatient follow-up will be adequate. A note will be written in the patient’s chart. Communication with her obstetrician will be established at the time of her admission and a discharge summary will be provided to her obstetrician upon discharge. If the patient does not have an established obstetrical provider, the maternity care coordinator will need to be notified so that appropriate referrals are made for future obstetrical outpatient care.

6. If a woman Veteran has a known established pregnancy, she should be transferred to a facility that can provide both obstetrical and non-obstetrical care. The VA facility is not equipped to provide obstetrical care that maybe required in a <24wk fetus.

7. If a woman Veteran is at least 24wks EGA, she must be transferred to a facility that can provide both obstetrical and non-obstetrical care. The VA facility is not equipped to provide obstetrical care for a viable fetus.

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