36C26318R0288-013.docx

WOMEN VETERANS HEALTH CARE PROGRAM

1. PURPOSE:

To establish a formal hospital policy for the VA Black Hills Health Care System (VABHHCS) concerning the care of women Veterans in accordance with standard medical practice and Department of Veterans Affairs.

2. POLICY:

To provide comprehensive health care services to all eligible women Veterans to include appropriate gender-specific care encompassing health promotion, disease prevention, and the promotion of quality improvement.

3. PROCEDURES:

A. OUTPATIENT CARE:

(1) Primary Health Care: Primary care is provided to women Veterans through the primary care clinics with a designated women's health Patient Aligned Care Team (PACT). The team consists of a provider (physician, physician assistant, or nurse practitioner), RN, LPN, and MSA.

(a) The women's health PACT is responsible for the treatment of all primary care needs including acute and chronic illness, basic gender-specific care, disease prevention, and evaluation and treatment of uncomplicated mental health disorders. Basic gender-specific care includes treatment for menopause, uncomplicated vulvovaginitis, osteoporosis, contraceptive needs, and hormone replacement therapy. The provider will perform complete physical examinations on female patients that include a pelvic exam, clinical breast exam, and a Pap smear according to established guidelines. If a pelvic exam, breast exam, and/or Pap smear are not included as a part of a complete physical examination, the reason(s) for deferring the examinations will be clearly documented in the medical record (VAVHA, 2010).

(b) A third party will be readily available at all times during a physical examination. A female chaperone must be in the examination room during examinations, procedures, or treatments involving the breast and genitalia regardless of the gender of the provider (VAVHA, 2010).

(c) Physical examinations will be performed maintaining patient dignity and adequate privacy. Privacy curtains will be present in all examination rooms to shield the examination area and the examining table from view when the door is opened. Each examination room will have a lock (manual or electric). Gowned patients will have access to gender-specific restrooms without entering public areas or be offered the use of the restroom prior to entering the exam room. Gowns, sheets, and/or other appropriate apparel will be available to protect the patient's privacy (VAVHA, 2010).

(d) A Women’s Health Specialty GYN Consult will be placed by the Primary Care Provider (PCP) for the evaluation and treatment of complicated gynecological conditions, abnormal Pap smears, certain contraceptive needs, and/or infertility. Reproductive oncology, surgery, and endocrinology may be provided through a referral to Care in the Community as appropriate.

(2) Specialty Care: Gynecologic care is provided to women Veterans through the primary care clinics. The care team consists of an OB/GYN physician, RN, LPN, and MSA. Upon receipt of the appropriate consult, the specialty care team will provide problem-focused care in regard to abnormal Pap smear/cervical dysplasia, abnormal uterine bleeding, uterine fibroids, PCOS, oligo/amenorrhea, pelvic pain, dysmenorrhea, infertility, ovarian cyst, endometriosis, vulvar/vaginal concerns, menopausal concerns, contraception, IUD placement, permanent sterilization, and sexual health concerns.

(3) Infertility Services: Limited infertility services are available to women Veterans. Care in the Community for specialized treatment not provided by the VABHHCS will be assessed and managed on an individual basis according to VHA guidelines. The VA does not authorize in-vitro fertilization (VAVHA, 2010).

(4) Mammography: Mammography service for screening and diagnostic purposes is available to women Veterans (not including CHAMPVA or TRICARE beneficiaries) through Care in the Community. Women Veterans, while either outpatient or inpatient, will receive mammography screening and diagnostic services according to the most current clinical practice guidelines. Ordering providers will counsel patients on the risks and benefits of screening and will document the counseling in the medical record. They will submit a Computerized Patient Record System (CPRS) Non VA Care Mammography consult. The Care in the Community staff will address the consult appropriately in regard to current VHA guidelines. Once the results of the completed mammogram are received, Radiology Service will scan the results into VISTA Imaging. Ordering providers are responsible for notifying the patient of their mammography results within required timeframes and ordering any further diagnostic test or intervention as medically indicated.

(5) Osteoporosis: Bone mineral densitometry for the screening and treatment of osteoporosis is available. Screening will be provided via a Dexa Scan at the VA at Fort Meade or through Care in the Community. Providers will submit a CPRS consult to the Fort Meade Radiology or Non VA Care Consult for Care in the Community. Radiology Service will enter the results into VISTA Imaging. Ordering providers are responsible for notifying the patient of the results and ordering any further intervention as medically indicated.

(6) Maternity Care: Maternity care is authorized for eligible women Veterans (not including CHAMPVA or TRICARE beneficiaries) via Care in the Community. The Department of Veteran Affairs (VA) provides prenatal and postpartum care and newborn care for the first seven days of life (38 U.S.C. § 101). The women Veteran's PCP will submit a consult for Non VA OB Care and notify the Women Veterans Program Manager (WVPM) via the WVPM Consult to initiate the "Pregnancy and Lactation" flag in CPRS and enroll the Veteran into the Maternity Care Telephone Care Program. The Maternity Care Coordinator will follow-up with Veterans according to the Maternity Care Telephone Care Program. The WVPM is responsible for the initiation, maintenance, and removal of the Pregnancy and Lactation flag (VAVHA, 2010; VAVHA, 2012).

(7) Mental Health Services: Outpatient Mental Health services including psychiatric care, individual therapy, and group therapy are available to women Veterans through the Mental Health Clinics or referral for Care in the Community per policies of the VHA and the VABHHCS.

(a) Sexual Trauma Counseling: Sexual trauma counseling is available to Veterans who have sustained any form of sexual trauma during military service or outside military service. All Veterans are screened for the need for sexual trauma counseling via the military sexual trauma clinical reminder. Upon agreement of the Veteran, she/he will be referred through a consult in CPRS to a mental health provider trained in the assessment and treatment of sexual trauma. Mental Health services may be obtained through Care in the Community per policies of VHA and the VABHHCS. Sexual trauma services are available on an outpatient basis only. Inpatient program referrals will be made to a VA medical center with an appropriate inpatient program (Pub. L. 108-442, 2004).

(b) Military Sexual Trauma (MST): Mental health services for the referral, evaluation, and treatment of MST will be provided in accordance with the policies of the VHA and VABHHCS (Pub. L. 108-442, 2004).

(8) Emergency Services: The Emergency Department and/or Urgent Care will be adequately equipped with pelvic exam equipment, privacy screens/curtains, and a private restroom to facilitate gender-related care for women. The VABHHCS is not staffed nor equipped to handle obstetrical or gynecological emergencies. These emergencies will be managed by rapid evaluation, stabilization, and transfer of such patients to the nearest facility that can appropriately manage and treat their condition.

(9) Treatment of Sexual Assault and/or Domestic Abuse: Treatment and management of sexual assault/rape and/or domestic abuse will be provided according to the policies of the VHA and VABHHCS.

B. INPATIENT/RESIDENTIAL CARE:

(1) Medical Care: Inpatient medical care is available to women Veterans who require acute and extended care. If any level of care cannot be provided at the Medical Center, women Veterans will be referred to either a VA tertiary center or a non-VA medical center that provides the necessary level of care according to policy (VABHHCS, 2013).

(2) Mental Health Care: Inpatient acute psychiatric care is available to women Veterans. Residential treatment for substance abuse, Post Traumatic Stress Disorder, Compensated Work Therapy, and addressing homelessness are all services available for women Veterans. If the Veteran requires mental health services that are not provided at the Medical Center, she will be referred to a VA medical center or non-VA facility with an appropriate inpatient or residential treatment program.

(3) Physical Examination: A complete physical examination will be conducted for women admitted to either a medical or psychiatric inpatient unit or residential treatment program. These examinations will include breast exams, pelvic exams, and Pap smear. If they are not included as part of a complete physical examination, the reason(s) for deferring the examinations will be clearly documented in the medical record. When clinically unrelated to an acute hospitalization, the examination may be deferred to the PCP to ensure that these examinations are provided at a later time.

(a) Exam rooms equipped with gynecological exam supplies will be available after clinic hours and on weekends/holidays to ensure availability of specialty equipment.

(b) For an emergency gynecological problem, patients will be transferred to the nearest facility that can appropriately manage and treat their condition.

C. CONTRACT COMMUNITY BASED OUTPATIENT CLINICS (CBOCs) & VA STAFFED RURAL HEALTH CARE CLINICS:

Ongoing evaluation of all CBOCs and VA staffed Rural Health Care clinics will ensure that comprehensive primary care is being provided to all eligible women Veterans. Physical and psychosocial privacy will be provided in these settings. Assessment and correction of physical and environmental barriers that limit the access of women to care in these facilities will be an ongoing process under the direction and guidance of the WVPM and CBOC Coordinator. Each CBOC will have a Women's Health Liaison who collaborates with the WVPM at the parent facility.

4. WOMEN VETERANS HEALTH CARE ADVISORY TEAM:

This interdisciplinary team will serve in an advisory capacity to the executive leadership of the Medical Center in all matters pertaining to the needs of women Veterans. Both in-reach and out-reach activities will be provided as part of the Women Veterans Health Program. The Women Veterans Health Care Advisory Team and the WVPM will collaborate in planning these activities. The WVPM will function as the chairperson of this team (See Appendix).

5. RESPONSIBILITIES:

The WVPM has the responsibility to collaborate with VABHHCS staff for the development and ongoing improvement of the Women Veterans Health Care Program. The WVPM will have direct access to executive leadership and will serve on appropriate administrative and clinical councils and/or committees as appointed. The WVPM will participate in the regular review of the physical environment to include the review of construction plans that impact women's care in order to identify potential privacy deficiencies and to assess availability and accessibility of appropriate equipment for the medical care of women. The WVPM will work with Organizational Improvement to ensure that processes are implemented to monitor and improve gender-specific performance measures. The WVPM will also facilitate in monitoring the tracking of Pap smears, mammograms, and maternity care coordination. The WVPM shall have adequate time allocated to successfully perform program administrative duties, as well as developing staff/patient education opportunities, and collaborate with staff for care coordination (VAVHA, 2012).

The Chief of Staff, Associate Chief of Staff for Primary Care, and Associate Chief of Staff for Mental Health are responsible for ensuring that the medical and/or mental health providers who provide women's health care are proficient to perform this care, maintain the appropriate competencies, and participate in ongoing education on women's health care.

6. REFERENCES:

A. Veteran Affairs Black Hills Health Care System COS-22 Inter-facility Acute Transfer Policy (2013, February 28). .

B. Department of Veteran Affairs Veterans Health Administration. (2010). VHA Handbook 1330.01: Health care services for women Veterans. Washington, DC: VHA Publication.

C. Department of Veterans Affairs Veterans Health Administration (2012). VHA Handbook 1330.02: Women veterans’ program manager. Washington, DC: VHA Publication.

D. Department of Veterans Affairs Veterans Health Administration (2012). VHA Handbook 1330.03: Maternity health care and coordination. Washington, DC: VHA Publication.

E. Veterans Health Care Act of 1992. Pub. L. 102-585.

F. Veterans Health Care Eligibility Reform Act of 1966. Pub. L. 104–262, 110 Stat. 3177, codified as amended at 38 U.S.C. § 101.

G. Veteran’s Health Program Improvement Act of 2004. Pub. L. 108-442.

7. RESCISSION:

VA Black Hills Health Care Policy COS – 90, dated January 11, 2012.

8. DATE OF COMPLETE REISUSSANCE:

March 31, 2019

9. FOLLOW-UP REPONSIBILITY:

Women Veteran Program Manger

SANDRA L. HORSMAN, MBM

Director

Appendix

WOMEN VETERANS HEALTH CARE ADVISORY TEAM

1. PURPOSE: To establish an interdisciplinary team to identify, plan, and evaluate the delivery of services and treatment to women Veterans at the Black Hills Health Care System. The Team will serve in an advisory capacity to the executive leadership of the Medical Center in all matters pertaining to the health care needs of women Veterans.

2. POLICY: The team will assess the treatment environment, clinical services and psychosocial needs related to women Veterans. The team will make recommendations regarding the access to care, delivery systems, and quality of services pertaining to the assessment and treatment of women Veterans as needed.

3. DELEGATION OF AUTHORITY AND RESPONSIBILITY: The team will report to the Executive Leadership Board through the Customer Service Council (CSC). The WVPM will serve as the Chairperson.

4. PROCEDURES:

A. Specific responsibilities of the team are:

(1) Identify areas for improvement related to women's health care

(2) Recommend and determine priorities for the development of policies and programs

(3) Evaluate effectiveness of the overall Women's Health Program

(4) Facilitate educational programs for clinical providers related to women's health

(5) Market services and resources available for women Veterans

(6) Assess customer satisfaction

B. Membership may include, but is not limited to:

(1) Women Veterans Program Manager

(2) Primary Care

(3) Mental Health

(4) Pharmacy

(5) Vet Center

(6) Nursing

(7) Non-VA Care

(8) Community Living Center

(9) Women Veterans

C. Meetings are held bi-monthly and/or at the discretion of the team chairperson.

D. The WVPM will report team progress/activities to the CSC through the Outreach and Retention Committee.

5. REFERENCE:

Department of Veteran Affairs Veterans Health Administration. (2010). VHA Handbook 1330.01: Health care services for women Veterans. Washington, DC: VHA Publication.