Attachment 13 - 11-63 HEALTH CARE SERVICES FOR WOMEN VETERANS.pdf

MEDICAL CENTER POLICY MEMORANDUMS

NUMBER/TITLE OF POLICY: 11-63/ HEALTH CARE SERVICES FOR WOMEN

VETERANS

CHANGES FROM PREVIOUS MCM: This is a new policy replacing Policy Memorandum 11C-01, “HEALTHCARE FOR WOMEN VETERANS”

POINT OF CONTACT FOR FURTHER INFORMATION:

Charmin Thomas, DNSc, FNP, BC extension 6612

36C24920R0114 - Attachment 13

1. PURPOSE: To establish policy, assign responsibilities, and provide procedural guidelines for providing primary care and gender-specific health care to women Veterans at the Veterans Affairs Medical Center (VAMC) Memphis and surrounding Community Based Outpatient Clinics (CBOCs).

2. POLICY:

a. VAMC Memphis will ensure that eligible women Veterans have access to comprehensive medical care, including care for gender-specific conditions and mental health conditions, that is comparable to care provided for male Veterans.

b. Definitions.

(1) Co-Location: Primary care and gender specific specialty care in the same physical location in order to optimize care delivery.

(2) Comprehensive Primary Care for Women Veterans: The provision of complete primary care and care coordination by one primary care provider at one site. The primary care provider should, in the context of a longitudinal relationship, fulfill all primary care needs, including:

(a) Care for Acute and Chronic Illness: Routine detection and management of acute and chronic diseases commonly seen in primary care including, but not limited to:

acute upper respiratory illness, cardiovascular disorders, screening for cancer of the breast and cervix, osteoporosis, thyroid disease, chronic obstructive pulmonary disease (COPD), etc.

(b) Gender-Specific Primary Care: Contraception counseling and care, sexually transmitted infection (STI) treatment, pharmacologic issues related to pregnancy and lactation, management of menopause-related concerns, initial evaluation and treatment of gender-specific conditions such as pelvic and abdominal pain, abnormal vaginal bleeding, vaginal infections, urinary incontinence, etc.

(c) Preventive Services: Age-appropriate cancer screening, nutrition counseling, weight management and fitness counseling, STI screening and counseling, smoking cessation counseling and treatment, immunizations, etc.

POLICY MEMORANDUM

VA Medical Center 1030 Jefferson Avenue Memphis, TN 38104

Number: 11- 63

Dated: July 1, 2019

Expires: June 30, 2022

Title: HEALTH CARE SERVICES FOR WOMEN VETERANS

(d) Mental Health Services: Assessment and psychosocial treatment as needed for a variety of mental health disorders, which include depression and problem drinking, within the parameters of Mental Health-Primary Care integration.

(3) Coordination of Care: Coordinating care and communicating with specialty providers regarding evaluation and treatment plans to ensure care continuity.

(4) Women’s Health Provider (WHP): A primary care provider who is interested and proficient in women’s health. A WHP is preferentially assigned women Veterans within their primary care patient panels.

3. RESPONSIBILITIES:

a. The Medical Center 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 the facility has appropriate resources such as equipment, space, and staffing, including gynecology and an appropriate number of WHPs 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 facility and CBOCs.

(3) Ensuring that all facilities provide all aspects gynecology care including but not limited to office visits, surgical procedures, emergency care, and consultations either on-site or through Care in the Community.

(4) Ensuring that a Women’s Health Medical Director (WHMD) is appointed to serve as the clinical leader for women’s health and ensuring the WHMD has a minimum of 4 hours per week administrative time separate from clinical duties.

(5) Ensuring that the facility has a Women’s Health Advisory Board (WHAB), 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 WHAB must maintain an active charter, meet at a minimum quarterly and report to leadership with signed minutes at the Executive level.

(6) Appointing a clinical health care professional as full-time Women Veterans Program Manager (WVPM) who reports to the Chief of Staff and has direct access to the Executive Team. The WVPM should serve on appropriate administrative and clinical boards and/or committees. 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 and 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 appropriate administrative support staff is designated and available to assist the WVPM and WHMD with data and reporting requirements.

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

b. The 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.

(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 interested, experienced, and proficient women’s health providers (WHPs) at each of the facility’s sites of care.

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

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

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

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

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

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

c. Women’s Veteran Program Manager (WVPM) is responsible for comprehensive planning and executing comprehensive care for women Veterans and achieving program goals and outcomes. WVPM works in coordination with diagnostic services and Women’s Health Navigator to develop, implement and maintain a formal tracking mechanism to assure proper and timely notification of gender-specific diagnostic studies. He/she attends national conference calls held monthly to learn about ongoing initiatives to improve the Veteran’s care. The WVPM participates in the regular review of the physical environment, including formal review of plans for renovation and construction, to identify potential privacy and safety deficiencies and facilitate availability and accessibility of appropriate equipment for the medical care of women. He/she partners with other programs such as Transition and Care Management Program Manager, Military Sexual Trauma (MST) Coordinator, Homeless Coordinator to ensure that women Veterans have access to and receive comprehensive primary and gender-specific health care and services. The WVPM works with the CBOC liaison to facilitate patient-related issues. The WVPM participates in outreach activities with the aim to educate women Veterans in the community of their eligibility and the available health care services. The WVPM will organize “In-reach” activities (internal marketing to Veterans already using the system and to facility staff) such as awareness month activities, educational seminars, and in-service programs. He/she will serve as the Chairman or the Co- Chairman of the Women Veteran’s Health Committee.

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

e. Primary Care Leadership is responsible for:

(1) Participating in the Women’s Health Advisory Board (WHAB).

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

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

(4) Ensuring that all newly enrolled women Veterans are assigned to WHP s, that all women already receiving care are offered assignment to WHPs, and that a minimum of 85% of women Veterans are assigned to WHPs.

(5) Ensuring that all WH-PACT teamlets where the provider is a WHP are designated in Primary Care Management Module (PCMM) as women’s health teamlets and have appropriate staffing ratios as outlined in VHA Directive 1101.10.

(6) Maintaining records of training or experience of WHPs.

f. The Women’s Health Medical Director (WHMD) is responsible for:

(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 and 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.

(5) Collaborating with the WVPM, VA medical facility leadership and primary care leadership to ensure that women Veterans are offered and assigned to WHPs.

(6) Collaborating with Primary Care Leadership and the WVPM to ensure that WHPs are given appropriate panel size reduction and to ensure that appropriate support staffing is provided to WH-PACT team.

(7) 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.

(8) Developing or supervising clinical education programs for women’s health providers and trainees to include collaborating with Education to assess clinical women’s health learning needs.

(9) Participating in monthly national Women’s Health calls.

g. The Women’s Health Advisory Board (WHAB) is responsible for:

(1) Developing and implementing a WH strategic plan to guide the women’s health program and assists with carrying out improvements for providing high quality equitable care for women Veterans.

(2) Maintaining an active charter, meeting quarterly, and report to leadership with signed minutes at the Clinical Executive Board (CEB) level.

(3) The WVPM must either chair or co-chair the WHAB. Core members of the WHAB must consist of the following:

(a) WVPM, WHMD, Women’s Health Nurse Liaison, 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.

(b) 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, prosthetics, chaplain, public and consumer affairs, VA Transition & Care Management, minority veteran coordinator, patient representative, Readjustment Counseling Service, nutrition services, Veterans Benefits Administration and homeless programs.

h. The Women’s Health Liaison (WHL) is responsible for: Coordinating and tracking women’s health care related to maternity care, breast cancer screening, cervical cancer screening, Non-VA Care Coordination. He/she works closely with the Non-VA Care Coordination Program (NVCC) and Patient Aligned Care Teams (PACT) to ensure appropriate coordination and follow-up of gender-specific referrals and results. He/she functions as primary case manager for all pregnant and lactating Veterans. He/she provides cross coverage for the WVPM. Reference VHA Directive 1330.03 for a detailed position description of MCC.

i. The Chief, Business Office (or designee) is responsible for determining eligibility for care through the Non-VA Care Coordination (NVCC) Program.

j. The Chief, Radiology Service (or designee) is responsible for ensuring that the contractor providing mammography services has appropriate certification by the American College of Radiology and meets appropriate accreditation requirements. In addition, he/she is responsible for ensuring that the mammography report is entered in Computerized Patient Record System (CPRS) with a notification to the ordering provider and the Women’s Health Nurse Liaison.

k. The Women’s Health Outreach Coordinator is responsible for outreach and in reach activities related to Women’s Health and ensuring that admitted female Veterans are given the brochure “Women Veterans Healthcare Program” which outlines services available to female Veterans. Responsible for all ensuring that Memphis VA Women’s Health Center is represented in the community.

l. The Chief, Environmental Management Service is responsible for ensuring the availability of appropriate patient apparel for women Veterans and stocking feminine hygiene products in designated dispensers at the medical center and affiliated CBOCs. Ensuring that changing tables are available in Family, male and female restrooms according to Directive 1330.01.

m. Women Veterans Health Liaisons serve as facilitators on behalf of women Veterans for any issue, question, or concern for their designated area.

n. Women’s Health Providers (WHP) are responsible for:

(1) Offering comprehensive health care services, are knowledgeable about gender-specific health care issues, and are familiar with referral services.

(2) Performing appropriate diagnosis and treatment for gender-specific primary care issues such as breast cancer screening, cervical cancer screening, osteoporosis screening, contraception and preconception counseling.

(3) Holding appropriate privileges and have current ongoing professional practice evaluations (OPPEs) reviewed by the Credentialing Committee.

(4) Maintaining at least (10) hours of CEU or CME in women’s health every 2 years.

o. Gynecologists are responsible for providing comprehensive gynecologic care and surgery to women Veterans.

p. Women’s Health Navigator (WHN) responsible for maternity, cervical and mammogram tracking and reporting. Training providers in the proper procedures for ordering, tracking and reporting.

4. PROCEDURES FOR 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 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 Directive 1101.10.

b. Assignment to a WHP. All newly enrolled women Veterans must be assigned to WHP s. Each woman Veteran already enrolled for primary health care must be offered assignment to a WHP and a WH-PACT Team, who assumes 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, they may continue assignment with these providers due to Veteran preference if appropriate arrangements are made for the veteran to receive gender-specific care (from different 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-WHP.

(3) Each VA medical facility must ensure that an adequate number of WHPs are available at each site of care to ensure that all VHA access goals are met for women Veterans.

(4) Transgender Veterans requesting primary care in a Women’s Health Clinic or a Women’s Health Provider (WHP) in a mixed gender primary care clinic should be assigned to WHC or WHP as requested. (VHA Directive 2013-003)

c. WH-PACT. All PACT teamlets with a WHP as the provider will be designated a WH- PACT teamlet and entered into PCMM as a WH-PACT teamlet. 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. WH-PACT must be staffed according to WH- PACT guidelines (see VHA Directive 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.

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

(1) Appointment Times. The Women’s Center provides comprehensive healthcare services that include primary care, gynecology, nutritional consults, and mental health services. Health services are provided available by scheduled appointments Monday through Friday 8:00-4:30 PM. The Women's Center is located in the medical center’s Annex, building number 5 with a separate entrance. The space allocated is specifically designated for the women to assure privacy and the availability of specialty equipment.

(2) 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 WHPs should be adjusted according to panel size guidelines (VHA Directive 1101.10 and VHA Directive 1101.01).

(3) Community-Based Outpatient Clinics (CBOCs).

(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 are encouraged to have at least two WHPs. It is necessary to have two WHPs 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) The CBOCs liaison assists with coordination of women’s health services along with the WVPM at the main facility. The liaison 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.

(4) Chaperones:

(a) For Physical Examinations: A female chaperone must be in the examination room during breast, pelvic and rectal exams. This includes procedures such as urodynamic testing or treatments such as pelvic floor physical therapy.

(b) For Radiologic Procedures: Breast Ultrasound, Breast MRI, Pelvic Ultrasound, Pelvic or Femoral Vascular Ultrasound or any procedure that exposes the breast 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 Transvaginal ultrasound requires a chaperone regardless of the gender of the radiologist or technologist. Clinical judgement should also be used when determining if a chaperone is indicated. Refer to Radiology Policy 114-27 Utilization of Chaperones for Radiologic Procedures and Memphis VAMC Standard Operating Procedure: Utilization of Chaperones for Imaging Procedures.

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

(5) Transgender Veterans: Patients will be addressed and referred to 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.

(a) Preventive Care for Women Veterans. Must follow VHA guidelines for Clinical Preventive Services http://vaww.prevention.va.gov/Guidance on Clinical Preventive Services.asp. women Veterans preventive care includes but is not limited to age and risk appropriate screening for breast, and cervical cancer and osteoporosis screening. Risk screening for intimate partner violence and military sexual trauma must be completed as part of preventive care.

(b) Breast Cancer Screening. Breast cancer screening is performed through Non-VA Medical Care. VHA Mammography Program Standards. NOTE: Refer to 38 U.S.C.

7319(b) and VHA Directive 1105.03, Mammography Program Procedures and Standards for full details. See FDA Mammography Standards Guidance at www.fda.gov\Radiation- EmittingProducts\MammographyQualityStandardsActandProgram\Guidance\PolicyGuidance HelpSystem\ucm135583.htm. Refer to Ambulatory Care Breast Cancer Screening Policy 11C-11 .

(c) Cervical Cancer Screening. Cervical cancer screening must be performed in accordance with VHA guidelines. The results of normal (no evidence of malignancy (NEM)) cervical pathology must be reported to the ordering provider within 30-calendar days of the pathology report being completed. The interpreting pathologist must ensure the ordering provider is contacted with abnormal results within 5-business days. The cervical pathology report of normal NEM results 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 HPV) becoming available to the ordering provider.

(d) Immunizations (human papilloma virus and influenza);

(e) Management of Osteoporosis;

(f) Management of Menopause and hormone replacement therapy;

(g) Contraception education/therapy.

(h) Treatment of sexually transmitted diseases (STDs), Vaginitis, Cervicitis;

(i) Gender-Specific Specialty Care.

1. Gynecologic Care. Gynecological related exams and procedures will be performed in the GYN clinic located in the Women's Center and through Non-VA for those http://vaww.prevention.va.gov/Guidance%20on%20Clinical%20Preventive%20Services.asp http://vaww.prevention.va.gov/Guidance%20on%20Clinical%20Preventive%20Services.asp http://vaww.prevention.va.gov/Guidance%20on%20Clinical%20Preventive%20Services.asp http://vaww.prevention.va.gov/Guidance%20on%20Clinical%20Preventive%20Services.asp http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/Guidance/PolicyGuidanceHelpSystem/ucm135583.htm http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/Guidance/PolicyGuidanceHelpSystem/ucm135583.htm http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/Guidance/PolicyGuidanceHelpSystem/ucm135583.htm http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/Guidance/PolicyGuidanceHelpSystem/ucm135583.htm http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/Guidance/PolicyGuidanceHelpSystem/ucm135583.htm http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/Guidance/PolicyGuidanceHelpSystem/ucm135583.htm who are eligible. These procedures include but are not limited to: Pap smears, colposcopies, endometrial biopsies, and cryosurgery. GYN services are usually available Monday–Friday in the Women's Clinic by GYN and GYN Residents. Gynecologic Oncology is available in the Oncology Department. Services are not available are offered through CITC.

2. Pregnancy Testing. All VA medical facilities including the CBOCs must have access “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. 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.

3. Maternity Care and Newborn Care. VHA is authorized to provide comprehensive prenatal, intra-partum, and postpartum 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, when the Veteran is medically released from obstetric care. The Women’s Health Liaison is responsible for monitoring the delivery of care, coordinating such care, and tracking outcomes of services that have been furnished through maternity purchased care. Also refer to reference sheet ‘Veterans Choice Program –Maternity Benefits’.

http://vaww.va.gov/CHOICE/docs/Maternity_Benefits_Veterans_Choice_Reference_Sheet.pd

a. 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.

b. Abortion and abortion counseling are excluded from the medical benefits package (see 38 CFR § 17.38(c)(1)).

(j) Infertility. Consistent with VA’s goal of improving Veterans’ health and the quality of their lives, VA health care includes infertility treatment. However, pursuant to 38 CFR 17.38, the medical benefits package specifically excludes in vitro fertilization (IVF).

Infertility services may be provided 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.

(k) Gender Specific Oncological Services. Gynecologic oncology and breast oncology care is provided through non-VA care to the extent the Veteran is eligible. Care will be coordinated by WHP, WVPM and Women’s Health Nurse Liaison.

(l) Mental Health. Mental Health Services are provided within Primary Care

Services.

d. Emergency Department Care. The Emergency Department (ED) is adequately equipped with pelvic exam equipment, privacy screens, and a private bathroom to facilitate gender related healthcare for women. Same day urgent consultation in the ED for emergency gynecological services is provided when the Gynecologist is available and E-Consult. When the Gynecologist is unavailable, the ED provider will use medical judgment to determine if the patient needs to be transferred to the Regional One Health (877 Jefferson Ave, Memphis, TN 38103) for emergency GYN or Obstetrical care.

e. Treatment of Alleged Sexual Assault Victims: The VA Memphis Police Department

(extension 5595) will be notified by the appropriate healthcare provider of a woman veteran’s complaint relevant to a sexual assault. The VA Memphis Police will notify the City of Memphis Police Department who will coordinate the investigation, including contacting the Sexual Assault Resource Center (SARC). The City of Memphis Police will provide a trained forensic provider to examine the patient in the VA Emergency Department. The forensic examiner will assume the responsibility for victim support, collection of evidence, and maintenance of the chain of evidence that is provided to the authorities. The patient will be offered Mental Health services immediately after arriving in the Emergency Department exam room. A mental health specialist is available in the Emergency Department 24 hours a day, 7 days a week.

Also reference Medical Center Policy Memorandum 11-12, Care and Reporting of Victims of Sexual Assault.

f. Telephone Triage. Telephone triage is available 24 hours a day, 7 days a week and is staffed by professionals trained in and aware of the health care needs of female patients.

The triage system uses Veterans Health Gateway, a clinical software application used by nurses who provide telephone triage services to veterans. VHG supports nurse clinical decision-making by systematically assessing a veteran's symptoms, while providing reference health information during the process. At the end of the triage process, VHG provides a triage follow-up recommendation, as well as self-care or interim-care instructions.

The system sorts patients into 7 distinct urgency levels: 911, <2 hours, 2- 8 hours, 12-24 hours, 2-3 days, 1-2 weeks, and self-care.

5. ADDITIONAL SERVICES FOR WOMEN VETERANS

a. Pharmacy Services. Emergency Contraception is available from Inpatient Pharmacy 24 hours to patients on the same day of their appointment even if a provider has requested to opt out from providing emergency contraception to the patient because of a Rights of Conscience (ROC) Claim. Pharm. D’s 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. An informed discussion with the Veteran must cover the risks and benefits of such prescriptions and documentation of patient counseling must be recorded in CPRS.

b. Physical Medicine and Rehabilitation. Available via consult.

c. Prosthetics Services. Intra-uterine devices (IUDs), breast pumps and lactation supplies, shoes, eyeglasses, compression stockings, etc.) are available by consult through prosthetic services.

6. Environment of Care (EOC):

a. Regular weekly rounds are made throughout the medical facility and affiliated CBOCs to ensure dignity, privacy, safety, and security.

b. The WVPM and Program Support Assistant (PSA) for Women’s Center must participate in EOCs rounds on a routine basis to ensure doors lock appropriately (allowing staff members to have key or code access in case of emergency) for required for all toilets, baths and showers.

c. 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.

d. A changing area must be provided behind a privacy curtain.

e. All examination tables must be placed with the foot facing away from the door, and tables must be fully shielded by privacy curtains.

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

Sanitary napkin and tampon dispensers and disposal bins must be available in women’s public restrooms.

g. Tampons and sanitary pads should also be available in examination rooms where pelvic examinations are performed and in bathrooms within close proximity.

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

7. RESPONSIBLE OFFICE: Chief of Staff (11).

8. REFERENCES:

a. VHA Directive 1330.1, “VHA Services for Women Veterans”, dated July 2018.

b. VHA Directive 1330.02, “Women Veterans Program Manager Position”, dated July

2018.

c. Public Law 102-585, Title 1, Section 106, “Women Veterans Health Programs”, dated

November 4, 1992;

d. Medical Center Policy Memorandum 00-14, ‘Women’s Health Advisory Board”, current version.

e. Medical Center Memorandum 116A-04, “Sexual Trauma Counseling Program”, current version.

f. Medical Center Policy Memorandum 11-12, “Care of Victims of Abuse, Neglect and

Assault”, current version.

g. VHA Directive 2006-068, “Reporting Cases of Abuse and Neglect”, dated December 28, 2006.

h. VHA Directive, 2010-014,” Assessment and Management of Veterans Who have Been

Victims of Alleged Acute Sexual Assault”, dated March 25, 2010;

i. Medical Center Policy Memorandum 114-27, “Utilization of Chaperones for Radiologic Procedures”, current version.

j. Medical Center Policy Memorandum 11C-06, “Health Promotion and Disease

Prevention”, current version.

k. Medical Center Policy Memorandum 11-12, Care and Reporting of Victims of Sexual Assault, current version.

l. Medical Center Standard Operating Procedure: Utilization of Chaperones for Imaging

Procedures, dated September 2018.

9. RESCISSION: Medical Center Policy Memorandum 11C-01, dated June 30, 2016.

Medical Staff Concurrence: Date:

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