D.10 PC-31 Womens Health.pdf

VA Butler Healthcare Medical Center Memorandum PC-31

Butler, PA March 22, 2018

MEDICAL CARE OF THE WOMAN VETERAN INCLUDING MAMMOGRAPHY (70)

I. PURPOSE: To establish a written plan for comprehensive services to Women Veterans, including the provision for breast and cervical cancer screening services for both resident and outpatient status. All eligible Women Veterans will have access to all necessary services as clinically indicated.

II. POLICY: To provide timely, equitable, high quality, comprehensive health services to meet the needs of Women Veterans in a sensitive and safe environment.

III. PROCEDURES:

A. In addition to medical care afforded every Veteran at this facility and Community Based

Outpatient Clinics (CBOCs), pelvic examinations, contraceptive counseling and care, evaluation and treatment for sexually transmitted and gynecological infections, pap smears, breast examinations, mammograms, referrals for obstetric care, management of menopausal symptoms and evaluations for osteoporosis are considered a routine part of the female physical examination and must be performed as indicated on every woman treated at this facility and CBOCs.

Exceptions are if the patient refuses such examinations, if a specific contraindication exists, or if the examination is not indicated. Exceptions are documented in the medical record.

B. Comprehensive primary care: All newly enrolled Women Veterans are assigned to a designated, interested, and proficient Women’s Health Provider (WHP) including CBOCs.

Women who are already assigned to a Primary Care Provider (PCP), who is not a WHP, are offered the opportunity for reassignment to a designated WHP. Basic primary care is provided to all female Veterans which will include:

1. Initial assessment and treatment to include history and physical, documentation of gynecological and obstetric history, last menstrual period, surgical and family history, psychosocial history, social support system, and military service history.

2. Preventive health care to include:

a. Breast examination screening;

b. Mammography, as indicated;

c. Cervical cancer screening;

d. Contraception and Plan B emergency contraception;

e. Dexa scans for osteoporosis (over age 64);

f. Other preventive health care procedures to include appropriate immunizations, nutritional, and cardiac risk factor assessments.

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g. Referrals for infertility, including in-vitro fertilization for women and spouses of men who have a qualifying service connection, elective sterilization, and surgery to reverse elective sterilization to eligible Veterans as part of contraceptive services.

h. Abortion and abortion counseling are excluded from the medical benefits package. Veterans Health Administration (VHA) also made a policy decision to no longer perform therapeutic abortions. RU 486 (Mifepristone) is an abortifactant not available through

VHA pharmacies.

3. Acute and chronic biopsychosocial care.

4. Center for Behavioral Health referral for counseling of sexual trauma, post-traumatic stress disorder, chemical substance abuse, depression, and smoking cessation.

5. Managing Overweight/Obese Veterans Everywhere (MOVE) Program.

6. Treatment for urinary incontinence, pelvic pain, and other disorders of the pelvic floor.

7. Maternity/Newborn care:

a. Benefits begin with confirmation of pregnancy, preferably in the first trimester, and continue through the final post-partum visit, usually at 6 to 8 weeks after delivery, when the

Veteran is medically discharged from obstetric care.

b. Public Law 111-163 authorized the VA to pay for routine medical care for the newborn child for not more than 7 consecutive days after the birth of the child, if medically necessary.

c. Childbirth education including Lamaze, breast feeding, parenting and education classes, fertility, and genetic testing.

d. Post-partum care until clinically discharged. This may include homecare nursing, well-mother care and breast pumps, if clinically applicable and ordered by the physician. Care should include a screen for post-partum depression.

e. The Women Veteran Program Manager (WVPM), or back up, will manage the alert system in the Computerized Patient Record System (CPRS) for any patient who is pregnant or lactating.

C. The following guidelines are applied to routine gynecology exams and cervical cancer screening:

1. All female Veterans are referred for initial evaluation to a VA Butler or CBOC WHP, VA Pittsburgh Healthcare System, or Non-VA care referrals as appropriate. Subsequent referral is done as needed. Exceptions are as in Section IIIA. A female chaperone must be in the exam room during exams, procedures, or treatments involving the breast and genitalia, regardless of

3 Medical Center Memorandum PC-31 the gender of the provider. Details are in VHA Handbook 1330.01.

2. All referrals for gynecology must be initiated via a consult into CPRS.

3. The VHA National Center for Health Promotion and Disease Prevention (NCP) recommend screening for cervical cancer:

a. With cytology (pap test) every 3 years for women ages 21-65 years of age who have a cervix; or

b. Women ages 30-65 years of age who want to lengthen the screening interval screening with a combination of cytology and Human Papillomavirus (HPV) testing every 5 years. These recommendations do not apply to high risk women.

c. VHA recommends against:

(1) Screening for cervical cancer in women who are younger than 21 years of age;

(2) Using HPV testing alone or in combination with cytology for cervical cancer screening in women younger than 30 years of age;

(3) Screening for cervical cancer in women older than 65 years of age if they have had adequate prior screening and are not otherwise at high risk for cervical cancer;

(4) Screening for cervical cancer in women who have had a total hysterectomy

(cervix removal) for benign disease;

4. Gynecology referrals are ordered at the physician’s discretion whenever there is clinical suspicion of disease.

5. Report of results:

a. The results of normal cervical pathology must be reported to the ordering provider within 30 calendar days of the pathology report being issued.

b. The interpreting physician must ensure the ordering provider is contacted with abnormal results within 5 business days.

c. The cervical pathology report of normal results must be communicated to the patient in terms easily understood by a layperson within 14 days from the date of the pathology report becoming available.

d. Documentation of a letter and/or verbal communication with the patient must be entered into CPRS.

e. For any abnormal cervical pathology report, the results must be communicated within 5 business days of the report being issued.

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f. All patients with abnormal Pap smear results are contacted by the PCP, consultant, or WVPM either by phone or in person and options are discussed with documentation in CPRS.

g. Follow-up for suspicious or positive reports is the responsibility of the ordering physician who will arrange for further diagnostic tests, surgical consultation, or biopsy after discussion of diagnosis and plan with patient. Verification that action is taken for abnormal test results are tracked and verified by the WVPM or designee.

D. The following American Cancer Society (ACS) guidelines are applied to mammography and physical examination of the breast:

1. Mammography services are obtained through community resources via the Care in the Community (CITC) office. The referring VHA facility must ensure, prior to services being rendered, that the facility providing the service is certified by the Food and Drug Administration

(FDA), or a state that has been approved by FDA under C.F.R. 900.21 to certify mammography facilities.

a. All screening and diagnostic mammograms must be initiated via a consult;

contracted CBOCs must place and order for screening mammograms, otherwise contracted sites will order diagnostic mammograms through CITC consults.

b. The ACS recommends screening for breast cancer with mammography for women at average risk and who do not have a personal or strong family history of breast cancer or a genetic mutation known to increase risk of breast cancer and has not had chest radiation therapy before the age of 30 (below are guidelines):

(1) Women between 40 and 44 have the option to start screening with a mammogram every year;

(2) Women 45 to 54 should get mammograms every year;

(3) Women 55 and older can switch to biannual mammography, or they can choose to continue yearly mammograms. Screening should continue as long as a woman is in good health and is expected to live 10 years or longer;

(4) All women should understand what to expect when getting a mammogram for breast cancer screening – what the test can and cannot do.

2. Women who are at high risk for breast cancer based on certain factors should get a

Magnetic Resonance Imaging (MRI) and a mammogram every year. This includes women who:

a. Have a lifetime risk of breast cancer of about 20% to 25% or greater, according to risk assessment tolls that are based mainly on family history.

b. Have a known Breast Cancer (BRCA) 1 or BRCA2 genetic mutation.

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c. Have a first-degree relative (parent, brother, sister, or child) with a BRCA1 or

BRCA2 genetic mutation and have not had genetic testing themselves.

d. Had radiation therapy to the chest when they were between the ages of 10 and 30 years.

e. Have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes.

E. Mammograms are ordered at the physician's discretion whenever there is clinical suspicion of disease. Tomosynthesis (3D-mammography) can be ordered by the physician for any patient.

F. All women are screened for the presence of breast implants through the mammogram order set in the medical record.

G. Mammography is obtained through referral of the patient through CITC, or through contract CBOCs third party vendors for screening mammograms only. Diagnostic mammography for contracted sites must be done through CITC. Third party contract sites include: Wexford Pavilion, Armstrong County Memorial, and Clarion Hospital.

H. Reporting of Results

1. It is the responsibility of the ordering practitioner to discuss the findings and a follow-up plan with the patient despite the fact that an outside radiologist may discuss findings with the

Veteran.

2. Suspicious or positive reports are communicated to the provider directly by the radiologist interpreting the x-ray.

3. Follow-up for suspicious or positive reports is the responsibility of the ordering physician who will arrange for further diagnostic tests, surgical consultation, or biopsy after discussion of diagnosis and plan with patient. Verification that action is taken for abnormal test results are tracked and verified by the WVPM.

I. Physical Examination of the breast: The ACS recommends against clinicians teaching women how to perform breast self-examination for breast cancer screening. Women are encouraged to report breast changes and abnormalities they discover to their provider.

J. Monitoring for Compliance: The WVPM will maintain a formal tracking mechanism to monitor breast and cervical cancer screening order dates, scheduling and completion dates, and results and results notification dates. The WVPM will receive VA alerts for each order, scheduled appointment, and results report which are maintained through tracking systems. If the patient is unable to be contacted after three attempts, a registered letter is mailed and all attempts to contact patient are documented in CPRS.

K. To ensure all of a Woman Veteran’s healthcare needs are met, prenatal, and labor and delivery care are provided through the facility’s CITC department using the CHOICE program.

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Female Tricare beneficiaries are referred to approved Tricare providers. These specialty services are not available at this facility but are provided on a referral basis to a provider in the community. Details in VHA Handbook 1330.01.

L. The WVPM will coordinate women’s issues with designated WVPM liaisons, which are knowledgeable of women’s services available on each Community Living Center (CLC), Outpatient department, CBOCs, and Mental Health Residential Rehabilitation Treatment

Program (MHRRTP).

M. The WVPM, or designee, will participate in regular review of the physical environment, including plans for renovations and construction, to identify potential privacy and safety deficiencies and facilitate availability of appropriate equipment for the care of women.

N. The Women Veterans’ Health Committee (WVHC) is available to assist the WVPM in carrying out responsibilities and provide recommendations to leadership for improving services and programs for Women Veterans.

IV. REFERENCES:

VHA Handbook 1330.01, Health Care Services for Women Veterans, May 21, 2010

VHA Handbook 1105.03, Mammography Program Policies and Procedures, April

28, 2011.

Clinical Preventive Services Breast Cancer Guidance, http://vaww.prevention.va.gov/Screening_for_Breast_Cancer.asp.

Clinical Preventative Services Cervical Cancer Guidance, http://vaww.prevention.va.gov/Screening_for_Cervical_Cancer.asp.

American Cancer Society (2017). Breast cancer screening guidelines: American Cancer

Society. https://www.cancer/org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/breast-cancer-screening-guidelines.html.

V. RESCISSIONS: Medical Center Memorandum PC-31 dated March 1, 2013.

PATRICIA O’KANE, MSS

Interim Director

(Automatic Review Date: March 22, 2021) http://vaww.prevention.va.gov/Screening_for_Breast_Cancer.asp http://vaww.prevention.va.gov/Screening_for_Cervical_Cancer.asp https://www.cancer/org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/breast-cancer-screening-guidelines.html https://www.cancer/org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/breast-cancer-screening-guidelines.html