D.13 VASDHS REPRODUCTIVE WORKFLOW - ATTACHED.pdf

Reproductive workflow

[ ] Veteran confirms she does not desire pregnancy with a VA staff member.

[ ] Veteran received pregnancy options counseling in a non-directive, unbiased manner from provider ( can be MD, SW, MH, RN). Discussed options below and helped Veteran understand options:

-Continue pregnancy (to parent, or place child for adoption)

-Not continue the pregnancy

[ ] If veteran eligible for services within the VA, provider submits referral to GYN.

[ ] If veteran not eligible for services, provider shares local community resources.

Community-

Adoption resources: Adoption Center of San Diego, Adoption Network(information and resources for San Diego)

Aidaccess.org : Aid access works with a team of US registered abortion providers who will provide FDA registered abortion pills. Website: https://aidaccess.org/en/. Cost to patient is $150 or less and medication is mailed to vets home.

Planned Parenthood (PP): Consultation, blood work, U/S, and medication provided all in same visit. Medication abortion offered up to 11 weeks. Follow up recommended 24-72 hours after completion of all medication. Services can be covered at PP if Veteran has Medicaid or separate insurance. Sliding fee scale if Veteran does not have insurance. Out of pocket costs for medication abortion at PP currently $525-650 if not below income criteria.

[ ] Provider shares pamphlets or website with Veteran.

VA-

VA: Can provide abortions when the life or mental/physical health of the Veteran would be endangered if the pregnancy were carried to term, or when the pregnancy is the result of rape or incest; there will be no burden of proof for women Veterans required for rape or incest.

[ ] Veteran confirms interest in abortion services at VA

[ ] Up to 10 weeks GSA- Medication abortion available

[ ] up to 12 weeks GSA- Surgical procedure (D&C) available

[ ] Greater than 12+ weeks GSA- Will require consult thru Community Care.

[ ] GYN visit required to discuss abortion services at VA . GYN referral must be submitted by VA clinician ( Response within 24 hours by GYN team).

*Patient should be scheduled within 2 business days of request with GYN ; 1130 urgent slots preferable with GYN.

[ ] If patient is requesting abortion services from VA clinician, a dating ultrasound can be ordered by PCP in Radiology to expedite care prior to GYN visit.

[ ] Pregnancy suspected due to/confirmed with:

[ ] Home pregnancy test

[ ] VA lab testing

D. 13 VASDHS REPRODUCTIVE WORKFLOW

D.13 VASDHS Reproductive Workflow - 36C26225R0004 https://aidaccess.org/en/

[ ] estimated LMP

[ ] Reason for requesting abortion services.

[ ] Veteran notified that the process can take approx. 3-5 business days before receiving medication; surgical services could be longer process.

GYN VISIT:

[ ] Pregnancy test provided (if not completed prior to visit).

[ ] Dating U/S (if not completed prior to visit).

[ ] Abortion counseling provided.

-Risk and benefits of abortion procedures and medications.

-Aided in understanding and exploring all possible options. Medication abortion available up to 70 days (10 weeks) gestation.

-Encouraged Veteran to make best decision for their health and wellbeing

[ ] Veteran confirms interest in abortion services at VA

[ ] Up to 10 weeks GSA- Medication abortion available.

[ ] up to 12 weeks GSA- Surgical procedure (D&C) available.

[ ] Greater than 12+ weeks GSA- Will require consult thru Community Care.

[ ] Veteran states they would like abortion for MH reasons (MH consultation is not required but available)

- GYN can reach out via teams channel of Reproductive MH team members & MH provider will meet with veteran within 24 hours.

- MH can set up an in-person, telephone, or VVC visit per patients preference.

- If veteran is suicidal, will need to have warm hand off during GYN visit. MH will meet with patient and notify providers of recommendation via teams chat and document in patients chart.

- [ ] Veteran meets with MH for shared decision making related to MH and desire for abortion.

- [ ] MH provides feedback to OB/GYN documenting the outcome of the shared decision making.

[ ] Veteran eligible for surgical (D&C) abortion. ( Up to 12 weeks GSA)

[ ] Healthcare provider provided counseling.

[ ] GYN consult required if not already submitted; GYN will arrange scheduling procedure for veteran.

[ ] Veteran eligible for medication abortion. ( Up to 10 weeks GSA)

[ ] Healthcare provider provided counseling.

[ ] If patient eligible for medication abortion services, the prescribe orders:

[ ] Mifepristone 200mg orally x1

[ ] Misoprostol 800 micrograms (buccally or vaginally) x2 doses

The Veteran/VA beneficiary should take mifepristone 200 mg orally followed by misoprostol 800 micrograms buccally or vaginally 24-48 hours later. Pregnant people with estimated GA >63 days should take a second dose of misoprostol 800 micrograms 4 hours after the first. Pregnant people with estimated GA ≤63 days should take the second dose if no bleeding occurs within the first 24 hours after the first misoprostol dose OR if gestations >63 days.

[ ] Healthcare provider obtained a signed Patient Agreement Form from the patient AFTER counseling and prior to prescribing Mifepristone 200mg tablets. The patient agreement form is available at this link:

https://genbiopro.com/patientagreement

[ ] A non-formulary request must be submitted to receive Mifepristone and the prescriber should clearly indicate that the Patient Agreement form has been completed.

[ ] The prescriber will provide Patient Agreement form to pharmacy to be scanned into the patient’s medical record and order medications.

[ ] The WH Pharmacist will review and approve the non-formulary request within 24 hours. Pharmacist will record serial number from mifepristone package in remark field. Pharmacy will have Mifepristone and Misoprostol medication stocked in La Jolla and can be overnighted to vet or available for pickup at La Jolla pharmacy. Overnighted medications must be ordered before 12 noon on weekdays.

[ ] Follow up visit will be offered to Veteran for MH services or can join perinatal monitoring group.

Post follow up for medication abortion:

- [ ] GYN follow up visit recommended in person, by phone, or VVC at 1-4 weeks post abortion.

- [ ] Follow up precautions hand-out provided.

[ ] Consider follow up beta-HCG in 1 week.

[ ] Urine HCG in 4 weeks to confirm completion of abortion.

Post follow up surgical abortion:

[ ] GYN post op visit in 2 weeks.

[ ] Follow up discharge instructions provided.

[ ] Office of Women’s Health will be notified of abortion case by WVPM https://genbiopro.com/patientagreement