D.17 36C26126R0014 SOP Tracking coordination of cervical and Breast Cancer screening.doc

VA Northern California Health Care System Policy Statement 11-127

April 20, 2018 16.

VA Northern California Health Care System Policy Statement 11-127

April 20, 2018

Amendment March 12, 2025, Language updated in response to the Presidential Executive Order on Defending Women.

HEALTH CARE SERVICES FOR WOMEN VETERANS

1. PURPOSE:

This Veterans Health Administration (VHA) policy establishes the minimum requirements to ensure that all eligible and enrolled women Veterans, irrespective of where they obtain care in the Northern California Healthcare System (NCHCS), have access to all medically necessary services that are comprehensive, timely, equitable and high-quality,

2. BACKGROUND:

NCHCS is improving access, services, resources, facilities, and workforce capacity to make health care more accessible, more sensitive to sex-specific needs, and of the highest quality for the women Veterans of today and tomorrow. While women Veterans constitute a minority of Veterans, they represent a “critical mass” deserving the same level of services provided to male Veterans. VA strives to be a national leader in the provision of health care for women, thereby raising the standard of care for all women.

3. AUTHORITY:

Title 38, United States Code (U.S.C.), sec. 501, 1710, 1720D, 7301(b), Public Law 102-585, Veterans Health Care Act of 1992, Public Law 103-452, Public Law 104-262, Public Law 106-117, Public Law 108-422, Public Law 110-387, Public Law 111-163, Public Law 113-146, VHA Handbook1330.01, 1330.02,1330.03, Under Secretary for Health’s Information Letter 10-2014-10, Guidance on Emergency Medical Services for Women. A full description of all applicable laws and authorities is available in the Veterans Health Administration (VHA) Handbook 1330.01, VHA Services for Women Veterans.

4. DEFINITIONS:

a. Administrative Parent - is defined as a collection of all the points of service that a leadership group (Medical Facility Director, Deputy Medical Facility Director, Chief of Staff, Associate or Assistant Director, and Nurse Executive) manages. The points of service can include any institution where health care is delivered. All of the data that originate from these points of service roll up to a single station number representing the administrative parent for management and programmatic activities. The administrative parent is hereafter referred to as NCHCS.

b. Designated Women’s Health Primary Care Provider (WH-PCP) - is a primary care provider who is interested, trained, and experienced in women’s health. A WH-PCP does not have to be of female gender. A WH-PCP is preferentially assigned women Veterans to their primary care patient panels.

c. Comprehensive Primary Care for Women - 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 care for acute and chronic illness, gender-specific care, preventive services, and mental health services. Comprehensive Primary Care is fully consistent with the principles of the Patient Centered Medical Home.

d. Gender-Specific Primary Care - screening for cancer of the breast and cervix, contraception counseling and care, sexually transmitted infection (STI) screening and 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, vaginal bleeding, vaginal infections, urinary incontinence, etc.

e. Specialty Gynecology Care - includes the management of gynecological conditions that require more advanced evaluation or management (medical or surgical) than can be provided through the gender-specific services offered by the primary care provider. Specialty gynecologic care includes, but is not limited to, evaluation and medical and/or surgical management.

f. Women’s Health Patient Aligned Care Team (WH-PCP) - is a team or teamlet in which the provider is a WH-PCP. All members of the team or teamlet must be able to competently perform their roles related to providing comprehensive primary care for women. WH-PACT members must have sufficient training and expertise to care for women Veterans.

g. Comprehensive Primary Care Clinic Models - there are three clinic models utilized to provide comprehensive primary care for women Veterans.

a. Model 1. General Primary Care Clinics: Women Veterans are incorporated into the WH PCP panel and seen within a general gender-neutral primary care clinic. Mental health services should be co-located (same physical location) in this clinic. Specialty gynecological services must be available on site or through fee-basis, contract or referral to another VA facility with a travel distance of less than 50 miles. Model 1 NCHCS clinics are Redding, Chico, Yuba City, Fairfield, and Mare Island.

b. Model 2. Separate but Shared Space: Comprehensive Primary Care services are offered by WH PCP in a separate but shared space that may be located within or adjacent to primary care clinic areas. Gynecologic care and mental health services should be co-located in this space. Model 2 NCHCS clinics are Martinez and McClellan.

c. Model 3. Women’s Health Center: Comprehensive Primary Care services offered by WH PCP in an exclusive separate space, preferably with a separate entrance and waiting room. Mental health services and gynecological services must be co-located in this space. Model 3 NCHCS clinic is the Mather WH clinic.

h. Exclusive Space - is a separate physical location for the delivery of comprehensive primary care to women Veterans and it is not shared by other services providing care to male Veterans.

i. Separate Shared Space - is a separate physical location for the delivery of comprehensive primary care to women Veterans that may be used by other services on days when women Veterans are not being seen.

5.

SCOPE:

The services offered at VANCHCS are consistent with the VHA Handbook, sec. 1330.01, 1330.02, and 1330.03. It is a VHA mandate that each facility, independent clinic, mobile clinic and community-based outpatient clinic (CBOC) ensure that women Veterans have access to all necessary medical care, including care for gender-specific conditions and mental health conditions, that is comparable to care provided to male Veterans. The requirements apply to all sites of care in NCHCS that provide care directly and indirectly to women Veterans.

NOTE: Women’s health centers require appropriate staffing above and beyond WH-PACT staffing ratios which are recommended for primary care teams. Appropriate Support Staffing must be provided for gynecology services and other specialty-care services within WHCs. Specialty gynecology clinics may not be utilized solely for routine breast and cervical cancer screening.

6. POLICY:

a. Assignment to a WH-PCP. All eligible women Veterans will be provided Comprehensive Primary Care services by designated Women’s Health Primary Care Providers (WH PCPs). New women Veterans enrolled for primary care will be assigned to a WH PCP. Women Veterans will be given the option to designate their preference for a female or male provider. Women who are currently receiving care at a VA medical facility must be offered the choice to receive their comprehensive medical care from a WH-PCP. The goal is at least 85% of women Veterans be assigned to a WH-PCP.

b. Women Veterans already assigned to a PCP, who is not designated as a WH PCP, will be offered the opportunity for reassignment to a WH PCP. For women Veterans who choose not to be assigned to a WH PCP, arrangements will be made for gender-specific care to be provided within the primary care setting. Women Veterans with spinal cord injury/disorder (SCI/D) may be assigned to a designated SCI/D primary provider who will provide or arrange for women’s health care and gender specific 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.

c. Requests for primary care provider reassignment from women Veterans will be honored and processed according to NCHCS standard procedure, even if the request is for a non-WH-PCP.

d. NCHCS 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. Every effort will be made to ensure that Cross-coverage for vacations and sick days is 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 Department of Veterans Affairs Medical Facilities and Selected Community Based Outpatient Clinics.

e. 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 per VHA Directive (2013-003)

f. WH-PACT. Women Veterans will be assigned preferentially to WH-PACT with trained nursing staff members to triage gender-specific complaints and assist with gender-specific procedures; processes for ordering and tracking mammography and cervical cancer screening and; ensuring chaperones and gender-specific equipment and supplies are readily available.

(1) 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.

(2) WH-PACTs will function in gender integrated primary care clinics, and in the women’s clinics. WH-PACTs in integrated primary care clinics may care for both men and women Veterans on a WH-PACT teamlet panel.

(3) WH-PACT must be staffed according to WH-PACT guidelines.

(4) Recommended staffing:

a) Primary care provider position: WH-PCP;

b) RN position: RN Care Manager;

c) License practical/vocational nurse (LPN/LVN) or health technician (HT) position: Clinical Associate;

d) Other Position: Chaperone (additional HT, LPN, etc.) and;

e) Clerk position: Administrative Associate.

(5) Discipline-specific team members for WH-PACTs are assigned in PCMM as follows:

a) SW position: Social Worker

b) Pharmacy: Clinical Pharmacy Specialist

c) Dietitian Nutritionist: Registered Dietitian Nutritionist

d) Other position: Gynecologist

e) Other position: Military Sexual Trauma Coordinator

f) Other position: Mental Health Provider and;

g) Other position: RN Mammogram/Pap/Maternity Care Coordinator

g. Requirements for Women’s Health Primary Care Providers and WH-PACT Teamlets.

(1) Recommend WH-PACT teamlets are assigned a panel size of at least 100 women Veterans,

(2) In order to be initially designated as a WH-PCP, a provider must have at least one of the following:

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

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

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

d) 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;

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

f) 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.

(3) 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.

h. Mental Health Services in Primary Care. NCHCS will provide integrated mental health services in the same physical location as primary care whenever possible notwithstanding environmental constraints. Patients requiring more intensive comprehensive and specialized mental health services will be referred to mental health clinics.

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

(1) Appointment times and duration. Adequate appointment lengths for both new and follow-up visits are necessary to provide comprehensive primary care to women Veterans.

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.

(2) Panel Sizes. Panel sizes will be adjusted downward in accordance with panel size guidelines (VHA Handbook 1101.10 and VHA Handbook 1101.01)

(3) Community-Based Outpatient Clinics.

a) All CBOCs must have at least 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.

b) CBOCs and independent clinics will designate a women’s health clinical liaison to coordinate women’s health services with the WVPM at the main facility. The liaison may be a nurse or social worker, or a practitioner. The role of the liaison is to be 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) Mobile Clinics. Mobile clinics which offer primary care services must assure equitable access to comprehensive primary care services for both men and women. This includes the provision of gender-specific primary care to women Veterans.

(5) Chaperones:

a) A female chaperone must be present in the examination room, regardless of the gender of the provider, during all examinations, procedures, or treatments involving the breast and genitalia, and for any visit when requested by the patient. A chaperone can be a female health technician, nurse’s aide, LVN, or trained volunteer (with written position description, prior experience in a clinical health care environment and approval by Chief of Voluntary Services. The chaperone can assist with the set up for Pap smears and pelvic exams, assist the Veteran with dressing and undressing, and provide gowns and other dressing apparel to the Veteran. The chaperone duties should not be of a nature that would require credentialing/ privileging. 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.

b) For Radiologic Procedures:

1. Mammography does not require a chaperone (all mammography technologists in VA are female); 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.

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

3. 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.

c) For Electrocardiograms and Echocardiograms:

1. 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.

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.

(6) Transgender Veterans:

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.

j. Maternity services are a benefit for Veterans and begin with the confirmation of pregnancy and continue through the postpartum visit (6-8 weeks) or when the Veteran is medically released from obstetric care. Obstetrical services will be provided in the community. Pregnant patients will be coordinated by a Maternity Care Coordinator (MCC). The MCC is responsible for monitoring the delivery of care, coordination of care and tracking outcomes of services furnished in the community.

k. Services will be timely, accessible and ensure safety, privacy, dignity, and sensitivity. 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 CBOC, all sites that offer primary care services must offer comprehensive primary care to women Veterans. Gender-specific primary care services must available at every site of care in NCHCS.

l. NCHCS will support a full-time Women Veterans Program Manager (WVPM) to execute comprehensive planning for women’s health care that ensures privacy, security, and dignity and improves the overall quality of care provided to women Veterans. NCHCS will appoint a WHMD responsible for clinical oversight of the women’s health program.

m. The WVPM will be a member of the VHA Environment of Care (EOC) Committee to review and evaluate structural, environmental, and psychosocial patient safety and privacy reviews. Reviews must be conducted on an annual basis, at a minimum, and be recorded through the EOC committee, including the plan for correction of deficiencies with a timeline for correction of deficiencies and an outline of budget commitment for corrections.

7.

RESPONSIBILITIES:

a.

Facility Director: Ensure that all staff members assume the responsibility of caring for women Veterans. Ensure appointment of a Women Veterans Program Manager (WVPM) and Women’s Health Medical Director (WHMD). Ensure establishment of planning and implementation team for comprehensive primary care for women Veterans. Ensure the WVPM has direct access to top management and serves on appropriate administrative and clinical committees. Ensure that name, location and business telephone number of the WVPM is posted and appropriately publicized in each facility. Ensures sufficient resources and support for data analysis and project implementation. Ensure each Community Based Outpatient Clinic (CBOC) has a Women’s Health Liaison.

b.

Clinical Executive Leadership: Ensure that all clinical leadership plan and implement equitable, high quality comprehensive healthcare services for women Veterans, including excellent and equitable performance measures in facility and CBOCs. Work closely with the WVPM and WHMD. Hold Primary Care Leadership accountable for identifying WH PCPs. Ensure designated WH PCPs are appropriately proficient, credentialed and privileged.

c.

Primary Care Leadership: Ensure appointment of designated WH PCPs at each facility and CBOC. Participate in planning and implementation for comprehensive care of women Veterans. Ensure excellent and equitable achievement on all primary care gender neutral and gender specific performance measures. Work collaboratively with WVPM and WHMD. Ensure that designated, interested and proficient CPC providers are appointed at each facility. Ensure women’s staff providing CPC are appropriately proficient, credentialed and privileged.

d.

WVPM: Execute comprehensive planning and implementation to achieve program goals and outcomes that will improve the overall quality of care provided to women Veterans. Collaborate with and coordinate planning efforts with the women Veterans Health Advisory Committee and other program leaders to ensure women receive quality, comprehensive care. Conduct regular reviews of the environment of care (EOC) to ensure compliance with all safety, privacy and dignity requirements. Work collaboratively with primary care and other services to ensure that the needs of women Veterans are met. Conduct outreach and in-reach activities. Coordinate with diagnostic services to assure proper and timely notification of gender-specific diagnostic studies. Promote systems and practices that enhance women Veterans’ satisfaction. Including:

(1) Identify and enroll women Veterans in need of health care.

(2) Increase utilization of women’s health care services in compliance with clinical practice guidelines.

(3) Identify gaps in health care services and develop new programs and services as needed.

(4) Support performance improvement activities that benefit all Veterans.

(5) Develop and provide education activities for facility staff to increase sensitivity and awareness of the unique needs of women Veterans and;

(6) Ensure the health care environment of each VHA facility addresses the privacy and security needs of women Veterans.

e.

Women’s Health Medical Director: NCHCS will designate a Women’s Health Medical Director (WHMD). The WHMD works closely with the WVPM to form the foundation of the Women’s Health Program. The WHMD serves as the clinical leader for the Women’s Health Program at the facility level. In collaboration with the WVPM, the WHMD works to develop clinical leadership for the Women’s Health Program, including participation in strategic planning, administration, quality improvement, and educational initiatives. The WHMD must maintain an active clinical practice in Women’s Health. The VA handbook 1330.01 recommends that the WHMD be a Designated Women’s Health Primary Care Provider (WH-PCP) but other specialty providers can serve as the WHMD. Responsibilities include:

1) Serving as a clinical leader for women’s health.

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.

5) Collaborating with WVPM and facility and PC leadership to determine the appropriate model of care for Comprehensive Women’s Health Care at all sites of care, including the VA medical facility and CBOC’s.

6) Collaborating with the WVPM, VA medical facility and primary care leadership to ensure that women Veterans are offered and assigned to WH-PCPs.

7) Collaborate WVPM to ensure that WH-PCPs are given appropriate panel size reduction.

8) Collaborating with WVPM and Primary Care / WH-PACT leadership and the WVPM to ensure that appropriate support staffing is provided to WH-PACT team.

9) Collaborating 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.

10) 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.

(11) Developing or supervising clinical education programs for women’s health providers and trainees.

(12) Collaborating with VA medical facility Learning Officer to assess clinical women’s health learning needs.

(13) Participating in groups created for Women’s Health Medical Directors. Participates in monthly national Women’s Health calls.

(14) WHMD must have at least 4 hours of administrative time per week to perform the above duties.

f.

Women Veterans Health Advisory Committee (WVHC): Assist the WVPM in carrying out duties and responsibilities of that position. Provide recommendations to leadership for improving services and programs for women Veterans. Membership is multi-disciplinary with representation from multiple service departments. The WVPM should chair or be a member of the committee. The WVHC should meet at least quarterly. Committee meeting minutes will be distributed to members and Executive Leadership.

g.

Mental Health: Appoint a designated Military Sexual Trauma (MST) Coordinator to serve as a point of contact (POC) for all MST related issues at VANCHCS. Ensure availability of complete mental health services to eligible women Veterans.

h.

Engineering and Facilities Management: Provide adequate facilities and appropriate physical environment to ensure that there are no physical plant limitations or privacy deficiencies that restrict a woman’s access to care at any VANCHCS site. Considerations include the following: auditory and visual privacy at check-in and interview areas; female pajamas and robes stocked on all inpatient units, gowns and drapes in exam rooms; maintain examination room privacy by providing privacy curtains that encompass adequate space for the healthcare provider to perform exam unencumbered by the curtain, face exam table foot away from door openings, locks on exam room doors; diaper changing tables and sanitary products dispensers and disposal bins available in public restrooms; private and secure sleeping areas, restrooms, bathing/shower facilities.

i.

Pharmacy Service: Facilitate care of the women Veteran by monitoring appropriateness, safety, and effectiveness of the use of drugs in VANCHCS, and ensuring an adequate supply of gender-specific pharmaceuticals are available. Ensure availability of emergency contraception, levonorgestrel (Plan B), to patients in a timely manner. Monitor prescriptions of high risk teratrogenic medications, and documentation of counseling of risks and benefits of such prescriptions.

j.

Radiology Service: Provide high quality mammography, ultrasound and other diagnostic radiology services for women Veterans, and maintain current Federal Drug Administration and American College of Radiology accreditation for mammography services. (see mammography policy 11-121, Breast Cancer Screening and Diagnostic Imaging) k.

Pathology and Laboratory Service: Ensure pap smears and other gynecologic specimens are processed and interpreted by qualified staff experienced in the interpretation of these specimens. Ensure urine pregnancy tests are available at all sites. Process urine pregnancy and wet prep tests within 15 minutes. Perform quantitative beta Human Gonadotropin (HCG) level on a blood sample. Assign a point of contact to track completion for point of care testing (Clinical Laboratory Improvement Amendment waivers).

l.

Quality Management: In collaboration with the WVPM, Radiology Service, Pathology Service, Gynecology and Primary Care Services, oversee the tracking and timeliness of follow-up of findings from breast and cervical cancer screening. Monitor differences in quality measures for women Veterans compared to male Veterans.

8.

PROCEDURES:

a.

Comprehensive Primary Care: Comprehensive Primary Care services will be provided to all eligible women Veterans by a designated WH PCP in one or of three primary care clinic models. Women Veterans who chose not to be assigned to a WH PCP will receive gender-specific care within the primary care setting.

b.

Comprehensive History and Physical Examination: Documentation of a detailed history will include current and past medical and surgical history, gynecologic and obstetric history, allergies, family history of disease, psycho-social history including military service and occupational history. The initial intake history must include screening for MST accomplished while patient is fully dressed. A complete primary care examination includes a breast and genital exam. If the patient is due for a cervical screening and this is not included as a part of the complete examination, the reason(s) for deferring the exam must be clearly documented in the medical record c.

Panel size: Patient panel size of a designated WH PCP must be comprised of at least 10% female patients to maintain proficiency (under current Primary Care Management Module guidelines, the number of female patients needs to be at least 120). Panel size reduction for WH PCP will be strongly considered to accommodate the unique needs of women Veterans in the primary care setting. The panel size may be reduced by the number of unique patients equal to 20% of the total number of women Veterans in the mixed gender panel.

d.

Appointment Times: The following appointment lengths are recommended for new and follow-up visits to allow for gender-specific care during the primary care encounter: New Women’s Health appointment and annual exam- 60 minutes, Routine follow-up appointment- 30 minutes, Urgent appointment- 30 minutes.

e.

Gynecological Care: Specialized services are provided in the Gynecology clinics for conditions requiring advanced expertise, including: abnormal cervical pathology, uterine fibroids, endometriosis, polycystic ovarian syndrome, abnormal uterine bleeding, pelvic pain, gynecologic malignancies, implantable contraceptives, sterilization, and infertility. Some routine women’s health can also be provided in Gynecology Clinics. Abortion and abortion counseling are excluded from the VA medical benefits package. The patient will be evaluated within 30 days for a routine gynecology referral and within 7 days for an urgent condition. A gynecologist will be available for emergency care consultation either on-site or by phone. When a woman Veteran requests a female or male gynecologist, accommodation must be made. In order to satisfy the patient request, referral to Network sites or use of fee basis may be utilized.

f.

Maternity Care: Maternity benefits are included in the benefits package for women Veterans. Pregnancy care will be provided through contractual agreements or fee basis with local non-VA facilities within 50 miles or one hour from the mother’s place of residence. Request for authorization for pregnancy care will be submitted via electronic consult to CHOICE and Fee Services as applicable. At this time, care to the newborn infant is provided for the first 7 days only and is not a covered benefit thereafter. The Veteran must be informed that VA cannot pay the cost of this care and this should be documented in the medical record. It is essential that the mother be advised to make alternative arrangements for newborn care prior to delivery.

g.

Infertility: VA is authorized to provide limited infertility services as medically indicated. Such services may include assessment of reproductive capacity and treatment of correction of abnormalities such as endometriosis. Surgical reversal of tubal ligation is a covered benefit for treatment of infertility. VA is not authorized to provide advanced reproductive in-vitro fertilization technologies.

h.

Breast and Reproductive Oncology: Genetic testing is authorized when needed for diagnostic, management and secondary prevention decisions. A telegenetics referral for care will be sent to to Salt Lake City (SLC) VAMCs or in-house specialty services or fee basis as appropriate.

i.

Mammography and Breast Evaluation: Mammography services, both screening and diagnostic, are provided on-site through the Radiology Services and through fee basis when appropriate. Mammograms must be accessible within 50 miles distance from the women Veteran’s residence. Breast cancer screening includes mammography, with or without clinical breast examination. VANCHCS Policy Statement 11-121, Breast Cancer Screening and Diagnostic Imaging, provides guidelines on mammography and breast imaging recommendations, orders, report tracking, provider and patient notification, and documentation.

j.

Cervical Cancer Screening: For guidance on cervical cancer screening, refer to VANCHCS Policy Statement 11-103, Cervical Cytology Screening and Dysplasia Patient Management.

k.

Mental Health: Mental health services should be provided in the same physical location that Comprehensive Primary Care is offered. Mental health staff must take responsibility to address safety and security within mixed gender therapy groups.

l.

Care for Conditions Related to Military Sexual Trauma: All primary care providers will screen all female patients for military sexual trauma and refer for counseling and treatment if appropriate. Providers must document screening in the Computerized Patient Record System (CPRS) MST clinical reminder. It is VHA policy to provide MST counseling including appropriate care and services, to overcome psychological trauma that resulted from a physical assault of a sexual nature, battery of a sexual nature or sexual harassment which occurred while the Veteran was serving on active duty or while the service member serviced on Active Duty for Training as defined under Title 38 United States Code 101(22). Mental health services for conditions related to MST must be available, referral to local Vet Center is an appropriate alternative if not available on site. Women Veterans being treated for conditions related to MST should be given the option of being assigned to a same-sex mental health provider or opposite-sex provider if the trauma involved a same sex perpetrator. Women Veterans receiving MST related counseling and treatment will not be billed for inpatient, outpatient, or pharmaceutical co-payments; however, applicable co-payments may be charged for services not related to military sexual trauma or for other non-service connected conditions. Women Veterans who report experiences of MST, but who are otherwise deemed ineligible for VA health care benefits based on length of military service requirements, may be provided MST counseling and related treatment only. The Veteran does not have to have reported the incident when it occurred and does not have to have applied for service connection to be eligible.

m.

Urgent and Emergent Care: Emergency and urgent care services, as well as a telephone triage system, are available at VANCHCS. These areas will be staffed by professionals trained in and aware of the health care needs of female patients. Necessary equipment will be available for care of the female patient, including: exam tables with stirrups, speculums, lights, appropriate supplies to make accurate diagnosis of vaginal and STIs at point of care. Certain conditions may require transfer to local community facilities for evaluation and treatment such as sexual assault evaluation, vaginal bleeding, and acute abdominal pain in a pregnant patient, or pregnant patient in labor. A VANCHCS gynecologist will be available for emergency care consultation either on-site or by phone.

n.

Inpatient Care: For those patients requiring hospitalization, inpatient care may be provided at Sacramento VA Medical Center, the Community Living Center, Sacramento VA Psychiatric Inpatient Care Unit (PICU), through sharing agreement at David Grant Medical Center, Travis AFB, referral to other VAMCs, or through contracts with local facilities. Contract hospitalization can be utilized in those cases where the patient’s condition warrants admission to a local facility and services are not available at a VA facility. Screening pelvic and breast exams may be deferred if clinically unrelated to an acute hospitalization. Upon discharge from acute hospitalization, a follow-up appointment will be made to complete these exams if indicated. Female patients must be placed in private or same-sex semi-private rooms with privacy curtains (privacy curtains not required in PICU). Female patients must have access to private and secure bathroom facilities (toilet and shower) with appropriate door locks, bathroom facilities must be in close proximity to the patient’s room. Female pajamas and robes must be stocked on all inpatient units.

o.

Physical Medicine and Rehabilitation: Services will be tailored to the unique needs of women Veterans including ordering and stocking equipment and supplies that are the correct size and fit. A chaperone will be present for pelvic floor physical therapy examinations and treatments.

p.

Prosthetics Services: Supplies specific to women Veterans should be properly stocked, easily requested and provided in a timely manner. Gender-specific prosthetic items include: breast pumps, nursing bras, mastectomy bras, breast prosthesis, post-mastectomy camisoles and bathing suits, wigs, pregnancy abdominal binder, vaginal/bladder prolapse device, IUD, and Implannon.

q.

Health Care Environment: VANCHCS will ensure a health care environment that enhances quality of care, promotes comfort, privacy, dignity, feelings of security, and a sense of welcome for women Veterans. This will be accomplished through:

(1) Review of the health care environment on a routine basis by the WVPM and appropriate facility EOC members. Participation in the facility’s annual review of health care environment

(2) Ongoing process to assess and correct physical deficiencies and/or environmental barriers to care for women Veterans

(3) Orientation and in-service education of employees to address attitudes and sensitivity towards women Veterans

(4) Accommodations with emphasis on privacy in exam rooms, restrooms, and bathing facilities

(5) Appropriate patient apparel and availability of personal hygiene products and;

(6) Canteen services that include appropriate products and services for women such as hair products.

r.

Privacy: All staff will maintain sensitivity and privacy, both visual and auditory, in the provision of care to women Veterans. The following must be adhered to:

(1) Regardless of the provider’s gender, a female chaperone must be in the examination room, during examinations, treatments or procedures of breast and genitalia.

(2) Women Veterans will be interviewed and treated in private rooms with privacy curtains, privacy curtains must shield the exam area, appropriate draping must be used during breast and pelvic examinations or procedures, and the examination table will be facing away from the door, exam room door must be locked during the examination, and adequate time given to the patient to disrobe in private;

(3) Prior to any examination, health care providers should explain the necessity of examination, the components of the exam, and the need for various diagnostic studies, in order to minimize the patient’s anxiety and possible misunderstandings.

(4) The patient will never be asked to disrobe in the provider’s immediate presence;

(5) When the patient is fully dressed after the exam, the provider must discuss any positive findings and provide opportunity for questions.

9.

REVIEW, RECISION OR REISSUE DATE:

The WVPM will review this policy for rescission or reissue within five years of the date of this issue. Target review date is within five years of the date of issue (April 20, 2023). If the review is not completed within the target review date, this policy will remain active and current, until the review is completed and a new policy is published or the existing policy is rescinded.

10.

REFERENCES:

VHA Handbook 1330.01, VHA Services for Women Veterans, May 21, 2010 VHA Handbook 1330.02, Women Veterans Program Manager Position, March 28, 2007 VHA Handbook 1330.03 Maternity Healthcare and Coordination, October 5, 2012

VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, September 11, 2008 VHA Handbook 1104.1, Mammography Standards, August 6, 2003 VHA Directive 2005-015, Military Sexual Trauma Counseling, March 25, 2005

VHA Directive 1102.2, Elective Sterilization (Tubal ligation and Vasectomy), July 16, 2004 VHA Directive 2006-031, Primary Care Standards, May 17, 2006 PL 102-585, Veterans Health Care Act of 1992, Sections 102-110

PL 104-262, Veterans Health Care Eligibility Reform Act of 1996

PL 106-117, Veterans Millennium Health Care and Benefits Act

IL -10-2005-014, August 8, 2005, Cervical Cancer Screening for Women

IL 10-2001-01, Guidance on Infertility Services for Veterans Enrolled in VA Health Care System

IL 10-99-002, Guidance on Maternity Benefits for Women Veterans Enrolled in VA Health Care System

IL 10-2014-10 Guidance on Emergency Medical Services for Women, April 15, 2015

VANCHCS Policy Statement 11-121, Breast Cancer Screening and Diagnostic Imaging, January 2016 VANCHCS Policy Statement 11-103, Cervical Cytology Screening and Dysplasia Patient Management, December 15, 2011 11.

ORIGINAL EFFECTIVE DATE: Unknown.

12.

RECISSION

Policy Statement 11-127 dated September 8, 2010.

David Stockwell, MHA Director