D.31 Maternity Mammogram Coordinator SOP, 36C25522R0052.pdf

Department of Veterans Affairs Truman VA Medical Center Columbia, MO

October 25, 2022

Mammogram Care Coordinator

Standard Operating Procedure

1. PURPOSE: To establish care guidelines for the safe, ethical, respectful and appropriate management of mammography, and maternity care.

2. POLICY: To provide eligible women veterans with all clinical and administrative services necessary for their care as outpatients and inpatients.

3. BACKGROUND: All Veterans who are enrolled and assigned in VA’s health care system. (ChampVA is not eligible for mammography services or any OCC services due to our facility has not in house services).

4. DEFINITIONS:

• BI-RADS score: The BI-RAD system was developed by radiologists for reporting mammogram results using a common language. The radiologist assigns a single digit BI-RAD score (ranging from 0 to 5) when the report of a mammogram is created.

• Community Care consults: Consults made to an outside facility

• HIMS: Health Information Management Section. This department handles the scanning in of records.

• OCC: Office of Community Care, the department within the VA Hospital who handles outside fee-based consults. Formally known as Fee Basis Department or Non-VA Community Care

• PACT: Patient Aligned Care Team. This is the patient’s PCP and members of the team.

• Provider: MD, NP

• CCRN: Primary Care PACT RN Care Coordinator

D.31 Maternity Mammogram Coordinator SOP, 36C25522R0052

• MCC: Maternity Mammogram Care Coordinator (OCC)

• OCC WHS PACT TEAM (OCC supervisor, RN, LPN, AMSA)

• OCC: Registered Nurse Supervisor

• WVPM: Women Veterans Program Manager

• WHMD: Women’s Health Medical Director

BI-RAD Score The meaning of weight Follow-up BI-RAD 0 = Incomplete The image does not give the radiologist enough information to make a clear diagnosis

More imaging is needed

BI-RAD 1 = Negative There is nothing abnormal on the image

Routine screening (annual mammogram) is recommended

BI-RAD 2 = Benign There is a finding on the images that is definitely benign

Routine screening (annual mammogram) is recommended

BI-RAD 3 = Probably Benign

There is a finding on the images that is probably (>98% certainty) benign

A shorter follow-up is recommended (typically 6 months)

BI-RAD 4 = Suspicious There is a suspicious abnormality. This abnormality has a 3-94% chance of being malignant

A biopsy is recommended to further evaluate this abnormality

BI-RAD 5 = Highly suggestive of malignancy

There is an abnormality that has a high probability (>95% chance) of being cancerous

A biopsy is needed to make a full diagnosis

5. RESPONSIBILITIES:

• Women’s Health Medical Director: Guidance and support of Women’s

Health Program. Supervision is by the Nurse Manager of Office of Community Care.

• Women Veteran Program Manager: Guidance and support of Women’s Health Program. Supervision is by the Nurse Manager of Office of Community Care.

• OCC Nurse Manager: Supervision, guidance, and support for MCC.

• Maternity Mammogram Care Coordinator – Clinical expert and support to the Women’s Health Program in OCC.

• Providers and Nursing staff: Work collaboratively with MCC in effort to provide seamless care in a mutually respectful manor. Mammogram completed in the community will be faxed directly to OCC WH fax 573- 814-6288. Upon receipt of results, MCC will review and notify PCP/CC team via a SMART BREAST IMAGING REMINDER (CPRS National Template). Ordering providers are responsible to review mammography and breast cancer screening results upon notification of results, formulate a plan of care within the chart and communicate results appropriately to the patient per VHA directive 1330.01, which states upon receipt of results within 7 days for abnormal results or 14 days for normal results.

Then provider or designee will complete the SMART BREAST NOTIFICATION note to document patient notification in veterans’ chart.

6. PROCEDURE:

A. Breast Care

• Provider enters the Community Care consult along with Radiology order.

• MCC tracks discontinued mammogram consults and attempts to reach patient to discuss reason consult was discontinued. A new consult will be entered if appropriate and sent to the provider for signature.

• PACT or designee is responsible to follow up with the veterans who decline services.

• If a veteran does not complete their mammogram due to no show or no contact (failed mandated scheduling with OCC), the MCC will attempt to reach the Veteran to facilitate scheduling. If unable to reach by phone, a letter will be mailed providing education on the risks of breast cancer and benefits of screening.

• OCC LPN requests records of mammograms if they have not been received by OCC in effort to receive these results as soon as possible after the mammogram test date. A comment is added using the Consult Toolbox (CTB) to the consult if results have been requested to prevent work duplication. The LPN or designee will also check the Right Fax files for receipt of records.

• All faxes received by OCC will be forwarded to HIMS for scanning via Right Fax. This is to ensure that all reports are received and are available to the provider in a timely fashion (usually within 24 to 48 business hrs. for normal results). Any abnormal results are sent to HIMS and PCP simultaneously for review.

If any hard copies in clinics the PACT teams will forward mammography reports to OCC WH fax number 573-814-6288 for review upon receipt.

• MCC documents the results in CPRS using SMART Breast Imaging Reminder note in CPRS that includes:

o Facility name o Date of test o Results o Recommendation o Clinical reminder o Alert to PCP/CC stating “Alerting PCP/CC, please review mammogram results and notify Veteran. Please document notification using CPRS note "SMART PATIENT NOTIFICATION." Thank you.” To notify and document results to the patient.

o This documentation must be cosigned by the ordering provider o For all normal results, a letter will be generated through either the SMART reminder or template and will be mailed by the RNCC to the Veteran, after reviewed by PCP. All abnormal results (BI-RADS 4-6) should be reported to the patient by the provider via phone if possible or certified letter if unable to reach by phone.

• RNCC calls or sends letter for BI-RAD 0, 1 ,2 and 3 results to the veteran within 14 days of receiving results (according to VHA directive 1330.01).

• OCC WHS PACT communicates with testing facility as an advocate concerning BI-RAD 0,3-6 advising that further testing is authorized within the authorization and the veteran should be scheduled as appropriate if not already. Follow-up appointment date is added to the consult by the OCC WHS PACT team. If testing facility needs additional orders, MCC or Designee places orders and/or alerts PCP for immediate signature. OCC WHS PACT team faxes order to testing facility. After confirmation that Veteran has been notified of results by PACT Team or Design then OCC WHS PACT assists veteran in getting scheduled for follow up imaging.

• MCC sets up a Self-alert in CPRS for short term follow-ups 3-6 months for BI-RAD 3. When the alert is received by MCC, notifies PCP to place consult for requested imaging in the future. OCC WHS PACT works with Veteran and vendor to get imaging scheduled for due date.

• OCC WHS PACT notifies PACT PCP of BI-RAD 4-6 results immediately upon receipt for additional services needed.

Additionally, the veteran is contacted by the provider as soon as possible within 3-5 business days (according to VHA directive 1330.01), and instructions are provided to ensure scheduled follow-up exams with the facility if not already done.

• When testing is complete the MCC will add to the National Spreadsheet and continue to track all abnormal results until the radiologist recommends return to annual screening or patient is referred to the breast surgeon. MCC is responsible to monitor for short term follow-up only. Notification of annual mammograms are a courtesy on behalf of the MCC and is contingent on MCC’s schedule. If the patient is high risk for breast cancer (greater than 20% lifetime risk, the MCC will alert the provider of alternating mammograms and MRI on every 6-month cycle as recommended by the radiologist. The clinical reminder should alert the provider for all other routine annual screenings. The MCC can run a list of all coming due mammograms for the next month in the preceding month on the Breast Care Registry.

• If the mammogram is discontinued for any reason other than refusal the MCC will attempt to call the Veteran to provide education. If unable to reach, a letter will be sent out by MCC advising the Veteran to contact their PACT if they desire to have the mammogram. PACT is responsible to enter another consult/order should the patient call back.

• In the event of communication with the vender related to “no show”, missed appt’s etc., the OCC WHS PACT team will attempt to reach the Veteran and get the appointment rescheduled or enter a new consult if the Veteran agrees to care and the consult is greater than 90 days old. A comment will be added to the consult with the new appointment date or other pertinent information.

• MCC manages/oversees CHAMPVA mammograms the same as above except the clinics are responsible for providing an order on a prescription pad, as these are not done through community care consult.

B. Breast Care Registry

• MCC will utilize the Breast Care Registry to identify veteran’s coming due for mammogram. Veteran’s will be notified via phone call, letter, or secure message their mammograms are coming due.

The MCC or Primary Care PACT Team can alert the veteran is coming due for mammograms. The report can be ran several months in advance to capture Veterans that will be coming due for an annual screening to give time to schedule and complete prior to due date past.

• MCC will utilize Breast Care Registry to identify veterans that are overdue. MCC will mail out letters to veteran, or call to verify if veteran is need of mammogram, or receiving care outside of VA.

Sometimes MCC will alert PACT team if there is not mention of mammogram in chart during last office visit. Then a new consult for mammogram will be ordered/placed by PCP/CC once veteran has agreed to mammogram in the community.

C. Maternity Care

• When maternity care consults are entered by the PACT, the MCC will contact the patient to determine where they wish to receive maternity care.

• The MCC will enter the co- pregnancy lactation flag in Vista.

• The MCC will mail a maternity packet which includes a booklet that discusses consult coverage in understandable verbiage. Also included in the packet is copies of the authorization letter, “the purple book” an educational pregnancy book, and a pregnancy passport where the patient can document medical information and pregnancy milestones. The pregnancy passport is meant to be a keepsake for the future. In some packets, if the patient states they smoke, they are given educational material to help them facilitate smoking cessation. Other educational material may be sent at the discretion of the MCC based on the individualized needs of the patient.

• The MCC will call each veteran approximately upon notification of positive pregnancy result, within one week of maternity consult, 12 weeks pregnant, 20 weeks pregnant, 28 weeks pregnant, 36 weeks pregnant, 41 weeks (delivered or not), 6 weeks postpartum and staring in June 2023 every 3 months in the postpartum period for a wellness check. The initial call is introductory, and information is shared concerning how to get emergency care, consult coverage, and to ask questions concerning their consult.

All other calls education is provided at the individual veteran’s needs and also based on recommendations from field guide book for maternity care coordinator calls: Maternity Toolkit_current.docx (sharepoint.com)

• Patients are advised all specialty care outside of their OB/GYN’s care should be reported to the Office of Community Care or MCC immediately. The MCC will facilitate getting any specialty consult orders needed by requesting office notes and Request for Service (RFS) be faxed to the PCP and alerting OCC through the consult https://dvagov.sharepoint.com/:w:/r/sites/VHAWomensHealth/_layouts/15/Doc.aspx?sourcedoc=%7B704E681F-66D2-4827-BAE9-EFECF450CB0B%7D&file=Maternity%20Toolkit_current.docx&action=default&mobileredirect=true https://dvagov.sharepoint.com/:w:/r/sites/VHAWomensHealth/_layouts/15/Doc.aspx?sourcedoc=%7B704E681F-66D2-4827-BAE9-EFECF450CB0B%7D&file=Maternity%20Toolkit_current.docx&action=default&mobileredirect=true comments of request for authorization. MCC is not responsible for entering consults but will assist the provider when necessary to facilitate care.

• All billing issues will be alerted to MCC or OCC WHS PACT team to help facilitate.

• Near the end of the pregnancy, the MCC will offer a custom nursing package to Veterans that plan to breastfeed.

• Maternity care patients are contacted by the MCC until 8 weeks postpartum. During the last call patients are encouraged to call their PACT as needed. PACTs are notified in the postpartum note to facilitate scheduling with PACT 10-12 weeks postpartum.

However new mandates will have MCC continue calling veterans throughout 1 year postpartum (starting in June 2023).

• Lactating Veterans will be called every 3 months to assess whether or not they are still breastfeeding so the co-pregnancy lactation flag can be maintained.

• Lactation services are available either in the community or by an interfacility consult to another VAMC via telehealth. The services are covered by the VA and available to the Veteran as long as needed even beyond the 8 weeks postpartum, a addition consult may be needed.

D. REFERENCES:

• Department of Veterans Affairs Medical Center, Medical Center

Policy 11-11PC-054, October 1, 2015

• Veterans’ Health Administration VHA HANDBOOK 1330.01 15

• Maternity Toolkit_current.docx (sharepoint.com)

In the public file for women’s health has resources and the trackers for mammograms, and maternity care.

https://dvagov.sharepoint.com/:w:/r/sites/VHAWomensHealth/_layouts/15/Doc.aspx?sourcedoc=%7B704E681F-66D2-4827-BAE9-EFECF450CB0B%7D&file=Maternity%20Toolkit_current.docx&action=default&mobileredirect=true

E. This Standard Operating Procedure has been reviewed and approved by the following officials:

OCC CARE NURSE MANAGER Date

WOMENS VETERANS PROGRAM MANAGER Date

WOMENS HEALTH MEDICAL DIRECTOR Date

Approved by WH Committee YES or NO

Reviewed Date(s)

Revised Date(s)