D.4 Women's Health Mammography and Cervical Screening Care Coordination 02.pdf

D.4. WOMEN’S HEALTH SCREENING CARE

36C25923R0040

Women’s Health Mammography and Cervical Cancer Screening Care Coordination

Eastern Oklahoma VA Healthcare

System Muskogee, OK, 74403

Signatory Authority:

Chief of Staff

Responsible Owner:

Women Veterans Program Manager

1. PURPOSE AND AUTHORITY

SOP 001

Service Line(s):

Medicine

Effective Date:

4/8/2022

Recertification Date:

4/8/2027

a. The purpose of this standard operating procedure (SOP) is to establish procedures on mammography and cervical cancer screening care coordination.

This SOP must be followed by Women’s Health Care Coordinator or designee(s) who provides care coordination for Women Veterans.

b. This SOP sets forth mandatory procedures and processes to ensure compliance with VHA Directive 1330.01(3), Health Care Services for Women Veterans, dated

February 15, 2017. Per VHA Directive 1330.01(3) Each facility must have standard operating procedures that specify the tracking process and assign breast, maternity, and gynecological care coordination to specific individuals.

1. PROCEDURES

a. Mammography Care Coordination

(1) RN Navigator will track mammography due dates for all eligible women using the Breast Cancer Registry (BCR) or other applicable care management tool. RN Navigator will alert ordering provider to the need for a mammogram by monthly email. RN Navigator will alert Veteran to the need for a mammogram through the use of a CPRS Women’s Health patient reminder letter.

i. Any PACT team that is aware of the need for a mammogram may notify the Veteran and enter the consult. The RN Navigator will be alerted to this action via a view alert in CPRS when the consult is signed.

(2) Care Coordination duties include but are not limited to:

ii. Tracking the following information: Date of screening consult, authorized date, date of appointment, available result date, requesting results from non-VA facility, result report date to provider, how reported to Veteran, BIRADS, and any need for follow up. This information is maintained in an Excel Spreadsheet saved in (W:) Women’s Health Drive.

iii. All BIRAD 0 results will have an additional/new consult entered for

Diagnostic Mammogram and/or additional studies as indicated. Consult

April 8, 2022 SOP 001 can be placed by the RN Navigator and will be held until signed by the provider.

iv. Ensuring communication between Veteran and providers, such as triaging questions, and ensuring that all results are communicated to patients. The RN Navigator or RN Care Manager will communicate via a CPRS Patient Results Notification letter all normal results that do not require follow up.

The RN Navigator/RN Care Manager/Provider will update the mammography clinical reminder for all normal results. The ordering provider will update the mammography clinical reminder for abnormal mammograms. Effective 1 August 2021, the significant findings tab in the Consult Toolbox (V2.0) will be used to alert ordering providers to significant findings requiring follow up actions. The ordering provider will notify the patient verbally by phone of any mammography results that require some level of follow up. All communication of results must be entered into the medical record by the provider.

v. Initiating coordination of breast cancer care within the VA including assisting Veteran with navigating appointments and services and ensuring communication between VA providers.

vi. Facilitating access to non-VA providers when needed and ensuring communication between VA and non-VA providers.

vii. Ensuring that pertinent copies of all non-VA medical records are obtained and entered into the VA medical record. The RN Navigator may request the records for a past mammography appointment. When obtained may place in Vista and sent to CITC for completion of consult.

viii. Radiology will enter the BIRADS score into the radiology package.

b. Cervical Cancer Care Coordination

(1) RN Navigator/RN care managers/LPN will track cervical cancer screening due dates for all eligible women using CPRS reminders or other applicable care management tool. RN Navigator/RN care managers/LPN will alert ordering provider to the need for a cervical cancer screening and alert Veteran to the need for cervical cancer screening using a CPRS Women’s Health patient reminder letter.

(2) Pap smears are not primarily sent to Community Care, and as such the PACT- Team members will coordinate the scheduling for these appointments.

(3) Care Coordination duties for cervical cancer screening include but are not limited to tracking the following information: appointment date, date results read, result report date to provider, date results reported to Veteran, how results are reported to Veteran, and any need for follow up. This information is maintained in an Excel Spreadsheet saved in (W:) Women’s Health Drive.

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(4) Ensuring communication between patient and providers, such as triaging questions, and ensuring that all results are communicated to Veterans. PACT Teams will communicate results, RN Navigator will track records and/or results that are received. All communication of results must be documented in the medical records.

(5) Ensuring that pertinent copies of all VA medical records are obtained when indicated and entered into the VA medical record. Providers should adjust the clinical reminder to reflect the most updated VA.

(6) Competency/Skills Check on the actions/responsibilities in this SOP will be completed on initial employment and annually thereafter.

2. ASSIGNMENT OF RESPONSIBILITIES

a. RN Navigator/RN Care Manager/Provider. Primarily responsible for the duties detailed above.

b. Women Veterans Program Manager. Provides a layer of coverage in the absence of the RN Navigator.

3. DEFINITIONS

a. None

4. REFERENCES

VHA Directive 1330.01, Health Care Services for Women Veterans, dated February 15, 2017; amended July 24, 2018; amended June 29, 2020.

5. REVIEW

SOP will be reviewed upon changes to the position, and/or processes outlined in this document.

6. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of April 2027.

In the event of contradiction with national policy, the national policy supersedes and controls.

7. SIGNATORY AUTHORITY

Michele J.

Digitally signed by Michele J.

Reeves 3626508

Reeves 3626508 Date: 2022.04.12 14:26:19

Michele Reeves Acting Women Veterans Program Manager Date Approved:

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Moncarm A.

Digitally signed by Moncarm

A. Fouche 954125

Fouche 954125 Date: 2022.04.12 20:43:41

Dr. Moncarm Fouche Acting Chief of Staff Date Approved:

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Saved in W:Womenshealth, Shared through email to relevant parties to include WHMD, COS, RN Navigator, DCOS, and Chief of PC.