S02 - Attachment 27 - Numbered Memorandum 11-68-18 Maternity Healthcare and Coordination.pdf

VA Medical Center Numbered Memorandum 11-68-18 Spokane, WA April 02, 2018

MATERNITY HEALTHCARE AND COORDINATION

1. PURPOSE: To provide policy, procedural guidance, and responsibility for providing and coordinating maternity care for pregnant women Veterans enrolled in the Department of Veterans Affairs (VA) health care system and receiving maternity services through the VA and/or Non-VA medical care.

2. POLICY:

a. It is the policy of Mann-Grandstaff Veterans Affairs Medical Center (MGVAMC), to provide comprehensive prenatal, intra-partum, and postpartum care to eligible women Veterans. Maternity benefits begin with the confirmation of pregnancy, preferably in the first trimester, and continue through the final post-partum visit, usually six to eight weeks after the delivery, when the Veteran is medically released from obstetric care.

MGVAMC must have a designated maternity care coordinator (see Veterans Health Administration [VHA] Handbook 1330.03). A maternity care coordinator functions as a liaison between the patient, the Care in the Community (CITC) provider, and MGVAMC.

This person is responsible for monitoring the delivery of care, coordinating such care, and tracking outcomes of services that have been furnished through maternity-purchased care. Maternity benefits consisting of prenatal care, including necessary medication, testing, monitoring, and professional consultation specific to pregnancy are covered benefits. This may include maternal-fetal specialist, childbirth preparation classes, breast milk bags, nipple cream, breast pads, labor, delivery, and post-partum care. In addition, home visitation, if needed, will be covered by VHA for all women Veterans who seek this service. Breast pumps, nursing bras, back supports, and maternity stockings will be provided by MGVAMC prosthetics via consult. Elective surgical sterilization during the immediate post-partum hospitalization will be authorized.

b. VA does not pay for home deliveries with lay midwives, or experimental or non-approved medical procedures.

c. Newborn care is available for Veterans enrolled in VA care and receiving VA maternity benefits. All medically necessary and appropriate post-delivery services, including transfer, are included in this benefit (see 38 Code of Federal Regulations [CFR] § 17.38 [a][1][xiv]) for seven days post-delivery.

d. Abortion and abortion counseling are excluded from the medical benefits package (see 38 CFR § 17.38 [c][1]).

e. When a Veteran presents with a miscarriage, also known as spontaneous abortion, the specialty provider may deem it medically necessary to provide care in the form of a

Attachment 27

2. April 02, 2018 Numbered Memorandum 11-68-18 procedure (i.e., dilation and curettage), or through medical management consistent with standard of care. Such medically necessary procedures for the management of miscarriage care are covered medical benefits.

3. PROCEDURES:

a. Pregnancies will be confirmed by a lab test done within MGVAMC or through

CITC.

b. Upon receipt of a positive pregnancy test, and confirmation that the eligible Veteran requests VA maternity benefits, the primary care provider or designee will complete a CITC maternity consult.

c. Once a positive pregnancy test is confirmed, the maternity care coordinator will be alerted via Electronic Medical Record (EMR) for the purpose of conducting a psychosocial risk assessment to identify presence of a broad range of social, economic, psychological, and emotional problems. Screening includes, but is not limited to, an assessment of barriers to care, unstable housing, communication barriers, nutrition, tobacco use, substance use, depression or other psychiatric illness, employment or financial status, safety, domestic abuse, sexual abuse, and stress. Approved tools, such as the Edinburgh Scale or the Patient Health Questionnaire 2 or Patient Health Questionnaire 9 will be used for screening for depression.

d. CITC will contact the patient and determine which maternity provider in the community the patient has chosen. CITC will send authorizations and information letters to the Veteran and to the maternity provider. The Veteran may schedule their maternity appointment(s).

e. Consultations and ongoing specialty care not directly related to the pregnancy may be managed by the VA Patient Aligned Care Team (PACT) per usual primary care referral or CITC process as necessary (i.e., orthopedic needs, behavioral health appointments).

f. The maternity care coordinator will assist the Veteran during the prenatal and postpartum period. Care will be coordinated to ensure that relevant information is exchanged between the maternity provider, the VA provider, the patient, and all sites of care, including the anticipated delivery site. He/she will contact the patient at least every two months and document contact in the medical record. Assessments and interventions will include:

(1) Contact the patient about maternity benefits including the benefit for newborn care for the first seven days, if necessary,

(2) Mail the patient a template maternity letter, the book “Pregnancy and Childbirth”, and the local VA maternity benefits brochure,

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(3) Contact the PACT Registered Nurse (RN) Care Manager on the patient’s healthcare team,

(4) Enter a record flag into the Veterans Health Information Systems and Technology Architecture (Vista) software program,

(5) Completion of preventive care visit and medication reconciliation, to include prenatal vitamins, this must be done immediately to remove any medications that are harmful to the pregnancy from the patient’s regimen,

(6) Completion of prenatal and postpartum depression screens,

(7) Appointment dates completed and scheduled with maternity provider,

(8) Obtain and document patient’s due date,

(9) Completion of immunizations, specifically Tetanus, Diphtheria, and Pertussis

(Tdap), and Influenza,

(10) Assist the patient in obtaining medications from the VA that have been ordered by the maternity provider,

(11) Facilitate obtaining and scanning outside maternity medical records,

(12) Ordering prosthetics items six to eight weeks prior to delivery date,

(13) Discuss contraception plans following delivery and advise patient tubal ligations are covered if completed during the maternity-related hospitalization, and

(14) Assure patient is placed in recall for a VA provider visit three months postpartum.

g. MGVAMC is not staffed or equipped to manage obstetric emergencies. Veterans shall be provided information about seeking emergency care for obstetric emergencies at the closest emergency room or at the hospital they will be using for the delivery of the infant, if necessary. Fee basis staff and the Women Veterans Program Manager (WVPM) shall guide the patient to seek payment for that care through CITC within 72 hours after the emergency care has been provided. Approval of these claims is subject to current VHA regulations.

h. Although medications such as prenatal vitamins are often prescribed by VA providers, other medications that are specific to the pregnancy shall be prescribed by the obstetric providers. Medications prescribed by the obstetric provider may be filled through MGVAMC’s Fee Pharmacy program. Prescriptions from obstetric providers can be faxed to MGVAMC and either mailed or set for window pick up at the Veteran's request.

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i. Additional approved maternity services which may be recommended by the maternity provider include:

(1) Standard and special laboratory tests,

(2) Counseling and screening for genetic disorders,

(3) Specialty consultation, for example Maternal-Fetal Medicine Specialists, Cardiologist, and Endocrinologist and diabetic educators for high-risk patients,

(4) Gestational dating ultrasounds,

(5) Emergency room visits and hospitalizations related to obstetric complications,

(6) Pregnancy-related education such as childbirth preparation classes, parenting classes, nutrition classes, breastfeeding support, and lactation classes, and

(7) Pharmacy items, to include breast milk bags, nipple cream, and nursing breast pads.

j. Non-approved maternity care includes home deliveries, deliveries by direct-entry midwives and experimental procedures and medical procedures not consistent with the standard of care. Women Veterans are authorized to deliver at birthing centers staffed with Certified Nurse Midwives.

k. The following items are available for pregnant women through Prosthetic and Sensory Aids Service (PSAS). These items may be requested by the WVPM, obstetric provider, maternity care coordinator, or primary care provider.

(1) Electric breast pump,

(2) Nursing bras,

(3) Pregnancy abdominal supports (maternity support belts), and

(4) Compression stockings for varicosities.

4. RESPONSIBILITIES:

a. Chief of Staff (COS) is responsible for ensuring:

(1) Appropriate maternity care is provided for pregnant patients on the inpatient psychiatric units or in residential care programs.

(2) The VA provider enters a CITC maternity referral consult request in the Computerized Patient Record System (CPRS), which will be shared within the VA and

5. April 02, 2018 electronically sent to offices affected by it, or that the CITC primary care provider enters a secondary authorization request (SAR) for maternity care.

(3) The consult includes a request for key services necessary in standard obstetric care.

(4) Ensuring that all pregnant women Veteran patients are screened for depression.

(5) Written guidance is in place to ensure that VA providers counsel women Veterans on the risks and benefits of high-risk teratogenic medications (i.e., Food and Drug Administration [FDA] class D or X), if those drugs are being considered for use and the Veteran has the potential to become pregnant. Such counseling must be documented in CPRS and must be accomplished personally by the prescriber prior to writing an outpatient prescription or inpatient doctor's order.

b. CITC is responsible for:

(1) Taking appropriate and timely action once a CITC maternity care referral consult is received.

(2) Ensuring that all purchased care authorizations include, as appropriate, the following: tests and procedures within the standard of care in monitoring the pregnancy, routine labor and delivery services, and postpartum services, including home visitation, if needed.

(3) Providing the requirements for a CITC provider to coordinate care and update the VA provider with any change in the Veteran’s condition that may require separate authorization for services.

(4) Providing instructions for all CITC providers to notify the Nursing Officer of the Day (NOD) of an emergency admission or transfer within 48 hours.

(5) Providing a letter to the Veteran and CITC provider explaining authorizations.

(6) Defining, for the purposes of participating in VA’s Purchased Care program for maternity care services, that the provider be a qualified provider under VA prescribed guidelines.

c. Maternity care coordinator or designee is responsible for:

(1) Monitoring the delivery of services, coordination of care, tracking of maternal and fetal outcomes, and maintaining statistical data on maternity care, including patient demographics, number of women Veterans receiving OB care, maternal complications, neonatal complications, method of delivery, and lactation status.

(2) Facilitating access to local and community resources.

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(3) Ensuring the coordination of maternity care through the local health care system, including Community Based Outpatient Clinics (CBOCs), and outpatient clinics that are distant from the main facility.

(4) Informing the Veteran of VA authority for newborn care, and reviewing the need for other Non-VA payment options for possible continued care past the VA payment authority.

(5) Ensuring that an electronic alert is added to the patient’s computerized health record indicating that she is pregnant or lactating.

(6) Maintaining a minimum of bi-monthly contact (every other month) with the patient while she is in the care of the non-VA provider.

(7) Documenting contact information in the electronic health record to include the name and location of the non-VA provider.

(8) Functioning as a liaison between the patient, contracted provider, and MGVAMC (i.e., providers, Fee Office, pharmacy).

(9) Assuring that the patient has a three month or earlier postpartum appointment with their VA primary care provider.

(10) Screening/collaborating with Intimate Partner Social Worker and Primary Care Mental Health Integration (PCMHI) for at-risk veterans.

(11) Ensuring coordination of care with the relevant VA providers and MGVAMC’s WVPM, especially if the Veteran has pre-existing medical or mental health conditions.

(12) Facilitating coordination of maternity care for pregnant patients on inpatient psychiatric units or in residential care programs.

d. Health Care Administrative Service (HCAS) staff are responsible for determining eligibility.

5. REFERENCES:

Title 38 United States Code (U.S.C.) §§1703, 1710, 1725, 1786, 7302, 8153 Title 38 CFR §§17.38, 17.52, 17.53, 17.1000 Section 206(a) of Public Law 111-163, The Caregivers and Veterans Omnibus

Health Care Services Act, dated May 5, 2010 VHA Handbook 1330.03, Maternity Health Care and Coordination, dated

October 5, 2012 VHA Directive 1330.01, Health Care Services for Women Veterans dated

February 15, 2017, amended September 8, 2017 VHA Directive 1101.05, Emergency Medicine, dated September 2, 2016, amended March 7, 2017

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6. RESCISSION: Numbered Memorandum 11-68-14, Maternity Health Care and Coordination, dated February 10, 2014

7. FOLLOW-UP RESPONSIBILITY: Chief of Staff (011), Women Veterans Program Manager

//signed// Robert J. Fischer, MD Medical Center Director

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