S02 ATTACHMENT D.18 - SOP 011-06 MATERNITY CARE.pdf
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- Attached to
- Q201--Harrison, AR Community Based Outpatient Center (CBOC) Federal contract opportunity
- Solicitation number
- 36C25623R0079
About this file
This document outlines standard operating procedures for a Veterans Health Administration facility's maternity care coordination program. Key responsibilities include the maternity care coordinator confirming pregnancy test results and coordinating care between VA and non-VA providers from prenatal to postpartum and lactation stages. The facility will maintain statistical data on maternity outcomes and report quarterly to the VHA Support Service Center and Women Veterans Health Committee.
This federal contract opportunity is to provide primary care and mental health support services through a Community Based Outpatient Clinic in Harrison, Arkansas to serve local Veterans. Required onsite services at the private facility include primary care, mental health support through telehealth, and support functions like pharmacy, laboratory, and x-ray. Mental health services will be directly provided by the Veterans Health Care System of the Ozarks while contractor staff will support those efforts. The performance period is within the city limits of Harrison, Arkansas, operating on behalf of Veterans Health Care System of the Ozarks, VISN 16, under the Department of Veterans Affairs.
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Text version
MATERNITY CARE COORDINATION
SOP 011-06
Veterans Health Care System of the Ozarks (VHSO) Fayetteville, AR 72703
Signatory Authority:
Chief of Staff
Responsible Owner:
Women Veteran Program Manager
Service Line(s):
Chief of Staff
Effective Date:
January 17, 2023
Recertification Date:
January 17, 2028
1. PURPOSE AND AUTHORITY
a. The purpose of this standard operating procedure (SOP) is to establish procedures on maternity care coordination.
b. This SOP sets forth mandatory procedures and processes to ensure compliance with Veterans Health Administration (VHA) Directive 1330.03, Maternity Health Care and Coordination, dated November 3,2020.
2. PROCEDURES: The MCC, Women’s Health Coordinator (WHC) and Women Veteran Program Manager (WVPM) functions as a liaison between the patients non- Veterans Affairs (VA) care provider, VA office and the local VA medical facility.
a. Prenatal Care.
(1) Identification of the Pregnant Veteran
(a) Veteran has a positive pregnancy test and notifies primary care provider, registered nurse or MCC.
(b) Review lab section in electronic medical record (EMR) for positive human chorionic gonadotropin (HCG) test or provider note stating positive home pregnancy test.
(c) The Primary Care Provider places a consult to the Office of Community Care
(OCC).
(d) The MCC is notified with an EMR alert when a consult has been placed.
(2) Documentation of Pregnancy
(a) A note will be placed in the medical chart updating the pregnancy review which will flag the chart to ensure the Veteran is identified as being pregnant and this will also identify that the Veteran is pregnant under the Women’s Health section on the cover page in the EMR.
https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9095 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9095
January 17, 2023 SOP 011-06
(b) Verify the Community Care Obstetrics Consult has been placed and approved by identifying the VA authorization number assigned to the consult.
(3) Maternity Care Coordination Visit Note
(a) Once the VA authorization number is assigned the MCC will contact the Veteran to assess for maternity care coordination needs utilizing the information in the Maternity Care Coordination Telephone Care Program and document the encounters in the EMR.
(b) All encounters are to be documented per Veterans Health Care System of the Ozarks (VHSO) guidelines and standards for nurse visits.
(4) Maternity Care Coordination Visit
(a) Maternity Care Coordination appointments are scheduled at the notification of pregnancy and in accordance with Maternity Care Coordination Telephone Care Program.
(b) Document all Maternity Care Coordination in EMR using the Maternity Care Coordination templates.
(5) Consults for the Pregnant Veteran
(a) Consults will be placed per the Maternity Care Coordination Directive.
(b) Document all consults in the EMR.
(6) Education for the Pregnant Veteran
(a) Maternity Packet will be sent to pregnant Veterans in accordance with the Maternity Care Coordination Telephone Care Program.
(b) Prenatal, postpartum, lactation and newborn care education will be provided to Veterans and staff periodically.
b. Postpartum.
(1) Complete visit at delivery in accordance with the Maternity Care Coordination Telephone Care Program.
(2) Update Pregnancy Status Review note in the EMR.
(3) Update Lactation Status Review note in the EMR.
(4) Complete postpartum visit and complete documentation in accordance with the Maternity Care Coordination Telephone Care Program.
c. Lactation Program.
(1) Lactation Coordination.
(a) Discuss Lactation Program with the Veteran at first contact.
(b) Refer to SOP for the Lactation Program.
(c) Refer to Maternity Care Coordination Telephone Care Program.
(d) A consult will be placed with prosthetics for a lactation package at the third trimester visit.
(e) Assess lactation status, offer tele-lactation, and provide assistance if needed at delivery.
(f) Maintains a list of community or VA resources for lactation consultation, pregnancy and childbirth classes and access to community or state assistance programs.
(2) Lactation Documentation.
(a) Lactation flag needs to be placed in the medical chart at delivery if they are breastfeeding and remains in place until lactation is stopped.
(b) Lactation Status Review documentation is completed at intervals refer to Lactation SOP.
(c) All documentation will be in accordance with the Maternity Care Coordination Telephone Care Program.
(d) Instruct the Veteran to call MCC if they stop breastfeeding. When lactation stops discontinue the flag on the cover page by completing a Lactation Status Update Review note.
d. Quality.
(1) Maintain statistical data on maternity care, including patient demographics, number of patients being managed for maternity care, pregnancy outcomes and lactation status.
(2) Record maternity outcomes and report quarterly maternity data in VHA Support Service Center (VSSC) and report to Women Veterans Health Committee (WVHC).
(3) Complete Maternity Care Coordination Action Items.
(4) Assist WVPM with women’s health program as needed to include outreach event planning.
(5) Update and maintain Maternity Care Log.
(6) Assist obtaining of hospital records including delivery notes for review and scanning.
(7) Assist with obtaining non-VA maternity appointment progress notes, and test results for review and scanning into record.
3. ASSIGNMENT OF RESPONSIBILITIES
a. Primary Care Provider. is responsible for:
(1) Confirming VA pregnancy test results.
(2) Adding Pregnancy to problem list.
(3) Ordering Prenatal Vitamins.
(4) Entering Community Care Consult for Obstetric provider.
b. Community Care. is responsible for:
(1) Receiving consult, process as urgent due to potential 1st trimester risks.
(2) Scheduling patient with provider.
(3) Sending consult paperwork to patient.
c. Computer Application Coordinator (CAC). is responsible for:
(1) Ensuring alerts are set to notify Maternity Care coordinator upon obstetrics (OB) consult.
(2) Updating all national templates and reminders.
d. Lab Manager. is responsible for ensuring list of positive pregnancy tests are sent to MCC monthly.
e. Chief of Emergency Department (ED). is responsible for ensuring processes are in place for pregnant Veterans who present to the ED to ensure safe patient care in compliance with VHA Directive 1330.03, Maternity Health Care and Coordination, dated November 3,2020 and VHSO Medical Center Policy (MCP), Addendum to 11-004A, dated February 25, 2022.
f. MCC/Nurse Navigator. is responsible for:
(1) Coordinating care for all pregnant Veterans and those who are wanting to become pregnant.
(2) Coordinating care between VA and maternity care providers in the community, and all relevant VA and community specialist providers treating the pregnant Veteran.
https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9095 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9095 https://dvagov.sharepoint.com/:b:/r/sites/VHAfav/policyreview/Approved/11-004A.pdf?csf=1&web=1
(3) Tracking all Maternity patients and record data.
(4) Is the functioning liaison between the patients non-VA care provider, VA Community Care office and the local VA medical facility.
g. WVPM. is responsible for:
(1) Is the liaison between the patients non-VA care provider, VA Community Care office and the local VA medical facility.
(2) Ensures that the Patient Aligned Care Team (PACT) teams have resources available to meet the Veteran’s needs.
(3) Monitors Maternity Outcomes data and report to WVHC.
4. DEFINITIONS
a. Maternity. Maternity includes the following stages preconception, pregnancy, intrapartum, postpartum and lactation.
b. Postpartum Period. The postpartum period is usually 6-8 weeks following the delivery or when the Veteran is medically released from obstetric care.
c. Newborn Care. Newborn care includes post-delivery care/services, including routine care/services that a newborn child requires on the date of birth and the stated days in the directive that the newborn is covered after birth providing mother is a Veteran enrolled in VA healthcare and receiving maternity care furnished by the VA.
d. Lactation. Production of milk during or after birth.
5. REFERENCES
a. VHA Directive 1330.03 Maternity Health Care and Coordination, dated November
3, 2020.
b. Maternity Health Care and Coordination Toolkit for VHA Directive 1330.03, last updated September 6, 2022.
c. VHSO MCP, Addendum to 11-004A, dated February 25, 2022.
6. REVIEW
Review at minimum at recertification or when there are changes to the governing document (for example, national policy or a health care accreditation body mandate).
7. RECERTIFICATION
This SOP is scheduled for recertification on or before the last working day of January 2028. In the event of contradiction with national policy, the national policy supersedes and authorization from the VA.
https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9095 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=9095 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&DefaultItemOpen=1 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&DefaultItemOpen=1
8. SIGNATORY AUTHORITY
James Slezak, MD, FACS Chief of Staff
NOTE: The signature remains valid until rescinded by an appropriate administrative action.
DISTRIBUTION: Via Intranet
| 2023-01-17T09:42:01-0600 | |
| JAMES SLEZAK |
File details come from the government source that posted it. Updated .