S02 Attachment Fourteen 14 Medical Care Memorandum Number 548 110 305 Womens Veterans Health Care.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER MEMORANDUM

MEDICAL CENTER NUMBER: 548-110-305

WEST PALM BEACH, FLORIDA MAY 6, 2016

WOMEN VETERANS HEALTH CARE

1. PURPOSE: To delineate policies and processes in the provision of comprehensive health care services to women receiving care in accordance with standard medical practice and Department of Veterans Affairs regulations. Facilities and procedures throughout the West Palm Beach VA Medical Center (WPBVAMC), including all Community Based Outpatient Clinics (CBOCs), are developed and maintained to ensure equitable care and privacy.

2. POLICY: All female Veteran/CHAMPVA/Tri-Care patients will receive competent, comprehensive medical care. Facilities and procedures throughout the West Palm Beach VA Medical Center (WPBVAMC), including all Community Based Outpatient Clinics (CBOCs), are developed and maintained to ensure equitable care and privacy. Physicians and other medical personnel will be instructed to ensure this care for all female patients, understanding the unique issues that surround them. Quality of care will be monitored on a continuous basis. Necessary equipment and supplies to examine female patients will be available at all times.

Privacy must be provided to women Veterans in all health care settings. A review to evaluate structural, environmental, and psychosocial patient safety and privacy must be conducted on an annual basis and incorporated into routine environment of care rounds. NOTE: Per VHA Handbook 1330.01 it is recommended that at a minimum, rounds include Facilities Management/ Engineering, the Associate Director or designee, and the Women Veteran Program Manager. The facility will engage in an on-going, continual process to assess and correct physical deficiencies and environmental barriers to care for women Veterans.

3. PROCESS: A female chaperone must be in the examination room during physical examinations, procedures, or treatments involving the breast and genitalia, regardless of the gender of the provider. In addition to breast examinations and pelvic examinations, and Pap smears, this may include procedures such

Attachment Fourteen (14) as Urodynamic testing or treatments such as Pelvic Floor Physical Therapy.

The following staff may function as female chaperones (health technicians, nurse’s aides, Licensed Practical Nurses) for all gender specific examinations (breast, genitalia and rectal).

Female chaperones need to be provided irrespective of whether the examination is being performed by a male or a female provider.

A chaperone must be present at all gender specific exams, procedures, or treatments and when requested by a female Veteran for any visit. Chaperones help with the set up for Pap smears and Pelvic examinations; assist the Veteran with dressing and undressing, and provide gowns and other dressing apparel to the Veteran. If chaperones are utilized, duties should not be of a nature that would require credentialing/privileging.

We also respect a patient’s right to privacy; therefore a provider may request to see a patient alone for the interview portion of the visit with their provider.

A. OUTPATIENT CARE

1) The Women Veterans Comprehensive Health Center (WVCHC).

This clinic operates a full spectrum of services for women Veterans that includes Primary Care, Gynecological services, nutritional consultation, psychological and counseling services. Services are available through scheduled appointments Monday through Friday 8:00 a.m. to 4:30 p.m., not including federal holidays. Some providers have extended Primary Care clinic hours on Wednesday, Thursday, and Friday from 7:00-5:30 p.m. and every other Tuesday and Saturday from 7 a.m. to 5:30 p.m. The allocated space for the WVCHC is specifically designed to promote privacy for women Veterans and ensure the availability of specialty equipment for gender-specific care.

Additional specialty referrals are available through consultation.

Gynecological (GYN) Examinations and Procedures. GYN clinic is a separate entity from the women's clinic. Exams and procedures will be performed in the GYN clinic, which is located in the Women’s Center. These procedures include, but are not limited to, Colposcopy, Loop Electrosurgical Excision Procedure LEEP), endometrial biopsies, and cryosurgery. GYN services are currently available every Thursday and alternating Tuesdays in the Women’s Center. The need for surgical treatment either through Ambulatory Surgery or as an inpatient will be coordinated through the Gynecology Clinic.

2) Refer to Attachment A, GYN Program, for additional details.

3) Primary Care Teams. Primary care and basic gender-specific care is available to all women Veterans through the WVCHC at WPBVAMC or Community Based Outpatient Clinics (CBOC). Women should ideally be assigned to designated WH primary care providers. Women may also be assigned to a gender-neutral primary care team, however the team must take into consideration the Veteran’s need for privacy, sensitivity, safety and emotional or physical comfort. A third party of the same gender should be readily available to act as chaperone at all times during a physical examination. A third party should be present whenever the provider performs an examination of the sexual or reproductive organs, including breasts or genitals.

The provider must inform the patient of the option to have a third party present regardless of the provider and/or patient gender. Refer to VHA Handbook 1330.1, VHA Service for Women Veterans, for additional information.

4) The Emergency Department (ED). The ED is available 24 hours/day, seven days a week to evaluate emergency gynecological problems. Emergency GYN consultation is available through inter-facility transfer to area hospitals with GYN coverage. The ED is equipped with pelvic exam equipment, privacy curtains and a private bathroom to facilitate gender-specific care for women.

1) Please consult MCM 548-122-426, “Sexual Assault Response”.

2) Management of Obstetrical Emergencies. WPBVAMC and its satellite CBOC’s are not staffed nor equipped to handle obstetrical emergencies. Patients experiencing obstetrical emergencies will be rapidly evaluated, stabilized, and transferred to the nearest facility that can appropriately manage their condition. When the ER physician determines that services cannot be provided by the West Palm Beach VA Medical Center, he/she will arrange for continuation of inpatient care at an appropriate VA or Non-VA medical center. (MCM 548-11-141)

B. INPATIENT CARE

1) Physical Examination. The breast and pelvic examination and/or nursing intake examination may be performed by a chaperoned provider when clinically indicated.

2) Examination Rooms. An examination room with supplies required for performing a gynecological exam will be available after clinic hours and on weekends and holidays to ensure availability of specialty equipment.

3) Emergency OB/GYN Inpatient Consultations. There is no inpatient OB/GYN consultation available. Inpatient OB/GYN issues that are urgent or emergent will be transferred interfacility to areas hospitals with OB/GYN coverage.

4) Discharge. Any female who is eligible and opts for ongoing care at West Palm Beach VA Medical Center can be enrolled in the Women’s Center or in general Primary Care and an appointment will be made for initial evaluation with an assigned primary care provider. Any female not eligible for care will be given instructions and referred for community follow up.

C. ADDITIONAL SERVICES

1) Radiologic Services

a. Mammography. Digital mammography is available on site at WPBVAMC. Exams are available for diagnostic purposes as well as routine screening. Additional mammography services are available if requested in outlying areas through Non-VA Care consults for women that live greater than 50 miles from the medical center. All mammography appointments are coordinated through Radiology Service.

Providers submit requests electronically through Computerized Patient Record System (CPRS). Preventive screening should be performed for all eligible women Veterans. Providers are encouraged to identify eligible patients per American College of Radiology and/or American Cancer Society guidelines and discuss the importance of mammography. Results of completed mammograms are reported to the ordering provider. The requesting provider is responsible for notifying the patient of the results and coordinating any further intervention, such as consults to Surgical Breast Clinic, ultrasounds, or recommended imaging follow-up.

b. Mineral Densitometry (BMD). Dexa Scan imaging is available on-site for the screening and treatment of osteoporosis. All requests are submitted electronically through CPRS and scheduled via Radiology Service.

2) Breast Cancer Committee: The Breast Cancer committee will meet bi-monthly to utilize a multidisciplinary approach to coordinate evidence based care and treatment options. All newly diagnosed breast cancer patients will be discussed before surgical intervention.

3) Breast Surgical Clinic. This General Surgery subspecialty service is staffed by general surgeons. Providers submit requests electronically through CPRS. Refer to Attachment B, Surgical Breast Clinic, for additional details.

4) Military Sexual Trauma Counseling. All eligible women Veterans may receive sexual trauma counseling. Women Veterans are screened to identify a history of military sexual trauma (MST); a positive history should prompt the provider to enter a consult to a mental health counselor if the patient agrees. The mental health counselor through consultation provides initial intake, assessment, evaluation, and determines a plan of treatment.

5) Maternity Care

a. Eligible women Veterans are authorized to receive maternity benefits through the VA; CHAMPVA or TRICARE beneficiaries are not eligible for this benefit. Public Law 104-262 authorizes the Dept of VA to provide prenatal and postpartum care for the Veteran. Public Law 111-163 provides authority to VA to pay care of newborn children of Veterans when the Veteran is receiving maternity care furnished by VA. The benefit is limited to post-delivery and routine care provided immediately after birth and not more than 7 days following the birth.

b. Providers submit a consult to Non-VA Care electronically through CPRS. A nurse case manager in Non-VA Care coordinates services with outlying contracted providers.

Maternity care is not provided by the West Palm Beach VA medical Center and its satellite clinics or CBOC’s. Refer to Attachment C, Maternity Services.

c. The WVPM (or Maternity Coordinator) initiates the “Pregnancy and Lactation Status” flag in CPRS. The flag is a safety measure designed to inform all care providers that the Veteran is pregnant or breastfeeding. Refer to Attachment C, Maternity Care Fee-Basis Program, for additional details.

d. For non-OB related issues primary care and mental health will evaluate issues individually and coordinate care with OB/GYN as needed.

6) Infertility Services. Eligible women Veterans are authorized to receive infertility evaluation through the VA.

Consults for infertility management will be submitted to Gynecology. Initial evaluation and treatment will be started through the GYN clinic in the Women’s Center. Non-VA care for specialized treatment will be assessed and managed on an individual basis according to VHA guidelines. The VA does not authorize in vitro fertilization or assisted reproductive technologies. Refer to VHA Handbook 1330.1, VHA Services for Women Veterans, for additional information.

7) Performance Improvement Measures/Activities. The WVPM will ensure that processes are implemented throughout WPBVAMC and the affiliated CBOCs to accurately monitor the following performance measures:

a. Screening Pap Smear for eligible women with timely notification of results,

b. Screening mammograms for eligible women with timely notification of results,

c. Quarterly review of Pregnancy Flags,

d. Military Sexual Trauma (MST) screening in coordination with MST coordinator,

e. Supporting fee-basis maternity care, and

f. Additional programs identified as gaps in care or gender disparity.

8) Women Veterans Program Manager (WVPM)

a. This individual is appointed by the WPBVAMC Director and acts on behalf of Veterans throughout the facility and associated CBOCs. The WVPM chairs the Women Veterans Health Care Committee and Women Veterans Committee. The WVPM reports to the Chief of Staff and serves on appropriate administrative and clinical boards and/or committees. The WVPM participates in the regular review of the physical environment, to include the review of plans for construction, to identify potential privacy deficiencies, as well as provide information about appropriate equipment for the medical care of women Veterans. Outreach is also an integral part of the WVPM role.

b. If the WVPM is authorized to perform clinical duties, the amount of time allocated to those duties must be 5 hours or less per week. For additional details about the WVPM roles and responsibilities, refer to VHA Handbook 1330.02, Women Veterans Program Manager (WVPM) Position.

9) Womens Health Champion. This physician reports directly to the Chief of Primary Care or designee. This individual assumes a leadership role in the overall management of the Women’s Center and works closely with the Women Veteran Program Manager in addressing all issues related to women’s health care. The Womens Health Champion also maintains a collaborative relationship with all members of the interdisciplinary team of the Women’s Center including Primary Care, Gynecology, Mental Health, Nutrition, Social Work Service, Nursing and Medical Administration Service.

10) Women Veterans Healthcare Committee. This interdisciplinary committee serves in an advisory capacity to the Hospital Director in all matters pertaining to Women Veterans needs.

The WVPM functions as chairperson of this committee. For additional details about the Women Veterans Health Care Advisory Committee, refer to WPBVAMC Women's Health Committee Charter.

D. COMMUNITY BASED OUTPATIENT CLINICS

Each off-site clinic shall develop and maintain adequate services for women Veterans that includes the ability to perform complete gender specific care and MST counseling. Each clinic will have a designated Women Veterans health liaison.

This individual will work closely with the Women Veterans Program Manager at WPBVAMC in developing, implementing and continually evaluating the provision of health care for women Veterans at the respective CBOC.

The Women Veterans Program Manager (WVPM) will make routine visits to the CBOCs and meet with the Clinic Administrator, the Women Veterans Health Liaison, and other designated staff.

Physical and psychosocial privacy must be provided in these settings. Assessment and correction of physical and environmental barriers, which limit the access of women to care in these facilities, will be an ongoing process under the direction and guidance of the WVPM.

4. RESPONSIBILITY:

A. The Chief of Staff (COS) has the ultimate responsibility for care provided to all women Veterans at WPBVAMC and will ensure that all staff is aware of the policy and procedures for care of women Veterans.

B. Each Service Chief has the responsibility for his/her service’s compliance with the policy. Clinical Service Chiefs are also responsible to ensure appropriate gender specific competencies for staff are maintained and documented.

C. The Chief, Quality Management is responsible to monitor the care provided and provide feedback to providers, service chiefs, and the COS to make improvements in the overall process.

D. The Chief, Logistics Service is responsible to ensure that supplies are available in all areas that may see and examine female patients.

E. The Associate Director, Patient Care Services is responsible to ensure that all reusable medical equipment is available where multiple female patients may be seen and treated.

F. The Chief, Medical Administration Service is responsible to ensure that referrals for maternity services or other specialized care is processed timely by Non-VA Care, and to resolve any administrative issues related to care or payment of claims.

5. REPORTING STRUCTURE: Clinical Executive Board.

6. REFERENCES:

VHA Handbook 1330.01 VHA Services for Women Veterans, May 21, 2010.

VHA Handbook 1330.02 Women Veterans Program Manager Position, May 24, 2012.

VHA Handbook 1330.03, Maternity Health Care and Coordination, October 5, 2012.

Public Law 102-585, Title 1, Section 106, Women Veterans Health Programs, November 4, 1992.

Public Law 111-163, Caregivers and Veterans Omnibus Health Services Act of 2010, May 5, 2010.

WPB Policy MCM: 548-11-141 Interfacility Admissions and Transfers

WPB Policy MCM: 548-122-426 Sexual Assault Response

7. FOLLOW-UP RESPONSIBILITY: Primary Care Service (110).

8. RESCISSION: MCM 548-110-305, dated May 6, 2013.

9. RECERTIFICATION DATE: May 6, 2019.

Charleen R. Szabo, FACHE Medical Center Director

ATTACHMENTS

1. Attachment A Gynecology Services

2. Attachment B Surgical Breast Clinic

3. Attachment C Maternity Services

4. Attachment D WVHP Performance Improvement Program

Distribution: Electronic

WEST PALM BEACH, FLORIDA MAY 6, 2016

ATTACHMENT A

GYNECOLOGY SERVICES

1. CLINIC VISITS

Gynecology consultations/visits are available by open/direct access to the GYN clinic. Women Veterans need to obtain a consult for access to the GYN Clinic. Patients who call the Triage Line with immediate concerns are referred to their primary care provider or the Emergency Department, whichever is more immediately available.

2. EMERGENCY DEPARTMENT

Consultation for emergency gynecological services will be obtained by interfacility transfer to St. Mary's Medical Center.

3. TREATMENT OF ALLEGED RAPE VICTIMS

See MCM 548-122-426.

4. OUTPATIENT PROCEDURES

GYN related exams and procedures will be performed in the GYN clinic located in the Women’s Center. These procedures include, but are not limited to, colposcopy, Loop Electrosurgical Excision Procedure (LEEP), endometrial biopsies, and cryosurgery. GYN services are available every Thursday and alternating Tuesdays in the Women’s Center. The need for surgical treatment either through Ambulatory Surgery or as an inpatient will be coordinated through the Gynecology Clinic.

MATERNITY CARE (NON-VA CARE)

Maternity Care Program Attachment C

5. BREAST CARE SERVICES

Breast exams are referred to Primary Care Provider or Gynecology Clinic. Abnormal breast exams should be referred to the Breast Surgical Clinic.

6. EMERGENCY INPATIENT CONSULTATIONS

There is no inpatient GYN consultation available. Inpatient GYN issues that are urgent or emergent will be transferred interfacility to areas hospitals with GYN coverage.

WEST PALM BEACH, FLORIDA MAY 6, 2016

ATTACHMENT B

SURGICAL BREAST CLINIC

Access: Consultations for breast related physical/diagnostic/pathological findings

1. Services provided:

Consultative service for breast issues o Clinical services, including clinical evaluation, diagnostic assessment, and determination of treatment plans

Biopsies:

o Recommendation for Ultrasound-guided biopsy o Needle Localization Breast Biopsy (NLBBX) (ultrasound & mammographic) o Excisional biopsy

Cancer surgery:

o Lumpectomy w/without node dissection o Mastectomy w/without node dissection o Sentinel lymph node o Axillary dissection when indicated

Coordination of surgery care:

o Manages all facets of Pre-op requirements, including lab work, radiology procedures, EKG, history and physical, antibiotics, and Self Care Unit availability o Staging studies obtained (CT, Bone Scan).

o Genetic Testing by Oncology and/or Breast Committee

Recommendation o Inpatient care

Referral to specialty service care:

o Reconstructive surgery coordination.

o Medical/Radiation Oncology, if indicated o Occupational Therapy for lymph edema assessment o Prosthetics

Interdisciplinary Breast Tumor board AJCC staging documentation

TeleHealth program with remote facilities desiring use of available consultative services

ATTACHMENT C

MATERNITY SERVICES

1. RESPONSIBILITIES

a) Chief of Staff: develops local policies that meet the intent of the VISN policy for Non-VA Care Maternity Care.

b) Maternity Care Coordinator: ensures the development and implementation of these local Maternity Care policies.

c) Non-VA Care Case Manager: is responsible for supporting the coordination of maternity care for women Veterans throughout WPVAMC (to include CBOC’s).

2. REFERRALS

a) After confirmation of pregnancy (Beta HCG or clinical exam for advanced pregnancy state), the referring medical provider shall enter an electronic consult for Non-VA Care Maternity Benefits.

b) The Non-VA Care Office within the healthcare system where the pregnant Veteran receives her care is responsible for payment of maternity care for qualifying veterans.

c) The Non-VA Care Nurse Case Manager coordinates Obstetric care for women Veterans. Patients may request a list of providers that accept VA payment or choose her own OB provider, as long as that provider is willing to accept VA payment. The WVPM may also be contacted for assistance from pregnant Veterans who are having difficulty with coordinating OB provider in the local community.

3. NON-VA CARE AUTHORIZATION/EDUCATION

a) When the Veteran’s maternity care has been approved by Non-VA Care, she is provided a Non-VA Care authorization letter that contains pertinent information regarding all services that are going to be provided for Obstetric and Infant care for the first 7 days of life. Information regarding emergency care, maternity supplies (breast pump, etc.) and contact numbers for the Nurse Case Managers is also included in this letter.

b) WPBVAMC Patient Information Maternity Brochure. Patient is provided this brochure by the WVPM who is alerted to the Maternity Consult. The patient may be referred to the WVPM or the Maternity Care Coordinator for further information. This brochure contains specific information related to:

1) Laboratory diagnostic tests. Most labs ordered by the OB provider may be completed at the lab the provider utilizes. This is approved under the Fee Authorization.

Bills will be referred to Fee Office for payment.

2) Imaging Diagnostic Studies (such as serial ultrasounds).

This is also covered by the Non-VA Care Authorization and will be performed at facilities in community chosen by the OB provider.

3) Specialty Consultations directly related to the Pregnancy. When pregnant Veterans require consultation to specialty providers the OB provider submits the request to Fee-basis with appropriate documentation of the need for the consult. Fee-basis will verify the need and specialty and approve.

4) Specialty Consultations not Related to Pregnancy Primary care in conjunction with fee-basis and OB provider will coordinate care for non-OB related issues.

5) Emergent Care needs. VA facilities are not staffed or equipped to manage obstetrical emergencies. Patients shall be provided information about seeking emergency care at closest Emergency Department or at the hospital designated for delivery of infant.

6) Pharmacy Prescriptions. Prenatal vitamins may be initiated by VA providers, but prescriptions written by OB providers will not be re-written by VA providers.

Medications written by OB providers should be filled by the VA Outpatient pharmacy.

4. PREGNANCY-LACTATION PATIENT RECORD FLAG

The Women Veterans Program Manager will receive a view alert when a consult is placed for Maternity Care. This consult will alert these individuals to initiate the Pregnancy/Lactation Record Flag in CPRS. This flag will be reviewed at 3 month intervals for continuation or inactivation. The function of the flag is to ensure safety to the patient when prescribing medications or any diagnostic testing when the Veteran is pregnant or breastfeeding.

ATTACHMENT D

WOMEN VETERANS HEALTH PROGRAM

PERFORMANCE IMPROVEMENT PROGRAM

1. QUARTERLY MONITORING: All clinics within the WPBVAMC and CBOCs will provide monthly tracking and assessment data to the WVPM to include the following data:

a) Number of mammograms completed

b) Number of breast procedures performed

c) Pap smear results, including normal and abnormal,

d) New maternity consults,

e) Tracking Logs-Breast screening, abnormal cervical pathology, and pregnancy/lactation log.

2. ADDITIONAL MONITORING

a) EPRP Review. Evaluation of performance measures related to breast cancer and cervical cancer screening as well as additional primary care measures pertinent to women Veterans.

The WVPM provides additional review of medical records as necessary.

b) Joint Commission Patient Safety Goals. The WVHP has implemented two elements that address pregnancy/lactation and pregnancy risk related to teratogenic medications and chronic disease. The Pregnancy-Lactation Patient Record Flag as a patient safety measure. This flag provides a mechanism to alert providers of patient’s pregnant or lactating status prior to initiating new medications or diagnostic procedures. Second, a clinical reminder is in place in the outpatient setting that screens for unintended pregnancy and alerts the provider to provide contraceptive counseling and teratogenic medication education. Finally, pharmacy supplies discharge sheets with pregnancy/lactation information on dispensed medications.