Department of Veterans Affairs VHA HANDBOOK 1330.1 Veterans Health Administration Transmittal Sheet Washington, DC 20420 July 16, 2004 VHA SERVICES FOR WOMEN VETERANS 1. REASON FOR ISSUE: This Veterans Health Administration (VHA) Handbook defines the scope of VHA services to women veterans. 2. SUMMARY OF MAJOR CHANGES a. Public Law 104-262 authorizes the Secretary of Veterans Affairs to provide health care to women veterans as determined to be medically needed. Maternity and infertility services, excluding in-vitro fertilization (IVF), are included as services provided by the medical benefits package. b. Public Law 106-117 extends the Department of Veterans Affairs’ (VA’s) authority to provide counseling and treatment for military sexual trauma. c. The Military Sexual Trauma Software must be installed and implemented at each VA facility, including Community-based Outpatient Clinics (CBOCs) and independent clinics. 3. RELATED ISSUES: VHA Handbook 1330.2. 4. RESPONSIBLE OFFICE: The Director, Women Veterans Health Program (133), is responsible for the contents of this Directive. Questions may be referred to the Director, Women Veterans Health Program, at (202) 273-8577, or FAX at (202) 273-6136. 5. RESCISSIONS: VHA Handbook 1330.1, dated May 2, 2001, is rescinded. 6. RECERTIFICATION: This VHA Handbook is scheduled to be recertified on or before the last working day of July 2009. S/ Arthur S. Hamerschlag for Jonathan B. Perlin, MD, PhD, MSHA, FACP Acting Under Secretary for Health DISTRIBUTION: CO: E-mailed 7/19/04 FLD: VISN, MA, DO, OC, OCRO, and 200 – E-mailed 7/19/04 CONTENTS VHA SERVICES FOR WOMEN VETERANS PARAGRAPH PAGE 1. Purpose ...................................................................................................................................... 1 2. Authority ................................................................................................................................... 1 3. Scope ......................................................................................................................................... 1 4. Primary Health Care ................................................................................................................. 2 5. Gender-Specific Care for Women Veterans ............................................................................. 4 6. Women Veterans Program Manager (WVPM) ......................................................................... 5 7. Women Veterans Health Committee (WVHC) ........................................................................ 6 8. The Health Care Environment .................................................................................................. 7 9. Performance Improvement ........................................................................................................ 7 10. Outreach .................................................................................................................................. 8 11. Inreach ..................................................................................................................................... 9 APPENDICES A Guidelines for Women Veterans’ Physical Examination .................................................... A-1 B Women Veterans Health Structural and/or Environmental Privacy and Safety ................... B-1 C Women Veterans Health Program Plan of Care and Clinical Inventory RCN 10-0910 .................................................................................................................. C-1 VHA SERVICES FOR WOMEN VETERANS 1. PURPOSE This Veterans Health Administration (VHA) Handbook defines the Women Veterans Health Program within VHA. NOTE: For purposes of this Handbook, the acronym WVPM refers to the Women Veterans Program Manager. For purposes of this Handbook, “facility” refers to all freestanding medical centers, primary and legacy facilities, Community-based Outpatient Clinics (CBOCs), and independent clinics, but does not include mobile clinics. 2. AUTHORITY a. Public Law (Pub. L.) 102-585, Veterans Health Care Act of 1992, Title I, enacted November 4, 1992, authorizes the Department of Veterans Affairs (VA) to provide gender- specific services, such as Papanicolaou tests (Pap smears), breast examinations, management of menopause, mammography, and general reproductive health care services to eligible women veterans. In addition, this law authorizes VA to provide women veterans counseling services needed to treat sexual trauma experienced while serving on active duty. b. Pub. L. 102-585 also mandates that a VHA official in each region must serve as coordinator of women’s services with specific responsibility for assessing the needs of and enhancing services for women veterans. As a result of the realignment of VHA from four Regions to 21 Veterans Integrated Service Networks (VISNs), the position of Regional Women Veterans Coordinator is retitled Deputy Field Director (DFD), Women Veterans Health Program. c. Pub. L. 103-452, the Veterans Health Programs Extension Act of 1994, signed November 2, 1994, authorizes VA to provide appropriate care and services for sexual trauma. The law also made VA’s authority to treat sexual trauma gender-neutral. d. Pub. L. 104-262, Veterans’ Health Care Eligibility Reform Act of 1996, required VA to establish and implement a national enrollment system. Maternity and infertility services, excluding in-vitro fertilization (IVF), are included in VA’s medical benefits package. e. Pub. L. 106-117, Veterans Millennium Health Care and Benefits Act, signed November 30, 1999, extends VA’s authority to provide counseling and treatment for sexual trauma. 3. SCOPE a. It is a VHA mandate that each facility ensure that eligible women veterans have access to all necessary medical care, including care for gender-specific conditions that is equal in quality to that provided to male veterans. b. In their statement of work, each contract provider must address how gender-specific care will be provided, and how they will collect and track data on preventive medicine women’s health indices. c. All VHA facilities must develop written policies that describe how care provided to women veterans at mobile clinics is coordinated to ensure continuity of care. d. Each facility must provide primary and basic gender-specific care. e. Physical and psychosocial 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. f. Assessment and correction of physical and environmental barriers, which limit the access of women to care in VA facilities, are an ongoing process. 4. PRIMARY HEALTH CARE a. The plan for providing primary care must include: (1) Intake and initial assessment, which must include screening for sexual trauma that may have occurred while the veteran was serving on active duty in the Armed Forces. (2) Preventive health index measures, including cervical cancer and breast cancer screening. (3) Acute and chronic biopsychosocial care. (4) Referral coordination. (5) Accessing all services and programs available to veterans. (6) Follow-up care. (7) Patient education. b. Research has shown that full-service women’s primary care clinics and/or teams, which provide comprehensive care, including basic gender-specific care, are the optimal milieu for providing care to women veterans. It is recognized that there are alternative models of health care delivery, influenced by local circumstances that may be equally effective in the delivery of quality health care for women. NOTE: Performance outcome data needs to guide facilities in designing the process of health care delivery that ensures the highest degree of quality, as well as customer satisfaction. c. VHA policy requires that each veteran enrolled for primary health care have a primary care provider and/or team, which assumes responsibility for planning, coordinating, and ensuring continuity of care, including the maintenance of health and treatment of illness. d. Primary care teams can be utilized when women’s primary care clinics and/or women’s primary care teams are not feasible. The assignment of women to gender-neutral primary care teams must take into consideration women’s need for privacy, sensitivity, safety, and emotional and physical comfort. When a facility serves only a small number of women veterans, it is preferable to assign all women to one primary care team in order to facilitate the development and maintenance of the provider’s clinical skills. NOTE: This recommendation is based on the fact that women veterans comprise approximately 5 percent of VA’s patient population, limiting VA primary care providers’ exposure to women’s health issues and routine gender-specific care. Rotating women veterans among a number of primary care teams further reduces the ratio of women in a VA practitioner’s case load, making it even more unlikely that VA clinicians will gain the clinical experience necessary to develop and maintain expertise in the area of women’s health. e. Clinicians caring for women veterans in any setting must be knowledgeable about women’s health care needs and treatments, must participate in ongoing education about the care of women, and must be competent to provide gender-specific care to women. NOTE: Skills in screening for history of sexual trauma and working with women who have experienced sexual trauma are essential. f. Primary care teams are expected to provide basic gender-specific care. g. The WVPM collaborates with primary care providers and/or teams, where care is provided to women, to ensure that the needs of women veterans are met. h. A complete primary care examination for women includes: (1) Pelvic Examination. A pelvic examination is performed, unless medically contraindicated or refused by the patient. (2) Breast Examination. Breast screening services offered include: clinical breast examination, education on performing breast self-examination, and mammography. Mammography is offered according to accepted screening standards. When mammography services are obtained through contractual arrangements or sharing agreements, the referring VA facility must ensure, prior to services being rendered, that the provider has current accreditation, and is certified by the Food and Drug Administration (FDA). (3) A Pap Smear. Pap smears are offered according to accepted screening standards. (4) Basic Gender-specific Care. Treatment of menopause, uncomplicated vulvovaginitis, osteoporosis, contraceptive needs, and hormone replacement therapy must be provided by the primary care provider and/or team. If a pelvic, breast examination, and/or Pap smear are not included as a part of a complete physical examination, the reason(s) for deferring the examinations must be clearly documented in the medical record. When clinically unrelated to an acute hospitalization, the examination may be deferred to a competent provider to ensure that these examinations are provided at a later time. A follow-up appointment will be arranged for the completion of these examinations. 5. GENDER-SPECIFIC CARE FOR WOMEN VETERANS a. All VA health care facilities must provide gender-specific and gynecologic services to eligible women veterans. NOTE: The goal is that these services will be provided in-house to the extent possible. If gynecology services are not available in-house, such services are to be provided through fee-basis, consultants, sharing agreements, or academic affiliates. b. Gender-specific services must include: (1) Gynecology (a) Primary Care Teams, preferably in a women’s health clinic, are expected to provide basic gynecology services that are part of primary care, such as: routine Pap smears and treatment of uncomplicated vulvovaginitis, fitting of diaphragms, prescription of oral or implantable contraceptives. (b) A gynecologist will be available to both inpatients and outpatients for evaluation: 1. And treatment of complicated conditions. 2. And treatment of abnormal Pap smears. 3. Of certain contraceptive needs or surgical sterilization. 4. Of infertility. (2) Maternity. VA is authorized to provide prenatal and postpartum care to eligible women veterans. At the present time, such care is best provided through contractual arrangements. VA is not authorized to provide newborn services, so it is essential that the mother be advised to make alternative arrangements for newborn care prior to delivery. (3) Infertility. The Veterans’ Health Care Eligibility Reform Act authorizes the Secretary of Veterans Affairs to provide health care to women veterans as determined to be medically needed. Since medical remedies for infertility exist, such services could be provided under Title 38 United States Code (U.S.C.) 1710, if the Secretary of Veterans Affairs determines that it is medically needed. Limited infertility services such as assessment of reproductive capacity and treatment or correction of some obvious abnormalities, such as endometriosis or varicocele, are available at VA facilities. NOTE: VA does not provide IVF. (4) Mental Health. Mental health services, including substance abuse treatment, are to be provided. (5) Osteoporosis. Osteoporosis screening and treatment must be provided. (6) Endocrinology. Endocrinology includes, but is not limited to, the evaluation and treatment of polycystic ovarian syndrome. (7) Oncology (surgical and medical oncology (breast and reproductive)). Reproductive and breast oncology, and endocrinology, may be addressed through network referrals, sharing agreements, academic affiliates, fee-basis, or in-house. (8) Counseling and Treatment for Sexual Trauma. Sexual trauma counseling must be available at all VA health care facilities. In-house programs are recommended, but fee-basis may also be used when clinically advisable and because of geographical accessibility. Vet Centers are also an appropriate referral resource for sexual trauma counseling. All facilities must collect and maintain performance outcome data on sexual trauma screening and counseling services provided. NOTE: Acknowledging the gender-neutrality of sexual trauma experiences, male veterans with a history of military sexual trauma will have access to comparable standards of sexual trauma counseling programs and services. c. Each medical center Director is responsible for: (1) Ensuring that necessary gender-specific medical equipment, supplies, and pharmaceuticals are identified and monitored. (2) Developing a Plan of Care and Clinical Inventory that addresses the unique needs of women veterans. This document must be submitted through channels to the offices of the Deputy Under Secretary for Health for Operations and Management (10N) and the Women Veterans Health Program (133) on an annual basis. 6. WOMEN VETERANS PROGRAM MANAGER (WVPM) NOTE: VHA Handbook 1330.2 “Women Veterans Program Manager Position”, dated March 21, 2003, describes the duties and responsibilities of Title V and Title 38 health care professionals who perform the duties of WVPM. a. Medical Center Director. Each medical center Director is responsible for: (1) Appointing a WVPM who should be a clinical health care professional sensitive to the needs of women in VA health care facilities, capable of working with both caregivers and patients. (2) Ensuring that the name, location, and telephone number of the WVPM is posted and appropriately publicized in each facility. (3) Ensuring that when a new WVPM is appointed, the name, title, commercial telephone number, and e-mail address is submitted to the appropriate DFD and to the Veterans Integrated Service Network (VISN) Director within 10 working days. The DFD then notifies the VHA Women Veterans Health Program (WVHP) Office, VHA Central Office, which maintains a list of current WVPMs. (4) Ensuring that the WVPM has adequate time allocated to successfully perform program administrative activities including, but not limited to, patient education and case management. Outreach is an integral part of the WVPM role. These responsibilities are to be considered in determining the amount of time allocated to the fulfillment of the responsibilities of this role. CBOCs and independent clinics must designate a WVPM contact and/or liaison to: (a) Coordinate women's issues with the parent facility; and (b) Meet reporting requirements. (5) Ensuring that the WVPM has direct access to top management in the facility and should serve on appropriate administrative and clinical boards and/or committees. b. WVPM. The WVPM must be a health care professional (Doctor of Medicine (MD), Nurse Practitioner (NP), and/or Physician’s Assistant (PA), social worker, psychologist, pharmacist, or Registered Nurse (RN)) who provides health care services to women as a part of their regular responsibilities, which include: (1) Participating as a member of the Women Veterans Primary Health Care Team. (2) Participating in the regular review of the physical environment, to include the review of all plans for construction, for the identification of potential privacy deficiencies, as well as availability and accessibility of appropriate equipment for the medical care of women. c. VISN Director. Each VISN is responsible for ensuring that a lead WVPM is designated to serve as the Network's representative on women veteran’s issues. NOTE: VHA Handbook 1330.2, Appendices A and B, describe work performed at the Network level. 7. WOMEN VETERANS HEALTH COMMITTEE (WVHC) a. Each VA facility should have a WVHC to assist the WVPM in carrying out the duties and responsibilities of that position, and to provide recommendations for improving services and programs for women veterans. b. The WVPM should chair the WVHC, but at a minimum must be a member of the committee. c. Membership on the committee may include, but is not limited to: representatives from clinical services such as primary care, specialty care, surgery, pathology and laboratory services, extended care, domiciliary care, chaplain, social services, behavioral and mental health services, public and consumer affairs, Readjustment Counseling Service (RCS), Veterans Benefits Administration (VBA), and a non-employee woman veteran consultant from the community. d. Minutes of the committee need to be distributed widely, with reporting requirements to include routing to the Chief Executive Officer and the Chief of Staff. NOTE: Women veteran consumers, representatives of veterans service organizations (VSOs), and other stakeholders may only serve as consultants to the WVHC. 8. THE HEALTH CARE ENVIRONMENT a. The health care environment directly and indirectly affects the quality of care provided to women veterans, significantly impacts the patients’ comfort and feelings of security, and invariably affects their perception of the care received. Annual reviews of the health care environment occur in all VA medical facilities to ensure that the environment promotes comfort, privacy, feelings of security, and a sense of welcome. The WVPM and/or appropriate members of the facility’s WVHC are to participate in these reviews. b. Programs addressing attitudes and sensitivity toward women veterans are essential components of orientation and in-service education of employees and trainees. Such education needs to include, but not be limited to, consideration of sensitivity to language, race, religion, ethnic background, sexual orientation or culture in the health care setting. c. Other elements within the environment that are of special concern to women veterans include, but are not limited to: (1) The admissions process. (2) Accommodations, with emphasis on privacy in examination rooms, restrooms, and bathing facilities. (3) Patient apparel. (4) Availability of personal hygiene products. (5) Canteen services, including hair care services and products. (6) Recreational and social programs. (7) Long-term care facilities. 9. PERFORMANCE IMPROVEMENT As part of VHA’s program to assess and improve the quality of health care, systematic data collection must be designed to collect information related to women veterans’ health care services. Identification of sources (data bases) to retrieve reliable data is essential. In addition to data about key performance measures and standards, the development of clinical guidelines, flowcharts, and other performance improvement tools are needed for standardization and improved outcomes of care. a. Medical Center Director. Each medical center Director is responsible for ensuring that: (1) An individual is designated at each facility to perform data entry of women veterans’ health care services furnished by the facility into existing software packages. Effective and accurate data management is an integral component of the WVHP. NOTE: The individual designated should be a clerical support staff member and not the clinical professional providing the care. (2) The Women's Health Software must be installed and implemented at each VA facility. (a) Pap smears and mammography data must be entered into Veterans Health Information Systems and Technology Architecture (VistA) using the Women's Health Software. This includes notification of test results and plans for follow-up care. Additional data can be entered to assist in performance improvement activities. (b) Reports generated from the software can be used to assess and improve outcomes in cervical and breast cancer screening. (3) The Women Veterans Health Program, Primary Care, and Mental Health and Behavioral Sciences Service, track and document treatment for Military Sexual Trauma (MST). All providers in these areas must screen veterans for MST and utilize the MST software for tracking. b. Activities. Expansion of performance improvement activities needs to include areas such as: (1) Screening and follow-up for sexual trauma. (2) Complete physical examination in all facilities. (3) Customer satisfaction initiatives and outcomes. (4) Research. Research in women’s health care issues needs to be encouraged at each VA facility, and women must be included in all appropriate studies. 10. OUTREACH a. Outreach to women veterans is an integral part of the Women Veterans Health Program, since women veterans tend to be less aware of their veteran status and eligibility for benefits than male veterans. b. Outreach can include activities such as: mailings, public speaking, public service announcements (PSAs), health fairs, recognition ceremonies, brochures, workshops, newsletters, newspaper articles, educational seminars, focus groups, and town hall meetings or forums where women veterans have the opportunity to provide input and/or feedback to program staff and facility management. c. In planning outreach activities, assistance may be available from a number of resources such as Public and Consumer Affairs, Social Work Service, volunteer staff, members of the WVHC, Vet Centers, VSOs, and Veterans Benefits Administration (VBA) staff. d. All outreach activities need to be coordinated with the local marketing plan. The local marketing plan needs to include, but not be limited to: consideration of cultural and regional issues and influences affecting women veterans, and sensitivity to language, race, religion, ethnic background, and sexual orientation in the health care setting. 11. INREACH a. “Inreach” is a term that describes internal marketing, both to women veterans already using the system and to other facility staff. b. Inreach may include: educational seminars, in-service programs and workshops, new employee orientation activities, and customer feedback mechanisms. c. Inreach activities can best be accomplished with the assistance of the WVHC. GUIDELINES FOR WOMEN VETERANS’ PHYSICAL EXAMINATION 1. Respecting the privacy and dignity of all patients during physical examination is as important as the medical evaluation. Allegations of sexual misconduct are among the most sensitive and difficult areas to investigate and resolve. The episodes leading to such allegations are rarely witnessed and often lead to great public distress for both the provider and the patient. As in many areas of health care, prevention is usually the best remedy. The following guidelines for Department of Veterans Affairs (VA) physicians and other health care providers are similar to those promulgated by a number of state medical boards to prevent misunderstandings and protect both provider and patient. 2. Patient dignity must be maintained during the course of a physical examination with adequate privacy at all times. The examination room should be safe, clean and well maintained and should provide both auditory and visual privacy. Privacy curtains should shield the actual examination area and the placement of the examination table should also minimize any inadvertent exposure of the patient during a physical examination. Gowns, sheets and/or other appropriate apparel should be available to protect the patient’s dignity and decrease embarrassment. The patient should never be asked to disrobe in the provider’s immediate presence. 3. A third party should be readily available at all times during a physical examination. A third party should actually be present when the provider performs an examination of the sexual or reproductive organs or rectum. The provider must inform the patient of the option to have a third party present regardless of the provider and/or patient gender. 4. All patients should be screened for sexual trauma and all providers should be attuned to MST status of each patient. Due to past sexual trauma, some women veterans may have a heightened sense of vulnerability when receiving medical care, in particular, during invasive procedures such as pelvic and/or rectal examinations and endoscopic procedures. 5. Full and complete discussion with the patient in advance of procedures helps both the provider and the patient to anticipate difficulties that might arise and to develop strategies for alleviating anxiety and fear. NOTE: Further information on specific interventions may be found on the Internet site for the National Center for PTSD at http://www.ncptsd.org/facts/specific/fs_female_primary.html. 6. The provider needs to explain the necessity of a complete physical examination or the components being performed during the examination, as well as the necessity for various diagnostic studies, and the purpose of disrobing, in order to minimize the patient’s anxiety and possible misunderstandings. 7. Following a physical examination, the provider should discuss any positive findings with the patient and give the patient a chance to ask questions. During this discussion, the patient should be fully dressed. WOMEN VETERANS HEALTH STRUCTURAL AND/OR ENVIRONMENTAL PRIVACY AND SAFETY 1. Outpatient Safety and Privacy a. Exam rooms need to be located so that they do not open into a public waiting room or a high-traffic public corridor. b. Privacy curtains must be present in exam rooms. c. Exam tables must be placed with the foot facing away from the door. If this is not possible, tables must be placed so they are fully shielded by privacy curtains. d. In integrated or high-traffic settings, locks for examination rooms should be considered. e. A changing area must be provided behind the privacy curtain. f. Toilet facilities must be immediately adjacent to examination rooms where GYN exams and procedures are performed. g. Sanitary napkin and/or tampon dispensers and disposal bins must be available in at least one women’s public restroom. 2. Inpatient Safety and Privacy a. With the exception of Psychiatry and/or Mental Health units, privacy curtains must be present in inpatient rooms. b. Female patients must have access to a private bathroom facility (toilet and shower) in close proximity to the patient’s room. 3. Psychosocial Patient Safety and Privacy a. Women veterans must be provided adequate visual and auditory privacy at check-in. b. Women veterans must be provided adequate visual and auditory privacy in the interview area. c. The use of chaperones during pelvic and breast examination is strongly encouraged (see App. A). d. Appropriate draping techniques must be used during examinations involving the sexual and/or reproductive organs or rectum. e. Female pajamas and robes must be provided on inpatient units. WOMEN VETERANS HEALTH PROGRAM PLAN OF CARE AND CLINICAL INVENTORY ANNUAL REPORT (RCN 10-0910) 1. PLAN OF CARE: This Plan of Care and Clinical Inventory defines and describes the Women Veterans Health Program (WVHP) as it exists within facilities and independent clinics, and ensures the provision of the full spectrum of services. a. Women Veterans Program Manager (1) Name:___________________________________________________________________ (2) Professional designation: ____________________________________________________ (3) If you are in a collateral role, list your other positions and/or obligations: ______________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (4) The number of administrative hours devoted to WVHP per week: ____________________ (5) Telephone number: _________________________________________________________ (6) Fax number: ______________________________________________________________ (7) Pager number: ____________________________________________________________ (8) Supervisor’s name and title: __________________________________________________ (9) Facility name: ________________________________________ Station number: _______ b. Integrated Health Care System (HCS) Yes _________ No _________ If an Integrated HCS, provide the following information: Legacy Facility Name Program Manager Name ______________________________ _________________________ ______________________________ _________________________ ______________________________ _________________________ ______________________________ _________________________ ______________________________ _________________________ NOTE: A plan and/or inventory is required for each facility within HCS and it needs to be submitted as a package by the parent facility. c. Community-based Outpatient Clinic (CBOC). Provide the “parent facility” for each CBOC. Clinic Name Liaison Name ______________________________ _________________________ ______________________________ _________________________ ______________________________ _________________________ ______________________________ _________________________ ______________________________ _________________________ ______________________________ _________________________ ______________________________ _________________________ ______________________________ _________________________ ______________________________ _________________________ NOTE: A plan or inventory is not required for CBOCs or mobile clinics. 2. POPULATION SERVED a. The number of counties or states that comprise your service area: _________________ b. Other groups of women for whom services are provided: (check all that apply) ____Tricare ____CHAMPVA ____Active Duty ____Other c. Potential Market. The number of women veterans in the service area is ________________. NOTE: Check with the VISN Office. d. Market penetration: The percentage of women veterans who use your services is ______. NOTE: Check with the VISN Office. e. Are women veterans seen as referrals from other facilities within your VISN? ___Yes ___No If yes, what services are provided? _____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. PROVISION OF SERVICES a. Clinic Programs (1) Does your clinic or program have a medical or clinical director? ____ Yes _____ No If yes, name of Director: _________________________ (2) Discipline of the Director: _______ Internist, ______ Obstetrics (OB) and/or Gynecologist (GYN ), ______Family Practice, ______ Surgeon, ______Oncologist, or ___________________________________________Other (specify) (3) Do you have a Women Veterans Health Committee and/or Advisory Group? ____ Yes _____ No (a) Are you the chairperson of this group? ____ Yes _____ No (b) Do you have a woman veteran consumer as a member of this group? ____ Yes _____ No (4) Does your facility host annual town hall meetings or forums to solicit input and feedback from women veteran consumers? ____ Yes _____ No b. Environment (1) Check the number of the statement that most closely resembles the environment or model for delivery of clinical services to women veterans. ____ (a) Separate women’s health center providing comprehensive, multidisciplinary care that includes primary care, gender specific care, mental health services and surgical services (i.e., breast clinic) within dedicated space. ____ (b) Separate women’s health center providing primary care and gender specific care within designated space. ____ (c) Separate gynecology clinic, primary care provided in a women’s primary care team within the facility. ____ (d) Separate gynecology clinic, primary care provided in mixed gender primary care teams within the facility. ____ (e) Integrated. Gender-specific services and primary care provided by primary care providers within the facility. ____ (f) Other model. Describe briefly: ____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (2) If you selected preceding model number (a), (b), (c), or (d), on which days of the week and when do you have gynecology clinic? (1/2 day clinics, check all that apply) Monday ____AM ____PM Tuesday ____AM ____PM Wednesday ____AM ____PM Thursday ____AM ____PM Friday ____AM ____PM (3) If you selected model number (a) or (b), on which days of the week and when do you provide primary care for women veteran patients? Monday ____AM ____PM Tuesday ____AM ____PM Wednesday ____AM ____PM Thursday ____AM ____PM Friday ____AM ____PM (4) If you selected model number (c), on which days of the week and when does your Women’s Primary Care Team meet to see patients? Monday ____AM ____PM Tuesday ____AM ____PM Wednesday ____AM ____PM Thursday ____AM ____PM Friday ____AM ____PM (5) If you selected model number (d) or (e), on which days of the week and when are women seen in primary care clinics? Monday ____AM ____PM Tuesday ____AM ____PM Wednesday ____AM ____PM Thursday ____AM ____PM Friday ____AM ____PM (6) If you selected model number (a), (b), (c), or (d), indicate the number of full time employee equivalents involved in the care of women veterans on the following table. (For example: Three full-time General Internists who provide care to women veterans 50 percent of their time = 1.5 Full-time equivalent (FTE) Provider FTE per pay period General Internists Family Practitioners Surgeons (excluding gynecology) Urologists Obstetricians and/or Gynecologists Psychiatrists Psychologists Nurse Practitioners (NP) Physicians Assistants (PA) Social Workers Women’s Health Fellows Registered Nurses Licensed Practical Nurses (LPN) Nursing Assistants (NA) Nutritionists and/or Dieticians (7) In your women’s clinic: (a) Do you have medical residents, interns or students providing care? ____ Yes _____ No (b) Do you have NP and/or PA students providing care? ____ Yes _____ No (c) Any others providing care? Specify. _________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (d) Do you have clerical support in your women’s clinics? ____ Yes _____ No (e) Do you have clerical support for your Women’s Health Program? ____ Yes _____ No (f) Do you utilize volunteers? ____ Yes _____ No (g) Any others being utilized? Specify. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4. ENVIRONMENT OF CARE a. For each of the following, indicate whether space is shared (used by both men and women), reserved (used by women, their families and significant others at designated times, but used by male patients at other times), or exclusive (used solely for the care of women). Shared Reserved Exclusive (1) Waiting rooms ______ ________ ________ (2) Hallway(s) outside exam rooms ______ ________ ________ (3) Exam Rooms ______ ________ ________ b. Indicate whether the privacy and/or safety standards are met in all areas where women veterans are seen: (1) Outpatient Yes No (a) Exam rooms located so they do not open into public waiting room or high traffic public corridors ___ ___ (b) Privacy curtains in exam rooms ___ ___ (c) Exam table with the foot not facing the doorway ___ ___ (d) Changing area behind privacy curtain ___ ___ (e) Toilet facilities adjacent to exam rooms where gynecology exams or procedures are performed ___ ___ (f) Sanitary napkin and/or tampon dispenser and disposal bin in at least one women’s public restroom ___ ___ (2) Inpatient Yes No (a) Privacy curtains are present in inpatient rooms (with the exception of Psychiatry and Mental Health units) ___ ___ (b) Access to private bathroom facility (toilet and shower) in close proximity to patient’s room ___ ___ (3) Psychosocial Yes No (a) Women are provided adequate visual and auditory privacy at check in ___ ___ (b) Women are provided adequate visual and auditory privacy in the interview area ___ ___ (c) Chaperones are present during pelvic and breast exams ___ ___ (d) Draping is used during pelvic and breast exams ___ ___ (e) Female pajamas and robes are provided on inpatient units ___ ___ c. Check the number of the statement that most closely resembles the environment or model for the delivery of mental health services. (1) Outpatient ____ (a) Mental health services provided within the women’s health center space. ____ (b) Services provided by a women’s only mental health team. ____ (c) Services provided in a mixed gender Mental Health Clinic. ____ (d) Services provided at another VA facility. ____ (e) Services provided by fee basis, contract or sharing agreement. ____ (f) Other (Describe briefly): __________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (2) Inpatient ____ (a) Separate psychiatry unit for women veterans ____ (b) Separate psychiatry beds provided for women in a room or wing within psychiatry unit ____ (c) Women are placed in available rooms on mixed gender unit ____ (d) Women are referred to a specific VA facility within the VISN ____ (e) Women receive inpatient care through fee basis, contract or sharing agreement ____ (f) Other (Describe briefly): __________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ d. Describe mechanisms for delivering information to women veterans at their initial contact with your VA health care system: ______________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ e. Briefly describe your program goals for the next year. ____________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ f. Software (1) Does your facility use the Women Veterans Health Program Software? ____ Yes _____ No If yes: (a) Who inputs mammography data? _____________________________________________ (b) Who inputs pap smear data? _________________________________________________ (c) Who generates your notification letters? _______________________________________ (2) Does your facility use the Military Sexual Trauma software? ____ Yes _____ No If yes, who inputs data? ___________________________________________________ g. Education. Does your facility host any mini-residencies or educational programs for providers of women veterans’ health care? ____ Yes _____ No If yes, title of program(s)? ___________________________________________________ CLINICAL INVENTORY Indicate where the following services for women are provided. Check all that apply. In-house Contract Fee- basis Sharing Other* Not available Primary care Routine physical exams Routine gynecology care (annual exam) Pregnancy testing Contraceptive counseling Contraceptive management Obstetrical care Tubal ligation Tubal reversal Sexually transmitted disease (STD) screening STD counseling STD treatment Menopause counseling Hormone therapy Infertility services Pap smears Clinical breast exam Human immunodeficiency virus (HIV) screening HIV counseling HIV treatment Bone densitometry Osteoporosis management Screening mammography Diagnostic mammography Sexual trauma screening Sexual trauma counseling and/or treatment Intimate partner violence screening Intimate partner violence counseling Depression screening Depression treatment Substance abuse treatment Smoking cessation counseling Smoking cessation treatment Mental health services *i.e., Vet Centers CLINICAL INVENTORY continued In-house Contract Fee- basis Sharing Other* Not available Eating disorders Nutrition counseling Weight management and fitness Rehabilitation Radiation therapy Surgical services: breast GYN-oncology Oncology Urology Uro-gynecology Telephone care Transitional residential care Services for homeless women veterans Homeless women veterans with children Long term care Domiciliary Pharmacy services Social work services *i.e., Vet Center