1. Family Planning Program Update – AR/CCSG Revisions PH Nurses Update August 16, 2012

2. Summary of NEC Recommendations for Family Planning Revisions of CCSG/AR Pages 4-8 Clinical Title X Requirements moved from PHPR/CCSG to the AR Deferred exam language added to the FP matrix – Physical Exam Agency specific OCP and administration for deferred exams and agency specific ECP and administration for ECP visits ordered by the LHD medical director via standing order was moved to the Introduction Page of the CCSG signature/initials of MD 2

3. FP Matrix Females and MALES - All males need to receive counseling about sexual and reproductive health such as: understanding anatomy and physiology of the male and female reproductive tract, fertility cycle for female partner and understand how of their partner’s contraceptive method if relying on for pregnancy prevention, withdrawal method, self- testicular exam, STD prevention - how to use a condom correctly, abstinence, and sterilization through vasectomy. (AR FP Guidelines, PEF Preferred Method) 3

4. FP Matrix – Medical History The risk assessment is the medical history, including the reported sexual/reproductive history, STD/HIV exposure risks, sexual abuse/violence/human trafficking risks, tobacco/alcohol/drug abuse, and/or reproductive life plan, that will determine the FP services, counseling, and referrals each individual patient needs 4

5. FP Matrix- Reported History Married, monogamous relationship, multiple sex partners, abstinence IV drug use or sex partners with IV drug use, prostitution, fear of partner, immigrant, young teen, forced sex Smokes Alcohol or drug abuse, MH/depressed Chronic disease, obesity, history breast/cervical cancer; date and result last cancer screening if 21 or older 5

6. FP Matrix- Initial History Previous contraceptive use; problems such as consist use, side effects or adverse outcome GYN problems, irregular menstrual cycle, post partum Planning for a child in next year, 2-5 years, does not want children or more children (reproductive life plan) High risk pregnancy (uncontrolled HTN, Diabetes, Obesity, hx premature birth or birth defects) The average woman spends 5 years having two children and 30 year trying to prevent pregnancy!! Update changes to history at annual visits 6

7. FP Matrix – BMI All patients do not need to be referred for MNT because of overweight or obese BMI measurement – Be creative and offer nutrition and exercise counseling, hook patient up with agency or community activities for obesity prevention – give them PH interventions known to benefit health!! Deciding a MNT referral should be based on total health risk (high blood pressure, heart disease, diabetes, etc.), patient desires nutritional counseling by a nutritionist, patient’s over/under normal weight is a risk to a healthy planned pregnancy or life threatening to patient Does the patient need a primary care referral to a FQHC/rural clinic because of BMI and health risks? 7

8. FP Matrix – Physical Exam FP requires Mid Level or higher providers to provide and code for initial and annual visits Know what you need to exam for a reproductive women’s well visit based on ACOG standards and for 3 rd party payer reimbursement 8

9. FP Matrix – Physical Exam Title X initial exam requirements do not require a head to toe system exam, vision or hearing testing, etc.: Title X requirements are listed in the matrix. APRNs do NOT need to follow DPH/Medicaid requirements for DPH RN’s performing in an expanded role!!! 9

10. FP Matrix – Physical Exam DO NOT DO A PELVIC ON ANYONE UNDER 21 UNLESS IT IS MEDICALLY NECESSARY DO NOT DO A CLINICAL BREAST EXAM ON ANYONE UNDER 20 Removed the ACOG language about an external pelvic exam for teens to educate on body parts A teens physical exam should be short and sweet… 10

11. FP Matrix - Laboratory Infertility Prevention Project – ANNUAL ROUTINE screening for CT and/or GC on all women 25 and younger in higher CT positivity areas– DO NOT “routinely” screen women over 26 11

12. FP CT Screening FPAR 2011 Age GroupFemale Users ScreenedFemale Users Percent of Female Users Screened Under 1515693416.7% 15 – 172782510954.5% 18 – 194648837255.5% 20 – 24167423079454.3% 25 and over174905099434.3% Total Users418189620343.5% 12

13. FP Matrix - Laboratory DO NOT DO A PAP TEST ON ANYONE UNDER 21, PERIOD Follow Cancer Program Guidelines for cervical cancer screening through PAP testing 13

14. FP Matrix - Laboratory Other labs as indicated: Base STD/HIV testing on CDC guidelines, patients exposure risk based on sexual history, and local prevalence Hemoglobin – History of heavy periods Cholesterol and glucose– Based on medical history, age, and method Urinalysis – complaints of UTI symptoms Fecal occult stool – screening starts at 50 unless patient reports problems 14

15. FP Matrix - Counseling Education and counseling should be based on the needs of the individual patient: New contraceptive user versus experience with contraception Reproductive life plan/preconception/inter-conception Young teen versus college student versus LEP patient versus married 15 years versus committed relationship with same partner to decide counseling for STD/HIV exposure/sexual coercion/violence/trafficking Healthy lifestyle changes 15

16. FP Matrix – Method Counseling Assure patient verifies understanding of: Correct and consistent use of method What to do if misses pill dose/s, ring, patch, injection Highest risk of pregnancy during ovulation Quick start – barrier method for 7 days Side effects or rare but serious adverse reactions (ACHES) If relevant, how to put on a condom correctly 16

17. Add to end of FP Matrix “Clinicians and nurses must follow the Title X clinical Requirements outlined in the Training Guidelines and Program Descriptions Section of the AR” 17

18. Protocol for Deferred Exams Deleted duplication of information within matrix – “Complete family planning minimum requirements matrix except for physical exam” Use the CDC U.S. Medical Eligibility Criteria for Contraceptive Use to screen for contraindications to a specific method based on patient and family medical history and risk factors. The CDC U.S. Medical Eligibility Criteria language is added to all method types in CCSG 18

19. New Page – 5 of 23 ESTROGEN/PROGESTERONE CONTRAINDICTIONS Decreases duplication of this information for each hormonal method; pill, patch, ring, DMPA, Mirena, and Nexplanon (previously Implanon) Hyperlinked to the Estrogen/Progesterone Contraindications 19

20. ESTROGEN/PROGESTERONE CONTRAINDICTIONS ‘This is not a complete list of contraindications. Nurses should use the “Managing Contraception For Your Pocket” and the CDC U.S. Medical Eligibility Criteria for Contraceptive Use to screen for contraindications to specific methods based on patient and family medical history and risk factors.” 20

21. ESTROGEN/PROGESTERONE CONTRAINDICTIONS ALL patients on hormonal methods must be counselled on potentially serious side effects, referred as "ACHES": Abdominal pain (stomach pain); Chest pain; Headaches (severe); Eye problems (blurred vision); and/or Swelling and/or aching in the legs and thighs. 21

22. All Methods Clinical review by Dr. Connie White for accuracy of information Minimal changes made to update information, remove duplication, and provide resources for nurses Nexplanon® has replaced Implanon® this year (new insertion device) 22

23. STD Program IPP Info Moved to FP Infertility Prevention Project (IPP)Guidelines for Chlamydia and Gonorrhea Screening During a Family Planning Visit was moved to the FP CCSG section – page 20 Algorithm for deciding if STD Physical Exam is necessary during a Family Planning Visit – page 21 23

24. Preconception Care PHPR Preconception Care/Folic Acid Program section deleted from CCSG Preconception Care and Folic Acid moved to FP CCSG – pages 22 – 23 Information condensed 24

25. AR – FP Program Guidelines Moved all of the Title X Clinical Requirements from the PHPR/CCSG to the AR Eliminated duplication of information 25

26. AR – FP Program Guidelines NEW “The following are OPA positions statements regarding Title X compliance with grant requirements and applicable federal and state laws, including state reporting laws: http://www.hhs.gov/opa/pdf/opa-11-01-program- instruction-re-compliance.pdf. http://www.hhs.gov/opa/pdf/opa-11-01-program- instruction-re-compliance.pdf http://www.hhs.gov/opa/pdfs/opa-06-01.pdf. http://www.hhs.gov/opa/pdfs/opa-06-01.pdf http://www.hhs.gov/opa/pdfs/opa-99-01.pdf.” http://www.hhs.gov/opa/pdfs/opa-99-01.pdf 26

27. AR – FP Program Guidelines NEW “All Title X funded clinic sites are required to comply with federal anti- trafficking laws, including the Trafficking Victims Protection Act of 2000 (Pub. L. No. 106-386) and 18U.S.C.1591.” 27

28. Title X Clinical Requirements: AR – FP Program Guidelines NEW Training Requirements Orientation for all new hires (providers and support staff) Complete the “Mandatory Reporting of Child/Adult Abuse, Neglect, Violence and Human Trafficking per Kentucky Statute” webcast, TRAIN # 1028362, per OPA requirements. 28

29. AR – FP Program Guidelines NEW Annual training requirements: All licensed health care professionals (MDs, APRNs, RNs, and LPNs) shall acquire 3.0 hours of training or contact hours; Complete the module “Kentucky State Laws Regarding Mandatory Reporting & Human Trafficking”, TRAIN #1034386, annually to meet the OPA requirements. 29

30. AR – FP Program Guidelines The Office of Population Affairs has closed the OPA Clearinghouse this year. The federal Sterilization Consent form is available on the OPA website. Hyperlink is in AR “Reporting Requirements” page 40. 30

31. AR – FP Program Guidelines NEW Added to Billing and Collection Procedures: Abnormal Pap smear or mammogram follow up and treatment should be coded to the Cancer Program 813 cost center, using an appropriate ICD 9 code Self-pay and/or adult vaccines should be placed on a separate PEF from the family planning visit. Vaccines should by full charge and not included in the sliding fee schedule for family planning services. Title X services do not require the provision of vaccines. E Reports – 0 8 12 CPT Codes Per Cost Center 31

32. Resources The website to assess the CDC U.S. Eligibility Criteria for Contraceptive Use documents is: http://www.cdc.gov/reproductivehealth/unintende dpregnancy/usmec.htmhttp://www.cdc.gov/reproductivehealth/unintende dpregnancy/usmec.htm. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use This document is a summary chart of the U.S. Medical Eligibility Criteria for Contraceptive Use which can be printed double sided, laminated, and used by health care providers when counseling women. Full Color Version [DOC - 77KB]Full Color Version [DOC - 77KB] 32

33. DWH Family Planning Contacts Debra Israel, RN, Nurse Consultant, Director FPP (502) 564-3236 Ext: 4590 email: debra.israel@ky.govdebra.israel@ky.gov Emily Adkins, RN, Nurse Consultant FPP (502) 564-3236 Ext: 3822 email: emily.adkins@ky.govemily.adkins@ky.gov Amanda Wilburn, MPH, Epidemiologist FPP (502) 564-3236 Ext: 3815 Email: amanda.wilburn@ky.govamanda.wilburn@ky.gov 33