11. TEACHING POINTS: OFFICE PRACTICE INTEGRATION

Purpose: These exercises will help you consider potential barriers and strategies for integrating reproductive health services into practice. Although they refer to abortion and miscarriage services, they could be used for other services you may be planning.

EXERCISE 11.1

  1. List 3 barriers that you think you may encounter in trying to integrate abortion and miscarriage services in your practice. How would you address them?
  • Controversy: There will tend be controversy where there is change. The most important step is to find the root cause of the controversy and try to directly address that issue.
    • Work gradually on building support for reproductive services, so staff might first understand the benefits to patients of offering comprehensive contraception and miscarriage services.
    • If staff objects to the idea of including abortion in your service, refer to the tools included for working through values clarification.
    • If the controversy is about ”turning into an abortion clinic”, the statistics in primary care settings suggest that most integrated clinics perform 1-2 abortions per week, and rarely draw such attention.
    • If the fear is security, there are many resources and people to help assess the actual risk, and determine if there are any areas that may need additional security re-enforcement. Also going through the security drills included here should help staff feel prepared.
    • Talk to other sites that have done the same thing for a “reality check.”
    • The most compelling response to these issues is the experience of patients. Being able to offer comprehensive care is the most important reason to start abortion services, and will benefit the practice in terms of client retention.
  • No one ever asks for an abortion here.  It’s not a needed service”  “We can just send our miscarriage patients to the ER.”
    • Consider that nearly half of pregnancies are unintended, and if you care for pregnant women in your practice, approximately 1 in 5 pregnancies end in miscarriage, and 1 of 4 pregnant patients choose to have an abortion. Women will make different choices at different points in their lives. You can safely project that a certain percentage of the women in your practice will seek these services. Offering your patients balanced options counseling and care may increase both access and comfort for your patients.  Studies show that offering these services in a primary care setting is more cost-effective and, especially with respect to miscarriage care, better for women’s emotional well-being (Dalton 2006). 
  • Fear of complications
    • First trimester abortion is one of the safest medical procedures, with minimal risk of major complication, less than .05% might need hospital care. About 89% of the women who obtain abortions are less than 13 weeks pregnant (GI 2016).
  • Myths about abortion (none of our patients have unintended pregnancies)
    • Women from every reproductive age group, every socio-economic background, and who use every type of contraception, seek out abortion services. When faced with these myths, the goal is to move the discussion away from punishing the patient who may need services to focus on the bias the speaker may have about abortion in general. Share this video (GI 2011) with staff and use it to debunk myths about who has abortions in the U.S..
  • There are other providers in the area. Why do we have to take this on?
    • There are many areas where there are multiple services being offered – management of hypertension, management of diabetes, dentistry. The reason to offer the services is to meet the needs of your patients, not to compete with other providers. The idea that abortion is just part of the spectrum of comprehensive care for women is the most compelling argument.
  • Abortion is out of our scope of practice.
    • Early pregnancy termination is within the scope of practice of primary care physicians, as well as advanced practice clinicians in certain states. Early abortion safety, efficacy and acceptability are found to be equivalent between physicians and most cadres of advanced practice clinicians (Bernard 2015). The similarity of safety and efficacy is true for both experienced and newly trained providers. Appropriate training in abortion care and demonstrated competency are the key issues. Clinicians from many specialties have excelled at abortion provision and have come to make significant advances in the reproductive health field.
  • Expense of malpractice/unable to obtain malpractice coverage.
  • Capital equipment cost
    • There are ways to bring abortion and miscarriage services on without investing too much early on.  One is to start with medication abortion. Medication abortion success may be assessed by clinical means in the office or by telephone, hCG testing, or ultrasound (NAF CPG 2016). You can refer out for ultrasound as needed. Investing in a manual vacuum aspiration (MVA) system is between $16 – 43 (depending on valve-type, and single-use vs. autoclavable), and a tray or two of dilators and a tenaculum may cost around $500.  Some organizations may help provide funding to offset start up costs for abortion and miscarriage services.
  • Reimbursement
    • Limited reimbursement will be more of an issue in states where there is no Medicaid funding of abortion.  Connecting to local or national abortion funds can help patients cover the cost of services.  Miscarriage care should be covered by Medicaid and other insurers as a standard component of prenatal care.    Return to Exercise

 

 

  1. Who are the key stakeholders in starting this service? How would you approach getting buy-in from your stakeholders or staff?

See Key Stakeholders Section for likely players. These parties may be swayed by the broadened services for women, increased patient retention, the cost-effectiveness of minimizing referrals or getting services out of the operating room, or the training or faculty development options associated with training.

In incorporating staff, first, allow time for this process and room for initial negative and mixed reactions. You may never get everyone to be enthusiastic, or even okay with providing abortions. That does not mean you will not be able to offer abortion services.  Try the following tactics to encourage their participation:

  • Model:
    • Commitment to patient centered care
    • Commitment to prevention of unintended pregnancies within a public health framework
    • Commitment to addressing patient’s sexual and reproductive health care needs
    • Confidence in your technical skills and your ability to assist staff in transition to offering this service
  • Train – offer formal and informal staff meetings on the following:
    • Q&A about abortion (safety of, who has them, types of abortion services)
    • Values Clarification exercises
    • Shared experience from your training
  • Reassure:
    • Offering abortion will not disrupt but rather enhance services
    • Do not intend to become an “abortion clinic”, but rather help our patients who trust us already
    • We will begin slowly and have all the training and support that we require
  • Personalize:
    • “I would want my sister or friend to be cared for by a staff like this.”
    • Share success stories from your training of specific patients.
  1. What might you do if you have a complication in your clinical site? How will you secure appropriate OB or hospital back up? How would you cover call?

Despite careful planning, systems development, and staff training, complications will occur. Prescreening and sound medical practices will minimize their severity.

When a complication arises, remain calm and clear. Let your other patients know there may be a delay. Document clearly and completely. Pay attention to the details. Allow time for staff to ask questions and debrief, particularly if the complication required a hospital transfer.  Send complete notes, and communicate directly with your referral MD. Meet all state and local reporting requirements.

Keep in mind that most complications can be cared for by the primary care doctor on either an outpatient or inpatient basis, as appropriate. Primary care doctors can do aspirations for retained products or hematometra, treat most hemorrhages (as they would in OB patients), and treat pelvic infections (even if the patient needs hospital admission and IV antibiotics) (Prine 2003).

Most early perforations are benign and can be managed conservatively. The rare occurrence that would require OB-Gyn backup is the major perforation requiring surgery or a ruptured ectopic.

For clinics looking to integrate medication abortion only, finding surgical back up is an important early step. For primary care providers working within a healthcare organization, this can be as simple as reaching out to the heads of the OB/GYN and Emergency Medicine departments to let them know that you will be starting to offer medication abortion. If no back up is available within network, a local surgical abortion clinic can serve as unofficial back up. The Reproductive Health Access Project  can help identify abortion-friendly hospitals if none are available locally. (See Key Stakeholders Section for details.)

Return to Exercise