New services take time to build. Incorporating reproductive health services into your practice is a process during which you will need to explore core values of your staff, while attending to the more concrete tasks of ordering supplies and implementing new protocols. Approaching this process with a commitment to open dialogue is fundamental to a successful outcome.
Be realistic and patient about the amount of time this process will take to integrate new services, and the number of staff meetings and trainings it may require. Be strategic. If you are working in a practice that has yet to offer all contraceptive options or miscarriage management, it may be helpful to start by integrating new contraception services, then management of EPL. If you are introducing abortion services, start with medical abortion before uterine aspiration. This may get staff on board and set the stage logistically for offering aspiration later.
This section addresses fundamental questions about the initial steps of integrating abortion and miscarriage care services.
ASSEMBLING A PLANNING COMMITTEE
Start by identifying other providers, administrators and staff who might be allies in providing reproductive services. Initiate informal discussions and begin to develop a Planning Committee, which can meet regularly to discuss tasks, timeline, potential obstacles and solutions.
Some initial considerations will be to consider which services should be integrated first, what strategies will be best for gauging staff interest, and a model for training staff in various skills (e.g., counseling, assisting in the procedure room, etc.).
Other tasks could include developing clinical protocols and policies, deciding a schedule for how to integrate services, and assigning administrative roles to research state regulations, order supplies, develop forms for consent and the medical record, set up protocols with the billing department, and research the cost of additional malpractice for abortion coverage.
For providers working in FQHCs and/or Title X clinics, research will be needed to figure out how to fiscally separate supplies and time to provide abortion services from Title X and 330 funds. Because many clinicians mistakenly believe that it is not possible to provide abortion care at FQHCs and/or Title X clinics, it may be important to do some education about this early in the process.
The committee could address other questions like:
- Who will take call for abortion patients?
- Who will provide suction back up if only medication abortion is provided?
- Will ultrasound be available onsite? If yes, how will clinicians be trained?
If no, how can you ensure smooth referrals and educate radiology staff?
- Will services be advertised?
- Will you accept abortion patients who are not already in your practice?
In planning to introduce new reproductive services, consider the “key players” in your institution, what interests to address to assure their support, and what collateral support will be helpful to demonstrate to them. Potential stakeholders and interests may include:
- CEO (impact on relationships, bottom line, overall game plan, efficiency)
- Medical or OB Director (need, expected volume, service organization, back-up)
- The partners in a practice (call sharing)
- Training Director / Trainees (nearby residents, nurses, students)
- CFO, Billing Manager (billing strategy, anticipated expenses / income)
- Operations or Nursing Director (nursing responsibilities, sedation, efficiency)
- ED/hospital (how rare referral issues will be handled, if not already arranged)
- Radiology Director (if hospital setting) for ultrasound needs and credentialing
- Patients (public health impact, needs, preferences)
- For those centers looking to integrate medication abortion only, finding back up for uterine aspiration 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 Departments to let them know that you will be starting to offer medication abortion.
- If your are outside of a network, is there a local abortion clinic for unofficial back up to refer stable patients with complications outside of your system?
- While getting their support for managing rare emergent cases may be challenging in politically conservative areas, their “support” is not absolutely necessary, as this care cannot legally be withheld in EDs. Fortunately, these complications are rare.
- In provider shortage areas where is limited or unsupportive, it may be in the best interest of your patients to offer both medication and uterine aspiration on site.
GETTING STAFF INTERESTED
Consider the variety of staff in the groundwork for reproductive health expansion, as patients interact with staff throughout their experience. Staff will need exposure to the principles of values clarification and non-judgmental language. Experience has shown that even those who may not support abortion are more likely to be involved if their feelings and beliefs are acknowledged and respected early on.
How to begin:
- Consider distributing anonymous staff attitude surveys to gauge people’s thoughts and feelings [Staff Attitude Survey (RHAP)].
- Offer a Values Clarification Workshop (NAF or RHAP) to provide a broader public health framework for the benefits of service provision. This process can help address anxiety around change, identify and dispel myths, and separate personal beliefs from professional roles and responsibilities. Working with an outside facilitator can help avoid the impression of pushing an agenda.
- Offer lunchtime trainings or discussions to:
- Introduce updates in contraception, unintended pregnancy, miscarriage management, and public health impact of limited access to reproductive health services including abortion. Helpful presentations can be found at http://www.guttmacher.org, www.arhp.org or http://www.prh.org.
- Use a Papaya MVA Workshop to serve as an orientation and icebreaker.
- Present data on regional needs or results of a patient attitude survey [available at Patient Attitude Survey (RHAP)] to counter potential resistance.
- Role-play options counseling and consent process (see Chapter 2).
- Practice answering common telephone questions abortion and EPL.
- This Phone Script (TEACH) is a helpful reference.
More information can be found at Integrating Early Abortion into Primary Care (RHAP).
DEVELOPING CLINICAL POLICIES
Once support is in place from key stakeholders, begin developing protocols that define and standardize clinical workflows around reproductive health services you will provide. These protocols standardize, for example, how many office visits are needed for the service, what pre-procedure lab work is needed, what supplies and medications are required onsite vs. by prescription, who is identified emergency back-up, etc.
Sample clinical policies can be found here:
- Medical Management of Miscarriage Policy (RHAP)
- MVA for Miscarriage Policy & Procedure (RHAP)
- Medication Abortion Protocol Using Mifepristone & Misoprostol (RHAP)
- Medication Abortion Protocol Using Misoprostol Alone (RHAP)
- Medication Abortion Protocol Using Methotrexate and Misoprostol (RHAP)
- MVA for Therapeutic Abortion Policy & Procedure (RHAP)
- Nursing Policy & Procedure for MVA (RHAP)
Develop a policy for pre-abortion early dating US referrals (e.g., indications, location of US on-site vs. off-site, etc.). Develop clinical policies that standardize the provision of services while considering Targeted Regulation of Abortion Providers (TRAP) laws.
TRAINING STAFF FOR NEW SERVICES
Having a structure for training current staff and onboarding new staff will help ensure consistence of care to your patients. Evaluate staff training needs in the following areas:
- Scheduling appointments and telephone triage
- Counseling and consent
- Ultrasound training
- Assisting in the procedure room for uterine aspiration
- Emergency preparedness
- Sterilization and disinfection
- Fetal tissue questions and disposal
“Patients often measure the clinic’s diligence in pursuing their best interest based simply on their perception of the clinic’s efforts in explaining and scheduling their appointment,” (Striving for Excellence in Abortion Care. CAPS, 2001).
Make every effort to minimize the time between the patient’s request for an appointment and the appointment, as well as the number of visits required to complete the process. This is among the most important factors associated with patient satisfaction in abortion care (Tilles 2016). Patient data show that women prefer a one-day abortion procedure and want an immediate appointment (within 3 days of calling). Based on patient forecasting, consider setting aside procedure-specific time slots to accommodate patients quickly, and using no-show slots to accommodate walk-in pregnancy test patients who may be clear about their decision and would like an abortion that day, if permitted by law.
Providers working in states where TRAP laws mandate waiting periods will struggle more with expediting care. Many providers working in heavily regulated areas have indicated that TRAP laws may cause mistrust within the provider-patient relationship. Most have developed verbal strategies for mitigating the emotional impacts for patients (Mercier 2015). For example, they may say “the state requires me to say… but as a provider, I will tell you the scientific evidence does not support that.”
If staff can be trained for the counseling and consent process, clinicians can facilitate a medication abortion or offer misoprostol for EPL within a routine visit. A less ideal option is to use two slots, or to provide a visit for counseling, US and / or lab work prior to the medication abortion visit. Again, mandated waiting periods and US ordinances may dictate the timing of these abortion-related visits. Visit Guttmacher’s State Laws and Policies center.
Importance of Confirmation Calls
Confirmation calls are particularly important with abortion patients, as making appointments may be a part of their decision-making process while they assess funds, transportation, privacy, support from friends/family, or ambivalence. Where services are more available, patients also shop around for abortion care. They may have an appointment with you and still plan to go elsewhere. Contacting them may ensure that you are the preferred provider or alert you to a cancellation. Beyond the reminder of their appointment, you are calling to:
- Show concern, answer questions, and demystify fears
- Address concerns about transportation or payment
- Give important instructions (e.g. wear 2-piece clothing and underwear for a pad, plan a ride home)
To address confidentiality concerns, the confirmation call can be done non-specifically or by using a code name. It is best to ask the patient whether and how they prefer to be contacted.
You may want to call your patients promptly who fail to show that day to ask if they would like to reschedule to a more convenient time, or if another service is needed. This continues to show concern during what may be a difficult time for them.
Your no show rate is not a measure of success or failure, but a reality in even the most successful, dedicated abortion clinics. Use the information gathered during confirmation and follow-up calls to tailor your service to better meet patient needs.
Occasionally, you may have a patient you cannot help. They may be too far into the pregnancy, need general anesthesia, or require counseling beyond your scope. Have referral numbers available for a variety of patient needs. Taking an active role in care coordination is even more important in areas where services are restricted and stigma greater (Zurek 2015). This can help dispel misperceptions or deliberate misinformation about legality and safety of abortion, or overcome complex social issues patients face.
After Hours Calls
If not already part of your practice, it is critical to provide your EPL or abortion patients with 24-hour contact number to triage questions and assure physician referral if indicated (NAF CPGs 2016). Counseling patients thoroughly con what to expect will help decrease the number of calls, but often a phone call can save your patients an ED visit. Print after-hours number on your written aftercare instructions. (See Medical Documentation for sample aftercare instructions.) Let your on-call service know you are now offering EPL, medication or aspiration abortion services. You can find a helpful Algorithm for Triaging Bleeding After Medication Abortion (RHAP) here.
Counseling and Consent
In many primary care settings, the provider does most of the counseling, but occasionally a lead counselor may take that on. In addition to having staff members review Chapter 2 of this Workbook, consider having lead counselors visit a high volume abortion site to get a thorough understanding of workflows and counseling styles.
Ultrasound (US) Training
US training for early dating is hard to come by! There is a 5-day intensive US course offered for CME credit for providers and health workers at Planned Parenthood of the Rocky Mountains (PPRM) in Denver, CO. Contact PPRM for more details. If you train or work in a Planned Parenthood environment, you may have access to the interactive online curriculum Ultrasound in Abortion Care (ARMS 2007). If US is available on site, it is also helpful to train staff on US guidance to assist with the occasional challenging procedure.
Assisting in the Procedure Room
Just as you went through your individual training to learn appropriate procedural support techniques for providers, your support staff will need training in many of the same techniques and language, and Chapter 2 of this Workbook is a good resource for them. A Training Checklist for Staff Assisting in the Procedure Room (TEACH) may be a useful training tool.
Preparing for Medical and Security Emergencies
Preparedness is the key to managing any medical emergency effectively. Limited patient encounters and heightened focus on safety have led to training that increasingly involves simulated complication scenarios. Simulation and drills build communication, improve stress readiness during a crisis, and decrease risk to patients. Many medical Emergency Simulation Drills (TEACH) and Security Drills (TEACH) are available and can be carried out on a quarterly or recurrent basis. In addition, a sample Incident Report Form is available. For current information on incidence, go to NAF Violence Statistics and History.
Sterilization and Disinfection
We have included easy-to-follow training posters on the following techniques:
- Wrapping Instruments and Trays for Sterilization (TEACH )
- Unwrapping Sterile Packages, Using Aseptic Technique (TEACH)
- Decontaminating, Cleaning & Disinfecting the IPAS Syringe (Ipas, pg. 15)
- Reprocessing Vaginal Ultrasound Probe (TEACH)
Fetal Tissue Questions and Disposal
Patients often have questions about fetal development and want to see or know what happens to the tissue. See Chapter 2 for how to answer these questions. All surgically removed tissue must be considered biohazard and be handled, stored, and disposed of in a manner that minimizes the risk of exposure (NAF CPGs 2016). A protocol for tissue handling, storage, and disposal must be in place. Contact your local Department of Health to find out current regulations or use this guide for general tissue disposal.
SETTING UP YOUR FACILITIES
It may take some time and up-front cost to order necessary medications and supplies. A comprehensive list of medications, supplies, and vendors necessary to provide medical and aspiration management of EPL and abortion can be found here, and in Chapter 4. For sites already doing IUD insertions, adding a set of dilators and manual vacuum aspirators to an IUD set up may be all that you need. A step-by-step guide for ordering mifepristone for medical abortion is available at Mifepristone Ordering Guide (RHAP).