I. GETTING STARTED

New services take time to build. Incorporating reproductive health services into your practice is a process during which you will need to explore your staff’s core values, while attending to the concrete tasks of ordering supplies, implementing new protocols, (RHAP and NAF (for members) have resources) identifying applicable laws and policies, and addressing administrative and financial concerns. Approaching this process with a commitment to open dialogue is fundamental to a successful outcome.

Be strategic, realistic, and patient about the time this process will take and the number of staff meetings and training it may require. If you are working in a practice that has yet to offer all contraceptive options or early pregnancy loss (EPL) management, it may be helpful to start by integrating new contraception services, then early pregnancy assessment and options counseling, and management of EPL. If you are introducing abortion services, consider starting with medication abortion before uterine aspiration. This may help to increase support among staff and set the stage for offering aspiration in the future.

It is also important to note that although much happens within formal healthcare settings, not all people access care this way. Moving beyond the silos of healthcare spaces to build coalitions and organize alongside communities is increasingly important.

1. 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 that can meet regularly to discuss tasks, timeline, potential obstacles and solutions. A multidisciplinary team is most helpful.

Some initial considerations include which services to integrate first, which strategies will be best for gauging staff interest, and a model for training staff in various skills (e.g., counseling, ultrasound, procedural assisting, etc.)

Create a project plan and draft roll-out schedule, including the following tasks. Each of these is described in more detail in respective sections of this chapter.

• Consider who should be involved as community stakeholders and partners
• Develop clinical protocols and policies, with consideration of state or country regulations (for APCs see the APC Toolkit – State Abortion Laws)
• Create a schedule to organize the steps you will take to integrate services
• Develop training programs/materials for providers and staff, including values clarification (see below).
• Adapt or develop forms for consent and medical record. Understand your state law; some states require segregation of records for sensitive services, such as abortion.
• Develop a realistic budget, projecting patient volumes, potential revenue sources (self-pay, insurance, donations, Medicaid, other) and costs (which could include training costs, staffing, equipment, supplies, additional malpractice)
• If billing insurance, understand requirements for each payer. Consider asking advice from peers in the same region for tips and tricks.
• Meet with the billing department: understand how services will be priced and billed, and what can be done within current billing processes, and what (if any) new processes will need to be developed. See below for special issues related to clinics supported by federal funding.
• Investigate current malpractice coverage, determine if additional coverage is needed, and research associated costs (especially important for FQHCs, who may need to purchase supplemental abortion coverage).
• Order procedural supplies
  • If needed, order ultrasound (consider point-of-care ultrasounds, which are portable, less expensive, and easy to use).
• For mifepristone use, set up accounts with manufacturers and certify prescribers:
  • GenBioPro (generic): set up a new a account
  • Danco (brand): set up a new account
• Order medications
• Develop a call pool, and train clinicians on commonly asked questions.
• Develop a referral protocol for services you don’t offer or back-up you’ll need
• Decide if you will serve people who are not already in your practice

2. Consider Technical Assistance Opportunities and Clinical Hotlines

Several technical assistance programs offer funding and technical support related to integrating either abortion and early pregnancy loss, or contraceptive care into health care settings, which may vary with funding streams.

3. Addressing Considerations for Federally Qualified Health Centers (FQHCs), Title X Clinics, and Teaching Health Centers (THCs)

Under the Hyde Amendment, federal funds cannot be used for supporting abortion services except in very narrow circumstances. However, these restrictions are on organizations’ federal funds, not on the institution as a whole. As such, FQHCs, Title X clinics, and THCs may provide abortion services if they are financially and operationally separated from their federally-funded services (e.g. an FQHC’s defined scope of project, Title X family planning services).

FQHCs and THCs, may self-refer and provide abortion services as an “other line of business,” as long as federal funds are not used for these services, and can only take place on property without a retained federal interest (which does not expire over time). Similarly, Title X funding is prohibited for paying for the cost or provision of abortion services. However,  relevant Title X rules have changed with presidential administrations, prohibiting or allowing Title X clinics to refer patients for abortion care and/or having abortion services located physically within family planning services, but financially separated.

For providers and administrators working at these clinics, resources are available to help navigate how to identify whether clinic sites are affected by federal property interest and to operationally and financially separate abortion from federally-funded services, such as separating supplies and staff time from federal funds in order to provide abortion services. This will include allocation of direct costs (i.e. direct care provider salaries, medications, and supplies) and indirect costs (i.e. EHR, equipment, facilities, etc.). Determine whether the service will be integrated into primary care sessions or held in a dedicated clinic session and which physical locations will be used to provide services. Some low-volume clinics choose to charge for related services (i.e. US and counseling) but waive fees for the abortion itself. Finally, the Federal Tort Claims Act malpractice (FTCA) will not cover abortion related care so you will need supplemental insurance.Various experts are available to consult on these issues.

It is important to note that the Hyde Amendment does not restrict the ability of FQHCs and THCs to provide options counseling, abortion referrals, EPL management, or ectopic pregnancy treatment and other early pregnancy care. These services are completely within an FQHC’s scope of federally-funded services.

• Essential Access Health Reproductive Health Access Project: Practical Guide on How to Provide Abortion Care at FQHCs and Title X Health Centers
• Federal Law Requirements for Reproductive Health Services at Health Centers

In planning to introduce new reproductive health services, consider key stakeholders in your community and institution and develop a proposal with key information that may be of interest to each stakeholder. Potential stakeholders and interests may include:

It will be important for staff and stakeholders to hear what you are considering, and what you are NOT planning to do. For example, you might tell them you intend to primarily focus outreach on people within your healthcare system, and are NOT intending to:

• provide services beyond a particular gestational duration,
• provide services to minors (based on the laws of your state),
• provide abortion services to patients outside of your system.

It is also important they have an opportunity to express concerns and understand how you’ve accounted for those concerns (which occasionally might require going back to the planning committee to come up with a plan).

For those integrating medication abortion only, an important early step will be finding backup for this service, unless you already provide it.

• For primary care providers working within healthcare systems with multiple specialties and departments, reach out to the OB/Gyn and Emergency Departments to let them know that you will be starting to offer medication abortion. Unless you offer this, see what community providers offer uterine aspiration services and can provide back-up.
• Consider offering both medication and uterine aspiration on site, when possible, particularly in areas where backup is limited or unsupportive.

For providers outside a network or without availability of backup providers for aspiration services, develop a relationship with an abortion health center in your region able to provide aspiration services to clinically stable patients.

When starting EPL or abortion services, there may be people within and outside your practice who are resistant to or directly impede implementation. For instance, if your head administrator or CEO continues to stall the initiation of abortion services, you may want to use some values exploration techniques (NAF, RHAP) to discover and address underlying concerns. This is a great time to highlight how these services will enhance access, broaden educational opportunities, improve recruiting and retention for trainees, including residents and staff. In some cases, new services may bring in additional revenue, which is another selling point.

5. Getting Staff Interested

All healthcare staff members (front desk, MAs, nurses) will interact with patients, and should be included in training on principles of person-centered care through values exploration and non-judgmental, gender inclusive 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.

1. First, consider distributing an anonymous staff survey to gauge people’s thoughts and feelings (example: Staff Attitude Survey (RHAP))
2. Offer a Values Exploration Workshop (NAF or RHAP) to present benefits of service provision, and evidence supporting the broader equity and public health reasons for broadening services. This process can help normalize anxiety around change, identify and dispel myths, and separate personal beliefs from professional roles and responsibilities. Often, the shared values within a clinic – such as providing comprehensive care that respects people’s lived experiences – prove to be a stronger force than staff anticipate when starting to think about controversial or stigmatized topics. Another shared value – mutual respect for differences – can help staff with anti-abortion religious beliefs be willing to work collaboratively in a clinic offering abortion services, if they feel their beliefs are respected as well.
3. Offer lunchtime trainings or discussions:

• • Introduce updates in contraception, pregnancy and options counseling, EPL management, and the public health impact of limited access to reproductive health services, including abortion. Helpful presentations can be found at http://www.guttmacher.org, www.reproductiveaccess.org, and www.providecare.org.
  • Present data on regional needs or results of a patient attitude survey [available at Patient Attitude Survey (RHAP)] to build buy-in.
  • To address common concerns, it is helpful to clarify that staff participation is elective, that services will not be advertised outside of established patients, and/or that there will be established gestational limits (i.e. < 14 weeks). Clarify during planning which responsibilities staff can opt out of and how they will be covered (e.g. scheduling, after-hours calls, etc.)
  • Role-play options counseling and consent (see Ch 2: Options Counseling).
  • Practice answering common and challenging phone and portal questions for abortion and EPL.
  • Use a Papaya MVA Workshop to serve as an orientation.

For more information and ideas, see Integrating Early Abortion into Primary Care (RHAP), as well as Ch 13: Staff Feedback Forms.

6. Developing Clinical Policies

Once support is in place from key stakeholders, adopt or begin developing protocols that define and standardize clinical workflows around the reproductive health services you will provide. We recommend adopting national evidence-based guidelines and creating supplemental guidelines and protocols as needed. These protocols can standardize the following:

• How many office and telehealth visits are appropriate for the service
• What pre-procedure evaluation is needed
• What supplies and medications are required onsite vs. by prescription
• Who is identified as emergency back-up
• How to adhere to local laws and regulations

Sample clinical policies can be found here:

• Medical Management of Early Pregnancy Loss Policy (RHAP)
• MVA for Early Pregnancy Loss Policy & Procedure (RHAP)
• Medication Abortion Protocol Using Mifepristone & Misoprostol (RHAP)
• Medication Abortion Protocol Using Misoprostol Alone (RHAP)
• Telehealth Care for Medication Abortion Protocol (RHAP)
• Sample Protocol for No Test Medication Abortion (Society of Family Planning)
• EPL Sample Protocols (TEAMM Project)
• Reproductive Health Sample Protocols (Access Bridge)
• NAF Clinical and Professional Guidelines

For practices also interested in integrating methotrexate treatment for stable, lower-risk ectopic pregnancies see Access Bridge Ectopic Pregnancy Management protocols.

7. Developing A Network

Building a supportive community is a key element to creating and sustaining abortion services. Building community support requires planning, creativity, and courage. As you work toward practice integration, consider connecting with local abortion providers, helpful listservs such as the RHAP network and its state-based and professional clusters, the Access List, local Planned Parenthoods, NAF, Abortion Care Network, and reproductive health care providers known to refer for abortion (this may be a list that other abortion providers can help generate). Professional organizations (such as specialty Ob/Gyn, primary care, or APC associations), political organizations (NOW, Reproductive Freedom for All, PRH, League of Women Voters) and local or national Reproductive Justice organizations (Sister Song, Reproductive Equity Now) are also useful allies for advocacy or to build collateral buy-in. See Chapter 9: Organization Resources.