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, implementing new protocols, 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 realistic and patient about the amount of time this process will take 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 early pregnancy loss (EPL) management, it may be helpful to start by integrating new contraception services, then 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.
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, what strategies will be best for gauging staff interest, and deciding on a model for training staff in various skills (e.g., counseling, ultrasound, procedural assisting, etc.).
Additional planning tasks:
- Develop clinical protocols and policies, with consideration of state regulations
- Create a schedule for how to integrate services
- Adapt or develop forms for consent and medical record
- Set up protocols with the billing department
- Understand reimbursement and develop realistic revenue projections
- Develop a budget for the new service and order supplies
- Research the cost of additional malpractice
- Develop a call pool
- Develop a referral protocol for services you don’t offer or back-up you’ll need
- Decide if an ultrasound will be on site
- Decide if you will accept patients who are not already in your practice
- For mifepristone use, certify providers with Danco or GenBioPro and complete account set up and prescriber agreement
For providers working at FQHCs or Title X clinics, resources are available to help navigate how to fiscally separate supplies and time from Title X and federal funds in order to provide abortion services. Some low volume FQHCs choose to charge for related services (US & counseling) but waive fees for the abortion itself.
Financial Record Keeping for Abortion Services in FQHCs
2. REACHING OUT TO KEY STAKEHOLDERS
In planning to introduce new reproductive health services, consider the key stakeholders in your institution and develop a proposal with key information that may be of interest to each stakeholder. Potential stakeholders and interests may include:
|Stakeholder (as applicable)||Role/Interests|
|Patients||Needs, barriers, preferences, and public health impact|
|Other practitioners in practice||Call sharing, collaborative practice|
|Department Chair||Guide relationships between other departments|
|Operations or Nursing Director||Nursing responsibilities, on site medications|
|OB Director||Expected volume, services coordination, back-up|
|Emergency Room Director||Back up in case of rare complications|
|Training Director/ Trainees||Training for local fellows, residents, medical students|
|Pharmacy||Medication supply on site or when appropriate, partnership for medication delivery|
|Pathology||Tissue processing (certain settings)|
|Radiology Director||Ultrasound access +/- credentialing (certain settings)|
|CEO||Impact on relationships, finances, strategy|
|CFO||Billing strategy, anticipated expenses|
|Board of Directors||If applicable, based on care setting|
For those integrating medication abortion only, finding back up for uterine aspiration is an important early step.
- For primary care providers working within a healthcare organization, reach out to the heads of the OB/GYN and Emergency Departments to let them know that you will be starting to offer medication abortion. Unless you offer uterine aspiration, see what providers offer this service 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, find a local abortion health center able to provide aspiration services to clinically stable patients.
3. GETTING STAFF INTERESTED
All clinic staff members (front desk, MAs, nurses) will interact with patients, and should be included in training on principles of patient-centered care through values clarification 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.
- Consider distributing anonymous staff 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, ethical and equity 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. Often, the shared values within a clinic – such as providing comprehensive care that respects patients’ lived experience – prove to be a stronger force than people anticipate when starting to think about controversial or stigmatized topics.
- Offer lunchtime trainings or discussions:
- Introduce updates in contraception, unintended pregnancy, 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
- Use a Papaya MVA Workshop to serve as an orientation.
- Present data on regional needs or results of a patient attitude survey [available at Patient Attitude Survey (RHAP)] to build buy in.
- Role-play options counseling and consent process (see Chapter 2).
- Practice answering common and challenging phone and patient portal questions for abortion and EPL.
For more information, see Integrating Early Abortion into Primary Care (RHAP).
4. 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 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 the local laws and regulations, etc.
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)
- MVA for Abortion Policy & Procedure (RHAP)
- Nursing Policy & Procedure for MVA (RHAP)
- NAF Clinical and Professional Guidelines
5. DEVELOPING A NETWORK
Building a supportive community is a key element to helping build and sustain abortion services. Building community support requires planning, creativity, and courage. Consider connecting with local abortion providers, helpful listservs such as the RHAP network and its clusters, access listserv, 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). Political organizations (NOW, NARAL, PRH, League of Women Voters) and local or national Reproductive Justice organizations (Sister Song, Reproductive Equity Now) are also useful allies for advocacy. See Chapter 9 for additional Organization Resources.
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 clarification techniques (NAF, RHAP) to discover and address underlying concerns. This is a great time to highlight how these services will enhance patient access and broaden educational opportunities for resident training.