WI WH-FP/RH Program Site Manual for Developing Dual Protection Services

WI WH-FP/RH Program Site Manual for Developing Dual Protection Services 1

Table of Contents SECTION I: UNDERSTANDING THE FULL SCOPE OF DUAL PROTECTION SERVICES... 5 A. INTRODUCTION TO DUAL PROTECTION SERVICES... 5 1. PURPOSE OF DUAL PROTECTION SERVICES... 6 2. BLUEPRINT FOR PROVIDING BASIC DUAL PROTECTION SERVICES... 6 3. DUAL PROTECTION SERVICE DESIGNS... 7 B. DEVELOPMENT OF DUAL PROTECTION SERVICES... 7 1. ESTABLISHING MEDICAL DIRECTOR ROLE AND SUPPORT... 8 2. STANDING ORDERS AND MEDICAL AUTHORIZATION... 9 3. TEMPLATES OF STANDING ORDERS... ERROR! BOOKMARK NOT DEFINED. C. RELEVANT STATE STATUTES AND OTHER LEGAL REQUIREMENTS... 9 D. RELEVANT STANDARDS OF CARE AND PRACTICE... 10 SECTION II: BUILDING DUAL PROTECTION SERVICES... 12 A. ORGANIZING BASIC DUAL PROTECTION SERVICE COMPONENTS... 12 1. STD TESTING/TREATMENT... 12 2. PREGNANCY TESTING... 19 3. DUAL PROTECTION... 20 4. PRIMARY/INITIAL METHOD... 21 5. PROVIDING INITIAL METHOD USING VIDEO ASSISTED PATIENT SERVICES (VAPS)ERROR! BOOKMARK NOT DEFINED... 23 SECTION III: AGENCY INFRASTRUCTURE... 23 A. FORWARDHEALTH PARTICIPATION AS A MEDICAID PROVIDER... 23 1. WISCONSIN FORWARDHEALTH FAMILY PLANNING PROVIDER... 24 2. CERTIFICATION FOR BC-FPOS EE/CE... 25 3. AUTHORIZATION FOR BADGERCARE ELECTRONIC EXPRESS ENROLLMENT... 25 B. ESTABLISHING/ORGANIZING FINANCIAL AND BILLING SYSTEMS... 25 1. CODING... 26 2. CVR/BILLING SHEET... 26 3. BILLING (CLAIMS)... 27 4. DOCUMENTATION (CLIENT RECORDS AND OTHER AUDIT TRAILS)... 27 5. CLAIMS SUBMISSION... 27 6. FPOS SCREENING AND ENROLLMENT TRACKING... 28 C. ORGANIZING PROCESSES AND PROTOCOLS TO ENSURE COMPLIANCE WITH LEGAL REQUIREMENTS... 28 1. CONFIDENTIALITY AND PATIENT IDENTITY AND PRIVACY PROTECTION FOR REPRODUCTIVE/SEXUAL HEALTH SERVICES 29 2. SEXUAL ABUSE REPORTS... 30 3. SEXUAL ASSAULT/ABUSE PREVENTION AND INTERVENTION PRACTICES *... 31 4. CONSENT FOR SERVICES... 32 2

5. CONSENT FOR RELEASE AND DISCLOSURE TO THIRD PARTIES BEYOND THE DUAL PROTECTION PROGRAM (WITHIN OR OUTSIDE THE AGENCY)... 32 6. REQUESTS FOR DISCLOSURE AND REPORTING WITHOUT PATIENT CONSENT... 33 7. SERVICES TO MINORS (INCLUDING CONSENT FOR SERVICES AND CONFIDENTIALITY)... 34 8. STATE STATUTES RELEVANT TO RN SCOPE OF PRACTICE... 36 D. ORGANIZING PROCESSES FOR QUALITY ASSURANCE/QUALITY CONTROL... 36 1. AUDIT TOOLS AND INTERNAL AUDIT PROTOCOLS (PATIENT SERVICES AND FINANCIAL AUDIT TRAILS)... 36 2. CONFIDENTIALITY AND PRIVACY PROTECTION REVIEW AND AUDITS... 37 E. ORGANIZING PROCESSES FOR MANAGEMENT AND STORAGE OF CLIENT INFORMATION (INCLUDING PHYSICAL AND ELECTRONIC INFORMATION)... 38 1. PHYSICAL AND ELECTRONIC STORAGE SECURITY (FROM LOSS OR UNAUTHORIZED ACCESS)... 38 2. ROLE-BASED SECURITY PROTOCOLS FOR ACCESS... 40 3. RELEASE AND DISCLOSURE (WITH AND WITHOUT CONSENT)... 40 F. MANAGEMENT AND STORAGE OF SUPPLIES... 44 1. INVENTORY... 44 2. PHARMACEUTICALS... 45 3. AGENCY RESPONSIBILITIES... 45 G. ORGANIZING PHYSICAL SPACE TO ACCOMMODATE SERVICE REQUIREMENTS AND TO ENSURE PATIENT PRIVACY, DIGNITY, AND SERVICE REQUIREMENTS... 47 1. HEALTH INTERVENTIONS/MEASUREMENTS... 47 2. CLIENT INTERVIEWS AND ASSESSMENTS... 47 3. PROCEDURES... 47 4. PATIENT RECORD SECURITY... 47 5. CLINIC AND PATIENT FLOW PLAN... 47 6. VAPS... 47 H. PHYSICAL SPACE REQUIREMENTS... 48 1. RECORD SECURITY... 48 2. LOGISTICS OF CLINIC FLOW... 49 3. PROCESS FOR HANDLING BODILY FLUIDS... 49 4. LABORATORY... 49 I. BASIC EQUIPMENT... 50 1. LABORATORY... 50 2. VAPS... 51 J. STAFF TRAINING AND PROFICIENCY... 51 1. STAFF TRAINING... 51 2. STAFF PROFICIENCY... 53 3. TRAINING CHECKLISTS FOR STAFF PROFICIENCY... 54 K. COMMUNITY AWARENESS... 54 1. OUTREACH AND INREACH... 54 2. ADVERTISING... 55 3

L. APPROVED EDUCATION MATERIALS AND RESOURCES... 55 M. REFERENCES AND RESOURCES... 55 N. ATTACHMENTS... 56 O. ACRONYMS/GLOSSARY OF TERMS... 57 P. FAQS... 58 4

Section I: Understanding the Full Scope of Dual Protection Services A. Introduction to Dual Protection Services The main purpose of the dual protection services program is to provide access to sexually transmitted disease screening, testing, and treatment services that are integrated into existing programs and services available through a local county health department or other agency. These services are provided according to established dual protection standards of care and practices for the protection of reproductive health and prevention and early detection and treatment of Chlamydia and Gonorrhea. Dual protection services support the following public health and maternal and child health promotion and prevention goals: Reproductive health promotion and risk reduction Protection of fertility Planned and prepared for pregnancy Health pregnancy and birth Healthy birth spacing Dual protection services provide a set of important interventions, provide an entry point into reproductive primary health care, and support timely continuity of care. They are intended to supplement comprehensive community-based reproductive health. They are not an alternative to, replacement, or substitution for full service reproductive health primary care. What is dual protection? Dual protection is a term used when a person wants to avoid both pregnancy and sexually transmitted infections. Dual protection is the use of condoms to reduce the risk of STD/STI exposure and a contraceptive method to reduce the likelihood of unintended pregnancy. Providing access to Dual Protection Kits in advance of need is an evidence-based practice which indicates greater use, thus greater pregnancy and STD/STI prevention. The Dual Protection Kit includes male and female condoms, emergency contraception, and educational materials for appropriate use. This site manual provides up-front information on how to build these new service components. It also discusses critical points for fully understanding the service components and key administrative decisions for when establishing dual protection services. There are two reference documents that can be made available to help guide an introductory presentation to local boards, health officials in making this decision. These documents are titled Dual Protection Overview of Main Intervention Steps and the Power Point presentation Dual Protection Services: An Entry Point into Reproductive Health Care. Essentially, if potential service sites have concerns or cannot meet the expectations described in Section I, they should stop here and go no further. 5

1. Purpose of Dual Protection Services Dual protection services provide a set of important interventions, provide an entry point into reproductive primary health care, and support timely continuity of care. They are intended to supplement comprehensive community-based reproductive health. They are not an alternative, replacement, or substitution for full service reproductive health primary care. The core interventions in dual protection services (depending on the presenting needs) accomplish the following functions: o o o o o o o To adequately address the primary presenting needs (including STD, pregnancy, primary method, and/or emergency contraception) To screen and enroll eligible clients into Badger Care Family Planning Only Services (BC- FPOS) health care coverage To provide the complete Dual Protection Kit To provide the opportunity for a primary (initial) contraceptive method To actively facilitate ongoing connections with a medical and pharmacy home To screen for potential sexual violence/abuse/coercion when possible, or to provide an opportunity for a client to express concerns To provide actively managed referrals with follow-up for a reproductive health care home and continuing services and supplies 2. Blueprint for Providing Basic Dual Protection Services Dual protection services are designed to inform, motivate, and support clients to adopt behaviors to decrease STD/STI risk exposure and to promote pregnancies that are intended. Interventions include medically delegated functions and nursing functions, including assessment, planning, intervention, and evaluation. Dual protection services are an integral part of public health s role in communicable disease control and assurance. The key to successful development of these services is to identify the key points of client entry into dual protection services. Key Points of Client Entry into Dual Protection Services Points of Client Entry into Services Request for STD Test Request for HIV Test Request for Pregnancy Test Request for EHC Request for health coverage Requests for HPV vaccine PNCC (Third Trimester and early post-partum) STD Testing (as part of Disease Intervention) STD Re-Test (Post Treatment) STD/STI Intervention Financial Financial Screening BC-FPOS enrollment (TE/EE & CE) Initial STD Intervention History/Risk Assessment Consents Obtained and Signed STD/STI Testing (CT & GC) HIV Testing Education/Anticipatory Guidance Dual Protection Intervention Standard Dual Protection (DP) Kit Provided Clinic services provided (as needed) Assessment of Contraceptive Needs (Primary Method) Primary method supplies/services as needed VAPS consultation (as needed) Reproductive Health Care Actively Managed Appointment for on-going: Clinical Services Supplies 6

Post Visit Follow-Up Treatment Referral and Follow-up Intervention and Quality Assurance STD Services Handling & Shipping Specimens Financial Temporary enrollment (TE form or EE) CE enrollment form Documentation Documentation Client Record Established (New Client) Results & Follow-Up Documentation in Client Record Patient Notification Treatment (as indicated) Documentation Billing Disease Intervention Documentation Client Visit Notes Recorded Financial Transaction Recorded on Billing Sheet Billing and Fee Collection Claims for third party reimbursement Financial Follow-Up BC-FPOS Managed Enrollment Assistance Provided as needed for Continuous Enrollment Follow-Up and Short-Term Care Navigation Appointment (Referral) Follow-up Quality Assurance and Accounting Reviews 3. Dual Protection Service Designs Dual protection services can be divided into three different designs for service delivery: Design I: Basic dual protection services: STD testing and treatment, pregnancy testing, health insurance eligibility screening and enrollment, dual protection education and supplies, and initial/primary method, and referral and follow-up. These are the basic requirements for agencies acting on behalf of the WI WH-FP/RH Program. Optimal Enhancements: Design II: Basic dual protection services, and in addition, on-going contraceptive supply site for returning clients. Design III: All of the above; and in addition, plus acting as a satellite clinic of the full service family planning partner. B. Development of Dual Protection Services Agency Infrastructure to Support Dual Protection Before we outline critical infrastructure support in providing dual protection services, it may be helpful to first review the brief outline of project implementation steps that need to happen, along with the corresponding decisions that will need to be made. 7

Implementation Steps Planning Client intake and flow: Self-presenting and screened clients Financial transaction/coding/audit trail Establishing WSLH account STD program agreement (for 340 B supplies) Supply inventory: (see also pages 92-93) Condoms EC Tests Treatment medications Client service materials (forms, charts, education materials) Inventory management Standing order/collaboration agreement for testing, treatment, and dual protection supplies Patient confidentiality/consent for care Consultation/training (as needed) Testing Client record documentation Financial transaction/audit trail documentation Protocols Project administration STD program in-service (as needed for disease intervention) Billing method (MD or PT71) PT71 certification (as decided) Agreements/arrangements for referrals (partnership with full service FP provider): On-going supplies Clinical services Laboratory set-up CLIA certification (as needed) Partnerships (as needed) VAPS partner (full services FP provider) Information to prospective clients about availability of service Coordination with STD program, such as GYT month Key Decisions How will primary method be provided at initial visit? How will project be a supply site (on-going supplies)? What is the billing method? 1. Establishing Medical Director Role and Support Infrastructure requirements for developing dual protection services are: Clinic services must be provided under the supervision of a registered nurse trained in reproductive/sexual health care. 8

Clinic services must have a medical director who supports the dual protection program of complete services and standards of care/practice. It s also important to have enlisted the support and approval for these new policies by both your county administrator and Board of Health. 2. Standing Orders and Medical Authorization In the references on the WI Administrative Code and Statutes are important background information specifically for medical directors on providing standing orders for dual protection services. Included in the dual protection program are only the interventions requiring medical supervision for delegated medical functions (through standing orders): the treatment and prescription/provision of medications. For nursing functions including assessment, planning, intervention, and evaluation you will have protocols and procedures (such as procedures for HIV OraSure testing). These do not require medical orders. For reference, relevant sections from Wisconsin Administrative Code and Statutes are found in the Attachments-Section I: A and B. Each function or dual protection service requires general medical supervision from the Medical Director. Sample standing order templates are found in the Attachments- Section I: C, in this order: Treatment of Sexually Transmitted Infections Dual Protection Supplies Initial Method of Contraception Medically Delegated Functions C. Relevant State Statutes and Other Legal Requirements Many laws affect reproductive health providers, whether you re providing full-service family planning or a limited scope of services such as dual protection. Before deciding to provide any type of reproductive health service, it s important to know and understand the laws that will allow your agency staff to function to their full potential and to be efficient. Our laws define the scope of practice and what functions can be delegated by one staff to another. Please see Attachments-Section I: A and B, are the Wisconsin state legislative documents that impact providing dual protection services. State statutes that address patient confidentiality, consent for services, sexual abuse reporting, and providing services to minors are outlined in Section III: Agency Infrastructure #3. 9

D. Relevant Standards of Care and Practice Presented in this section are three important bodies of work that reflect the recommended priority practices in Wisconsin reproductive health settings. These practice standards, include Just the Basics, WI WH-FP/RH Program Priority Practices and national evidence-based resources, all represent backbone material used to develop practice standards for dual protection services. 1) Just the Basics Series Practice standards have been written to summarize key principles, policies, and practices, which are reflected here in the Just the Basics document series developed specifically for the Wisconsin WH-FP/RH Program. These standards of practice also reflect principals that would be required of new dual protection services sites. Several documents in this series summarize basic principles that uniquely define the field of family planning and related reproductive/sexual health and can be adopted by dual protection sites: Mission and Commitment to Patients outlines basic legal and ethical principles that are an integral part of family planning and reproductive/sexual health services and care. Definition and Essential Components of Care reviews definitions of the field of family planning and summarizes the essential components of care and policies and practices that must be in place in a family planning service. Fundamental Patient Rights and Core Values defines family planning in terms of basic rights and summarizes the essential practices necessary to support these rights. Core Reproductive Health Knowledge Areas summarizes basic messages (reproductive/sexual health literacy) considered essential for the reproductive age population for which providers have a responsibility to provide. The remaining documents in the Just the Basics series summarize services, care, and practices that are both an essential part of quality family planning and reproductive/sexual health care and required in the WI WH- FP/RH Program. View the full versions of this series at HCET website: http://hcet.info/our-projects/wisconsin-family-planning/provider-resource-center/just-thebasics/ The Just the Basics policy specific to providing dual protection is in the Attachments- Section I: D. 2) Women s Health-Family Planning/Reproductive Health Services-Priority Practices See Attachments-Section I: E. 3) References for evidence-based practices in dual protection services: This dual protection services site manual and the accompanying Procedure Manual for Dual Protection Client Services manual both reference practice standards based on the use of evidencebased clinical practices. We have utilized documents developed by experts in the field of 10

reproductive health, including the Centers for Disease Control and Prevention (CDC) and U.S. Office of Population Affairs Recommendations for Quality Family Planning Services; US Medical Eligibility Criteria for Contraceptive Use and the American College of Obstetricians and Gynecologists. These references for evidence-based practices are found in the Attachments- Section I: F, of this manual. 11

Section II: Building Dual Protection Services A. Organizing Basic Dual Protection Service Components As outlined in Section I of this manual, core services for providing dual protection build on the communicable disease responsibilities of a health department or agency and include basic STD testing and treatment, pregnancy testing, and much more. Patients will enter services presenting with one or more of these primary health care needs. This section of the manual will help you identify the various entry points for providing dual protection services, the decisions that you need to make, and the steps toward actual implementation. Remember, regardless of the client s presenting need, the overarching goal is that clients leave with dual protection intervention and care regardless of initial reasons for visit. Basic decisions for all dual protection services: Establishing WSLH Account. STD Program Agreement (for 340 B supplies) Standing Order/Collaboration Agreement for Testing, Treatment, and Dual Protection Supplies. WFPRHA Membership for Dual Protection Kits supplies. Billing Method (MD or Provider Type71) PT71 Certification (as decided; see Section III) How will Primary Methods be provided? Will project be a supply site (on-going supplies)? Partnerships: o Full service family planning partner o Video Assisted Patient Services (VAP) partner Information to Prospective Clients about Availability of Service o Coordination with STD Program, such as Get Yourself Tested TM (GYT) initiative 1. STD Testing/Treatment The following guidelines are for STD risk assessment and testing in the dual protection program setting a different setting and patient population than established women s health-family planning program patient populations. Initially, the patient population might be more similar to a traditional STD clinic population. Subsequent surveillance (using WSLH data from the Laboratory Request Form [LRF]) can help inform and refine testing algothrims. 12

The WI WH-FP/RH Program Selective Screening Criteria (SSC) should be used for risk assessment. Testing may not strictly adhere to the SSC, particularly for clients presenting with an STD concern. The presumption may be to test unless otherwise indicated. To establish community awareness of the dual protection program, a Get Yourself Tested initiative might be useful. Initially, testing may deviate from the SSC established for comprehensive WH-FP programs and patient populations. Flow of services STD program agreement (for 340B supplies) Establishing WSLH account Standing order/collaboration agreement for testing, treatment, and dual protection supplies Supply inventory: Condoms, EC, tests, treatment medications, and client service materials (forms, charts, education materials) Client intake: Self-presenting and screened clients Access risk Screen and enroll eligible clients into BC-FPOS health care coverage Financial transaction/coding/audit trail The following are resources for service arrangements and decisions that need to be in place before offering STD testing and treatment as part of a dual protection program. a. Wisconsin STD Program Business Agreement Dual protection sites must first complete an MOU with the Wisconsin DPH, BCD, HIV/STD Control Section. This MOU is also part of the process for 340B certification. See section c., 340B Certification, below for sample MOU and steps. b. WSLH Business Agreement Dual protection sites will be required to send their tests to the Wisconsin State Laboratory of Hygiene (WSLH). Initiating a business agreement and setting up an account with the WSLH are the first steps in this process. At the time of account set-up, a new dual protection site can receive a starter kit of supplies and laboratory request form (LRF), as well as decide preferences for receiving patient test results. These steps can be done by contacting Michele Smith at michele.smith@slh.wisc.edu. More information about the WSLH and the tests they perform is below. Tests offered at the WSLH include: 13

Chlamydia/Gonorrhea Screening, including these sources: o Cervical o Urethral o Urine o Vaginal o Rectal o Pharyngeal HPV Testing with 16 & 18 Genotyping Liquid Based Cytology o Cervical o Vaginal Herpes Screening HIV 1 & 2 & HIV Orasure Syphilis Screening Hepatitis C Screening Chlamydia and Gonorrhea Screening Sites must have available, on site a full range of testing modalities for Chlamydia and Gonorrhea screening. o Vaginal swabs (either self-collected or staff collected) are preferred for women. However, urine is acceptable. o Urine is the preferred specimen for men. Sites must provide Chlamydia and Gonorrhea screening to men and women. Patients with a positive result must receive notification and treatment. If a site is unable to notify the patient and the patient was not treated at the time of screening, the local public health department must be notified. Sites are required to follow the WI WH-FP/RH Selective Screening Criteria Chlamydia and Gonorrhea Testing. HPV screening may be done at clinician s discretion with appropriate documentation. Herpes Screening Must be available on site or by referral. Human Immunodeficiency Virus (HIV) Screening Sites are encouraged to have HIV testing available via: o Blood (optional) or oral rapid testing. A reactive rapid HIV test must be confirmed by WSLH. o Oral testing via the WSLH. o Venipuncture for blood HIV testing at the WSLH. (Optional) 14

Syphilis Screening Blood specimen collection could be available on site or by referral. c. 340B Certification What is 340B? Section 340B of the Public Health Services Act was created under Section 602 of the Veterans Health Care Act of 1992. Section 340B requires manufacturers participating in the Medicaid program to enter into a pharmaceutical pricing agreement with the United States Department of Health and Human Services (HHS). Under such an agreement, individual manufacturers agree to provide discounted prices to certain defined covered entities for covered outpatient drugs. These covered entities typically serve more vulnerable patient populations. Dual protection service sites are required to become certified in providing 340B program pharmaceuticals for their clients. Participating agencies must complete an MOU with the WI STD Control Section, as a first step. A sample MOU is shown in the Attachments- Section II: A. Contact Lori Amsterdam for further assistance: lori.amsterdam@wisconsin.gov or 608-267- 5220. Local management of 340B registration and re-certification activities: The Authorizing Official (AO) for local management of the entity(ies) to ensure new and continuing eligibility for 340B drug pricing under the umbrella of federal STD 318 funding must meet each of the following requirements: o Assign a local AO to proactively manage the 340B program for each entity(ies) o o o o Update and maintain the 340B entity profile for registration and recertification whenever there are any changes to profile information, including turnover of staff responsible for managing 340B services, address changes, contact information, etc., and act on direct communication from HRSA regarding 340B policy updates Maintain a tickler file to ensure timely management of registration and recertification periods throughout the year Provide training to new staff responsible for managing/maintaining 340B services Notify DPH/STD Control Section Staff regarding questions related to any change in status for STD 318 funding eligibility: lori.amsterdam@wisconsin.gov 608 267 5220 15

o o Notify DPH/STD Control Section Staff regarding application for new entities to receive 340B services through STD 318 funding eligibility: lori.amsterdam@wisconsin.gov 608 267 5220 A user manual for recertification is available at: http://opanet.hrsa.gov/opa/manuals/opa%20database%20guide%20for %20Public%20Users%20-%20Recertification.pdf If your organization has additional eligible sites that are not yet registered in the 340B Program database, please complete the online registration forms at http://opanet.hrsa.gov/opa/default.aspx during the open registration period (the first 15 days of each calendar quarter). This activity is separate from the recertification of existing covered entity sites. o Questions regarding recertification/registration may be directed to the 340B Prime Vendor Program at 1-888-340-2787, or by sending an e- mail to ApexusAnswers@340bpvp.com. d. Standing Orders Medical standing orders, sufficient for the Dual Protection scope of practice, will be in place: Treatment of Sexually Transmitted Infections Dual Protection Supplies Initial Method of Contraception Medically Delegated Functions See Attachments-Section I: C, for sample standing orders. e. Local Pharmacy Agreement Why is a local pharmacy agreement needed for this program? The answer to this question depends on how the dual protection site will provide prescription medications, like those used for EPT. Medications not stocked by the dual protection site can be provided by the local pharmacy and billed via the patient s BC-FPOS coverage. Agencies may then reimburse the local pharmacy an agreed-upon dispensing fee as outlined in the MOU. f. Guidelines for Lab Set-up All sites Must offer lab tests that are specific to dual protection services on site or by referral to contracted service providers. Are responsible for their Clinical Laboratory Improvement Amendment (CLIA) certificate and appropriate compliance responsibilities. 16

Are to assure compliance with Wisconsin Department of Transportation (DOT) regulations for handling, packaging, and transport of laboratory specimens. Are to assure labeling of specimens is in accordance with the laboratory requirements. Are to assure that all laboratory specimens sent to the Wisconsin State Laboratory of Hygiene (WSLH) have two unique identifiers and, preferably, a printed label that includes this information. Are to assure compliance with the Occupational Safety and Health Administration (OSHA), with special emphasis on the Bloodborne Pathogen Standard. g. Expedited Partner Therapy (EPT) On-site patient/partner treatment is the gold standard for STD treatment. Providing EPT is an acceptable approach to treatment when direct patient intervention is not possible. See the CDC website for additional resources on providing EPT: http://www.cdc.gov/std/ept/default.htm. Dual protection sites may offer the partners of their patient s access to EPT following the outlined steps for a positive test or contact for Chlamydia and/or Gonorrhea: Patient The patient will be treated utilizing the Centers for Disease Control & Prevention (CDC) STD/STI treatment guidelines. The patient s medical record will be reviewed for allergies to medication and contraceptive use. The patient will be instructed to take all medication as instructed. The patient will be instructed to abstain from sex for seven days after treatment is finished. The patient will be instructed and offered dual protection information and coverage. The patient will be instructed to have their partner(s) screened and treated. Retesting: o ALL patients (women and men) should be advised to receive a retest per the current CDC STD Treatment Guidelines. o Note: Female patients are to be instructed to return for re-testing in 90 days per CDC Treatment Guidelines. o Retesting should not be done sooner than four weeks. o The appropriate State of WI epidemiologic reporting will be completed. Partner If for any reason the staff feels that the partner will not seek treatment, then the agency may utilize expedited partner treatment (EPT). 17

If expedited partner treatment (EPT) is initiated, the agency must provide a prescription or medication and EPT/medication information sheet to the patient for the partner. The agency must follow the State of WI EPT requirements. EPT Information sheets must include: o Information about the STD/STI. o Treatments. o Risk of drug allergies. o Advice to call his/her healthcare provider/pharmacist or local health department with questions. h. Partnership with Full Service Family Planning Provider A partnership with a full service family planning provider is critical for dual protection site client consultation and referral to a reproductive medical home. A partnering agency can also assure that a primary method of contraception is accessible for clients at the dual protection site. This partnership is required in providing the full scope of dual protection services. This full service partnership has the potential to offer essential public health services and increase access to residents in the counties served by the dual protection site. These essential services contribute to women s health, healthy birth, healthy birth spacing, and communicable disease control. A requirement of Design Level III (see Section I) in providing dual protection services is to partner with a full service family planning provider in offering various services on behalf of the dual protection site. Partnerships with multi-county women s health providers can add depth to staffing (primary and back-up) and sharing of resources and expertise. These partnerships with full service family planning sites can provide: Video Assisted Patient Services (VAPS) consultation for initial OHC VAPS consultation for other provided services, STD and pregnancy testing, etc. Referral for reproductive health medical home Acting as an agent on behalf of the dual protection site by offering medications and supplies Acting as an agent on behalf of the dual protection site by offering billing and reimbursement services A simple MOU or collaborative agreement can be drafted to establish goals in this working relationship between a full service provider and the dual protection site. i. Procurement of Supplies/Meds There are many resources used by full service family planning providers in the procurement of supplies and medications. Dual protection sites will also need to obtain limited supplies, such as emergency contraception (Plan B One-Step or Plan B Generic), condoms (male and female), tests 18

(STD/STI, PG, HIV), treatment medications, charts, client forms, educational materials, and client services materials. Routine supplies such as paper goods and syringes can be ordered from any durable medical supplier, such as McKesson. Pregnancy tests are also cheaper when purchased through a durable medical supplier. Medications (including OHC) can be purchased via a buying club such as WFPRHA or R&S Northeast or by using a local pharmacy. Condoms can be purchased directly from Global One or Total Access. Supplies for STD testing and shipping and handling of specimen materials are received from the WSLH. 2. Pregnancy Testing Flow of services Client intake and flow: Self-presenting and screened clients Screen and enroll eligible clients into BC-FPOS transaction/coding/audit trail History/assess risk Pregnancy test: Lab set-up and procurement of supplies Follow protocols outlined for positive or negative test result Assessment for contraceptive needs: Dual Protection Kit Active referral to medical home Clinical services/supplies a. Guidelines for Lab Set-up See Attachments- Section II: B. b. Standing Orders Medical standing orders are not needed in providing pregnancy testing services. c. Partnership with Full Service Family Planning Provider A partnership with a full service family planning provider is critical for dual protection site client consultation and referral to a reproductive medical home. A partnering agency can also assure that a primary method of contraception is accessible for clients at the dual protection site. This partnership is required in providing the full scope of dual protection services. This full service partnership has the potential to offer essential public health services and increase access to residents in the counties served by the dual protection site. These essential services contribute to women s health, healthy birth, healthy birth spacing, and communicable disease control. A requirement of Design Level III (see Section I) in providing dual protection services is to partner with a full service family planning provider in offering various services on behalf of the dual protection site. 19

Partnerships with multi-county women s health providers can add depth to staffing (primary and back-up) and sharing of resources and expertise. These partnerships with full service family planning sites can provide: Video Assisted Patient Services (VAPS) consultation for initial OHC VAPS consultation for other provided services, STD and pregnancy testing, etc. Referral for reproductive health medical home Acting as an agent on behalf of the dual protection site by offering medications and supplies Acting as an agent on behalf of the dual protection site by offering billing and reimbursement services A simple MOU or collaborative agreement can be drafted to establish goals in this working relationship between a full service provider and the dual protection site. d. Procurement of Supplies/Meds There are many resources used by full service family planning providers in the procurement of supplies and medications. Dual protection sites will also need to obtain limited supplies, such as emergency contraception (Plan B One-Step or Plan B Generic), condoms (male and female), tests (STD/STI, PG, and HIV), treatment medications, charts, client forms, educational materials, and client services materials. Routine supplies such as paper goods and syringes can be ordered from any durable medical supplier, such as McKesson. Pregnancy tests are also cheaper when purchased through a durable medical supplier. Medications (including OHC) can be purchased via a buying club such or R&S Northeast or by using a local pharmacy. Condoms can be purchased directly from Global One or Total Access. 3. Dual Protection Flow of services Client intake and flow: Self-presenting and screened clients Screen and enroll eligible clients into BC-FPOS Transaction/coding/audit trail History/assess risk to include PG, STD, etc. Assessment for contraceptive needs: Dual Protection Kit Active referral to medical home Clinical services/supplies a. Standing Orders See attachment section for sample standing order. b. 340B Certification Dual protection service sites are required to become certified in providing 340B program pharmaceuticals for their clients. See Section II on STD procedures/340b process. 20

c. Partnership with Full Service Family Planning Provider A partnership with a full service family planning provider is critical for dual protection site client consultation and referral to a reproductive medical home. A partnering agency can also assure that a primary method of contraception is accessible for clients at the dual protection site. This partnership is required in providing the full scope of dual protection services. This full service partnership has the potential to offer essential public health services and increase access to residents in the counties served by the dual protection site. These essential services contribute to women s health, healthy birth, healthy birth spacing, and communicable disease control. A requirement of Design Level III (see Section I) in providing dual protection services is to partner with a full service family planning provider in offering various services on behalf of the dual protection site. Partnerships with multi-county women s health providers can add depth to staffing (primary and back-up) and sharing of resources and expertise. These partnerships with full service family planning sites can provide: Video Assisted Patient Services (VAPS) consultation for initial OHC VAPS consultation for other provided services, STD and pregnancy testing, etc. Referral for reproductive health medical home Acting as an agent on behalf of the dual protection site by offering medications and supplies Acting as an agent on behalf of the dual protection site by offering billing and reimbursement services A simple MOU or collaborative agreement can be drafted to establish goals in this working relationship between a full service provider and the dual protection site. d. Procurement of Supplies/Meds There are many resources used by full service family planning providers in the procurement of supplies and medications. Dual protection sites will also need to obtain limited supplies, such as emergency contraception (Plan B One-Step or Plan B Generic), condoms (male and female), tests (STD/STI, PG, HIV), treatment medications, charts, client forms, educational materials, and client services materials. Routine supplies such as paper goods and syringes can be ordered from any durable medical supplier, such as McKesson. Pregnancy tests are also cheaper when purchased through a durable medical supplier. Medications (including OHC) can be purchased via a buying club or R&S Northeast or by using a local pharmacy. Condoms can be purchased directly from Global One or Total Access. 4. Primary/Initial Method Flow of services 21

Client intake and flow: Self-presenting and screened clients Screen and enroll eligible clients into BC-FPOS health care coverage Financial transaction/coding/audit trail History/assess risk to include PG, STD, etc. Assessment for contraceptive needs: Dual Protection Kit VAPS consult with full service partner Clinical services/supplies Active referral to medical home a. Standing Orders See attachment section for sample standing order for provision of contraception in advance. b. 340B Certification Dual protection service sites are required to become certified in providing 340B program pharmaceuticals for their clients. See Section II on STD procedures/340b process. c. Partnership with Full Service Family Planning Provider A partnership with a full service family planning provider is critical for dual protection site client consultation and referral to a reproductive medical home. A partnering agency can also assure that a primary method of contraception is accessible for clients at the dual protection site. This partnership is required in providing the full scope of dual protection services. There are many resources used by full service family planning providers in the procurement of supplies and medications. Dual protection sites will also need to obtain limited supplies, such as emergency contraception (Plan B One-Step or Plan B Generic), condoms (male and female), tests (STD/STI, PG, HIV), treatment medications, charts, client forms, educational materials, and client services materials. Routine supplies such as paper goods and syringes can be ordered from any durable medical supplier, such as McKesson. Pregnancy tests are also cheaper when purchased through a durable medical supplier. Medications (including OHC) can be purchased via a buying club or R&S Northeast or by using a local pharmacy. Condoms can be purchased directly from Global One or Total Access. d. Procurement of Supplies/Meds There are many resources used by full service family planning providers in the procurement of supplies and medications. Dual protection sites will also need to obtain limited supplies, such as emergency contraception (Plan B One-Step or Plan B Generic), condoms (male and female), tests (STD/STI, PG, HIV), treatment medications, charts, client forms, educational materials, and client services materials. Routine supplies such as paper goods and syringes can be ordered from any durable medical supplier, such as McKesson. Pregnancy tests are also cheaper when purchased through a durable medical supplier. Medications (including OHC) can be purchased via a buying club such as Family 22

Planning Health Services, Inc or R&S Northeast or by using a local pharmacy. Condoms can be purchased directly from Global One or Total Access. e. Formulary Dual protection clients would have the opportunity to leave a visit with an initial primary method of depo-provera or an OHC commonly prescribed in the WH-RH Program. 5. Providing Initial Method using Video Assisted Patient Services A video-assisted/telemedicine patient service is a live, interactive videoconferencing communication between patients and health care professionals at physically separate locations. See the Attachments-Section II: G of this manual for more information about using VAPS services for family planning and related reproductive health services (FP/RH services) within the DP model, for providing services through a partnership with a full service family planning provider. Section III: Agency Infrastructure This section of the manual is dedicated to helping agencies build the key infrastructure components that will be necessary in starting a dual protection program. Establishing a limited set of services to meet the common presenting needs of clients will require implementation of the following: Financial management practices: Insurance (BC-FPOS),billing method, Collaborative agreements: WSLH, STD program, SecureVideo (VAPS), dual protection supplies, full service FP partner Quality assurance: Practice standards, patient privacy, confidentiality, audit systems, record security Physical space and equipment Supplies purchasing and management Staff proficiency and training Information to prospective clients This foundation will help assure the success of your dual protection program. Individualized client procedures and protocols, along with specialized dual protection client forms, are presented in the Procedure Manual for Dual Protection Client Services manual. A. ForwardHealth Participation as a Medicaid Provider Dual protection services need to be financially self-sustaining. In order for provider sites to remain sustainable, Medicaid reimbursement is a key source of revenue for these new program services both regular Medicaid and BadgerCare Family Planning Only Services (FPOS). BC-FPOS enrollment (temporary and continuous) is essential for financial support of the dual protection program and a clients continued access to care. Dual protection programs will need to make decisions that are appropriate for their agency, on the best way to become an eligible provider. 23

There are various arrangements that could be used for obtaining reimbursement via submitting a (FPOS) claim for dual protection services. Services could be submitted using a physician s Medicaid provider number. This would most likely be the physician with whom you would work. The physician would sign off on a collaboration agreement to provide the dual protection scope of services. This could be a way to get started, and it could evolve into another approach. Services could be provided (and billed) in conjunction with a provider (who is enrolled as a Medicaid provider) under a partnership agreement. Patients would be dual enrolled as a dual protection site client and as a patient of the partner agency. The partnership agency would submit claims on behalf of the partnership and reimburse the dual protection agency for services provided. For example, the dual protection agency would be reimbursed for the office visits, the specimen handling, shipping fee, and treatment medications. The partner agency might retain reimbursement for the Dual Protection Kit (which it would procure and re-supply). This approach would dovetail well with a Video Assisted Patient Service (VAPS) arrangement through which primary methods could be available and distributed to patients (which it would procure and re-supply). This has some advantages in establishing a linkage for ongoing guidance and technical assistance, until the program is firmly established. 1. Wisconsin ForwardHealth Family Planning Provider Dual protection sites could enroll as a Wisconsin Medicaid family planning provider. To be reimbursed for services provided to members enrolled in Wisconsin Medicaid, BadgerCare Plus, or SeniorCare, dual protection program providers are required to be enrolled in Wisconsin Medicaid as described in WI State Legislature-DHS 105.36 Family Planning Clinics or Agencies. For MA certification, family planning clinics or agencies shall meet the following criteria: http://docs.legis.wisconsin.gov/code/admin_code/dhs/101/105/36 Provider enrollment application: https://www.forwardhealth.wi.gov/wiportal/subsystem/kw/display.aspx?ia=1&p=1&sa=21&s= 1&c=1&nt=Provider+Enrollment+Information+Home+Page There is an application fee. This fee is relatively new and required as part of the changes implemented under healthcare reform. Dual protection services provided under the framework of a ForwardHealth family planning/public health clinic (provider type 71), are under the direction of the medical director. 24

2. Certification for BC-FPOS EE/CE Once an entity has completed the process through ForwardHealth to be authorized to Express Enrollment, they are then able to get set up at the ACCESS website to start doing Express Enrolllment applications for people who want to temporary enrollment in BadgerCare Plus or FPOS. Anyone can assist an individual with applying for continuous enrollment in FPOS. There is no need for an entity to enroll or sign up somewhere in order to be able to assist an individual with the application. The online application for FPOS is found at access.wisconsin.gov. When applying online, one of the screens at the beginning of the application asks about how the user is using ACCESS. If a staff person/volunteer at an entity is helping someone apply, they can click I am using ACCESS to apply for another person and then click the appropriate selection under Applying on Your Behalf. If the applicant had applied for EE in the last 90 days, the entity can also fill in the EE information to link the EE application to this new application for continuous benefits. 3. Authorization for BadgerCare Electronic Express Enrollment Provider Enrollment Application: Medicaid-enrolled providers interested in Making PE determinations for pregnancy women may access the online provider enrollment application via their secure ForwardHealth Portal account. (www.forwardhealth.wi.gov) The Express Enrollment for Pregnant Women provider application link is located in the Quick Links box on the right side of the secure Provider home page. ForwardHealth will notify providers in writing whether their application is approved or denied. When an application is approved, ForwardHealth sends the provider two communications: o o The approved letter includes a provider number that identifies the provider as qualified to use the EE tool to temporarily enroll pregnant women in BadgerCare Plus. An email sent to the provider s security administrator that includes a one-timeuse PIN. Once the security administrator receives the PIN, he or she is able to log in and set up administrative rights for individuals in the agency to begin using the EE application on the ACCESS Web site. The provider also receives information about where to find instructional materials and information needed to begin using the Badger-Care Plus Express Enrollment. Once an entity has completed the process through ForwardHealth to be authorized to Express Enrollment, they are then able to get set up at the ACCESS website to start doing Express Enrolllment applications for people who want to temporary enrollment in BadgerCare Plus or FPOS. See Attachment Assisting a client for Continuous Enrollment B. Establishing/Organizing Financial and Billing Systems It s critical that dual protection sites establish sound financial practices. One of these practices is setting a schedule of charges for all dual protection services: establishing a summary of the full cost 25

or the full fee for each service, procedure, and supply. This is the amount from which discounts will be subtracted and submitted in the ForwardHealth claim form. To guarantee accurate reimbursement from Medicaid and other third-party payers, assurances need to be in place for use of appropriate CPT coding, chart documentation and knowledge of the claims submission process. 1. Coding Coding is a complicated topic. It involves services provided and what procedures and testing were done. Accurate coding is absolutely necessary for reimbursement. Incorrect coding can result in overpayment by MA and the risk of recoupment. Correct coding allows the dual protection agency to maximize reimbursement. All services provided need two codes: A diagnosis code (ICD-10) A procedure code (CPT): Office visit, preventative visit, testing a. Diagnosis Codes (ICD-10) Because BC-FPOS is for family planning services, the primary diagnosis code for the visit has to be in the Z30 series. The Z30 codes relate to client encounters for contraceptive management. The primary diagnosis code is attached to the office visit/preventative visit or the supplies given. For example, this is appropriate if a client is coming into a dual protection site for a Dual Protection Kit. For all FPOS client visits, you MUST have a Z30 series diagnostic code as your primary visit code. b. Procedure Codes (CPT) These codes are more complicated. The CPT/procedure codes change yearly and must be reviewed annually. Examples of CPT codes for office visits that are typical for a dual protection client are outlined in the Procedure Manual for Dual Protection Client Services manual. (One example is a client requesting a pregnancy test.) This manual showcases specific forms to use, the appropriate use of ICD-10 and CPT codes, and procedures to follow. 2. CVR/Billing Sheet Dual protection sites will be encouraged to use a client visit record (CVR) for each client encounter. This is a recommended practice among current reproductive health providers. CVR or billing sheet instructions: See Attachments-Section II: C. A client signature should be obtained for multiple purposes: Acknowledgement that the client received the service. Awareness of charges and retail value of services/supplies received. Reminds the client that the program accepts donations to maintain services in the community, and assists those who do not have insurance. 26