Innovative Practices Among Publicly Operated Family Planning Centers

COMPANION WORKBOOK

COMPANION WORKBOOK

Table of Contents

CDPHE “Sustainability Coordinator” Job Description...... 1

HCCMS Organizational History...... 4

DHEC Regional Map...... 5

HCCMS Organizational Chart...... 6

Sample Supply Requisition Sheet...... 7

Sample Job Aid of Available Birth Control...... 9

Example Title X and FQHC Sliding Fee Scale...... 10

Example Guideline for Contraception...... 12

Example Contraception Wall Chart...... 14

Example Clinical Guideline...... 15

Sample Adolescent Services Policy...... 17

South Carolina Campaign to Prevent Teen Pregnancy Mission Statement...... 19

“One Key Question” Educational Tool...... 21

Secret Shopper Campaign: DeBriefer Form...... 22

Secret Shopper Findings Report...... 24

Sample Marketing Survey...... 28

Sample Marketing Survey 2, English & Spanish...... 30

Sample Charter to Share Branding...... 32

Sample MOU between a Health Care Provider and Community College...... 33

Example of Local SC Campaign Promotional Materials...... 34

Example Data Collection Spreadsheet...... 36

Example Referral Tracking Form...... 42

Example Work Plan to Develop a Strategic Plan...... 43

Example Short-Term Strategic Plan...... 44 Example Competencies for Preventative Health Nurse Course...... 46

Preventative Health Course Brochure...... 47

Example Roles for PHRN and APRN in an Integrated Setting...... 49

Sample Patient Insurance Information Collection Form...... 50

Sample Policy for Charges, Billing, and Collections...... 51

Sample Standing Order Policy for Initiating a Prescription without an Exam...... 53

Insurance Information Collection Job Aid...... 55

LARC Paperwork Job Aid...... 56

Sample Superbill...... 57

Chlamydia Coding Job Aid...... 58

Sample Insurance Reimbursement Tracking Form...... 59

Sample Insurance Contact Tracking Spreadsheet...... 60

Questions Regarding Electronic Health Records (EHR)...... 61

Example Family Planning Waiver Application...... 62

Patient Medicaid Eligibility Job Aid...... 65

A List of Women's Preventive Health and Family Planning CPT Codes...... 66

Example Image for Confidential Communications...... 71

About NFPRHA...... 72 Document 1 (Page 1 of 3)

This job description is from the Colorado Department of Public Health and Environment's Women’s Health Branch for a Family Planning Sustainability Coordinator position. This position is dedicated to organizing ACA implementation activities and serves as a state-wide consultant and resource to Title X program administrators.

CDPHE “Sustainability Coordinator” Job Description

Purpose of this position The Sustainability Coordinator serves as a state-wide consultant and resource to the Title X Family Planning Program (FPP) and Colorado Family Planning Initiative (CFPI) leadership and local contractors, and interfaces with internal and external partners to advance the program goal of increasing access to family planning services in Colorado. The position provides training, technical assistance, funding distribution and contract monitoring related to program service delivery, including clinic management issues and requirements. Other duties include determining processes, methods of operation, guidelines and tools (forms, technical assistance, training) to improve client outreach, clinic management and services, and to identify and effectively resolve problems impeding the quality, stability and sustainability of the program. The position requires knowledge of family planning, clinic management processes and health reform, including third-party payers (Medicaid and private insurance), and the ability to provide training and technical assistance to local contractors, other health care providers and community partners around these issues. Management and program staff rely on the position’s consultation to develop and implement administrative policies and procedures regarding quality program operations, growth and sustainability.

Please describe why the requested class is appropriate for this position The position calls for autonomy, discernment and judgment based on thorough analysis, including the benefits and consequences, of varied strategies and complex options. While the position functions under specific guidance, rules and directives, it requires independent learning and comprehension of the program parameters, and appropriate application of public health practice within daily business operations, including purposeful planning and implementation. Decision-making is conducted within the necessary limits of the program; however, recommendations for change, improvement or direction, predicated on solid reasoning, are developed by the position. The position requires knowledge of family planning, clinic management processes and health reform, including third-party payers, and the ability to facilitate training and technical assistance to local contractors around these issues. Management and program staff rely on the position’s consultation to develop and implement administrative policies and procedures including contract oversight.

Duty Statement #1: Family Planning Program Infrastructure and Sustainability Develops strategies and implements population-based activities for Title X and CFPI; designs and coordinates outreach efforts to increase public awareness of and access to family planning services and available efficacious contraceptive methods; creates effective approaches to share program information with management, colleagues, local providers and community stakeholders; demonstrates implementation of evidence-based programs, best practices or promising practices; anticipates data and information needs and develops plans to address the project evaluation requirements; originates and implements family planning outreach and clinic management guidelines and procedures at the state and local level; assesses local agency needs and develops guidelines, tools and operational processes to maintain or improve program sustainability at the local level and improve efficiency of clinic management; evaluates outreach and clinic management compliance with federal and state regulations, statutes, guidelines, program standards, outreach procedures and service delivery processes; and investigates and identifies reasons for non- compliance, co-creates corrective action plans with contractors and monitors for successful implementation of the action plan.

Provide specific examples of regular, ongoing decisions made by this position related to this duty.

• Determines tailored sustainability assessments and implementation procedures for each local agency based on robust analysis of client level data, Medicaid and private insurance coverage projections, cost efficiency and observations of clinic business processes to establish agency integration under health care reform and monitors compliance with federal and state guidelines, statutes, regulations, and effective management standards. • Decides the family planning guidelines necessary for clinic management policies and procedures at both the state and local level.

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In performing this duty, provide examples of typical problems or challenges encountered by this position, and the guidance used to resolve the problem.

• Assists local providers with development and maintenance of quality business services within the agency’s given resources in order to access more sustainable funding sources in order to address unmet community needs for family planning services. • Interprets and conveys the relevance and importance of various aspects of the Title X family planning program guidelines to local family planning delegate agencies and to state women’s health staff to ensure maximum service standards.

Duty Statement #2: Funding Distribution and Contract Monitoring Assists with several unique funding distribution processes, including writing and reviewing documented quotes, writing sole source justification language, developing new scopes of work and creating an application process for Title X agencies to access sustainability funding through the Colorado Family Planning Initiative. This includes outreach to medical coding and billing specialist, medical billing clearinghouses, soliciting grant applications from local agencies, developing multiple application tracking systems, coordinating multiple review processes, communicating with the applicants, and participating on the review panels by scoring proposals and making funding recommendations; conducts on-site monitoring of local contractors regarding clinic management and contract compliance, including staff interviews, clinic observations and reviews of local program policies and procedures; and develops monitoring reports and corrective action plans for contractors that are out of compliance.

Provide specific examples of regular, ongoing decisions made by this position related to this duty.

• Provides logical and feasible funding recommendations commensurate with available funding levels and program objectives. • Determines contractor compliance and decides a proper course of corrective action, if needed, to improve contractor service operations.

In performing this duty, provide examples of typical problems or challenges encountered by this position, and the guidance used to resolve the problem.

• Communicating clearly, professionally and effectively, both verbally and in writing, all aspects of the funding distribution and contract monitoring processes, which is guided by state and federal procurement requirements and program objectives. • Ensuring contract compliance with federal and state guidelines and rules, which is determined by adherence to statutory and programmatic requirements and the contract between the state and the contractor.

Duty Statement #3: Training and Technical Assistance • Organizes training for family planning healthcare providers and provides technical assistance for local agency program coordinators, including contacting, engaging and training providers from many disciplines through professional education seminars, conference calls and other methods; assures, facilitates and coordinates training in identified areas of need for the FPP consumer and target population; provides consultation and technical assistance to local health agencies regarding family planning outreach and clinic management; evaluates the effectiveness of corrective action plans and institutes further analysis or technical assistance as needed; develops and updates program guidance materials for local agencies and state program staff; develops a training budget based on availability of funds; evaluates training effectiveness and revises the training plan based on evaluation data; and acts as a reproductive health resource for providers and community stakeholders. • Maintains a professional knowledge of cultural, social and behavioral factors that contribute to the issue of unintended pregnancy and reducing barriers to services to educate internal and external partners. • Maintains a professional knowledge of current trends, developments, guidelines and recommendations related to family planning and health care reform to inform internal and external partners. • Maintains a professional knowledge of evidenced-based programs and best practices in health systems and policy change to educate internal and external partners. • Effectively identifies and communicates with public agencies and private organizations at the state and local level with the potential to be strategic partners to participate in coordinated activities related to promoting family planning services through specific Title X work plan activities and Colorado Family Planning Initiative responsibilities. • Demonstrates effective skills in collaboration, negotiation, relationship-building, and facilitation, communication and conflict management in working with partners.

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Provide specific examples of regular, ongoing decisions made by this position related to this duty.

• Recommends training activities for Title X and non-Title X healthcare providers. Conducts needs assessments and identifies state, regional and local training priorities related to increasing meaningful access to family planning services throughout the state. • Develops training budget based on available funds, and facilitates or directly provides the training on behalf of the Family Planning Program. • Provides on-going technical assistance to Title X contractors and other family planning stakeholders regarding health care reform, clinic management and increasing access to family planning services.

In performing this duty, provide examples of typical problems or challenges encountered by this position, and the guidance used to resolve the problem.

• Determines local family planning training needs based on agency-specific circumstances and resources. Resolution is guided by program rules and regulations and established clinical guidelines and best practices to ensure health care providers are at optimal performance compliance. • Answers daily questions and resolves program issues relative to sustainability and clinic management as guided by the family planning sustainability plan and quality assurance standards.

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This document provides a brief history of the formation of the five-county collaboration known as HCCMS Family Health Services. Documents that provide a history of collaborations, projects, or major events are necessary to maintain organizational knowledge.

HCCMS Organizational History

HCCMS FAMILY PLANNING CRAWFORD COUNTY HOME HEALTH/HOSPICE AND PUBLIC HEALTH 105 NORTH MAIN STREET, DENISON, IOWA 51442 HARRISON, CASS, CRAWFORD, MONONA AND SHELBY CLINICS

In 1999 the HCCMS group was formed to provide public health services for a five-county area in Iowa, including Harrison, Crawford, Cass, Monona, and Shelby. Historically, the larger counties received many of the grants in the state, and the state was not encouraging of partnerships. During a regional meeting the possibility of obtaining a new state grant to provide public health services was discussed. In response, the five administrators rallied together to compete for the opportunity to provide these services in their area. By joining together, the group felt that they had more resources and volume to decrease costs as compared to operating alone. A partnership also decreases duplication and therefore decreases administrative dollars to provide public health services.

The formation of HCCMS was not without challenges. In the beginning, it was difficult to identify and separate out each county’s resources and issues with providing service. For example, each county received different amounts of money from the state. As a result, each county’s Board of Health (BOH) approved different measures. The group quickly identified that each BOH would have to be on board with the activities and financial aspects of the group. BOH approval was then received from each county in order to have foundational adherence.

The grant management was split by section and county. The group agreed that each county would lead one program of the grant (lead, child health, maternal health, family planning, care for yourself, etc). At times there have been disagreements within HCCMS about some management decisions, but overall the partnership between the five counties has been a success.

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South Carolina Department of Health and Environmental Control (DHEC) is organized into eight health regions, with each health region having several county public health departments under its jurisdiction. This map illustrates DHEC organization of the health regions.

DHEC Regional Map Health Regions

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HCCMS is a five-county consortium in Iowa created to administer Title X, Title V, and other federally funded health programs. This organizational chart illustrates how the HCCMS Family Planning program is organized and administered. HCCMS Organizational Chart

HCCMS Family Health Services/Family Planning Services

Kim Family Planning Director

Jennifer Family Planning Coordinator

Clinical Staff Nurses Office Staff

Calla BJ Linda Jaime Jessica Rachel Nurse Practitioner Harrison Co. Cass Co. Crawford Co. Monona Co. Shelby Co.

Sara Barb

Interpreter Peggy

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This form is used by HCCMS to track supplies needed for the family planning program across the five-county collaboration. Sample Supply Requisition Sheet

HCCMS FAMILY PLANNING CRAWFORD COUNTY HOME HEALTH/HOSPICE AND PUBLIC HEALTH 105 NORTH MAIN STREET, DENISON, IOWA 51442 HARRISON, CASS, CRAWFORD, MONONA AND SHELBY CLINICS

Cost Center: 7410 Date:

Dept: HCCMS - Family Planning (Home and Public Health Department) County:

Per box Description O & M # Qty Per box Description O & M # Qty 1 250cc NaCl (Btl) 6663 500 Cotton Balls 03803 100 pr slv Dixie Cups 5 oz. 04819 200 Alcohol Prep Pads 03807 100 pr slv Dixie Cups 8oz. 1 Isopropyl Rubbing Alcohol (70%) 01300 1 Red Bio Hazard Bag LARGE 50 Band-Aide 3/4 Inch Box of 50 03621 1 Red Bio Hazard Bag Medium 100 Band-Aide Spots Box of 100 03629 1 Clear Bio Hazard Bag SMALL 200 2x2's non-sterile gauze 03593 1 LARGE Sharps Container 01013 25/box PG Test 1 MEDIUM Sharps Container 01012 25/box Hemocuvettes WCDC 1 In Wall Sharps Container 05611 100 Unistix Lancets AT0702 100 Uristix 1 Betadine Swabs Stix 05202 50/box Disposable Scalpel Blade #15 372615 100/box Syringes 3 ml 01019 50/box Needles 22 gauge X 1.5 00995 1 Thermometer, Oral Holder 02750 50/box Needles 25 gauge X 1 25/box Small Specula (Box of 25) 06802 25/box Medium Specula (Box of 25) 06800 1 Betadine Solution (Btl) 20/box Large Specula 12(1bx) Ammonia inhalant 1 Xylocaine jelly Phone order slips 100(1pack) Silver Nitrate Stix 50 pr Large Blue Gloves 05503 1 Xylocaine with Epi 50 pr Medium Blue Gloves 05502 50 pr Small Blue Gloves 05501 Specula lamp (08800) 100 Scopettes, Jr. (Phoenix swabs) 01125 Specula lamp (07800U) 06807 1 Table Paper Roll 01503 1 KY Jelly 09600 100 40 x 48 Drape Sheet 01504 50/box Exam Gowns 1506 Sterile Items 1 Poly Towels 01502 50/box Polylined Sterile Field Drape (with hole) 697 1 Sani Cloth-Grmcdl Dspsble Cloth-MD 04942 200/box Utility Drapes (Sterile) 89731 1 Blue Chux Pads 50/box Sterile Gloves (size 7) 00306 1 Coban 3 in. 04404 100/box Sterile Gloves (size 6 1/2) 31465 1 Suture Removal Kit SR-1010 50/box Sterile Gauze 2X2 03609 35 pr slv Otoscope Sleeves 52434-U 1 Steri - Strip 04407 1 Nitrazine Paper 1 Intrauterine Sounds 6727-920008 25/bx Marking Pens with Ruler 111013

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Cost Center: 7410

Dept: HCCMS - Family Planning (Home and Public Health Department)

Per box Description Supplier Qty Qty 6/box Lutera R & S ORDER FROM IIPP (COLLEEN BORNMUELLER) 6/box Sronyx R & S Gen-Probe Aptima Urine CT Collection Kit 6/box Lo Ovral R & S Gen-Probe Aptima Cervical Swab CT Collection Kit 48/box Ortho Cyclen J-O-M 48/box ON 777 J-O-M ORDER THROUGH CDD 6/box OrthoTricyclen J-O-M Sure Path Supplies 6/box OrthoTricyclen Lo J-O-M 12/box MicroNor J-O-M 1 Plan B Barr 3/box Nuva Ring R & S 6bx/box Ortho Evra J-O-M 1 Depo Provera Pfizer 1 IUD - Para Gard Paragard 1 Mirena IUS Theracom l Nexplanon CuraScript 2X91 Seasonique R & S 1 Female Condoms R&S 1 Latex Free Condoms Total Access 100 Colored Condoms IBI 1 Plain Condoms Total Access 1 bx of 3 Contraceptive Sponge Total Access 1 Veridate Compacts J-O-M Ledger Cards Manila File Folders - 2 Clasps Manila File Folders 12x15 1/2 Manila Envelopes 10x13 Manila Envelopes 9x12 Manilla Envelopes 5x7 Manila Envelopes 1 bundle Paper Bags Large -8lb 1 bundle Paper Bags Medium-6lb 1 bundle Paper Bags Small-2lb Labels (Avery) - address labels IFPN Copy of NOD given to client Label Contraceptive Labels - Orals Contraceptive Labels - Nuva Ring Contraceptive Labels - Patch Business Cards

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This document is a job aid to inform providers of the types of birth control available through HCCMS. Sample Job Aid of Available Birth Control

HCCMS FAMILY PLANNING CRAWFORD COUNTY HOME HEALTH/HOSPICE AND PUBLIC HEALTH 105 NORTH MAIN STREET, DENISON, IOWA 51442 HARRISON, CASS, CRAWFORD, MONONA AND SHELBY CLINICS

HCCMS Available Family Planning Prescriptions Oral Contraceptives • TRIPHASICS: ¡¡ Tri-Cyclen ¡¡ Tri-Cyclen LO ¡¡ O-N 7-7-7 • MONOPHASICS ¡¡ Lutera ¡¡ Sroynx ¡¡ Lo-Ovral ¡¡ Ortho-Cyclen ¡¡ Seasonique ¡¡ Micronor (progestin-only pill – usually for breastfeeding mothers)

Transdermal Patch System • Ortho-Evra: patient must weigh less than 190lbs Vaginal Ring • Nuva Ring: worn internally for 3 weeks, then removed for 1 week

**HCCMS policy states that we cannot provide birth control pills, rings, or patches to women OVER 35 who smoke.** Injectable Contraception • Depo-Provera (depo-subq provera-104): every 3 months; different formulation and route from 150 mg given IM at medical clinic. (Because of risk of osteoporosis with long-term use, counsel calcium intake and exercise, and consider other methods) Long-term contraceptives • Nexplanon • Para-Gard IUD • Mirena IUS Emergency Contraception • Plan B: must be given within 120 hours of unprotected intercourse - consensual or sexual assault - with a medical provider’s order and negative pregnancy test per HCCMS policy Condoms • We give condoms free to any male or female with completed paperwork.

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This sliding fee scale document meets the programs requirements for both Title X and FQHC programs. Example Title X and FQHC Sliding Fee Scale

2012 Schedule of Discounts Based Upon 2012 HHS Federal Poverty Guidelines CODE INS — All Medicaid, Medicare, Commercial Insurance Medicaid — $2 Co-pay for Adults — $0 if lab draw only Insurance — $0 Co-pay if lab draw only

NEW CICP & CHC Z N A B C D E # in Family From To From To From To From To From To From To 1 Homeless $0 $4,468 $4,469 $6,925 $6,926 $9,048 $9,049 $11,170 $11,171 $13,069 $13,070 $14,856 2 $0 $6,052 $6,053 $9,381 $9,382 $12,255 $12,256 $15,130 $15,131 $17,702 $17,703 $20,123 3 $0 $7,636 $7,637 $11,836 $11,837 $15,463 $15,464 $19,090 $19,091 $22,335 $22,336 $25,390 4 $0 $9,220 $9,221 $14,291 $14,292 $18,671 $18,672 $23,050 $23,051 $26,969 $26,970 $30,657 5 $0 $10,804 $10,805 $16,746 $16,747 $21,878 $21,879 $27,010 $27,011 $31,602 $31,603 $35,923 6 $0 $12,388 $12,389 $19,201 $19,202 $25,086 $25,087 $30,970 $30,971 $36,235 $36,236 $41,190 7 $0 $13,972 $13,973 $21,657 $21,658 $28,293 $28,294 $34,930 $34,931 $40,868 $40,869 $46,457 8 $0 $15,556 $15,557 $24,112 $24,113 $31,501 $31,502 $38,890 $38,891 $45,501 $45,502 $51,724 9 $0 $17,140 $17,141 $26,567 $26,568 $34,709 $34,710 $42,850 $42,851 $50,135 $50,136 $56,991 10 $0 $18,724 $18,725 $29,022 $29,023 $37,916 $37,917 $46,810 $46,811 $54,768 $54,769 $62,257 % of FPL 40% 62% 81% 100% 117% 133%

Primary Care Copay $0 $7 $15 $15 $20 $20 $25 Primary Care Lab $0 $5 $10 $10 $15 $15 $20

*FP POS Payment $0 $19 $28 Mirena $0 $30 $75 Paraguard $0 $19 $46 Nexplanon $0 $33 $81 ** Supply, Pills, patches, etc $0 $2 $4

Immz POS Payment $0 $5 $7 Immz/Admin Discount $0 $5 $10

Prenatal Package $0 $200 $200 $200 $200 $400 $400

* Family Planning Point of Service (POS) Payment includes office visit, procedures and FP labs ** Supply includes Birth Control supplies, Ex. Pills Revised: 4/2012

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F G H I I I J From To From To From To From To From To From To From To $14,857 $17,760 $17,761 $20,665 $20,666 $22,340 $22,341 $24,239 $24,240 $26,138 $26,139 $27,925 $27,926 and over $20,124 $24,057 $24,058 $27,991 $27,992 $30,260 $30,261 $32,832 $32,833 $35,404 $35,405 $37,825 $37,826 and over $25,391 $30,353 $30,354 $35,317 $35,318 $38,180 $38,181 $41,425 $41,426 $44,671 $44,672 $47,725 $47,726 and over $30,658 $36,650 $36,651 $42,643 $42,644 $46,100 $46,101 $50,019 $50,020 $53,937 $53,938 $57,625 $57,626 and over $35,924 $42,946 $42,947 $49,969 $49,970 $54,020 $54,021 $58,612 $58,613 $63,203 $63,204 $67,525 $67,526 and over $41,191 $49,242 $49,243 $57,295 $57,296 $61,940 $61,941 $67,205 $67,206 $72,470 $72,471 $77,425 $77,426 and over $46,458 $55,539 $55,540 $64,621 $64,622 $69,860 $69,861 $75,798 $75,799 $81,736 $81,737 $87,325 $87,326 and over $51,725 $61,835 $61,836 $71,947 $71,948 $77,780 $77,781 $84,391 $84,392 $91,003 $91,004 $97,225 $97,226 and over $56,992 $68,132 $68,133 $79,273 $79,274 $85,700 $85,701 $92,985 $92,986 $100,269 $100,270 $107,125 $107,126 and over $62,258 $74,428 $74,429 $86,599 $86,600 $93,620 $93,621 $101,578 $101,579 $109,535 $109,536 $117,025 $117,026 and over 159% 185% 200% 217% 234% 250% >250%

$25 $35 $35 $40 $40 $40 FULL FEE $20 $30 $30 $35 $35 $35 FULL FEE

$37 $46 $55 $64 $71 $78 $85 $120 $165 $210 $255 $270 $285 $300 $74 $102 $130 $157 $167 $176 $185 $130 $179 $228 $276 $293 $309 $325 $6 $8 $10 $12 $13 $14 $15

$10 $15 Full Fee $10 $14

$600 $600 $800 $800 $800 $800 Full Fee

11 Document 8 (Page 1 of 2) Example Guideline for Contraception

Guideline for Contraception Promote planned pregnancy. Ask about birth control at every visit and start a method today.

Not using contraception or using inconsistently? At every visit, • 85 out of 100 sexually active women will become pregnant within 1 year when not using contraception. ask your patients: • Almost half of all pregnancies in the U.S. are unplanned. What are • There is a safe and method for every woman. you doing about birth • Concerns about privacy are a major barrier to patient-provider communications. • Minors in Colorado (anyone <18 yrs.) are legally authorized access to services for control? contraception/Sexually Transmitted Infection (STI)/Human Virus (HIV) testing without 1 parental consent. Always encourage communication with parents.

Screen for conditions that may require additional counseling. • Refer to chart on U.S. Medical Eligibility Criteria for Contraceptive Use, 2010, if medical condition (link to chart: http://www.healthteamworks.org/guidelines/contraception.html). • Conditions that limit use of methods with estrogen (Oral Contraceptive Pills, Patch, Ring): Smoking and ≥35 yrs. old; History of stroke/clot/thrombophilia; Uncontrolled hypertension; Migraine with aura. Targeted • Refer to Health TeamWorks Preconception Guideline for other recommended screening for lifestyle and clinical co-morbidities. evaluation Pelvic exam not required to provide contraception. • Start Pap screening at age 21 no matter age of intercourse, then every 2-3 years.*† • CDC recommends annual screening for chlamydia/gonorrhea in sexually active women <26 years old.** 2 o Age alone is indication to screen, even in absence of symptoms or high-risk behaviors.† o High risk women of any age should be screened annually. †** o Test via urine or self-collected vaginal swab.‡

Start method today, using this “Quick Start” Protocol: § • WHY? Women are more with their method if they start now instead of waiting until their next period. • HOW? Instruct women to start their method TODAY (this includes pill, patch, ring, Depo) no matter the timing in the menstrual cycle. Backup method (like condoms) still recommended for the week. Suggest Emergency Contraception (EC) if unprotected sex within past 5 days (see EC on reverse side). • Pregnancy test not needed if: Start o Within the 5 days of menstrual cycle, or o Currently using an method. method • Pregnancy test recommended if: today o Unexpected or irregular bleeding, or “late” for menses. o Sexually active and not using consistent, method. o Unprotected sex in the last 14 days. Quick Start today if negative pregnancy test; repeat test in 2 weeks. 3 • What is the risk of pregnancy with “Quick Start”? o Studies indicate a 3% chance of pregnancy during the cycle that Quick Start is used. o Overall, risk is decreased because women can become pregnant while waiting to start their method. o Hormones in contraception do not cause birth defects or increase risk of miscarriage if pregnancy does occur.

‡ * ACOG Practice Bulletin, Number 109 (December 2009). Sexually Transmitted Diseases, Volume 32, Number 12 (December 2005). § † United States Preventive Services Task Force. Contraceptive Technology, 19th edition (2007) and Zieman M, Hatcher RA et al. A Pocket Guide to Managing ** STD Treatment Guidelines, 2010 (CDC) Contraception. Tiger, Georgia: Bridging the Gap Foundaton (2010).

This guideline is adapted from the U.S. Medical Eligibility Criteria for Contraceptive Use (CDC 2010) and is designed to assist the primary care provider when counseling on contraception. It is not intended to replace a clinician’s judgment or establish a protocol for all patients. For guideline updates, including new drugs or products, resources, references, and additional copies of the guideline go to www.healthteamworks.org or call (720)297-1681. This guideline was supported through funds from The Colorado Department of Public Health and Environment. Approved 12/10/10

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Guideline for Contraception Promote planned pregnancy. Ask about birth control at every visit and start a method today.

Long-Acting Methods: most eﬀ ective methods and considerations Can be initiated: 1. anytime during the menstrual cycle if the woman is using another eﬀ ective method, or 2. within the fi rst fi ve days of menses. If referring to another provider for these methods, start another method today. Most Method Considerations effective <1 pregnancy Implant  Subdermal Arm Implant (Implanon®): Lasts 3 years. Progestin-only. Long-acting, reversible methods are safe for per 100  Mirena® (Levonorgestrel IUS): Lasts 5 years. Intrauterine women of all ages, including adolescents and women in Also indicated for the treatment of heavy bleeding. 1 year Devices women who have not had children. ParaGard® (Copper T): Lasts 10 years. Contains no hormones. Sterilization  Male: Vasectomy Female: Tubal ligation. Hysteroscopic options: Essure® and Adiana®

All Providers: “Quick Start” Today Method Considerations Progestin  • Repeat injection every 11-13 weeks. Can be given up to 16 weeks after previous injection.¶ Injection • Can use for any duration (i.e. longer than 2 years) if method is best choice for the patient.\\ (Depo-Provera) Estrogen and • Patient needs to obtain refi lls frequently and use as directed to be eff ective. Progestin • Indicated to treat acne, PMS, heavy periods, cramping, pain, regulate bleeding. • Can be prescribed to reduce or eliminate periods with extended or continuous use. Write to dispense up Oral Contraceptive Pills: Start w/ most cost- Vaginal Ring (NuvaRing®): Patch (Ortho Evra®): to a 12 month eff ective pill; despite advertising, blinded Hormones are released into Hormones are released into supply. Women studies show little or no diff erence between the blood stream through a the bloodstream through a who pay out of pill brands in effi cacy or side eff ects. vaginal ring. skin patch. pocket can choose to make fewer trips : Generic or Brand* : NuvaRing® : OrthoEvra® to the pharmacy. Sig: 1 tab po QD Sig: insert vaginally Sig: apply weekly x 3 Many insurers Disp: up to 12 months for 21 days; remove x weeks; off x 7 days; (like Medicaid) will Refi lls: prn x 1 year 7 days; repeat w/ new repeat provide a 3 month ring Disp: up to 12s months supply. Not having Disp: up to 12 months Refi lls: prn x 1 year refi lls is a common Healthy women do not need to be seen by Refi lls: prn x 1 year reason for method their provider each year for birth control refi lls. failure.

Less Progestin Only  • Need to take an active pill every day; no placebo week. effective Pills • Also called a “mini pill.” About 15 pregnancies Condoms  • Only method that prevents STIs. Male latex condoms are 99% eff ective in preventing HIV with correct, per 100 consistent use. women in • Can also be used to prevent infection during oral and anal sex. one year • Encourage use with all other methods for prevention of STIs. = safe for breast-feeding and safe to use immediately postpartum *Find out which generic OCP is on the pharmacy’s low cost drug list: see table at http://www.healthteamworks.org/guidelines/contraception.html

EMERGENCY CONTRACEPTION (EC) 1. Recommend to any woman with unprotected intercourse in the last 120 hours (= 5 days). 2. No exam, no testing needed. No medical condition (or age) that precludes use. : Levonorgestrel 1.5 mg 3. Provide information and Rx if needed. Sig: 1.5 mg po x 1 • Available over the counter to anyone age 17 or older. (Generic: Next Choice; Brand: Plan B One Step®, EllaOne®) dose • For anyone 16 years or younger write/call Rx. Disp: 1 • Works by delaying ovulation; not harmful if already pregnant. Reﬁ lls: prn • See Health TeamWorks website for EC information, patient handout, and a list of oral contraceptive pills that can be used as EC. 4. Recommend “Quick Start” contraceptive method. Start method now and perform pregnancy test in 2 weeks.

¶ Zieman M, Hatcher RA et al. A Pocket Guide to Managing Contraception. Tiger, Georgia: Bridging the Gap \\ ACOG Committee Opinion Number 415 (2008). Foundaton (2010).

13 Document 9 (Page 1 of 1) Example Contraception Wall Chart

What are you doing about birth control? Start a method today.

Choosing a method: What matters most to me?

Cost Privacy I’m Breastfeeding Varies, but all methods are less costly than pregnancy. How private does my method need to be? I need a method that is safe for breastfeeding.

Effectiveness Convenience Other Benefits How well does it prevent pregnancy? How often do I need to think about it? Many methods reduce bleeding/cramping.

Birth Control Options: Choose a method

What is it? What have you heard? Method Type Strong Points Other Considerations How does it work? Here are the facts: Levonogestrel IUS (Mirena) What: Small, plastic device that • Very effective, safe, and forgettable. • IUDs are safe for women of • Expect spotting and irregular bleeding during sits inside the uterus. • Works for 5 years but can remove anytime. all ages and women who the first 3-6 months of use. How: It prevents male sperm • Also treats heavy and painful menstrual have not had children. • Having no periods (or very light periods) is an from reaching the female egg. bleeding. • IUDs are often the preferred expected benefit of this method and not a cause • Often makes periods very light or go away method for women with for concern; the progestin in the IUD keeps the altogether (after 2 years of use, 7 out of 10 medical conditions (like lining of the uterus very thin. women will have lighter or no periods.) high blood pressure). • Safe to use after having a baby and when breastfeeding. Copper T IUD (ParaGard) • Very effective, safe, and forgettable. • Some women may have heavier periods with Intrauterine Device Intrauterine • Contains no hormones at all. the Copper IUD, especially in the first year: this • Use for 10 years but can remove anytime. usually improves with time. • Safe to use after having a baby and when breastfeeding. Implanon What: Small, plastic rod that is • Very effective, safe, and forgettable. • Implant is safe for almost all • Some women have irregular and frequent inserted under the skin. • Use for 3 years but can remove anytime. women to use. bleeding; some women have no bleeding at all. How: The hormone progestin • Easy for a trained provider to insert; pelvic inside the implant prevents an exam not needed. MOST EFFECTIVE egg from being released. • Safe to use after having a baby and when Arm Implant Arm breastfeeding. Female What: The tubes are permanently • Permanent method for women/men who • Sterilization is a permanent • Surgical procedure is required; check with your • Tubal Ligation and surgically closed. no longer want to have children. method and not reversible. clinic to connect with a trained provider. • Hysteroscopic How: Male sperm cannot reach • Tubal ligation can be done with c-section • Male vasectomy does • May regret the decision to be permanently the female egg. or soon after having a baby. Hysteroscopic not change sexual sterilized; if young or not in a long term Male methods are done through the uterus. performance. relationship should strongly consider an • Vasectomy • Male vasectomy can be done in the office alternative, reversible method.

Sterilization with local anesthesia. • Safe after having a baby and when breastfeeding. Depo-Provera What: An injection every 3 • No pills, no trips to the pharmacy; instead, • Very safe. Almost all women • Irregular bleeding is common and expected in months. go to your provider every 3 months for an can safely use this method. the first 6 months: with continued use, you are How: The progestin hormone in injection. • Very effective. Very very likely to have no bleeding or periods. the shot prevents an egg from • May stop your periods after 6-9 months of few pregnancies when • Need to visit your health clinic every 3 months being released. continued use; this is safe and expected. injections every 3 months. for an injection. • Can also be used to treat heavy, irregular, • Safe to use for longer than • Some women will have an increased appetite unwanted bleeding. 2 years if it is the best when they use Depo and may gain weight. • Safe to use after having a baby and when choice for you. Weight gain can be managed with diet and breastfeeding. exercise, but you may also want to consider Progestin InjectionProgestin another method if you are gaining too much weight while on Depo. Pills a pill; take What: These • Will lessen bleeding and cramping, make • Are safe for almost all • Require that you get refills every 1-3 months. each day methods (pills, periods more regular. women. (Some insurance companies will only dispense a patch, ring) deliver • Can improve acne and decrease PMS. • Do not cause weight gain. 1 month supply.) Consider if this will be easy for the hormones • Can be used for menstrual suppression • Do not make it harder to you to do. estrogen and (extend periods to every few months or get pregnant later on. • Vary in cost depending on your insurance Patch a skin progestin to your have no scheduled bleeding). • Do not cause miscarriage. coverage - check with your pharmacy. Only VERY EFFECTIVE VERY patch; body. • Do not cause breast cancer brand names of the patch and ring are available change (and actually reduce the at this time. For pills, check your pharmacy’s each week How: These are the risk of ovarian and uterine low cost drug list and request that your provider same hormones cancer). prescribe one of these pills.

Methods with Ring a vaginal that women make • Common side effects include irregular spotting ring; naturally but when and bleeding, sore breasts, and mild stomach Estrogen and Progestin Estrogen change they are given in upset. These may occur in the first 1-3 months of each constant dose, the use. Keep taking the method and symptoms will month ovary does not improve with time. produce an egg. Progestin-Only Pills What: A pill that contains the • Safe to use after having a baby and when Need to take a pill every day: consider another hormone progestin. breastfeeding. method if you forget pills. Use condoms (or don’t How: Progestin causes the have sex) if you miss a pill. cervical mucus to thicken and blocks sperm. Male Condoms What: A plastic cover that catches • Only method that prevents sexually • Asking your partner to use • Some couples only use condoms right before (Latex and Polyurethane) sperm and prevents genital skin transmitted infections/HIV a condom does not mean ejaculation; to be effective at preventing contact. • Over The Counter (OTC): anyone can buy that you mistrust them or pregnancy and sexually transmitted infections, a How: The sperm stay in the condoms at the pharmacy, grocery store, are “easy.” Condoms protect condom needs to be covering the penis anytime condom and do not get inside a or wherever sold. your health and the health it is near or inside a woman’s vagina.

EFFECTIVE woman’s vagina. • Can also be used to prevent infection of your partner. • Some men and women may not want to use during oral and anal sex. • Condoms are very good condoms because it doesn’t feel romantic, or Female Condoms

Condoms • Safe to use after having a baby and when at preventing pregnancy “it doesn’t feel good”; try different condoms breastfeeding. and sexually transmitted (textures, sizes) and use lubrication. infections when they are • Some couples find it really hard to talk about used correctly and with sex and condoms; get help from your health every sexual encounter. provider, counselor, or trusted friend. • Breastfeeding as birth control may be effective in preventing May be best option for some women. High failure rate (over 1 out of every 4 women will pregnancy if: breastfeeding exclusively; day and night feedings; get pregnant during 1 year of use). no menses since delivery; the baby is less than 3-6 months old. • Fertility Awareness (Natural Family Planning): 25% failure rate. • Sponge: 16% (nulliparous) and 32% (parous) failure rate. • Diaphragm: 16% failure rate. • Withdrawal: 27% failure rate. Other Methods • Spermicide: 29% failure rate. LEAST EFFECTIVE

For more information, see the HealthTeamWorks website: www.healthteamworks.org

14 Example Clinical Guideline Document 10 (Page 1 of 2)

Guideline for Preconception and Interconception Care Why should women, menarche to menopause, have preconception screening? • Half of all pregnancies in the United States are unplanned. • Most fetal organs and placental vessels are developing before the fi rst prenatal visit. • Many interventions to prevent birth defects or adverse outcomes must happen before early pregnancy to be eff ective.

Has patient had hysterectomy or permanent sterilization? 50% of all pregnancies in the United States are No: Discuss contraception options in Yes: See CCGC Prevention Guideline unplanned. addition to routine interventions.

Factors Recommendations All women should take a multi-vitamin with 0.4 mg (400 mcg) of folic acid daily. This can reduce severe anomalies by 46%. Folic Acid Preconception intake of folic acid is crucial because neural tube development is essentially complete by 4 weeks after conception (6 weeks from last menstrual period). Women with a seizure disorder or history of neural tube defects should take 4.0 mg/day. Underweight (BMI = 18.4 and below) assess for eating, malabsorption and/or endocrine disorder. Counsel patients that they are at risk for an IUGR infant. Overweight (BMI = 25.0-29.9) off er specifi c strategies to decrease caloric intake and increase physical activity. Body Weight * Overweight (BMI = 25.0-29.9) and one additional risk factor, test for glucose intolerance with a FBS or a 2 hour OGTT with a 75 gram (Ideal = 18.5 - 24.9) glucose load. (Additional risk factors: physical inactivity, family history of DM, HTN, CVD, dyslipidemia, history of gestational diabetes or a previous 9 lb. baby, polycystic ovary syndrome, insulin resistance, IGT or high risk ethnicity [African American, Native American, Latina, Asian American or Pacifi c Islander]). Obesity (BMI = 30.0 and above) increases the risk for hypertension, gestational diabetes, C-section and incision complications. ASK: Do you currently smoke or use any form of tobacco? ADVISE: for the health of the pregnancy. REFER: to Quitline (1-800-784- 8669) or access other community-based resources. Infant mortality could be reduced by 10% if smoking were eliminated. Associated Smoking * with increased risk of miscarriage, premature rupture of membranes, preterm delivery, abruption, intra-uterine fetal demise, low birth weight, and SIDS. Smoking accounts for the highest proportion of preventable problems in pregnant women. ASK: When was the last time you had more than 3 drinks in one day? (positive = in the past 3 months) How many drinks do you have per week? (positive = more than 7) Have you used drugs other than those required for medical reasons (illicit or prescription drug Alcohol & Drugs * misuse) in the past year? Do a brief intervention to address hazardous or harmful use of alcohol or drugs; refer for more intensive treatment, if indicated. Discuss contraception options. Pregnancy should be delayed until individuals are alcohol and drug free. Alcohol is a teratogen. COUNSEL: No amount of alcohol is considered safe during pregnancy. Screen sexually active women <25 years (CDC recommends at least annually). High risk women‡ of ANY age should be screened Chlamydia annually. STIs & Other Infectious Women at risk‡ for gonorrhea, HIV, TB, syphilis and Hepatitis B should be screened and treated. Diseases Women should be up to date on all immunizations. Check and document immunization status for MMR, varicella, TdaP, HPV and Immunizations * Hepatitis B. ASK: Over the past 2 weeks, have you felt down, depressed or hopeless? Over the past 2 weeks have you felt little interest or pleasure in doing things? If yes, use validated screening tool such as Edinburgh Postpartum Depression scale or PHQ-9. Treat or refer to Psychosocial Risks * specialist if indicated. Assess for intimate partner violence. ASK: Do you feel safe? If no, or ambivalent response, refer to the Colorado Coalition Against Domestic Violence (www.ncadv.org), a safe house and/or law enforcement. History of preterm delivery, stillbirth, recurrent pregnancy loss or uterine anomaly should be evaluated for modifi able risk factors. Women with a prior C-section should be counseled to wait at least 15 months before next conception. Postpartum women with a Reproductive History history of gestational diabetes should be screened for diabetes using a 2 hour OGTT with a 75 gram glucose load. After the postpartum period, perform a FBS every 1 to 3 years. Assess for genetic disorders, congenital malformations, mental retardation, and ethnicity of woman and partner. Refer to March of Family & Genetic History Dimes checklist. Consider household, environmental and occupational exposures. Refer women with soil and/or water hazard concerns to the local Environmental / health department for soil and water testing. Refer women with household or workplace exposure concerns to an occupational Occupational Exposures medicine specialist for modifi cation of exposures. Medical, Psychiatric See back page for specifi c conditions, appropriate testing, counseling and treatment. History & Medications

*See CCGC guidelines for: Adult Cardiovascular Disease and Stroke Prevention; Adult Diabetes Care; Adult Obesity; Alcohol and Substance Use Screening, Brief Intervention, Referral to Treatment; Depression Disorder in Adults; Gestational Diabetes; Immunizations; Preventive Health Recommendations; and Tobacco Cessation and Secondhand Smoke Exposure. ‡See United States Preventive Services Task Force (USPSTF) definitions for high risk.

Assess for specifi c health conditions and contraception choices (review side two of this document).

This guideline is adapted from the AJOG Supplement, December 2008 and CDC Proceedings of the Preconception Health and Health Care Clinical, Public Health and Consumer Workgroup Meetings, June 2006, and USPSTF Recommendations 2009. The guideline is designed to assist the clinician in preconception and interconception care. It is not intended to replace a clinician’s judgment or establish a protocol for all patients. For references and additional copies of the guideline go to www.coloradoguidelines.org or call 720-297-1681. Supported by Grant No. B04MC11264 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources & Services Administration, Department of Health and Human Services. Final 12/18/09

15 Document 10 (Page 2of 2)

Specific Health Conditions Contraindicated Condition Counsel Tests Contraception † Medications § Asthma * Women with poor control of their asthma should See CCGC Asthma Guideline. No restrictions. Safe: all methods. use contraception until it is well controlled. Cardiovascular Pregnancy is a stressor on the cardiovascular Consult with a Cardiac Find an alternate Safe: Copper IUD, sterilization, LNG IUD, Disease * system. Discuss potential life-threatening Specialist. medication for ETG implant, DMPA, and POPs. Avoid: risks especially with pulmonary hypertension. ACE inhibitors and estrogen containing methods. Contraception should be strongly recommended Coumadin beyond when pregnancy is contraindicated. 6 weeks gestation. Depression * Screening prior to pregnancy allows for Use PHQ-9 or other validated Paroxetine. Safe: all methods. treatment and control of symptoms that may test to monitor. help prevent negative pregnancy and family outcomes. Diabetes * Three-fold increase risk of birth defects, which Patients should demonstrate ACE Inhibitors, Safe: all methods (including those with may be reduced with good glycemic control good control of blood sugars Statins. estrogen) are safe for women who are <35 prior to conception. Women with poor glycemic with HgbA1c <6.5. Use years, non-smokers and no hypertension or control should use effective birth control. effective contraception. See vascular disease. Avoid: estrogen methods CCGC Diabetes Guideline. for all other women. HIV HIV may be life-threatening to the infant if Refer to specialist. Efavirenz Safe: all methods in HIV-infected women transmitted. Antiretroviral can reduce the risk of (Sustiva®). who do not have AIDS. Antiretroviral transmission, but the risk is still about 2%. therapy may interfere with hormonal methods. Concomitant use of condoms is strongly recommended. Hypertension * Increased maternal and fetal risk during Women with HTN of several ACE Inhibitors. Safe: all methods (including those pregnancy, especially pre-eclampsia. Discuss years’ should be assessed with estrogen) for women who are <35 importance of finding alternative to ACE for ventricular hypertrophy, years, non-smokers and have controlled inhibitor prior to pregnancy. retinopathy and renal disease. hypertension (by way of meds or lifestyle Consult with a Cardiac changes). Avoid: estrogen methods for all Specialist. other women. Obesity * Use effective contraception until ideal body Screen for diabetes with Weight loss Safe: all methods. weight (BMI = 18.5-24.9) is achieved. Offer either a FBS or a 2 hour OGTT medications specific strategies to decrease caloric intake and with a 75 gram glucose should not be used increase physical activity. For bariatric surgery, load. Refer to page 1 for risk during pregnancy. avoid pregnancy until weight stabilization and factors. wait 1-2 years after surgery before conceiving. Renal Disease Counsel to achieve optimal control of condition Consult with Renal Specialist. Find alternative to Safe: Copper IUD and LNG IUD, ETG prior to conception. Discuss potential ACE Inhibitors if at implant, DMPA, sterilization. life-threatening risks during pregnancy. risk of pregnancy. Contraception should be strongly recommended to those who do not desire pregnancy. Seizure Disorder Counsel on potential effects of seizures and Whenever possible, Valproic Acid Safe: all methods. seizure medications on pregnancy outcomes. monotherapy in the lowest (Depakote®). Certain anticonvulsants decrease levels Patients should take 4mg of folic acid per day for therapeutic dose should be of steroid hormones and may decrease at least 1 month prior to conception. prescribed. contraceptive efficacy. SLE & Rheumatoid Disease should be in good control prior to Evaluate for renal function and Cyclophosphamide. Safe: Progestin only methods and IUDs. Arthritis pregnancy. end-organ disease. Thyroid Disease Proper dosage of thyroid medications prior TSH should be <3.0 prior to Radioactive iodine. Safe: all methods. to conception for normal fetal development. pregnancy. Free T4 should be Iodine intake 150 mcg per day. normal. Other Common Health Conditions Counsel Contraception† Uterine Fibroids, Nulligravity, Tension Headaches, History of Reassure patient that these conditions do not Safe: all methods. Progestin only methods Ectopic Pregnancy, Fibrocystic Breast or Family History of Breast generally effect pregnancy. History of ectopic and IUDs may be used immediately post- Cancer, Breastfeeding, and Healthy Women Age >35 years pregnancy: advise to seek care immediately upon partum and in breastfeeding women. conception.

*See CCGC guideline †Contraception column based on ACOG Practice Bulletin No 73, Use of Hormonal Contraception in Women with Coexisting Medical Conditions, June 2006, and The World Health Organization, Medical Eligibility Criteria for Contraceptive Use, 2008 Update. §See Physicians’ Desk Reference® (PDR) for comprehensive medications list. Other Medical Conditions Where Special Counseling Is Recommended Bipolar Disorder, Migraine Headaches, Phenylketonuria, Schizophrenia. Contraception Key Barrier Methods: Latex condoms, diaphragm with spermicide, and sponge have a high failure LNG IUD: Levonorgestrel intrauterine device (progestin only). rate with typical use (20-30 pregnancies per 100 women in one year): encourage more effective Patch: Combined contraceptive patch (contains estrogen and progestin). methods. Condoms are the only contraceptive method that also prevent STIs. When used POP: Progestin only pills (sometimes referred to as the “mini-pill”). correctly and consistently, they reduce the risk of infection by 99%. Progestin-Only Emergency Contraception: May be safely used in any woman of reproductive COC: Combined Oral Contraceptives (contains estrogen and progestin). age; there is no medical condition that precludes its use. DMPA: Depot Medroxyprogesterone Acetate (progestin only). Ring: Combined vaginal ring (contains estrogen and progestin). ETG Implant: Etonogestrel Implant (progestin only).

This guideline is adapted from the AJOG Supplement, December 2008 and CDC Proceedings of the Preconception Health and Health Care Clinical, Public Health and Consumer Workgroup Meetings, June 2006. The guideline is designed to assist the clinician in preconception and interconception care. It is not intended to replace a clinician’s judgment or establish a protocol for all patients. For references and additional copies of the guideline go to www.coloradoguidelines.org or call 720-297-1681. Supported by Grant No. B04MC11264 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources & Services Administration, Department of Health and Human Services. Final 12/18/09

16 Document 11 (Page 1 of 2)

This policy statement from DHEC establishes the standards, rules, and procedures around prioritizing family planning services for adolescents. This policy document can serve as a model for developing policy around adolescent services in your provider setting. Sample Adolescent Services Policy

Subject: Adolescent Services Policy Statement: Adolescents < 17 years of age will be given priority for family planning services.

Laws/Regulations: Federal Family Planning Services and Population Research Act of 1970 (Public Law 91-572) Federal Title X Regulations (42 CFR Part 59, Subpart A; Part 50, Subpart B) Minor’s Law, South Carolina General and Permanent Laws, 1972. No. 1349. Compilation of State Statutes-South Carolina

Standards: 1. Appointments will be made available to adolescents for medical services and counseling as soon as possible. 2. The services and the sequence in which they are provided will depend upon the nature of the services needed.

Rules: 1. Title X providers must not require written consent of parents or guardians for the provision of services to minors. (See Minor’s Law) 2. Title X providers must not notify parents or guardians before or after a minor has requested and received Title X family planning services. 3. DHEC staff must not assume that adolescents are sexually active because they have come for family planning services. Many teenagers are seeking assistance in reaching this decision. 4. To promote ongoing utilization of family planning services by teens ≤ 17 years of age, follow-up must be provided to increase the probability of satisfaction with and utilization of newly chosen birth control methods. 5. Each site providing family planning services must have a mechanism in place to follow-up with adolescents who can’t be reached via phone or mail.

Procedures: 1. Assess the adolescent/parent/guardian communication and encourage clients to discuss their family planning needs with a trustworthy adult family member or another adult if they state that they absolutely cannot talk with a parent/guardian. Efforts to involve parents/guardians in counseling and decisions about services will be documented. 2. Provide adolescents with skilled counseling and detailed information. Counseling must include: • Resisting attempts of coercion regarding sexual activities; • Using abstinence as a valid and responsible option; • Information about all methods of contraception; • Preparing adolescents to use a variety of methods effectively; • Using safer sex practice options to reduce risks for STI/HIV and pregnancy; and • Information regarding child abuse, child molestation, sexual abuse, rape, and incest with appropriate follow-up. (See “Compilation of State Statutes-South Carolina” and DHEC Administration Policy Manual’s Abuse Policy for reporting abuse. Reports should be documented on the Protective Services Report (DHEC 3604).

17 Document 11 (Page 2 of 2)

3. Implement the current Family Planning Grant Application work-plan regarding community outreach and youth development. 4. Assure adolescents that the sessions are confidential and if follow-up is necessary then every attempt will be made to assure the privacy of the individual. 5. Obtain an alternate phone number, contact a friend, contact a school nurse, send a picture of a butterfly or some other agreed upon signal that will let clients know that they should contact the health department if adolescents can’t be reached via phone or letters to home. 6. Confirm adolescents ≤ 17 years of age appropriate use of birth control methods. At least three attempts to follow-up will be made within 60 days of their first family planning appointment and starting a new method. One attempt at contact will be direct, if possible. Direct contact may include a phone call, a home visit, or a conference with another provider who can confirm appropriate use of method and care. If direct contact is not possible, a letter will be sent to encourage each client to call if there are any needs. 7. Document all attempts to follow-up on the continuation sheet, DHEC 1619A or the Clinical Encounter form, DHEC 3212 ; (see FP Follow-up Policy.)

Responsibility: Physicians, APRNs, Nurses and Administrative Staff

References: Program Guidelines for Project Grants for Family Planning Services, United States Department of Health and Human Services, January 2001. Accessed July 24, 2007.

Minor’s Law, South Carolina General and Permanent Laws, 1972. No. 1349. Accessed July 20, 2007.

Compilation of State Statutes-South Carolina. Accessed July 20, 2007.

Date of Approval: 11/05 Date of Revisions: 09/10

18 Document 12 (Page 1 of 2)

This marketing material from the South Carolina Campaign to Prevent Teen Pregnancy concisely explains the mission and work of the Campaign to external audiences. The “about us” boilerplate can be used on the website, in publications, when applying for funding, etc. without much change. This one-pager can serve as a guide for developing marketing material for your provider setting. South Carolina Campaign to Prevent Teen Pregnancy Mission Statement About Us Mission As a 501(c)(3) non-profit organization, our mission is to improve the health and economic well-being of individuals, communities, and the state of South Carolina by preventing teen pregnancy.

We Believe • The prevention of teen pregnancy is in the best interest of adolescents, their families and their communities. • Parents should be equipped to be the primary educators of their children about love, sex, and relationships. • The most effective health and sexuality education is age-appropriate and medically accurate, emphasizes abstinence and provides information about contraception. • The use of research-proven curricula and programs will reduce teen pregnancy. • In partnering with all sectors of the community to implement effective strategies to reduce teen pregnancy. • Young men and women should be respected for their unique traits and characteristics and empowered to take control of their own reproductive health and wellness. • In maintaining a staff and board of directors that is talented, diverse and representative of the populations we serve.

Our Promises Communication: We vow to communicate with and listen to parents, providers, key leaders and community members throughout South Carolina to gain an increased understanding of local needs and assets.

Customization: We promise to customize approaches that combine evidence-based approaches with the unique fabric of every community we serve.

Capacity Building: We will strive to increase the capacity of community members (parents, youth serving organizations, school staff, faith leaders and youth) to address the complex issue of teen pregnancy.

Commitment: We are committed and fully invested in prevention for the long term.

What We Do Build the Capacity of Local Communities: A broad range of learning opportunities are offered to meet the needs of youth-serving professionals, school staff, clinicians and faith leaders. Programs and communities around the state benefit from our organization’s onsite, personalized technical assistance, large groups trainings, an Online Learning Center, and annual Summer Institute.

Communicate with a Variety of Audiences: Intensive public awareness efforts are paramount to our success. In addition to traditional media opportunities and public awareness activities, our staff are frequently called upon to deliver keynote addresses and presentations in South Carolina and beyond. During the Legislative session and throughout the year, staff can be found at the State House serving as advocates for our state’s most valuable resource – young people.

19 Document 12 (Page 2 of 2)

Conduct Innovative Research and Distribute Publications: Our commitment to the most up-to-date research and resources results in the creation and distribution of numerous fact sheets, publications and research briefs. We contribute to the ongoing learning of the field by conducting original research, partnering with external researchers and sharing the collective knowledge of our nationally recognized staff. Our continuously updated resource library holds resources, curricula and publications available for loan or purchase.

Promote the use of Research Proven Prevention Approaches: We work with countless school districts and community based organizations across the state to identify appropriate teen pregnancy prevention programs based on the characteristics of the youth they serve. Our staff are considered national experts on the selection, implementation and evaluation of teen pregnancy prevention programs. As part of this work, we also provide more than $1.5 million annually in mini-grants to help facilitate the implementation of research proven programs.

Evaluate our Work: We embed evaluation activities into every project to ensure we’re meeting the needs of the target population and being good stewards of our funding. Through qualitative and quantitative evaluation strategies, we monitor progress and make programmatic improvements as necessary. Our work in this area also extends to partnerships with state agencies to ensure the timely and broad dissemination of state data metrics such as the Youth Risk Behavior Survey and annual teen pregnancy data.

What Others Say… “The SC Campaign plays a vital part in advocating and educating on the issue of unplanned and unwanted pregnancies among our state’s youngest citizens. I applaud their leadership and vision.” –Dr. Jim Rex, Former SC State Superintendent of Education

“Simply put, the SC Campaign’s commitment to EXCELLENCE is unparalleled and results in the highest quality programming in the country.” –James Sacco, Healthcare Consultant and Trainer

“The SC Campaign is the model of a successful state effort to help young people avoid too-early pregnancy and parenthood.” –Bill Albert, Chief Program Officer, National Campaign to Prevent Teen and Unplanned Pregnancy

“The SC Campaign helps communities find research proven programs that make a difference in the lives of teens. Because of that commitment, teen pregnancy in our state has declined.” –Dr. Don Flowers, Jr., Pastor, Providence Baptist Church

www.teenpregnancysc.org • 803.771.7700 • [email protected]

20 Document 13 (Page 1 of 1)

This document from the South Carolina Campaign to Prevent Teen Pregnancy outlines how to implement One Key Question (OKQ), a pregnancy intention screening tool, into a primary care setting. The process can be modified in a way that works best for your provider setting. “One Key Question®” Educational Tool

Target: Medical Facilities for 15-19 year olds patients; male and female.

Priorities: Increase contraception distribution and increase rate of pre-conception care.

Summary: An initiative to better integrate reproductive health into primary care. Aims to improve both preconception care and contraceptive counseling by asking the question, “Do you want to become pregnant in the next year?” routinely during primary care visits. If a teen answers “yes”, he/she would be screened for conditions that would affect a pregnancy and be advised to take folic acid or encourage partner to take folic acid. If a teen answers “no,” the clinician would ensure that he/she is abstaining or using contraceptive method he/she is satisfied with and that he/she is aware of and has access to emergency contraception.

Outline of Process:

• One Key Question (OKQ) partners are willing to integrate the question, “Do you want to become pregnant in the next year?” into medical screening for teen patients. • Two types of providers can participate with different levels of expectations: • If contraception services are not offered, OKQ expects referral providers to provide information on CarolinaTeenHealth. org and DHEC. à “Do you want to become pregnant in the next year?” • If yes, provide folic acid educational resources provided by March of Dimes and refer to OB/GYN to flag preconception needs • If no, refer patient to adolescent friendly family planning provider (DHEC) and provide teen friendly information (CarolinaTeenHealth.org • If full range of contraception services can be provided, OKQ expects contraceptive providers to ask the following series of questions and activities. à “Do you want to become pregnant in the next year?” • If yes, provide folic acid and flag preconception needs • If no, Are you currently using some type of contraception or are you abstinent? • If yes, abstaining from sex ask: “Did you have any questions today for me about sexual health?” • If yes, using contraception: “Are you satisfied with your method of choice?” • If no, not using contraception: Counsel on contraception with an emphasis on LARC, provide contraception as requested, increase awareness of EC and give condoms.

The South Carolina Campaign to Prevent Teen Pregnancy conducted research assessing condom access points and what the experience was like for adolescents to purchase condoms. This secret shopper form was used to document the overall expereince for adolescents "secret shoppers" at various stores and can serve as a guide if your provider setting is conducting similar fact-finding projects. Secret Shopper Campaign: DeBriefer Form

1. ¡ Site 2. Name of Site:

¡ Drug Location: (Address) (City) ¡ Grocery store ZIP Code: ¡ Gasoline station Date: / / ¡ Barbershop Month Day Year ¡ Vending machine, where?

¡ Other, where?

Condom Accessibility

3. How many different brands of condoms were available? (Durex, Trojan, Lifestyle…)

4. How many different types of condoms were available (Ribbed, Colored, Mangum…)

5. Location of condoms ¡ open shelf ¡ behind counter ¡ restroom (check all that apply) ¡ other, where?

6. Visibility ¡ easy to find ¡ could not easily find

Cost per item

7. Lowest $ for pack of (# of condoms) ______

8. Highest $ for pack of (# of condoms) ______

Experience with Assistance

9. Did you have to ask someone for help finding items? yes (continue to row below, question #11) no (skip to question #14, “purchasing…”)

10. Why did you choose this person to ask for help? ¡ It was the first person I saw in the store (Check all that apply) ¡ It was the only person in the store ¡ This person looked nice ¡ This person looked close to my age ¡ This person asked me if they could help me ¡ This person was the same gender as me ¡ This person looked like me (racially, ethnically) ¡ This person was the only person available ¡ I had to ask for help because I could not get the condoms without a sales associate ¡ Other______

22 Document 14 (Page 2 of 2)

11. Rate your experience with person you asked for help. ¡ Very uncomfortable ¡ Sort of uncomfortable ¡ Sort of comfortable ¡ Very comfortable

12. What would have made you feel more comfortable?

13. Tell me what happened when you asked for help.

Purchasing Experience

14. Did you purchase condoms? ¡yes ¡ no (skip to question #18) If you did not purchase condoms, please explain why.

15. Purchasing the items ¡ I used the self check-out lane ¡ I used a regular check-out lane ¡ I purchased the items at the pharmacy counter ¡ I purchased the items from a vending machine

16. Rate your experience purchasing the items. ¡ Very uncomfortable ¡ Sort of uncomfortable ¡ Sort of comfortable ¡ Very comfortable

17. Tell me what happened when you purchased the condoms.

Overall Experience

18. Rate your overall experience. ¡ Good ¡ Okay ¡ Bad

19. Is there anything else that you would like to share?

Shopper’s Characteristics

20. Age: ______22. Race/Ethnicity: ¡ African-American ¡ White 21. Gender: ¡ Male ¡ Female ¡ Latino ¡ Multi-Racial/Bi-Racial ¡ Other, please describe ______

Debriefer’s Notes:

Describe the shopper’s overall demeanor before and after the experience. Please write any additional information that you gathered from the shopper and/or any non-verbal cues that you observed.

*** Special thanks to Philliber Research Associates for generously sharing survey tools, methods, and findings to inform this project. 23 Document 15 (Page 1 of 4) Secret Shopper Findings Report

Over half of all South Carolina high school students have in stores. The SC Campaign previously conducted research had sexual intercourse (53.4%) and over one-third (38.6%) assessing the availability of contraception for young people of South Carolina high school students are currently sexually on college campuses in South Carolina* and wanted to expand active (had sex in the last three months).1 Only 60% of sexually its understanding of other condom access points. Thus, a active high school students in South Carolina used a “Secret Shopper” project was conducted to explore condom the last time they had intercourse, putting them adolescents’ overall experience and potential barriers when at risk for unintended pregnancy and sexually transmitted purchasing condoms at various stores. The ﬁndings from this diseases.2 A sexually active young person who is not using project would subsequently inform efforts to increase access contraception has a 90% chance of becoming to condoms and contraception.

pregnant within 12 months.3 From 2004 to 2007, teen METHODS pregnancy rates in South Carolina increased by 10%, from a rate of 33.1 to 36.5 (per 1,000 girls).4 Beyond the risk of The Secret Shopper project assessed 92 stores in Sumter and Spartanburg counties. A diverse group of 19 young unintended pregnancies, sexually active young people are people ages 15-19 were recruited from various youth serving organizations to participate as “secret shoppers” (shoppers). at risk for sexually transmitted infections Shoppers were required to complete a consent form and were and HIV. South Carolina’s youth under the age of 19 compensated with a $100 gift card.

years old account for 38% of all Chlamydia cases in the state Prior to shoppers entering the store, SC Campaign staff and 32% of all Gonorrhea cases in the state.5 Abstaining members gave shoppers instructions on how to assess each store (i.e., identify where condoms are located in the store, from all sexual behaviors is the most reliable way to identify the cost of condoms available). SC Campaign staff protect against sexually transmitted infections, HIV and members interviewed the shoppers after going to each store and recorded the shoppers’ experience. The interview guide pregnancy.6 However, for sexually active young people, was based on an assessment previously conducted by Philliber i the correct and consistent use of latex condoms can be an Research Associates. One month after the shopping day participants and SC Campaign staff were asked to complete a effective method to prevent pregnancy, sexually transmitted follow-up survey or interview, respectively, to gain feedback about their experience. infections and HIV. The South Carolina Campaign to Prevent Teen Pregnancy (SC Campaign) believes that sexually active

young people should have access to condoms and *Kershner, S. and Flynn, S. (2009). Population Left Behind 2009: An Assessment of sexual health information and services provided by South Carolina colleges and universities. Colum- bia, SC: SC Campaign to Prevent Teen Pregnancy. Available to download at www.teenpregnan- contraception. However, it was not clear what the cysc.org/pdf/PopulationLeftBehind2009.pdf iThe SC Campaign to Prevent Teen Pregnancy gratefully acknowledges Philliber Research As- experience was like for young people to purchase condoms sociates for their support in the development and implementation of the Secret Shopper project.

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24 Document 15 (Page 2 of 4)

FINdINGSii type of site. Of the 92 sites assessed, almost half (44%) of the stores were categorized as “gasoline stations”, 24% were categorized as “grocery stores” and 17% were categorized as “drug stores.” The remaining 15% were categorized as “other” such as megastores (WalMart) or dollar stores. N = 92 sites

100% Figure 1. Brands and Types of Condoms Available Brands and types of Condoms Available. 90% Shoppers reported that 14% of stores did not have 80% any condoms in stock. About one-third (30%) of 70% 66% stores had only one brand of condom available 60% 56% and 20% of stores had only one type of condom 50% 40% available. However, the majority of stores had more 30% 30% than one brand of condom available (56%) and 20% more than one type of condom available (66%), see 20% 14% 14% figure 1. 10% 0% No brands 1 brand More than 1 No types 1 type available More than 1 Visibility of Condoms. Shoppers reported that available available brand available available type available almost two-thirds of the sites (63%) displayed Brands Available Types Available condoms in a way that was easy to find and over half of the stores (56%) displayed condoms on N=86 sites an open shelf. Of the sites where condoms were difficult to find, the reason most reported was that condoms were located behind the counter or someplace where the shoppers had to ask for assistance to obtain condoms. Almost half of the stores (42%) displayed condoms behind the counter and were not available for purchase without asking for help. experience Asking for Assistance: Shoppers asked for assistance at over half (n=54, 59%) of the sites. In these sites, SC Campaign staffers asked the shopper to describe why they chose the particular person to ask for assistance. A total of 70 reasons were given as to why shoppers asked for assistance (shoppers were able to select more than one response when asked this question). Figure 2 shows that most of the responses indicated that the shopper requested assistance based on the sales associate’s availability. Relatively few shoppers chose the sales associate to approach based on personal characteristics (i.e. gender and age).

Figure 2. Reasons Why Shopper Chose the Salesperson to Ask for Assistance In the sites (n = 54) where shoppers asked for The person looked nice. 1% help, the shoppers were subsequently asked to rate their overall experience asking for help. The person looked close to the shopper’s age. 4% Most of the experiences with sales associates The person asked the shopper if they could help them. 6% (77%) were rated as “sort of comfortable” or

The person was the same gender as the shopper. 6% “very comfortable” by shoppers, while only

The shopper had to ask for help because they could not get the 23% of experiences with sales associates 13% condoms without a sales person. were rated “sort of uncomfortable” or “very Other 13% uncomfortable” by shoppers. The person was the only person available in the store. 19%

It was the only person in the store. 19% The results of the Secret Shopper project did not identify any common themes regarding comfort It was the first person that shopper saw in the store. 20% of young people when purchasing condoms. In 0% 5% 10% 15% 20% fact, shoppers expressed contradictory views N = 70 reasons given regarding what made them feel comfortable in the stores. One shopper felt uncomfortable because the sales person was close to the shopper’s age, although another shopper felt comfortable because the sales person was close to their age. The majority of shoppers who indicated feeling uncomfortable with the sales person reported that their perception of being judged was a factor in their level of comfort.

iiDue to different experiences at each site, all questions were not answered by every shopper. For example, if a shopper did not purchase condoms at a site, there were no data available on the purchasing experience of that shopper. Therefore, some figures may not be representative of the entire sample since not all participants answered every question.

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25 Document 15 (Page 3 of 4)

Price per Condom. Shoppers were asked to $4.50 $4.20 Figure 3. Price per Condom recall the least expensive $4.00 condoms and the most $3.50 expensive condoms $3.00 available at each site. $2.50 The price per pack was divided by the amount in $2.00 the pack and the price per $1.50 $1.12 condom was determined. $1.00 Shoppers were instructed to $0.50 $0.25 purchase the least expensive $0.00 package of condoms, and Most expensive Least expensive Average cost of purchased the average price of the condom condom purchased by a N=71 sites shopper was $1.12 per condom (see figure 3). The most expensive condom available was a non-latex condom selling for $4.20 per condom and the least expensive condom available cost $0.25 per condom.

overall experience. Shoppers who purchased condoms were asked to describe the experience. Sales persons in three sites did not allow shoppers to purchase condoms because the salesperson thought that the shopper was “too young.” Some stores (14%) did not have condoms Figure 4. Overall Experience in stock and thus the shoppers were unable to purchase condoms. Shoppers purchased condoms Bad, 11% in over three-quarters (77%) of stores.

Shoppers indicated that the overall experience was “good” at two-thirds of the stores (69%) and the Good, 69% experience was “okay” at 11% of the stores. Only 19% of experiences were rated “bad” by shoppers, Okay, 19% see figure 4.

The overall experience of shoppers was examined by various demographic and site characteristics. There were no statistically significant differences based on the type of store, gender of the shopper or age of the shopper. However, there was a N = 88 sites significant difference (p < .05) in how stores were rated based on the race of the shopper. African American shoppers rated 76% of the stores as “good” compared to 50% of White shoppers and 68% of multi-racial shoppers.

oVeRALL ReCoMMeNdAtIoNS

Gas stations, grocery stores and convenience stores can reach a broad population of young people. Some stores are open 24 hours a day and sell condoms at little cost. To link the supply of condoms (retail stores) with demand for condoms (sexually active young people), youth serving organizations should promote these stores as access points. The findings from this project do not suggest that retail stores should take the place of medical services. Young people should continue to use medical providers for annual screenings, STD/HIV testing and other services. Promoting retail stores as access points for condoms should be one strategy - of many - to increase the availability of sexual health resources for sexually active youth.

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26 Document 15 (Page 4 of 4)

the SC Campaign has developed the following recommendations to increase condom access for sexually active youth:

Recommendations for Stores 1. Make sure condoms are easily visible - displayed on an open shelf, in an aisle or in front of the counter 2. Develop signs and print materials that identify where the condoms are located 3. Clearly display the cost of condoms on each box or shelf 4. Sell multiple types of condoms at multiple price points and stock different packs of condoms (e.g., single condom, 3 pack, 6 pack, etc) 5. Combine educational materials with condom purchases, such as information about lubrication with condom use or testing for sexually transmitted infections 6. Provide local family planning clinic information to young people purchasing condoms 7. Educate sales persons on the benefits of condom use among sexually active young people 8. Correct any misconceptions about legal issues regarding the sale of condoms to young people (i.e., an age limit to purchasing condoms) 9. Encourage sales persons to be helpful with young people who purchase condoms 10. Work with local organizations to market store as an access point for condoms

Recommendations for Youth Serving organizations 1. Promote retail stores as an access point to purchase condoms for sexually active youth: talk with young people about positive experience of the Secret Shopper project, discuss common myths and facts about condom access (i.e., there is no legal age to purchase condoms, anyone can purchase condoms) 2. Conduct a Secret Shopper project in your community 3. When implementing a science-based program that uses a condom purchasing activity, include that lesson if possible 4. Educate other organizations about condom access so that they can provide free condoms (such as barber shops, nail salons and other places that young people frequently visit)

NoteWoRtHY

Thank you to the BlueCross BlueShield of South Carolina Foundation, Mary Black Foundation, and Spartanburg Regional Healthcare System Foundation for funding this project.

ABoUt tHe SC CAMPAIGN

Now in its 16th year, the SC Campaign to Prevent Teen Pregnancy works state-wide to prevent adolescent pregnancy in South Carolina through education, technical assistance, public awareness, advocacy and research. The Campaign is the only organization in the state, working in all 46 counties, to reduce teen pregnancy.

1Youth Risk Behavior Surveillance System (YRBS) 2009 Fact Sheet on Sexual Behaviors, Department of Education, retrieved April 7, 2010 from http://www.cdc.gov/yrbss 2Youth Risk Behavior Surveillance System (YRBS) 2009 Fact Sheet on Sexual Behaviors, Department of Education, retrieved April 7, 2010 from http://www.cdc.gov/yrbss 3Guttmacher Institute, In Brief Facts on American Teens’ Sexual and Reproductive Health, retrieved November 5, 2010 from http://www.guttmacher.org/pubs/FB-ATSRH.pdf 4Data provided by the Division of Biostatistics, Public Health Statistics and Information Services, SC DHEC 5STD/HIV Division Surveillance Report. December 31, 2008, retrieved April 7, 2010 from http://www.scdhec.gov/health/disease/sts/docs/HIVSTD_SurvRpt_Dec2008.pdf 6Centers for Disease Control and Prevention (CDC) Condoms and STDs: Fact Sheet for Public Health Personnel, retrieved November 8, 2010 from http://www.cdc.gov/condomeffectiveness/latex.htm

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27 Document 16 (Page 1 of 2)

This anonymous survey tool was used by South Carolina DHEC and the South Carolina Campaign to Prevent Teen Pregnancy to collect feedback on DHEC's teen health center, The Point. This survey tool can be modified and implemented in your provider setting to evaluate marketing efforts targeting adolescents. Sample Marketing Survey

 The Point: Spartanburg Main  Marketing Survey

This is an anonymous survey, which means you cannot be identified by your answers. However, you do not need to answer questions you are uncomfortable answering.

1. What month is it? January February March April May June July August September October November December

2. What is your age? 14 years or younger 15 years old 16 years old 17 years old 18 years old 19 years old 20 years or older

3. Are you a new patient at The Point? Yes No

4. How did you make your appointment? Online/by email Phone

5. Please select the top reason(s) you chose to come here today: Staff are friendly TV/Wii Convenient Hours Convenient Location I feel comfortable here I like the atmosphere Other (please specify):______

6. Please indicate your school enrollment status below. Student in high school Not enrolled in school College student, please specify: ______Other, please specify: ______

Questions continue on the back

28  C88 Page 1   Document 16 (Page 2 of 2)

 The Point: Spartanburg Main  Marketing Survey

7. How did you hear about The Point? Select all that apply. Regina from The Point College campus, list college: ______Community Event, please specify: ______Friend or classmate Family member Radio SC DHEC website (scdhec.gov) CarolinaTeenHealth.com You Tube NRN (Not Right Now) Spartanburg Tobias Health Department ReGenesis BirthMatters Edward L. Enterprises, Inc. Mt. Calvary Baptist Church REACH Upstate South Side Unity in the Community Spartanburg 7 School District Spartanburg County Parks & Recreation Spartanburg Regional Hospital USC Upstate Waccamaw Youth Center Other, please specify: ______For Questions 8-14: Overall, how much do you feel you know about the following methods for preventing pregnancy? Would you say you know nothing, you know a little, or you know a lot about each method? 1=Know nothing, 2=Know a little, 3=Know a lot 1 23 8. Injectable birth control, like Depo Provera (the Shot, Lunelle)......  9. Birth control pills or oral contraceptives (the pill)......  10. The birth control patch, or Ortho Evra ......  11. An IUD or intrauterine device, like Mirena......  12. Male condoms (rubbers)......  13. A vaginal ring or nuva-ring......  14. Birth control implants, like Implanon (Norplant, tubes in your arm)...... 

Thank you for taking this survey!  C88 Page 2  

29 Document 17 (Page 1 of 2)

 The Point-Northwoods Clinic wants to know...  *** TO BE ADMINISTERED TO CLIENTS AGE 18-19 BEFORE VISIT *** This is an anonymous survey, which means you cannot be identified by your answers. However, you do not need to answer questions you are uncomfortable answering. 1. What month is it? ______2. What is your age? 17 years and younger 18 years 19 years 20 - 24 years 25 years and older 3. Are you a new patient at The Point-Northwoods Clinic? Yes No 4. Did you make your appointment online/by email? Yes No 5. Please indicate your school enrollment status below. Student at College of Charleston Student at Trident Technical College Student at Charleston Southern University Student in High School Not enrolled Other 6. Did you hear about The Point-Northwoods Clinic on your campus? Yes No If yes, how did you hear about The Point-Northwoods Clinic on your campus? (Select all that apply) 7. Event at Trident Technical College ......  8. Class at Trident Technical College......  9. CarolinaTeenHealth.com ......  10. Flyer......  11. Other: ______For Questions 12-18: Overall, how much do you feel you know about the following methods for preventing pregnancy? Would you say you know nothing, you know a little, or you know a lot about each method? 1=Know nothing, 2=Know a little, 3=Know a lot 1 23 12. Injectable birth control, like Depo Provera (the Shot, Lunelle) ......  13. Birth control pills or oral contraceptives (the pill) ......  14. The birth control patch, or Ortho Evra......  15. An IUD or intrauterine device, like Mirena ......  16. Male condoms (rubbers)......  17. A vaginal ring or nuva-ring......  18. Birth control implants, like Implanon (Norplant, tubes in your arm)...... 

19. I expect to have a good experience at this clinic. Strongly Disagree Disagree Agree Strongly Agree

30  6E8 Page 1   Document 17 (Page 2 of 2)

 La clinica The Point-Northwoods quiere saber...  ***para ser administrado antes de la cita a los clientes entre 18-19 años*** 1. ¿Que mes es? ______2. ¿Qual es su edad? 17 años o menor 18 años 19 años 20 - 24 años 25 años o mayor 3. ¿Eres un paciente nuevo? Sí No 4. ¿La cita fue hecha por el internet o correo electrónico? Sí No 5. ¿Favor de indicar su estado de matrícula escolar? Estudiante en el College de Charleston Estudiante en el Trident Technical College Estudiante en el Charleston Southern University Estudiante en la escuela secundaria No inscrito Otro 6. ¿Te enteraste de esta clinica en la escuala? Sí No Si la respuesta es sí, como te enteraste de la clinica? (Seleccione todos los que le aplican.) 7. Un evento en Trident Technical College......  8. Classes en Trident Technical College ......  9. CarolinaTeenHealth.com ......  10. Folleto ......  11. Otro: ______Para las preguntas 12-18: En general, cuanto crees que conoces sobre los siguientes methodos para prevenir el embarazo? Diría que usted sabe nada, poco o mucho acerca de cada método? 1=Sabe nada, 2=Sabe poco 3=Sabe mucho 1 23 12. Anticonceptivos inyectables, como depo provera (the Shot, Lunelle)......  13. Las píldoras anticonceptivas o los anticonceptivas orales (la píldora)......  14. El parche para prevenir el embarazo o Ortho Evra ......  15. Un DIU o dispositivos intrauterinos, como Mirena ......  16. Preservativos masculinos......  17. Un anillo vaginal o anillo nuva ......  18. Implantes para prevenir el embarazo, como Implanon (Norplant, tubos en sus brazos)...... 

19. Espero tener una buena experiencia en esta clinica. Totalmente en desacuerdo Desacuerdo De acuerdo Totalmente de acuerdo

 276 Page 1  

31 Document 18 (Page 1 of 1)

This draft organizational charter establishes the criteria health centers must adhere to in order to access the branding and marketing materials developed for The Point Teen Health Center. Sample Charter to Share Branding

The Point Charter The Point – it’s all about you! à Mission à Services à Facilities à Staff/Training Team/ICE Coordinator à Technology à Messages à Client Education à Partnerships à Outreach marketing à Data/Outcomes à Mandatory Reporting

Mission - The mission is to provide confidential reproductive health care, education, and empowerment to teens in South Carolina and surrounding areas.

Services - All family planning services are available for females and males. • All types of contraception available on site • STD care will be provided on site by provider • Provided to anyone 21 and under • Offer Medicaid coverage to all • UCG will be offered on a walk-in basis whenever clinic is open

Facilities - Incorporate components of teen friendly environments

Staff - Focused, trained, and motivated to meet the needs of the teen population as directed best practices

Technology - Utilize available technology to optimize targeted outcomes

Messages - Empower adolescents to prevent unplanned pregnancies and the spread of STDs, thereby reducing the socioeconomic impact of these conditions on the community

Client Education - Utilize age appropriate educational materials/messages to achieve optimal knowledge gain and desired behavioral change

Partnerships - Identify and develop stakeholder partnerships to advance the mission of The Point

Outreach/Marketing - Utilize agency approved, age appropriate marketing tools to increase awareness of teen reproductive health needs

Outcomes - Clinic operations should be flexible and based on the demands of the community

Mandatory Reporting - Agency policies will provide guidance for adherence to current laws

32 Document 19 (Page 1 of 1)

This memorandum of understanding establishes a partnership between a community college and a local family planning provider to prevent unplanned pregnancies among 18-19 year old students. This MOU can serve as a model for establishing a partnership between your provider setting and schools. Sample MOU between a Health Care Provider and Community College

Memorandum of Understanding Between [Provider] Health Care and [Community College] in [County] Project Need: In 2007 [County] experienced an increase in teen pregnancies after years of steady decline. According to the 2007 data, the overall teen pregnancy rate increased by 8%, this increase was largely due to a dramatic increase of the 18-19 year old population.

In fact, two thirds of teen pregnancies are to 18-19 year olds. In an effort to increase knowledge and access to reproductive health care, [Provider] and [Community College] will partner to link students to quality health care. According to national data, nearly half (48%) of community college students have ever been pregnant or gotten someone pregnant. Unplanned pregnancies increase the risk of dropping out or stopping college—61% of women who have children after enrolling in community college fail to complete their degree, which is 65% higher than the rate for those who didn’t have children. The partnerships between a [Provider] and [Community College] will be crucial to reduce drop out and prevent unplanned pregnancies in [County].

Project Overview: [Provider] is a medical facility with the ability to offer health care including family planning, will begin working on the [Community College] (CC) Campus one day per week. [Provider] will be present on campus during a day and time that is determined at a later date to sufficiently meet the needs of the freshman students but will remain consistent each week. [Provider] will provide a staff member one day per week to be available to [CC] students in regards to their health needs. [Provider] will develop outreach strategies for freshman specifically and will prioritize the 18-19 year old population in their outreach strategies. [Provider] will promote the importance of utilizing their services especially in regards to family planning and will offer services that are affordable and “friendly” to the adolescent patient. [CC] will provide space and time that is high traffic for freshman students, and provide opportunities on campus (via student activities and/or courses) for [Provider] to increase awareness of services in [County].

Each of the individuals included below indicate via their signature an understanding of their participation in the project. The individual will be responsible for providing support on site to the program indicated above, which includes aiding in the logistical planning and execution of evaluation of students for programming purposes, implementation of the curriculum, and participation in events as outlined above. The dates are subject to change with one week’s notice to the indicated individuals below for their respective locations. Participation is crucial in the success of this project and represents a commitment to this project and to young people in their community.

Name of Organization, Title Signature Date

33 Document 20 (Page 1 of 2) Example of Local SC Campaign Promotional Materials

who we are

Mission stateMent

As a 501(c)(3) non profit organization, we are committed to the prevention of adolescent pregnancy in South Carolina through education, technical assistance, public awareness, advocacy and research.

organizational Beliefs

• The prevention of adolescent pregnancies is in the • Communities play a key role in reducing adolescent best interest of adolescents, their families and society. pregnancy. • Parents should be the primary sex educators of their children. • Youth should be recognized as assets and involved as • The most effective health and sexuality education is equal partners in all aspects of prevention activities in abstinence-first, age-appropriate and comprehensive. their communities. • The use of research proven curricula and programs will • The prevention of adolescent pregnancies will improve reduce adolescent pregnancy. the health and economic prosperity of South Carolina.

organizational ProMises

CoMMuniCation: We vow to communicate with and listen to parents, providers, key leaders and community members throughout South Carolina to gain an increased understanding of local needs and assets.

CustoMization: We promise to customize approaches that combine evidence-based approaches with the unique fabric of every community we serve.

CaPaCity Building: We will strive to increase the capacity of community members (parents, youth serving organizations, school staff, faith leaders and youth) to address the complex issue of teen pregnancy.

CoMMitMent: The Campaign is committed and fully invested in prevention for the long term. sPartanBurg staff Dana Becker, a resident of Boiling Springs, leads the Campaign’s efforts in Spartanburg County out of her office in downtown Spartanburg. Her role is to bring together partners in the community to address the issue of teen pregnancy. If you would like additional information or want to get involved, contact Dana. Meredith Talford, a resident of Spartanburg, provides Technical Assistance to providers in the Upstate. She shares an office with Dana in downtown Spartanburg. To contact Meredith, email her at [email protected].

www.teenpregnancysc.org ~ 864.573.9542 ~ 349 east main street, spartanburg, sc 29302 ~ [email protected]

Who We Are_What We Do Spartanburg Update.indd 1 3/29/2012 3:32:27 PM 34 Document 20 (Page 2 of 2)

what we do i n spartanburg c o u n t y

ince 1994, the SC Campaign has worked in all 46 counties suPPort health eduCation in sChools: We Sof South Carolina. Historically, our work has been are dedicated to working with all seven school focused at the individual and organizational level to strengthen districts in Spartanburg County to assess current programs and educate youth-serving professionals on the health education curricula and provide training prevention of teen pregnancy. Our experience and knowledge and technical assistance as needed to enhance gained during this time has led us to better understand how pregnancy prevention efforts. We encourage all to approach the issue on a community-wide level. Thus, in schools to implement a proven effective program 2009, through the support of community leaders a Spartanburg in achieving behavioral outcomes among students. Initiative was established. Our goals in Spartanburg fall directly in line with the organization’s strategic plan. ContraCePtion aCCess: Sexually active young people have the right to easily access condoms and 1. High quality teen pregnancy prevention programs and contraception. Through work with retail locations, services are available to Spartanburg youth. college campuses, health centers, and non-traditional 2. High priority youth have access to teen pregnancy access points, the Campaign works in Spartanburg to prevention services tailored to their unique needs. guarantee availability. 3. Public schools are delivering age-appropriate, science- based pregnancy prevention programs. PuBliC aWareness: To effectively address teen 4. Young people who are sexually active have access to pregnancy prevention in Spartanburg requires condoms and other forms of contraception. a clear, consistent message about love, sex and 5. Parents and/or trusted adults are having open, honest relationships. Our efforts reach across all audiences conversations with their children about love, sex and with the message that teen pregnancy is a problem relationships. in Spartanburg, and we all have a role to play in the solution. Look for the Campaign logo on many of sPartanBurg CoMMunity aCtion grouP (sCag): our dedicated efforts. SCAG exists to identify needs in the community and seeks to meet those needs using the goals listed above. outreaCh to Parents: We work to increase the Members are all concerned about the young people understanding of the critical role parents play of Spartanburg County and include business people, in shaping their children’s decisions about sex. community leaders, volunteers, mentors, parents, and Educational opportunities and awareness activities leaders in the faith community. offer “tips for parents” and ways parents can get involved in prevention efforts including becoming Work With CoMMunity health Centers: Our work advocates for effective teen pregnancy prevention with health centers revolves around one key phrase - programs in schools and communities. teen friendliness. Building the capacity and increasing the understanding of how medical facilities serve involving youth: Young people should not be sexually active teens can improve the teen experience, viewed as the “problem” in teen pregnancy, but ultimately resulting in teens seeking care customized to recognized as assets and a vital part of the solution. meet their needs. We are committed to involving the young people of Spartanburg County in all aspects of prevention. Partner With youth serving organizations: In Youth have been involved in public awareness Spartanburg County, youth serving organizations seek campaigns, assessments of contraception access, services from the Campaign in training, personalized media appearances and the Teen Expressions contest. technical assistance, evaluation support, and funding for We continue to seek creative and innovative ways to teen pregnancy prevention projects. The Campaign is engage young people in this work. dedicated to quality programming. These partnerships result in greater resources and support for Spartanburg To learn more, please visit www.nrnspartanburg.com County teens.

www.teenpregnancysc.org ~ 864.573.9542 ~ 349 east main street, spartanburg, sc 29302 ~ [email protected]

Who We Are_What We Do Spartanburg Update.indd 2 3/29/2012 3:32:32 PM 35 Document 21 (Page 1 of 6)

This is an example spreadsheet that can be used to gather and analyze multi-year data on patient trends, staffing distribution, appointment scheduling, and contraceptive use. This template was developed by TRAINING 3, a program of the Family Planning Council.

Example Data Collection Spreadsheet

Table 1 - Users and Visits

Table 1a - Family Planning (Title X) Users and Visits % Change % Change 2009 2010 2011 09-10 10-11 Number of family planning 3,026 2,744 2,649 -12.0% -3.0% (Title X users) Number of new users 1,567 1,422 1,266 -19.0% -11.0% Number of continuing users 1,459 1,322 1,383 -5.0% 5.0% Retention rate 43.7% 52.2% 20.0% Total family planning (Title X visits) 5,266 4,887 4,499 -15.0% -8.0% Total average Title X visits per user 1.74 1.78 1.7 -2.0% -5.0%

Table 1b - Family Planning (Title X) Users and Visit by Site 2009 2010 2011 Percent of Users Percent of Visits Sites Users Visits Users Visits Users Visits 2009 2010 2011 2009 2010 2011 Site 1 2598 4545 2744 4887 2649 4499 85.9% 100.0% 100.0% 8630.0% 10000.0% 10000.0% Site 2 428 721 0 0 0 0 14.1% 0.0% 0.0% 1370.0% 0.0% 0.0% Site 3 Site 4 Site 5 Site 6 Site 7

Table 1c - Family Planning (Title X) Users by Selected Indicators % Change % Change Percent of Percent of Percent of 2009 2010 2011 09-10 10-11 Users 09 Users 10 Users 11 Number of Users Under 20 697 694 560 -20.0% -19.0% 23.0% 25.0% 21.0% Number of Users at 100% 2403 2264 2175 -9.0% -4.0% 79.0% 83.0% 82.0% Poverty Number of Users with 179 213 320 79.0% 50.0% 5.9% 7.8% 12.1% Medicaid Number of Users with Private 22 12 6 -50.0% 1.4% 0.4% 0.2% Insurance Number of Limited English 52 73 86 65.0% 18.0% 3.6% 2.7% 3.2% Proficiency Users

36 Document 21 (Page 2 of 6)

Table 1d - Selected Site, Family Planning (Title X) Visits by Type 2009 2010 2011 % Change 09-10 % Change 10-11 Comprehensive/annual/initial 1166 1023 1116 -4.0% 9.0% Clinician visit/problem/revisit 2273 1523 1319 -42.0% -13.0% Pregnancy tests 1910 1710 1486 -22.0% -13.0% Non-clinician visit/RN 2993 2923 2099 -30.0% -28.0% Method check/depo Medical problem with clinician Other [please define:] Supply visits (non chargeable) 250 229 308 N/A N/A Number of clinician visits 3439 2546 2435 -29.0% -4.0% Percent of clinician visit 76.0% 52.0% 54.0% -28.0% 4.0%

Table 2 - Center Staffing

Table 2a - Total Program, All Sites Family Planning (Title X) Day of Week NP RN MA Clerical Monday 1 5 5 Tuesday 1 7 5 Wednesday 1 7 4 Thursday 5 5 Friday 1 5 4 Saturday Total FTEs 0.8 5.8 0 4.6

Table 2b - Selected Site Family Planning (Title X) Day of Week NP RN MA Clerical Monday Tuesday 1 2 0 1 Wednesday 1 2 0 1 Thursday 1 2 0 1 Friday Saturday Total FTEs 0.6 1.2 0 0.6

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Table 3 - Hours of Operation

Table 3a - Site Hours Table 3b - Title X Day of Week Total Hours for Selected Site Family Planning (Title X) Day of Week Total Hours Monday 8 Monday 8 Tuesday 8 Tuesday 8 Wednesday 8 Wednesday 8 Thursday 8 Thursday 8 Friday 8 Friday 8 Total Hours Per Week 40 Total hours per week 40 Percent of total hours 100% Average visits per hour - 2.45 46 weeks per year

Productivity Table 2009 2010 2011 %Change 09-10 %Change 10-11 Average total visits per clinician FTE 6583 6109 5624 -15.0% -8.0% Average clinician visits per clinician FTE 5732 4243 4058 -29.0% -4.0%

Table 4 - Appointment Summary

Note: For each day of the week, please list the average number of appointments availabe on the schedule template for that visit type by hour of the day in the space provided

Table 4a - Title X Available Appointments Monday Tuesday Wednesday Thursday Friday Total 7:00-7:59am 0 0 0 0 0 0 8:00-8:59am 3 3 0 3 2 11 9:00-9:59am 3 3 0 3 4 13 10:00-10:59am 3 5 0 3 4 15 11:00-11:59am 0 1 0 0 1 2 12:00-12:59pm 3 2 1 2 2 10 1:00-1:59pm 2 4 3 2 4 15 2:00-2:59pm 3 4 4 3 4 18 3:00-3:59pm 2 3 1 2 3 11 4:00-4:59pm 0 5:00-5:59pm 0 6:00-6:59pm 0 7:00-7:39pm 0 2nd and 4th 3rd, 4th, 5th 1/2 day once a month NC 3x month Total 19 25 9 18 24 95

Percent between 7 31.6% 24.0% 0.0% 33.3% n/a 25.3% & 10 Percent between 10 31.6% 32.0% 11.1% 27.8% n/a 28.4% & 1

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Percent between 1 26.3% 32.0% 77.8% 27.8% n/a 34.7% & 3 Percent between 3 10.5% 12.0% 11.1% 11.1% n/a 11.6% & 7

Average appoint- 2.38 3.13 1.13 2.25 3 2.38 ments per hours

Table 4b - Title X Available Appointments Monday Tuesday Wednesday Thursday Friday Total 7:00-7:59am 0 0 0 0 0 8:00-8:59am 0 3 2 3 8 9:00-9:59am 0 4 4 3 11 10:00-10:59am 0 4 4 3 11 11:00-11:59am 0 1 1 0 2 12:00-12:59pm 2 3 2 2 9 1:00-1:59pm 3 2 4 2 11 2:00-2:59pm 3 3 4 3 13 3:00-3:59pm 3 2 3 2 10 4:00-4:59pm 3 3 5:00-5:59pm 1 1 6:00-6:59pm 0 7:00-7:39pm 0 1st and 3rd 1st and 2nd NC 3x month once a month Total 15 22 0 24 18 79

Percent between 7 0.0% 28.0% N/A 33.3% 25.0% 20.0% & 10 Percent between 10 10.5% 32.0% N/A 38.9% 20.8% 23.2% & 1 Percent between 1 40.0% 22.7% N/A 33.3% 27.8% 30.4% & 3 Percent between 3 36.8% 8.0% N/A 16.7% 8.3% 14.7% & 7

Average 1.88 2.75 3 2.25 1.98 appointments per hours

39 Document 21 (Page 5 of 6)

Table 5 - Title X Appointment No Show and Walk-Ins For Selected Site Family Planning (Title X) Visits 2010 2011 % Change 10-11 Total scheduled appointments 3531 3679 4.2% Number of appointments not kept 734 817 11.3% Total walk in visits 1627 1250 -23.2% Average annual no show rate 20.8% 22.2% 6.8%

Table 6 - Contraceptive Coverage Table 6a - 2010 # of female users # users using highly reliable # of females seeking on a contraceptive contraception - oral, ring, Age group Total Female Users pregnancy method patch, IUD, implanon Younger than 15 18 0 16 12 15-17 226 0 244 167 18-19 410 4 321 221 20-24 1018 17 766 520 25-29 505 4 376 243 30-34 and up 527 9 401 244 Total 2704 34 2124 1407

Table 6b - 2011 # of female users # users using highly reliable # of females on a contraceptive contraception - oral, ring, Age group Total female users seeking pregnancy method patch, IUD, implanon Younger than 15 17 0 17 15 15-17 204 0 187 136 18-19 339 3 284 191 20-24 960 13 769 525 25-29 567 12 444 292 30-34 and up 561 8 454 302 Total 2648 36 2155 1461

Table 6c - Summary of Contraceptive Coverage Age Group 2010 2011 Percent of users on Percent of users on Percent of users on Percent of users on contraception hormonal contraception contraception hormonal contraception Younger than 15 89% 67% 100% 88% 15-17 108% 74% 92% 67% 18-19 79% 54% 85% 57% 20-24 77% 52% 81% 55% 25-29 75% 49% 80% 53% 30-34 and up 77% 47% 82% 55% Total 80% 53% 83% 56%

40 Document 21 (Page 6 of 6)

Table 7 - Revenue and Expenses

Table 7a - Total for Program 2009 2010 2011 % Change 09-10 % Change 10-11 State/Title X funding $276,579 $276,579 $276,572 0.0% 0.0% MD DHMH contraceptive $24,000 $24,000 $24,000 0.0% 0.0% drug/device funding Other funding - DHMH Core $643,097 $792,254 $591,463 -800.0% -2500.0% Other funding - county $0 $0 $0 Medicaid not including managed care Medicaid managed care $5,997 $23,495 $23,155 28600.0% -100.0% Medicaid waiver Other (full and sliding fee $11,283 $24,222 $26,337 13300.0% 900.0% payments) Third party reimbursement $14 $300 $2,251 1644100.0% 65000.0% (commercial, medicare) Other $6,250 $702 $109 -9800.0% -8400.0% Total revenue $967,220 $1,141,552 $943,887 -200.0% -1700.0% Total expenses (clinic) $967,220 $1,141,552 $943,887 -200.0% -1700.0%

Average cost per user $320 $416 $356 1100.0% -1400.0% Average cost per visit $184 $234 $210 1400.0% -1000.0%

Table 7b - Selected Site Revenue and Visits by Payer

2009 2010 2011 Total Avg rev/ Total Avg rev/ Total Avg rev/ Sites Revenue Visits visit Revenue Visits visit Revenue Visits visit Medicaid not including managed care Medicaid managed care 5997 143 41.94 23495 199 118.07 23155 306 75.67 Medicaid waiver 35 0 14 0 14 0 Other (full and sliding 11283 2814 4.01 24222 2516 9.63 26337 2323 11.34 fee pmts) Third party reimbursement 14 22 0.62 300 12 25.01 2251 6 375.2 (commercial, Medicare) Other (bad debt, donations) 6250 702 109

41 Document 22 (Page 1 of 1)

A chart used to track referrals given to patients for additional health care and/or social services. This template was developed by TRAINING 3, a program of the Family Planning Council. Example Referral Tracking Form

RN/SW Comprehensive Women’s Health Care Referrals

Patient: Date: Date: Date: Date: FP

PAC

PCP

MCHP

Dental

Smoking Cessation

Weight Mgmt.

Mental Health

Substance Abuse

Housing

Transportation

ACCU

Other:

Misc. Comments

Signed

42 Document 23 (Page 1 of 1)

This action plan helps identify tasks, staff, and a timeline needed to meet an objective or goal. Example Work Plan to Develop a Strategic Plan

HCHD Strategic Plan – Workplan Template

Strategic Priority #1: Ensuring Financial Stability and Sustainability Actions Responsible Parties Timeline Measures Convene Financial Stability Administration, Selected November 2012 Meeting. and Sustainability Team to programs review charge and expected outcomes Assess baseline service levels Financial Stability and Sustain- January 2013 Present service data for the for selected programs: ability Team past 1-3 years for each pro- • WIC gram. • Family Planning • Behavioral Health • Dental • Home Visiting Set 1-year (FY 2014) and Selected programs February 2013 Each program will set a target 3-year (FY 2016) service objective for service growth. growth objectives for each of these programs (e.g., 5%/ year growth) Delineate current service deliv- Selected programs March 2013 Each program will present its ery model for each program current service delivery model to the group. Delineate at least 3 strategies Selected programs April 2013 Each program will present its (with projected costs and 3 strategic options for growth outcomes) for increasing the to the group. service level in each program Present options to the group Financial Stability and May 2013 The group will develop con- in order to develop consensus Sustainability Team, Selected sensus recommendations. recommendations programs Present options to HCHD Senior staff June 2013 Presentation will be made and Senior Staff for feedback feedback incorporated. Begin implementation of the Selected programs July 2013 Each program begins imple- selected strategies mentation. Evaluate outcomes Financial Stability and Sustain- October 2013 October 2013 ability Team January 2014 January 2014 April 2014 April 2014 July 2014 July 2014

43 Document 24 (Page 1 of 2)

This short-term strategic planning tool from HCHD identified action areas to focus on for future sustainability. Example Short-Term Strategic Plan

Harford County Health Department Short Term Strategic Plan Priority 1: Increase Appointments and Visits

Actions December January February Triple book at 8:15 and 12:30, (new, short, annual) Double book the 1st 2 hours of each session Allow walk-in clients for clinic Allow FP clients who call in with problems to bee seen the same day See FP for c/o UTI Provide gyn service regardless of need for BC Make all appts 20 mins

Priority 2: Marketing

Potential Markets December January February Local newspaper Other HD services, WIC, X Addictions, smoking cessation Food bank High schools – Outreach Coordinator Community agencies – DJJ, Drug Court, Ruth’s House Minute Clinic

Priority 3: Review Clinic Hours

Actions December January February Survey clients as to preferred hours

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Priority 4: Gather Data

Actions December January February Gather stats on location of most clients, least clients. Consider satellite site if indicated Track hospital clients referred to FP/Women’s Care Check reimbursement rates on X X X a monthly basis Review monthly clinic stats X X X Modify paperwork to include X at a minimum, title X requirements. Fiscal review after patient X seen through clinic

Priority 5: Become In-Network with Private Insurance

Actions December January February TBD

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This competencies document from South Carolina DHEC defines the knowledge and skills a registered nurse is expected to master upon completion of the Preventive Health Course and preceptorship. This list of competencies could be used as a sample to develop competencies for a similar type of course. Example Competencies for Preventative Health Nurse Course

Upon completion of the Preventive Health Course and preceptorship period the RN will be able to:

1. Define the role of the public health nurse 12. Perform a male genital examination to include inspection of penis and testicular examination; differentiate between 2. Take a complete health history to include reason for services, normal and abnormal findings; teach patients about chief complaints/history of present illness, review of testicular self‑exam symptoms, medical history, family history, personal, social, GYN and sexual history as well as immunization status 13. Collect laboratory specimens appropriate for patient’s reason for services, history, signs/symptoms, and 3. Identify risk factors for: program standards a. HIV infection 14. Collect appropriate laboratory specimens that may b. syphilis and other STDs include syphilis serology, Pap smear, Gen‑Probe for c. hepatitis and other vaccine preventable diseases gonorrhea and chlamydia, gonorrhea culture, Gram stain d. contraception specimen, saline and KOH prep, herpes culture, HIV test, e. drug interaction pregnancy test, hemoglobin/hematocrit f. nutritional deficiencies 15. Perform laboratory procedures 4. Utilize open ended questions when taking the health history and discussing risk factors; conduct the history in a 16. Participate in CLIA Proficiency Examinations with non‑judgmental, interactive, and client‑centered manner passing grade

5. Utilize open-ended questions to assess the patient’s 17. Synthesize information from subjective and objective data knowledge of HIV, STDs, contraception, and other collection to make a diagnosis/management option pertinent health issues 18. Provide appropriate contraceptive method according to 6. Perform a neck examination (thyroid and lymph nodes) standing orders for screening purposes; differentiate between normal and 19. Provide appropriate treatment for STDs according to abnormal findings. standing orders

7. Perform a screening examination of the heart and lungs; 20. Provide appropriate immunizations according to differentiate between normal and abnormal findings. Standing Orders

8. Perform a screening examination of the breast and 21. Provide appropriate education based on patient’s axillae; differentiate between normal and abnormal knowledge and diagnosis, utilizing both verbal and findings; teach patients about self‑exam techniques printed information

9. Perform an abdominal examination for tenderness, 22. Provide client‑centered counseling masses, and other abnormalities; differentiate between normal and abnormal findings 23. Provide appropriate follow-up

10. Perform a generalized inspection of the skin to assess for 24. Initiate appropriate consultation and make lesions/rashes associated with STDs and/or to identify appropriate referrals other common skin disorders; differentiate between normal and abnormal findings 25. Document findings and appropriate plan of care based on diagnosis/management options in the patient’s record 11. Perform a female genital examination to include examination of external genitalia, speculum examination, and bimanual examination; differentiate between normal and abnormal findings; teach patients Genital Self Exam (GSE) techniques

46 Preventative Health Course Brochure Document 26 (Page 1 of 2)

and for for THE Sponsored by COURSE HEALTH HEALTH Office of Nursing, of Nursing, Office S.C. DHEC Division of STD/HIV PREVENTIVE Family Planning Program Family S.C. Department of Health and Environmental Control Control and Environmental Division of Women’s Services Women’s Division of Registered Nurses Registered Division of Women’s Services 10/2012 Services Women’s of Division Notes: ______

Box101106 Box101106 (803)898-0547 (803)898-8028 Division of STD/HIV STD/HIV of Division the course contact: Columbia, SC 29211-0106 Columbia,SC 29211-0106 Columbia,SC STD/HIV Nurse Consultant Consultant Nurse STD/HIV Susan Watts, RN, MSN, CS CS MSN, RN, Watts, Susan Region 2: Kathryn Arflack Arflack 2: Kathryn Region Region3:Cynthia Dodd Roberson JoEllen 3: Region Region 4: SharonWalters Region5: Debra Cain Jones Carolyn 6: Region Perkins Constance Office: Central Olawsky Angie Office: Central Watts Susan Office: Central Williams Maxine Central Office: Division of Women’s Services Services Women’s of Division SCDHEC-Mills/Jarrett Complex Complex SCDHEC-Mills/Jarrett SCDHEC-Mills/Jarrett Complex Complex SCDHEC-Mills/Jarrett Family Planning Nurse Consultant Consultant Nurse Planning Family Constance Perkins, RN, MA, MPH MPH MA, RN, Perkins, Constance For more information about about For more information PreventiveHealth Course Coordinator PreventiveHealth Course Coordinator Preventive Health Course Workgroup:

47 Document 26 (Page 2 of 2) tialing Center’s Commission on Accreditation. Accreditation. on Commission tialing Center’s Creden- Nurses’ the American by tinuing education approver of con- an accredited Association, Nurses the South Carolina continuing nursing education by of Nursing is an approved provider DHEC Office of will receive contact hours. The SC each participant The course takes up to six months and to complete in the health region. preceptor tered Nurse (APRN) Practice Regis- Advanced pleted with a designated is com- practicum The clinical long. is three weeks and in Columbia, held portion is Fall. The didactic The course is held twice a year in the Spring and appropriate. vices as tients or 5 patien five of the 30planning patients. Additionally, pa- Family males) and fifteen 5 and tients (10 females minimum,on, at a fifteen STD pa- the APRN by mustthe clinical preceptorship, RN be evaluated of preceptorship. and practicum At the completion of an APRN during the clinical clinical supervision the under RN practice that the The course requires practice are a necessity. and Outside study and clinical practice. observation, clinical assignments, study materials, individual audiovisual effective: lectures, group discussion, most makelearning process are used to the methods and clinicalinstruction, practice. self-study, Various combines methodology didactic The instructional and immunization. transmitted diseases inticularly the areas of planning, sexually family par- ment, intervention problemidentification, and assess- physical taking, risk assessment, of history majorhealth services. The the skills emphasis is on will prepare them to provide integrated preventive that Nurses Registered Public Health instruction for curriculum assessment and didactic ized physical provide a standard- the course is to The purpose of Preventive Health t s must receive immunization ser- immunization must receive s Course The

with 6 months with 6 for course completion in the health district APRN Preceptor Nurse (APRN) or MD preceptor Practice Registered with an Advanced per andweek 1 day for clinical practice week per 4 days 2 weeks with didactic adult clients Course created role nurse” for the “extended SC Board of Nursing provided guidance essential services outcomes achieving desired and adopted             Central Office staff DHEC by Training for APRN Preceptors an with Included practicum training over held in Columbia First course was Family and STD. Planning providing services in those especially for all Public Health Nurses Opportunity and to adolescent providing services in and abilities of Public Health Nurses skills the knowledge, Purpose: enhance 1996: Integrated Preventive Health the by given approval SC DHEC was functions and Core Public Health for the process Integrated services holistic services Comprehensive, services and seamless with streamlined Focus on the customer Plan formulated 1995 DHEC Strategic History of the Course

Health Courses. Health Courses. of future Preventive tinue to be a critical component preceptor will con- Clinical time with an assigned Course. portions of the Preventive Health to attend didactic an opportunity updates ers needing plan to oth- ing. also offer past participants and We learn- with the instructors to facilitate discussion and time face-to-face continue to include The course will of the course. clinical portions in the didactic and what is taught could enhance other material that and for prerequisites modules workgroup would also like to see on-line learning on-line. The PHC be able to practice documentation will record, PHC participants to an electronic moves cies on-line participants. with As S.C. DHEC Poli- Orders and to pull up and review the Standing learning. In the plannear future the PHC instructors on-line more for the future of course includes vision Workgroup’s Health Course The Preventive

Where We Are Now

48 Document 27 (Page 1 of 1)

This document defines the activities that a public health RN and an advanced practice RN perform in the delivery of patient care. This list of roles can serve as an example when defining roles for your provider setting. Example Roles for PHRN and APRN in an Integrated Setting

Role of the Public Health Registered Nurse and the Advanced Practice Registered Nurse in the Integrated Clinic

Role of the Public Health Registered Nurse: 1. Obtain pertinent history and risk assessment on both male and female patients according to established guidelines. 2. Perform a physical assessment on both male and female patients according to established guidelines. 3. Obtain the following tests: Pap smear, Syphilis Serology, GenProbe for Gonorrhea and Chlamydia, Herpes test, HIV Test based on established screening criteria. 4. Obtain/perform the following stat tests: Wet Prep, KOH Prep, Gram stain, RPR, Hematocrit, pH, based on established screening criteria. 5. Administer PPD and immunizations according to standing orders. 6. Make diagnosis based on patient’s history, laboratory results, and clinical findings. 7. Administer/dispense medication for treatment of STDs according to standing orders. 8. Dispense barrier methods. 9. Dispense and/or administer contraceptive methods according to standing orders. 10. Administer other medications per order of the APRN or MD. 11. Provide education related to contraceptive method, STD diagnosis, HIV, medications. 12. Provide client-centered counseling related to identified risk factors/problems. 13. Manage follow-up of test results, including STD tests, Syphilis tests, HIV, Pap smears. 14. Make referrals. 15. Evaluate for FSS and refer as needed.

Role of the Advanced Practice Registered Nurse (APRN): Provide the above Family Planning, STD, HIV, and Immunization Services in addition to the following:

1. Postpartum evaluation. 2. Post-abortion evaluation. 3. Insertion/removal of Implant. 4. Insertion/removal of IUD. 5. Fit diaphragms. 6. Examine/Evaluate patients with complicated health problems (eg. PID, cystitis, epididymitis, etc.) according to protocols. 7. Provide clinical consultation to Public Health Registered Nurses. 8. Serve as preceptor/clinical instructor for public health nurses attending the Preventive Health Course. 9. Participate in the clinical evaluation of Registered Nurses providing integrated services.

49 Document 28 (Page 1 of 1)

This form from HCCMS Family Planning collects medical insurance information from a patient in order to bill the patient’s insurance companies for services rendered. This form can be modified and implemented in your provider setting to collect insurance information from your patients. Sample Patient Insurance Information Collection Form

HCCMS FAMILY PLANNING Name______CRAWFORD COUNTY HOME HEALTH, HOSPICE AND PUBLIC HEALTH DOB______105 NORTH MAIN STREET, DENISON, IOWA 51442 SS#______HARRISON, CASS, CRAWFORD, MONONA AND SHELBY COUNTY CLINICS

INSURANCE INFORMATION FORM

1. Do you have health insurance that could be billed for your family planning services? o Yes o No If “yes” please present your insurance card to the Family Planning clerk to be copied. 2. I understand that if insurance is billed the holder of the policy will become aware of this visit. Based on the potential loss of confidentiality to the holder of your insurance policy, do you give permission to bill your insurance? o Yes o No * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Patient Mailing Address______City ______State ______Zip Code ______Clinician’s Name ______Are you on Title 19? o Yes o No Card Number______Effective Date Phone Number where you can be contacted______

Medical Insurance Information Other Than Medicaid (Title 19)

Primary Insurance Company______

Group #______Policy #______

Policy Holder Name ______Policy Holder Date of Birth______

Patient Relationship to Policy Holder______

Policy Holder Address______

Employer of Policy Holder______

Authorization for Use of Protected Health Information and Assignment of Benefits

I hereby authorize the exchange of any confidential medical information necessary to process my health insurance claims between Crawford County Home Health, Hospice and Public Health—doing business as HCCMS Family Health Services and my insurance carrier. I authorize payment of insurance benefits directly to HCCMS Family Health Services. I understand that this consent is subject to revocation at any time. I will not hold HCCMS Family Health Services or its staff liable for divulging such information until such written notice is received by them, or until this consent automatically expires (12 months from the date of signature). It is understood a photocopy or fax of this authorization shall be effective and valid as the original. I understand that I may inspect or request copies of any information disclosed by this authorization. I understand that if my insurance requires me to pay an office co-payment, this amount should be paid at the time of service. I understand that if I have insurance that can be billed that HCCMS Family Health Services must file my insurance claim at full price. If my insurance company denies my claim my account will be adjusted to the discounted rate I qualify for based on the sliding fee scale.

I have been informed and fully understand the above release of information. Circle one of the following:

I accept a copy of this authorization. I refuse a copy of this authorization.

Patient Signature______Date______

50 Document 29 (Page 1 of 2)

This policy statement from HCCMS Family Planning establishes the standards, rules, and procedures around charges, billing, and collections for family planning services. This policy document can serve as a model for developing policy around charges, billing, and collections in your provider setting.

Sample Policy for Charges, Billing, and Collections

HCCMS FAMILY PLANNING CRAWFORD COUNTY HOME HEALTH/HOSPICE AND PUBLIC HEALTH 105 NORTH MAIN STREET, DENISON, IOWA 51442 HARRISON, CASS, CRAWFORD, MONONA AND SHELBY CLINICS Policy: 1. Clients will not be denied services or be subjected to any variation in quality of services because of the inability to pay.

2. Charges are based on a cost analysis of all services provided by the project. At the time of services, clients are given a bill directly. In cases where a third party is responsible, bills must be submitted to that party showing total charges (Title XIX, Iowa Family Planning Network, and private insurance).

3. Income information shall be obtained from every client, documented, and updated annually. Everyone who is a Title X user must be placed on a sliding fee scale regardless of whether or not they have a third party payer.

4. Iowa Family Planning Network will be billed for all eligible clients.

5. All clients must submit, if available, a copy of their driver’s license and social security card.

6. A schedule of discounts (sliding fee scale) is used for individuals with family incomes between 101% and 250% of the Federal poverty level. Fees will be waived for individuals with family incomes above this amount who, as determined by the Family Planning Agency Coordinator in each county, are unable, for good cause, to pay for family planning services. The reason for the waiver must be charted. This information must be verified and updated annually to determine if circumstances have changed.

7. Clients whose documented income is at or below 100% of the Federal poverty level are not charged. All third parties authorized or legally obligated to pay for services are billed at full charge (Title XIX, Iowa Family Planning Network and private insurance) as long as the billing does not breach the confidentiality of a minor.

8. Individual eligibility for a discount is documented in the client’s record on the voluntary data and income declaration form.

9. To determine the discount for each client, income will be verified using pay stubs, tax forms or other statements of income. 20% will then be taken off of the verified income amount to determine the client’s discount. The Federal Poverty Guidelines will be used for income calculation.

10. Clients who report they have no income are not required to prove absence of income, but may be asked about how they pay for living expenses.

11. Clients who report employment but are unwilling to provide income verification may be charged full fee. Clients must be informed that failure to provide proof of income where available may result in full fees being applied. Clients who choose not to provide information regarding income must sign a release stating that they are choosing not to participate and agree that they will be charged full fee for services.

12. Eligibility for discounts for minors who receive confidential services is based on the income of the minor. Those resources normally provided by parents/guardians (i.e., food, shelter, etc.) shall not be included in determining the income.

13. Depreciation for self-employment: If depreciation keeps the client from eligibility on the Medicaid waiver, depreciation must be disregarded for Title X placement.

14. Client income is re-evaluated at least annually either at the time of their yearly exam or review of their Iowa Family Planning Network case. They are then charged the appropriate fee based on their income.

51 Document 29 (Page 2 of 2)

15. Bills to third parties will show total charges without applying any discount. 16. Crawford County Home Health and Hospice (HCCMS Family Services) has a written agreement with Title XIX.

17. Bills to clients who are responsible for paying any fee for their services show total charges that day, the allowable discount, what the client was charged that day, the previous balance, the amount paid that day, and the balance due. Each time a bill is given it is checked on the log under “Bill Given to Client.”

18. The following reasonable efforts to collect charges without jeopardizing client confidentiality will be made:

• Present the client with the bill at the time of service and request payment. • Present the client with the bill each time they come in for services and request payment. • HCCMS Family Planning Administration will send a bill to clients with an outstanding balance monthly, whom are not confidential. Accounts are reviewed annually by the project coordinator to determine whether to pursue collection that is protective of client confidentiality. 19. Clients with Title XIX or Iowa Family Planning Network:

• Clinic staff will copy their Title XIX or Iowa Family Planning Network card and call the ELVS line at the time of service. Staff will listen to the entire message. If they have Title XIX or Iowa Family Planning Network, staff will mark that on the CVR “Bill Medicaid or Elves line checked” and send that with a copy of the Title XIX or Iowa Family Planning Network card to project coordinator for her to bill Medicaid. 20. If the client has insurance other than Title XIX or Iowa Family Planning Network, including Medicare, staff will also copy their insurance or Medicare card. If it is their parent’s card, staff will ask if they are confidential from their parents. If they are confidential, staff will write on the CVR, “has insurance but can not file as confidential to parents”, and ask the client for a voluntary donation. If they are not confidential, staff will send ELVS information written on the CVR and a copy of their insurance and Title XIX card to the HCCMS Administrative Assistant to bill insurance.

21. Voluntary donations from clients are permissible. However, clients will not be pressured to make donations, and donations will not be a prerequisite to the provision of services or supplies. Donations from clients do not waive the billing/charging requirements set out above.

52 Document 30 (Page 1 of 2)

This standing order from HCCMS Family Planning outlines the process for initiating prescription contraception for patients before a physical examination has been done. The process can be modified in a way that works best for your provider setting.

Sample Standing Order Policy for Initiating a Prescription without an Exam

HCCMS FAMILY PLANNING CRAWFORD COUNTY HOME HEALTH/HOSPICE AND PUBLIC HEALTH 105 NORTH MAIN STREET, DENISON, IOWA 51442 HARRISON, CASS, CRAWFORD, MONONA AND SHELBY CLINICS

Initiation of Prescription Contraception with Exam Deferred for Clients of HCCMS Family Planning

Female clients of HCCMS Family Planning may be started on prescription contraception method before exam based on client request.

1. For those requesting an oral contraceptive: • Start on Ortho Tri-Cyclen one daily p.o. • If client is breastfeeding and is at least 6 weeks postpartum Micronor one tab po daily may be used • May use Micronor if client is under 35 years old, is a non smoker, and blood pressure is between 140/90- 160/95 • Clients should be free of any migraine with aura, blurred vision, swelling, shortness of breath, pain in arms and legs, or history of blood clots or clotting factors • If client has been on a different O.C. recently, may continue that Rx if HCCMS carries the same brand or equivalent generic • May use either the “quick-start” or “Sunday start” methods • May not be prescribed if smoker and age 35 years or older 2. For those requesting Depo-Provera: • Depo-Subq Provera 104 mg subq q 12-14 weeks • If currently on Depo Provera 150 mg IM from another provider, switch to 104 mg subq per HCCMS protocol • May use “quick-start” method 3. For those requesting transdermal patch system: • Ortho-Evra weekly X 3 then off 1 week per protocol • May not be prescribed if smoker and age 35 years or older 4. For those requesting the vaginal ring: • Use Nuva Ring one ring inserted for 3 weeks, then off 1 week per protocol • May not be prescribed if smoker and age 35 years or older • May use “quick-start” method

53 Document 30 (Page 2 of 2)

Female clients of HCCMS Family Planning may be started on prescription contraception method before a full exam has been done under the following conditions:

1. The “Request for Contraception before Physical Examination/Deferred Exam” form has been read and signed by the client and co-signed by the HCCMS family planning staff 2. Blood pressure is within normal limits and a pregnancy test is negative 3. The medical history is completed and reviewed with the client. If patient has negative history DVT or PE, negative DM on insulin, negative for migraine with aura, and negative cancer history, then they may start method of choice. Refer to U.S. Medical Eligibility Criteria for Contraceptive Use 2010 4. The consent form for the method has been signed by the client 5. Information on alternative methods of contraception, breast self-examination, and sexually transmitted infections has been given to the client and other client-centered counseling has been completed 6. The patient agrees to have a physical examination within 12 weeks which includes a breast exam, weight, BP, and pelvic exam. STI screening is done then as per Iowa Infertility Program guidelines 7. A STI screen for Chlamydia and gonorrhea may be done on a voided urine sample or vaginal swab before the physical exam, if high risk factors exist 8. No refill of the method may be given after 12 weeks have elapsed without a full exam 9. All clients should be offered condoms and counseled regarding prevention of STIs 10. Client must be 21 days postpartum before receiving an estrogen-containing birth control method and not breast feeding

Reviewed & approved Date [Physician Name] Family Planning Medical Director

54 Document 31 (Page 1 of 1)

Step-by-step instructions on what to do when a patient presents with an insurance provider that the organization is not contracted to bill.

Insurance Information Collection Job Aid

HCCMS FAMILY PLANNING CRAWFORD COUNTY HOME HEALTH/HOSPICE AND PUBLIC HEALTH 105 NORTH MAIN STREET, DENISON, IOWA 51442 HARRISON, CASS, CRAWFORD, MONONA AND SHELBY CLINICS Insurance Procedure

When we receive an insurance card we look on the back to see where to send the claims. If it is a new insurance please follow these steps.

1. Call the provider number on the back of the insurance card 2. Ask if you are a participating provider and have your Tax ID and NPI# ready 3. If you are not a participating provider, ask what you need to fill out to become a participating provider with them. They will tell you where to get the forms or will send you something for you to fill out. 4. Once you have filled in all necessary information, send back to insurance company to the address they recommend (this address may be different than a claims address). 5. Processing time will depend on the insurance. 6. Once you hear back, you will receive a contract that will need to be signed. Fill everything out that is necessary and send back to the insurance (make sure you include a start date). When contract has been accepted usually you will receive a letter in the mail or an email. Once you receive the contract, file away for record-keeping purposes.

55 Document 32 (Page 1 of 1)

This document details which paperwork is needed to initiate the various long-acting reversible contraceptive options. This can be kept behind the front desk as a resource for staff. LARC Paperwork Job Aid

Necessary Paperwork for Long Term Contraceptives NEXPLANON *Schedule Letter (circle either IUD/IUS or Nexplanon and send/give to client prior to insertion) (Policy 516.12) *Nexplanon Consent Form (from Organon pharmaceutical company) (Put in patient’s chart with the HCCMS Nexplanon Consent) *Informed Consent for Use of Nexplanon (Policy 516.10) *Nexplanon Insertion Form (Policy 516.11) *If an exam is not being performed the day of insertion, place the Nexplanon Insertion Form on top of the right side of the chart, followed by the exam sheet and then the Lab Flow Sheet. *If an exam is being performed the day of the insertion, place the Nexplanon Insertion Form behind the exam sheet. *Patient Labeling (comes with the Nexplanon product) (give to client) *Nexplanon Insertion Sticker for Patient’s Chart (comes with Nexplanon product) (Place on 2nd page of Nexplanon Insertion Form where there is blank space and fill out) *Nexplanon plastic card (comes with Nexplanon product) (fill out and give to client) PARAGARD *Schedule Letter (circle either IUD/IUS or Nexplanon and send/give to client prior to insertion) (Policy 516.12) *ParaGard Information for Patients (comes with ParaGard product) (give to client) *ParaGard Date of Placement Sticker (comes with ParaGard product) (Place on 2nd page of IUD/IUS Insertion Form where there is blank space and fill out) *ParaGard Appointment Card (comes with ParaGard product) (fill out and give to client) *Informed Consent for Use of ParaGard (Policy 516.20) *IUD/IUS Insertion Form (Policy 516.21) *If an exam is not being performed the day of insertion, place the IUD/IUS Insertion Form on top of the right side of the chart, followed by the exam sheet and then the Lab Flow Sheet. *If an exam is being performed the day of the insertion, place the IUD/IUS Insertion Form behind the exam sheet. *Post IUD/IUS Insertion Instructions (Policy 516.22) (give to client) MIRENA *Schedule Letter (circle either IUD/IUS or Nexplanon and send/give to client prior to insertion) (Policy 516.12) *Mirena Patient Information Booklet & Consent (comes with Mirena product) (give booklet to client; keep the consent in the patient’s chart with the HCCMS Mirena consent) *Informed Consent for Use of Mirena (Policy 516.30) *Mirena Follow-Up Reminder Card (comes with Mirena product) (fill out and give to client) *IUD/IUS Insertion Form (Policy 516.21) *If an exam is not being performed the day of insertion, place the IUD/IUS Insertion Form on top of the right side of the chart, followed by the exam sheet and then the Lab Flow Sheet. *If an exam is being performed the day of the insertion, place the IUD/IUS Insertion Form behind the exam sheet. *Post IUD/IUS Insertion Instructions (Policy 516.22) (give to client)

*Do HGB before each LARC insertion (1 week before ok) *No PG test needed before LARC insertion if pt. on Depo

56 Document 33 (Page 1 of 1)

A superbill is a form that is used to document the charges associated with a patient visit in order to bill insurance companies. Superbills save time for providers by providing a pre-defined list of procedure codes that they can use to simply "check off" the services rendered. Please refer to the most recent ICD-9 and CPT coding manuals for up-to-date codes.

Sample Superbill

HCCMS FAMILY PLANNING NAME:______CRAWFORD COUNTY HOME HEALTH/HOSPICE AND PUBLIC HEALTH DOB:______105 NORTH MAIN STREET, DENISON, IOWA 51442 HARRISON, CASS, CRAWFORD, MONONA AND SHELBY CLINICS

HARRISON CASS CRAWFORD MONONA SHELBY CLINICIAN: ______NEW ESTABLISHED FEDERAL I.D. NO. 426004496 Medicaid IFPN INSURANCE CFY Non-‐insured Age _____ (E/M)New Patient 3/3 Lab Tests/Etc Diagnosis(ICD-‐9) Service 99201 99202 99203 99204 99205 88142 Pap $30 Abscess: site______346.9 Migraine HX PF PF EPF DET COMP 99000 Specimen Collection/Handling fee $5 789.07 Abdominal Pain-‐Genrl 625.2 Mittelschmerz EXAM PF PF EPF DET COMP 87621 HPV Test $55 789.01 -‐ RUQ 78.0 Molluscum Contagiosum DEC MKG SF SF LOW MOD HIGH 81002 UA $4 789.02 -‐ LUQ 787.02 Nausea 50% COUNSEL USE TIME 10 20 30 45 60 87210 Wet Mount/KOH $44 789.03 -‐ RLQ 278.00 Obesity FEE $50 $100 $130 $ 186 $ 251 81025 Pregnancy Test $10 789.04 -‐ LLQ 382.9 Otitis Media (E/M)Established Patient 2/3 85018 Hemoglobin (N) $7 791.9 Abnormal UA 625.3 Painful Menstrual Cycle Service 99211 99212 99213 99214 99215 36416 Drawing Blood Capillary $4 706.1 Acne 789.3 Pelvic Mass HX R PF EPF DET COMP 87490 CT -‐ Phys Lab 626.0 Amenorrhea 625.9 Pelvic Pain $33/$0 EXAM N PF EPF DET COMP 87590 GC -‐ Phys Lab 285.9 Anemia 618.89 Pelvic Relaxation/Prolapse DEC MKG SF LOW MOD HIGH 87491 Urine GC/CT -‐ Phys Lab $33/$0 300.00 Anxiety 618.05 Perineocele 50% COUNSEL USE TIME 10 15 25 40 Injection Fees 626.6 Breakthrough Bleeding 614.9 PID FEE $20 $60 $120 $ 153 $ 237 96372 Depo Admin Fee $15 611.79 Breast Discharge 625.4 PMS (PM)Preventitive Exam Codes 90649 Gardasil Vaccine(XIX) $160 V04.89 611.72 Breast Mass 256.4 Polycystic Ovarian Disease New 99383 99384 99385 99386 99387 90471 Gardasil Vac Admin Fee $15 V04.89 611.71 Breast Pain 622.7 Polyp-‐Cervical Age 5-‐11 12-‐17 18-‐39 40-‐64 65+ Procedures V76.10 Breast Screen Unspec. 623.7 Polyp-‐Vaginal Fee $175 $175 $175 $175 $175 Service Description Fee ICD-‐9 Cervical Dysplasia V67.00 Post AB Follow-‐up Est 99393 99394 99395 99396 99397 11981 Nexplanon Insertion(+) $185 V25.5 622.10 -‐ Unspecified Dysplasia 627.1 Post Menopausal Bleeding Age 5-‐11 12-‐17 18-‐39 40-‐64 65+ 11976 Nexplanon Removal $200 V25.43 622.11 -‐ Mild (CIN 1) 626.7 Postcoital Bleeding FEE $140 $140 $140 $140 $140 11983 Nexplanon Removal/Reinsert $350 V25.43 622.12 -‐ Moderate (CIN 2) V72.41 Preg Test Negative Destruction Lesion/Wart 58300 IUD/IUS Insertion(+) $150 V25.11 233.1 -‐ Severe (CIN 3) V72.42 Preg Test Positive 54050 Male/Destruction Lesion Simple $185 58301 IUD/IUS Removal $130 V25.12 622.7 Cervical Polyp 256.31 Premature Menopause 54065 Male/Destruction Lesion Extensive $185 Contraceptive Method 616.0 Cervicitis 618.04 Rectocele 56501 Des. Lesion-‐Vulva-‐Simple (10) $185 Service Description Qty/ ICD Fee Contraception V72.32 Repeat Pap 56515 Des. Lesion-‐Vulva-‐Extensive (10) $185 S4993 Oral Pills @ $25 /pkg V25.01 Int RX Oral BCP V78.0 Screening for Anemia 57061 Des. Lesion/condyloma, vagina (10) $185 S4993 Seasonique @ .90/pills 91 pills $81.9 V25.02 Int RX Evra/Ring/Depo V74.5 Screening for GC/CT 46900 Destruction Lesion -‐Anus(simple) $185 J7304 Evra Patch (NDC)@$35/box V25.11 Insert IUD/IUS V76.2 Screening Pap smear J7303 NuvaRing (NDC)ea@$40 V25.40 PrvRX Rng/Evra/Depo 701.9 Skin Tag Non-‐billable to IFPN for Lesions J7307 Nexplanon (NDC) V25.5 $675 V25.41 Prev RX for Oral BCP V74.5 STD testing Symbols J7302 Mirena (NDC) V25.11 $760 311 Depression V25.2 Sterilization (Tubal Consult) -‐ Bill Supply also (+) -‐ NDC(NDC) Global Days -‐ (10) (90) J7300 ParaGard (NDC) V25.11 $645 787.91 Diarrhea 625.6 Stress Urinary Incontinance Modifiers J1055 Depo Injection (NDC)(+) $55 626.8 Dysfnct Uterine Hemrg 305.1 Tobacco Abuse 24 -‐ unrelated service during postoperative period J3490 ECP Pills (PlanB) (NDC) V25.03 $20 796.2 Elevated Blood Pressure V70.9 UA Screen(General) 25 -‐ separately identifiable EM service on same DOS A4269 Contraceptive Sponge@$6.52/spng $19.56 621.2 Enlarged Uterus V72.9 Unspecified Exam 52 -‐ failed insert/procedure IFPN Diag Codes CFY Diag Codes 789.06 Epigastric Pain 599.0 Urinary Tract Infection 53 -‐ discontinued insert/procedure V25.01 New Exam/Pills V10.3 PH Malign Breast 780.79 Fatigue 788.41 Urination-‐Frequency 58 -‐staged/related procedure during postop period V25.02 New Exam/Contrac/Othr V10.41 PH Malign organs 610.1 Fibrocystic Breast 788.63 Urinary Urgency 59-‐separate service provided in addition on sameday V25.40 Est Exam/Contrac/Othr V17.41 FH chrnc disease 704.8 Folliculitis 708.9 Urticaria Symptoms or Diagnosis V25.41 Est Exam/Pills V17.49 FH cardio diseas 939.2 Foreign Body Vulv/Vag 627.3 Vaginal Atrophy 1 V25.03 ECP Counseling V67.01 Followup pap 939.1 Foreign Body-‐Uterus 623.0 Vaginal Dysplasia 2 V25.09 Counseling V70.0 Gen exam, counsel V04.89 Gardasil Vaccination 623.9 Vag Irritation/Odor/Burning 3 V25.11 Insert IUD/IUS V71.1 Sus malignant 618.9 Genital Prolapse 698.1 Vaginal Itching 4 V25.2 Sterilization V72.32 Pap smr/norm smear V70.0 Exam M/F (no gyn) Vaginitis 5 V25.42 Check IUD V76.10 Brst scrn, unspcfd V72.31 Gyn Exam Annual(Priv.Ins) 627.3 -‐ Atrophic RX/Tests/Follow Up Appt/Referral V76.2 Follow up/Repeat Pap V76.11 Brst scrn, hgh risk 784.0 Headache 616.10 -‐ Bacterial V25.43 Nexpl Remov\Insrt/Chk V76.12 Othr scrn mamm 599.7 Hematuria 112.1 -‐ Vulva/Vag Yeast V25.5 Insert Nexplanon V76.19 Othr scrn brst ex V82.89 Hemocult Screen 112.3 -‐ Skin and Nails V72.41 Preg Test Negative V76.2 Cervix screen 54.10 Herpes, Genital 616.1 Vaginitis/Vulvovaginitis V72.42 Preg Test Positive V77.1 Diabetes mellitus 79.4 HPV 221.2 Vulvar Lesion V25.12 Remove IUD V81.0 Ischemic hrt disse 078.1 HPV Warts/Condyloma V74.9 Wet Mount V25.13 Remove&Reinsert IUD V81.1 Hypertension 401.9 Hypertension V81.2 Othr unspcfd cardio 242.9 Hyperthyroidism Providers Signature 244.9 Hypothyroidism 704.8 Ingrown Hair X______280.1 Iron Deficiency Anemia 626.4 Irregular Menstrual Cycle Date of Service: 623.8 Labial/Vaginal Lesion 626.2 Men/Metorr/Polymenorrhea 50% or greater counsel time: # min:______627.2 Menopaus Disorder/Sympt

Reason for counseling______

Policy 227.00 Rev 1/11; 2/11; 3/11; 4/11; 7/11; 8/11; 1/12; 4/12; 8/12; 10/12 Document 34 (Page 1 of 1)

This document instructs providers how to code Chlamydia tests for Iowa Family Planning Network (IFPN) and Medicaid patients. Please refer to the most recent ICD-9 and CPT coding manuals for up-to-date codes. Chlamydia Coding Job Aid

Codes to use on CT/GC forms for IFPN and Medicaid Clients

When an IFPN client receives a comprehensive exam (either initial or annual), IFPN will pay for a Chlamydia test if it is part of that examination. IFPN will not pay for a limited visit Chlamydia test.

In order for the lab to be paid for that Chlamydia test, the ICD-9 diagnosis code the lab uses must be one of the IFPN approved ICD-9 codes. When completing the lab slip for the Hygienic Lab, there is a place on the lab slip for the clinic to provide the ICD-9 diagnosis code. That code should be the same ICD-9 code that the clinic uses to bill IFPN for the comprehensive visit. Therefore, the ICD-9 diagnosis code should be provided every time you submit a specimen for an IFPN client who has received a comprehensive examination so the lab can bill IFPN correctly.

The clinic needs to continue to provide the Hygienic Lab with the client’s IFPN number followed by the notation of IFPN so the lab knows this is IFPM and not full Medicaid.

IFPN Codes V25.01 Initial Exam; Prescription of Oral Contraceptives (pills) V25.02 Initial Exam; Initiation of Other Contraceptive Measures V25.40 Annual Exam; Contraceptive Surveillance (every other kind) V25.41 Annual Exam; Contraceptive Pill Surveillance

Medicaid Codes V73.9 (Initial or Annual) Screening for unspec & chlamydial dz V72.31 CT/GC test done outside of initial, annual or IUD insertion

CT/GC Test Prior to IUD Insertion Code V25.11 Medicaid Code

**IFPN will not cover STD test unless it is with annual, initial or IUD insertion.

58 Document 35 (Page 1 of 1)

A sample spreadsheet to track reimbursement rates for CPT and ICD-9 codes for insurance contracts. Please refer to the most recent ICD-9 and CPT coding manuals for up-to-date codes. *Identifying details and rates have been changed Sample Insurance Reimbursement Tracking Form V70.9 V25.5 V25.5 078.11 078.11 078.11 078.11 078.11 V72.42 V25.09 V25.09 V25.09 V25.09 V25.09 V72.31 V72.41 V25.11 V25.42 V72.31 V72.31 V25.09 V25.09 V25.09 V25.09 V25.09 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V25.40 V25.40 V25.43 V25.43 V25.41 V25.41 V25.03 V25.40 V25.40 V25.40 Continue ICD-‐9 code New New V70.9 V25.5 V25.5 078.11 078.11 078.11 078.11 078.11 V72.42 V25.09 V25.09 V25.09 V25.09 V25.09 V72.31 V72.41 V25.11 V25.42 V72.31 V72.31 V25.09 V25.09 V25.09 V25.09 V25.09 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V25.11 V25.11 V25.43 V25.43 V25.01 V25.01 V25.03 V25.02 V25.02 V25.02 9 0 0 0 0 1 0 64 74 78 5.5 7.5 6.5 118 384 270 302 168 132 143 126 586 740 212 364 269 148 15.5 10.5 46.8 83.2 83.2 15.5 47.6 23.23 65.56 97.43 218.5 296.5 33.85 195.5 30.05 26.13 65.27 49.47 97.25 141.19 128.67 150.32 120.25 119.63 140.25 104.87 198.52 135.25 136.25 109.53 105.23 4 Reimbursment* Insurance Company V70.9 V25.5 V25.5 078.11 078.11 078.11 078.11 078.11 V72.42 V25.09 V25.09 V25.09 V25.09 V25.09 V72.41 V25.11 V25.42 V72.31 V72.31 V25.09 V25.09 V25.09 V25.09 V25.09 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V25.40 V25.40 V25.43 V25.43 V25.41 V25.41 V25.03 V25.40 V25.40 V25.40 Continue ICD-‐9 code New New V70.9 V25.5 V25.5 078.11 078.11 078.11 078.11 078.11 V72.42 V25.09 V25.09 V25.09 V25.09 V25.09 V72.41 V25.11 V25.42 V72.31 V72.31 V25.09 V25.09 V25.09 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V25.09 V25.09 V72.31 V25.11 V25.11 V25.43 V25.43 V25.01 V25.01 V25.03 V25.02 V25.02 V25.02 0 5 7 0 0 11 33 60 10 10 95 89 10 63 33 11 97 33 70 82 72 93 93 10 5.3 5.6 135 179 160 115 380 116 125 115 270 135 15.2 166.3 299.3 105.3 28.39 105.3 93.26 69.59 81.26 81.26 256.6 26.87 26.78 675.5 47.96 33.32 70.84 139.81 126.53 646.48 758.92 117.82 3 Reimbursment* Insurance Company V76.2 V70.9 V25.5 V25.5 078.11 078.11 078.11 078.11 078.11 V72.42 V25.09 V25.09 V25.09 V25.09 V25.09 V72.41 V25.11 V25.42 V72.31 V72.31 V25.09 V25.09 V25.09 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V25.09 V25.09 V25.40 V25.40 V25.43 V25.43 V25.41 V25.41 V25.03 V25.40 V25.40 V25.40 Continue ICD-‐9 code New New V76.2 V70.9 V25.5 V25.5 078.11 078.11 078.11 078.11 078.11 V72.42 V25.09 V25.09 V25.09 V25.09 V25.09 V72.41 V25.11 V25.42 V72.31 V72.31 V25.09 V25.09 V25.09 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V72.31 V25.09 V25.09 V25.11 V25.11 V25.43 V25.43 V25.01 V25.01 V25.03 V25.02 V25.02 V25.02 5 5 0 0 38 33 38 38 72 12 42 56 99 95 95 25 5.2 4.9 148 201 121 154 250 110 109 198 120 8.75 4.23 7.89 42.3 8.35 8.75 73.8 98.65 12.68 74.98 83.68 42.86 86.22 52.49 11.48 37.27 135.22 121.35 121.59 158.26 116.35 106.35 136.98 564.71 729.92 203.93 123.12 119.58 670.26 2 Reimbursment* Insurance Company V76.2 V70.9 V25.5 V25.5 078.11 078.11 078.11 078.11 078.11 V72.42 V25.09 V25.09 V25.09 V25.09 V25.09 V72.41 V25.11 V25.42 V25.09 V25.09 V25.09 V25.09 V25.09 V25.40 V25.40 V25.43 V25.43 V25.41 V25.41 V25.03 V25.40 V25.40 V25.40 Continue ICD-‐9 code New New V76.2 V70.9 V25.5 V25.5 078.11 078.11 078.11 078.11 078.11 V72.42 V25.09 V25.09 V25.09 V25.09 V25.09 V72.41 V25.11 V25.42 V25.09 V25.09 V25.09 V25.09 V25.09 V25.11 V25.11 V25.43 V25.43 V25.01 V25.01 V25.03 V25.02 V25.02 V25.02 0 0 0 0 0 0 0 0 31 54 31 54 31 36 52 5.5 4.8 3.5 155 159 105 3.61 9.63 6.23 3.49 9.63 46.5 0.93 0.93 61.23 83.18 123.3 152.9 19.98 38.83 77.47 80.88 34.86 70.26 99.75 110.8 127.8 83.79 94.78 92.25 10.86 37.97 107.57 103.81 105.53 570.73 756.49 208.84 115.23 118.84 674.95 1 Reimbursment* Insurance Company 7 5 4 4 10 44 33 33 33 55 30 20 15 15 50 10 60 75 20 55 35 40 100 130 186 251 160 150 130 185 185 185 185 140 120 153 237 175 175 175 175 175 140 140 140 140 645 760 350 185 185 200 185 675 Our Our 81.9 6.52 Charge skin tag skin tag J7300 J7302 J7307 J3490 J1055 J7304 J7303 S4993 S4993 85018 87210 87490 87491 87590 87621 88142 99202 99203 99204 99205 99211 90471 90649 96372 99201 99000 58300 58301 81002 57061 56515 56501 54065 99397 11200 99212 99213 99214 99215 99383 99384 99385 99386 99387 99393 99394 99395 99396 11977 36416 46900 54050 11976 11975 11201 A4269 81025(-‐) 81025(+) CPT Code CPT Total Amount Reimbursed #PrivateH Total Amount Reimbursed #Public 16 352 1.54 6.15 13.42 17.04 149.37 266.97 Costs for Costs .80/.57 1st Quarter Vendor Total Access LAB LAB ParaGard TheraCom LAB LAB CuraScript Lab rate

59 Document 36 (Page 1 of 1)

A sample spreadsheet of the elements needed to manage and track third party payer contracts. *Names and identifying information have been changed Sample Insurance Contact Tracking Spreadsheet

Participating/ Non Contract Contact Contact Phone Contact Fax Participating Effective Date Person* Number * Number Fee Schedule? NOTES Insurance Com- participating June 1, 2010 Sally Ryder 1-800-605-8009 Y Anyone who has pany 1 - PPO* X1234 this insurance should have logo PPO Payer participating CP-4/1/10 XXX-392-8111 Y on his/her insur- Partner 1 ance card. PPO Payer participating Y Partner 2 PPO Payer participating Y Partner 3 PPO Payer participating Y Partner 4 PPO Payer participating Y Partner 5 PPO Payer participating Y Partner 6 PPO Payer participating JB - 6/17/2010 Cheryl Provider Relations Y Partner 7 PPO Payer SP - 1/2/2010 Gloria XXX-445-8210 Partner 8

Insurance participating JB - 4/6/2010 Fred Kaiser 1-800-808-2345 Health Center is Company 2* PPO provider in state participating Fred Kaiser 1-800-808-5678 Y participating CP - 4/6/10 Susanne Frazier XXX-369-7654

Insurance participating CP - 5/16/11 Tammy XXX-915-9028 N Company 3*

Insurance non-participating 1-800-262-1472 Company 4*

Insurance participating 25-May-10 XXX-790-1005 Y Company 5* CP - faxed 11/20/12

Insurance non-participating Diane XXX-823-4761 faxed contract Company 6* 12/3/12

Timely filing Insurance Company 1 - after 6 months Insurance Company 2 - 3 months Insurance Company 3 - 1 year Federal - 1 year

60 Document 37 (Page 1 of 1)

Below is a list of questions generated by HCCMS Family Planning during their research to select an EHR system. Questions Regarding Electronic Health Records (EHR)

1. What type of set up do we want to start with or have capabilities of (cloud, server, ASP model, (who hosts the server))? 2. What hardware issues do we have in each of the 5 counties? Do we need to purchase new hardware? 3. What hardware will we need? 4. Does each county have wireless internet? 5. How do we sustain ourselves to afford this technology? 6. What forms will we build into the EHR? Will they be the same across all 3 Family Planning programs (HCCMS, Northeast Iowa Community Action, and New Opportunities)? Do we use one that another FP program is using already with this program, develop new ones? 7. What are the monthly maintenance fees? 8. Who will be accessing system (front office staff, admin, nurses, providers?) 9. What records will we scan into the new electronic record? What will that process look like in the beginning? Who will be responsible for that? 10. What fields will we make mandatory (VS, meaningful use…)? 11. What reports are available? 12. Do we want to use the billing component or stay with our current one? 13. How much training do we think we will need? 14. Do we want onsite support when we go “live”? 15. What are the “electronic world capabilities” of my staff? 16. Do I have staff buy in? 17. Will I qualify for incentive dollars offered by Medicaid and Medicare? If both, what is best option? 18. Will this program work with other partners I currently work with (lab, FPAR, Ahlers, local hospital, doctor’s clinics)? 19. Do I need or use a supply tracking program? 20. Who will do scheduling? (Each county or will all calls come to one place for appointments) 21. Is there a cost to add or change forms? 22. Billing purposes (will they have their own clearing house and is this an extra cost?) 23. Will data be encrypted for being HIPPA compliant? 24. Are they a certified EHR? 25. Going electronically, does this have the capability to sign documents electronically for both patient and provider? 26. Capable of building your own report if not a selection?

61 Document 38 (Page 1 of 3) Example Family Planning Waiver Application This application for Family Planning Waiver Services was designed specifically for use by the South Carolina DHEC health centers, which streamlines the enrollment process. : NUMBER Medicaid. SOCIAL SECURITY : Application Date: (City, County, State) County, (City, STATUS MARITAL GROSS MONTHLY INCOME : NO Grade/Year: Grade/Year: Your Mother’s Full Maiden Name Maiden Full Mother’s Your Place of Birth: of Place Telephone Number Telephone ) ( County SC RESIDENT? YES Insured’s Name Name Insured’s : : If yes, complete the following: the complete yes, If US CITIZEN?

If yes, complete the following: the complete yes, If NO Zip Code Zip Zip Code Zip SEX

NO (Social Security, Child Support, etc.) YES : : : Social Security Numbers are not required for persons who are not applying for applying not are who persons for required not are Numbers Security Social State State RACE Page 1 of 3 of 1 Page YES SOURCE OF INCOME Your Full Name at Birth at Name Full Your BIRTHDATE If yes, do you have a Medicaid card with you? with card Medicaid a have you do yes, If NO Policy Number Policy Number ers who live with you: with live who ers NO School: of Name : : City City YES Applicant RELATIONSHIP may help us process your application faster. income if applying for full Medicaid benefits. Medicaid full for if applying income

covers doctor visits and lab tests? lab and visits doctor covers YES Russian Other Other you and other family memb family other and you family have income from work or any other source? other any or work from income have family Chinese

Vietnamese NAME (if different from above): from different (if Spanish

NAME OF PERSON WHO GETS THE INCOME (First, Middle Initial, Last): Initial, Middle (First, Are you currently receiving Medicaid? receiving currently you Are Tell us who you are and where you live. you where and are you who us Tell that insurance health have you Do your in anyone or you Do Are you currently a student? a currently you Are If you tell us the Social Security Numbers, it Tell us information about information us Tell of weeks 4 last of proof provide Please Sign Language Sign English 3. Company of Name 1. 2. 5. 6. 4.

Name (include apartment number): apartment Mailing Address (include Address Home What is your primary language? South Carolina Department of Health and Human Services Family Planning Application Planning South Carolina Department of Health and Human Services Family 1. 2. 3. 4. 5. 6. 7. 1. 2. 3. 4. 2011) DHHS Form 400 (July

62 Document 38 (Page 2 of 3) NO NO YES YES 3b. How often? ity value of $3000.) of value ity Date Date Date $20,000 of equity value per vehicle for vehicle per value equity of $20,000 on at any time. any at on No, my assets are less than $30,000 than less are assets my No, ties on Page 3 have been read. l processing of my application. I application. my of processing l CDs. Equity value is how much something much how is Equity value CDs.

DHHS USE ONLY USE DHHS each month retroactive coverage is requested — —

– – Name: 3a. How much? C for the purpose of the initia the of purpose the for C NO Yes, my assets are over $30,000 $30,000 over are assets my Yes, for someone to care for the child, and how often you pay you often how and child, the for care to someone for ment if applying for full Medicaid benefits. Medicaid full for applying if ment Gross Monthly Earned Income Income Earned Monthly Gross Deduction Standard Income Unearned Gross Deduction Care Child Income Family Net Limit Income +

ized Representative should sign the application.) 2b. How often? other Medicaid program? Medicaid any other under benefits full Page 2 of 3 of 2 Page YES Income information must be provided for cle that is valued at $5000, and $2000 is still owed on it, has an equ an has it, on owed still is $2000 and $5000, at valued is that cle the home you live in or up to up or in live you home the of value the count not $30,000?Do and/or Guardian below indicate that the Rights and Responsibili for my application to be processed and I can remove permissi mily Planning application withDHE application Planning mily - DHHS/DHEC USE ONLY NAME OF CHILD(REN) RECEIVING CARE RECEIVING CHILD(REN) OF NAME (Please attach a sheet for additional children) children) additional sheet for attach a (Please ilers, non-homestead property, checking and savings accounts, cash, and cash, accounts, savings and checking property, non-homestead ilers, Name: 2a. How much? ) Please provide proof of last 4 weeks pay weeks 4 last of provide proof Please your child(ren) under age 12? age under child(ren) your form with the applicant/beneficiary. When applicable, both the Applicant and Author benefit program; would you like to apply for If yes, tell us the name of each child, how much you pay you much how child, each of name the us tell yes, If ) DHEC ( 1b. How often? 1-888-549-0820 (toll-free number) is worth minus any money owed on it. (For example, a vehi , does the equity value of all your assets add up to more than more to up add assets your all of value equity the does , (The signatures of Applicant, Authorized Representative, Parent YES Assets are things that you own, such as cars, boats, tra boats, cars, as such own, you that things are Assets If Do you pay someone to take care of care take to someone pay you Do months? 3 past the in services medical receive you Did limited a is Planning Family Which month(s)? month(s)? Which I give DHHS my permission to share information regarding my Fa my regarding information share to my permission DHHS give I understand that I do not have to share my information with DHEC DHEC. with information my share to permission DHHS give not do I No, each licensed driver. DHHS ( 7. 8. 9. LOCAL MEDICAID ELIGIBILITY OFFICE IN YOUR COUNTY. YOUR IN OFFICE ELIGIBILITY MEDICAID LOCAL MAIL YOUR SIGNED FAMILY PLANNING APPLICATION TO THE If you have questions or need help locating your local eligibility office, please call: Name: I have reviewed the statements on this Date: Location: Initial: 2011) DHHS Form 400 (July Authorized Representative’s Signature Signature Representative’s Authorized 1a. How much? Applicant’s Signature Signature Applicant’s

63 Document 38 (Page 3 of 3) I ider and employer. ider and employer. de, under §1137(a)(1) of the and Control Board, Office of Research of Research Office Board, and Control provide services to me or my family will to be sure that services provided to my SW, Washington, DC 20201 or call (202) ed as a release form to verify information. sex, age or disability. , color, national origin, sex, age in my income, deductions, resources, living an equal opportunity prov an equal opportunity information that will affect medical help within my data a in stored be will me and family re. This assignment applies to any of my minor my re. This assignment applies to any of ho injures me, is supposed to pay. I therefore liable third party to the DHHS up to the payment payment the liable third party to the DHHS up medical expenses that a third party, such as may include payments from hospital and health is required on an absent parent(s) if the custodial understand that if I fail to notify the department essary to establish my family's eligibility. ], may be used or released in connection with the ], may be used or released in connection with Department of Health and Human Services (HHS) ected to penalties or prosecution. the information I have provided to DHHS is true and ed as a settlement from an accident. (including medical services) provided to provided services) medical (including Budget warehouse operated by the South Carolina and Statistics, and that other state agencies be allowed to access that information in order family and me are sufficient necessary. I know that, unless I specifically ask not to be included, information about services services about information included, be to not ask specifically I unless that, know I d. accurate to the best of my knowledge. authorize the copying of this signature page to be us It shall remain valid and in force until: revoked by me in writing; my application has been denied; or my case has been closed. arrangements, members of the household, or other I change(s). ten (10) days of the date application. promptly, I may lose benefits and be subj Social Security Act [42 U.S.C. 1320b-7(a)(1) exceptions in Item 2, above. policy, DHHS cannot discriminate on the basis of race of Office Director, HHS The to writing by To file a complaint of discrimination, I should contact HHS Civil Rights, Room 506F, 200 Independence Avenue, 619-0403 (voice) or (202) 619-3257 (TDD). HHS is private health insurance company or someone w assign and give my rights to any payments from a amount that Medicaid has made for my medical ca children who may These payments be injured. insurance policies or payments receiv parent/caregiver relatives want Medicaid coverage. 3. I to provi am required know that my Social Security Number, whic h I 4. I know that and US law Federal according to 5. I know that the Medicaid program does not pay 6. Completion of a Medical Support Referral Form 7. I understand that I must report any and all changes believe an error has been made in processing my processing in made been error has an 8. I know that may request a hearing if believe 9. I have read the Rights and Responsibilities, or they been to me. that I certify application, 10. By signing this 11. I authorize the release of any information nec Page 3 of 3 of 3 Page Rights and Responsibilities Department of Health and Department of Health rvice, Social Security Administration, states’ Medicaid programs, and the ate). Immigration status will be verified is needed to get verification or other or verification get to needed is iving a Notice of Privacy Practices along their programs. Other agencies include, their programs. Other agencies organizations that they hire to carry out carry out hire to that they organizations ion gathered on this application to verify my family and me to a computer system other state (including agencies from other other from agencies other state (including al rules governing the Medicaid Program, Medicaid al rules governing the rules governing the Medicaid Program, any any Program, the Medicaid governing rules y reporting, DHHS must report, and cannot re, I know that personal health information I re, I know that personal health information ewed and verified by DHHS staff. Also, I Also, staff. by DHHS and verified ewed evention program called Early and Periodic eligible for Healthy Connections Medicaid can on can be released only for purposes directly purposes only for be released on can accordance with federal and state law. When covered by the Health Insurance Portability and Program. At times, the confidential. I understand that, except as specified as confidential. I understand that, except ons will have agreed to be bound by the same Treatment (EPSDT). possible, I, or my to agree. However, I further responsible party, will be asked understand that in the case of mandator contrary. to the my specification honor shared by DHHS for the purpose of making a proper referral of my case to other to case my of referral a proper of making by DHHS for the purpose shared sources of services or treatment, in information I have given must be revi be must given have I information is case my if workers and federal fully with state I must cooperate that understand reviewed. me by permission additional No about DHHS staff must provide information called the State Income and Eligibility Verification System (IEVS). This computer with me system allows DHHS to compare the information about my family and information from other agencies, and allows states) and federal agencies to use informat eligibility and determine benefit amounts for but are not limited to, the Internal Revenue Se and Employment Security Commission, other (DSS, in this st agency Food Stamp TANF and with the Department of Homeland Security (DHS). information. I know that, unless I specify otherwise, information about my family and me may be I know that, in accordance with the federal I know that, in accordance with the feder a. c. b. have free health checkups under a special pr Screening, Diagnosis and below, information including medical informati Medicaid of the to the administration related to Human Services (DHHS) will release information organizati but those purposes, specific guidelines for release of information. Furthermo provide or that is later gathered by DHHS is Accountability Act of 1996 (HIPAA) and I will be rece with my Medicaid Card(s). 1. I know that my children under age 19 who are 2. I know that the information have given is application this obtained you where us tell Please 2011) DHHS Form 400 (July

64 Document 39 (Page 1 of 1)

This document is used determine patient eligibility for Medicaid Iowa Family Planning Network benefits. This can be kept behind the front desk as a resource for staff. Patient Medicaid Eligibility Job Aid

Iowa Family Planning Network (IFPN) Cheat Sheet When a patient has health insurance, ask the patient if their insurance covers birth control. If the patient says yes then do not sign this patient up for IFPN. If the patient says no their health insurance does not cover birth control or they do not know, then sign the patient up for IFPN as a secondary insurance.

IFPN covers: • women age 13 to 55 • men can sign up for IFPN - we will be asked if the patient is a male or female when entering the IFPN application, so specify what gender the patient is. • income limit is 300% of the poverty level (see income limits below) • persons who have health insurance that doesn’t include coverage for benefits provided under IFPN

Income Limits If above this income, then patient will be insurance Family Size IFPN Eligible and Title X income schedule X-E 1 up to $2723.99 $2,724 2 up to $3678.99 $3,679 3 up to $4633.99 $4,634 4 up to $5588.99 $5,589 5 up to $6543.99 $6,544 6 up to $7498.99 $7,499 7 up to $8453.99 $8,454

Additional information that we need to know from patients: • Gender • Does the patient have health insurance that covers family planning services provided under the IFPN? • If not a U.S. citizen, did the patient legally enter the United States? If yes, record date of entry shown on Permanent Resident Card or any legal document. • If client is not a U.S. citizen, have they been in the U.S. legally for 5 years? If yes, date entered the U.S.? • Is the patient requesting the case to be confidential? If yes, make sure address line on application reflects this and is stamped CONFIDENTIAL.

65 Document 40 (Page 1 of 5)

A comprehensive list of CPT codes related to women's preventive health and family planning used to negotiate contracts with and bill insurance companies. Please refer to the most recent ICD-9 and CPT coding manuals for up-to-date codes.

A List of Women's Preventive Health and Family Planning CPT Codes

Family Planning Procedures 00851 Anesthesia, tubal ligation/transection 00921 Anesthesia for vasectomy, unilateral or bilateral 11975 Insertion of implantable contraceptive capsules 11976 Removal of implantable contraceptive capsules 11977 Removal w/ reisertion of implant contraceptive capsules 36415 Collection of venous blood by venipuncture 36416 Collection of capillary blood specimen 54050 Destruction of lesion, penis, simple, chemical 54056 Destruction of lesion, penis, simple, cryosurgery 55250 Vasectomy, uni or bilateral, incl post-op semen exam 56501 Destruction of lesion, vulva, simple 56515 Destruction of lesion, vulva, extensive 56605 Biopsy of vulva or perineum, one lesion 56606 Each separate additional lesion 57170 Diaphragm or cervical cap fitting with instruction 57420 Colposcopy of entire vagina, with cervix if present 57421 Colposcopy of entire vagina, with cervix if present w/ biopsy 57452 Colposcopy including upper/adjacent vagina (no biopsy) 57454 Colposcopy w/ biopsy and endocervical currettage 57455 Colposcopy w/ biopsy of the cervix 57456 Colposcopy w/ endocervical currettage 57460 Colposcopy w/ loop electrode biopsy of the cervix 57461 Colposcopy w/ loop electrode conization of the cervix 57500 Biopsy of cervix, single or multiple, or local excision of lesion, w/ or w/o fulguration 57505 Endocervical currettage 57511 Cautery of cervix, cryotherapy, initial or repeat 57522 Conization of cervix, loop electrode excision 58100 Endometrial sampling w/ or w/o endocervical sampling w/o cervical dilation 58110 Endometrial sampling performed in conjunction w/ colposcopy 58300 Insertion of IUD 58301 Removal of IUD 58340 Catheterization, SIS or hysterosalpingography (HSG) 58565 Hysteroscopy - bilat fallopian tube cannulation to induce occlusion (Essure) 58600 Ligation/transection of fallopian tubes, abdom or vaginal 58615 Occlusion of fallopian tubes by device, vag or suprapubic 58670 Laparoscopy, surgical, w/ fulguration of oviducts

66 Document 40 (Page 2 of 5)

Family Planning 58671 Laparoscopy, surgical, w/ occlusion oviducts by device 74740 HSG, radiological supervision and interpretation Labs 80061 Lipid panel 81000 UA, by dipstick or tablet reagent, non-auto, w/ micro 81001 UA, by dipstick or tablet reagent, automated, w/ micro 81002 UA, by dipstick or tablet reagent, non-auto, w/o micro 81025 Urine pregnancy test, by visual color comparison 82270 Hemocult 82947 Assay, glucose, blood, quant (except reagent strip) 82948 Reagent strip blood glucose 82950 Glucose test 83986 pH of other than blood 84702 Chorionic gonadotropin (quantitative) 84703 Chorionic gonadotropin (qualitative) 85013 Hematocrit (blood count spun microhematocrit) 85014 Hematocrit (blood count other than spun) 85018 Hemoglobin (blood count) 86592 Syphilis test, qualitative 86689 HIV antibody confirmatory test (Western Blot) 86695 Herpes simplex, type 1 86696 Herpes simplex, type 2 86701 HIV-1 86703 HIV-1, HIV-2, single assay 86706 Hepatitis B surface antibody 86762 Rubella 86803 Hepatitis C antibody 87205 Smear, gram stain 87210 Wet mount for infectious agents 87490 Chlamydia trachomatis, direct probe technique 87491 Chlamydia trachomatis, amplified probe technique 87590 Gonorrhoeae, DNA, direct probe technique 87591 Gonorrhoeae, amplified probe technique 87621 Papillomavirus, human, amplified probe technique 88141 Cytopathology, cervical or vaginal (c/v), interpret by phys 88142 c/v, fluid, auto thin layer prep, manual, phys suprvsn 88143 c/v, fluid, auto thin layer prep, manual, rescreening 88147 smears, c/v, screen by auto system 88148 smears, c/v, screen by auto sys, manual rescreen 88164 slides, c/v, Bethesda Sys, manual screen 88165 slides, c/v, Bethesda Sys, manual screen, rescreen 88166 slides, c/v, Beth Sys, screen, comp-assist rescreen 88167 slides, c/v, Beth Sys, screen, comp-assist rescreen 88174 c/v, fluid, auto thin layer, screen by auto system 88175 c/v, fluid, auto thin layer, auto screen, man rescreen 88305 Level IV - Surgical pathology, gross and micro exam 88307 Level V - Surgical pathology, gross and micro exam 99000 Handling and/or conveyance of specimen to lab

67 Document 40 (Page 3 of 5)

Family Planning Visit Types 99201 E + M, new patient, self-limit or minor problem, 10 min 99202 E + M, new patient, low to moderate severity, 20 min 99203 E + M, new patient, moderate severity, 30 min 99204 E + M, new patient, moderate to high severity, 45 min 99205 E + M, new patient, moderate to high severity, 60 min 99211 E + M, established patient, minimal, 5 min 99212 E + M, established patient, self-limited or minor, 10 min 99213 E + M, established patient, low to mod severity, 15 min 99214 E + M, established patient, mod to high severity, 25 min 99215 E + M, established patient, mod to high severity, 40 min 99385 E + M, new, comprehensive preventative, age 18-39 99386 E + M, new, comprehensive preventative, age 40-64 99395 E + M, established, comprehensive preven, age 18-39 99396 E + M, established, comprehensive preven, age 40-64 99401 E + M, preven counsel, risk factor reduction, 15 min 99402 E + M, preven counsel, risk factor reduction, 30 min Pharmacy A4261 Cervical cap A4266 Diaphragm A4267 Male condom A4268 Female Condom A4269 Contraceptive Foam/Suppositories J0696 Rocephin injection J1055 Inject, medroxyprogesterone, 150 mg (Depo shot) J7300 IUD, intrauterine copper contraceptive (Paragard) J7302 IUD, levonorgestrel (Mirena) J7303 Contraceptive vaginal ring J7304 Contraceptive patch J7307 Etonogestrel implant system, implant and supplies S4993 Oral contraceptives (may bill up to 6 mo per DOS) (includes Plan B) Ella Rx Benefit Family Planning Therapeutic Drug Class Rx Benefit Select List of STD Treatments: (Generic alternative to be used as appropriate) Acyclovir Aldara Cefixime Ciprofloxacin Clindamyacin Doxycycline Erythromycin Famvir Metronidazole Penicillin Podofilox Valtrex Zithromax

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Family Planning Terazol cream or suppositories Fluconazole Bactrim Macrodantin

Breast Screening & Diagnostic Procedures Radiology 76098 Radiological examination, surgical specimen 76645 Ultrasound, breast(s), unilateral or bilateral, B-scan and/or real time with image documentation 76942 Ultrasonic guidance for needle placement, imaging supervision and interpretation 77031 Stereotactic localization guidance for breast biopsy or needle placement 77032 Mammographic guidance for needle placement, breast 77053 Ductogram, single duct 77054 Ductogram, multipule duct 77055 Mammography, Diagnostic Follow-up, Unilateral 77056 Mammography, Diagnostic Follow-up, Bilateral 77057 Screening Mammogram, Bilateral (2 view film study of each breast, analog) G0204 Diagnostic Mammogram, Digital G0206 Diagnostic Mammogram, Digital, Unilateral G0202 Screening Mammogram, Bilateral, Digital Surgury 10021 Fine needle aspiration without imaging guidance 10022 Fine needle aspiration with imaging guidance 19000 Drainage of breast lesion, cyst aspiration 19001 Drainage of breast lesion, each additional cyst, used with 19000 19100 Breast biopsy, percutaneous, needle core, not using imaging guidance, stereotactic core biopsy 19101 Breast biopsy, open, incisional, stereotactic core biopsy 19102 Breast biopsy, percutaneous, needle core, using imaging guidance; for placement of localization clip use 19295 19103 Breast biopsy, percutaneous, stereotactic automated vacuum assisted or rotating biopsy device, using imaging guidance 19120 Excision/removal of breast lesion 19125 Excision/removal of breast lesion identified by preoperative placement of radiological marker; open; single lesion 19126 Excision/removal of breast lesion identified by preoperative placement of radiological marker, open; each additional lesion separately identified by a preoperative radiological marker 19290 Preoperative placement of needle localization wire, breast 19291 Preoperative placement of needle localization wire, breast; each additional lesion 19295 Image guided placement, metallic localization clip, percutaneous, during breast biopsy Pathology 88172 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s) 88173 Cytopathology, evaluation of fine needle aspirate, interpretation and report 00400 Anesthesia for procedures on the integumentary system, anterior trunk, not otherwise specified. Must be administered by anesthesiologist or nurse anesthetist. Billed for in units, base rate of 3 units for the procedures always applies (3x$21.18 = $63.54) plus time ($2.18 per 15 minute interval, if time goes 1 minute into next 15 minute interval, that counts as 1 unit)

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Cervical Screening & Diagnostic Procedures Pathology 88331 Pathology consultation during surgery, first tissue block, with frozen section(s), single specimen 88332 Pathology consultation during surgery, first tissue block, with frozen section(s), each additional specimen Surgery 57520 Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser Other 99070 Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided). Supplies and materials should be billed for with specific HCPC codes.

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This image of a ladybug is an agreed upon symbol that providers use to correspond with teens. Mailed to teens with no identifying information from the health center, this image informs patients to contact the health center for information, like test results or explanation of benefits.

Example Image for Confidential Communications

71 About NFPRHA

The National Family Planning & Reproductive Health Association (NFPRHA) represents the broad spectrum of family planning administrators and clinicians serving the nation’s low-income and uninsured.

NFPRHA serves its members by providing advocacy, education and training to those in the family planning and reproductive health care fields.

For over 40 years, NFPRHA members have shared a commitment to providing high-quality, federally funded family planning care - making them a critical component of the nation’s public health safety net. Every day NFPRHA members help people act responsibly, stay healthy and plan for strong families.

www.nationalfamilyplanning.org www.nationalfamilyplanning.org