Dept.- Specific Procedure or Protocol
General Policy and Procedure
Major Policy / x

International Community Health Services

Women’s Preventive Health and
Breast and Cervical Health Program Referral Form
Applies To: All Clinic Staff / Approved: 9/26/07
Approved By: Management Team / Next Review: 9/26/08
Department Responsible: Health Education Services / Revised: N/A
Policy Statement / ICHS is committed to providing women and staff an efficient referral process with appropriate scheduling and follow up.
Purpose / To outline steps for completing and processing the “Women’s Preventive Health Services (WPHS) and Breast and Cervical Health Program (BCHP) Referral Form.” This form is used by Community Advocates and other ICHS staff for recruitment.
Definitions / Breast and Cervical Health Program (BCHP): A program funded by the Centers forDisease Control and Prevention and Washington State that provides free breast and cervical cancer screening for women who meet income, age, and insurance requirements.
Community Advocate: Para-professional health educators who (a) teach ICHS patients and community members about various health issues; (b) represent ICHS at community events and health fairs; and (c) provide interpretation and translation for ICHS.
Women’s Preventive Health Services: This department coordinates reproductive health care and screening services aimed at early detection of the most common medical conditions affecting women, e.g. breast cancer, cervical cancer, bone health and osteoporosis. WPHS also coordinates BCHP.
Procedure/Protocol /
  1. A Community Advocate/ICHS Staff meets a woman who needs an annual exam.
  2. The Community Advocate explains the importance of women’s preventive health screenings and encourages the woman to make an appointment.
  3. Simultaneously, the Community Advocate assesses potential eligibility for BCHP and explains what services the program does and does not cover.
  4. Regardless of insurance status, if the woman wants to schedule an appointment the Community Advocate helps the woman complete the “Women’s Preventive Health Services (WPHS) and Breast and Cervical Health Program (BCHP) Referral Form.”
  5. Preferred appointment site. The Community Advocate writes “ID” or “HP.”
  6. Do you have health insurance? If the potential patient says “yes,” the Community Advocate writes down what type of insurance. If the patient says that they are with an HMO, she will have to talk with her HMO about her eligibility.
  7. Family size and income. The Community Advocate refers to the table at the back of the referral form. ICHS uses the Federal guidelines for family size. The Community Advocate may have to explain these guidelines when asking the potential patient for their family size. If the patient meets the WBCHP Income Eligibility Guidelines (per the table), then the Community Advocate checks “eligible (to be confirmed).” If potential patient does not meet the guidelines, the Community Advocate checks “not eligible (to be confirmed).”
  8. Referred by. The Community Advocate writes her own name.
  9. The Community Advocate makes two copies of the completed referral form. She gives one to the potential patient and keeps one for her records.
  10. The Community Advocate sends the original form to the PSR/EW Lead at the potential patient’s preferred appointment site.
  11. The PSR/EW Lead receives the referral form and distributes to team for follow up. Calls will be made to the potential patient within two business days to confirm eligibility and make an appointment.
  12. The PSR/EW will make three attempts,at various times within four business days,tocontact the patient. If no contact is made, the PSR/EW Lead will make a note of no contact and send the referral form to the Community Advocate making the original referral.
  13. If an appointment is made, the PSR/EW will stamp “BCHP” (for women eligible for BCHP) or “WPHS” (for women ineligible for BCHP) on the referral form and forward it to the WPHS Coordinator. Additionally, a copy will be mailed to the patient if the patient requests.
  14. If patient is not reached or scheduled for an appointment, the PSR/EW mails form back to Community Advocate.
  15. If returned, the Community Advocate attempts to reach the patient to explain the importance of preventive screenings and assess barriers that are preventing follow through on scheduling will be made.
  16. WPHS Coordinator will review and update income guidelines as needed.

Authors / Michael McKee, M.Ed., Health Education and Grants Manager
Jessica Guidry, MPH, Patient Services Administrative Coordinator / September 24, 2007
References
Addenda / Women’s Preventive Health Services (WPHS) Breast and Cervical Health Program (BCHP) Referral Form. **Updated annually when new guidelines are published.
BCHP Screening Guidelines and Sliding Scale Fees for Non-BCHP Tests WPHS/BCHP Script

[Core Standard]: [Women’s Preventive Health and Breast and Cervical Health Program Referral Form]

International Community Health Services revised 10/8/07