Same-Visit Contraception: A Toolkit for Family Planning Providers
Welcome to the Toolkit
According to the Centers for Disease Control and Prevention (CDC) and the Office of Population Affairs (OPA), clients should have access to their contraceptive method of choice without unnecessary delays. “Same-visit” provision of contraception means providing immediate access to contraceptive methods using Quick Start, and not requiring clients to return for a separate appointment on another day or even later the same day to initiate contraception.
As long as a clinician can be reasonably certain a client is not pregnant, there is no medical reason to require clients to return for a follow-up visit or to initiate methods during menses. This includes provider-dependent methods like the intrauterine device (IUD), implant, and injectable.
This toolkit offers suggested action steps, tools, and other resources inspired by family planning providers offering the full range of methods same-visit. Title X grantees and service site staff such as managers and clinicians may find this guide and associated tools useful as they begin—or streamline—offering same-visit contraception. The tools and resources in this guide can be used in any order according to needs and priorities. The guide is organized by four strategies.
- Stock Devices and Make Supplies Readily Available
- Adjust Systems to Ensure Efficient and Sustainable Service Delivery
- Engage, Train, and Support All Staff
- Use a Quality Improvement Approach to Implementation
To start, listen to these providers share why they think it is important to provide contraception same-visit, and how they have been able to do so in their clinics.
Although it has been common practice to require multiple appointments for methods such as the IUD or implant, there is agreement by CDC and the American College of Obstetricians and Gynecologists (ACOG) that clinicians can provide contraceptive counseling and initiate the client’s method of choice in a single visit, if they can be reasonably certain that the client is not pregnant, and unless additional complex medical management is indicated. Receiving a method same-visit should be by client preference; if the preference is to wait, this should be respected. Clients should never be pressured to accept a particular method, or accept any method of contraception at all.
Providers should follow the U.S. Medical Eligibility Criteria (MEC) and the U.S. Selected Practice Recommendations (SPR) to ensure clients are candidates for same-visit provision. If screening for sexually transmitted diseases (STD) is indicated, it can be performed at the time of the IUD insertion and insertion should not be delayed unless there are medical contraindications (e.g., clients with current purulent cervicitis, chlamydial infection, or gonococcal infection). The table below summarizes additional contraception needed as back-up, and examinations or tests needed before initiating contraception.
According to CDC, a health care provider can be reasonably certain that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets any one of the following criteria:
- Is ≤7 days after the start of normal menses
- Has not had sexual intercourse since the start of last normal menses
- Has been correctly and consistently using a reliable method of contraception
- Is ≤7 days after spontaneous or induced abortion
- Is within 4 weeks postpartum
- Is fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority [≥85%] of feeds are breastfeeds), amenorrheic, and <6 months postpartum
Contraceptive method | When to start* | Additional contraception | Examinations or tests needed before initiation |
|---|---|---|---|
Copper IU | Anytime | Not needed | Bimanual examination and cervical inspection** |
Levonorgestrel IUD | Anytime | If >7 days after menses started, use back-up method or abstain for 7 days | Bimanual examination and cervical inspection** |
Implant | Anytime | If >5 days after menses started, use back-up method or abstain for 7 days | None |
Injectable | Anytime | If >7 days after menses started, use back-up method or abstain for 7 days | None |
Combined hormonal contraceptive | Anytime | If >5 days after menses started, use back-up method or abstain for 7 days | Blood pressure measurement |
Progestin-only pill | Anytime | If >5 days after menses started, use back-up method or abstain for 2 days | None |
*If the provider is reasonably certain that the woman is not pregnant.
**Most women do not require additional STD screening at the time of IUD insertion. If a woman with risk factors for STDs has not been screened for gonorrhea and chlamydia according to CDC’s STD Treatment Guidelines (http://www.cdc.gov/std/treatment), screening can be performed at the time of IUD insertion, an insertion should not be delayed. Women with current purulent cervicitis or chlamydial infection or gonococcal infection should not undergo IUD insertion (U.S. MEC 4).
Source: U.S. Selected Practice Recommendations, 2016
Many providers already prescribe short-acting methods—like the pill, patch, and ring—when requested by the client. Provider-dependent methods have not been always been stocked in the clinic, thus requiring clients to return for a second visit. However, when clients are required to return for a second visit for the insertion of a long-acting reversible contraception (LARC) method, the likelihood they receive their method of choice decreases. Up to 50% of clients will not return for a LARC insertion visit (Bergin 2012). Moreover, a two-visit insertion protocol disproportionately impacts low-income clients (Higgins 2016).
Clients face many barriers when trying to get to a medical appointment. For some clients, it can be challenging to take time off of work, obtain child care, or secure transportation to and from the clinic. Some clients are only in the area for a limited period of time—for example, students who are home on college break.
Given their challenges, clients are satisfied when they can obtain a contraceptive method same-visit. When major barriers to contraception are eliminated and clients can receive the method they want, they are satisfied and have high method continuation rates (Diedrich 2015, Dehlendorf 2018). High client satisfaction drives continued demand for services, and contributes to increased staff satisfaction for being able to meet client needs.
As with any improvement initiative, starting with an assessment of the current status ensures that improvements build on existing efforts.
| Action Steps | Supportive Resources |
|---|---|
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Assess what methods clients can currently obtain same-visit and reflect on barriers that prevent all methods from being available same-visit. |
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Discuss with staff what strategies that support same-visit provision are already being implemented in the clinic. |
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Brainstorm ideas for improvement and develop an action plan for implementing same-visit contraception. |
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Strategy 1. Stock Devices and Make Supplies Readily Available
Title X-funded projects are required to provide a broad range of acceptable and effective family planning methods and services. Although some methods can be obtained without a provider, or by prescription, the provider-dependent methods need to be stocked on-site in order to ensure clients can access them without delays. Strategies and related tools for stocking devices and making supplies readily available are described below.
At a minimum, at least one type of each Food and Drug Administration (FDA)-approved contraceptive methods-approved provider-dependent method (i.e., hormonal IUD, copper IUD, implant, and injectable) should be stocked on site. Other methods should also be readily available, either stocked on-site or through a pharmacy.
| Action Steps | Supportive Resources |
|---|---|
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Identify what methods are currently stocked on site and, if necessary, what methods need to be added. |
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Forecast demand for new methods based on prior client interest, experience of other sites, or national data. |
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Utilize the buy and bill approach to obtain methods prior to the client’s arrival. |
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Use distributor programs that make devices more affordable, including volume discounts, 90-day net terms, pay by credit, and patient assistance programs. |
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Utilize the 340B drug pricing program to obtain contraceptive methods at reduced cost. |
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Having the supplies and devices stocked in (or at a minimum, accessible to) the exam rooms expedites the insertion process when a client requests a method same-visit.
| Action Steps | Supportive Resources |
|---|---|
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Maintain a checklist of materials needed for IUD and implant insertions and removals. |
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Pre-assemble the materials in kits (e.g., sealable bags), on trays, or in a portable caddy. Try different approaches to determine what works best. |
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Designate a staff person to routinely (e.g., weekly) monitor and ensure that an adequate supply of materials has been pre-assembled. |
To consistently offer methods same-visit, an adequate supply of each method must be maintained. Strict inventory control prevents both over-stocking (which may lead to expired contraceptives) and shortages or stock-outs of contraceptive supplies.
| Action Steps | Supportive Resources |
|---|---|
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Use an inventory control system to ensure that the amount of stock on hand is always between desired maximum and minimum levels. |
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Monitor utilization trends and adjust ordering as needed. Consider low-technology strategies, such as a logbook, to track devices. |
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Designate a staff person to monitor stock levels and order supplies, and include this task in the job description. |
Strategy 2. Adjust Systems to Ensure Efficient and Sustainable Service Delivery
If staff already feel they have hectic and full clinic schedules, asking them to add another service to the visit without making adjustments may frustrate them. That said, many clinics are not working to their full productivity potential. This section describes efficiency-increasing strategies to ensure that integration of same-visit contraception is successful.
A clear, written policy stating that methods should be available same-visit can be critical for obtaining buy-in from key staff and will serve as the foundation upon which clinic processes are established.
| Action Steps | Supportive Resources |
|---|---|
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Listen to a family planning provider talk about how they adopted a policy for same-visit contraception. |
A Case Study: Same-Visit Provision of Contraception at NYC Health + Hospitals, Morrisania Health Center and Lincoln Hospital Video |
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Adopt a policy that:
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Many providers are concerned that they will not have enough time for same-visit provision within their existing schedules. However, many providers find that the amount of time for LARC insertions is just a few minutes when supplies can be assembled quickly. Use data to determine if changes to the appointment system are necessary.
| Action Steps | Supportive Resources |
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Conduct a time study to learn how long IUD and implant insertions actually take when the materials are already gathered. |
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Eliminate designated appointment slots for LARC insertions. Listen to a family planning provider talk about how eliminating designated appointments for LARC insertions increased their ability to provide methods same-visit. |
A Case Study: Same-Visit Provision of Contraception at the Louisiana Office of Public Health, Rapides Parish Health Unit Video |
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Use a standard length for all appointment types, including LARC insertions. Some appointments will take more (or less) time but will balance out over the course of the day and should not cause delays for clients. |
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Consider adjusting the length of the standard appointment or blocking appointments during the day to catch up for same-visit insertions if the clinic is already at maximum capacity and its no-show rate does not allow same-visit procedures to be absorbed in the existing schedule. |
If the process by which clients move through the visit is not efficient to start with, it may be hard to add another service to the existing workflow. Eliminating waste, reducing client stops, and increasing flow through the visit can allow for the integration of same-visit provision of contraception and increase overall efficiency of services.
| Action Steps | Supportive Resources |
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Assess clinic flow to identify opportunities for freeing up clinician availability for same-visit insertions. |
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Eliminate waste and duplication of effort in order to ensure sufficient time during the visit to provide contraceptive methods. |
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Collect data and track improvements on selected clinic flow measures, such as client cycle time, wait time, and number of client stops. |
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Strategy 3. Engage, Train, and Support All Staff
Although having clinic systems set up to support same-visit provision is important, it is the staff who will actually implement same-visit services. All staff have a role to play in making methods available same-visit, and thus it is essential that they receive appropriate training and support. Strategies and related tools for involving all staff in a collaborative way are described below.
For many staff, same-visit provision may represent a significant change in practice, and it will be helpful for them to see how other providers have done it. Involving staff in discussions about implementation can not only increase buy-in, but also identify opportunities for streamlining processes.
| Action Steps | Supportive Resources |
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Involve staff in a discussion about the importance of same-visit contraception, the agency’s protocols and policies, and how staff can work together to provide same-visit contraception. |
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Share standards of care including QFP, SPR, MEC, and STD Treatment Guidelines. |
How to Be Reasonably Certain a Client is Not Pregnant and When to Start Contraceptive Methods Palm Card |
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Share success stories with staff to show that same-visit services can be successfully implemented. |
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In order for same-visit to be an option, trained clinicians must be available all hours during which the clinic is open. Training should address both the technical skills for insertion and removal of the full range of methods, along with the current standards of care related to provision of contraceptive services.
| Action Steps | Supportive Resources |
|---|---|
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Train clinicians on current standards of care related to the provision of contraceptive services including QFP, SPR, MEC, and STD Treatment Guidelines. Available training resources include training slides with speaker notes, quick reference guides, and mobile and desktop applications. |
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Train clinicians to insert and remove LARC methods. Obtain training at conferences, through pharmaceutical representatives, or at other venues. |
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Provide job aids for clinicians—such as CDC recommendations for How to Be Reasonably Certain a Woman is not Pregnant and When to Start Contraceptive Methods—in exam rooms. |
How to Be Reasonably Certain a Client is Not Pregnant and When to Start Contraceptive Methods Palm Card |
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Offer copper IUD as emergency contraception (EC). According to CDC, the copper IUD can be placed within seven days of unprotected intercourse as a form of EC. Use videos and handouts to motivate and train staff. |
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Clients often ask clinic assistants and front desk staff about obtaining contraception during an appointment. All staff should be able to answer basic questions from clients about obtaining methods, and be able to direct questions to appropriate staff as needed.
| Action Steps | Supportive Resources |
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Provide sample language for responding to questions about obtaining contraception to clinic assistants and front desk staff. |
Sample Responses to Frequently Asked Questions about Obtaining Contraception for Front Desk Staff |
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Use role-playing exercises to help staff practice responding to client questions. |
All Title X clients should have access to services regardless of ability to pay. That said, obtaining reimbursement for services will always be important for a clinic’s sustainability. According to the Title X Program Requirements when there is legal obligation or authorization for third-party reimbursement, all reasonable efforts must be made to obtain third-party payment. Using the proper codes, sites can get reimbursed for an evaluation and management code, the insertion procedure, and device in one visit.
| Action Steps | Supportive Resources |
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Train staff on how to bill accurately for same-visit contraception. |
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Train staff on the use of coding modifiers, and provide quick reference guides to support implementation. |
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Track billing and reimbursement for IUDs, implants, and injectables to ensure adequate reimbursement is being obtained. |
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Strategy 4: Use a Quality Improvement Approach to Implementation
Use a quality improvement approach to monitor what implementation strategies are working, and where continued improvement is needed.
| Action Steps | Supportive Resources |
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Become familiar with quality improvement approaches. |
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Develop an action plan to track implementation of improvement strategies. |
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Use Plan-Do-Study-Act (PDSA) cycles to test small changes and see what works. For example, try a same-visit insertion with one clinician, one time, or for one day. |
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Regularly meet as a clinic staff to discuss ongoing challenges and to identify next steps until same-visit contraception is implemented routinely. |
References
- American College of Obstetricians and Gynecologists. Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Practice Bulletin No. 186. Obstet Gynecol 2017;130:e251–69.
- Bergin A, Tristan S, Terplan M, et al. A missed opportunity for care: two-visit IUD insertion protocols inhibit placement. Contraception 2012;86(6) 694–7
- Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep 2015; 64(No. RR-3):1–137.
- Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65(No. RR-4):1–66.
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65(No. RR-3):1–104.
- Dehlendorf C, Henderson JT, Vittinghoff E, et al. Development of a patient-reported measure of the interpersonal quality of family planning care. Contraception 2018;97(1):34-40.
- Diedrich JT, Zhao Q, Madden T, et al. Three-year continuation of reversible contraception. Am J Obstet Gynecol 2015;213(5):662.e1-8.
- Gavin L, Moskosky S, Carter M et al. Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep 2014; 63(No. RR-4):1–54.
- Higgins T, Doughtery A, Heil S. Does a two-visit protocol for long-acting reversible contraception differentially impact socioeconomically disadvantaged women? Contraception 2016; 94(4):413.
- Office of Population Affairs. Title X Program Requirements.
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